Public/Community Health and Nursing Practice

CARING FOR POPULATIONS

SECOND EDITION

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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

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F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com

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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 Planning | Population Characteristics

Classification: LCC RT97 (ebook) | LCC RT97 (print) | NLM WY 108 | DDC 610.73/4—dc23

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

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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.

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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

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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

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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

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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

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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.

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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

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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.

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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)

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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.

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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

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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

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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

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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

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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

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

2. American Nurses Association. (2015). Nursing: scope and standards of practice (3rd ed.). Silver Spring, MD: ANA.

3. Winslow, C.E.A. (1920). The untilled field of public health. Modern Medicine, 2, 183-191.

4. Turnock, B.J. (2016). Public health: What it is and how it works (6th ed.). Sudbury, MA: Jones & Bartlett.

5. Fawcett, J., & Ellenbecker, C. H. (2015). A proposed concep- tual model of nursing and population health. Nursing Out- look, 63(3), 288-298. http://dx.doi.org/10.1016/j.outlook. 2015.01.009.

6. World Health Organization. (2018). About WHO. Retrieved from http://www.who.int/about/en/.

7. Issel, L.M. (2018). Health program and evaluation: A practi- cal, systematic approach for community health (4th ed.). Sudbury, MA: Jones & Bartlett.

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

9. Centers for Disease Control and Prevention, National Public Health Performance Standards Program (NPHPSP). (2017). The public health system and ten essential public health serv- ices. Retrieved from https://www.cdc.gov/stltpublichealth/ publichealthservices/essentialhealthservices.html.

10. Institute of Medicine. (2012). For the public’s health: invest- ing in a healthier future. Washington, DC: The National Academies Press.

11. U.S. Department of Health and Human Services, Healthy Peo- ple 2020. (2018). Public health infrastructure. Retrieved from http://www.healthypeople.gov/2020/topicsobjectives2020/ overview.aspx?topicId=35.

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?

References 1. Beil, L. (2018, January 16). The parasite on the

playground. New York Times. Retrieved from https:// nyti.ms/2ELVbmS.

2. Centers for Disease Control and Prevention. (2013). Toxocariasis: epidemiology & risk factors. Retrieved from https://www.cdc.gov/parasites/toxocariasis/ epi.html.

3. Woodhal, D.M., Garcia, A.P., Shapiro, C.A., Wray, S., Montgomery, S.P., et al. (2017). Assessment of U.S. pediatrician knowledge of toxocariasis. The American Journal of Tropical Medicine and Hygiene, 97(4), 1243-1247. DOI: https://doi.org/10.4269/ ajtmh.17-0232.

4. Walsh, M.G., & Haseeb, M.A. (2012). Reduced cognitive function in children with toxocariasis in a nationally representative sample of the United States. International Journal for Parasitology, 42(13-14), 1159-1163. https://doi.org/10.1016/ j.ijpara.2012.10.002.

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12. Yach, D., & Bettcher, D. (1998). The globalization of public health, I. Threats and opportunities. American Journal of Public Health, 88(5), 735-738.

13. Smith, M.J., & Silva, D.S. (2015). Ethics for pandemics beyond influenza: Ebola, drug-resistant tuberculosis, and anticipating future ethical challenges in pandemic prepared- ness and response. Monash Bioethics Review, 33(2-3), 130-47. doi: 10.1007/s40592-015-0038-7.

14. Weber, M. (2018). Our world in data. Published online at OurWorldInData.org. Retrieved from https:// ourworldindata.org/.

15. Roser, M., & Ortiz-Ospina, E. (2017). Global rise of educa- tion. Published online at OurWorldInData.org. Retrieved from https://ourworldindata.org/global-rise-of-education.

16. Roser, M., & Ortiz-Ospina, E. (2018). Global extreme poverty. Published online at OurWorldInData.org. Retrieved from https://ourworldindata.org/extreme-poverty.

17. Ritchie, H., & Roser, M. (2018). Water access, resources, and sanitation. Published online at OurWorldInData.org. Retrieved from https://ourworldindata.org/water-access- resources-sanitation.

18. World Health Organization, Global Health Observatory (GHO) data. (2018). Life expectancy. Retrieved from http://www.who.int/gho/mortality_burden_disease/ life_tables/situation_trends_text/en/.

19. Winslow, C.E. (1926). Public health at the crossroads. American Journal of Public Health, 89(11), 1075-1085. Reprinted in American Journal of Public Health, 89(11), 1645-1648.

20. World Health Organization. (2018). Tobacco. Retrieved from http://www.who.int/topics/tobacco/en/.

21. Institute of Medicine. (2003). The future of the public’s health in the twenty-first century. Washington, DC: National Academies Press.

22. Institute of Medicine. (2012). For the public’s health: invest- ing in a healthier future. Washington, DC: The National Academies Press. https://doi.org/10.17226/13268.

23. Dahlgren, G., & Whitehead, M. (1991). Policies and strategies to promote social equity in health. Stockholm, Sweden: Institute for the Futures Studies.

24. Bauer, G., Davies, J.K., Pelikan, J., Noack, H., Broesskamp, U., & Hill, C. (2003). Advancing a theoretical model for public health and health promotion indicator development: Proposal from the EUHPID consortium. European Journal of Public Health, 13(3s), 107-113.

25. National Academies of Sciences, Engineering, and Medicine. (2017). Communities in action: Pathways to health equity. Washington, DC: The National Academies Press. doi:10.17226/24624.

26. Sullivan, B.J., & Bettger, J.P. (2018). Community-informed health promotion to improve health behaviors in Honduras. Journal of Transcultural Nursing, 29(1), 14-20. doi:10.1177/ 1043659616670214.

27. Caldwell, J. (1996). Demography and social science. Popula- tion Studies, 50, 1-34.

28. World Health Organization. (1948). The WHO definition of health. Preamble to the constitution of the World Health Organization. Retrieved from http://who.int/about/ definition/en/print.html.

29. MacQueen, K.M., McLellan, E. Metzger, D.S., Kegeles, S., Strauss, R.P., & Trotter, R.T. (2001). What is community?

An evidence-based definition for participatory public health. American Journal of Public Health, 91(12), 1929-1938.

30. Fallon, L.F., & Zgodzinski, E.J. (2012). Essentials of public health management (3rd ed.). Sudbury, MA: Jones & Bartlett.

31. Jackson, S.F. (2017). How can health promotion address the ecological determinants of health? Global Health Promotion, 24(4), 3-4. https://doi.org/10.1177/1757975917747448.

32. MacDonald, M.A. (2004). From miasma to fractals: The epidemiology revolution and public health nursing. Public Health Nursing, 21(4), 380-381.

33. Prochaska, J.O., & Velicer, W.F. (1997). The transtheoretical model of health behavior change. American Journal of Health Promotion, 12, 38-48.

34. Central Intelligence Agency. (2017). The world factbook. Retrieved from https://www.cia.gov/library/publications/ the-world-factbook/rankorder/2102rank.html.

35. Have, T.H. (2016). Global bioethics: an introduction. Routledge: London.

36. Merriam Webster Dictionary. (2018). Definition of culture. Retrieved from https://www.merriam-webster.com/ dictionary/culture.

37. Spector, R.E. (2017). Cultural diversity in health and illness (8th ed.). Upper Saddle River, NJ: Pearson.

38. O’Neill, D. (2006). The nature of ethnicity. Retrieved from http://anthro.palomar.edu/ethnicity/ethnic_2.htm.

39. Humes, K.R., Jones, N.R., & Ramirez, R.R. (2011). Overview of race and Hispanic origin: 2010. 2010 Census Briefs. Retrieved from http://www.census.gov/prod/cen2010/ briefs/c2010br-02.pdf.

40. U.S. Census Bureau. (2017). Race: FAQ. Retrieved from https://www.census.gov/topics/population/race/about/ faq.html.

41. Morganthau, T. (1995, February 13). What color is black? Newsweek, 62-69.

42. Murphy, N. (2008). An agenda for health promotion. Nursing Ethics, 15(5), 697-699.

43. Foronda, C., Baptiste, D., Reinholdt, M.M., & Ousman, K. (2016). Cultural humility. Journal of Transcultural Nursing, 27(3), 210-217. http://dx.doi.org.ezp.welch.jhmi.edu/ 10.1177/1043659615592677.

44. Sommers, J. (1989). Soho—a history of London’s most colorful neighborhood (pp. 113-117). London, England: Bloomsbury.

45. The Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Retrieved from http:// www.iom.edu/Reports/2010/The-Future-of-Nursing- Leading-Change-Advancing-Health.aspx#.

46. American Public Health Association, Public Health Nursing Section. (2013). The definition and practice of public health nursing: A statement of the public health nursing section. Washington, DC: American Public Health Association. Retrieved from https://www.apha.org/~/media/files/pdf/ membergroups/phn/nursingdefinition.ashx.

47. Quad Council of Public Health Nursing Organizations. (1997). The tenets of public health nursing. Unpublished white paper.

48. American Nursing Association. (2013). Public health nursing: Scope and standards of practice. Silver Spring, MD: Nursesbooks.org.

49. Bekemeier, B. (2008). A history of public health and public health nursing. In L. Ivanov & C. Blue (Eds.), Public health

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nursing: Leadership, policy, and practice (pp. 2-26). Clifton Park, NY: Thomson Delmar Learning.

50. Brainard, A.M. (1922). The evolution of public health nursing. New York, NY: Garland.

51. Monteiro, L.A. (1985). Florence Nightingale on public health nursing. American Journal of Nursing, 75(2), 181-186.

52. Florence Nightingale Museum. (2018). Florence Nightingale biography. Retrieved from http://www.florence- nightingale.co.uk/resources/biography/?v=7516fd43adaa.

53. Doona, M.E. (1994). Gertrude Weld Peabody: Unsung patron of public health nursing education. Nursing & Health Care, 15(2), 88-94.

54. Buhler-Wilkerson, K. (1985). Public health nursing: In sickness or in health? American Journal of Public Health, 75, 1155-1161.

55. Jewish Women’s Archive. (2009). JWA—Lillian Wald— introduction. Retrieved from http://jwa.org/womenofvalor/ wald/.

56. Buhler-Wilkerson, K. (1993). Bringing care to the people: Lillian Wald’s legacy to public health nursing. American Journal of Public Health, 83(12), 1778-1786.

57. U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions. (2018). Registered nurses: Work environment. Retrieved from https://www.bls.gov/ooh/healthcare/ registered-nurses.htm#tab-3.

58. Emanuel, E.J. (2018, February 25). Are hospitals becoming obsolete? New York Times. Retrieved from https://nyti.ms/ 2sWY9nc.

59. Quad Council Coalition Competency Review Task Force. (2018). Community/public health nursing competencies. Retrieved from http://www.quadcouncilphn.org/wp- content/uploads/2018/05/QCC-C-PHN-COMPETENCIES- Approved_2018.05.04_Final-002.pdf.

60. Council on Linkages. (2014). Core competencies for public health professionals. Retrieved from http://www.phf.org/ resourcestools/Documents/Core_Competencies_for_ Public_Health_Professionals_2014June.pdf.

61. American Nurses Association. (2015). Code of ethics for nursing with interpretive statements. Silver Spring, MD: ANA.

62. Public Health Leadership Society. (2002). Principles of ethical practice in public health. Retrieved from https://www. apha.org/~/media/files/pdf/membergroups/ethics_brochure. ashx.

63. Beaglehole, R., & Bonita, R. (2010). What is global health? Global Health Action. Published online. doi:10.3402/ gha.v3i0.5142.

64. World Health Organization. (2018). About the WHO. Retrieved from www.who.int/about/en/.

65. United States Department of Health and Human Services, Healthy People 2030. (2018). Leading health indicators. Retrieved from http://www.healthypeople.gov/2020/LHI/ default.aspx.

66. World Health Organization. (2018). Constitution of WHO: Principles. Retrieved from http://www.who.int/about/ mission/en/.

67. World Health Organization. (2018). Nursing now. Retrieved from http://www.who.int/mediacentre/events/2018/ nursing-now/en/.

68. World Bank. (2018). How we classify countries. Retrieved from data.worldbank.org/about/country-classifications.

69. World Health Organization. (2018). Global health observa- tory: Under five mortality. Retrieved from www.who.int/ gho/child_health/mortality/mortality_under_five/en/ index.html.

70. United Nations. (2018). The sustainable development goals. Retrieved from http://www.un.org/sustainabledevelopment/ sustainable-development-goals/.

71. Centers for Disease Control and Prevention. (2015). CDC 24-7: Our history, our story. Retrieved from https:// www.cdc.gov/about/history/ourstory.htm.

72. Centers for Disease Control and Prevention. (1999). Ten great public health achievements in the 20th century. Morbidity and Mortality Weekly Report, 48, 241-243.

73. Centers for Disease Control and Prevention, Office of Public Health Preparedness and Response. (2013). Funding and guidance for state and local health departments. Retrieved from http://www.cdc.gov/phpr/coopagreement.htm.

74. Centers for Disease Control and Prevention. (2014). About CDC: Mission goal and pledge. Retrieved from http://www.cdc.gov/about/organization/mission.htm.

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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.

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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

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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

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

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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,

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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)

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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.)

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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

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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

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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].)

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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

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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)

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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.)

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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

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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

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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

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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)

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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.

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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.

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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

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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

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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

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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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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.

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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).

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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

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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

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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.

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7. Bauer, G., Davies, J.K., Pelikan, J., Noack, H., Broesskamp, U., & Hill, C. (2003). Advancing a theoretical model for public health and health promotion indicator development: Proposal from the EUHPID consortium. European Journal of Public Health, 13(3s), 107-113.

8. Institute of Medicine. (2003). The future of the public’s health in the twenty-first century. Washington, DC: National Academies Press.

9. Golden, S.D., McLeroy, K.R., Green, L.W., Earp, J.A.L., & Lieberman, L.D. (2015). Upending the social ecological model to guide health promotion efforts toward policy and environmental change. Health Education & Behavior, 42(1 suppl), 8S-14S. https://doi.org/10.1177/ 1090198115575098.

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11. O’Donnell, M.P. (2008). Evolving definition of health promotion: What do you think? American Journal of Health Promotion, 23(2), iv. doi: 10.4278/ajhp.23.1.iv.

12. Li, A.M. (2017). Ecological determinants of health: food and environment on human health. Environment Science and Pollution Research International, 24, 9002-9015. doi: 10.1007/s11356-015-5707-9.

13. World Health Organization. (2018). Social determinants of health. Retrieved from http://www.who.int/social_ determinants/sdh_definition/en/.

14. Braveman, P., Egerter, S., & Williams, D.R. (2011). The social determinants of health: coming of age. Annual Review of 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?

REFERENCES

1. U.S. Department of Health and Human Services, Healthy People. (2018). Healthy people 2030 draft framework. Retrieved from https://www.healthypeople.gov/2020/About-Healthy- People/Development-Healthy-People-2030/Draft-Framework.

2. Kennedy, P. (2018, March 9). The secret to a longer life? Don’t ask these dead longevity researchers. The New York Times. Retrieved from https://nyti.ms/2Gd1NMI.

3. World Health Organization. (2019). Health Work Force: Nursing Now Campaign. Retrieved from https://www.who. int/hrh/news/2018/nursing_now_campaign/en/

4. UN General Assembly. (2015). Transforming our world: the 2030 Agenda for Sustainable Development. Retrieved from http://www.un.org/ga/search/view_doc.asp?symbol=A/RES/ 70/1&Lang=E.

5. U.S. Department of Health and Human Services, Office of the Surgeon General, National Prevention Council. (2011). National prevention strategy, Washington, DC. Retrieved from http://www. surgeongeneral.gov/initiatives/prevention/strategy/report.pdf.

6. U.S. Department of Health and Human Services, Office of the Surgeon General, National Prevention Council. (2014). Annual status report, Washington, DC. Available at http:// www.surgeongeneral.gov/initiatives/prevention/about/ annual_status_reports.html.

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24. Gordon, R. (1987). An operational classification of disease prevention. In J.A. Steinberg & M.M. Silverman (Eds.), Preventing mental disorders (pp. 20-26). Rockville, MD: De- partment of Health and Human Services.

25. Substance Abuse and Mental Health Services Administra- tion. (2004). Clinical preventive services in substance abuse and mental health update: From Science to services (DHHS Publication No. [SMA] 04-3906). U.S. Department of Health and Human Service, Rockville, MD.

26. Whelton P.K., Carey, R.M., Aronow, W.S., Casey, D.E., Collins, K.J., Dennison Himmelfarb, C.,… Wright, J.K. (2018). ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/ NMA/PCNA Guideline for the prevention, detection, evalu- ation, and management of high blood pressure in adults. Journal of the American College of Cardiology, 71(19), 2275-2279. DOI: 10.1016/j.jacc.2017.11.006.

27. Havas, K., Bonner, A., & Douglas, C. (2016). Self-manage- ment support for people with chronic kidney disease: Patient perspectives. Journal Of Renal Care, 42(1), 7-14. doi:10.1111/jorc.12140.

28. Enworom, C.D., & Tabi, M. (2015). Evaluation of kidney disease education on clinical outcomes and knowledge of self-management behaviors of patients with chronic kidney disease. Nephrology Nursing Journal, 42(4), 363-373.

29. Salvatore, A. L., SangNam, A., Luohua, J., Lorig, K., Ory, M. G., Ahn, S., & Jiang, L. (2015). National study of chronic disease self-management: 6-month and 12-month findings among cancer survivors and non-cancer survivors. 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 Statistics.

33. Institute of Medicine and National Research Council. (2015). Measuring the risks and causes of premature death: summary of workshops. Washington, DC: The National Academies Press. https://doi.org/10.17226/21656.

34. Keller, L.O., Strohschien, S., Lia-Hoagberg, B., & Schaffer, M. (2004). Population-based public health interventions: Practice-based and evidence-supported, part 1. Public Health Nursing, 21, 453-468.

35. Minnesota Department of Health, Division of Community Health Services, Public Health Section. (2001). Public health interventions: Applications for public health nursing practice. Retrieved from http://www.health.state.mn.us/divs/opi/ cd/phn/docs/0301wheel_manual.pdf.

36. Joint Committee on Health Education and Promotion Terminology. (2014). Report of the 2011 Joint Committee on Health Education and Promotion Terminology. American Journal of Health Education, 43(sup 2), 1-19. DOI: 10.1080/19325037.2012.11008225.

37. World Health Organization. (2018). Health education. Retrieved from http://www.who.int/topics/health_ education/en/.

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). Health literacy: A prescription to end confusion. Washington, 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 Health Policy and Management, 4(11), 747–755. Retrieved from http://doi.org.ezp.welch.jhmi.edu/10.15171/ ijhpm.2015.151.

45. Centers for Disease Control and Prevention. (2016). Talking points about health literacy. Retrieved from https://www.cdc.gov/healthliteracy/shareinteract/ 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- tion: cultural respect. Retrieved from https://www. nih.gov/institutes-nih/nih-office-director/office- communications-public-liaison/clear-communication/ cultural-respect.

49. Bloom, B.S. (1956). Taxonomy of educational objectives: Handbook 1. The cognitive domain. New York, NY: David McKay.

50. Commission on Chronic Illness. (1951). Chronic illness in the United States (Vol. 1, p 45). Cambridge, MA: Harvard University Press, Commonwealth Fund.

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- sion scale for research in the general population. Applied Psychological Measurement, 1, 385-401.

54. Andresen, E.M., Malmgren, J.A., Carter, W.B., & Patrick, D.L. (1994). Screening for depression in well older

C H A P T E R 2 n Optimizing Population Health 53

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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/ cancer/colorectal/statistics/index.htm.

56. Centers for Disease Control and Prevention. (2017). Chronic disease prevention and health promotion: National Center for

Chronic Disease Prevention and Health Promotion. Retrieved from https://www.cdc.gov/chronicdisease/resources/ 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.

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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.

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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

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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)

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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.)

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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

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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

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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

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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

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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.

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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

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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

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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)

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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

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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.

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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

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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

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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.

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• 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.

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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.

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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

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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)

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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)

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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)

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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

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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)

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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.)

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• 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.

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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

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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).

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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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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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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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10

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0 0

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0 0

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5 5 (Thousands)

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5

FemalesMales

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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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10

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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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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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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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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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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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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

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• 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.

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REFERENCES

1. National Association of County and City Health Officials. (n.d.). Community Health Assessment and Improvement Planning. Retrieved from https://www.naccho.org/programs/ public-health-infrastructure/performance-improvement/ community-health-assessment.

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7. Centers for Disease Control and Prevention. (2016). Partnerships to improve community health (PICH). Retrieved from https://www.cdc.gov/nccdphp/dch/programs/ partnershipstoimprovecommunityhealth/index.html.

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9. Goeppinger, J., & Baglioni, A.J. (1985). Community compe- tence: A positive approach to needs assessment. American Journal of Community Psychology, 13(5), 507-523.

10. McKnight, J. & Block, P. (2010). The abundant community. San Francisco: Barrett and Koelher.

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12. Centers for Disease Control and Prevention. (2015). assess- ment & planning models, frameworks & tools. Retrieved from http://www.naccho.org/topics/infrastructure/mapp/ chahealthreform.cfm.

13. National Association for State Community Service Pro- grams. (2011). A community action guide to comprehensive community needs assessments. Washington DC: Author.

14. Centers for Disease Control and Prevention. (2015). Assess- ment & planning models, frameworks & tools. Retrieved from https://www.cdc.gov/stltpublichealth/cha/assessment.html.

15. Alves, H., Da Silva Brito, I., Rodrigues Da Silva, T., Araújo Viana, A., & Andrade Santos, R.C. (2017). Adolescent pregnancy and local co-planning: a diagnostic approach based on the PRECEDE-PROCEED model. Revista de Enfermagem Referência, 4(12), 35–44. https://doi-org.ezp. welch.jhmi.edu/10.12707/RIV16058.

16. World Health Organization. (2018). Indicators of maternal, newborn and child health. Retrieved from http://www.who.

int/woman_child_accountability/progress_information/ recommendation2/en/.

17. Centers for Disease Control and Prevention. (2018). The school health index. Retrieved from https://www.cdc.gov/ healthyschools/shi/index.htm.

18. Centers for Disease Control and Prevention. (2015). Workplace health promotion: assessment. Retrieved from https://www.cdc.gov/workplacehealthpromotion/model/ assessment/index.html.

19. Salkas, S., Conniff, J., & Budge, S.L. (2018). Provider quality and barriers to care for transgender people: An analysis of data from the Wisconsin transgender community health assessment. International Journal of Transgenderism, 19(1), 59–63. https://doi-org.ezp.welch.jhmi.edu/10.1080/ 15532739.2017.1369484.

20. World Health Organization. (2018). Health impact assessments (HIA). Retrieved from http://www.who.int/hia/en/.

21. Mueller, N., Rojas-Rueda, D., Basagaña, X., Cirach, M., Cole-Hunter, T., Dadvand, P, Nieuwenhuijsen, M, et al. (2017). Urban and transport planning related exposures and mortality: a health impact assessment for cities. Environmen- tal Health Perspectives, 125(1), 89-96.

22. Pennington, A., Dreaves, H., Scott-Samuel, A., Haigh, F., Harrison, A., Verma, A., & Pope, D. (2017). Development of an urban health impact assessment methodology: indicating the health equity impacts of urban policies. European Journal of Public Health, 27(suppl_2), 56-61. doi:10.1093/eurpub/ ckv114.

23. Centers for Disease Control and Prevention. (2017). Health impact assessment. Retrieved from https://ephtracking. cdc.gov/showHealthImpactAssessment.

24. Pan American Health Organization & World Health Organization. (n.d.). Rapid needs assessment. Retrieved from http://www.paho.org/disasters/index.php?option=com_ content&view=article&id=744:rapid-needs-assessment& Itemid=0&lang=en.

25. International Federation of Red Cross and Red Crescent Societies. (n.d.). Emergency needs assessment. Retrieved from http://www.ifrc.org/en/what-we-do/disaster-management/ responding/disaster-response-system/emergency-needs- assessment/.

26. Witkin, B., & Altschuld, J.W. (1995). Planning and conduct- ing needs assessments. Thousand Oaks, CA: Sage.

27. Kretzmann, J.P., & McKnight, J.L. (1993). Building communi- ties from the inside out: A path toward finding and mobilizing a community’s assets. Evanston, IL: Institute for Policy Research.

28. McKnight, J.L. & Kretzmann, J.P. (1997). Mapping commu- nity capacity. In M. Minkler. Community organizing & community building for health. New Brunswick, NJ: Rutgers University Press.

29. Mayan, M.J. & Dum, C.H. (2016). Worth the risk? Muddled relationships in community-based participatory research. Qualitative Health Research, 26(1) 69–76.

30. Oetzel, J.G., Wallerstein, N., Duran, B., Sanchez-Youngman, S., Nguyen, T., Woo, K., Alegria, M, et al. (2018). Impact of participatory health research: a test of the community-based participatory research conceptual model. BioMed Research International, 2018, 1–12. https://doi-org.ezp.welch.jhmi. edu/10.1155/2018/7281405.

31. Whisenant, D.P., Cortes, C., Ewell, P., & Cuellar, N. (2017). The use of community based participatory research to assess

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perceived health status and health education needs of persons in rural and urban Haiti. Online Journal of Rural Nursing & Health Care, 17(1), 52-72. http://dx.doi.org/ 10.14574/ojrnhc.v17i1.427.

32. Flicker, S., Travers, R., Guta, A., McDonald, S., & Meagher, A. (2007). Ethical dilemmas in community-based participa- tory research: Recommendations for institutional review boards. Journal of Urban Health, 84(4), 478-493.

33. Centers for Disease Control and Prevention. (2018). Commu- nity health assessment and group evaluation (CHANGE) tool. Retrieved from https://www.cdc.gov/nccdphp/dnpao/state- local-programs/change-tool/action-steps.html.

34. National Association of County and Community Health Officials. (2018). Mobilizing for action through planning and partnerships (MAPP). Retrieved from https://www.naccho. org/programs/public-health-infrastructure/performance- improvement/community-health-assessment/mapp.

35. National Association of County and Community Health Officials. (n.d.). APEXPH. Retrieved from http://www. naccho.org/topics/infrastructure/APEXPH/index.cfm.

36. Savage, C.L., Anthony, J.S., Lee, R., Rose, B., & Kapesser, M. (2007). The culture of pregnancy and infant care African American women: An ethnographic study. Journal of Transcultural Nursing, 18(3), 215-223.

37. U.S. Census Bureau. (n.d.). Geography reference. Retrieved from https://www.census.gov/geo/reference/.

38. University of Wisconsin Population Health Institute. (2018). County health ratings. Retrieved from http://www. countyhealthrankings.org/.

39. Centers for Disease Control and Prevention. (2018). National health interview survey. Retrieved from http://www.cdc.gov/ nchs/nhis.htm.

40. Centers for Disease Control and Prevention. (2018). National health and nutrition examination survey. Retrieved from http://www.cdc.gov/nchs/nhanes.htm.

41. Centers for Disease Control and Prevention. (2018). Behavioral risk factor surveillance system. Retrieved https:// www.cdc.gov/brfss/index.html.

42. U.S. Department of Agriculture. (2017). Food access research atlas. Retrieved from https://www.ers.usda.gov/data-products/ food-access-research-atlas.aspx.

43. Centers for Disease Control and Prevention. (2016). Health- related quality of life: Methods and measures. Retrieved from http://www.cdc.gov/hrqol/methods.htm.

44. Carey, M.A. & Asbury, J-E. (2016). Focus group research. London and New York: Routledge.

45. Savage, C.L. (Ed.). (1996). Health of Lancaster County. Lancaster, PA: Lancaster Health Alliance.

46. Valiquette-Tessier, S., Vandette, M., & Gosselin, J. (2015). In her own eyes: PhotoVoice as an innovative methodology to reach disadvantaged single mothers. Canadian Journal of Community Mental Health, 34(1), 1-16. doi:10.7870/ cjcmh-2014-022.

47. Skovdal, M. (2011). Picturing the coping strategies of care- giving children in western Kenya: From images to action. American Journal of Public Health, 101(3), 452-453.

48. Beck, A.F., Sandel, M.T., Ryan, P.H., & Kahn, R.S. (2017). Mapping neighborhood health geomarkers to clinical care decisions to promote equity in child health. Health Affairs, 36, 999-1005. doi:10.1377/hlthaff.2016.1425.

49. Aronson, R.E., Wallis, A.B., O’Campo, P., & Schafer, P. (2007). Neighborhood mapping and evaluation: A methodol- ogy for participatory community health initiatives. Maternal Child Health Journal, 11, 373-383.

50. Croner, C.M., Sperling, J., & Broome, F.R. (1996). Geographic information systems (GIS): New perspectives in understand- ing human health and environmental relationships. Statistics in Medicine, 15, 17-18, 1961-1977.

51. Salehi, F., & Ahmadian, L. (2017). The application of geographic information systems (GIS) in identifying the priority areas for maternal care and services. BMC Health Services Research, 1, 482. doi:10.1186/s12913-017- 2423-9.

52. Suplee, P.D., Bloch, J.R., Hillier, A., & Herbert, T. (2018). Using geographic information systems to visualize relation- ships between perinatal outcomes and neighborhood charac- teristics when planning community interventions. JOGNN: Journal Of Obstetric, Gynecologic & Neonatal Nursing, 47, 158-172. doi:10.1016/j.jogn.2018.01.002.

53. Pennel, C.L., Burdine, J.N., Prochaska, J.D., & McLeroy, K.R. (2017). Common and critical components among commu- nity health assessment and community health improvement planning models. Journal of Public Health Management & Practice, 23, S14-S21. doi:10.1097/PHH.0000000000000588.

54. U.S. Census Bureau. (n.d.). American FactFinder. Retrieved from https://factfinder.census.gov/faces/nav/jsf/pages/index. xhtml.

55. World Life Expectancy. (2018). World population pyramid. Retrieved from http://www.worldlifeexpectancy.com/ world-population-pyramid.

56. U.S. Census Bureau. (2018). Retrieved from https://www. census.gov/.

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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.

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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)

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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.

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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.

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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.

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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.

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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.

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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

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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

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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

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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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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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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.

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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.

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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

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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.

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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.

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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.). About the community guide. Retrieved from https://www. thecommunityguide.org/about/about-community-guide.

3. Centers for Disease Control and Prevention. (2017). National public health performance standards. Retrieved from https://www.cdc.gov/stltpublichealth/nphps/index.html.

4. Fawcett, S.B. (2018). Section 3. Our model of practice: Build- ing capacity for community and system change. Retrieved from https://ctb.ku.edu/en/table-of-contents/overview/ model-for-community-change-and-improvement/building- capacity/main.

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

6. Institute of Medicine. (2002). The future of the public’s health in the 21st century. Washington, DC: National Academies Press.

7. Institute of Medicine. (2012). For the public’s health: Investing in a healthier future. Washington, DC: National Academies Press.

8. American Public Health Association: Public Health Nursing Section. (2018). Public health nursing. Retrieved from http:// 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, 21(5), 453-468.

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).

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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?

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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

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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.

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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)

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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

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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.

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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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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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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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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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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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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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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

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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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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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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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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.

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• 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)

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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.)

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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

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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)

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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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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

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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.)

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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

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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.)

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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.

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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.

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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)

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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)

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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.

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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)

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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.

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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)

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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

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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)

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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,

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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.

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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)

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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

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SD

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OK

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AR

MN

WI

IL

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TN

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AL

MA

MS

FL

KY

ID

MI

OH

GA SC

NC

WV VA

MD DE

CT

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VT

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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/)

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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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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

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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

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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

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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)

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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

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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.

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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

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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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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 vulnerable populations live in poverty and often in a community and/or country that lacks the financial re- sources to provide needed medical care. For example, low-income countries are often unable to treat strep throat due to lack of funding to do basic throat cul- tures and provide antibiotics when children present with a sore throat. Untreated strep throat can lead to rheumatic fever, which in turn can result in life-threat- ening damage to the heart valves. One group, Team Heart, composed of 40 to 60 volunteers, started by an intensive care nurse and her husband, a cardiac sur- geon, goes to Rwanda once a year to provide needed surgery to persons with rheumatic health disease.

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3. The issue of rheumatic heart disease in Rwanda ex- emplifies the upstream, midstream, and downstream approach to addressing health at the population level. Discuss this in more detail. With limited re- sources what should be the main focus when ad- dressing this issue in Rwanda?

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54. Stafford, A., & Wood, L. (2017). Tackling health disparities for people who are homeless? start with social determinants. International Journal of Environmental Research and Public Health, 14(12), 1535. http://doi.org.ezp.welch.jhmi.edu/ 10.3390/ijerph14121535.

55. U.S. Department of Health and Human Services. (2009). The McKinney-Vento Homeless Assistance Act as amended by S. 896 The Homeless Emergency Assistance and Rapid Transition to Housing (HEARTH) Act of 2009. Retrieved from http://portal.hud.gov/hudportal/documents/ huddoc?id=HAAA_HEARTH.pdf.

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77. Pager, T. (2018, Aug 22). Blame Trump’s tariffs and the weather. New York’s farmers do. The New York Times. Retrieved from https://nyti.ms/2nZ50aD.

78. National Center for Farm Worker Health. (2017). A profile of migrant health: 2016. Retrieved from http://www.ncfh.org/ fact-sheets—research.html.

79. U.S. Department of Agriculture. (2018). Farm labor housing direct loans & grants. Retrieved from https://www.rd. usda.gov/programs-services/farm-labor-housing-direct- loans-grants.

80. Wiltz, T. (2016, May 2). States struggle to provide housing for migrant farmworkers. Stateline. Retrieved from https:// www.pewtrusts.org/en/research-and-analysis/blogs/ stateline/2016/05/02/struggle-to-provide-housing-for- migrant-farmworkers.

81. National Center for Farm Worker Health. (2018). Maternal and child health. Retrieved from http://www.ncfh.org/uploads/ 3/8/6/8/38685499/fs-maternal_and_child_health_2018.pdf.

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83. U.S. Department of Justice. (2018). Immigrant and employee rights section. Retrieved from https://www.justice.gov/crt/ immigrant-and-employee-rights-section.

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86. U.S. Department of Homeland Security. (2018). Refugees and asylees. Retrieved from https://www.dhs.gov/ immigration-statistics/refugees-asylees.

87. United Nations. (2018). World Refugee Day. Retrieved from https://www.un.org/en/events/refugeeday/ background.shtml.

88. United Nations High Commissioner for Refugees. (2018). Figures at a glance. Retrieved from http://www.unhcr.org/ en-us/figures-at-a-glance.html.

89. International Rescue Committee. (2018). Breaking down the stats as the U.S. plans to cut refugee arrivals to 30,000. Retrieved from https://www.rescue.org/ article/breaking-down-stats-us-plans-cut-refugee- arrivals-30000.

90. Jonassen, M., Shaheen, A., Duraidi, M., Qalalwa, K., Jeune, B., & Brønnum-Hansen, H. (2018). Socio- economic status and chronic disease in the West Bank and the Gaza Strip: In and outside refugee camps. International Journal of Public Health, 63(7), 875–882. https://doi-org.ezp.welch.jhmi.edu/10.1007/s00038- 018-1122-6.

91. Wachter, K., Horn, R., Friis, E., Falb, K., Ward, L., Apio, C., Puffer, E., et al. (2018). Drivers of intimate partner violence against women in three refugee camps. Violence Against Women, 24(3), 286–306. https://doi-org.ezp.welch.jhmi. edu/10.1177/1077801216689163.

92. Ali, S.I., Ali, S.S., & Fesselet, J.-F. (2015). Effectiveness of emergency water treatment practices in refugee camps in South Sudan. Bulletin of the World Health Organization, 93(8), 550–558. https://doi-org.ezp.welch.jhmi.edu/ 10.2471/BLT.14.147645.

93. Walpole, S.C., Abbara, A., Gunst, M., & Harkensee, C. (2018). Cross-sectional growth assessment of children in four refugee camps in Northern Greece. Public Health (Elsevier), 162, 147–152. https://doi-org.ezp.welch.jhmi. edu/10.1016/j.puhe.2018.05.004.

94. Soykoek, S., Mall, V., Nehring, I., Henningsen, P., & Aberl, S. (2017). Post-traumatic stress disorder in Syrian children of a German refugee camp. Lancet, 389, North American Edition (10072), 903–904. https://doi-org.ezp.welch.jhmi. edu/10.1016/S0140-6736(17)30595-0.

95. Schweitzer, R.D., Vromans, L., Brough, M., Asic-Kobe, M., Correa-Velez, I., Murray, K., & Lenette, C. (2018). Recently resettled refugee women-at-risk in Australia evidence high levels of psychiatric symptoms: Individual, trauma and post- migration factors predict outcomes. BMC Med. 16(1), 149. doi: 10.1186/s12916-018-1143-2.

96. Silove, D., Ventevogel, P., & Rees, S. (2017). The contem- porary refugee crisis: An overview of mental health chal- lenges. World Psychiatry, 16(2), 130-139. doi: 10.1002/ wps.20438.

97. Centers for Disease Control and Prevention. (2014). Medical examination of immigrants and refugees. Retrieved from https://www.cdc.gov/immigrantrefugeehealth/exams/ medical-examination.html.

98. U.S. Department of Health and Human Services, Office of Refugee Resettlement. (2015). Health insurance. Retrieved from https://www.acf.hhs.gov/orr/health.

99. U.S. Department of Justice Bureau of Justice Statistics (n.d.). Total Correctional Population. Retrieved from https://www. bjs.gov/index.cfm?tid=11&ty=t.

100. Gramlich, J. (2018, May 2). America's incarceration rate is at a two-decade low. Pew Research Center. Retrieved from https://www.pewresearch.org/fact-tank/2018/ 05/02/americas-incarceration-rate-is-at-a-two-decade- low/.

101. Centers for Disease Control and Prevention. (2014). Correctional Health. Retrieved from https://www.cdc.gov/ correctionalhealth/default.htm.

102. Kaeble, D., & Cowhig, M. (2018). Correctional populations in the United States, 2016. U.S. Department of Justice Office of Justice Programs Bureau of Justice Statistics Bulletin. Retrieved from https://www.bjs.gov/content/pub/pdf/ cpus16.pdf.

103. Zeng, Z., (2018, Feb 22). Jail inmates in 2016. Office of Justice Program, Justice Bureau of Statistics. Retrieved from https://www.bjs.gov/index.cfm?ty=pbdetail&iid=6186.

104. Love, D. (2018, Feb 12). Black incarceration rates are drop- ping while white rates rise, but what’s really behind this sur- prising trend? Atlantic Black Star. Retrieved from https:// atlantablackstar.com/2018/02/17/black-incarceration- rates-dropping-white-rates-rises-whats-really-behind- surprising-trend/.

105. Wagner, P., & Sawyer, W. (2018). States of Incarceration: The Global Context 2018. Prison Policy Initiative. Retrieved from https://www.prisonpolicy.org/global/2018.html.

106. Estelle v. Gambelle, 429 U.S. 97. (1976). Retrieved from http://caselaw.lp.findlaw.com/cgi-bin/getcase.pl?court= US&vol=429&invol=97.

107. Larney, S., Zaller, N.D., Dumont, D.M., Willcock, A., & Degenhardt, L. (2016). A systematic review and meta- analysis of racial and ethnic disparities in hepatitis C anti- body prevalence in United States correctional populations. Annals of Epidemiology, 26(8), 570–578.e2. https:// doi-org.ezp.welch.jhmi.edu/10.1016/j.annepidem. 2016.06.013.

108. Skarupski, K.A., Gross, A., Schrack, J.A., Deal, J.A., & Eber, G.B. (2018). The health of America’s aging prison population. Epidemiologic Reviews, 40(1), 157–165. https://doi-org.ezp.welch.jhmi.edu/10.1093/epirev/ mxx020.

109. Turney, K., & Goodsell, R. (2018). Parental incarceration and children’s wellbeing. Future of Children, 28(1), 147–164. Retrieved from http://search.ebscohost.com.ezp. welch.jhmi.edu/login.aspx?direct=true&db=rzh&AN= 129524480&site=ehost-live&scope=site.

110. World Health Organization. (2018). Gender equity and human rights: Gender. Retrieved from http://www.who.int/ gender-equity-rights/understanding/gender-definition/en/.

111. Human Rights Campaign. (2018). Glossary of terms. Retrieved from https://www.hrc.org/resources/glossary- of-terms.

112. The Joint Commission. (2011). Advancing effective commu- nication, cultural competence, and patient- and family centered care for the lesbian, gay, bisexual, and transgender (LGBT) community: A field guide. Oak Brook, IL: Author. Retrieved from https://www.jointcommission.org/assets/ 1/18/LGBTFieldGuide.pdf.

113. Bonvicini, K.A. (2017). LGBT healthcare disparities: What progress have we made? Patient Education & Counseling, 100(12), 2357–2361. https://doi-org.ezp.welch.jhmi.edu/ 10.1016/j.pec.2017.06.003.

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114. Healthy People 2020. (2018). Lesbian, gay, bisexual, and trans- gender health. Retrieved from https://www.healthypeople. gov/2020/topics-objectives/topic/lesbian-gay-bisexual-and- transgender-health/objectives.

115. National Center for Health Statistics. (2016). Chapter 25, Lesbian, gay, bisexual and transgender health: Healthy People 2020 midcourse review. Hyattsville, MD: Author. Retrieved from https://www.cdc.gov/nchs/data/ hpdata2020/HP2020MCR-C25-LGBT.pdf.

116. Newport, F. (2018, May 22). In U.S., estimate of LGBT population rises to 4.5%. Gallup: Politics. Retrieved from https://news.gallup.com/poll/234863/estimate-lgbt- population-rises.aspx.

117. Centers for Disease Control and Prevention. (2014). Lesbian, gay, bisexual, and transgender health. Retrieved from https://www.cdc.gov/lgbthealth/about.htm.

118. Park, Y., & Mykhyalyshyn, I. (2016, June 16). L.G.B.T. people are more likely to be targets of hate crimes than any other minority group. New York Times. Retrieved from https://nyti.ms/2jSzpDG.

119. Langenderfer-Magruder, L., Walls, N.E., Whitfield, D., Brown, S., & Barrett, C. (2016). Partner violence victimiza- tion among lesbian, gay, bisexual, transgender, and queer youth: Associations among risk factors. Child & Adolescent Social Work Journal, 33(1), 55–68. https:// doi-org.ezp.welch.jhmi.edu/10.1007/s10560-015-0402-8.

120. Langenderfer-Magruder, L., Whitfield, D.L., Walls, N.E., Kattari, S.K., & Ramos, D. (2016). Experiences of intimate partner violence and subsequent police reporting among lesbian, gay, bisexual, transgender, and queer adults in Colorado. Journal of Interpersonal Violence, 31(5), 855–871. https://doi-org.ezp.welch.jhmi.edu/10.1177/ 0886260514556767.

121. Heina, L.C., Stokes, F., Smith-Greenberg, C., Saewycd, E.M. (2018). Policy brief: Protecting vulnerable LGBTQ youth and advocating for ethical health care. Nursing Outlook, 66, 505-507.

122. Clay, R. (2014). Double-whammy discrimination. American Psychological Association, Monitor on Psychology, 45(10), 46.

123. Perez-Brumer, A., Nunn, A., Hsiang, E., Oldenburg, C., Bender, M., Beauchamps, L., Mena, L., MacCarthy, S. (2018). We don’t treat your kind: Assessing HIV health needs holistically among transgender people in Jackson, Mississippi. PLoS One, 1;13(11), e0202389. doi:10.1371/ journal.pone.0202389.

124. Bauermeister, J.A., Muessig, K.E., Flores, D.D., LeGrand, S., Choi, S., Dong, W., Harper G.W., Hightow-Weidman, L.B. (2018). Stigma diminishes the protective effect of social support on psychological distress among young black men who have sex with men. AIDS Education and Prevention, 30(5), 406-418. doi: 10.1521/aeap.2018.30.5.406.

125. United States Department of Justice. (2015). Matthew Shepard and James Byrd, Jr., Hate Crimes Prevention Act. Retrieved from https://www.justice.gov/crt/matthew- shepard-and-james-byrd-jr-hate-crimes-prevention- act-2009-0.

126. American Psychiatric Association. (2015). Guidelines for psychological practice with transgender and gender nonconforming people. American Psychologist, 70, 832–864. http://dx.doi.org/10.1037/a0039906 Retrieved from https://www.apa.org/practice/guidelines/ transgender.pdf.

127. Fredriksen-Goldsen, K.I., Kim, H.-J., Shiu, C., & Bryan, A.E.B. (2017). Chronic health conditions and key health indicators among lesbian, gay, and bisexual older U.S. adults, 2013-2014. American Journal of Public Health, 107(8), 1332–1338. doi:10.2105/AJPH.2017.303922.

128. Muraco, A., & Fredriksen-Goldsen, K.I. (2014). The highs and lows of caregiving for chronically ill lesbian, gay, and bisexual elders. Journal of Gerontological Social Work, 57(2–4), 251–272. doi:10.1080/01634372.2013.860652.

129. Centers for Disease Control and Prevention. (2016). HIV Surveillance Report, 2015; vol. 27. Retrieved from http://www.cdc.gov/hiv/library/reports/hiv-surveillance. html.

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191

Chapter 8

Communicable Diseases Michael Sanchez and Christine Savage

LEARNING OUTCOMES

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

KEY TERMS

1. Apply the cycle of transmission to specific communicable diseases.

2. Describe the steps in an outbreak investigation. 3. Investigate the role of culture and environment in the

management of an epidemic.

4. Discuss current issues related to emerging communicable diseases.

5. Describe the role of the nurse in the prevention and treatment of hospital- and community-acquired infections.

Active immunity Agent Antigenicity Attack rate Carrier Case fatality rate Cellular immunity Chronic carrier Colonization Common source Community immunity Continuous source

Convalescent carrier Endemic Environment Epidemic Epidemic curve Epidemic threshold Generation time Herd immunity Host Humoral immunity Immunity Inapparent carrier

Incubating carrier Index case Infectivity Inherent resistance Intermittent source Outbreak investigation Pandemic Passive immunity Pathogen Pathogenic Pathogenicity Point source

Reservoir Resistance Secondary attack rate Secondary case Sexually transmitted

disease Susceptibility Toxigenicity Vaccine Vector Virulence

n Introduction Communicable diseases (CDs) make national headlines on a regular basis. There was an outbreak of Zika virus that placed fetuses at risk for adverse outcomes. In the U.S., there were 116 live infants with Zika-related birth defects and 9 pregnancy losses due to Zika-related defects.1 In May 2018, an Ebola outbreak in the Democratic Republic of Congo in a less remote area brought concerns of a wider outbreak.2 In June of 2018, an outbreak of Salmonella Adelaide infec- tions related to pre-cut melon affected 60 people in 5 states.3 These headlines demonstrate the very real threat of CDs in today’s world as a result of both acute outbreaks and the long-term adverse effects of chronic infection.

CDs have plagued humankind throughout recorded history. As recently as the first part of the last century, CDs were the leading causes of death. In the 1950s and 1960s, chickenpox, measles, and mumps were endemic

in school-age children. With the advent of antibiotics and vaccines, CDs were no longer the primary killer of humans with a resulting increase in life expectancy. In the 1980s, the effectiveness of vaccines and antibiotics led some health-care providers to predict that CDs would be eliminated in many sections of the world, especially after the successful eradication of smallpox worldwide.4 While these pronouncements were being made, a new CD emerged, AIDS caused by HIV. During this period, other diseases emerged such as those caused by the Ebola fam- ily of viruses and the Zika virus. At the same time the predicted decline in the incidence of other CDs, such as tuberculosis (TB), did not occur.

In the 21st century, CDs are a main reason for mor- bidity and mortality in the United States and the world. In the United States, acute respiratory infections, includ- ing influenza and pneumonia, are listed in the top 10 leading causes of death.5 In low-income countries, 5 of

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the 10 top leading causes of death are related to CD.6 For lower-middle-income countries, 3 of the top 10 leading causes of death are related to CDs. For upper-middle- income countries and high-income countries, acute res- piratory diseases are the only CDs on the list of the top 10 causes of death (Table 8-1).6

A major responsibility of public health officials from the local to the global level is to conduct surveillance to deter- mine whether there is a CD epidemic that threatens the health of populations. The surveillance in turn can help de- termine what if any action will be necessary to stop an epi- demic. The term epidemic is the combination of two Greek terms, epi (upon) and demos (people), and has the same roots as the term epidemiology (see Chapter 3). At first the term epidemic was used to describe a collection of illnesses based on their characteristics such as diarrhea or cough,

but with the arrival of the Black Death (bubonic plague) in Europe, the word was used to describe the increased oc- currence of a single disease.7 In the 21st century, the term epidemic is used when there is a significant increase in number of cases than would normally occur. Endemic refers to the usual number of cases of a disease that occur within a population. At the other end of the spectrum, pandemic describes epidemics occurring across the globe.

Communicable Diseases and Nursing Practice CDs are a public health issue and an important concern for nurses working in the community and in acute care settings. Nurses are confronted with CDs on a constant

192 U N I T I I n Community Health Across Populations: Public Health Issues

TABLE 8–1 n Top 10 Leading Causes of Death by Level of Income

Lower Middle Upper Middle High Cause of Death Low Income Income Income Income

Lower respiratory disease

Diarrheal diseases

Ischemic heart diseases

HIV/AIDS

Stroke

Malaria

Tuberculosis

Preterm birth complications

Birth asphyxia and birth trauma

Road Injury

Chronic obstructive pulmonary disease

Diabetes mellitus

Cirrhosis of the liver

Trachea, bronchus, and lung cancers

Alzheimer’s disease and other dementias

Liver cancer

Stomach cancer

Colon and rectal cancers

Kidney diseases

Breast Cancer

Number 1

Number 2

Number 3

Number 4

Number 5

Number 6

Number 7

Number 8

Number 9

Number 10

Number 6

Number 1

Number 2

Number 5

Number 8

Number 4

Number 3

Number 7

Number 9

Number 10

Number 6

Number 1

Number 2

Number 8

Number 3

Number 7

Number 4

Number 5

Number 9

Number 10

Number 3

Number 6

Number 1

Number 2

Number 5

Number 8

Number 10

Number 4

Number 7

Number 9

(See WHO; http://www.who.int/news-room/fact-sheets/detail/the-top-10-causes-of-death for updates.) Source: (6)

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basis. Nurses provide care to patients with a CD and also must incorporate preventive measures in their practice, such as the use of personal protective equipment (PPE) and proper cleaning of patient areas to prevent transmis- sion of these diseases to themselves, co-workers, and other patients. These practices protect individuals and populations. For the practicing nurse, an understanding of CDs at both an individual level and a population level is essential. If the nurse only focuses on caring for the pa- tient with a CD without considering the implications for the population, the care falls short and potentially en- dangers others.

The key to all these activities is to understand the in- fectious agents that cause disease, the environment rele- vant to the transmission of disease from one person to another, and who is at risk for becoming infected. Pro- fessional nurses back up their interventions related to the prevention and treatment of CDs with knowledge of the public health science behind these interventions. In the same way that nurses do not dispense medications without understanding the pharmacokinetics behind the medications, nurses cannot intervene in relation to CDs without understanding the science behind these diseases.

Public health science provides the basis for understand- ing how CDs have an impact on the health of humans. Professional nurses armed with scientific knowledge re- lated to infectious agents can intervene in ways that reduce the risk for not only their individual patients and them- selves but also for the larger population they serve, with prevention the primary goal.

Communicable Disease and the Burden of Disease Twenty-first-century improvements in technology and transportation have brought populations closer together and eliminated geographical barriers to transmission of disease. This increases the possibility of spreading CDs that in the past may have been contained in one geo- graphical area. This chapter provides an overview of the CDs that are leading causes of death with a focus on in- cidence and prevalence in the United States.

Infectious Respiratory Disease Many agents are associated with respiratory disease (Box 8-1). These diseases are either bacterial or viral. Many of these diseases can be prevented through vacci- nation. Children are required to receive vaccination for many CDs before attending public schools, such as vaccines for prevention of chickenpox, diphtheria, and rubella. A new policy for most health-care settings is to

require that all employees receive an annual flu vaccine. Because of vaccination programs across the United States and other countries, the incidence of many communi- cable respiratory diseases is declining. Despite these advances, respiratory disease caused by infectious agents continues to be a significant public health issue. Some of these diseases are seasonal, for example, in- fluenza (flu). Many have a higher morbidity and mor- tality rate in vulnerable populations, such as older adults and children.

Influenza, or flu, is a communicable respiratory dis- ease and is a major public health concern. Flu is seasonal, with a peak in early December and a peak in February. Because of the higher mortality rate in vulnerable popu- lations such as children, older adults, and those who are already ill, many hospitals require that all employees re- ceive a flu vaccination. The CDC publishes a report titled FluView that follows trends in flu across the year. Trends in flu vary from year to year. In 2009–2010, there was a pandemic outbreak of H1N1 influenza that peaked ear- lier in October, which resulted in an estimated midrange of 61 million cases, 240,000 hospitalizations, and 12,470 deaths. Then the following 2011–2012 flu season was the mildest season on record.8 In 2015-2016 H1N1 re- emerged as the predominant virus for the season.9 Unlike the 2009-2010 season, the peak month for flu activity was January (Fig. 8-1). 10

Malaria Malaria is a subtropical disease caused by a parasite, the intraerythrocytic protozoa of the genus Plasmodium transmitted through the bite of an infected female

C H A P T E R 8 n Communicable Diseases 193

Chickenpox Diphtheria Group A Streptococcus Haemophilus influenzae type b Influenza Legionnaire’s disease Measles (rubeola) Mumps Pneumococcal meningitis German measles (rubella) Tuberculosis Whooping cough (pertussis) Anthrax Hantavirus pulmonary syndrome Plague

BOX 8–1 n Respiratory Communicable Diseases that Can Infect the Respiratory System

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Anopheles gambiae mosquito, often referred to as the “malaria vector”.11 About half of the world’s population is at risk for malaria. According to the World Health Or- ganization (WHO), in 2016, an estimated 445,000 deaths, mostly African children, were caused by malaria.12 The estimated number of cases in 2016 was 216 million worldwide, an increase of 5 million from the year prior.12

By comparison, in 2014, in the United States, there were 1,724 cases of malaria with 5 fatalities.13 Malarial infec- tions in the United States are primarily the result of ex- posure that occurred during travel abroad. In addition, these travelers had not adhered to recommended malaria prophylaxis. Malaria is a preventable disease, and much is being done globally to eradicate it. Globally, the eco- nomic and social burdens affect both individuals and governments including the cost of care, lost work, and burial expenses. Direct costs (for example, illness, treat- ment, premature death) have been estimated to be at least U.S. $12 billion per year.14

Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS) HIV impairs and destroys the immune cells in the infected person’s body, affecting the ability to fight off infection. A person infected with HIV may not develop AIDS until 10 to 15 years after the initial infection.15 HIV/AIDS status is classified across five stages: 0, 1, 2, 3, unknown. A negative HIV test within 6 months of the first HIV infection diag- nosis is stage 0 and remains 0 until 6 months after diag- nosis. If a stage-3-defining opportunistic illness has been diagnosed, the stage is 3 (Box 8-2). Otherwise, the stage is determined by the CD4 test immunologic criteria based on the CDC case definition guidelines.15 According to UNAIDS, HIV has killed 35 million people over the past 3 decades, and, in 2016, an estimated 36.7 million people

were living with HIV/AIDS worldwide, with 1.8 million new cases in 2016.16 In the United States, an estimated 1.1 million people are living with HIV/AIDS. In 2016, in the U.S., 39,782 persons were newly diagnosed with HIV/AIDS, and nearly 15% of those infected with HIV are unaware they are infected.17,18

In the U.S., the prevalence of HIV and AIDS is higher among persons in the 25- to 44-year-old age group, those who are African American and Hispanic, and in men. Racial disparity is especially apparent in children, with 80% of all pediatric cases being African American or His- panic.17,18 HIV infection is also on the rise among older adults because of increased longevity of those living with HIV as well as an increase in risky behaviors in this age group.19 Certain behaviors increase the risk for transmis- sion of HIV, including men having sex with men, those engaging in injection drug use, and those engaging in un- protected sex. There is also variation in the distribution of cases geographically. The South has the highest num- ber of people living with HIV, whereas the highest rates of new infections occurred in California, Florida, Texas, New York, and Georgia.20

Healthy People (HP) has a specific topic related to HIV/AIDS.21 The objectives related to the topic not only address disparity but also prevention, screening, and treatment.

194 U N I T I I n Community Health Across Populations: Public Health Issues

Peak Month of Flu Activity 1982–1983 through 2015–2016

Octo be

r

Nov em

be r

Dec em

be r

Ja nu

ar y

Fe br

ua ry

M ar

ch Apr

il M

ay

16

1 1

7 5

14

6

0 0

14 12 10 8 6 4 2

Figure 8-1 Peak flu activity. (Data source reference 10.)

HIV infection is classified as stage 3 (AIDS) when the immune system of a person infected with HIV becomes severely compromised (measured by CD4 cell count) and/or the person becomes ill with an opportunistic infection. In the absence of treatment, AIDS usually develops 8 to 10 years after initial HIV infection; with early HIV diagnosis and treatment, this may be delayed by many years.

BOX 8–2 n CDC: Definition of Stage Three HIV Infection/AIDS

n HEALTHY PEOPLE HIV

Goal: Prevent human immunodeficiency virus (HIV) infection and related illness and death. Overview: HIV infections in the United States con- tinue to be a major public health crisis. An estimated 1.2 million Americans are living with HIV, and 1 out of 8 people with HIV do not know they have it. Although recent data show that annual HIV infections declined

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UNAIDS 909090 Along with the HP goals related to HIV/AIDS are the 2014 UNAIDS goals related to the AIDS epidemic titled UN AIDS 909090: An ambitious treatment target to help end the AIDS epidemic. They have since published a midcourse review as well.

The three main goals by 2020 were:

• 90% of all people living with HIV will know their HIV status.

• 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy.

C H A P T E R 8 n Communicable Diseases 195

Little or no change Improving Met or exceeded

30%

50%

20%

Healthy People 2020 Midcourse Review: HIV

Figure 8-2 Healthy People 2020 Midcourse Review: HIV. (Data source reference 22.)

18% in the U.S. from 2008 to 2014, HIV continues to spread.

In 2010, the White House released a National HIV/AIDS Strategy. The National HIV/AIDS Strategy was updated to 2020 (NHAS 2020) in July 2015. The strategy includes three primary goals:

1. Reducing new HIV infections. 2. Increasing access to care and improving health

outcomes for people living with HIV. 3. Reducing HIV-related disparities and health

inequities.22

Midcourse Review: Of the 27 objectives under the topic of HIV in Heathy People 2020, 11 were measura- ble. Of these, two exceeded or met targeted goals, five were improving, three had little or no change, and one was baseline only (Fig. 8-2). For persons aged 13 or older, there was no change in the number of new infections.23

• 90% of all people receiving antiretroviral therapy will have viral suppression.24

Midcourse Review 2016: • 70% of all people living with HIV knew their

HIV status. • 77% of all people with diagnosed HIV infection were

on sustained antiretroviral therapy. • 82% of all persons on treatment were virally

suppressed.25

Diarrheal Disease Diarrhea is defined by the WHO as the passage of three or more loose or liquid stools per day. There are approx- imately 2 billion cases of diarrheal disease worldwide each year.26 In low-income countries, it is a leading cause of death among children. In 2017, the WHO esti- mated that 525,000 deaths in children under the age of 5 were caused by diarrhea.27 The most common route for transmission of diarrheal disease is the fecal-oral route. Good hand hygiene, especially hand washing, and soap alone can reduce the incidence of diarrheal disease by as much as 48%.28 Efficient sanitary systems and safe drinking water also play a huge role in preventing diar- rheal diseases.

Pathogens that cause diarrheal disease include viruses, bacteria, and protozoa. Transmission is usually waterborne (e.g., cholera), foodborne (e.g., Escherichia coli [E. coli]), or through person-to-person contact; pathogens can infect the small bowel, the colon, or both.29 Worldwide, rotavirus is the most common cause of diarrheal disease among children, accounting for al- most 40% of all cases of infant diarrhea and is responsi- ble for a half million deaths in children under 5 years old.26 Until recently, infections with rotavirus among children under the age of 5 resulted in up to 70,000 hos- pitalizations and 60 deaths annually. In 2006, a vaccine was introduced that has helped reduce the incidence of this disease. There are now two vaccines available for use with infants. Since the introduction of these vaccines, the incidence of rotavirus-associated diarrheal infec- tions in children has declined.30

Emerging and Re-emerging Communicable Diseases The WHO defines an emerging disease as “one that has appeared in a population for the first time, or that may have existed previously but is rapidly increasing in inci- dence or geographic range.”31 Through public health efforts, some CDs are close to eradication, for example, polio mellitus and dracunculiasis (guinea worm disease),

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or have been eradicated, as in the case of smallpox. Yet, at the same time, new CDs have emerged such as severe acute respiratory syndrome (SARS), West Nile virus, and the Zika virus. Other diseases, such as malaria, TB, and bacterial pneumonias, are reemerging in forms that are resistant to drug treatments, for example, multidrug- resistant tuberculosis (MDRTB).33 New diseases are emerging at a rate of one per year. In the 21st century, emerging CDs continue to make global headlines such as the Zika virus. Response to such diseases results in a bur- den on the economic, social, and health-care systems of countries. Pandemics such as the SARS outbreak and epi- demics within countries such as the West Nile virus epi- demic in the summer of 2012 required a coordinated early response across political entities such as countries or states.

Tuberculosis TB is an infectious disease caused by the Mycobacterium tuberculosis. It has been called many names, including white death, the great white plague, and consumption. The word consumption is even found in the Bible. It wasn’t until the end of the 19th century that the disease received the name tuberculosis after the agent that caused the dis- ease was identified. In 1889, the National Tuberculosis Association (now the National Lung Association) real- ized that TB was preventable and not inherited. Since that time, prevention efforts have resulted in a steady downward trend in the incidence and prevalence of TB, so much so that 100 years later, in 1998, a TB elimination project was initiated in the United States with the target date of 2010 for TB elimination. Although this has not occurred, the downward trend in TB incidence and prevalence is encouraging. The WHO End Strategy and the United Nations’ Sustainable development goals also have the goal of ending the global TB epidemic. These organizations aim to have a 90% reduction in TB deaths and 80% reduction in TB incidence.34,35 In the U.S., continued efforts are needed to address the disparity in incidence between U.S.-born and foreign-born individ- uals as well as between whites and minorities.35

Back in 1988, infection control experts were optimistic that the elimination of TB was a realistic goal. Unfortu- nately, at the same time, reports began to emerge of hospital-acquired MDRTB outbreaks. Between 1988 and 1992, five clusters of TB cases appeared in six hospitals. Four occurred in New York City, one in Florida, and one in New York State. What stood out about these cases was that the agent M. tuberculosis had mutated (changed) and was now resistant to drugs used to treat active TB. Sur- veillance was initiated that identified more patients who met the case definition of MDRTB. Upon investigation,

some issues emerged. First, most of the patients were also infected with HIV. With HIV, TB does not always present in a classic manner, and diagnosis was delayed in these cases. In addition, recognition of drug resistance was hampered by the length of time it took to complete the drug susceptibility tests. The case fatality rate (CFR) was high. A CFR is determined by taking the number of fatal cases and dividing it by the total number of cases. Within 16 weeks of diagnosis, 72% to 89% of patients had died.36

Since that time, dramatic changes have taken place in acute care settings including strict Occupational Health and Safety Administration (OSHA) guidelines.

Globally, in 2015, there were 10.4 million new cases of TB and 1.4 million TB deaths in HIV-negative per- sons, and an additional 0.4 million deaths due to HIV- associated TB.34 In 2015, in the United States, there were 9,577 reported cases of TB with an incidence rate of 3.0 per 100,000. Overall, both the prevalence and incidence of TB are decreasing, albeit at a slow rate of 3% per year.37

It was estimated that the rate of decline would need to accelerate to a 4%-5% annual decline to achieve the End TB Strategy by 2020. The number of new cases in 2015 in the United States was the lowest since 1953. However, the national goal to eliminate TB (less than 0.1 case per 100,000 population) was not met.37

The story of TB rates in the United States illustrates the importance of following trends of CDs. As men- tioned earlier, many CDs must be reported to the health department. This information is electronically forwarded from all 50 states and the District of Columbia to the CDC. The CDC follows these trends of data over time. On the surface, this is a simple process in that the total number of cases is followed by year. However, just know- ing the number of cases does not provide the CDC with additional information needed to protect the health of the public. Through careful surveillance of TB, the CDC can determine who is at greatest risk based on numerous factors including race, age, geographical location, and place of birth. The CDC can then examine whether the goal of eliminating TB is being met, and if not, where it needs to concentrate its efforts to meet the goal.

196 U N I T I I n Community Health Across Populations: Public Health Issues

w SOLVING THE MYSTERY The Case of the Wandering Patient In February 2002, a 42-year-old man with HIV and schizophrenia was admitted twice to one hospital for fever and unproductive cough. Chest radiographs were read as normal, and a sputum culture was negative for M. tuberculosis. In April, he was admitted to another

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Infectious Agents and the Cycle of Transmission Public health departments are charged with protecting the population at large from the spread of infection. This requires understanding the cycle of infection. The key components of the cycle of infection begin with the epi- demiological triangle, which includes the three main con- structs needed for disease to occur in humans: the agent, the environment, and the host (see Chapter 3, Fig. 3-2). In CDs, the epidemiological triangle is expanded to help understand the cycle of transmission of the infectious agent from the reservoir to the host (Fig. 8-3).

Agent Characteristics The term agent or pathogen refers to the infectious or- ganism that causes the disease such as a virus or bacteria. Knowledge of agent characteristics begins with a review of the six general categories of pathogens based on the biological properties of the pathogens (Table 8-2). The

C H A P T E R 8 n Communicable Diseases 197

hospital with similar symptoms, treated with antibiotics, and released. Three days later he was readmitted and treated for suspected pneumonia. However, his stool culture came back positive for M. tuberculosis. A subse- quent acid-fast bacillus (AFB) smear test was 4+, indi- cating that he was highly infectious. Although he was placed in isolation, he continued to have contact with other patients and hospital personnel because of a lack of vigilance on the part of the staff to observe strict iso- lation procedures, with serious consequences.38

The investigation into this case started with identify- ing the index case, that is, the first case identified in a particular outbreak. Because the normal mode of transmission is airborne from person to person, identi- fying the index patient provides the investigators with the starting point for their investigation. The investiga- tors working on this case identified this 42-year-old man as the index case.

Their next step was to identify secondary cases, that is, patients who were diagnosed with active TB and who had contact with the index patient. Five secondary cases were identified; one had diabetes and HIV, one had diabetes, two had end-stage renal disease, and one was a phlebotomist. The first two steps of the investiga- tion were now complete, identifying the index patient and secondary patients, but the investigation did not stop there. Because the index patient’s sputum came back with a 4+ AFB smear, there was a high level of in- fectivity, that is, anyone who came in contact with the patient was probably exposed to a high level of the M. tuberculosis bacillus. If that were the case, then everyone who came in contact with the patient would be at risk.

The next step in the investigation was to identify all contacts. With some agents, once humans are infected the incubation period prior to the occurrence of symp- toms is short and can last less than a week. In others, it might be a little longer and last up to 3 months, as with syphilis. With TB, a person can become infected and show no sign of disease for decades. This is known as latent TB. The investigators identified a total of 1,045 contacts, both patients and employees of the hospital. They were able to test close to two-thirds of all these contacts. Eleven percent of the tested employees tested positive, and 23% of the tested patients tested positive. Those who tested positive were provided appropriate interventions to prevent development of the disease.38

This case illustrates the challenges faced in identi- fying the presence of an active infection and the urgency of taking measures to prevent further spread of the infection. The investigation focused on three

stages: (1) identification of the index patient; (2) find- ing secondary cases; and (3) investigation of contacts. The report included recommendations for hospital in- fection control programs. The patient had been placed in isolation, and the investigators established that the isolation room was in accordance with appropriate isolation procedures. However, the patient came into contact with other patients, so the possibility is raised that the patient did not remain in his room.38

This case highlights the issue of isolation procedures in health-care agencies (see Chapter 14). The type of isolation is based on the cycle of transmission. Nurses are required to institute appropriate isolation proce- dures based on the known or suspected agent. These procedures are public health interventions aimed at preventing the spread of disease in three populations (other patients, employees, and community visitors). For airborne agents such as the bacterium that causes TB, isolation procedures involve preventing the spread of the agent through the hospital ventilation system, thus the need for negative pressure rooms. A negative pres- sure room is used in hospitals when respiratory isola- tion is needed. The ventilation system uses negative pressure so that air can come into the room but does not go back out into the building and is instead venti- lated to the outside. Choosing the right level of isola- tion requires knowing how the agent is transmitted to humans (person-to-person, airborne, etc.).

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categories include bacteria, rickettsia, viruses, mycoses (fungi), protozoa, and helminths. Also grouped with these agents are arthropods, parasitic insects that in themselves do not cause disease but transmit disease (e.g., ticks, fleas, and mosquitoes). This category also in- cludes head, body, and pubic lice, though only body lice are known to transmit disease. The other two types of lice are included, because scratching from lice can result in a secondary bacterial infection of the skin and because lice are transmitted from human to human.

Once the class of the pathogen is known, the specific characteristics of the category provide further necessary information. For example, if the pathogen is a helminth, it is a parasitic worm. This relates directly to the biolog- ical characteristics of the group of pathogens. Knowing the class of pathogen can help with the care of the indi- vidual patient. For example, because general antibiotics work with bacteria but not with viruses, knowing the

198 U N I T I I n Community Health Across Populations: Public Health Issues

Reservoir

Portal of Entry

Etiological Agent

Susceptible Host

Portal of Exit

Mode of Transmission

Figure 8-3 The cycle of communicable disease transmission.

TABLE 8–2 n Types of Infectious Agents

Category Type of Agent Examples of Diseases

Bacteria

Rickettsia

Viruses

Mycoses

Protozoa

Helminths

Anthropods

Microorganism, unicellular Either gram-positive or gram-negative

Though in a separate class, they are a genus of bacteria that grows in cells. They are structurally similar to gram-negative bacteria

A submicroscopic organism with a protein coat that are a piece of genetic material (RNA or DNA) are microorganisms. They are unable to grow or reproduce outside a host cell.

A disease caused by fungi

Single-celled animals such as flagellates, amoeboids, sporozoans, and ciliates

Parasitic worm-like organisms that feed off living hosts

Insects that act as vectors and transmit the agent from its reservoir to its host.

Bacterial meningitis Anthrax Bubonic plague Tuberculosis Streptococcal infections

Typhus Rocky Mountain spotted fever

HIV Common cold Influenza

Candida Histoplasmosis Fungal meningitis

Malaria Giardia Toxoplasmosis Trichomoniasis

Hookworm Pinworm Trichinosis

Malaria Dengue fever Lyme disease Bubonic plague

Source: Friss, R.H., & Sellers, T.A. (2014). Epidemiology for public health practice, (5th ed.) Burlington, MA: Jones & Bartlett.

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class of the pathogen can help to determine whether the patient should receive an antibiotic or an antiviral.

In addition to the class of the agent, other character- istics of the agent are helpful to understand. The first characteristic is the infectivity of the agent. This reflects the capacity of an agent to enter and multiply in the host. Some agents have low infectivity, meaning either they have a decreased capacity to enter a human host and/or they have a decreased capacity to multiply once they are in the human host. The next characteristic of an agent is its pathogenicity, which is the capacity of the agent to cause disease in the human host. Not all infectious agents have the same capability to cause disease.

Toxigenicity is another key issue with an infectious agent and reflects the pathogen’s ability to release tox- ins that contribute to disease within the human host. Not all agents release toxins. There is also variability among agents in relation to their resistance to survive environmental conditions. For example, HIV survives for only a short time outside its host (the human body), whereas anthrax can survive for decades in the soil or in warehouses where untreated animal hides have been processed.

Another important characteristic of the agent is virulence, which is defined as the ability of the pathogen to cause disease. Finally, agents differ on antigenicity, that is the ability of the agent to produce antibodies in the human host. For example, prior to the arrival of vaccines, parents attempted to expose their children to infectious parotitis (mumps). Because a case of mumps usually results in the development of antibodies, the par- ents hoped their children would develop immunity to mumps during childhood because the disease can cause serious complications in adults. Thus, mumps virus has a high level of antigencity.

Environmental Characteristics Reservoir The environment refers to the conditions external to the host and the agent associated with the transmission of the agent. The first of these is the reservoir, or where the agent resides. For most CDs, the reservoir is a human (the agent resides in an infected human). An- other common reservoir is animals, and these CDs are known as zoological diseases (e.g., Lyme disease and anthrax). For Lyme disease, the agent is a spirochete, Borrelia burgdorferi, and the reservoir is both animals and humans. For anthrax, the reservoir is also animals, including elephants, hippopotami, cattle, sheep, and goats; in spore form, the reservoir is soil exposed to the feces of these animals. Reservoirs also include water

(waterborne diseases), food (foodborne diseases), and the air (airborne diseases).

The human reservoir can be a person who is acutely ill or someone who is a carrier, that is, a human who is infected but who has no outward signs of disease. There are four main types of carriers: an incubating carrier, an inapparent carrier, a convalescent carrier, and a chronic carrier. An incubating carrier is someone who has been infected but has not yet shown signs of the disease. An inapparent carrier is someone who is infected but does not develop the disease, yet continues to shed the agent, such as Typhoid Mary (Box 8-3). A convalescent carrier is a person who is infected but who no longer shows signs of acute disease. The chronic carrier remains infected with the agent with no sign of disease for a long period of time.

Mode of Transmission The next consideration is the mode of transmission, the method through which the agent leaves its reservoir and enters its host. Transmission can occur through water, food, air, vectors, fomites, unprotected sexual contact, or penetrating trauma (Table 8-3). Vectors are usually

C H A P T E R 8 n Communicable Diseases 199

Mary Mallon worked as a cook and had no idea that she was an inapparent carrier of typhus. She was the first identified “healthy carrier” of typhoid fever in the United States. She worked in several households between 1900 and 1907. During that time, members in each household came down with typhus. She even nursed those who were sick, continuing to spread the disease. Although public health officials explained to her the reason she needed to be quarantined, she did not believe that she could spread the disease. Because of her disbelief, she escaped from her quarantine and went back to working as a cook. When she was once again apprehended, she was taken to North Brother Island near New York City and remained there for 3 years. She was released when she promised not to work as a cook. She worked as a laundress for a period of time, but the wages were low, so she changed her name and once again took a job as a cook, this time at New York’s Sloane Hospital for Women. She infected 25 people and one died. She was apprehended again by authorities and spent the rest of her life on North Brother Island. Her name has become synonymous with the healthy carrier of disease.

BOX 8–3 n Typhoid Mary

Source: Leavitt, J.W. (1996). Typhoid Mary: Captive to the public’s health. Boston, MA: Beacon Press.

For more information, watch the PBS special The Most Dangerous Woman in America: http://www.pbs.org/wgbh/nova/typhoid/

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insects that carry the disease from the reservoir to hu- mans without becoming ill themselves. A fomite is an inanimate object. An infected host touches the object and sheds the agent onto the object. The agent is then trans- mitted to the next person who touches the object. Possi- ble fomite transmission of the cold or the flu virus is used by marketers to sell their disinfecting products.

Life Cycle of an Infectious Agent The two aspects of the environment, reservoir and mode of transmission, are best illustrated through a review of the life cycle of an infectious agent. The life cycle provides essential information on the environment and how an agent goes from its normal reservoir to the host, known as the mode of transmission. Some agents have complex

life cycles, such as the human hookworm (Ancylostoma duodenale or Necator americanus) (Fig. 8-4).39 For other agents the life cycle of the vector is more important than the agent’s own life cycle, as in the case of the agent re- sponsible for Lyme disease, B. burgdorferi. A vector transmits the agent without becoming infected itself. The reservoir for B. burgdorferi includes mice, squirrels, and other small animals. This is where the agent resides. The blacklegged tick then transmits the agent among these animals to humans by biting an animal infected with the agent (the reservoir) and then biting a human. The black- legged tick has a 2-year life cycle. This life cycle, rather than the life cycle of the agent, provides the environmen- tal information needed to develop prevention programs. The tick feeds on small animals in the larval and nymphal

200 U N I T I I n Community Health Across Populations: Public Health Issues

TABLE 8–3 n Types of Transmission

Examples of Breaking the Cycle Type of Transmission Examples of Transmission

Fomite transmission: An inanimate object carries the

pathogen from the reservoir to the host.

Aerosol or airborne transmission: The agent is contained in aerosol

droplets and is transferred from one human to another or animal to human.

Oral transmission: The agent is transferred through

food or water.

Vector borne transmission: An insect acquires the agent from

an animal and transmits it to another.

Zoonotic transmission: The agent is transmitted directly

from animals to humans.

Person-to-person transmission: The agent is transmitted through

direct contact between persons, usually through contact with mucous membranes, blood, or saliva. It also occurs through venereal and in utero routes.

Transferring of viruses on the surface of inanimate objects such as a phone. Transferring of lice through exchange of clothing. Using a cutting board for meat products and then vegetables without cleaning the board in between use.

Transferring of the agent through the air, usually after the human host expels droplets into the air by coughing or sneezing.

Ingestion of food or water contaminated with the agent such as cholera in untreated water and E. coli through the ingestion of contaminated beef

Fleas, ticks, and mosquitoes are common vectors of agents to humans.

Dogs, sheep, pigs are common sources of direct transmission from animals to humans such as hookworm or rabies.

Decontamination of the fomite through the use of disinfectants or proper cleaning.

Use of negative pressure rooms in hospitals and personal protective equipment such as facemasks.

Eradication of the agent through cleaning of the water supply, implementation of food processing regulations, proper cooking of foods, hand hygiene.

Eradication of the vector such as control of mosquito breeding grounds, use of insect repellent, and mosquito netting.

Vaccination of the animal.

Vaccination such as the hepatitis B vaccine, use of personal protective equipment.

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stage and on deer in the adult stage. During the nymphal stage, the tick is most aggressive and more apt to bite the host. The tick’s life cycle explains what seasons of the year humans can become infected and clarifies the mode of transmission.

The life cycle of the agent or the vector provides added information on the transmission of an infectious agent, including how the agent exits its reservoir (portal of exit), the mode of transmission (water, vector, fomite, etc.), and how the agent enters the host (the portal of entry). For example, the agent that causes TB, M. tuberculosis, primarily infects the lungs; thus, the portal of exit is coughing. The action of coughing expels the agent from the reservoir (human) into the air. The agent has now left its reservoir and is contained in the droplets expelled from the lungs. The mode of transmission is through the air, so TB is considered an airborne disease. The portal of entry for TB is almost always through the host’s res- piratory system (the host breathes in the droplets that contain the agent and inhales them into the lungs).

Host Characteristics The final aspect of the cycle of transmission is the host. The host is the human who is at risk for disease due to exposure to the agent. The main characteristic is the sus- ceptibility of the host, that is, the likelihood of becoming infected with the agent. This is expressed in terms of the host’s immunity, or resistance to the disease.

Immunity There are two types of immunity, humoral and cellular. Humoral immunity means that the host carries antibod- ies to the agent in the blood, and cellular immunity is

specific to each type of cell. Immunity is passive or active. When a person has passive immunity, immunity is transferred from one individual to another. It can occur naturally or artificially and lasts for only a short time. Passage of immunity from the mother to her infant is an example of natural passive immunity. Artificial passive immunity involves the transfer of antibodies and can be done in various forms. Active immunity is acquired through exposure to the agent. It is long-lasting and can last for life, as when a person who had mumps as a child remains immune for the rest of his life.

Inherent Resistance Another measure of the host’s level of susceptibility is in- herent resistance. This is the ability of the host to resist the disease independent of antibodies. It can be inherited or acquired and is often linked to health status and is tempo- rary rather than permanent. Even if exposed to the agent, the host does not become ill due to her own ability to resist the disease because of other factors that boost the body’s ability to resist the disease, such as adequate nutrition.

Colonization Another host characteristic is colonization. In this case, a person is infected with the agent but has no signs of in- fection. This term is mentioned frequently in acute care settings in relation to multiple drug resistant agents such as methicillin-resistant Staphylococcus aureus. Patients are admitted with no signs of infection but are colonized with a serious multidrug-resistant pathogen. Colonized hosts are able to spread the disease despite not being ap- parently ill.

Breaking the Chain of Infection When clinical signs and symptoms are present, the host is not only infected, but disease has now occurred. The cycle of transmission is complete. The agent has travelled from the reservoir to the new host and has caused dis- ease. For the nurse, understanding the cycle of transmis- sion for a specific pathogen can guide the type of intervention developed to break the chain of infection. Interventions can be aimed at any point in the cycle of transmission. For example, with the outbreak of the Zika virus in the summer of 2016, Florida attempted to break the cycle of infection by eradicating the vector, the Aedes aegypti mosquito, through application of pesticides. The use of mosquito nets in malaria-prone areas attempts to block the mode of transmission by placing a barrier between the portal of exit and the portal of entry.

One of the key components in breaking the chain of transmission is to reduce the susceptibility of the host.

C H A P T E R 8 n Communicable Diseases 201

= Infective Stage = Diagnostic Stage

i

d

Adults in small intestine

Eggs in feces

Rhabditiform larva hatches

Filariform larva

Filariform larva penetrates skin

http://www.dpd.cdc.gov/dpdx

5

1

2

3

4

i

d

Figure 8-4 Life cycle of the hookworm.

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the sudden increase in the incidence of a CD. Conducting an outbreak investigation requires solving the mystery, similar to what a detective does in solving a murder case. With CDs, though, solving the mystery always involves more than knowing “whodunit.” In the game Clue, the winning player announces their final conclusion that it was, for example, Mrs. White who did it in the parlor with the lead pipe, based on a process of elimination. Unlike Clue, a CD outbreak investigation requires much more. Investi- gators seek to identify who got sick, what made them sick, when they got sick, and at what point it happened. The public health team’s goal is to gather enough information so that measures can be put in place to halt the spread of disease. These facts are essential to determine what is the best action to take to break the chain of transmission and prevent further spread of the disease to uninfected mem- bers of the population. Public health science provides the guide for answering these questions (see Chapter 3). Some- times the investigation is completed more quickly, as in some foodborne disease outbreaks, but sometimes unrav- elling the mystery takes much more time and detective work, especially if the disease is an emerging disease, as was the case with HIV in the 1980s.

This is primarily achieved through vaccination. Because of the importance of this approach, the HP topic related to CDs includes a strong focus on immunization. The first objective under this topic is to “reduce, eliminate, or maintain elimination of cases of vaccine-preventable disease” and has 10 vaccine-related targets, 4 of which have a target of total elimination (no cases). The four CDs targeted for elimination through vaccination include acute paralytic poliomyelitis, rubella, hepatitis B, and congenital rubella syndrome.40

Outbreak Investigation Despite efforts to prevent transmission of disease, out- breaks of infectious disease continue to occur. When they do, public health departments conduct outbreak investiga- tions. An outbreak investigation, related to CDs, involves conducting a systematic epidemiological investigation into

202 U N I T I I n Community Health Across Populations: Public Health Issues

n HEALTHY PEOPLE Immunization and Communicable Diseases

Goal: Increase immunization rates and reduce preventable CDs. Overview: The increase in life expectancy during the 20th century is largely a result of improvements in child survival associated with reductions in infectious disease mortality because of immunization.1 However, CDs remain a major cause of illness, disability, and death. Immunization recommendations in the United States currently target 17 vaccine-preventable diseases across the life span.

HP 2020 goals for immunization and CDs are rooted in evidence-based clinical and community activities and services for the prevention and treatment of CDs. Objectives new to HP 2020 focused on tech- nological advancements and ensuring that states, local public health departments, and nongovernmental or- ganizations are strong partners in the attempt on the part of the United States to control the spread of CDs. Objectives for 2020 reflected a more mobile society and the fact that diseases do not stop at geopolitical borders. Awareness of disease, and completing preven- tion and treatment courses remain essential compo- nents for reducing infectious disease transmission.40

Midcourse Review: Of the 67 measurable objectives, 21 were met or exceeded targets, 26 were improving, 11 had little or no change, and 6 were worse (Fig. 8-5). Among the objectives that were getting worse were the number of U.S.-acquired cases of mumps, pertussis, and measles.41

16%

9%

39%

31%

3% 2%

Healthy People 2020 Midcourse Review: Immunization and Infectious Diseases

Getting worse Little or no change Improving Met or exceeded Base line Informational

Figure 8-5 Healthy People 2020 Midcourse Review: Immunization and Infectious Disease. (Data source reference 41.)

w SOLVING THE MYSTERY The Case of the Halloween Cider Public Health Science Topics Covered: • Epidemiology • Surveillance

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C H A P T E R 8 n Communicable Diseases 203

In this hypothetical case, Susan and Mary, the infec- tion control nurses in two hospitals located in the same county, noticed an increase in positive laboratory results for E. coli 0157:H7 infections in their patients. On Monday, the laboratory informed Mary that there were two patients with positive results for E. coli 0157:H7. Mary called Susan to see whether her hospi- tal had any cases. Susan called Mary back on Tuesday to report three cases; Mary had an additional seven cases. As required, they reported their findings to the county public health department. The public health nurse, Joe, asked them to join the investigation team. In any outbreak investigation, identifying the culprit, that is, the infectious agent responsible for causing the dis- ease, is crucial.

Outbreak Investigation The first thing Joe did was to determine whether there was an epidemic. He accomplished this through a re- view of the 10 reported cases at the time of Susan and Mary’s first call. Most E. coli bacteria are harmless and are normal flora living in the intestines. However, Shiga toxin-producing E. coli (STEC) such as 0157:H7 are pathogenic; that is, they cause disease.42 There are federal health regulations that require that certain dis- eases are designated as notifiable. E. coli 0157:H7 is one of these diseases. For each notifiable disease, there is a CDC case definition.37,38 To begin the investigation, they used the CDC guide to define what constituted a case. Case identification provides the investigators with information needed to plot the outbreak and helps to determine whether there is a common source.

Sometimes the agent is not known at the outset, so clinical parameters define a case until the pathogen is identified. When the pathogen is not known, a patient is considered a case if he or she manifests specific clini- cal symptoms such as fever, diarrhea, and vomiting, which the team determines based on review of the presenting cases. Because Mary and Susan had already identified the agent, a case was defined based on labo- ratory-confirmed E. coli 0157:H7. Much is known about the agent E. coli 0157:H7, which was isolated in the early 1980s, and there are specific guidelines for defin- ing a case (Box 8-4).43 In addition to the guidelines, the team included in the case definition the date on which symptoms first occurred. This helped to confirm that the case occurred within a similar time frame as the other cases. The team members also extended their search outside of the county to determine whether there were any cases that had occurred within the same time frame but diagnosed elsewhere.

Because the team members knew the identity of the agent, they also knew the common reservoir and method of transmission. Because E. coli normally lives in the intestinal tracts of humans and animals, the usual route for transmission is the fecal-oral route. E. coli, therefore, is either water- or food- borne and has been traced in previous outbreaks to various types of produce, such as spinach, as well as meats, such as undercooked hamburger. Thus, the team must determine whether there was a common source of infection and whether it was foodborne or waterborne. A common source of infection occurs when the pathogen is transmitted from a single source, such as cantaloupes grown on a particular farm or hamburgers served at a particular restaurant.

To help determine the severity of the outbreak, the team calculated the CFR using the total number of fatal cases divided by the total number of cases. In this outbreak, there was a total of 106 cases including 5 deaths. The CFR was 4.7%. Because of the CFR and the potential that this E. coli outbreak could be multistate, the county public health department

Culture-independent diagnostic testing (CIDT), defined as the detection of antigen or nucleic acid sequences of the pathogen, is rapidly being adopted by clinical labora- tories. For Shiga toxin-producing Escherichia coli (STEC), these are generally PCR-based testing methods that do not require a stool culture and thus do not yield an isolate. Although concerted efforts are being made to ensure reflexive culture is performed at the clinical laboratory or the state public health laboratory, CIDT- positive reports are not always culture-confirmed. The current STEC case definition classifies a positive CIDT result detecting Shiga toxin, that is not culture-confirmed, as a suspect case.

To prevent an increase in underreporting of STEC infection cases and to make case definitions for enteric bacterial pathogens more consistent, this position state- ment proposes that: 1. Detection of Shiga toxin, Shiga toxin genes, E. coli O157, or STEC/EHEC by CIDT with- out culture-confirmation in a clinically compatible person be classified as a probable STEC case. 2. Illnesses among persons who are epidemiologically linked to a confirmed or laboratory-diagnosed probable case will be classified as probable epidemiologically-linked cases.

BOX 8–4 n Escherichia coli 0157:H7—CDC Clinical Description

Source: (43)

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204 U N I T I I n Community Health Across Populations: Public Health Issues

worked in collaboration with the state health depart- ment and the CDC to help locate cases outside the county.

CFR = Number of fatal cases Total number of cases

Once the team defined what constituted a case based on laboratory confirmation of infection with the agent, the members used basic epidemiology to help plan the next step. The team began to figure out the essential aspects of this potential outbreak and then plan the prevention efforts based on whether the inter- vention was aimed at the agent (eradicating the agent), the environment (interrupting transmission), or the host (reducing susceptibility). To do this, they collected further data on each of the cases, such as onset of symptoms, place of residence, and information about where they were and what they ate, starting with the maximum exposure date. Because the range of incuba- tion is 8 to 10 days, the team started with the day of onset of symptoms and worked backward to the maxi- mum date of exposure. For example, for case number one symptoms began on November 7. The team worked backward to October 28 and collected data on where the person was and what he or she ate.

The team used the data to build an epidemic curve. An epidemic curve is constructed by plotting on a graph the number of cases (y-axis) based on the date of onset (x-axis). This requires making a graph that includes the number of new cases per day and month (Fig. 8-6). The graph helped determine how much time elapsed between exposure to the pathogen and the beginning of clinical symptoms. Because the incubation ranges from 8 to 10 days, the team could estimate what date(s) the exposure probably occurred.

The epidemic curve also helped determine whether there was a point source, that is, the source of the exposure happened at one point in time; a continuous source, that is, the exposure is ongoing; or an intermittent source, that is, expo- sure comes and goes. After looking at the epidemic curve (see Fig. 8-5), Joe noted that after day 5 there was a decline in the number of cases, but there was a subsequent increase in cases on days 10 and 11. This represented a bimodal curve that could be a result of two different point sources or of possible household exposure, because E. coli can be transmitted from person to person. When the cases that occurred on the second curve were reviewed, all of them were family members of an earlier case. This led the

P er

ce nt

ag e

(% )

Day

# New Cases

# New Cases

1 2 3 4 5 6 7 8 9 10 11 12 13 14

30

20

15

5

25

10

0

Figure 8-6 Plotting the epidemic curve.

team to conclude that there was a point source for the exposure.

Because it appeared to be a point source, team members then examined all the cases to determine whether there was a common source, that is, some- thing that all of the cases ate, drank, or did that could have been contaminated with E. coli. The team also examined the data on where the patients were and whether there was a common restaurant or a food market where the people purchased food or drink.

The team next needed to determine how the cases come in contact with the agent. To help with this process, the team mapped out the cycle of transmis- sion for E. coli 0157:H7. Mapping out this information helped the team’s investigation because members needed to know the most likely places where patients may have come in contact with E. coli. Knowing some- thing about the pathogen helped the team members develop a hypothesis for the source of the infection so they could begin to build an intervention to prevent further cases.

Generating a hypothesis about the sources of in- fection is a key step in outbreak investigations. The team began by reviewing the sources of infection in prior E. coli 0157:H7 outbreaks. There was an out- break of E. coli 0157:H7 in Washington State in 1993 that resulted in 700 cases and 4 deaths. All of the fa- talities were children. In 1999, there was an outbreak

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Infectious Agents and Attack Rates The hypothetical Case of the Halloween Cider illustrates how humans become infected with an agent that can cause disease. A few other pieces of information are use- ful to have when conducting an outbreak investigation related to an infectious disease. First, transmission can occur from the reservoir directly or indirectly. Person- to-person contact is an example of direct transmission and occurs with sexually transmitted infections (STIs). Indirect transmission occurs when the agent leaves the

C H A P T E R 8 n Communicable Diseases 205

at the Washington State Fair. A total of 781 people were infected, and 2 died.44 An outbreak in 2007 resulted in only 12 cases but caused the recall of 21.7 million pounds of ground beef and the closing of the Topps Meat Company.45 E. coli outbreaks contin- ued with one in 2018 linked to romaine lettuce that resulted in a nationwide alert to avoid eating any ro- maine lettuce.46 Based on these cases, the team mem- bers developed the hypothesis that the outbreak was foodborne and began by examining the data to deter- mine whether there were any commonalities among the cases. The data they examined included their sur- vey of all the patients who met the definition of being a case. The infection control nurses, Susan and Mary, interviewed patients still in the hospital, and Joe con- ducted phone interviews with those who were dis- charged or who were cared for at home. Based on information from the CDC, cases were located out- side the county and outside the state. The CDC and the state health department helped coordinate data collection for these cases.

Based on the epidemic curve, the team narrowed the possible date of the initial exposure to a 5-day pe- riod that extended from October 28 to November 1. During that time, the county held a Halloween festival, and all of the primary cases had attended the festival. At the festival, there were multiple possible sources for exposure, including a petting zoo, the sale of apple cider from a local farm, a fresh fruit and salad stand, and a hamburger stand. With all the information gath- ered, the team then narrowed down possible sources based on the ones that the cases had in common. About half of the cases had gone to the petting zoo, a quarter of the cases had eaten fresh salads from the fruit and salad stand, and a third had consumed ham- burgers. In contrast, all but four of the cases reported drinking cider. The team then calculated relative risk (see Chapter 3) for the disease based on the possible exposure to hamburgers, petting zoo, and cider. Based on their survey, they found that approximately 95% of the cases reported consumption of the apple cider sold at the food stand next to the kiddy rides. They then questioned the vendor and found that the cider came from a local farmer who made the cider just for the fair.

Management of the Epidemic Now that the team had identified the probable source of the outbreak, the team had to isolate the source. In some of the E. coli 0157:H7 outbreaks,

isolating the source had proved to be problematic. For example, in the 2018 epidemic associated with the consumption of romaine lettuce, cases were dis- tributed across multiple states.46 In this hypothetical case, to manage the epidemic, the team located the farmer who supplied the cider to the stand at the fair. The cider was homemade and unpasteurized cider thus a possible source of E. coli 0157:H7. If the cider had come from a commercial enterprise, the health department would want to intervene and make sure no further sale of the cider occurred. In this case, the public health department questioned the farmer about further sale of the product and dis- covered that the farmer had a vegetable stand. The county public health department closed the stand and all of the cider the farmer had was destroyed. The public health department also alerted the public to the threat of infection for those who had consumed the cider so that they could be screened for possible infection and provided with treatment if needed. A public service announcement was released advising the public to destroy any cider that had been pur- chased from this farm.

Managing an outbreak, especially in the case of a disease known to have an increased risk for mortality, requires prompt action on multiple levels. The key is to know how best to break the cycle of transmission. In this case, the reservoir was the target. The team focused on removal of the cider, the actual reservoir for the E. coli 0157:H7. The team also sought to elimi- nate further consumption of the Halloween cider. In this hypothetical case, a local intervention would work if the farmer who made the cider sold only to the ven- dor at the fair who then sold only single servings of the cider at the fair. Instead, the farmer owned a farm stand with cider products; therefore, a broader intervention was warranted.

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reservoir and is transferred to the human host through an indirect means such as a vector or in the case of fomite transmission.

Once transmission has occurred, disease is not neces- sarily immediately apparent. As mentioned earlier, inap- parent infection is the subclinical phase during which there are no apparent clinical symptoms. From a public health perspective, it is often important to identify those with inapparent infection not only to provide early treat- ment, but also to stop the spread of infection, as you will see in the next case. To help understand how long this inapparent infection phase can last, it is important to know the incubation period. This is the time interval be- tween infection and the first clinical signs of disease. For E. coli, the incubation period is short, but for other pathogens, it can be quite long. For example, persons in- fected with TB during childhood may not develop the disease until later in life.

As discussed in Chapter 3, time is a key issue in epi- demiology. With CDs, the incubation period for the pathogen is one example of time that must be considered when investigating an outbreak and planning prevention. Another factor to consider is the generation time, which is the interval between infection with the agent and the maximum time that the host is infectious, that is, the communicability of the host. Sometimes the incubation and generation time are the same. If that is the case, then when symptoms appear, the host can no longer transfer the agent to other hosts, but that is not always the case. Generation time helps when dealing with the spread of agents that have a large number of subclinical cases.

Another issue related to infection at the population level is community or herd immunity. This refers to the immunity of a population to an agent. If a large por- tion of the population is immune (by vaccine or past infection), that can prevent the spread of the disease to persons in the population who do not have immunity. There is usually a threshold of immunity that needs to be achieved to establish herd immunity. In other words, a certain percentage of the population must be immune to achieve herd immunity to a specific agent. With herd immunity, even if a few members of the community

become infected, the population as a whole is protected from an outbreak.

In the hypothetical Case of the Halloween Cider, the team calculated a CFR. There are other rates that can be helpful in an investigation, including attack rate and sec- ondary attack rate. An attack rate is actually a type of incidence rate (see Chapter 3 for more in-depth discus- sion). It is calculated using the number of persons who are ill divided by the total number of the population, which includes persons who are ill plus those who are well. This is multiplied by a constant (usually 100) and expressed over a certain time period. The attack rate can be calcu- lated based on a particular risk factor. For example, sup- pose the team had narrowed down the possible risk factors at the county fair as the consumption of burgers at the burger stand, the petting zoo, and the cider. For each risk factor, the team would calculate a separate attack rate for those exposed to the risk factor and those not exposed. Group A could be those who drank the cider and group B could be those who did not drink the cider. Once these two attack rates are calculated, the difference between the two attack rates would be determined. This process would then be repeated for the burgers and the petting zoo (Box 8-5). The risk factor with the greatest difference in attack rates may be your common source for the outbreak.

Another calculation useful in an outbreak investiga- tion is the secondary attack rate. This reflects the spread of disease from those who contracted the disease from the initial source to others usually within the same household or other unit where people come in close contact with others. The secondary attack rate is calculated by dividing the number of new cases in a particular group minus the initial case(s) by the number of susceptible persons in the group minus the initial case(s) (see Box 8-5).

Sexually Transmitted and Reproductive Tract Infections Not all CD outbreaks follow the course described in the Case of the Halloween Cider. In that case, the outbreak required public health officials to take action related to a

206 U N I T I I n Community Health Across Populations: Public Health Issues

Attack Rate = ill

× 100 during a time periodill + well

Number of new cases in group – initial cases Secondary Attack Rate (%) = Number of susceptible persons in the group – initial cases × 100

BOX 8–5 n Rate Calculations

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food product and those who became ill were not aware of their risk. On the other hand, Sexually transmitted in- fections (STIs), also referred to as sexually transmitted diseases, are related to behavior. Much has been done to alert those who are sexually active to the risk involved in unprotected sexual activity.

In HP, the topic “sexually transmitted disease” is a separate topic area from the topic “immunization and infectious diseases.” Specific diseases targeted in the objectives are chlamydia, pelvic inflammatory disease (PID), gonorrhea, syphilis, and human papillomavirus.

Burden of Disease and Sexually Transmitted Infections STIs are caused by pathogens transmitted from human to human through sexual contact. The reservoir of the agent is the human body. These infections can cause se- rious illness and disability, and are preventable. There are three notifiable sexual infections that have federally

funded control programs: chlamydia, gonorrhea, and syphilis.49

The incidence rate of chlamydia (agent: Chlamydia trachomatis) has increased from 160.2 per 100,000 in 1990 to 497 per 100,000 in 2016 with the rate in women double the rate in men.50 Chlamydia is associated with PID and can be passed on to the infant during delivery. The agent Chlamydia trachomatis is a bacterium and is treatable with antibiotics. Unfortunately, for many women there are no symptoms, and often the infection goes undiagnosed. If the infection is not treated and PID develops, women can experience complications such as infertility, ectopic pregnancy, and chronic pelvic pain. As this is a treatable infection public health efforts focus on screening and early treatment, as well as education and promotion of condom use during intercourse.

Another serious STI is gonorrhea (Neisseria gonor- rhoeae). After chlamydia, it is the most commonly re- ported STI in the United States. At the end of the 20th century, the incidence rate fell 75% from 1975 to 1997 and reached a historic low in 2009 with a national rate of 98.1 cases per 100,000. However, in 2016 there was an 18.5% increase from 2015 with a total of 468,514 cases of gonorrhea (a rate of 145.8 per 100,000).51 Like chlamy- dia, it is a major cause of PID, infertility, and ectopic pregnancies. Also, like chlamydia, the infection is treat- able, but serious health consequences occur if it is un- treated. In addition, there is now widespread resistance to a class of antibiotics used to treat gonorrhea, the fluo- roquinolones, resulting in a change in CDC guidelines for the treatment of gonorrhea with cephalosporins.52

C H A P T E R 8 n Communicable Diseases 207

n HEALTHY PEOPLE Sexually Transmitted Diseases

Goal: Promote healthy sexual behaviors, strengthen community capacity, and increase access to quality services to prevent STDs and their complications. Overview: Sexually transmitted diseases (STDs) refer to more than 25 infectious organisms transmitted primarily through sexual activity. STD prevention is an essential primary care strategy for improving reproductive health.

Despite their burdens, costs, and complications, and the fact that they are largely preventable, STDs remain a significant public health problem in the United States. This problem is largely unrecognized by the public, policy makers, and health-care providers. STDs cause many harmful, often irreversible, and costly clinical complications, such as:

• Reproductive health problems • Fetal and perinatal health problems • Cancer • Facilitation of the sexual transmission of HIV

infection47

Midcourse Review: Of the 14 measurable objectives, 4 were met or exceeded targets, 4 were improving, 3 had little or no change, and 3 were worse (Fig. 8-7). Among the objectives that were getting worse were the number of new cases of primary and secondary syphilis among males and the number of new cases of gonorrhea among males.48

50%

14%

14%

11%

11%

Healthy People 2020 Midcourse Review: Sexually Transmitted Diseases

Measurable Getting worse Little or no change Improving Met or exceeded

Figure 8-7 Healthy People 2020 Midcourse Review: Sexually Transmitted Diseases. (Data source reference 48.)

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The third STI under national surveillance is syphilis, a genital ulcerative disease caused by the bac- terium Treponema pallidum. Syphilis has four stages: primary, secondary, tertiary, and latent. The primary stage occurs between 10 and 90 days following infec- tion, and is evidenced by a sore, or multiple sores, at the site where the bacterium entered the infected per- son. The sore or chancre often heals without treatment. If there is no treatment, then the infection enters the secondary stage. During the secondary stage, the per- son develops a skin rash and mucous membrane le- sions can occur while the chancre is healing or shortly thereafter. It can be accompanied by various other symptoms such as fever or swollen lymph nodes, or the symptoms may be so mild that they are not noticed. These symptoms will also resolve with or without treat- ment. However, if no treatment is given it can progress to the latent stage of syphilis, which is a period of time when there are no symptoms of the infection and can last for years. The tertiary stage does not occur in all cases of untreated syphilis, but a person with tertiary syphilis can experience adverse effects on numerous internal organs, including the brain, resulting in paral- ysis and dementia. Historical examples of people with late-stage syphilis include Al Capone and King George III of England, who was on the throne at the time of the American Revolution.

In 2017 there were a total of 30,644 cases of both pri- mary and secondary syphilis reported in the United States, a rate of 9.5 cases per 100,000 population, up from 8.6 per 100,000 in 2016. In 2017, in the U.S., the rate in men was 10 times higher than in women (16.9 cases per 100,000 males vs. 2.3 cases per 100,000 females) with men accounting for 87.7% of primary and secondary syphilis cases. Men who have sex with men accounted for

57% of the cases. The rate of congenital syphilis increased in 2017 to 23.3 cases per 100,000 live births, a 43.8% in- crease from 2016 (16.2 cases per 100,000 live births) and a 153.3% increase from to 2013 (9.2 cases per 100,000 live births).53

Risk Factors The main risk factor for STIs is unprotected sexual contact. The pathogens responsible for STIs are transmitted through the exchange of bodily fluids. Some groups are more at risk than others based on gender, ethnicity, and socioeconomic status. As noted earlier, men accounted for almost 90% of all cases, and men who have sex with men accounted for more than half the cases. (Fig. 8-8).54 There was also a difference in the number of syphilis cases among racial groups. For example, according to the CDC in 2017, the rate of reported primary and secondary syphilis increased across all racial ethnic groups with the highest preva- lence rate in blacks with 24.2 cases per 100,000 popu- lation, up from 23.1. For whites the rate increased from 4.1 to 5.94 cases per 100,000.53,55 The disparity in rates of STIs across ethnic and socioeconomic status has been well documented over the past decades.56,57 For example, although blacks represent only 13% of the population, rates of gonorrhea among blacks was 8.6 times higher than the rates among whites.51 This may be due in part to socioeconomic factors. For example, those with less health insurance coverage are more apt to seek care at public health clin- ics. Although STIs are reportable infections, compli- ance with this law for reporting cases is higher in public clinics than it is in private physicians’ offices. Access to care may also prevent early diagnosis and treatment.56,57

208 U N I T I I n Community Health Across Populations: Public Health Issues

Syphilis Cases by Gender and Sexual Partner

52%

12%

15%

0%

15%

6%

Men who have sex with men only (n = 15,953) Men who have sex with men and women (n = 1,783) Men who have sex with women only (n = 4,548) Men without data on sex of sex partners (n = 4,601) Women (n = 3,722) Cases with unknown sex (n = 37)

Figure 8-8 Syphilis cases by gender and sexual partner. (Data source reference 54.)

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C H A P T E R 8 n Communicable Diseases 209

l APPLYING PUBLIC HEALTH SCIENCE The Case of Syphilis in Baltimore City Public Health Science Topics Covered:

• Health planning • Community assessment

The Baltimore Syphilis Elimination Project provides an excellent example of how a collaborative effort between a public health department and health care providers, including nurses, can result in a reduction in disease. The project began due to a 40% increase in prevalence of syphilis in Baltimore City that prompted an assessment of the data related to the new syphilis cases and the implementation of a population-level in- tervention.58 Because syphilis is a notifiable disease, all diagnosed cases in Baltimore are reported to the local public health department, which in turn reports the cases to the state health department. This information is then reported to the CDC. The case of syphilis in Baltimore City helps to illustrate the differences be- tween a public health response to a foodborne infec- tious disease outbreak and an increase in new cases of an STI.

The first step for the team in Baltimore City was to determine whether the increase in cases was an epi- demic. An excess of cases above the endemic levels in a specific community or region is considered an epi- demic. To decide whether there is a need for action, public health officials examine the increase in cases to determine whether the increase has reached an epi- demic threshold, that is, the number of cases above the endemic rate associated with an increased risk for spread of the disease. The epidemic threshold is used to make decisions about whether to alert the public about a possible epidemic. Epidemic thresholds differ from disease to disease, and the methods for determin- ing the threshold can also vary. These calculations re- quire a sophisticated approach, but they help guide public health officials in deciding when an epidemic alert is needed.59,60 The choice of an epidemic thresh- old usually reflects the number of cases that exceeds a certain number per 100,000 population over a specified time period. Because the term epidemic is emotionally charged, public health officials use it with caution. When a general public alert is needed, the epidemic threshold can help the public health officials either as- sure the public that there is not an epidemic or alert the public to a real risk.

Next, it is important to determine the type of epi- demic related to the specific mode of transmission.

The Case of the Halloween Cider fits the description of a common-source epidemic as do other water- and foodborne infections. There can also be a vector-borne epidemic such as the Zika epidemic, which was spread by mosquitos. In the case of syphilis, the disease has been endemic in the human population for thousands of years. Therefore, unlike an E. coli outbreak, the in- crease in syphilis cases in Baltimore City did not reflect a national epidemic or a pandemic but rather a specific increase in one particular geographical area.

In this case, once the public health officials realized there was a dramatic increase in the number of cases, they first defined what constituted a case. They looked at the cases based on demographics and found that the increase was occurring mainly in the Hispanic popula- tion. In that population, the incidence rate had in- creased by 73% compared with a 40% increase for the population in general. Another interesting detail also emerged in their review of cases. They found that the majority of all Hispanic cases were primary cases.58

Health Planning

Now the team was ready for action. Instead of a na- tional media campaign and product recall as in the case of an E. coli 0157:H7 or Salmonella outbreak, a local pro- gram was put together, the Syphilis Elimination Project, an excellent example of how to plan a health program (see Chapter 5). It is also a good example of incorporat- ing both a primary and a secondary approach to preven- tion. In addition, they developed a prevention program that targeted a population at increased risk with a selected level of prevention (see Chapter 2).

The Syphilis Elimination Project had two goals. The first goal focused on knowledge, awareness, and de- creasing incidence of syphilis in the Baltimore City His- panic community, and the second was to get those with syphilis into treatment. Under the first goal, the objective was to increase the number of Hispanics tested for syphilis by 50% from baseline.58 This is an example of case finding. Case finding comes under the umbrella of secondary prevention. The purpose of find- ing cases is to identify those who are infected and get them into treatment. In STIs, the reservoir is humans. If there is an effective treatment for the disease, it is pos- sible to eliminate the agent in the reservoir. Early treat- ment for the disease from a population perspective is therefore both a primary and a secondary prevention measure. Through case finding, public health officials can intervene in relation to the agent’s reservoir.

For the Baltimore City Syphilis Elimination Project, there were specific challenges related to culture, stigma,

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Emerging Sexually Transmitted Infections Gonorrhea and syphilis are mentioned throughout his- tory, whereas other STIs are new arrivals. In 1981, a new STI emerged that grabbed the attention of the world— HIV. Unlike gonorrhea and syphilis, there currently is no cure for this infection. When it was first identified, those with the infection had few treatment options and the CFR was high. Over the years, science has developed successful treatments, and the diagnosis of HIV infection is no longer a death sentence in the United States. At the end of 2015, it was estimated by the CDC that 1.1 million people aged 13 and older were living with HIV infection in the United States. This estimate included more than 162,500 (15%) persons with undiagnosed infection.61

The emergence of this STI changed how nurses pro- vide care. Unlike other STIs, this virus could be trans- mitted through exposure to other bodily fluids, including blood. In the late 1980s, when surveillance data indicated that health-care workers were at increased risk for HIV infection through exposure to blood and other bodily se- cretions, a legal approach was taken to prevent the spread of this disease in health-care workers. OSHA put into law the requirement that health-care workers use PPE. As al- ways, the prevention measures taken were based on the mode of transmission and targeted a population at risk for becoming infected. Following the institution of this law, the incidence rate of HIV in health-care workers with no other risk factors dropped dramatically. The use of PPEs has become routine in all health-care settings. This dramatic change in hospital-based infections con- trol created as dramatic a shift in care as hand hygiene did after the discovery that germs cause disease (see Chapter 1).

HIV/AIDS is a pandemic and has had a severe impact on certain portions of the globe, especially in developing countries where access to treatment is limited. Once again, disparity exists related to this STI because of so- cioeconomic status, culture, and governmental support of prevention efforts. This infection is an example of the emerging diseases affecting the United States and world as a whole.

210 U N I T I I n Community Health Across Populations: Public Health Issues

and access to the population. Before the team members initiated their project, they had to address these chal- lenges. In addition, skills related to cultural competency were needed to develop a program that would be ac- cepted by the intended recipients. The team members combined their efforts at case finding with a multi- method patient education campaign. Bilingual outreach workers conducted street outreach by providing educa- tion on syphilis in bars, stores, and on the street. Because there is no known method of reducing our biological susceptibility to syphilis, the Elimination Project could not reduce biological susceptibility of the host. Instead, they developed a culturally relevant edu- cational program that provided the population at risk, Hispanics living in Baltimore City, with behavioral strategies to reduce their chances of becoming infected.

When there are no means available to reduce the biological susceptibility of the host, the focus of pri- mary prevention in CD becomes both the mode of transmission and the portal of entry. Through educa- tion, it is hoped that those who are not infected be- come educated on how the disease is transmitted and how it enters the body so that they can implement ef- fective strategies to prevent becoming infected. In this case, an additional challenge was to reach the popula- tion most at risk, because the project fit the definition of a selective prevention program (see Chapter 2). The Syphilis Elimination Project team members had done their homework on who was getting infected, and they had a good grasp of where this selected population resided. They designed a program that incorporated cultural and geographical issues related to the popula- tion. They used bilingual outreach workers who con- ducted their educational interventions during the evening hours and in the early mornings in high-traffic areas. They chose these times to try to reach the most people by targeting working and partying hours. By the end of 10 weeks they had met their first goal, with 2,825 Hispanics having received patient education and health information materials. Thus, by taking into con- sideration the role of culture and the importance of engaging the community, the project was successful in primary prevention (providing education to those not yet infected). They were also able to meet their second goal, screening (secondary prevention) and identifying those in need of treatment. Because the cases that were identified through screening were almost all pri- mary infections, few needed tertiary interventions, that is, treatment of clinical disease as seen in secondary and latent syphilis.

n CULTURAL CONTEXT Prevention of Sexually Transmitted Infections

Due to the mode of transmission, STIs bring additional challenges to prevention efforts. Changing risky behav- iors in general can be difficult but addressing sexual behaviors may be tied to feelings of shame, guilt, or

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Communicable Diseases and Communicability Not all diseases caused by an infection are communi- cable. Understanding the difference between an agent that infects humans and causes disease, and the com- municability of the agent is based on the transmission of the infection from one person to another. A person may become infected with a pathogen, but no public health response is required to prevent further transmis- sion of the agent to other persons, because the agent is not actually communicable. One example that helps il- lustrate the difference between the agent and the threat of transmission from one person to another is the Case of the Flesh-Eating Bug.

C H A P T E R 8 n Communicable Diseases 211

powerlessness, and that can present barriers to the nurse wishing to intervene. The Syphilis Elimination Project demonstrates that these barriers can be over- come, especially if a population approach is taken that includes consideration of the culture of the target pop- ulation and that includes that population in the design, implementation, and evaluation of the intervention. However, stigma continues to present a barrier to health-care providers attempting to care for persons with an STI. One group of researchers in Uganda con- cluded stigma associated with HIV resulted in poor communication between HIV clients and providers about childbearing.62 In other cases, the loosening of cultural norms around sexual behaviors may actually increase the risk of contracting an STI. For example, a group of nurses working to address the rise in STIs in Thailand noted that the increase in tourism, the adopt- ing of western culture, and the loosening of cultural norms has coincided with the increase in the demand for entertainment and sex business by tourists includ- ing sex shows and sexually provocative performances.63

w SOLVING THE MYSTERY The Case of the Flesh-Eating Bug Public Health Science Topics Covered: • Epidemiology • Surveillance

On June 20, 2006, David Walton, a leading econo- mist in the United Kingdom, was admitted to Chel- tenham General Hospital complaining of fever and stomach pain. Within 24 hours, he was dead. According

to one physician, the infection “seemed to spread be- fore our eyes, down the thigh, growing towards the shoulder and chest”.64

In another case, a 3-year-old girl, Isabel Maude, was brought to the emergency room with high fever, nau- sea, and vomiting. Her parents explained that their daughter had recently come down with chickenpox. The physician reviewed the care of chickenpox with the parents and sent the child home. The symptoms worsened, and the child was readmitted to the pedi- atric intensive care unit because of organ failure. The first physician had missed the diagnosis based on the recent history of chickenpox. The child actually had a much more serious infectious disease. She eventually recovered after a 2-month stay at the hospital.65 The case would have turned out differently if the health- care provider who first saw the little girl had asked more questions. The health-care providers failed to solve the mystery when they first saw the girl. They did not go beyond the obvious clinical conclusion that this was chickenpox and ask what else might be going on.

A third case related to this same infectious disease occurred in Lanarkshire, England. Between December 24, 2008, and January 3, 2008, two persons with a history of intravenous (IV) drug use died of the flesh-eating bug. There was one other confirmed case and one suspected case. These deaths prompted a public health announcement from the public health authorities in Lanarkshire. The first two cases did not result in a pub- lic health alert. This third case did, but it was different from the other CD investigations reviewed in this chapter. In the Case of the Halloween Cider and in the syphilis epidemic in Baltimore City among Hispanics, the infection occurred within a population. The hypo- thetical E. coli outbreak took place at a fair, and anyone who attended that fair and drank the unpasteurized cider was at risk for becoming infected. In Baltimore City, an increase in the incidence rate for an STI occurred within a specific ethnic population with less access to care and less awareness about their risk for infection. In both cases, interventions were aimed at reducing the incidence rates within a population. The cases also differed on the CFR. In the first case, though the CFR is low for many E. coli outbreaks, many of those deaths are in children and older adults, and occur soon after infection. In the second case, the period between infection and death in untreated cases can be as long as 20 years. Therefore, the urgency related to an E. coli outbreak is fueled not only by the need to decrease illness but also by the importance of

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212 U N I T I I n Community Health Across Populations: Public Health Issues

decreasing the risk of mortality, especially in children. In this case, the case of the flesh-eating bug, although the virulence of the disease was extreme, the disease was not spreading to the general public. One group of persons appeared to be at greater risk.66

One of the issues in CDs is separating the agent from the disease or diseases caused by the agent. In the case of the “flesh-eating bug,” the agent can cause rapid death in some cases and no illness at all in other cases. In addition, the disease is linked to more than one agent. This is where the cycle of transmission gets in- teresting. Although the specific agent may differ, the portal of entry is the same; bacteria are introduced through an opening in the skin. In some cases, the in- troduced bacteria are those that are often found on the skin or in the throat.67 This was not the case with the men who had a history of IV drug use. Therefore, although the disease was the same and the portal of entry was the same, the reservoir differed. This then has implications for the decision of whether or not to proceed with a public health alert. In relation to E. coli 0157:H7, the primary concern was to deal with an out- break. In the case of the “flesh-eating bug”, only one of the scenarios given earlier resulted in a public health initiative similar that in E. coli outbreaks.

To answer the question about whether a public health alert is needed, it helps to go back to the lessons learned in the Case of the Halloween Cider. In that case, the team conducted an assessment to determine whether this was a common source of outbreak. Based on the agent, the team members rightly suspected that this was a foodborne outbreak. In the three scenarios presented related to the “flesh-eating bug”, the first two cases represented an isolated incident. No new cases were admitted to the hospital. Knowing the usual portal of entry of an agent that causes this disease low- ered the public health concern that others were at risk. However, in the third case there were three more cases in rapid succession. The one thing the patients had in common was IV heroin drug use. This raised the potential threat to the health of persons who were IV drug users of heroin, not the public in general.

One reason for the public health response was the virulence of the “flesh-eating bug”. When it enters the body through a wound, the agents associated with the “flesh-eating bug” have a very high level of viru- lence; that is, the severity of the disease produced by the agent and the CFR were high. In the United States, the CFR for this disease ranges from 20 to 30 per 100 cases.67 However, not all persons exposed to

agents that cause this disease become ill. Bacteria that cause this disease include S. aureus, Clostridium perfrin- gens, Bacteroides fragilis, Aeromonas hydrophila, and others. Again, the presence of the agent is not what is important but rather the portal of entry. The agent itself can be present on the skin or in the throat and cause no disease or mild disease with a very low CFR. However, when introduced to the host through a wound, the disease agent causes changes. The formal name for this infectious disease is necrotizing fasciitis (NF). One of the known agents responsible for this dis- ease is group A (-hemolytic streptococci (GABHS). In the throat, GABHS can cause mild illness, but when in- troduced into the human body through a break in the skin, NF can result.

This leads us back to the issue of the infectivity of the agent. From one perspective, the infectivity is low because there must be an opening in the skin for the agent to enter and cause disease. Therefore, the CDC does not recommend antibiotic prophylaxis in all per- sons exposed to the patient, unless there are certain other risk factors present. However, from another perspective, the infectivity of the agent is a key issue. Once the agent has entered the host through a break in the skin, it can rapidly multiply in the host, resulting in what is reflected in the quote that the infection “seemed to spread before our eyes, down the thigh, growing towards the shoulder and chest”.64

For the first two cases, no public health alerts were made, but in the third case there was reason to believe that it was actually a common source outbreak. All of the cases had a history of heroin IV drug use. Although there were only four cases and two deaths, the viru- lence of the agent prompted action. In addition, a simi- lar outbreak a few years earlier in the United Kingdom had resulted in 43 deaths. What the public health offi- cials discovered was each of the cases had injected heroin that had been contaminated with the causative agent that was in spore form. They had a common source outbreak. This discovery led to a selective pre- vention effort that targeted those at risk, persons en- gaged in current IV drug use. Their efforts included alerting emergency departments. This part of their alert focused on case finding and early treatment.

The three examples of NF provided here illustrate that not all CDs require an immediate public health response and that various issues come into play when making these decisions. Key issues include the viru- lence of the agent or agents causing the disease, whether or not there is a common source for the

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Controlling Communicable Diseases In all the cases presented here, the main focus is to con- trol the spread of disease. There are three main ap- proaches: (1) changing the environment; (2) inactivating the agent; and (3) increasing host resistance. Changing the environment can involve altering or eliminating the reservoir, controlling the vector, applying personal meas- ures of hygiene, and using aseptic technique. Nurses en- gage in these measures regularly in patient care settings through their own use of proper hygiene and aseptic technique. In this way, they help reduce the occurrence of healthcare-acquired infections. Public health officials actively engage in these measures on a regular basis through general community-level sanitation measures related to water, food, and sewerage. They also actively participate in vector control. Communities at risk for mosquito-borne diseases have mosquito control pro- grams aimed at eliminating the breeding grounds of the insects. This may include the use of insecticides or the draining of swampy areas.

Inactivating the agent includes the use of physical and chemical agents. Pasteurization of cider uses heat to in- activate infectious agents such as E. coli 0157:H7. One of the main issues with transmission of E. coli 0157:H7 through beef products is the failure to properly cook the beef at a high enough temperature to inactivate the agent. Cold is also used to inactivate agents in food products. The advent of refrigeration greatly reduced the spread of foodborne diseases. There are specific guidelines related to adequate refrigeration of foods to prevent the growth of bacteria that can cause disease. Chemical methods in- volve the use of chemicals to control agents such as the chlorination of water or the use of disinfects to clean po- tentially infected areas or items.

Finally, breaking the cycle of transmission can be accomplished through increasing host resistance. As mentioned above, resistance can be active or passive. Eradication of smallpox was accomplished through the use of vaccines. This was a global campaign launched in

1967. At that time, smallpox had a CFR of 24% and left most of the survivors either scarred or blind. Once a per- son had the disease, there was no known treatment. However, since the late 1700s, it was known that inocu- lation with cowpox protected against the disease. The global effort to increase host resistance was successful and in 1977 the last documented case occurred. The use of vaccines to increase host resistance has dramatically changed the impact of CDs on populations, especially children. Vaccine refers to the immunizing agent used to increase the host’s resistance to viral, rickettsial, and bacterial diseases.68 They can be killed, modified, or changed into a variant form of the agent. In the United States, children routinely receive a series of vaccines that protect against measles, mumps, diphtheria, po- liomyelitis, and rubella.69 Recently, there has been con- troversy over the potential risk of autism related to childhood vaccinations despite the lack of scientific evi- dence to support the link. The CDC has put together a guide for parents on the use of vaccines.70 The use of vac- cines is a good example of evidence-based practice, be- cause all vaccines go through a vigorous process to establish safety and effectiveness prior to being used.69

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n CELLULAR TO GLOBAL Using the WHO definition, CDs begin with a pathogen: Infectious diseases are caused by pathogenic microorganisms, such as bacteria, viruses, parasites, or fungi; the diseases can be spread, directly or indirectly, from one person to another. Zoonotic diseases are infec- tious diseases of animals that can cause disease when transmitted to humans.71

Addressing CD requires action at the population level, with the WHO providing a central leadership role through their emergency preparedness program. Their stated vision: An integrated global alert and response system for epidemics and other public health emergencies based on strong national public health sys- tems and capacity and an effective international system for coordinated response. In the first 6 months of 2018, the WHO responded to the following outbreaks: Ebola in the Democratic Republic of Congo, Measles in Japan, Rift Valley Fever in Kenya, Middle East Res- piratory Syndrome Coronavirus in Saudi Arabi, and Cholera in Cameroon. Preventing and responding quickly to CD outbreaks requires the ability to treat at the cellular level and implement actions at the national and global level to reduce the impact of CDs.72

outbreak, and whether the public health alert will reduce the occurrence of more cases as well as pro- mote early detection and treatment. Of interest in the second case, the disease resulted in the parents of the child developing an organization, Isabel Health- care, that provides a diagnosis system that prompts health-care providers to reach a timely diagnosis, thus preventing the delay in treatment experienced by their daughter.65

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n Summary Points • CDs are significant health issues that place

populations at risk for increased morbidity and mortality.

• Preventing the transmission of disease requires an understanding of the cycle of transmission.

• Specific actions taken by nurses and other health- care providers at the population level include: • Participating in an outbreak investigation • Instituting appropriate isolation within an acute

care setting • Screening patients or aggregates for an infectious

disease • Developing and implementing a community outreach

program to educate the public on a specific disease • Vaccination is an important public health interven-

tion aimed at reduction of the transmission of infec- tious agents.

214 U N I T I I n Community Health Across Populations: Public Health Issues

n EVIDENCE-BASED PRACTICE Vaccination Recommendations During Childhood

Practice Statement: Vaccination is recommended by the CDC for all children as outlined on the CDC’s Web site for parents related to vaccination.70

Targeted Outcome: Decrease in incidence of vaccine preventable diseases in children. Evidence to Support: Childhood vaccinations have been part of pediatric care for more than 70 years with a significant reduction of childhood CDs. Recommended Approaches: Vaccines are held to the highest standard of safety. The United States cur- rently has the safest, most effective vaccine supply in history. Years of testing are required by law before a vaccine can be licensed. Once in use, vaccines are continually monitored for safety and efficacy. Immu- nizations, like any medication, can cause adverse events. However, a decision not to immunize a child also involves risk. It is a decision to put the child and others who come into contact with him or her at risk of contracting a disease that could be dangerous or deadly. Consider measles. One out of 30 children with measles develops pneumonia. For every 1,000 children who get the disease, 1 or 2 will die of it. Thanks to vaccines, we have fewer cases of measles in the United States today. However, the disease is ex- tremely contagious, and each year dozens of cases are imported from abroad into the United States, threat- ening the health of people who have not been vacci- nated and those for whom the vaccine was not effective.73 The CDC and the Food and Drug Admin- istration continually work to make already safe vac- cines even safer.69 In the rare event that a child is injured by a vaccine, he or she may be compensated through the National Vaccine Injury Compensation Program (VICP).74

Vaccines are used to increase host resistance to other diseases. These include influenza, pneumonia, and tetanus. Health-care workers are immunized for hepatitis B. In some countries, a tuberculosis vaccina- tion program is in effect for all members of the popu- lation. Several factors influence the decisions of public health agencies to make vaccines mandatory and how much protection will be provided by vac- cines. First, vaccines are given when the risk to the population is high. For example, hepatitis B is not given to the general public because the risk is low. Health-care providers are at higher risk from their exposure to blood and bodily fluids; thus, health-care

workers providing direct care to patients are re- quired to be vaccinated for hepatitis B. For most of the childhood diseases, the risk is high for all chil- dren, so vaccination is often required prior to enrollment in schools, and health departments have active outreach programs for all the children in the population.

The vaccine for TB is not used universally in all countries. In a country such as India, where the prevalence of TB is high, the vaccine is used to pre- vent childhood TB. However, in the United States it is not recommended because of the low risk of infec- tion related to receiving the vaccine and the variabil- ity of effectiveness of the vaccine against adult pulmonary TB.75

Vaccines continue to be a major prevention tool in public health. Science continues to work at develop- ing new vaccines such as a possible vaccine against HIV. In addition to the development and testing of vaccines, continued efforts are needed to implement effective vaccination programs. Not all persons at risk for increased morbidity and mortality related to influenza and pneumonia get vaccinated. There continues to be negative press related to the side effects of vaccines. However, without vaccines, smallpox eradication would not have happened. Altering the environment, inactivating the agent, and increasing the resistance of the host are all powerful tools that nurses can use to decrease the incidence of CDs.

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t CASE STUDY The Measles Epidemic

Learning Outcomes By the end of this case study, the student will be able to:

• Gain understanding of the investigation of an epidemic.

• Describe appropriate prevention measures. • Apply the cycle of transmission to individual

infectious agents.

In 2016, there were 86 cases; in 2017, there were 118 cases; and from January 1 to April 25, there were 63 confirmed cases of measles reported to the CDC with the majority unvaccinated.76 Starting with the current year, plot the number of cases of measles for the past decade then answer the following questions:

1. What would represent an endemic incidence rate, and at what point would the CDC decide there was an epidemic that required action?

2. What is the mode of transmission for the agent? 3. In 2018, the CDC identified lack of immunization as

the key issue. Using the epidemiological triangle, is the appropriate prevention approach related to the agent, the environment, and/or the host?

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43. Council of State and Territorial Epidemiologists. (2017). Public health reporting and national notification for Shiga Toxin-Producing Escherichia coli (STEC). Retrieved from https://c.ymcdn.com/sites/www.cste.org/resource/resmgr/ 2017PS/2017PSFinal/17-ID-10.pdf.

44. Rangel, J.M., Sparling, P.H., Crowe, C., Griffin, P.M., & Swerd- low, D.L. (2005). Epidemiology of Escherichia coli 0157:H7 out- breaks 1982–2002. Emerging Infectious Disease, 11(4), 603–609.

45. Centers for Disease Control and Prevention. (2007). Multistate outbreak of E. coli 0157 infections linked to Topp’s brand ground beef patties. Retrieved from http:// www.cdc.gov/ecoli/2007/october/100207.html.

46. Centers for Disease Control and Prevention. (2018). Multistate outbreak of E. coli O157:H7 infections linked to romaine lettuce. Retrieved from https://www.cdc.gov/ ecoli/2018/o157h7-04-18/index.html.

47. U.S. Department of Health and Human Services. (2018). Healthy People 2020. Topic—sexually transmitted diseases. Retrieved from http://www.healthypeople.gov/2020/ topicsobjectives2020/overview.aspx?topicid=37.

48. U.S. Department of Health and Human Services. (2017). Healthy People 2020 Midcourse review Chapter 37: sexually transmitted disease. Retrieved from https://www.cdc.gov/ nchs/data/hpdata2020/HP2020MCR-C37-STD.pdf.

49. Centers for Disease Control and Prevention. (2017). 2016 sexually transmitted disease surveillance. Retrieved from https://www.cdc.gov/std/stats16/natoverview.htm.

50. Centers for Disease Control and Prevention. (2016). Sexually transmitted disease surveillance: Chlamydia 2016. Atlanta, GA: U.S. Department of Health and Human Services. Retrieved from https://www.cdc.gov/std/stats16/chlamydia.htm.

51. Centers for Disease Control and Prevention. (2016). Sexually transmitted disease surveillance: Gonorrhea 2016. Atlanta, GA: U.S. Department of Health and Human Services. Re- trieved from https://www.cdc.gov/std/stats16/gonorrhea.htm.

52. Centers for Disease Control and Prevention. (2017). Gonorrhea treatment and care. Retrieved from https:// www.cdc.gov/std/gonorrhea/treatment.htm.

53. Centers for Disease Control and Prevention. (2017). Sexually transmitted diseases surveillance: Syphilis 2017. Atlanta, GA: U.S. Department of Health and Human Services. Retrieved from https://www.cdc.gov/std/stats17/syphilis.htm.

54. Centers for Disease Control and Prevention. (2017). Syphilis statistics. Retrieved from https://www.cdc.gov/std/stats17/ figures/39.htm.

55. Centers for Disease Control and Prevention. (2017). Syphilis. Retrieved from https://www.cdc.gov/std/stats16/Syphilis.htm.

56. Hogben, M., & Leichliter, J.S. (2008). Social determinants and sexually transmitted disease disparities. Sexually Transmitted Disease, 35, S13-S18.

57. Chesson, H.W., Kent, C.K., Owusu-Edusei, K., Jr., et al. (2012). Disparities in sexually transmitted disease rates across the “eight Americas”. Sexually Transmitted Disease, 39, 458-464.

58. Endyke-Doran, C., Gonzalez, R.M., Trujillo, M., Solera, A., Vigilance, P.N., Edwards, L.A., & Groves, S.L. (2006). The Syphilis Elimination Project: Targeting the Hispanic commu- nity of Baltimore City. Public Health Nursing, 24(1), 40–47.

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59. Martin P.M.V., & Martin-Granel, E. (2006). 2,500-year evolution of the term epidemic. Emerging Infectious Diseases, 12(6), 976–980.

60. Green, M.S., Swartz, T., Mayshar, E., Lev, E.B., Leventhal, A. Slater, P.E., & Shemer, J. (2002). When is an epidemic an epidemic? Israel Medical Association Journal, 4, 3–6.

61. Centers for Disease Control and Prevention. (2017). HIV/AIDS. Atlanta, GA: U.S. Department of Health and Human Services Retrieved from https://www.cdc.gov/hiv/ basics/statistics.html.

62. Beyeza-Kashesya, J., Wanyenze, R.K., Goggin, K., Finocchario- Kessler, S., Woldetsadik, M.A., Mindry, D., … Wagner, G.J. (2018). Stigma gets in my way: Factors affecting client- provider communication regarding childbearing among people living with HIV in Uganda. PLoS One, Open Access. https://doi.org/10.1371/journal.pone.0192902.

63. Praditporn, P., & Wilawan, M. (2016). Challenges in the prevention of HIV among Thai homosexual males in the era of diversity and freedom of culture. Australian Nursing & Midwifery Journal, 24(5), 41.

64. Koster, O. (2007). Flesh-eating bug killed top economist in 24 hours. Mail Online. Retrieved from http://www.dailymail. co.uk/news/article-428234/Flesh-eating-bug-killed-economist- 24hours.html.

65. Isabel. (2018). Isabel’s story. Retrieved from https:// symptomchecker.isabelhealthcare.com/about-isabel- symptom-checker.

66. Waldron, C., Solon, J.G., O’Gorman, J., Humphreys, H., Burke, J.P., McNamara, D.A. (2015). Necrotizing fasciitis: The need for urgent surgical intervention and the impact of

intravenous drug use. Surgeon, 13(4), 194-9. doi: 10.1016/ j.surge.2014.01.005.

67. Centers for Disease Control and Prevention. (2017). Necrotizing fasciitis. Retrieved from https://www.cdc. gov/features/necrotizingfasciitis/index.html.

68. U.S. Department of Health and Human Services, Vaccines.gov. (n.d.). Glossary of terms. Retrieved from http://www.vaccines.gov/more_info/glossary/index.html.

69. Centers for Disease Control and Prevention. (2017). Vaccine safety. Retrieved from https://www.cdc.gov/vaccinesafety/ index.html.

70. Centers for Disease Control and Prevention. (2017). For parents: Vaccines for your children. Retrieved from https:// www.cdc.gov/vaccines/parents/vaccine-decision/index.html.

71. World Health Organization. (2018). Infectious diseases. Retrieved fromhttp://www.who.int/topics/infectious_ diseases/en/.

72. World Health Organization. (2018). Emergency preparedness, response. Retrieved from http://www.who.int/csr/en/.

73. Centers for Disease Control and Prevention. (2018). Measles (rubeola). Retrieved from http://www.cdc.gov/measles/.

74. Health Resources and Services Administration. (n.d.). National Vaccine Injury Compensation Program. Retrieved from http://www.hrsa.gov/vaccinecompensation/index.html.

75. Centers for Disease Control and Prevention. (2018). Fact sheet: BCG vaccine. Retrieved from http://www.cdc.gov/tb/ pubs/tbfactsheets/BCG.htm.

76. Centers for Disease Control and Prevention. (2018). Measles cases and outbreaks. Retrieved from https://www.cdc.gov/ measles/cases-outbreaks.html.

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Chapter 9

Noncommunicable Diseases Christine Savage

LEARNING OUTCOMES

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

KEY TERMS

1. Describe the impact of noncommunicable diseases on the health of a population.

2. Define the burden of noncommunicable diseases using current epidemiological frameworks.

3. Describe the risk factor at the individual and population levels related to development of a noncommunicable disease.

4. Apply current evidence-based population interventions to the prevention of noncommunicable diseases.

Burden of disease Chronic disease Chronic disease

self-management Cultural shift Disability-adjusted life

years (DALY)

Health-adjusted life expectancy (HALE)

Health-related quality of life (HRQoL)

Human genome epidemiology

Human genomics Life expectancy Monogenetic Noncommunicable

disease (NCD) Polygenetic

Premature death Years of productive life

lost (YPLL)

n Introduction In contrast with communicable diseases, a noncommu- nicable disease (NCD) is a disease that is not passed from one person to the next through direct or indirect means and is not associated with an infectious agent. The broader term, chronic disease, refers to either communicable dis- eases such as AIDS, or NCDs such as diabetes that have a long duration and usually slow progression, require med- ical attention over time, and/or limit the ability to perform activities of daily living (ADLs).1 According to the World Health Organization (WHO) there are four main cate- gories of NCDs: cardiovascular diseases (CVD), cancers, chronic respiratory diseases (CRD), and diabetes.1

The news and talk shows constantly reference our risk for NCDs and encourage us to engage in healthy behav- iors. We are told to eat healthfully, engage in regular ex- ercise, and avoid unhealthful behaviors such as tobacco use, overeating, and risky use of alcohol and drugs. For those of us who are currently healthy, it is easy to assume that NCDs do not affect us directly. The truth is that the

burden of disease associated with NCDs affects us all. NCDs decrease our community’s ability to reach optimal productivity and health, and contribute to the increasing cost of health care. If we solely focus on combating NCDs on the individual level after disease has occurred, we are doomed to failure in the long run. Many risk factors that contribute to the development of NCDs, such as expo- sure to secondary smoke in public places, are beyond the ability of an individual to control or modify. True change requires a population-level approach that encompasses interventions that require action at the individual, family, and community level. Nurses in all settings play an im- portant role in prevention of NCDs across the contin- uum of prevention through primary-, secondary-, and tertiary-level interventions.

Noncommunicable Chronic Diseases The majority of NCDs cannot be prevented or cured through vaccination or medication; rather, they require maintaining a healthy lifestyle, early diagnosis and

218

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treatment, and long-term management. Annually, a total of 40 million people die from a NCD, approxi- mately 70% of all deaths globally.2,3 In the United States, preventing NCDs is a major priority as reflected in many of the Healthy People (HP) objectives.4 The majority of NCDs could be prevented through a reduc- tion in behavioral risks such as tobacco use, sedentary lifestyle, harmful alcohol use, and an increase in health- ful eating.2

Health-care providers, including nurses, typically care for those with NCDs on an individual basis, often during an acute phase of the disease or at the end stages of disease. More recently, especially with the imple- mentation of the Affordable Care Act, the care of NCDs is moving away from an acute care model to a chronic care model in which the disease is managed over time and the focus is decreasing morbidity and mortality associated with NCDs through an integrated care delivery model (Fig. 9-1).5 This model requires health-care providers to reframe the care provided from the treatment of acute phases of an NCD within an acute care setting to long-term management in the community. Care of an existing NCD should be provided within a secondary and tertiary prevention framework that focuses on early detection and treat- ment as well as a long-term plan of care aimed at re- ducing morbidity and mortality (see Chapter 2). To accomplish this, nurses must use not only their knowl- edge of the pathophysiology of an NCD but an under- standing of the public health issues associated with the

disease. All nurses have a role to play in reducing the burden of disease related to NCDs in populations they serve. Nurses across settings and specialties become part of national and global efforts aimed at reducing the toll that chronic diseases take on the health of not only individuals but also of populations.

C H A P T E R 9 n Noncommunicable Diseases 219

ProductiveProductive InteractionsInteractions

Delivery System Design

Organization of Health Care

Health Systems

Improved Outcomes

Prepared, Proactive

Practice Team

Productive Interactions

Informed, Activated Patient

The Chronic Care Model

Resources and Policies

Community

Self- Management

Support

Decision Support

Clinical Information

Systems

Figure 9-1 The Chronic Care Model. (Developed by the MacColl Institute, ®American College of Physicians-ASIM Journals and Books.)

n CELLULAR TO GLOBAL Chronic noncommunicable disease occurs at the cel- lular level for an individual, yet management of a NCD over time requires an understanding not only of the risk factors across the continuum of cellular to global but also of the resources needed to provide care to those with NCDs. There is also a need for commu- nity and global level interventions aimed at reducing morbidity and mortality associated with NCDs. Build- ing on the chronic disease care model that focuses on care of individuals and families is the wider scope of factors that contribute to the morbidity and mortality associated with NCDs. The WHO acknowledges that action to reduce the burden of disease associated with NCDs includes “… a comprehensive approach … requiring all sectors, including health, finance, trans- port, education, agriculture, planning and others, to collaborate to reduce the risks associated with NCDs, and promote interventions to prevent and control them.”2 Prevention of NCDs and care for in- dividuals with NCDs occurs within the context of the community where they live.

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Burden of Disease NCDs add significantly to the overall burden of disease for a population. The burden of disease uses the disability- adjusted-life-year (DALY) measure to determine the extent of the burden a disease has on a population (see later).6 Knowing about the burden of disease associated with a specific disease helps in understanding the impact the disease has on the population or community. Esti- mating the burden of a disease can help a community prioritize health promotion and prevention efforts by targeting those diseases that account for the greatest bur- den to the community. Determining the burden of dis- ease involves calculating not only the cost of treatment but also the social and economic impacts. Analysis of the burden of a disease allows for the assessment of the com- parative importance of a disease, injury, or risk factor. This assessment takes into account how much the dis- ease, injury, or risk factor contributes to overall disability and premature death in the population.

For example, if in Berryton, a hypothetical U.S. town of 8,000 adults, the prevalence of type 2 diabetes rose from 160 (2%) to 800 (10%) cases, the impact on the town would involve more than the cost to treat the indi- viduals with the disease. Let’s add another aspect to this town. It is a rural farming community recently hit with a shortage of migrant farm workers resulting in an in- ability to harvest all of the tomatoes, the town’s main crop. The new cases are occurring for the most part in 35- to 45-year-old males, and the closest medical center is 100 miles from the town. With a depressed economy, rural setting, and reduced access to care, the potential for adverse consequences and premature death associated with diabetes is increased. This could result in a decrease in the number of able-bodied people to work on the farms, further depressing the economy. Thus, the impact of an NCD extends beyond individuals and their fami- lies. For this community, the disease contributed to re- duced productivity and adversely affected the economic viability of the town.

Life Expectancy Estimating the health of a population is calculated based on a number of measures. First, mortality rates are used to estimate the life expectancy of a group of people. Life expectancy is defined as the number of years a person could be expected to live based on the current mortality rates in a specific setting, usually a country. There is great variability across countries in life expectancy, especially between developed and developing countries. For exam- ple, the estimated life expectancy in the United States for 2017 was 80 years and in Afghanistan it was 51.7 years.7

Life expectancy is a valuable tool, but it fails to capture the burden of ill health caused by NCDs. To help ad- just for these factors, public health officials use the healthy life expectancy measure. Health-adjusted life expectancy (HALE) reflects the average number of years that a person can expect to live in good health by adjust- ing for disease and/or injury. The WHO uses HALEs to measure the average level of health in countries and re- gions by evaluating population-specific prevalence of dis- ease and injury as well as severity distribution of health states.8 As a result of problems with comparable health state prevalence data, the WHO uses a four-stage strategy to compute HALE (Box 9-1). This allows the WHO to estimate HALE for countries across the globe. Epidemi- ologists compute the HALE for a chronic disease using data related to age, the number of survivors, and the number of years lived.

Premature Death NCDs often lead to premature death, that is, a death that occurs earlier than the standard life expectancy. For those who die prior to reaching the age they would be ex- pected to live, their death is defined as premature. There- fore, premature death reflects the number of potential life years lost. Premature death is usually expressed as the

220 U N I T I I n Community Health Across Populations: Public Health Issues

The World Health Organization uses death registration data that are reported annually to estimate HALE. This information is part of the WHO Global Burden of Disease (GBD) study. Other sources of data include the WHO Multi-Country Survey Study (MCSS) and World Health Survey (WHS). Information use includes estimates for the incidence, prevalence, duration, and years lived with disability for 135 major causes. However, compara- ble health state prevalence data are not available for all countries, so a four-stage strategy is used:

• Data from the WHOGBD study are used to estimate severity-adjusted prevalence by age and sex for all countries.

• Data from the WHOMCSS and WHS are used to make independent estimates of severity-adjusted prevalence by age and sex for survey countries.

• Prevalence for all countries is calculated based on GBD, MCSS, and WHS estimates.

• Life tables constructed by WHO are used to compute HALE for countries.

BOX 9–1 n Application: Health-Adjusted Life Expectancy (HALE): Methods of Estimation

Source: (8)

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years of potential life lost (YPLL). YPLL is calculated by subtracting the age at which a person dies from their expected life expectancy.10 For example, if a man died of a heart attack in the United States in 2011 at the age of 42, the YPLL would be 36 because the life expectancy in the United States was 78 years that year.11 By contrast, the YPLL for a man who died in a motor vehicle crash at the age of 21 would be 57.

From a population perspective, premature death is calculated based on the number of potential life years lost prior to the life expectancy of the population per 100,000 persons—in other words, how many total years of useful life were not available to the population because of early death. If you calculated the YPLL for a 50-year-old man who died of a heart attack in Afghanistan in 2011, the YPLL would be 0 because the life expectancy for males was 49.

Disability-Adjusted Life Years In addition to premature death, most NCDs lead to dis- ability that can affect an individual’s quality of life and productivity. For that reason, YPLL does not adequately capture the full burden of disease. A method for quanti- fying the burden of disease that takes into account both premature death and disability is called the disability- adjusted life year (DALY). This is defined as measure- ment of the gap that exists between the ideal health status of a disease- and disability-free population that lives to an advanced age.9 It is calculated using population-level data. One DALY represents 1 lost year of life. It is calcu- lated as a sum of the years of life lost (YLL) related to pre- mature death in the population plus the years lost to disability (YLD) related to the disease.

To calculate the DALY, you start with the YLL. The YLL is the number of deaths multiplied by the standard life expectancy at the age at which death occurs. For this you need the number of deaths attributed to the disease or risk factor and the expectancy at age of death in years. YLL measures lost years of life due to deaths using an in- cidence perspective (number of new cases or deaths), this perspective is also taken to calculate the YLD. For an es- timation of the YLD for a particular cause in a particular time period, you take the incidence (number of new cases) during that time period and multiply it by the av- erage duration of the disease. To account for the variabil- ity of the severity of the disease, a weight factor is included that reflects the severity of the disease on a scale from 0 (perfect health) to 1 (dead). The basic formula for YLD requires multiplying the incidence times the dis- ability weight times the average duration of the disease until remission or death (Box 9-2).9

Noncommunicable Diseases in the United States NCDs are the number one cause of death and disability in the United States. The four common risk factors that account for much of the NCDs in our country are the same as the risk at the global level and are modifiable. These include (1) nutrition, (2) physical activity, (3) to- bacco use, and (4) alcohol use. One-fourth of all persons living in the United States with an NCD have one or more limitations in their daily activities.10 The first pro- posed goal of HP 2030 is to “Attain healthy, thriving lives and well-being, free of preventable disease, disability, in- jury, and premature death.”11 This requires prevention and early treatment of NCD. Healthy People includes multiple topics related to specific NCDs as well as the four common risk factors associated with development of NCDs.

Diabetes is an example of a topic for HP 2020 re- lated to NCD that will continue to be a focus of HP 2030. According to the American Diabetes Associa- tion, in 2015 more than 30 million people, almost 10% of the population of the U.S., had diabetes with 7.2 million undiagnosed and was the seventh leading cause of death. The annual cost in 2017 was $327 billion USD. 11

C H A P T E R 9 n Noncommunicable Diseases 221

DALY = YLL (Years of Life Lost) + YLD (Years of Life Disabled)

The basic formula for YLL is:

YLL = N × L

where:

• N = number of deaths • L = standard life expectancy at age of death in years

The basic formula for YLD is the following (again, without applying social preferences):

YLD = I × DW × L

where:

• I = number of incident cases • DW = disability weight • L = average duration of the case until remission or

death (years)

BOX 9–2 n Application: Disability-Adjusted Life Year (DALY) calculation

Source: (9)

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Leading Causes of Death and Disability According to the WHO, NCDs are not only costly but are common and often preventable causes of death and dis- ability.1 Seven of the top ten leading causes of death in the United States are NCDs including heart disease, cancer, chronic lower respiratory diseases, stroke (cerebrovascu- lar disease), Alzheimer’s disease, diabetes, nephritis, nephrotic syndrome, and nephrosis (Box 9-3).14 Under- standing NCDs from a public health perspective allows us to step back and examine the context of these diseases and the causal factors linked to the occurrence of disease.

Heart Disease and Stroke In the U.S., CVD and stroke are the first and fifth leading causes of death.14 They are costly and widespread. One

in every four deaths in the U.S. is attributable to CVD,15

and one in every 20 deaths is attributable to stroke.16 To- gether they account for close to one-third of all deaths in the United States.15, 16 Although rates for coronary heart disease have dropped over the last 3 decades, large re- gional variations in the burden associated with CVD exist across the U.S. with dietary risk exposures being the largest attributable risk factor related to CVD burden of disase.17,18 Other risk factors include high blood pressure, obesity, tobacco use, high cholesterol, and low levels of physical activity.18

Understanding the risk factors for CVD has come from public health science. Before World War II, hyper- tension was accepted as a part of the normal aging process and little was understood about how to treat it, never mind how to prevent it. As life expectancy im- proved, the prevalence of CVD grew. Because of this in- crease in prevalence, the National Heart Institute (now

222 U N I T I I n Community Health Across Populations: Public Health Issues

n HEALTHY PEOPLE Noncommunicable Disease: Diabetes

Goal: Reduce the disease burden of diabetes mellitus (DM) and improve the quality of life for all persons who have, or are at risk for, DM. Overview: DM occurs when the body cannot produce enough insulin or cannot respond appropriately to in- sulin. Insulin is a hormone that the body needs to ab- sorb and use glucose (sugar) as fuel for the body’s cells. Without a properly functioning insulin signaling system, blood glucose levels become elevated and other meta- bolic abnormalities occur, leading to the development of serious, disabling complications.

Many forms of diabetes exist. The three common types of DM are:

• Type 2 diabetes, which results from a combination of resistance to the action of insulin and insufficient in- sulin production

• Type 1 diabetes, which results when the body loses its ability to produce insulin

• Gestational diabetes, a common complication of pregnancy. Gestational diabetes can lead to perinatal complications in mother and child, and substantially increases the likelihood of cesarean section. Gesta- tional diabetes is also a risk factor for the mother and, later in life, the child’s subsequent development of type 2 diabetes after the affected pregnancy.12

Midcourse Review: Of the 20 objectives for this topic area, 2 were developmental and 18 were measurable. For 4 of the measurable objectives, the target was met or exceeded, and 1 was improving. For 10 there was little or no detectable change, and 1 objective was baseline only and 2 were informational (Fig. 9-2).13

22%

11%

6%

56%

5%

Baseline only Target met or exceeded Little or no change Improving Informational

Healthy People 2020 Midcourse Review: Diabetes

Figure 9-2 Midcourse Review Diabetes.

• 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 9–3 n Top 10 Leading Causes of Death, CDC 2017

Source: (14)

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known as the National Heart, Lung, and Blood Institute) initiated a longitudinal cohort study in 1948 (defined in Chapter 3) in Framingham, Massachusetts, which is still going on today.19 From the data collected over the past 6 decades, we now know a great deal about the risk fac- tors for CVD and stroke. Based on the findings from this study, both individual and population level interventions have been developed aimed at reducing risk and subse- quently reducing the prevalence of CVD.

Cancer Although great strides have been made in the prevention and treatment of cancer, it is the second leading cause of death in the United States and the world.14,20, 21 In the U.S., cancer mortality rates rose over the 20th century but are now declining mostly due to the drop in tobacco use. In addition, public health efforts to promote in- creased screening for breast and colorectal cancer have resulted in a decrease in deaths because of early detection and screening, and the length of cancer survival has in- creased.20 Globally, cancer accounts for 1 in 6 deaths with 30% to 60% preventable.21 Tobacco use is the leading risk factor for cancer with Lung cancer the leading cause of cancer death in both men and women; 80% of all lung cancers result from smoking or exposure to secondhand smoke.21

Risk for cancer is a combination of behavioral, ge- netic, and environmental factors. For example, in breast cancer all three levels of risk apply. Family history, diet, exercise, reproductive history, and alcohol use have all been associated with increased risk for breast cancer (Fig. 9-3).22,23 An example of genetic risk is the harmful mutation of BRCA1 or BRCA2, tumor suppressor genes. Women who test positive for this gene mutation have an increased lifetime risk for developing breast and ovarian cancers.24

Chronic Lower Respiratory Disease According to the WHO, CRD includes chronic obstruc- tive pulmonary disease (COPD), asthma, occupational lung diseases, and pulmonary hypertension. One of the most common is COPD, which includes emphysema and chronic bronchitis. Although treatable, these diseases are not curable and 90% of the deaths attributable to CRD occur in middle-income and low-income countries.25

The major risk factor for COPD and other CRDs is tobacco use, and the causative link between the two is the abnormal inflammatory response of the lungs to the nox- ious particles or gases present in tobacco smoke. Other risk factors include exposure to air pollutants, chemical fumes, and dust from the environment or workplace.25

Globally, indoor air quality is thought to play a bigger role in the development of COPD.26

Diabetes Over the past few decades, great improvements have oc- curred in the management of diabetes and the reduction in complications such as blindness and diabetes-related end-stage renal disease. Despite these advances, diabetes remains a leading cause of death in the U.S. and globally. According to the WHO, 422 million adults worldwide have diabetes, representing an almost quadrupling inci- dence since 1980.27

Although the incidence of diabetes in the U.S. has de- clined since 2008, the prevalence of diabetes is growing. In 2015, a little over 9.4% of the U.S. population and 12.2% of adults had diabetes.28 Differences exist in age- adjusted prevalence based on ethnic group with 15.1% of Native Americans and 12.7% of African Americans com- pared to 7.4% of white non-Hispanic and 8.1% of Asians, which may reflect socioeconomic status rather than an underlying genetic risk factor.28 Two underlying factors that have contributed to the increase in the incidence of type 2 diabetes globally are changes in lifestyle, especially exercising and diet. In addition, improved treatment has resulted in a longer survival rate. Thus, an increased in- cidence combined with an increased survival rate has re- sulted in an overall increase in the prevalence of type 2 diabetes (see Fig. 3-7, Chapter 3).27

C H A P T E R 9 n Noncommunicable Diseases 223

Figure 9-3 Risk Factors for Breast Cancer.

Family History

Reproductive History

Lifestyle

Alcohol Use

Age

Estrogen

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Public health efforts are in full force in attempting to turn this trend around. The focus has been on behavioral change to reduce individual risk. The prevention or delay of the onset of type 2 diabetes can happen through a healthy lifestyle that includes making healthful changes to diet, increasing the level of physical activity, and main- taining a healthy weight.27, 29 These recommendations are based on solid epidemiological data related to risk, that is, persons who exercise regularly, eat healthy, and maintain a normal body mass index (BMI) are at a much lower risk for type 2 diabetes. Type 1 diabetes is another story. Less than 10% of persons with diabetes have type 1. It is usually diagnosed in childhood and is associated with genetic risk rather than behavioral risk.

Risk Factors Risk for NCDs is complex and related to numerous fac- tors, individual behaviors, genetics, and environmental exposure as well as the larger socioeconomic context in which people live. To prevent NCDs, the epidemiologist explores factors that increase the risk of disease occur- ring. As explained in Chapter 3, two types of studies are often conducted to help determine what leads to devel- opment of disease: a case control study and a cohort study. Based on these studies, we can determine the rel- ative risk or the odds ratio of disease that can occur based on exposure to a risk factor. In chronic diseases, there are two major categories of risk that have received a great deal of attention nationally: lifestyle or behavioral risk factors and socioeconomic risk factors.

224 U N I T I I n Community Health Across Populations: Public Health Issues

w SOLVING THE MYSTERY Applying Public Health Science: The Case of the Struggling Heart Patients Public Health Science Topics Covered: • Assessment • Program Planning and Evaluation • Building Partnerships

In the Mississippi Delta, a section of western and northwestern Mississippi bordered by the Mississippi River and the Yazoo River, health-care providers were alarmed by the high rate of CVD in the Delta. According to the Mississippi State Health Depart- ment, residents of the Delta have the highest rates of stroke in Mississippi. In addition, the Delta and the state have the highest rates of obesity and CVD in the

United States.30 This area of Mississippi is faced with serious socioeconomic risk factors including poverty and low educational attainment. The poverty rate for the Delta ranges from 30% to 40% compared to 22% for Mississippi and 15% nationally.30,31 The chal- lenge, then, was to develop a program to increase access to routine health screenings and improve on disease self-management.

The Mississippi Department of Health, in partner- ship with the CDC, formed the Mississippi Delta Health Collaborative (MDHC) that included individu- als and groups across the community. They currently report progress in attaining their goal of reducing stroke and heart disease through three program areas: clinical, community, and faith-based. The clini- cal component has involved incorporating commu- nity health workers (CHWs) into the health-care team.30 Evidence has demonstrated the effectiveness of using community workers to address health needs in populations at risk. One of the challenges is to clarify the role of these workers.32 The most com- monly used definition is the one by the American Public Health Association: “A Community Health Worker (CHW) is a front line public health worker who is a trusted member of and/or has an unusually close understanding of the community served. This trusting relationship enables the CHW to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery. A CHW also builds individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support, and advocacy.”33

The MDHC conducted an initial assessment and identified community assets including mayoral health councils, schools, and churches. Building on these as- sets, they partnered with the CDC and implemented the Clinical-Community Health Worker Initiative (CCHWI). The focus was to improve clinical outcomes for CVD through use of the ABCS— appropriate Aspirin use, A1c (hemoglobin control), Blood pressure control, Cholesterol management, and Smoking cessation.34

The CCHWI program uses a system in which referrals are made from multiple sources including health-care providers in federally qualified health centers (FQHCs) and rural clinics as well as referrals

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based on elevated blood pressure readings ob- tained during from health screenings conducted in barbershops, churches, and other MDHC partner locations. A MDHC program manager and two regis- tered nurses provide oversight for the CHWs and are available for consultation.34 According to the CDC, a total of 8 CHWs visit patients throughout 17 of the 18 Delta counties. 34 CHWs follow the ABCS protocol during their visit (Box 9-4).

As noted in Chapter 5, evaluation is a key compo- nent of health planning. For this program, evaluation demonstrated the benefits of using CHWs to help reduce the morbidity and mortality associated with CVD. According to the MDHC report they had seen 1,057 patients and found significant mean changes in both diastolic and systolic blood pressure readings indicating better controlled blood pressure. They established relationships with churches and barbershops. Of the 27 barbershops who joined the collaborative, 17 became smoke free. In the 77 churches that partnered with the collaborative, 73 congregational nurses and advocates were trained. They concluded their report with the following: “Every time a local barber identifies someone with high blood pressure, every time a church holds a

wellness fair, every time a clinical CHW encourages her clients to get up and move, and every time some- one doesn’t light up a cigarette in public spaces, the Delta becomes a healthier place.”30

The Case of the Struggling Heart Patients illustrates the role that socioeconomic status plays in increasing risk for CVD as well as the importance of in- corporating community members into population-level programs to assure that the programs are relevant to the community, reflect an understanding of the cultural context of a community, and the power of bringing together multiple groups and individuals to address a serious health issue in the face of limited resources. Using CHWs, the program provided patients with members of their own community to help them self-manage their disease and address behavioral risk factors, specifically smoking and obesity.

Once referrals are made, the CHWs follow-up with patients within 48 hours through face-to-face contact, phone calls, or mailings to establish and maintain linkages to health care, promote adherence to treatment proto- cols, and work toward improvement in the ABCS. Specif- ically, CHWs conduct home visits that last about 1 hour, where they:

• Offer informal counseling on medication adherence, to- bacco cessation, healthy nutrition, and physical activity.

• Encourage patients to use a primary care provider if screenings indicate the need.

• Reduce barriers to health-care access by arranging transportation, assisting patients with scheduling appointments, and helping patients prepare for medical visits.

• Contact clinical systems when patients have elevated blood pressures.

• Use an online web-based portal to collect quantitative and qualitative information during the home visits as part of MDHC’s ongoing evaluation.

BOX 9–4 n ABCS protocol

Source: (30, 34)

Behavioral Risk Factors The WHO posed a question: “Why treat people’s illnesses without changing what made them sick in the first place?”35 We must strive to understand what contributes to the occurrence of NCDs. In addition to environment, much attention has been given to the role of individual behaviors. The current focus is on healthy nutrition, adequate exercise, and avoidance of substance misuse, es- pecially tobacco and alcohol (see Chapter 11). The evalu- ation of risk factors has been the dominant paradigm of the late 20th century and through the first decade of the 21st century. Understanding risk factors requires an un- derstanding of public health science, especially epidemi- ology. Most of the studies that have established the link between a risk factor and a disease are based on case con- trol and cohort studies (see Chapter 3). Often, the explo- ration of risk factors begins with a basic community/ population assessment (see Chapter 4).

Nutrition, Exercise, and Obesity More than a third of U.S. adults are obese (have a BMI greater than or equal to 30).36 Differences in prevalence exist in relation to racial/ethnic groups, an age-adjusted obesity rate of 48.1% in African Americans, 42.5% in Hispanic non-blacks, 34.5% of white non-Hispanic, and 11.7% in Asians.36 About 17% of children and adoles- cents are obese.37 It is well-known that obesity and over- weight increase the risk for NCDs, especially heart disease, type 2 diabetes, certain cancers, and stroke.

The main risk factors associated with obesity are poor nutrition and lack of exercise, which reflect individual

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the air quality and alert residents when the air quality places a person at risk for health consequences (see Chapter 6). The environment plays a key role in under- standing the risk for NCDs and is best understood through the application of public health science methodologies.

behaviors that are thought to be modifiable, that is, they can be changed with intervention. However, using the web of causation (see Chapter 3), these two risk factors are linked to numerous other factors at the population level, including changes in population behaviors, envi- ronmental factors, and socioeconomic factors. The risk factor model often fails to establish the complex link be- tween individual behaviors, population-level factors, and the development of NCDs. A good place to start when faced with a growing health problem such as obe- sity is to do a population-level focused assessment that allows for assessment of both the individual level and community level data. This type of assessment can help identify who is at greatest risk for obesity as well as the population-level factors that contribute to obesity. For example, the prevalence rate for obesity in Mississippi was higher than the national level.30 A more thorough population-level assessment can help the primary health network (PHN) develop an intervention that is cultur- ally relevant and takes into consideration barriers faced by the population.

Environmental Risk Factors for Noncommunicable Disease It is also important to remember that environment plays a key role in the development of NCDs (see Chapter 6). Pollutants in the environment increase the risk for asthma, cardiovascular health problems, and cancer.38,39

These pollutants include those found in the air, the home, the water supply, and the ground. Since 1950, the United States has experienced drastic changes in the food supply, the built environment, increased population, and prolif- eration of environmental chemicals. The built environ- ment includes the structures that exist in our towns and cities such as buildings, roads, sewage systems, parks, and recreation facilities (see Chapter 6). In 1800, only 3% of the world’s population lived in an urban setting. In 2018, 55% of the population was urban, and the United Nations (UN) projected that, by 2050, 68% of the world’s popula- tion will be urban. The most urbanized region in the world is North America with 82% of the population living in an urban area. By contrast, 48% of the population in Africa lives in a rural setting, but this is changing, with most of the future urban growth projected by the UN to occur in Africa and Asia (see Chapter 16).40 The growth of cities reflects a growth in commerce, economic oppor- tunities, and opportunities for building social capital. However, it also increases issues related to environmental pollutants. For example, most of us are aware of the po- tential pollutants in the air. Local news stations report on

226 U N I T I I n Community Health Across Populations: Public Health Issues

l APPLYING PUBLIC HEALTH SCIENCE The Case of the Growing Children Public Health Science Topics Covered:

• Assessment • Program planning

In Marksville County, a hypothetical county located in the state of Florida close to the Everglades, there was a growing concern among the citizens about the prevalence of obesity and overweight among the chil- dren as well as county adults. The issue arose at a city council meeting in Yonston, the only major city in the county. The mayor and city council charged the health officer with heading up a task force to address this issue and asked the task force members to concentrate on childhood obesity. The most obvious step in ad- dressing the issue was first to conduct an assessment. The county had a population of 10,576. The ethnic pro- file of the county was 5% Seminole Indians, 11% African American, 17%, Hispanic, 65% Caucasian, and 2% other races. Seventeen percent of the population was under the age of 18. The health officer knew that the first step would be to mobilize a broad band of stakehold- ers and community residents. Before doing so, the health officer decided to seek a commitment from a smaller group, the steering committee.

After thinking about this in consultation with other people, the health officer chose the following people for the steering committee: the principal of the local high school, a university professor from the local nurs- ing school, the county political representative, CEO of the local hospital, two businesspeople, and the director of the Head Start program. The CEO talked with the nurse manager of the pediatric unit and asked her to represent him on the committee. Orientation meetings were held, and goals and objectives of the initiative were set. The overall goal was to conduct a community assessment focused on determining the extent of obe- sity and overweight in Marksville County, to examine trends of the epidemic, to identify resources for ad- dressing the issue, and to develop an action plan.

An assessment related to a specific health issue helps bring about a greater understanding of the

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C H A P T E R 9 n Noncommunicable Diseases 227

factors influencing that health issue for that particular population. This committee conducted a focused as- sessment (see Chapter 4) related to obesity in chil- dren and adolescents. Overweight and obesity, which are determined by using weight and height to calcu- late a BMI, are growing public health problems for adults and children.37 An adult who has a BMI that ranges between 25.0 and 29.9 is considered over- weight. If the BMI is 30 or higher, then the person is considered obese. For children and adolescents, over- weight is often defined as at or above the 95th per- centile of the sex-specific BMI for age growth chart. Ranges above a normal weight have different labels: at risk for overweight and overweight.41

After establishing the steering committee, a larger coalition was formed to build the structure needed to conduct the assessment. Invitations were sent out to a broader constituency to develop a coalition to ad- dress the issue. Initially, the public was invited to a town hall meeting. The goal was to increase aware- ness about obesity and overweight within the commu- nity and to gain a commitment to get involved. They provided the community with the data on obesity in their county based on data from the Florida Depart- ment of Health.

The committee then presented the community with the facts about why childhood obesity is an important public health issue for their county. They explained that obesity occurs when more calories are consumed than are expended. They further explained that they were tackling this problem because childhood obesity has both immediate and long-term health impacts. If the community did not act, they would be faced with sicker children as well as the long-term cost of caring for more adults with chronic diseases occurring at an ear- lier age. According to the CDC, 70% of obese youth have at least one risk factor for CVD, such as high cho- lesterol or hypertension. Obese children and adoles- cents are at greater risk for bone and joint problems. They also suffer from psychological problems because of social stigma and low self-esteem. As adults, they are at higher risk for CVD, type 2 diabetes, stroke, cancer, and osteoarthritis.37

The committee was able to grab the community’s attention when they gave the facts about type 2 dia- betes among the children of the county. Based on hos- pital discharge data from the county hospitals, 50 of their children were already being treated for type 2 diabetes with an overall prevalence rate of 2.8 per 1,000 children and adolescents, higher than the national

prevalence of 1.7 per 1,000. The subpopulation most affected in their community was the Seminole Indians, with 14 Seminole children in their county diagnosed with type 2 diabetes, a prevalence rate of 4.9 per 1,000 children under the age of 18. Thus, 28% of the children diagnosed with type 2 diabetes in their county were Seminole Indians.

With the support of the community, the committee added key members suggested by the community to help them complete a more in-depth assessment. They began by reviewing national statistics related to the prevalence of obesity/overweight in children and ado- lescents and comparing those rates with their own rates. They were able to find national reports on the extent of the problem as well as a national-level con- cern related to the problem. One of the objectives of HP is concerned with reducing the proportion of children and adolescents who are obese.42

n HEALTHY PEOPLE Nutrition and Weight Status

HP 2020: Objective: Nutrition and weight status (NWS)—children and adolescents NWS-10: Reduce the proportion of children and adolescents who are considered obese

NWS-10.1 Children aged 2 to 5 years NWS-10.2 Children aged 6 to 11 years NWS-10.3 Adolescents aged 12 to 19 years NWS-10.4 Children and adolescents aged 2 to

19 years

HP 2020 Midcourse Review: Based on the data reported in the Healthy People Midcourse review, there was little or no detectable difference from baseline.

Source: (42, 43)

The team reviewed the National Center for Health Statistics Data Brief and found that the prevalence of obesity among children remained high.43 After further review they also discovered that, on the national level, the prevalence of obesity is higher in Native American children than the population as a whole.44 Another source of secondary data came from the Youth Risk Behavioral Surveillance System (YRBSS), which is a state-based health survey that annually collects infor- mation on health conditions, behaviors, preventive practices, and access to health care.45 It is used to monitor health problems in youth as well as healthy

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228 U N I T I I n Community Health Across Populations: Public Health Issues

and unhealthy behaviors, including the prevalence of obesity among youth and young adults. They also located information on youth behaviors specific to Florida that was helpful in comparing the state statistics with national statistics.46

Based on their review of the YRBSS, they noticed that, not only were the health behaviors of individual students assessed, but environmental factors were in- cluded as well. The nurse manager of the pediatric unit at the community hospital remembered a discussion in a recent nursing practice committee meeting about the problem of only focusing on individual risk factors when examining a health problem. She went back to the literature and examined new developments in public health science and again reviewed the web of causation (see Chapter 3). She brought back to the committee her concerns about focusing on behavioral

risk factors alone. She argued that the risk factor para- digm targets individual change only and ignores the dif- ference between individual risk factors and population risk factors; she encouraged the committee to take a macro-look at risk factors as well.47 The committee agreed to do this.

Taking this broader view of risk related to healthy diet and exercise in children and adolescents, the com- mittee reviewed the importance of a healthy school environment that should include a focus on health education, healthy food availability, and physical education (PE). On the CDC’s Web site they found a model for schools to use to help prevent childhood obesity called the Whole School, Whole Community, Whole Child (WSCC) (Fig. 9-4).48 The four main components of this model were: (1) Physical education and physical activ- ity; (2) Nutrition environment and services; (3) School

Figure 9-4 Whole School, Whole Community, Whole Child (WSCC). (From the CDC https://www.cdc.gov/healthyyouth/ wscc/)

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Tobacco Use In addition to nutrition and exercise, tobacco use is a major behavioral risk factor for chronic disease (see Chapter 11). The use of tobacco is strongly associated with increased risk for adverse health outcomes includ- ing cancer, pulmonary disease, and CVD. According to the CDC, approximately 90% of all lung cancer deaths in men and close to 80% of lung cancer deaths in women are directly related to tobacco smoking.50 Although to- bacco use has declined over time, in 2015, 15% of adults in the U.S. were current smokers and 1.1 billion people smoked tobacco worldwide with 80% of users living in low-income countries.51-53 The single most preventable cause of morbidity and mortality is the use of tobacco.51

Globally, tobacco use kills half of its users with an esti- mated 7 million people dying each year prematurely of diseases related to smoking.53 To address this major health issue, in 2000 Healthy People 2010 set an objective of reducing tobacco use to 12% of adults aged 18 or older (see Chapters 3 and 11). By 2016 this goal was met in only two states, California and Utah. The percentage of current smokers in the United States in 2016 by state ranged from 8% in Utah to 24.6% in Kentucky and 24.8% in West Virginia.54

There is strong evidence to support the benefit of smoking cessation. People who quit smoking have a lower risk of lung cancer than if they had continued to smoke.55,56 The challenge is that the use of tobacco is more than an individual issue and requires interventions at the population and community level. Both the WHO and the U.S. Department of Health and Human Services have presented population-level strategies aimed at re- ducing tobacco use. From a global perspective, the WHO initiated an international tobacco treaty in 2005. Based on a recent study, researchers concluded that there was a significant association between the demand-reduction measures included in the treaty and lower smoking prevalence. They concluded that there would be future reductions in tobacco-related morbidity and mortality.

C H A P T E R 9 n Noncommunicable Diseases 229

health services to support physical, psychological, and emotional health; and (4) Family and community en- gagement. The committee now had some important data using secondary data sources from the national, state, and county level as well as a framework to help design a prevention program.

They decided they were missing key information, especially the information found in the YRBSS, be- cause their analysis of county data was hampered by a small numbers problem; that is, there were not enough respondents in the national survey to make any conclusions. They decided to do their own survey of school-age children in the county as well as collect institution-level data on the schools in the county to determine what was being offered related to health education, PE, and nutrition. In addition, they col- lected data from the Head Start and the Women, Infants, and Children (WIC) programs.

In looking at the data, a growing trend in the com- munity was noted from the 2015-2016 program year and the 2016-2017 program year. During the 2015- 2016 program year, 22% of children in Head Start and 18% of children in Early Head Start were identified as overweight. In the 2016-2017 program year, the per- cent for Early Head Start stayed the same but for Head Start it increased to 24%. In the two WIC programs in the county, 18% of children were identified as over- weight. These percentages were higher than the popu- lation of those under the age of 18 as a whole. These data on the under-5 age group illustrated the need to develop a program that extended beyond school-age children. Also, based on their earlier data, those at greatest risk for adverse consequences related to obesity were the Seminole Indian children.

They also examined the school data and found that the county schools performed similarly to the rest of the state on the CDC indicators. Healthy nutrient and dietary behavior habits were taught at both the ele- mentary and high school levels, but they did not include key physical activity topics in these courses. Because of recent budgetary problems, PE was no longer offered in the schools, though they had an intramural sports program at the high school and middle school levels. The vending machines in the school did not sell healthy foods, and soft drinks were advertised in the school. Notably, the Pepsi Cola Company donated the new school football scoreboard. They also found that the school cafeteria prepared foods using a deep-fat fryer.

Based on these findings, the committee began to put together action steps to address the issues specific to

their community. They wanted to develop a broad pro- gram that would include children aged 5 and below as well as children and adolescents attending school. They also felt it was important to engage the Seminole Indian community in the planning to make sure that any inter- vention developed was culturally relevant. They started with the nine guidelines found on the CDC Web site.49

In this way, the schools became leaders in the fight against childhood obesity and in the promotion of a healthier lifestyle in their community.

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These findings demonstrate the value of implementing population-level interventions.57

Alcohol Use Alcohol use accounts for 5.1% of the global burden of disease and is a component cause of more than 200 dis- eases and injury conditions (see Chapter 11).58-60 Reduc- tion in the burden of disease associated with alcohol use requires a health-care workforce capable of implement- ing evidence-based interventions across the continuum of alcohol use and the life span. If health-care providers understand the continuum of alcohol use across the life span, including adverse alcohol-related health conse- quences for both the drinker and non-drinker, the scope of prevention and intervention efforts is greatly ex- panded. Although alcohol consumption is a socially ac- ceptable and normative practice in the United States, it has the potential to adversely affect health across the life span, including but not limited to injury, breast cancer, hypertension, stroke, liver disease, and brain damage.58,59

Genomics and Risk for Noncommunicable Disease Understanding risk for NCDs includes the genetic risk each person or group of genetically related persons has for dis- ease. Human genomics is the study of the genetic structure or genome of a living human. Evidence gathered through genomics clearly demonstrates that there is a genetic role in the major NCDs including cancer, diabetes, health dis- ease, and asthma.61,62 Genetic risk predisposes a person to disease independent of environmental and behavioral risks. Understanding genetic risks and identifying genetic muta- tions offer hope for both prevention and treatment of chronic disease. An example of genetic risk is the BRCA1 and BRCA2 gene mutations, known as tumor suppressors, which increase the risk for breast cancer.63 Persons who screen positive for BRCA1 and BRCA2 mutations can choose either to undergo prophylactic surgery (removal of both breasts) or to avoid known risk factors associated with the development of breast cancer.63 The WHO has a human genetics research project that is critically evaluating genetic research related to the four NCDs, cancer, asthma, diabetes, and CVDs, in the hopes of identifying strategies to control or prevent these diseases.61

The CDC has a dedicated site on human genomics and public health. The organization states that the study of the relationship among genes, environment, and be- haviors will help us understand why some people get sick and others do not.62 The role of family history in the de- velopment of disease is not a new concept, but the map- ping of the human genome has allowed scientists to

identify the actual genes linked to the development of disease and thus increase the ability of researchers to de- velop and evaluate genetic screening and other interven- tions that can improve health and prevent disease.

Despite the promise of genomics to help control NCDs, there are potential problems with reliance on ge- nomics to help solve the problem of these diseases. Most chronic diseases are not monogenetic; that is, the disease is linked to a single gene mutation such as cystic fibrosis. Only 2% of total diseases are monogenetic. All other dis- eases result from multifactorial causes and are polyge- netic, meaning multiple genes act together to cause the disease. Many diseases are experienced in the later years of life rather than early in life when genetic interventions are more apt to be beneficial. To further complicate the understanding of the role of genetics in the development of disease, Strohman pointed out in the early 1990s that slower genetic change fails to compensate for rapid en- vironmental change. He explained that “genes are regu- lated by cellular responses to the external world and that diseases are initiated by those responses.”64 In other words, our genetic makeup is not static and as we age will adapt to the environment we are exposed to. Thus, ge- netic risk is not a linear source of complex chronic dis- ease but is rather a dynamic process based on interaction between the gene and the environment. The question Strohman raised was whether genomic research should focus on genetic engineering that would fit the individual human organism to a hostile environment or on envi- ronmental engineering that would refit the environment to be consistent with the evolving human genome.64

Building on the complexity of the interaction between genetics and the environment described in detail by Strohman64 a new field is emerging, human genome epi- demiology. This field provides the scientific basis for the study of the distribution of gene variants, gene-disease as- sociations, and gene-environment and gene-gene inter- actions within and across populations. This allows public health scientists to estimate the absolute, relative, and at- tributable risks for disease based on genomic factors (see Chapter 3). Thus, the growing understanding of the human genome from a population perspective offers new essential information on the occurrence of chronic dis- ease based on population-level as well as individual risk.

Disparity and Noncommunicable Disease Differences in socioeconomic status are a major contrib- utor to health status and risk for development of disease and thus a disparity in life expectancy.65 As defined in Chapter 7 disparity is a difference or inequality in some

230 U N I T I I n Community Health Across Populations: Public Health Issues

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aspect of health such as a disparity in the infant mortality rate between two groups. Disparity in morbidity and mortality statistics for NCD persists (see Chapter 7). For example, African Americans and persons living in the southeastern United States bear a statistically greater dis- ease burden related to stroke.66 The challenge is to un- derstand the upstream determinants of these disparities and to separate out biological causes from those related to the conditions of life, that is, the infrastructure of so- ciety and why society is set up as it is.65

Socioeconomic Risk for Noncommunicable Disease As demonstrated previously, the development of an NCD is multifactorial. In addition to the physical envi- ronment, behavior, and genetic risk, socioeconomic fac- tors play a role in determining who is at greater risk for developing an NCD. Health is remarkably sensitive to the social environment, and those who are less well-off are at greater risk for experiencing ill health. The term often used to describe these factors is the social determi- nants of health (see Chapter 7). According to the WHO, multiple factors contribute the differences in health sta- tus (Box 9-5) with poverty a major driving factor.67,68 The premise is that it does not make sense to treat people for disease without addressing the things that make them sick in the first place. Interventions aimed at reducing risk must consider the social determinants of health and the barriers that exist within a socioeconomic context that reduce the ability of individuals, families, and com- munities to experience a healthy lifestyle.

Disparity in NCD rates between different populations is also linked to socioeconomic and geographical factors (see Chapter 7). As evidenced by regional disparity in the United States relative to prevalence rates of NCDs. For example, West Virginia has the highest prevalence rate of diabetes at 15% in 2016 (Table 9-1).69 These regional disparities reflect differences in socioeconomic factors and cultural lifestyle. Within states, disparity exists between counties and is often correlated with socioeconomic status, as exemplified by the difference in tobacco use and obesity rates.

There is good news. There has been a narrowing of the gap in premature deaths between African Americans and whites in the United States. Researchers from the Uni- versity of Pittsburgh reported that between 1990 and 2014 African Americans had a 28% reduction in YLL compared to whites with a 4% reduction. The decline in heart disease and cancer death rates helped to account for the decline in YLL especially in African American adults aged 30 to 40.70

C H A P T E R 9 n Noncommunicable Diseases 231

Income and social status: Higher income and social sta- tus are linked to better health. The greater the gap between the richest and poorest people, the greater the differences in health.

Education: Low education levels are linked with poor health, more stress, and lower self-confidence.

Physical environment: Safe water and clean air, healthy workplaces, safe houses, communities and roads all contribute to good health.

Employment and working conditions: People in employ- ment are healthier, particularly those who have more control over their working conditions

Social support networks: Greater support from families, friends, and communities is linked to better health.

Culture: Customs and traditions, and the beliefs of the family and community all affect health.

Genetics: Inheritance plays a part in determining lifespan, healthiness, and the likelihood of developing certain illnesses.

Personal behavior and coping skills: Balanced eating, keeping active, smoking, drinking, and how we deal with life’s stresses and challenges all affect health.

Health services: Access and use of services that prevent and treat disease influences health.

Gender: Men and women suffer from different types of diseases at different ages.

BOX 9–5 n Social Determinants of Health

Source: (67, 68)

TABLE 9–1 n Top 10 Highest Rates of Type 2 Diabetes (2016)

Rank State Diabetes Rate

1

2

3

4

5

6

7

8

9

10

Source: (69)

West Virginia

Alabama

Mississippi

Arkansas

Kentucky

South Carolina

Tennessee

Georgia

Louisiana

Oklahoma

15.0% ±0.9

14.6% ±1.0

13.6% ±1.1

13.5% ±1.4

13.1% ±0.9

13.0% ±0.8

12.7% ±1.0

12.1% ±1.0

12.1% ±1.2

12.0% ±0.9

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The relationship between socioeconomic status and prevalence of NCD presents an ethical dilemma for providers of health care (Box 9-6). A central risk factor for increased morbidity and mortality related to NCD is access to health care including preventive screening, early and ongoing treatment, and resources needed to manage care. In the United States, the Affordable Care Act (ACA) was designed to attempt to increase access to care. How- ever, for the most part, U.S. health care is based on a fee- for-service basis, and health-care providers are reimbursed based on the care they provide (see Chapter 21). For those who are unable to obtain adequate insurance or who do not have adequate transportation to services, care is often delayed until the disease has become advanced. For ex- ample, an insulin-dependent diabetic single man who is currently homeless faces daily challenges, which may in- clude maintaining an adequate diet when he is dependent on soup kitchens, checking his blood sugar when he does not have his own glucometer, obtaining insulin and in- sulin supplies, and storing those supplies in a safe place. By contrast, an insulin-dependent diabetic married man currently employed and domiciled has the financial means and the social support needed to meet those chal- lenges. For both men, diabetic care will continue for the rest of their lives. Prevention of morbidity and mortality related to their diagnosis requires careful self-management over time including monitoring of blood sugar, diet and exercise, foot care, adherence to medication regimens, and regular check-ups with their health-care provider. Is it ethical for those who have the financial means to have the resources needed to meet their ongoing daily health- care needs necessary for survival whereas those who do not have the financial means do not?

Prevention Strategies for Noncommunicable Diseases Prevention and management of NCDs are global priori- ties.1 Prevention strategies extend across the continuum from primary to tertiary prevention (see Chapter 2). Pre- vention of NCD across all three levels occurs across many settings (see Chapters 13 to 20). Prevention efforts are often focused on reducing the individual risk factors mentioned earlier, but often the success of prevention ef- forts require multifaceted interventions at the individual, family, community, and policy levels. For the nurse, these efforts can seem overwhelming.

At the individual and family levels, primary preven- tion focuses on behavioral change with a strong emphasis on healthy eating and exercise. These approaches not only provide information as to what constitutes a healthy lifestyle but also provide participants with strategies for making improvements in nutrition and physical activity and accessing the resources needed. The difficulty is that the populations at greatest risk for NCDs are those with limited access to the resources needed to maintain a healthy lifestyle. Thus, population-level primary preven- tion programs help to change barriers to a healthy lifestyle. For example, obtaining an adequate level of ex- ercise in an urban setting requires safe streets for walking and/or access to recreational activities. This requires ac- tion at the community and policy levels. Nurses, espe- cially those working in a public health role, can help facilitate community engagement in improving the safety of streets and improving access to healthy foods at rea- sonable prices.

Secondary prevention efforts are also associated with reduced morbidity and mortality related to NCD, espe- cially screening (Chapter 2). Examples of screening pro- grams recommended by the CDC for the prevention of NCDs include mammograms and screening for colorec- tal cancer.71,72 Such programs result in the early detection of disease and thus in early treatment.

Often the nurse provides care related to tertiary pre- vention efforts aimed at reducing the adverse conse- quences experienced by a person who has already been diagnosed with a disease. The goal is to reduce the mor- bidity and disability associated with the disease and to pre- vent premature death. During the course of the disease, there can be periods of acute illness that are usually shorter and often require admission to an acute care facility for care. Chapter 14 provides in-depth coverage of the role of public health science in the nursing care of patients during an acute phase of an NCD that requires interventions to

232 U N I T I I n Community Health Across Populations: Public Health Issues

Critical ethical questions related to chronic disease health care include the following:

• Is health care for the management of chronic diseases a right or a privilege?

• Should government pay for medically necessary serv- ices when an individual cannot afford those services? • If yes, does this approach truly serve the greater

good for the greater number? • If no, who should be responsible for paying for these

services? • How does failure to provide services to those in need

impact the community in general?

BOX 9–6 n Ethics and Disparity Related to Chronic Diseases

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address an acute stage of an illness. Primary care settings provide care to help patients manage a chronic disease as well as care for milder acute phases of the disease (see Chapter 15). Two concepts grounded in public health pre- vention models and used in both acute care and primary care settings are health-related quality of life and chronic disease self-management.

Health-Related Quality of Life Health-related quality of life is central to the overarching goals for HP. The primary goal is to attain and promote “a high quality of life for all people, across all life stages.”4

Health-related quality of life (HRQoL) is a multidimen- sional construct related to the desired physical and psychological health outcomes for most of the interven- tions that nurses provide to individuals and families. HRQoL is defined here as the self-perceived impact of physical and emotional health on quality of life, includ- ing the effects on general health, physical functioning, physical health and role, bodily pain, vitality, social functioning, emotional health and role, and mental health.73,74 The CDC has a whole Web site dedicated to HRQoL.74 Included on the Web page is the four- questions measure it uses for HRQoL that can easily be used in any health-care setting, and the evidence supports it as a reliable and valid measure of HRQoL. This healthy data measure not only can help in measuring an individ- ual’s HRQoL, but according to the CDC, it is also being used at the national and state levels to identify health dis- parities (see Chapter 7), to track population trends, and to build broad coalitions around a measure of population health. This measure is compatible with the WHO’s defi- nition of health (see Chapter 1).75 The CDC uses the Healthy Days measure in the Behavioral Risk Factor Surveillance system.73,76 Numerous studies have been conducted using HRQoL as a central measure.77,78

C H A P T E R 9 n Noncommunicable Diseases 233

n EVIDENCE-BASED PRACTICE Measuring Health-Related Quality of Life (HRQoL)

Screening for HRQoL Practice Statement: The use of the HRQoL screen- ing tool can help health-care providers identify persons whose health is negatively impacting their quality of life and can provide a means to measure key health indica- tors for public health assessments. Targeted Outcome: Identify those in need of inter- ventions aimed at improving their quality of life and identifying vulnerable populations.

Evidence to Support: The CDC’s 14-item HRQoL tool includes the standard four-item set of Healthy Days core questions and the Standard Activity Limita- tion and Healthy Days Symptoms modules. When used together, these measures make up the full CDC HRQoL-14 Measure. Public health departments have used the tool to identify vulnerable groups when con- ducting community assessments. The screening tool not only provides a method for assessing an individual’s HRQoL but also provides PHNs with a useful indicator of health at the population level. Recommended Approaches: The CDC HRQoL screening tool is used in community assessments and surveillance. A guide published in the late 1990s de- scribed the use of HRQoL as one of the main indica- tors for monitoring health in populations and evaluating outcomes, and is still recommended by the CDC. Ac- cording to the CDC, the following are the main rea- sons for measuring HRQoL:

• HRQoL is related to both self-reported chronic diseases (diabetes, breast cancer, arthritis, and hyper- tension) and their risk factors (BMI, physical inactiv- ity, and smoking status).

• Measuring HRQoL can help determine the burden of preventable disease, injuries, and disabilities, and can provide valuable new insights into the relationships between HRQoL and risk factors.

• Measuring HRQoL will help monitor progress in achieving the nation’s health objectives.

Sources Linde, L., Sørensen, J., Ostergaard, M., Hørslev-

Petersen, K., & Hetland, M. (2008). Health-related quality of life: validity, reliability, and responsiveness of SF-36, EQ-15D, EQ-5D, RAQoL, and HAQ in patients with rheumatoid arthritis. Journal of Rheumatology, 35(8), 1528-1537.

Andresen, E.M., Catlin, T.K., Wyrwich, K.W., & Jackson- Thompson, J. (2003). Retest reliability of surveillance questions on health-related quality of life. Journal of Epidemiology Community Health, 57(5), 339-343.

Centers for Disease Control and Prevention. (2016). Health-related quality of life methods and measures. Retrieved from https://www.cdc.gov/hrqol/ measurement.htm.

Ware, J.J., Kosinski, M., & Keller, S.D. (1996). A 12-item short-form health survey: Construction of scales and preliminary tests of reliability and validity. Medical Care, 34(3), 220-233.

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Chronic Disease Self-Management An evidence-based approach to improving HRQoL for persons with NCD is chronic disease self-management (CDSM). CDSM is an ongoing process by which indi- viduals with a chronic illness or condition engage in self- management of medications, symptoms, and promotion of their own health, and can be applied to both noncom- municable and communicable chronic disease.79 CDSM requires implementation of health-promotion and health protection strategies, which are fundamental concepts for nursing practice (Chapter 2). Extensive research ex- ists related to the efficacy of patient education programs for specific chronic diseases such as asthma and diabetes and has now shown effectiveness with diverse popula- tions and diseases.79-83 Evidence is accumulating that heterogeneous CDSM programs that include persons with different chronic diseases are effective, reduce emer- gency department usage and health distress, and tran- scend ethnic boundaries.81,83 Moreover, they apply to underserved populations who do not have regular health-care providers.80,84 CDSM has great potential for improving self-management of disease, health behaviors, health-care utilization, and health status.

NCD prevention and reduction of risk factors that lead to NCDs continues as a focus in the development of the Healthy People 2030 framework and objectives.85

It is an issue across all health-care settings. Strategies for specific NCDs are discussed across the chapters in this text. The key is to remember that prevention efforts require interventions at all levels with the goal of not only reducing the prevalence of NCD but also of im- proving the overall HRQoL for individuals, families, and populations.

234 U N I T I I n Community Health Across Populations: Public Health Issues

n CULTURAL CONTEXT Noncommunicable Diseases

Culture plays a big part in the prevention and treat- ment of NCDs. For the most part, when culture is mentioned in conjunction with prevention of NCDs, the focus is on its role in relation to individual risk be- haviors such as food, nutrition, and exercise. Culture is also important in the development of education materi- als (Chapter 2). However, another issue in relation to culture and NCDs has to do with the cultural shifts that have occurred at the national level in relation to prevention.

Cultural shifts occur over time because no culture is static. In the past 50 years, there have been cultural shifts in the United States in relation to risk behaviors

associated with NCDs. A cultural shift is defined as a change in society’s dominant views, morals, and behav- iors. When applied to health, it represents a shift in how society views that issue and the risk factors asso- ciated with development of disease. For example, there has been a cultural shift in how society perceives drink- ing alcohol and driving; once this was viewed as a nor- mal behavior and now it is one that is not tolerated and results in criminal consequences. Another example is the shift in how we view the foods we eat. Some states have passed laws prohibiting the sale of large, sugary drinks or the use of deep-fat fryers in schools. A cultural shift changes the way organizations are struc- tured, the environment we live in, and the activities we participate in.

Let’s examine a major cultural shift in the United States related to a major preventable risk factor associ- ated with the development of NCDs. In the 1950s, no one questioned a person’s right to smoke in public. Smoking occurred in all public places, including banks, hospitals, and restaurants. As the evidence grew that secondhand smoke affected the health of the non- smoker, public health policy initiatives were begun to reduce smoking in public places. In the beginning, sci- ence drove the change. Based on the evidence, public health policies were put in place that required restau- rants to designate no smoking sections, and employers constructed separate places for their workers to smoke, often referred to as “butt huts.” However, what began as evidence-based public health policy shifted to a social reality. As fewer people smoked, tolerance of smoking declined, and the culture shifted from viewing tobacco use in a positive manner to viewing it as a negative and unpleasant behavior. In the 1930s and 1940s, movie stars smoked on screen, and in the 1950s, cigarette ads depicted the male smoker as rugged and manly, as in the Marlboro Man. Today, most public spaces are smoke free. It is hard to deter- mine which comes first, the policy or the cultural shift. Often, one reflects the other. However, to be effec- tive, public polices need the support of the community. When the culture matches the policy, the policy is more apt to bring about change.

Not only does the culture of groups play a role in individual behavior, but also the cultural norms of a population shift over time and can have a significant im- pact on health. Sometimes there are opposing cultural values in relation to a risk factor. For example, people may have differing views about the appropriateness of using public policy to restrict the ingredients that

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n Summary Points • NCDs contribute significantly to the overall burden

of disease. • Seven out of the top ten leading causes of death in

the United States are NCDs. • Risk for NCD is a combination of individual

behaviors, the environment, genes, and socioeco- nomic factors.

• Prevention occurs across the continuum, starting with primary prevention during the perinatal period through tertiary prevention measures such as chronic disease self-management programs.

C H A P T E R 9 n Noncommunicable Diseases 235

restaurants put in foods. Understanding that cultural shifts occur over time related to reducing NCD is im- portant for the nurse who wishes to actively engage in prevention efforts. Nursing can play a role in helping the cultural shift along. As the largest segment of the health-care workforce, nurses can be in the forefront of positive cultural shifts related to prevention; the shift can happen at a more rapid pace and populations will get healthier. A world with reduced morbidity and mortality related to NCDs and improved HRQoL can happen, and nurses are major drivers of the shift to healthier living as part of our culture.

t CASE STUDY Prevention of Chronic Obstructive Respiratory Disease (COPD)

A group of nurses on a medical-surgical unit in a hospi- tal that serves an Appalachian community in Kentucky on the West Virginia border were growing frustrated with the continued readmission of persons with COPD. One of the nurses came across statistics on the age-adjusted death rate of COPD in Kentucky. It was 62.8 per 100,000 compared to other states such as Hawaii at 15.5 per 100,000. She also found that COPD death rates were highest in the states sur- rounding the Ohio and Mississippi Rivers.85 The nurses decided to put together a proposal related to the pre- vention of COPD.

1. Choose a primary, secondary, and/or tertiary pre- vention approach and support your decision.

2. Choose a target population based on age and level of intervention (primary, secondary, and tertiary).

3. Access information on the Huntington/Ashland area of West Virginia and Kentucky and see what can be learned about: a. Cultural considerations b. Possible partners for the intervention c. Possible barriers

4. Review the literature again for evidence-based inter- ventions relevant to your chosen population and prevention level.

5. Using Chapter 5 as a guide, draft a possible preven- tion intervention the nurses in the journal club could help initiate.

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84. Savage, C., Xu, Y., Richmond, M.M., Corbin, A., Falciglia, M., Gillespie, G. (2014). A pilot study: Retention of adults experiencing homelessness and feasibility of a CDSM diabetes program. Journal of Community Health Nursing, 31, 238-48. doi: 10.1080/07370016.2014.958406.

85. Healthy People. (2018). Healthy People 2030 Framework. Retrieved from https://www.healthypeople.gov/2020/ About-Healthy-People/Development-Healthy-People- 2030/Proposed-Framework.

86. Centers for Disease Control and Prevention. (2016). Chronic obstructive pulmonary disease (COPD): Data and statistics. Retrieved from https://www.cdc.gov/copd/data.html.

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239

Chapter 10

Mental Health Bryan R. Hansen and Christine Savage

LEARNING OUTCOMES

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

KEY TERMS

1. Define the global burden of disease related to mental disorders using current epidemiological frameworks.

2. Apply the National Academy of Medicine framework related to prevention of mental health disorders.

3. Define the difference between behavioral, biological, environmental, and socioeconomic risk factors related to mental health disorders.

4. Apply current evidence-based population-level interventions to the prevention of mental disorders and the promotion of optimal mental health for communities and populations.

5. Describe systems approaches to the promotion of mental health and the prevention and treatment of mental health disorders.

Any mental illness (AMI)

Behavioral health Burden of disease Deinstitutionalization Emotional health

Health-related quality of life (HRQoL)

Indicated prevention Intersectoral strategies Major depressive disorder

(MDD)

Mental disorder Mental health Mental illness Protective factors Resilience Selective prevention

Serious mental illness (SMI)

Stigma Transinsitutionalization Universal prevention

n Introduction Achieving optimal mental health is an essential compo- nent of programs aimed at improving the health of populations. Mental health is defined as mental and psychological well-being, which includes our emotional, psychological, and social well-being, and is essential to health overall.1,2 In 2005, the Institute of Medicine (IOM), now named the National Academy of Medicine, reported that mental or substance-use problems and disorders are the leading cause of combined disability and death for women and the second highest for men.3 Of the 10 lead- ing health indicator topics of Healthy People 2020 (HP 2020), four topics related directly to behavioral health: mental health, substance abuse, tobacco, and injury/ violence.4 These four topics come under the umbrella of the term behavioral health. Each of these interrelated issues has an impact on the health of individuals, families, and communities. Often mental illness, substance abuse, and/or intentional injury and violence co-occur. Thus, there is a logical and empirical connection among these

health issues. Taken together, they make up the most serious and prevalent public health problems of our times. So that each aspect of behavioral health can be covered in depth, these four leading health indicator topics of health are covered in three separate chapters. Chapter 10 covers mental health and mental health disorders; Chapter 11 covers substance use including alcohol, tobacco, and other drugs; and Chapter 12 covers injury and violence.

This chapter focuses on promotion of mental health, which is best defined by HP 2020 as “a state of successful performance of mental function, resulting in productive activities, fulfilling relationships with other people, and the ability to adapt to change and to cope with chal- lenges.”4 The term emotional health is used interchange- ably with mental health and is defined the same way. HP also includes mental disorder and mental illness under the topic of mental health. Mental health reflects a positive state of health, whereas mental disorder refers to the diagnosable disorders that negatively affect the mental health of individuals and affect an individual’s

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ability to cope with everyday life. Mental illness is a term that refers to all mental disorders collectively. The terms mental disorder and mental illness are often used inter- changeably and are defined as “clusters of symptoms and signs associated with distress and disability (i.e., impair- ment of functioning), yet whose pathology and etiology are unknown.”1,4 Mental illnesses are disorders, not dis- eases. Disease is a term used when the pathology is known or can be detected, which is not the case with a mental health disorder. Diagnoses that come under the category of mental disorders include depression, anxiety disorders, bipolar disorder, and schizophrenia. Not all mental health disorders have the same etiology (cause) or require the same population-level interventions.

Mental disorders can vary in severity from mild to severe. The term any mental illness (AMI) is defined as a mental, behavioral, or emotional disorder. AMI can vary in impact, ranging from no impairment to mild, moderate, and even severe impairment.5 The term serious mental illness (SMI) is used to refer to a diagnosable mental dis- order that severely disrupts a person’s ability to function socially, to obtain and maintain employment, to have adequate financial resources, and to access appropriate and adequate support or maintain family supports.5 SMI does not refer to any particular diagnosis; rather, it implies eligibility for specific kinds of support services. The mental disorders that can lead to SMI include major depression, schizophrenia, bipolar disorder, obsessive-compulsive disorder (OCD), panic disorder, post-traumatic stress disorder (PTSD), and borderline personality disorder.

In contrast with mental disorders, mental health rep- resents a state of emotional well-being. Persons who are emotionally healthy are those who can meet the demands and stresses of everyday life and function in society. Mental health does not merely represent the absence of a mental disorder but rather the cognitive and emotional ability to deal with the ups and downs of life while con- tributing to society through work and play. Viewed from a population perspective, the health of a population re- flects not only the physical well-being of the members of the population or community but also their social and emotional well-being. Because of their overall impor- tance to health, mental health and mental disorders are included in the HP list of topics

Optimal mental health is an essential component of healthy communities. The promotion of mental health involves interventions at the individual and community levels. At the individual level, promotion of optimal mental health requires not only the delivery of inter- ventions focused on behavioral change but also the availability of adequate systems for care of those with mental health disorders. At the community level, pro- motion of mental health requires an environment that encourages strong social networks and a safe place to work and live. Because of the importance of mental health, in 2012, the World Health Organization (WHO) issued a resolution on mental health that aims to reduce the global burden of mental disorders and improve the overall mental health of countries. This resolution in- cludes recognition of “the need for a comprehensive, coordinated response to addressing mental disorders from health and social sectors at the country level. The delegates recognized this includes approaches such as programs to reduce stigma and discrimination, reinte- gration of patients into workplace and society, support for care providers and families, and investment in men- tal health from the health budget.”6

240 U N I T I I n Community Health Across Populations: Public Health Issues

n HEALTHY PEOPLE Mental Health

Goal: Improve mental health through prevention and by ensuring access to appropriate, quality mental health services.

Overview: Mental health is a state of successful performance of mental function resulting in produc- tive activities, fulfilling relationships with other peo- ple, and the ability to adapt to change and to cope with challenges. Mental health is essential to personal well-being, family and interpersonal relationships, and the ability to contribute to community or society.

Mental disorders are health conditions characterized by alterations in thinking, mood, and/or behavior associated with distress and/or impaired functioning. Mental disorders contribute to a host of problems that may include disability, pain, or death. Mental illness is the term that refers collectively to all diagnosable mental disorders.4

n HEALTHY PEOPLE Objectives: Reduce the proportion of persons who experience major depressive episode (MDE) MHMD-4.1: Adolescents aged 12 to 17 years Baseline: 8.3% of adolescents aged 12 to 17 years experienced an MDR in 2008. Target: 7.4% Target-Setting Method: 10% improvement

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Epidemiology of Mental Disorders Tracking the prevalence of mental health disorders at the global level is challenging due to differences in tracking and the reliance on diagnoses that results in an underes- timation of disease. It is estimated that globally 1 billion people have a mental health disorder.7 In the United States, in 2018, an estimated 25% of adults reported hav- ing mental disorders within the previous year.8 The U.S.

annual economic burden associated with SMI, including direct costs such as medical care, loss of earnings, and indirect costs such as disability, homelessness, incarcer- ation, and early mortality, have been estimated to exceed $317 billion.9 As reviewed in Chapter 9, the burden of disease is measured in years of life lost related to ill health and reflects the difference between total life expectancy and disability-adjusted life expectancy. Ex- amining the burden of disease related to mental disor- ders allows us to consider what impact mental disorders have on the population or community. The best place to start is to examine the prevalence of mental disorders across the life span from both a global and an interna- tional perspective.

Surveillance of Mental Health Disorders Estimating the prevalence of mental disorders is chal- lenging because there has been no centralized method for conducting surveillance of mental health disorders in the United States or globally. The Centers for Disease Control and Prevention (CDC) compiles data from eight surveillance systems to identify gaps in surveillance and make recommendations for an improved method for collecting data on mental health disorders. This allows the CDC to address the broad spectrum of mental health using surveillance systems that, in many cases, do not focus specifically on mental health but include important indicators of mental health and mental health disorders. Through this process of examining data from all data sources, they were not only able to provide some esti- mates of prevalence of different mental disorders but also to help make recommendations about how to address the gaps in mental illness surveillance. The data sources included the Pregnancy Risk Assessment Monitoring System (PRAMS), National Nursing Home Survey, National Health Interview Survey, National Hospital Discharge Survey, National Health and Nutrition Exam- ination Survey, National Ambulatory Medical Care Sur- vey, National Hospital Ambulatory Medical Care Survey, and Behavioral Risk Factor Surveillance System.10 At the global level, the WHO has developed the World Mental Health Survey to help determine estimates of human capital costs and prevalence of mental disorders in a wide range of countries.11

Prevalence of Mental Health Disorders Mental health is an important part of overall health across the entire life span. Differences exist among age groups in relation to specific disorders. To understand the importance of the issue and to evaluate the effective- ness of interventions from a population perspective

C H A P T E R 1 0 n Mental Health 241

Midcourse Review: In the 4 years from 2008 to 2012, the percentage of adolescents aged 12 to 17 reporting having had a major depressive episode (MDE) in the past 12 months increased about 10%, from 8.3% to 9.1%, moving away from the Healthy People 2020 target of 7.5%. See Figure 10-1. Data Source: National Survey on Drug and Health, SAMHSA

Source: (4)

Percentage of Adolescents Experiencing Major Depressive Episode in Previous 12 Months

10.0% Percentage of MDE HP 2020 Target

9.5%

9.0%

8.5%

8.0%

7.5%

7.0%

6.5%

6.0%

5.5%

5.0% 2008 2012

Figure 10-1 Percentage of Adolescents Experiencing Major Depressive Episode in Previous 12 months. (See reference [4].)

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requires knowledge of the prevalence of mental disorders within and across communities and populations.

The 12-month prevalence is a measure that esti- mates the occurrence of a disorder within 1 year prior to assessment. In 2015, the 12-month prevalence of all mental disorders not including substance-use disor- ders in the U.S. was 4% and most prevalent in those aged 18-44.12

There are gender, ethnic, and age differences in the prevalence of SMI (Fig. 10-2).12 In 2015, the 12-month prevalence of any mental disorder was higher in females than in males.12 Those reporting two or more races had the highest prevalence of SMI, followed by American Indians/Alaska Natives.13 American Indians/Alaskan Natives also have a high rate of lifetime PTSD compared to other races.14 Children also experience mental disor- ders, with 49.5% of teens diagnosed with AMI between the ages of 13 and 18 years.12

Under the umbrella of SMI are specific diagnostic cat- egories that have been the focus of population level pre- vention efforts, especially major depressive disorder (MDD). MDD is a mood disorder that is diagnosed based on the occurrence of one or more major depressive

episodes in the absence of a manic or hypomanic episode. In 2016, about 13%, or 3.1 million, of U.S. teens between 12 and 17 years had at least one episode of MDD in the previous 12 months, as did about 6.7%, or 16.2 million adults.15,16 For adults, it is most prevalent among those aged 18 to 25 years and is more prevalent in women than in men.16 Because of the high prevalence and the impact on health, HP 2020 includes reduction of the number of persons who experience an MDD as one of the mental health objectives.

Over the beginning of this century, the morbidity and mortality rate associated with SMI increased, with 4.2% of all adults in the U.S. experiencing SMI in 2016. Persons diagnosed with an SMI died 10 to 20 years ear- lier than the general population. Part of this is attrib- uted to suicide and injury. The other contributing factor is the strong association among SMI, chronic dis- ease, and substance use.17–19 Persons with SMI are less likely to receive preventative screening and interven- tions, less likely to receive treatment for diagnosed co- morbidities, and more likely not to adhere to medical interventions, which exacerbates the disparity in mor- tality rates.20

242 U N I T I I n Community Health Across Populations: Public Health Issues

12%

In 2015, 4.0% of adults aged 18 or older in the United States (an estimated 9.8 million adults) had a serious mental illness (SMI) in the past year. This percentage was not significantly different from the percentage in 2011 (3.9%).

In 2015, the percentage of adults aged 18 or older in the United States with past year SMI was higher for females than for males. This percentage was higher than the national average for Whites, and for those aged 18–25 or aged 26–44. This percentage was lower than the national average for those who were Black, Native Hawaiian or other Pacific Islander, Asian, or Hispanic or Latino. This percentage was also lower than the national average for adults aged 65 or older.

American Indian or Alaska Native non-Hispanic other Pacific Islander Estimate is significantly different from the estimate for males (p � .05) Estimate is significantly different from the national average (p � .05) Source SAMHSA, Center for Behavioral Health Statistics on Drug Use and Health, 2015

AI/AN = NH =

OPI = # +10%

8%

6%

4%

2%

0% United States

Male Female

Gender Race/Ethnicity Age Group

White, NH

Black, NH

AI/AN, NH

Native Hawaiian

or OPI, NH

Asian, NH

Hispanic or Latino

18–25 26–44 45–64 65 or older

4.0% 3.0%

5.0%# 4.5%+

2.9%+

6.3%

1.8%+

1.7%+ 2.9%+

5.0%+ 5.0%+

4.0%

1.6%+

Past Year Serious Mental Illness (SMI) Among Adults Aged 18 or Older in the United States, by Gender, Race/Ethnicity, and Age Group (2015)11

Figure 10-2 Prevalence of serious mental illness among U.S. adults, 2015. (See reference 12.)

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Behavioral, Biological, Environmental, and Socioeconomic Risk Factors Numerous factors contribute to the development of mental disorders at both the individual and community levels, and must be considered when attempting to understand the etiology of mental disorders. There is interplay among the individual, the family, and the com- munity environment. From a public health perspective, improving the mental health of a population requires taking all these factors into account when developing interventions.

Individual-Level Risk Factors for Mental Disorders At the individual level, both nature and nurture play roles; that is, genetics, family environment, and individ- ual behavior are associated with the risk of developing a mental disorder, along with socioeconomic factors and community environment. Therefore, it is difficult to define the exact etiology of most mental disorders; the precise cause is poorly understood. There are, however, specific factors that have been associated with the devel- opment of mental disorders (Box 10-1). Recent work has helped demonstrate the link between genotype and mental illness through an environmental pathway. For example, PTSD is moderately heritable, but environmen- tal factors play a large role in whether a person who has a susceptible genotype develops PTSD after severe trauma.21

Another issue related to the development of a mental disorder is the relationship between physiology and mental health. Conditions that affect brain chemistry, hormonal imbalances, or exposure in utero to viruses or toxins can increase the risk for development of a mental disorder.22 Physical trauma such as traumatic brain injury is also associated with an increased risk of developing a mental disorder.23 Individuals who have experienced malnutrition or low birth weight are also at higher risk for development of a mental disorder.24

Some medication side effects include depression, anxi- ety, or suicidal ideation. In addition, an interaction between medications can result in increased risk for depression and other mental health disorders. Also, persons with diseases that reduce their quality of life or terminal diseases such as cancer may experience mental health disorders.25 Conversely, there is evidence that mental disorders are themselves independent risk factors for cardiovascular disease, type 2 diabetes, and injuries.26

Family instability is a factor in the development of mental disorders, with a higher incidence rate in individ- uals raised in situations of abuse or neglect, including sexual abuse, or for those who have experienced exposure to traumatic events, including serious loss.24 In addition, children of parents with mental disorders are at increased risk for developing mental disorders themselves because of the negative impact a mental disorder has on parenting skills.27 Exposure to family stress because of poor financial situations, death, divorce, or unemployment is also asso- ciated with mental disorders.22 Along with family envi- ronment, individual characteristics can increase the risk for development of a mental disorder. For example, individuals with low self-esteem; those who are lonely, isolated, and/or have poor social skills; and those who have unhealthy thinking patterns are at higher risk. Some behaviors also increase the risk of mental disorders, or substance use disorders (Chapter 11).24

An emerging issue is the increased incidence of men- tal disorders in Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ+) adolescents (see Chapter 7). They are more likely to be depressed and anxious, and attempt

C H A P T E R 1 0 n Mental Health 243

• Family history of mental disorders or history of being diagnosed with a mental disorder in the past

• Traumatic events: military combat, assault, or witness to a violent crime

• In utero exposure to viruses and toxins; poor nutrition • Cerebral injury: experiencing brain damage as a result

of a serious injury such as a violent blow to the head, traumatic brain injury

• Stressful life situations: financial problems, the death of a loved one, or marital problems and/or divorce

• Social isolation: having few friends or few healthy relationships

• Developmental delays • Substance use: illicit drugs, alcohol, medication side

effects, and drug interactions • Poor health: living with a chronic medical condition

such as cancer • History of being abused or neglected as a child • Low self-esteem, social isolation, poor social skills • Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ+)

adolescents • Anxiety, depression, suicidal tendencies • Poverty and socioeconomic level • Rural versus urban populations • Lower education level • Dangerous communities, high crime rates

BOX 10–1 n Risk Factors for Mental Illness

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and/or commit suicide because of insecurity and diffi- culty in negotiating their coming out, family disapproval, rejection, victimization, and chronic stress from stigma- tization.28 Thus, the development of a mental disorder is a complex combination of genetics, other physical dis- orders, and family environment.

Community-Level Risk Factors for Mental Disorders The determinants of health also play a role in the devel- opment of mental disorders because the community environment plays a pivotal role. There is a clear inverse relationship between poverty and prevalence of mental disorders, with a greater prevalence of mental disorders in populations and communities experiencing social and economic disadvantages.29 Part of this risk is associated with a lower level of education, fewer job opportunities, and lower job satisfaction.29 Living in dangerous com- munities (Chapter 12), especially those with high crime rates, is another risk factor.

Protective Factors: Building Resilience Although a risk-based approach is one strategy for addressing the prevention of mental disorders, an examination of protective factors is equally important. Understanding why some individuals can overcome adversity is a key component in the development of in- tervention programs focused on prevention of mental disorders. Protective factors are processes within individuals, families, or communities that exist, can be strengthened, or can be incorporated into interventions for purposes of building resilience. They are the supports and opportunities that buffer adversity.30 Resilience is an individual’s ability to access protective factors that exist at different levels to withstand chronic stress or re- cover from traumatic life events (Box 10-2).31 Individual strengths such as social competence, problem-solving ability, autonomy, and a sense of purpose show re- silience. Protective factors can reduce risk for mental health disorders and can promote optimal mental health. Understanding what factors help individuals, families, and communities reach optimal health, then, is as important as understanding the factors that in- crease the risk for developing a mental disorder. Both prevention and treatment interventions can build on these protective factors to help promote optimal mental health.

Research on individual protective factors provides the foundation for supporting protective factors in preven- tion interventions. According to Harvard University’s

Center on the Developing Child, “… the single most common factor for children who develop resilience is at least one stable and committed relationship with a supportive parent, caregiver, or other adult.”32 The use of resilience building in children exposed to adverse childhoods to reduce the potential of mental health diagnoses holds promise.33,34

More than 2 decades ago, the report from the Presi- dent’s New Freedom Commission on Mental Health was published, emphasizing that the transformation of the mental health delivery system depends on a focus on coping with challenges in life and building resilience.35

Interventions to promote resilience focus on a strengths- building approach. Because strengths recognized in re- silience are inherent psychological needs, humans are compelled to meet them throughout their lifetime, and the factors determining whether they do meet them are often dependent on the wider systems in which an individual interacts, including families, schools, and communities.31

A community can also be resilient.31 Similar to how resilience in an individual is defined, a resilient commu- nity is characterized by social competence, problem- solving, a sense of identity, and hope for the future. A resilient community has certain resources available that are important for human development. These resources include health care, childcare, housing, education, job training, employment, and recreation.31 A journal’s spe- cial edition addressed the factors that are important for communities to promote childhood resilience, including increasing the availability of programs that foster healthy parent-child interactions and increase parental social support.36

A community’s resilience contributes to an individ- ual’s capacity to develop resilience and whether a MHD is present or not. The community develops and nurtures resilience by valuing and providing the means of con- nectedness, by supporting and nurturing commitment

244 U N I T I I n Community Health Across Populations: Public Health Issues

• Environmental capital: structural factors and features of the natural and built environments

• Environment that enhance community capacity for well-being

• Social capital: norms, networks and distribution of resources that enhance community trust, cohesion, influence, and cooperation for mutual benefit

• Emotional and cognitive capital as resources that buffer stress and/or determine outcomes and contribute to individual resilience and capability

BOX 10–2 n Protective Factors and Resilience

Source: (32)

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and shared values where everyone participates in mean- ingful structure and role responsibilities, and by engaging in critical reflection and skill building that feeds back into the community. The ability of a community to build resilience is called community capacity.37

An example of community-level resilience is that of community members and organizations working in partnership with youths, families, and schools. A sense of connectedness can result when schools work in partnership with students, families, and community groups. An example of this connectedness is a program called Elev8 in Baltimore, Maryland, which is focused on improving educational and social outcomes for middle grade adolescents and their families in East Baltimore.38,39 “Each Elev8 Baltimore school is assigned a site manager and a family advocate responsible for collaborating with the principal and staff; building relationships with students and families; responding to the needs of students, parents and school staff; pro- moting the integration of learning, health and family support strategy; and developing a family engagement plan to facilitate connections among families, the school, and the broader community.”39

School connectedness is an example of a way to build community resilience. Such programs demonstrate that building resilience at the community level not only can improve the mental health of children and youth but also can have a positive impact on children’s behavioral and academic outcomes.40,38 The importance of inter- disciplinary programs that work together to build com- munity resilience is also increasingly recognized as an approach to address social determinants of health, inequities in education, and the urban environment overall.32,41 Some programs operate at the intersection of public health, education, and urban planning. Exam- ples have included the Obama administration’s Neigh- borhood Revitalization Initiative, which focused on standardized test scores and educational inequities, and the Choice Neighborhoods program, which is based on Hope VI, which targets severely distressed public hous- ing developments.42,43A focus in these programs is to develop community health centers and full-service com- munity schools, and to pursue community development for purposes of revitalizing neighborhoods.38

Cultural Context and Stigma Culture has tremendous influence on the meaning of mental illness for individuals, families, and communities. A culture’s deeply rooted beliefs and attitudes exert con- siderable influence on how mental illness is viewed by society, the individual with the illness, his family, and the community. It may be viewed as real or imagined, adap- tive or maladaptive, or as a valued distinction or inten- tional deviance from the norm. Beliefs and attitudes determine how likely it is that support will be available and whether a person with a mental health disorder will seek help or accept treatment.44–47 For example, studies of cross-cultural stigma have suggested that Latino groups may view taking psychoactive medications as a sign of weakness, preferring instead to be self-reliant, whereas some Asian groups may see mental health as emotional weakness that causes one to “lose face,” thus jeopardizing family lineage.47

C H A P T E R 1 0 n Mental Health 245

n CELLULAR TO GLOBAL The factors affecting mental health exist on a contin- uum from the cellular to the global. The interactions among an individual’s genetics, epigenetics, and the larger environment are myriad, predicting much of

what we know about mental well-being. Although individuals may have a stronger genetic predisposition for certain types of mental illness, factors across the life span heavily influence its expression. Even beginning before birth, factors such as access to nutrients in utero and exposure to maternal trauma contribute to an individual’s mental health risk profile. As a person ages, employment opportunities and exposure to dis- ease also cumulatively affect mental health status. Even into older age, factors such as social integration and chronic illness continue to impact mental well-being. Thus, public health interventions to promote mental wellness must address all levels of this continuum.24

n CULTURAL CONTEXT Cultural Influences on Mental Health48

“People often think of mental health as a very per- sonal matter that has to do only with the individual. However, mental illnesses and mental health in general are affected by the combination of biological and ge- netic factors, psychology, and society. This intersec- tionality is important, but the heavy influence of societal factors often goes ignored. An interesting aspect of society is its diversity in cultures and back- grounds that affect an individual’s mental health related experiences … For instance, culture affects the way in which people describe their symptoms, such as whether they choose to describe emotional or physical symptoms. Essentially, it dictates whether people

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Stigma is one of the barriers to the treatment of men- tal health problems.48 Goffman’s classic definition views stigma as a combination of personal attributes and soci- etal stereotypes related to human characteristics viewed as unacceptable.49 Stigma refers to a trait or attribute of a person that results in the discrediting of that person. Stigma occurs when the person, rather than the trait or condition, is held responsible for the inability to per- form an action.50, 51 Cultural belief systems can produce stigma, the form of social disapproval that pervades the attitudes and actions of the community, the family, and even the individual.

Stigma acts as a barrier to achieving health and well- being, and can greatly undermine a community’s efforts to capitalize on strengths. There is a growing awareness of disparities in access and use of mental health services among ethnic and racial minority populations. Treatment disparities among African American and Hispanic groups, for example, are especially acute. Although African Americans and Hispanics are more than 20% more likely to report psychological distress than non-Hispanic whites, African Americans are 15% less likely and Hispanics are half as likely as non-Hispanic whites to receive mental health care.52-55 There are many possible explanations for these disparities, including variations in expression of symptoms, bias or prejudice among providers, experiences of mistreatment, difficulties in accessing treatment, and stigma among various populations.56 These groups also have the highest numbers of people who lack insurance coverage.57 Stigma can cause individuals with mental illness to adopt a number of behaviors that serve to protect them from stigma but may result in failure to seek treat- ment (Box 10-3).56

The American Psychiatric Association (APA) has de- veloped strategies to address issues related to culture and stigma. These strategies address challenges related to the complexity of the issue, including illness progression, family history and cultural influences, impenetrable iso- lation reinforced by stigma, and multiple system failures. An example is the organization’s recommendations for

providing culturally competent care for Asian Americans who may have a mental disorder (see Box 10-4).58 The term Asian refers to people whose country of origin is located in the Far East and includes people from South- east Asia, the Indian subcontinent, and the Pacific Islands. Providing care requires an understanding of the diversity of cultures as well as the possibility that present- ing symptoms may represent culture-bound syndromes that can affect Asian American populations.58

The importance of understanding culture and stigma is exemplified by the incident that occurred on April 16, 2007. Seung-hui Cho, aged 23 years and a senior at Virginia Polytechnic Institute and State University (Virginia Tech), wounded 25 people and killed 32 and then himself in a shooting rampage that lasted several hours. Cho was only 8 years old when his family arrived in the United States from South Korea. He was a shy child and apparently was bullied. His childhood years had been troubled, and in middle school, he was diagnosed with selective mutism, a severe anxiety disorder, and an MDD. He began to re- ceive treatment and therapy, which continued through his sophomore year in high school. During college, he was hospitalized for mental illness symptoms and offered treatment, which he declined.59, 60

The tragic shooting incident led campus police and state government officials to investigate and make recom- mendations. Due to this incident and others, colleges and universities across the nation have evaluated and revised safety and security plans, and strengthened campus men- tal health services.61 This case illustrates that a traumatic experience of this nature has a widespread impact on a community, with lasting psychological distress. Violent acts such as this; the Columbine High School shootings; the movie theater shootings in Aurora, Colorado; the shootings in Newtown, Connecticut; and the shootings in Parkland, Florida, are linked with mental disorders and social-identity threats.61

The high-profile case at Virginia Tech is an example of the impact that culture has on understanding the

246 U N I T I I n Community Health Across Populations: Public Health Issues

selectively present symptoms in a ‘culturally appropri- ate’ way that won’t reflect badly on them … Every culture has its own way of making sense of the highly subjective experience that is an understanding of one’s mental health. Each has a prevailing attitude about whether mental illness is real or imagined, an illness of the mind or the body or both, who is at risk for it, what might cause it, and perhaps most importantly, the level of stigma surrounding it.”

• Not telling other people about symptoms • Masking the symptoms • Normalizing mental health symptoms • Emphasizing somatic aspects • Refusing to seek treatment • Fearing rejection by family and friends • Concern about difficulty finding housing and employment • Being socially ostracized

BOX 10–3 n Impact of Mental Health Stigma

Source: (56)

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to optimize the mental health of individuals and com- munities. Promotion focuses on building communities with living conditions and environments that support mental health. Prevention focuses on implementing strategies that prevent mental disorders and providing early intervention and adequate treatment for those with mental disorders.64

Measure of Mental Health: Health-Related Quality of Life One way to assess mental health is to measure health- related quality of life (HRQoL). It is a marker not only of physical health but also of mental health. As noted in Chapter 9, HRQoL is central to the overarching goals for HP 2020. HRQoL as defined in Chapter 9 is the self-perceived impact of physical and emotional health on quality of life, including the effects on general health, physical functioning, physical health and role, bodily pain, vitality, social functioning, emotional health and role, and mental health.65,66 The HRQoL measure used by the CDC includes items specifically aimed at measuring

C H A P T E R 1 0 n Mental Health 247

A Few Best Practices for Working with Asian Patients • Assess the language barrier. Ascertain whether the

patient speaks English or not, their native dialect, and the degree of acculturation.

• Ask about traditional beliefs as part of your cultural formulation. These may influence how the individual expresses mental distress, such as through somatic symptoms. For non-English speaking unacculturated individuals, particularly among the elderly, many hold traditional values and a concept of health and disease (e.g., Yin/Yang) that may influence the individual’s expression of mental distress such as through somatic symptoms. They may seek traditional healers such as acupuncturists and herbalists. Their ideas about bodily symptoms may affect drug compliance.

• Many Asian immigrants view physicians and other providers as authority, so encourage patients’ participa- tion in their care. Taking blood pressure, checking pulse, and giving advice about diet and foods/use of herbal products can promote rapport.

• Involve the family in health-care decisions. If interde- pendence among family members is valued, treat the family as a unit.

• Familiarize yourself with ethnopsychopharmacological research. You may, for example, start with a lower pre- scribed dosage of psychotropic medications for Asians.

• Prescribe cognitive behavioral therapy, where appropri- ate. Talking therapy is foreign to many Asians. If psy- chotherapy is indicated and involvement of the family is discouraged to maintain confidentiality, explain the rationale and procedure to both the patient and the family.

• Allow sufficient time for interviews. Translation needs extra time, and it takes time for Asian patients to feel comfortable in sharing very intimate, personal informa- tion with outsiders.

• Be attentive to comorbid medical problems. • Consider traditional interventions in addition to

medication and, if indicated, diets, exercises, and other traditional methods (Tai Chi, breathing exercises) of stress-reduction and relaxation.

• Ask detailed clinical history with open-ended questions first, and be attentive to nonverbal clues (facial expres- sion, tearing, etc.).

Please refer to the APA Web site for further informa- tion on treating Asian patients and resources to help you provide culturally competent care: https://www. psychiatry.org/psychiatrists/cultural-competency/ treating-diverse-patient-populations/working-with- asian-american-patients.

BOX 10–4 n APA Best Practices for Working with Asian American Patients

Source: (58)

expressions and presentation of mental disorders. Korean Americans make up 9% of the Asian population in America, up 41% from 2000. Of these, a little less than two-thirds are foreign born, but they rank 12th of all U.S. naturalizations since 2012 and fifth among Asians.62 Han and Pong (2015) reported that Asian American college students are unlikely to present to a health-care provider and complain of mental problems. Rather, their concerns are focused on schooling, and vocational or employment- related problems. Families are likely to insist that a family member suffering with mental problems should keep her or his problems hidden because of the shame it can bring on the family. By the time help is sought, the problems have often become severe.63

Prevention of Mental Disorders and Promotion of Mental Health Because mental health is not simply the absence of a mental disorder, prevention of mental disorders and pro- motion of mental health are key components of efforts

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emotional and mental health. It is a useful tool for the nurse who wishes to assess the level of mental health in a patient as well as a tool for assessing the overall mental health in a population. The tool is available on the CDC Web site and can be easily downloaded.

National Academy of Medicine Model of Prevention In 1997, the IOM, now the National Academy of Medi- cine, reported that the primary, secondary, and tertiary continuum of prevention was confusing when applied to mental disorders and developed a new model that more clearly separates prevention from treatment.67

This framework, presented in Chapter 2 and again in Chapter 11, divides the prevention category into three levels developed specifically for behavioral health issues: (1) universal, (2) selective (also referred to as selected), and (3) indicated, with possible interventions at each level. Universal prevention refers to prevention interven- tions provided to the entire population, not just those who might be at risk. The interventions include but are not limited to public service announcements provided to the public at large through billboards, media messages (print and electronic), or general health education programs. Selective prevention includes interventions provided to specific subgroups who are known to be at high risk for mental disorders because of biological, psy- chological, social, or environmental factors but who have not yet been diagnosed with mental disorders. High-risk subgroups include but are not limited to those with a family history of mental disorders, with a history of ad- verse childhood events, or who are victims of violence. An example is counseling delivered to students at a school where violence has occurred, such as the extensive coun- seling required following the Parkland, Florida, shootings. Selective interventions include opportunities for learning strategies to prevent the development of a mental disorder as well as early warning signs to help individuals and families seek help early. Indicated prevention addresses specific subgroups at highest risk for development of a mental disorder or individuals who are showing early signs of a mental disorder. The purpose of indicated tech- niques is to delay or reduce the severity of a mental dis- order. At this level, there is less concern about community prevention and more emphasis on individuals who demonstrate early signs of mental disorders.67

Promotion of Mental Health and Policy The WHO strongly supports the implementation of strategies that will create healthful living conditions and environments that result in optimal mental health.

The organization stated that mental health promotion depends on intersectoral strategies. These are defined as strategies that engage more than one sector of society with a shared interest such as governmental agencies, grass roots citizen groups, nonprofit groups, and/or businesses. Some strategies proposed by the WHO in- clude those that address needs of specific age groups, vulnerable populations, and women. Other strategies focus on the environment, such as the workplace, schools, housing, and community development. The WHO recommended that governments main- stream mental health promotion across policies and programs.64 The WHO warns against focusing only on mental disorder treatment and stresses that an up- stream approach (see Chapter 2) is vital to the health of communities.

To support its efforts related to mental health im- provement, the WHO developed a model to guide its activities called the Mental Health Improvements for Nations’ Development (MIND) (Fig. 10-3). It includes four components: (1) Action in Countries, (2) Mental Health Policy, Planning & Service, (3) Mental Health, Human Rights & Legislation, and (4) Mental Health, Poverty & Development. This model demonstrates not only the need for intersectoral strategies but also for interrelationships between multiple factors that con- tribute to mental health.68

Secondary Prevention: Screening for Mental Disorders The focus of the National Academy of Medicine’s report Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series is the need for appropriate behavioral health treatment.69 The report has a strong emphasis on early identification and treatment. The model for secondary intervention in mental health is screening, brief intervention, and refer- ral for treatment (SBIRT), an approach also used in sec- ondary prevention programs related to at-risk alcohol use (Chapter 11). The Substance Abuse and Mental Health Service Administration (SAMHSA) issued a re- port on the use of screening for behavioral health that includes screening for depression and trauma/anxiety disorders. Although SAMHSA concludes that no evi- dence exists to support a comprehensive SBIRT pro- gram for these disorders, there is evidence that screening is effective.70

Reliable screening tools exist that have validity across the life span and across health-care settings. Tools differ based on the specific mental disorder being screened. The screening tools most often used in primary care are

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for depression and anxiety disorders. Tools to screen for depression include the Patient Health Questionnaire 2 and the Center for Epidemiological Studies Depression Scale. Screening tools for anxiety disorders include the Brief Symptom Checklist-18 of the My Mood Monitor.70

The challenge is not only to screen but also to provide care to those who screen positive. Thus, universal screening for depression is only recommended in situa- tions in which accurate diagnosis and treatment are available.70

One approach related to screening and engagement into treatment for disorders is to integrate care for men- tal disorders within primary care settings. Because most people identified with mental disorders are seen in a primary care setting, integrating care within this setting is a logical approach. Without an integrated system, those who screen positive may not receive the care they need. Kroenke and Unutzer (2017) suggest there are six key components to successfully integrating mental health care into primary care settings (Box 10-5).71

C H A P T E R 1 0 n Mental Health 249

Mental Health, Poverty & Development

Mental Health, Human Rights & Legislation Mental Health Policy, Planning

& Service Development

Action in Countries

NATIONS’ DEVELOPMENT

MENTAL HEALTH IMPROVEMENTS

Figure 10-3 WHO Mental Health Improvements for Nations’ Development (MIND). (From World Health Organization. [2012]. Mental Health, MIND— mental health in development. Retrieved from http://www. who.int/mental_health/policy/en/index.html.)

• Population-Based Care: Depends on systematic efforts to identify all patients with disease, provide treatment, and track outcomes. This may be difficult to do with current system of nonintegrated electronic health records.

• Measurement-Based Care: Essential for public health surveillance, but most mental disorders depend on patient-reported outcomes (PROs). The ideal PRO is brief, self-reported, public domain, multipurpose, easy to score and interpret, and available in multiple lan- guages. Although a few scales meet these criteria, most do not. One that does meet most of these criteria is the Patient Health Questionnaire family of scales.

• Treatment to Target: Requires regular monitoring of disorder severity and adjusting treatment based on monitored outcomes. Interventions must be evidence- based and, if patients are not improving as expected,

there is a systematic protocol to incorporate measure- ment results in treatment changes.

• Care Management: Dedicated clinician who follows patients with particular disorders in (a) practice(s). Also, maintains disease registry, provides disease-related education, tracks treatment adherence, and coordinates care.

• Psychiatric Consultation: Accessible and dedicated psychi- atrist who can meet frequently with care manager and occasionally will also meet with patients. Can also facili- tate referrals and may be integrated by telepsychiatry.

• Brief Psychological Therapies: Can be administered in primary care clinics or remotely by trained behavioral health specialists. Approaches include motivational interviewing, behavioral activation, and problem-solving treatment.

BOX 10–5 n Six Key Components for Mental Health Care Integration into Primary Care Settings

Source: (71)

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250 U N I T I I n Community Health Across Populations: Public Health Issues

suicidal ideation, self-harm, and suicide attempts than their heterosexual, cisgender counterparts.72,73

As is recommended, when Enrico considered cultural risk factors as part of his suicide risk assessment, he discovered that one protective factor for Yuichi was that Asian adolescents had lower odds of suicidal ideation, planning, and self-harm when compared to white adolescents, despite the continuing issue of stigma that has not yet been eliminated in Japanese culture.73-75

Enrico discussed these findings with his colleagues and nursing supervisor. Given the sensitive nature of Yuichi’s disclosure, he cautioned the team that it was especially important they consider how to address Yuichi’s suggestion that he was considering suicide, while also not outing him to his parents against his will. Enrico pointed out to his colleagues that social support is critically important to the mental health of LGBTQ+ adolescents.76 He explained how he is concerned that if Yuichi is outed to his parents, he may lose a key com- ponent of his current social support network. The team discussed whether they had a duty to tell Yuichi’s par- ents about his sexual orientation and his thoughts about ending his life. One reference Enrico found provided support and guidance for the team’s conclusion.77 The team decided that they would only tell Yuichi’s parents that the team was concerned about Yuichi’s mental well-being and had requested a consult with a psychia- trist while he was still inpatient. The team also recom- mended that Yuichi follow up with counseling once he was discharged from the hospital.

Following Yuichi’s discharge with this recommended plan, Enrico worked with the hospital policy committee to develop a new policy outlining the protocol for noti- fication of parents about sensitive issues regarding their children. He also worked with the policy committee to update the suicide risk assessment protocol to include a cultural component.

Four months after Yuichi was discharged, he re- turned to the hospital to thank Enrico for his help. He told Enrico that the counselor his parents had found had been very helpful to him and that, with the coun- selor’s guidance, he had decided to wait until after his 18th birthday and his high school graduation before coming out to his parents. Yuichi did say, however, that he was feeling much better and more hopeful for the future. Enrico thanked him for coming in to update him and told Yuichi that his experience as a patient had helped the hospital create new policies to make things better for the patients who followed him.

l APPLYING PUBLIC HEALTH SCIENCE The Case of Sadness Under the Rainbow Public Health Science Topics Covered:

• Epidemiology • Surveillance • Program Planning

Enrico, a nurse for 2 years, recently started working in a pediatric medical-surgical unit in a rural, critical access hospital. Last week, he was involved in the care of Yuichi, a 17-year-old male who was admit- ted for surgery to remove a ruptured appendix. As Enrico provided care to Yuichi on the third day after surgery, he noticed that Yuichi was withdrawn and quiet, rarely looking at Enrico or even appearing to notice his attempts to start a conversation. However, when Enrico brought in his afternoon pain medicine, Yuichi seemed to notice Enrico’s left wrist and bright- ened visibly. Enrico looked at his left wrist where he had a rainbow band on his wristwatch. Yuichi asked, “Why do you wear the rainbow watch?” Enrico considered carefully for a moment, then decided to disclose personal information because he felt this was the first time there was an opening to develop a therapeutic connection with Yuichi. Enrico disclosed he was gay and wore the wristband in solidarity with the LGBTQ+ community. Immediately, Yuichi, smiling shyly, visibly relaxed. He then told Enrico that he was also gay and had recently come out to his friends at school but was still in the closet to his parents and family. He told Enrico that his parents emigrated to the United States from Japan when he was a baby and are very conservative. He confessed that he has been very worried about how his parents will react to his coming out and has even been feeling like “being dead would be better than living like this, especially if they kick me out.”

After Enrico had returned to the nurses’ station, he started to review the evidence about LGBTQ+ adolescents, mental health risks, and mental health interventions. Over the next day, Enrico found sev- eral journal articles and a book chapter that helped him to better understand the current evidence about the prevalence of and interventions for the mental health challenges of sexual and race/ethnic minority youths.72-77 Enrico learned that, among the many risk factors for suicide, LGBTQ+ youths have been reported to experience higher odds of sadness,

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Tertiary Prevention: Treatment for Mental Disorders At the individual level, a person diagnosed with a mental disorder must meet the clinical criteria for the diagnosis. Because there are no definitive diagnostic laboratory tests or scans useful for diagnosing mental disorders, experts in the field developed a manual, the Diagnostic and Statistical Manual of Mental Disorders (DSM), to guide diagnostic decision making and provide consis- tency and accuracy in diagnoses among clinicians. The newest revision of the manual, DSM-5, is organized so the chapters are based on underlying vulnerabilities as well as symptom characteristics. The goal of the DSM is to facilitate a more comprehensive approach to diag- nosis and treatment, and the DSM-5 represented a major change from earlier versions of the manual.78

Thus, at the individual level, experts re-examined diag- nostic criteria based on the best evidence in developing the DSM-5. Treatment of mental health usually focuses on the individual and can include many different treat- ment modalities. At the population level, tertiary treat- ment and policy are closely related with access to treatment as the central issue.

Mental Health Policy Related to Treatment Access to treatment and the type of treatment available have been central issues since the end of World War II. Prevention at the population level related to treatment entails reduction of disparity in access to treatment, whereas promotion of mental health requires policies that will strengthen the mental health of populations.79

Historically, government policy focused on treatment of mental disorders and was influenced by underlying attitudes concerning mental disorders. In the latter half of the 20th century, policy changes were put in place that led to deinstitutionalization. Other events that influenced policy related to treatment include pharmacological ad- vances, for example, the introduction of drugs such as Thorazine, as well as a cultural change from focusing on treatment of those with mental disorders to improving mental health for all.

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n EVIDENCE-BASED PRACTICE Screening for Suicide Risk Among Adolescents in Primary Care

Practice Statement: Adolescents should be screened in primary care for suicide risk using a validated and reliable screening tool if there is reason to believe an adolescent is at elevated risk. Targeted Outcome: Identification of those at risk, initiation of prevention strategies, and, when indicated, referral to treatment Evidence to Support: The evidence for the effective- ness of screening for suicide risk in adolescents, as well as in adults and older adults, has been found to be incomplete by the U.S. Preventive Services Task Force (USPSTF).1 The American Academy of Pediatrics recommends that, if adolescents are screened for suicide risk, they should be asked directly about suici- dal ideation.2 There is some evidence that screening for suicide can detect adolescents who are at increased risk for suicide, but there is insufficient evidence yet to determine whether that identification translates to improved outcomes, such as decreased attempted and completed suicide rates.3 Recommended Approaches: Adolescents that have known risk factors for suicide, such as recent mental illness, increased substance use, or withdrawal from social support networks, should be screened by suicide assessment. Direct questioning regarding suicidal ideation should be used, such as asking, “Have you ever had thoughts about taking your own life or wishing you were dead?” Standardized assessments may be helpful, but most have been found to be too sensitive while lacking specificity in this population.1-3 If adolescents are positive for suicidal ideation, they should be referred for immediate psychiatric evaluation by hospitalization, transfer to an emergency department, or same-day appointment with a mental health provider.2

Sources: 1. LeFevre, M.L. (2014). Screening for suicide risk in

adolescents, adults, and older adults in primary care: U.S. Preventive Services Task Force recommenda- tion statement. Annals of Internal Medicine, 160(10), 719-726. doi:10.7326/M14-0589.

2. Shain, B.N. (2007). Suicide and suicide attempts in adolescents. Pediatrics, 120(3), 669-676. doi:10.1542/ peds.105.4.871.

3. Kennebeck, S., & Bonin, L. (2017). Suicidal ideation and behavior in children and adolescents: Evaluation

and management. UpToDate. Retrieved from https://www.uptodate.com/contents/suicidal- ideation-and-behavior-in-children-and-adolescents- evaluation-and-management.

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Supreme Court decisions also affected policy. For example, the “least restrictive alternative” principle in the ruling in Shelton v. Tucker (1960), which allowed invol- untary admission to a psychiatric facility only if there were no another alternative that would allow more freedom, and the ruling in O’Connor v. Donaldson (1975), which stated that mental patients who were not dangerous and involuntarily institutionalized had the right to be treated or discharged.80 These landmark decisions resulted in deinstitutionalization of those diagnosed with mental disorders from psychiatric hos- pitals to independent living arrangements, thus shifting the burden of treatment to the community. President John F. Kennedy signed the Community Mental Health Centers Act in 1963, which opened the way for a network of community mental health centers to provide compre- hensive services and continuity of care.81

Unfortunately, community facilities did not develop at the same pace as deinstitutionalization. In addition, insufficient planning for alternative facilities and services (medical and psychiatric care, social services, housing and nutrition, income and employment, and vocational and social rehabilitation) resulted in thousands of vulnerable and severely ill persons left behind to be- come imprisoned by poverty, neglect, victimization, substance abuse, and homelessness, all conditions that exacerbate psychiatric disorders.82,83 The term transin- stitutionalization began to appear in the literature in the 1980s and refers to the growing numbers of men- tally ill persons ending up on the streets, in jails and prisons, in nursing homes, boarding houses, and home- less shelters, and not in places of their own or in the hospital. Today, it is estimated that between 30% and 50% of persons in the United States who are homeless are also mentally ill.80, 83

The Mental Health Parity Act represents a step for- ward as the United States grapples with accepting treat- ment of mental illness as integral to promoting and ensuring a healthy public. The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 was signed into law October 3, 2008, and mandates that group health plans of 50 or more persons, which cover mental health and substance-use disorders, must provide benefits equivalent to (or better than) those benefits provided for medical or surgical benefits. The Affordable Care Act of 2010 has also helped to fill in some of the gaps by requiring Medicaid and plans purchased by small businesses to include mental health and substance abuse coverage. However, significant gaps remain, and further work is needed to transform the delivery of health care to those with mental disorders.

Attention is needed not only on parity of access but also on the ethics of providing treatment for mental disorders at parity with treatment for physical disorders.

n Summary Points • Behavioral health is essential to overall health. • Behavioral health disorders will surpass all physical

diseases as a major cause of disability worldwide. • Mental health, substance abuse, and violence are

interconnected. • Mental health is the vehicle for developing meaning-

ful relationships, sound thinking, skills for learning and communication, emotional maturity, resilience, and self-esteem.

• Resilience is an individual’s ability to access protec- tive factors.

• Risk factors and protective factors related to mental health outcomes occur at several levels: individual, family, social, and community.

• Interventions occur at all levels, but societal inter- ventions are critical to transforming the mental health system.

252 U N I T I I n Community Health Across Populations: Public Health Issues

t CASE STUDY Promoting Mental Health among Older Adults

Learning Outcomes At the end of this case study, the student will be able to:

• Apply demographic methods to determine the sever- ity of a problem at the population level.

• Examine the role that members of the community play in addressing a population level health issue.

• Discuss policy approaches to a population-level health problem.

• Examine the evidence to support a population-based intervention.

The nurses working for a primary health clinic were concerned about the increase in suicides among older adults in the clinic’s practice population. One of the nurses brought in an article about suicide risk among older adults.84 The nurses found the risk of suicide among older adults to be startling and decided to investigate what steps they might be able to take to address this type of situation in their own primary care clinic. One of the nurses stated they should not proceed without including members of the local

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C H A P T E R 1 0 n Mental Health 253

community, including the senior center. How should they begin?

To complete this case study, do the following:

1. Starting with Jahn’s article, review the national statistics on suicide among older adults.

2. Determine which stakeholders should be involved in helping to design a community-level intervention.

3. Critique proposed policy initiatives in relation to their utility in reducing suicide among older adults—are there any?

4. Critique the evidence for programs aimed at preventing suicide and evaluate whether they have been tested with older adult populations.

5. Complete a draft plan.

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31. World Health Organization. (2009). Mental health resilience and inequalities. Retrieved from http://www.euro.who. int/__data/assets/pdf_file/0012/100821/E92227.pdf.

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33. McAllister, M., Knight, B.A., Hasking, P., Withyman, C., & Dawkins, J. (2018). Building resilience in regional youth: Impacts of a universal mental health promotion programme. International Journal of Mental Health Nursing 27(3), 1044-1054. doi:10.1111/inm.12412.

34. Lou, Y., Taylor, E.P., & DiFolco, S. (2018). Resilience and resilience factors in children in residential care: A systematic review. Children & Youth Services Review, 89, 83-92. doi:10.1016/j.childyouth.2018.04.010.

35. New Freedom Commission on Mental Health. (2003). Achiev- ing the promise: Transforming mental health care in America, Final Report. (DHHS Publication No. SMA-03-3832). Rockville, MD: U.S. Department of Health and Human Services.

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37. Hargreaves, M.B., Verbitsky-Savitz, N., Coffee-Borden, B., Perreras, L., White, C.R., Pecora, P.J., … Hunter, R. (2017). Advancing the measurement of collective community capac- ity to address adverse childhood experiences and resilience. Children and Youth Services Review, 76, 142-153. doi:10.1016/j.childyouth.2017.02.021.

38. Maier, A., Daniel, J., Oakes, J., & Lam, L. (2017). Community schools as an effective school improvement strategy: A review of the evidence. Palo Alto, CA: Learning Policy Institute. Retrieved from https://learningpolicyinstitute.org/sites/ default/files/product-files/Community_Schools_Effective_ REPORT.pdf.

39. Elev8 Baltimore. (n.d.). Retrieved from http://www. elev8kids.org/local-initiatives/content/baltimore.

40. World Health Organization. (2015). Child and adolescent mental health. Retrieved from http://www.who.int/ mental_health/maternal-child/child_adolescent/en/.

41. Monahan, K.C., Oesterle, S., & Hawkins, J.D. (2010). Predic- tors and consequences of school connectedness: The case of prevention. The Prevention Researcher, 17(3), 3-6.

42. The White House. (n.d.). Neighborhood revitalization initia- tive. Retrieved from https://obamawhitehouse.archives. gov/administration/eop/oua/initiatives/neighborhood- revitalization.

43. U.S. Department of Housing and Urban Development. (n.d.) Choice neighborhoods. Retrieved from https:// www.hud.gov/program_offices/public_indian_housing/ programs/ph/cn.

44. Mascayano, F., Tapia, T., Schilling, S., Alvarado, R., Tapia, E., Lips, W., & Yang, L.H. (2016). Stigma toward mental illness in Latin America and the Caribbean: A systematic review. Revista Brasileira de Psiquiatria, 38(1), 73-85. doi:10.1590/ 1516-4446-2015-1652.

45. Shannon, P.J., Wieling, E., Simmelink-McCleary, J., & Becher, E. (2015). Beyond stigma: Barriers to discussing mental health in refugee populations. Journal of Loss and Trauma, 20(3), 281-296. doi:10.1080/15325024.2014.934629.

46. Angermeyer, M.C., & Schomerus, G. (2017). State of the art of population-based attitude research on mental health: A systematic review. Epidemiology and Psychiatric Sciences, 26(3), 252-264. doi:10.1017/S2045796016000627.

47. Andrade, S. (2017). Cultural influences on mental health. The Public Health Advocate. Retrieved from https://pha.berkeley. edu/2017/04/16/cultural-influences-on-mental-health/.

48. Yang, L.H., Thornicroft, G., Alvarado, R., Vega, E., & Link, B.G. (2014). Recent advances in cross-cultural measurement in psychiatric epidemiology: Utilizing ‘what matters most’ to identify culture-specific aspects of stigma. International Journal of Epidemiology, 43(2), 494-510. doi:10.1093/ije/dyu039.

49. Goffman, E. (1963). Notes on the management of spoiled identity. Englewood Cliffs, NJ: Prentice-Hall.

50. Thornicroft, G. (2006). Actions speak louder … Tackling discrimination against people with mental illness. Mental Health Foundation. Retrieved from https://www. mentalhealth.org.uk/sites/default/files/actions_speak__ louder_0.pdf.

51. Mayo Clinic.com. (n.d.). Mental illness: Mental health; Overcoming the stigma of mental illness. Retrieved from https://www.mayoclinic.org/diseases-conditions/ mental-illness/in-depth/mental-health/art-20046477.

52. U.S. Department of Health and Human Services Office of Minority Health. (2017). Mental health and African Americans. Retrieved from https://minorityhealth.hhs.gov/ omh/browse.aspx?lvl=4&lvlid=24.

53. U.S. Department of Health and Human Services Office of Minority Health. (2017). Mental health and Hispanics. Retrieved from https://minorityhealth.hhs.gov/omh/ browse.aspx?lvl=4&lvlid=69.

54. Mental Health America. (n.d.). Black & African American communities and mental health. Retrieved from http://www. mentalhealthamerica.net/african-american-mental-health.

55. National Alliance on Mental Illness. (n.d.). African American mental health. Retrieved from https://www.nami.org/ Find-Support/Diverse-Communities/African-American- Mental-Health.

56. Clement, S., Schauman, O., Graham, T., Maggioni, F., Evans-Lacko, S., Bezborodovs, N., … Thornicroft, G. (2015). What is the impact of mental health-related stigma on

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help-seeking? A systematic review of quantitative and quali- tative studies. Psychological Medicine, 45(1), 11-27. doi:10.1017/S0033291714000129.

57. National Center for Health Statistics. (2016). Health, United States, 2015: With special feature on racial and ethnic health disparities. Retrieved from https://www.cdc.gov/nchs/data/ hus/hus15.pdf.

58. Gaw, A. (n.d.). Working with Asian American patients. Cultural competency: Treating diverse populations. Retrieved from https://www.psychiatry.org/psychiatrists/cultural- competency/treating-diverse-patient-populations/working- with-asian-american-patients.

59. Biography.com Editors (2014). Seung-Hui Cho Biography. Retrieved from https://www.biography.com/crime-figure/ seung-hui-cho

60. Virginia Tech Review Panel. (2007). Mental health history of Seung Hui Cho. Retrieved from http://wayback.archive-it. org/263/20070904222258/http://www.governor.virginia.gov/ TempContent/techPanelReport-docs/8%20CHAPTER %20IV%20LIFE%20AND%20MENTAL%20HEALTH %20HISTORY%20OF%20CHOpdf.pdf.

61. Bonanno, C.M., & Levenson Jr, R.L. (2014). School shooters: History, current theoretical and empirical findings, and strategies for prevention. Sage Open, 4(1), 1-11. doi:10.1177/ 2158244014525425.

62. Asia Matters for America, America Matters for Asia. (n.d.). Korean-American population data. South Korea Matters for America, America Matters for South Korea. Retrieved from http://www.asiamattersforamerica.org/southkorea/data/ koreanamericanpopulation.

63. Han, M., & Pong, H. (2015). Mental health help-seeking be- haviors among Asian American community college students: The effect of stigma, cultural barriers, and acculturation. Journal of College Student Development, 56(1), 1-14.

64. World Health Organization. (2018). Mental Health Atlas: 2017. Geneva, Switzerland: Author. Retrieved from http:// apps.who.int/iris/bitstream/handle/10665/272735/ 9789241514019-eng.pdf?ua=1&ua=1.

65. Centers for Disease Control and Prevention. (2016). Health-related quality of life. Retrieved from http://www. cdc.gov/hrqol.

66. Ware Jr., J.E., & Sherbourne, C.D. (1992). The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Medical Care, 30(6), 473-483. doi:10.1097/00005650-199206000-00002.

67. Substance Abuse and Mental Health Services Administra- tion. (n.d.). Mapping interventions to different levels of risk. Retrieved from https://www.samhsa.gov/capt/tools- learning-resources/mapping-interventions-levels-risk.

68. World Health Organization. (n.d.). Mental Health, MIND—mental health in development. Retrieved from http://www.who.int/mental_health/policy/en/.

69. Institute of Medicine. (2005). Improving the quality of health care for mental and substance-use conditions: Quality Chasm Series. Retrieved from https://www.nap.edu/catalog/ 11470/improving-the-quality-of-health-care-for-mental- and-substance-use-conditions.

70. Substance Abuse and Mental Health Services Administra- tion. (2017). Screening, brief intervention and referral to treatment (SBIRT). Retrieved from https://www.samhsa. gov/sbirt.

71. Kroenke, K., & Unutzer, J. (2017). Closing the false divide: Sustainable approaches to integrating mental health services into primary care. Journal of General Internal Medicine, 32(4), 404-410. doi:10.1007/s11606-016-3967-9.

72. Puckett, J.A., Horne, S.G., Surace, F., Carter, A., Noffsinger- Frazier, N., Shulman, J., … Mosher, C. (2017). Predictors of sexual minority youth’s reported suicide attempts and men- tal health. Journal of Homosexuality, 64(6), 697-715. doi:10.1080/00918369.2016.1196999.

73. Bostwick, W.B., Meyer, I., Aranda, F., Russell, S., Hughes, T., Birkett, M., & Mustanski, B. (2014). Mental health and suicidality among racially/ethnically diverse sexual minority youths. American Journal of Public Health, 104(6), 1129-1136. doi:10.2105/ajph.2013.301749.

74. Chu, J., Robinett, E.N., Ma, J.K., Shadish, K.Y., Goldblum, P., & Bongar, B. (2018). Cultural versus classic risk and protec- tive factors for suicide. Death Studies, 43(1): 56-61. doi:10.1080/07481187.2018.1430085.

75. Kasai, M. (2017). Sexual and gender minorities and bullying in Japan. In S.T. Russell & S. S. Horn (Eds.), Sexual orienta- tion, gender identity, and schooling: The nexus of research, practice, and policy (pp. 185-193). New York: Oxford University Press.

76. McDonald, K. (2018). Social support and mental health in LGBTQ adolescents: A review of the literature. Issues in Mental Health Nursing, 39(1), 1-14. doi:10.1080/ 01612840.2017.1398283.

77. Hyatt, J. (2015). Maintaining the privacy of a minor’s sexual orientation and gender identity in the medical environment. Journal of Healthcare Risk Management, 35(1), 31-36. doi:10.1002/jhrm.21176.

78. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA; American Psychiatric Association.

79. Thompson, J.W. (1994). Trends in the development of psychiatric services, 1844–1994. Hospital and Community Psychiatry, 45(10), 987-992. doi:10.1176/ps.45.10.987.

80. Krieg, R.G. (2001). An interdisciplinary look at the deinstitutionalization of the mentally ill. The Social Science Journal, 38(3), 367-380. Retrieved from http://www. accessmylibrary.com/article-1G1-78901856/interdisciplinary- look-deinstitutionalization-mentally.html.

81. Talbott, J.A. (1982). Twentieth-century developments in American psychiatry. Psychiatric Quarterly, 54(4), 207-219. doi:10.1007/bf01064816.

82. Reddi, V. (2005). Dorthea Lynde Dix (1802–1887). Center for Nursing Advocacy. Retrieved from http://www. nursingadvocacy.org/press/pioneers/dix.html.

83. Sisti, D.A., Segal, A.G., & Emanuel, E.J. (2015). Improving long-term psychiatric care: Bring back the asylum. JAMA, 313(3), 243-244. doi:10.1001/jama.2014.16088.

84. Jahn, D.R. (2017). Suicide risk in older adults: The role and responsibility of primary care. JCOM, 24(4).

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Chapter 11

Substance Use and the Health of Communities Michael Sanchez, Christine Savage, and Amanda Choflet

LEARNING OUTCOMES

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

KEY TERMS

1. Describe the impact of substance use on the health of a population.

2. Define the burden of disease related to substance use using current epidemiological frameworks.

3. Apply current evidence-based population interventions to the prevention of harm associated with substance use across the continuum of use.

4. Describe population-level approaches to the prevention and treatment of substance use disorders.

Abstinence At-risk substance use Binge drinking Blood alcohol level Duration Environmental tobacco

smoke (ETS) Frequency

Harmful use Low-risk use Heavy drinking Involuntary smoke

exposure Moderate use Opioid epidemic Passive smoke exposure

Pattern Physical dependence Psychological dependence Psychoactive substances Screening and Brief

Intervention (SBI) Secondhand smoke

exposure

Stigma Substance use Substance use disorder Tolerance Quality Quantity Withdrawal

n Introduction In 2017, media headlines blared alarming statistics on the opioid overdose epidemic in the U.S. In the fall of 2017, the president declared a national public health emergency, and states scrambled to both prevent at-risk opioid use and provide life-saving treatment for opioid overdoses.1 The recent opioid epidemic in the U.S. put a spotlight on the dangers associated with the use of psychoactive drugs and brought a media-driven public health response to substance use that had not occurred since perhaps the emergence of cocaine use and the media spotlight on “crack babies” in the 1980s. The number of states that have legalized marijuana for medical and/or recreational use is increasing, with a subsequent increase in current use. At the same time, federal efforts focus on continuing to criminalize the use of marijuana. Current use of marijuana in- creased from 6.2% in 2004 to 7.9% in 2017.2 In the past decade, the largest increase occurred among

those 55 years of age or older with 1.1% reporting current use in 2004 and 6.1% reporting current use in 2014.3

Despite the recent focus on opioids, tobacco and alcohol, both legal substances, are leading causes of preventable deaths both globally and in the U.S.4,5,6,7 In 2017, based on the National Survey on Drug Use and Health, 87.1% of Americans aged 26 or older reported lifetime alcohol use. Of those aged 12-17 years old, 21.9% reported alcohol use within the past year, and 5.3% reported binge drinking.6 Although tobacco use has dropped over the past few decades, in 2017, 22.4% of those aged 18 or older reported past month tobacco use, and 62.7% reported lifetime use.2 With such a large pro- portion of the population using tobacco and/or alcohol, which are two leading causes of preventable death6,8,9, as well as the emerging issues such as the opioid epidemic and the emergence of legalized use of marijuana, it is important for nurses to have evidence-based knowledge and competency related to the prevention and treatment

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of at-risk substance use at the individual and community level.

At-risk substance use, defined as use linked to ad- verse health consequences for individuals, families, and communities, occurs across the globe. From a public health perspective, the consequences go beyond the neg- ative impact on the health of the individual using the substance.8,9 Substance use increases the risk for injury, crime, and adverse health issues, and poses a risk for other individuals through environmental factors. For ex- ample, illicit drug use is linked to increased crime in a neighborhood, alcohol use while driving injures and kills drinkers and nondrinkers, and tobacco use pollutes the environment through the release of toxic chemicals. Sub- stance use is a major public health issue affecting all ages, populations, and countries.6,7,9

Substance use occurs within the social, cultural, and economic context of the community with different impacts at the national level. These differences can include quantity consumed, the type of substance consumed, and the cultural norms around consump- tion. In relation to the quantity consumed, the U.S. represents 4.8% of the global population, yet globally, in 2015, the U.S. accounted for 49% of all consumption of morphine, 29.8% of fentanyl consumption, and 69% of oxycodone.7, 10 Lower socioeconomic status is associated with an increased risk of alcohol-related harm due to increased vulnerability to alcohol based on nutritional and health status, as well as decreased access to care. The other economically associated issue is the quality of the alcohol, with a higher rate of alcohol- related deaths due to consumption of illegal alcohol that contains toxins.9

In addition, cultural differences exist around the use of substances. Cultural norms in some countries such as the U.S. and Russia include the acceptance of binge drinking, that is, consumption of more than the recom- mended limits of total alcohol during one episode of drinking. By contrast, in some countries, any consump- tion of alcohol can result in adverse social consequences. Finally, lack of economic resources within a country or community can reduce the ability to develop and/or enforce policies aimed at preventing at-risk substance use. These policies include ones designed to reduce dis- tribution of illicit substances, control distribution of legal substances, and provide programs aimed at preventing substance use-related harm. Advocating to prevent harm associated with substance use and to provide access to treatment for those with a substance use disorder (SUD) requires an understanding of the context in which sub- stance use occurs, the extent of the burden of disease, and

evidence-based approaches that work across the contin- uum of use and life span.

Substance Use and the Global Burden of Disease Substance use is a term used across the globe in reference to the use of psychoactive substances. These are chemical substances that have a pharmacological effect on the brain and central nervous system (CNS). The effects of these substances on an individual include altered mood, perception, and level of consciousness.6 The classes of psychoactive substances include stimulants, depressants, inhalants, dissociative anesthetics, narcotics, hallucino- gens, and cannabis (Table 11-1).11 Some are legal, such as alcohol and tobacco, whereas others are illegal (or illicit), such as heroin. Some are legal with a prescription, such as narcotics prescribed for pain. Although cannabis is still illegal at the federal level in the U.S., in a growing number of states, marijuana (cannabis) can be obtained with a prescription. In a growing number of U.S. states and some Western European countries, it is legal for recreational use.

Understanding Substance Use and Risk Across the Continuum of Use and the Life Span Substance use includes four components: quantity, fre- quency, pattern, and duration.12 Assessment of these four components helps to determine the risk of adverse con- sequences. Consequences range from low to high risk with a diagnosis of an SUD at the high-risk end of the continuum (Fig. 11-1). Quantity is defined as the amount consumed, in other words, the dose. Frequency refers to how often the substance is consumed: daily, weekly, or monthly. The pattern of use refers to whether the use is consistent or occurs in an episodic manner, usually referred to as binging. Finally, duration of the use refers to how long over a lifetime the use has occurred.

Another important factor is the quality of the sub- stance consumed.9 Quality reflects the process for the manufacturing of the substance consumed and whether the product might include toxins, other substances such as Fentanyl-laced heroin, or not reflect a consistent dose. This usually occurs when manufacturing of the substance is done through an illegal and/or unregulated process. This is most apt to occur when the substance itself is illegal or when it is legal, but there are inadequate regu- lations controlling manufacturing.

Risk for harm associated with substance use occurs across the life span from fetal exposure to the last decades

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of life. Life span-associated risk for adverse conse- quences, both acute and chronic, differs based on human stages of development, ability to metabolize the sub- stance, and peer influence. Fetal exposure to alcohol can result in fetal alcohol spectrum disorders (FASD), which can occur due to fetal exposure to maternal alco- hol use, and it can include physical, behavioral, and/or learning problems.13 Based on findings from multiple studies on heavy alcohol use by adolescents, there is strong evidence of an association between alcohol use

and adverse effects on the brain including brain devel- opment, brain functioning, and neuropsychological per- formance.14-17 For older adults, changes in the ability to metabolize alcohol, frailty, and other health issues in- crease the risk of alcohol-related acute adverse outcomes such as falls, interactions with other medications, and in- creased risk of intoxication.16 Duration of use over the lifetime can increase the risk for other health issues such as liver disease, cancer, and cardiovascular disease even in the absence of an SUD.8

258 U N I T I I n Community Health Across Populations: Public Health Issues

TABLE 11–1 n Classes of Drugs

Category

Stimulants

Narcotics

Dissociative Anesthetics

Depressants

Inhalants

Hallucinogens

Cannabis

Description

Overstimulate the CNS resulting in accelerated heart rate, high blood pressure, and other symptoms related to stimulation of the CNS.

Relieve pain and can result in a state of euphoria and other mood changes.

Inhibit the body’s ability to perceive pain.

Depress the CNS thus slowing down the brain and the body.

Come from a wide range of chemicals inhaled producing mind-altering effects.

Result in altered perception of reality.

Result in a feeling of euphoria, and can include distorted perceptions, memory impairment, as well as difficulty thinking and solving problems.

Examples

Cocaine, amphetamines, methylphenidate, nicotine, methamphetamine, Ritalin, caffeine, and Methadrine

Vicodin and OxyContin, opium, morphine, heroin, codeine, hydromorphone, meperidine, methadone, Darvon

PCP

Alcohol, barbiturates, and anti-anxiety tranquilizers (e.g., Valium, Librium, Xanax, Prozac, and Thorazine)

Butyl nitrite, amyl nitrite gas used in some aerosol cans, gasoline and toluene vapors from correction fluid, glue, marking pens

PCP, LSD, mescaline, peyote, psilocybin, ecstasy, PCE, and methamphetamine, and Cannabis

Cannabinoids including marijuana, tetrahydrocannabinol, or THC; hashish; hashish oil; and synthetics like Dronabinol

Source: (11)

Substance Use Disorder

Adverse Health Consequences

Abstinence Low Risk Use

Adolescent Young Adult

Adult Older Adult

At Risk Use

Fetus Child

Figure 11-1 Substance use across the continuum of use and the life span.

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Differences exist in the addictive properties of sub- stances, yet all have the potential to result in an SUD. Other factors that play a role in increasing the risk for substance use related adverse outcomes include genet- ics, the health of an individual, age, psychological is- sues, environment, cultural norms, exposure to stress, and access to social support.7,8,18 Prevention of harm associated with substance use requires much more than prevention of an SUD. It requires reframing our ap- proach to substance use from the cellular to the global level. Substance use places persons and communities at risk for adverse consequences that encompasses more than 200 diseases and injuries, as well as economic bur- dens to populations.8

A comparison of substance use across the life span from the cellular to global level helps to illustrate the variability of use. Alcohol is the most prevalent substance used worldwide. Globally, more than 50% of adults reported current use of alcohol. When broken down by gender, 65% of males and 45% of women re- port current alcohol use.6 In the U.S., the statistics are similar, with a little more than 50% of adults reporting current alcohol use. The second most prevalent sub- stance is tobacco with 19% of adults in the U.S. reporting current tobacco use.2 The World Health Organization (WHO) reported that, in 2008, 155 to 250 million people, or 3.5% to 5.7% of the global population used psychoactive substances other than alcohol and tobacco. The most commonly used substance after alcohol and to- bacco was cannabis.18,19 In 2017, the percent of adults 12 or older in the U.S. who reported current drug use was higher, at 11.2% of that portion of the population.2

The Global Burden of Disease Globally, the burden of disease (see Chapter 3) associated with alcohol use has risen over the past decade from 4.2% to 5.1%.9 A total of 3 million deaths every year are due to the harmful use of alcohol, which represents 5.3 % of all deaths in 2016.8 For young adults, the mortality risks are higher, with 25% of all deaths in persons aged 20 to 39 attributable to alcohol use.18 Estimates of the global burden of disease attributable to drug use is 0.8%, with opioid use the largest contributor.19 Tobacco contributes significantly to the global burden of disease, accounting for 1 in 10 deaths, killing more than 6 million people an- nually, almost double the number of deaths attributable to alcohol use.20 Taken together, alcohol, tobacco, and drug use contribute significantly to the burden of disease, with alcohol and tobacco as two of the three top leading causes of preventable death. Substance use is linked to a wide spectrum of adverse health consequences at the

individual, family, and community levels (Table 11-2). Worldwide, tobacco and alcohol are among the top 10 risk factors for mortality, with tobacco being the number one risk factor in high-income countries.18-22

C H A P T E R 1 1 n Substance Use and the Health of Communities 259

n CULTURAL CONTEXT World Health Organization Report on Alcohol and Health: Culture and Context9

“The degree of risk for harm due to use of alcohol … varies with the physical and socioeconomic context in which a given drinking occasion and the ensuing hours take place. Moreover, the nature and extent of the harm that results from drinking can vary widely depending on the context. In some contexts, drinkers will be vulnerable to alcohol-related social harm, disease, injury, or even death if any volume of alcohol is consumed. This is the case, for instance, if a person drinks before driving a car or piloting an aeroplane [sic], when consuming alcohol can result in serious penalties and harm. Also, in many countries, there can be serious social or legal consequences for drinking at all, due to laws and regulations or cultural and religious norms, which can increase the vulnera- bility of drinkers to alcohol-related social harm.”

Substance Use Disorders Use of alcohol, tobacco, and other drugs all have the potential to result in an SUD. A substance use disorder is “a maladaptive pattern of substance use leading to clinically significant impairment or distress” and can be diagnosed as moderate or severe.23 The broader term used to refer to SUDs is addiction, defined as meeting the criteria for an SUD. In recent years, the professional literature has moved away from the term addiction in an effort to view the full continuum of risk rather than dichotomize the problem into categorizing a person as addicted or not addicted, thus negating the full contin- uum of harm associated with substance use. The gold standard for diagnosing an SUD used by health-care providers in the U.S. is the Diagnostic and Statistical Manual of Mental Disorders (DSM). In 2015, new criteria were introduced that represented a radical change from the approach used in earlier editions of the DSM, which included two diagnoses: substance abuse and substance dependence. With the fifth edition of the manual, DSM-V, an SUD is presented as a continuum that uti- lizes severity, evidence of physiological dependence, and course of treatment to classify the disorder (Box 11-1).23

An SUD can be established with or without physiological

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dependence. Physiological dependence is defined as ev- idence of tolerance to or withdrawal from a foreign sub- stance. Tolerance involves an adaptation of the body to a drug that results in needing more of the drug to achieve a certain effect. If use of the drug is stopped abruptly, drug-specific physical and/or mental symptoms occur, also known as withdrawal.23 Physical dependence alone does not meet the criteria for a diagnosis of an SUD be- cause withdrawal can occur even with chronic use of a

drug as prescribed.24 Thus, the terms substance abuse and substance dependence are not legitimate clinical terms. This also shifts the clinical picture away from pejorative language, such as abuser or addict, to a disease-oriented approach of a person with an SUD.

For years, much of the focus related to substance use was on the treatment of those who met the criteria for an SUD. In other words, the focus was a downstream ap- proach (Chapter 2) with a simultaneous policy approach that focused on criminalization of certain substance use and control of access to legal psychoactive substances such as alcohol and tobacco. Over the past few decades, the global focus has shifted to include a broader up- stream approach. This new focus attempts to reduce harm at the population level through prevention of harmful substance use, reduction of harms associated with use and early treatment of SUDs, decriminalization of substance use, and broader policy initiatives.6,9

260 U N I T I I n Community Health Across Populations: Public Health Issues

TABLE 11–2 n Adverse Consequences Related to Substance Use

Level

Individual

Family

Community

Injury

Increased risk for unintentional injury and suicide

Increased risk for intentional and unintentional injury

Increased risk for intentional and unintentional injury

Environment

Adverse effect on home environment (e.g., secondhand smoke in the home)

• Secondhand smoke • Increased crime • Decreased property

values

Physical Health

Increased risk for adverse health outcomes

Increased risk for adverse health outcomes secondary to impaired family member

Increased burden for cost of health care

Psychosocial Health

Negative impact on: • Mental health • Employment • Social networks

Negative impact on: • Mental health • Employment • Social networks

Negative impact on: • Community Social

networks

Source: (7-10)

Severity Specifiers: Moderate: 2-3 criteria positive Severe: 4 or more criteria positive

Specify If: With Physiological Dependence: evidence of tolerance or withdrawal (i.e., either Item 4 or 5 is present) Without Physiological Dependence: no evidence of tolerance or withdrawal (i.e., neither Item 4 nor 5 is present)

Course Specifiers (see text for definitions): Early Full Remission Early Partial Remission Sustained Full Remission Sustained Partial Remission On Agonist Therapy In a Controlled Environment

BOX 11–1 n Diagnosis of Substance Use and Addictive Disorders

Source: (23)

n CELLULAR TO GLOBAL Alcohol provides an excellent example of the poten- tial adverse outcomes associated with use from the cellular to global level. At the cellular level, continued use of alcohol at higher than recommended levels can result in a toxic effect on cellular DNA, increasing the risk of developing cancer. Harm associated with use affects the family, the community, all the way up to global impacts on population health related to the burden of disease. In 2016, more than 3 million peo- ple died globally as a result of alcohol use, more than deaths associated with diseases such as tuberculosis,

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Measurement, Surveillance, and Risk Before developing interventions to help reduce the harm related to substance use, it is important to understand how surveillance of substance use and associated adverse health outcomes (see Chapter 3) is conducted in the U.S. and across the globe in relation to the prevalence of substance use and adverse health consequences asso- ciated with use. The first step in conducting surveillance is defining how substance use is measured. Across all substances, there is a classification of use that reflects the associated level of risk (Fig. 11-1). Because multiple terms are sometimes used, clarity is needed. The first term is abstinence, defined as no use of the substance. For alcohol, it is usually measured as two or fewer drinks in the past 12 months, and for tobacco and other drugs, it reflects no use at all in the past 12 months. Low-risk use or moderate use is use of the substance that places the user at little or no risk. For example, if a healthy person drinks at or below the recommended limits for alcohol consumption of no more than two drinks in one day for adult men (one drink for adult women) and no more than 14 drinks (7 drinks for women) in a week, they are considered low-risk.24 A number of terms are used to describe the next level of use including risky use, at-risk use, binge/heavy episodic use, harmful use, and nondependent heavy use. For example, at-risk use and harmful use are used interchangeably. For the purpose of this chapter, we will use the term at-risk use, defined as use associated with harm to the individual, family, and/or community.6,12,13

Moderate- or low-risk alcohol use is defined as no more than four drinks in one day for healthy adult men and no more than three in one day for healthy adult women and persons over the age of 65. At-risk alcohol use in- cludes heavy drinking and binge drinking. Heavy drinking is defined based on the number of drinks con- sumed during a week. For adult men, heavy drinking is

15 or more drinks in a week, and for women or adults over 65, it is 8 or more in a week. Binge (episodic heavy) drinking is defined as five or more drinks (four or more for women) consumed on a single drinking occasion and is associated with drinking that brings the blood alcohol level up to a blood alcohol concentration (BAC) of 0.08 grams percent or above.24

For substances other than alcohol, the distinction between low-risk use and risky use is less clearly defined. In general, any use of tobacco or illegal substances is con- sidered at-risk use. Use of psychoactive substances avail- able by prescription is termed risky use when the use is not in alignment with the prescription. At the end of the spectrum of risk is an SUD, as described earlier. For some substances or some situations, all use is seen as at-risk. For example, there is no level of low-risk use of substances during pregnancy including tobacco, alcohol, marijuana, and illegal drugs.

When collecting individual substance use data, it is important to measure the four aspects of consumption of use: quantity, frequency, pattern, and duration. For alcohol use, quantity is measured as a standard drink, so the intake reflects the amount of alcohol (or dose) consumed rather than the amount of beverage con- sumed (Fig. 11-2). In the United States, a standard drink is 0.6 fluid ounces or 14 grams of pure alcohol. The amount of pure alcohol varies based on the type of beverage. For example, 12 ounces of beer or 5 ounces of wine represent one standard drink because they contain the same amount of pure alcohol.24 For some sub- stances, especially street drugs like heroin, quantity is hard to determine because there is no standard. Frequency is usually measured as number of times a week. Duration questions reflect how long over the life- time the substance has been used, and pattern is meas- ured based on whether the use is constant or varying. These terms are important not only when asking an in- dividual about substance use but also when measuring use at the population level.

Surveillance related to substance use is conducted on a regular basis to help measure the prevalence of sub- stance use. How use is measured in these surveys helps public health officials determine the level of risk at the population level. Eleven different national surveillance surveys that involve the collection of data on substance use are listed on the Centers for Disease Control and Prevention (CDC) Web site, including the Behavioral Risk Factor Surveillance System (BRFSS), the National Survey on Drug Use and Health (NSDUH), and the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). This surveillance process

C H A P T E R 1 1 n Substance Use and the Health of Communities 261

HIV/AIDs, and diabetes.9 The range of harm associ- ated with the use of alcohol extends across the full continuum of risk and requires not only mechanisms to care for individuals and families negatively affected by at-risk alcohol use but public health approaches at the local, state, national, and global level.8 The WHO’s global strategy is currently the most compre- hensive international policy document that provides guidance on reducing harmful alcohol use, which impacts many of the health-related targets of the Sustainable Development Goals.9

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provides information on the distribution of substance use and SUDs, as well as information on health-related consequences. Understanding the terms helps in the in- terpretation of the findings. For example, the report on binge drinking in the U.S. released by the CDC requires an understanding of what binge drinking is and is not.25

Models for Prevention and Treatment of Substance Use Disorders Prevention efforts related to substance use and adverse health consequences have shifted over the past 20 years from a narrow focus on the end of the continuum of use, an SUD, to a broader focus that includes the continuum of use across the life span. There are two models that guide prevention efforts: the harm reduction model and the Health and Medicine Division (HMD) of the National Academies of Sciences, Engineering and Medicine’s (formerly the Institute of Medicine [IOM]) prevention model presented in Chapter 2.

Health and Medicine Division Prevention Model Prevention is aimed at promoting resilience. In 1997, the HMD of the National Academies of Sciences, Engineer- ing and Medicine identified the primary, secondary,

and tertiary continuum of prevention as confusing and developed a new, simpler model that more clearly sepa- rates prevention from treatment.26 As explained in Chap- ter 2, this framework divides the prevention category into three levels—universal, selective, and indicated—and includes possible interventions at each level that can be applied easily to behavioral health issues.

Universal Level of Prevention The universal level of prevention addresses identified populations regardless of identified risk. In the case of substance abuse prevention, older adults, pregnant women, and teenagers can be offered skills to allow the postponement of use of substances of abuse. Universal prevention techniques include: education regarding the effects of alcohol, tobacco, and other drugs on one’s own health, on the health of children, and the danger of fetal alcohol syndrome (FAS)/effects and risk factors; the dan- ger of using substances of abuse when using prescribed medication; and special education for older adults in an age-appropriate manner. It includes appropriate decision-making and social skills to empower partici- pants to make good decisions.

Selective Level of Prevention With substance abuse, the selective level of prevention addresses specific subgroups known to be at risk for

262 U N I T I I n Community Health Across Populations: Public Health Issues

Figure 11-2 Standard drink. (From NIH, National Institute on Alcohol Abuse and Alcoholism. [2018]. What is a stan- dard drink? Retrieved from https://www. niaaa.nih.gov/alcohol-health/overview- alcohol-consumption/what-standard- drink.)

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at-risk substance use by virtue of biological, psychologi- cal, social, or environmental factors. Whether or not in- dividual members of the specific subgroups are using alcohol, tobacco, or other drugs is not taken into con- sideration when applying selective interventions. What is important is that the subgroups are at higher risk for at-risk substance use than the general population. The selective interventions are tailored to specific character- istics of the subgroups such as age, gender, reproductive status, availability of drugs in the communities in which the members live, community attitudes toward sub- stance use, substance use by peers, family history of substance use, family attitudes, social problems, history of sexual abuse, and marginal or poor academic achieve- ment in school. Selective interventions include oppor- tunities for learning social skills that might delay initial use of alcohol, tobacco, and other drugs. After-school activities, services and resources available at community centers, classes on how to interview for a job, drug and alcohol education, role-playing, and self-esteem build- ing exercises and opportunities are examples of selective interventions.

Indicated Level of Prevention The indicated level of prevention addresses specific subgroups at highest risk for development of an SUD or that are showing early signs of an SUD. These groups may appear to be experimenting with substances and, without aggressive preventative action, some members of the group will develop a full-fledged SUD. In addition to delaying initial substance use, the purpose of indi- cated techniques includes delaying or reducing the severity of an SUD. At this level, there is less concern about community prevention and more emphasis on those demonstrating early SUD. Indicated techniques might include continued alcohol and drug education, with specific attention to the consequences of continued use, and self-tests to determine the level of SUD a person might be experiencing, providing an opportunity for the early user to identify his or her risk factors and any signs or symptoms of SUD that might be present.

Harm Reduction Model The harm reduction model is another model used in the prevention of adverse consequences associated with alcohol and drug use. Harm reduction refers to any pro- gram, policy, and/or intervention that seeks to reduce the harm related to alcohol and drug use or other high-risk behavior, rather than focusing solely on attainment of abstinence of the risky behavior at the individual level.27

Thus, it includes a wide spectrum of interventions from

safer use (needle exchange programs) to abstinence. Thus, those engaged in at-risk use of substances who are not willing or able to engage in treatment that leads to abstinence are provided with options to minimize the harm associated with substance use. From a public health perspective, harm reduction is used to minimize the physical, emotional, social, and economic harm associated with substance use not only in relation to the individual but also to the larger population and the com- munity. The guiding principles of harm reduction are based on the assumption that interventions aimed at reduction of the adverse consequences associated with substance use should be free of judgment or blame.27 The Canadian Center for Substance Abuse proposed guiding principles for harm reduction (Box 11-2).28 The reduc- tion of the harm associated with substance abuse is a goal of Healthy People.29

C H A P T E R 1 1 n Substance Use and the Health of Communities 263

n HEALTHY PEOPLE AND SUBSTANCE USE

Goal: Reduce substance abuse to protect the health, safety, and quality of life for all, especially children. Overview: Although progress has been made in substantially lowering rates of abuse of some sub- stances, the use of mind- and behavior-altering sub- stances continues to take a major toll on the health of individuals, families, and communities nationwide. Substance abuse—involving drugs, alcohol, or both—is associated with a range of destructive social conditions, including family disruptions, financial problems, lost productivity, failure in school, injuries, domestic vio- lence, child abuse, and crime. Moreover, both social attitudes and legal responses to the consumption of alcohol and illicit drugs make substance abuse one of the most complex public health issues. Midcourse Review: Of the 44 objectives for this topic area, 2 were developmental and 42 were measurable. For 10 of the measurable objectives, the target was met or exceeded, and 1 was improving. For 12 there was little or no detectable change and 9 were getting worse. Eight of the objectives were informational (Fig. 11-3).

Source: (30)

Alcohol Use Alcohol consumption is a socially acceptable and nor- mative practice in the U.S. As noted earlier, more than half (51.7%) of the U.S. population 12 years of age or

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For those between the ages of 18 and 25, 36.9% re- ported binge drinking and 9.6% reported heavy drink- ing.2 As noted earlier, alcohol accounts for 5.1% of the global burden of disease. According to the WHO, at- risk alcohol use is the third leading risk factor for poor health with approximately 3 million deaths each year associated with the at-risk use of alcohol. Worldwide, binge drinking is highest in middle to high per capita consumption countries and is higher for males than for females.2

Until recently, much of the focus in health care was on the person with an alcohol use disorder (AUD). Now,

264 U N I T I I n Community Health Across Populations: Public Health Issues

19%

2%

29%

21%

24%

5%

Baseline only Informational Target met or exceeded Getting worse Little or no change Improving

Healthy People 2020 Midcourse Review: Substance Abuse

Figure 11-3 HP 2020 Midcourse Status of Objectives; Substance Abuse Objectives. (Data from National Center for Health Statistics. [2016]. Chapter 40, Substance Abuse in Healthy People 2020 Midcourse Review. Hyattsville, MD: National Center for Health Statistics.)

Figure 11-4 Alcohol Use by Age Group. (Data from World Health Organization. [2017]. Global status report on alco- hol and health 2017. Geneva, Switzerland: WHO Press.)

• Clients are responsive to culturally competent, non- judgmental services, delivered in a manner that demon- strates respect for individual dignity, personal strength, and self-determination.

• Service providers are responsible to the wider community for delivering interventions that attempt to reduce the economic, social, and physical consequences of drug- and alcohol-related harm and harms associated with other behaviors or practices that put individuals at risk.

• Because those engaged in unsafe health practices are often difficult to reach through traditional service venues, the service continuum must seek creative opportunities and develop new strategies to engage, motivate, and intervene with potential clients.

• Comprehensive treatments need to include strategies that reduce harm for those clients who are unable or unwilling to modify their unsafe behavior.

• Relapse or periods of return to unsafe health practices should not be equated with or conceptualized as “failure of treatment”.

• Each program within a system of comprehensive services can be strengthened by working collaboratively with other programs in the system.

• People change in incremental ways and must be offered a range of treatment outcomes in a continuum of care from reducing unsafe practices to abstaining from dangerous behavior.

BOX 11–2 n Guiding Principles on Harm Reduction

Source: (28, 29)

older reported current use of alcohol. In the U.S., in 2016, nearly a quarter (24.5% up from 23.1% in 2010) of Americans age 12 and over reported binge (heavy episodic) alcohol use (five or more drinks on the same occasion at least once in the past 30 days for men and four or more drinks on the same occasion for women), and 6.1% reported heavy alcohol use (five for men and four for women or more drinks on the same occasion on at least five different days in the past 30 days) as depicted in Figure 11-4.2

80%

50%

40%

70%

60%

30%

20%

10%

0% Aged 12+ Aged 12–17 Aged 18–25 Aged 26+

Alcohol Use

Lifetime alcohol use Current alcohol use Binge alcohol use Heavy alcohol use

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efforts are emerging to address at-risk alcohol use earlier to prevent acute and chronic harm associated with alcohol use. An AUD takes time to develop whereas one episode of heavy/at-risk alcohol use can lead to seri- ous adverse health consequences such as motor vehicle crashes, drowning, and alcohol poisoning. Health issues related to at-risk alcohol use occur across the life span beginning with fetal exposure to alcohol and can affect the nondrinker as well. For example, researchers looked at state data related to pediatric mortality in turn related to motor vehicle crashes and found that in 9% of the cases the operator was under the influence of alcohol.31

Overall, 16% of all pediatric and 29% of all motor vehicle-related deaths were due to alcohol.32

At-risk alcohol use increases the risk for adverse con- sequences both in the short and long term. Short-term or acute harms include injury, violence, interaction with medications, increased risk for unprotected sex, and other harms. Long-term or chronic harms include an increased risk for a number of cancers, cardiovascular disease, liver disease, dementia, and AUD.33,34 Thus harm associated with alcohol use as laid out by the WHO is not only due to the actual consumption of alcohol but is also due to societal and individual level vulnerability factors (Fig. 11-5).9 Timely prevention and early treatment is the key to saving lives, and the professional health-care workforce is the key to meeting national and global objectives related to reducing alcohol-related morbidity and mortality, and increasing the age and proportion of adolescents who remain alcohol-free.

Because of the severity of consequences associated with at-risk alcohol use, prevention of adverse alcohol- related health consequences is a major public health issue across the life span. Since its inception, Healthy People has included prevention of adverse alcohol-related con- sequences related to at-risk use including reduction in

motor vehicle crash deaths and injuries, alcohol-related hospital emergency department visits, alcohol-related violence, lost productivity related to alcohol use, and deaths of adolescents riding with a driver who has been using alcohol.35 Of the 21 main objectives listed under the substance abuse topic in HP 2020, 10 were specific to alcohol. The objectives included primary, secondary, and tertiary prevention. The objectives were grouped under three headings: policy and prevention, screening and treatment, and epidemiology and surveillance. HP 2020 also chose specific objectives under different topic areas as leading health indicators (see Chapter 1). For substance abuse, two leading health indicators were chosen, one related to adolescent use and the other to binge drinking in adults. Although use among adolescents dropped, the target for binge drinking among adults was not met.

C H A P T E R 1 1 n Substance Use and the Health of Communities 265

Figure 11-5 WHO Concep- tual causal model of alcohol consumption and health out- comes. (Data from World Health Organization. [2017]. Global sta- tus report on alcohol and health 2017. Geneva, Switzerland: WHO Press.)

Alcohol Production, Distribution, Regulation

Drinking Context

Culture

Level of Development

Mortality by Case Socioeconomic Consequences

Harm to Others

Health Outcomes Chronic/Acute

Volume/Patterns

Socioeconomic Status

Familial Factors

Gender

Age

Societal Vulnerability

Factors Alcohol Consumption

Individual Vulnerability

Factors

n HEALTHY PEOPLE AND ALCOHOL USE

Healthy People Leading Health Indicator relevant to alcohol use reduction Targeted Topic: Substance use Specific Objective: SA 14-3 Objective: Reduce the proportion of persons engaging in binge drinking during the past 30 days – adults aged 18 or older Baseline: 26.9% of adults aged 18 years and over re- ported that they engaged in binge drinking during the past 30 days in 2008 Target: 24.4% Progress: The percentage of adults aged 18 and older who had engaged in binge drinking in the past 30 days has remained the same, measuring 27.1% in 2012 and 26.9% in 2015.34,36

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Consequences of Alcohol Use Alcohol is a causal factor in 200 types of diseases and in- juries9 and as noted earlier accounts for 5.1% of all deaths worldwide.6 The underlying pathophysiology reflects that alcohol use can result in multi-organ toxicity, and toxicity in one organ system affects other systems.4,8

Damage occurs not only in the liver and brain but also in the gastrointestinal (intestinal mucosa), endocrine (pancreas), and other organ systems, including the im- mune and cardiovascular systems.37 Acetaldehyde, the primary metabolic product of ethanol, is thought to be the instrumental toxin in developing alcohol-related dis- ease. For example, long-term exposure to alcohol results in alteration of cellular DNA, thus increasing the risk for cancer.38,39

In addition to physical problems, there are many psy- chosocial consequences associated with alcohol use for individuals and their families.40 These can include legal problems such as traffic violations, driving while intoxi- cated, and public intoxication. Early employment prob- lems can include lateness, frequent absences, an inability to concentrate on the job, and decreased competency, which can eventually lead to on-the-job accidents and injury, or loss of employment leading to chronic unem- ployment. It does not take a great deal of exposure to problem drinking for the family to also manifest dys- function. Family conflict, erratic child discipline, neglect of responsibilities, and social isolation can progress to di- vorce, spousal abuse, and child abuse or neglect. Other problems associated with at-risk alcohol use include in- jury (Chapter 12) and psychiatric illness (Chapter 10).9,40

Comorbidity of psychiatric illness and alcohol use is also common with evidence that alcohol is a causal factor for depression.41,42

Alcohol and Vulnerable Populations Across the Life Span Alcohol use can affect vulnerable populations interacting with their environment at key points over the life span (see Fig. 11-1). For the fetus exposed to alcohol, there is the risk of FASD, often characterized by prenatal or post- natal growth deficiency, certain facial features, and CNS structure or function changes.43,44 Alcohol is a leading teratogen, and it is estimated that the ratio of school chil- dren who were born with FASD is 1 in 20.44 Globally, ap- proximately 8 in every 1,000 live births (0.8%) had FASD, and a little under 8% of women who used alcohol during pregnancy delivered a child with FASD.43

The vulnerable time periods following pregnancy are those of childhood and early adolescence followed by

early adulthood. Adolescence is a time often marked by willingness to take risks and experiment with alcohol, which can extend into early adulthood.45 In 2017, among young adults aged 18 to 25, the rate of binge drinking was 39% compared to 24.9% for all persons aged 12 and older.2 This underlines the need to begin primary pre- vention with children prior to the age of 12. The signifi- cance of focusing on children is twofold. First, children who initiate drinking before the age of 15 are five times more likely report a diagnosis of an AUD than persons who first used alcohol after the age of 20.46 In addition, the brain is developing during adolescence. The lack of executive functioning among this age group may inhibit good decision making, and unique characteristics in the adolescent brain may increase the reaction to the reward- ing sensations of alcohol use.44,45

To address the issue, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) published a guide to screening and brief intervention for youth. The guide uses an approach to screening that includes asking adolescents about peer use as a marker of at-risk use. It also suggests different questions based on age. The guide stresses that health-care providers are in an ideal position to prevent use as well as to identify those who may be drinking. The age range covered in the guide is 9 to 15.46 The impor- tance of prevention within this age range is underlined by the fact that those who start drinking before the age of 15 are at greater risk of developing an AUD.47,48

Older adults are another group at particular risk of detrimental consequences of alcohol use (Chapter 19). For older adults who continue to drink heavily throughout their life, the cumulative effect of alcohol exposure may result in damage to cells, tissues, and organs.40,49 In addi- tion, there is the possibility that even low-risk alcohol use may place the older adult at a higher risk because of the increased potential for falls and the interaction of alcohol with prescriptive drugs for comorbid conditions.45,50

Screening Brief Intervention and Referral for Treatment Globally, screening for at-risk alcohol use is an essential component in the fight to prevent the harm related to alcohol use.51 In the past, screening tools were devel- oped to help identify those who may have an AUD, but screening tools now in use also help the health-care provider identify persons at risk for adverse conse- quences related to alcohol use across the continuum of use (see Fig. 11-1).51 More recently, acute care settings are adopting a universal approach to screening for alcohol use.52-55

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C H A P T E R 1 1 n Substance Use and the Health of Communities 267

l APPLYING PUBLIC HEALTH SCIENCE The Case of the Drinking Oncology Patients Public Health Science Topics Covered:

• Setting Assessment • Secondary data analysis • Screening

Jane worked with lung, esophagus, and head and neck cancer patients in the radiation oncology clinic in an urban academic hospital on the east coast. After several alcohol- and drug-related incidents with her cancer patients, she became concerned that the hospi- tal was not doing enough to help cancer patients with risky alcohol and drug use. One patient in particular, who completed chemotherapy and radiation for a large neck tumor and subsequently died from alcohol with- drawal, motivated Jane to try to find some solutions. The doctors, nurses, and social workers were doing everything they knew to do for patients with alcohol- and drug-related problems but commented frequently that the advice they were giving to patients was contra- dictory and often insufficient. Jane asked around and convened a small team of doctors, nurses, social workers, clinical nurse specialists, and advance practice providers to develop an action plan for these patients.

The first step was to consult the literature. Jane and her team knew there were recommendations for drug screening as it related to cancer pain management and started with big organizations, like the Oncology Nursing Society56 and the National Cancer Institute,57

to look for guidelines. She was right—these groups suggested basic practices, like routine urine drug test- ing and the use of validated instruments designed to screen for substance “abuse” potential. The use of words like “abuse” and “addiction” common in the cancer literature told Jane and her team that the thinking might be out of date. Jane knew it would be difficult to ask the oncology doctors and nurses to use a long, unfamiliar screening tool in routine practice, especially without identifying strategies to cope with substance use issues simultaneously. A PubMed review of the oncology literature wasn’t very helpful; beyond the basic recommendations that oncology providers keep the potential for substance abuse and addiction in mind when writing prescriptions for narcotics, there were no prospective trials testing screening tools or interventions specific to the cancer population.

Jane was hopeful that the substance use literature would be more instructive, and she was right. Whereas many chronic pain and substance use studies specifically excluded cancer patients because of the complex na- ture of their pain issues, there were some important lessons to be gleaned from the literature. First of all, Jane and her team learned about validated screening tools that were easy to apply in the ambulatory clinics to help providers identify patients whose substance use might place them at risk, meaning drug and alcohol use that would place them at higher risk for unintended negative consequences. The team reached out to experts in the area affiliated with the hospital who confirmed that a new approach to the problem, framing it with the context of risk rather than assigning a label such as “addict”, would help reframe their approach to prevention of harm in their patients associated with substance use.

The experts explained that nurses and doctors could be taught a quick and relatively easy intervention in the clinic to give practical and meaningful advice called a “brief intervention.” The Substance Abuse and Mental Health Services Administration (SAMHSA)58

recommends using screening, brief intervention, and referral to treatment (SBIRT) in primary care offices, emergency departments, and trauma centers. One example of this strategy was validated by a small study of upper aerodigestive cancer patients. Lopez-Pelayo et al. (2016) noted that patients who received direct feedback about alcohol risk from their head and neck surgeon after a diagnosis of cancer were much more likely to reduce their alcohol intake than those who did not.59

Several public health-orientated resources were available to help guide the implementation of this strat- egy of screening, and then using brief interventions in the clinic; examples include the WHO’s SBIRT guide60

and the CDC guide, Planning and Implementing Screening and Brief Intervention for Risky Alcohol Use.61 For patients who needed more than brief advice to cut back on their drug and alcohol consumption, such as patients who might be at risk for alcohol withdrawal or patients who use illicit drugs daily, a referral to treatment or substance use specialists would be called for.

The team met to review the literature and decided to implement an SBIRT program as a pilot project in one of the oncology clinics. Although there was no evidence that SBIRT had been previously attempted in an oncology clinic, there was good reason to believe it might be a good place to start. The technique had been

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268 U N I T I I n Community Health Across Populations: Public Health Issues

shown to be effective in reducing alcohol consumption in different groups of primary care and emergency de- partment patients, both of whom are similar to oncol- ogy patients.

First, the team met with colleagues from the psychia- try department to discuss the concept of motivational interviewing, an approach to patient care that encour- ages clinicians to partner with patients to make positive behavioral changes to enhance their health. Jane learned that motivational interviewing techniques were used when delivering an effective brief intervention. Experts from the psychiatry department agreed to work with Jane and her team to develop a short education pro- gram to introduce the idea of SBIRT and motivational interviewing to the clinicians in the department.

A training program for nurses, residents, and other allied health professionals combined motivational inter- viewing skills with specific substance use in oncology patients training. The project team worked with the training facilitators to incorporate oncology-specific considerations into the curriculum. The training in- cluded two 2-hour sessions (four sessions total). Confirmation of fidelity to the process of screening, brief intervention, and referral to treatment was obtained using standardized patients and role playing. The project trainers created pre- and post-training assessment tools, which were used to evaluate the effectiveness of the training.

The team next turned their attention to the elec- tronic health record. They understood from their col- leagues that the best way to implement valid screening tools would be to incorporate them into the patients’ electronic record. Working with the Information Technology (IT) department, they developed an elec- tronic documentation infrastructure using validated instruments for SBIRT and clinical decision support in patients’ electronic medical records. Electronic forms were developed for patients’ radiation oncology electronic health records (Mosaiq) that incorporated validated and reliable instruments for screening (the three-item Alcohol Use Disorders Identification Test-Consumption [AUDIT-C] and a single question drug screen).59-66 This approach allowed the popula- tion of patient data into patients’ medical records and into the data system that facilitated retrospective, aggregate data collection. The forms included a clinical decision support feature that totaled results from screenings and assessments.

Finally, electronic “just in time” toolkits were in- stalled on every computer in the clinic to help clinicians

find the information they needed to implement SBIRT at the moment they needed to use it. Toolkits for staff use contained resources for low-, moderate-, and high-risk patients. The low-risk toolkit included oncology-specific substance use handouts, copies of the screening tools, and a list of resources for self-referral. The moderate-risk toolkit included examples of brief intervention language and all resources available in the low-risk folder. The high-risk toolkit included a readi- ness for change ruler, a brief intervention script, refer- ral resources and instructions, oncology-specific fact sheet, tips for reducing substance use, and follow-up recommendations.

The department tracked screening rates for all new patients, and Jane and her team discovered that clinicians were struggling with the three-question AUDIT-C screening tool. Fortunately, the team found that researchers were validating single-question alcohol and drug screening tools in other settings, which Jane believed would increase the screening rate in her department. After the initial 3-month implementation process using longer screening tools, the department converted to two one-item screening questions. They also knew that an oncology-specific guide or set of recommendations would be helpful in the future. Their experience taught them that specialties do not always communicate and providing specific recommen- dations for the cancer patient population would be essential.

Policy Level Interventions to Reduce Alcohol-Related Harm The interest in developing and disseminating both evidence-based practices and policies to minimize the harms associated with alcohol misuse is widespread.8,9

From a policy perspective, the WHO has brought to- gether member states to come up with policy strategies. They have outlined 10 areas for national action and four at the global level (Box 11-3).68 In the U.S., alcohol poli- cies focus on five main areas. The first is regulation of the physical availability of alcohol (e.g., minimum age, restrictions on sites). Next is altering the drinking con- text (e.g., serving intoxicated clients). A third policy approach is limiting alcohol promotion, such as the ban on advertising hard liquor on TV. A fourth policy is deterrence though sanctions on drunk driving. The fifth approach is developing policies related to treatment and early intervention as evidenced by the policy on includ- ing Screening and Brief Intervention (SBI) on level one

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and level two trauma units. These policies can be enacted at the national, state, and local level, or may be instituted outside of the government.

Tobacco Use According to the WHO, tobacco use accounts for more than 7 million deaths each year. Of these deaths, 6 mil- lion are linked to direct tobacco use and the rest are due to exposure to secondhand smoke.69 Tobacco is the num- ber one cause of preventable death in the U.S., causing approximately 480,000 deaths each year attributable to smoking, with 41,000 attributable to secondhand smoke exposure. In the U.S., tobacco use accounts for one out of every five deaths.70 It is the only legal product that causes the death of half of its regular users. More than one billion people use tobacco products worldwide.70

According to the U.S. Surgeon General’s 2014 report, The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General, there is enough evidence to infer a causal relationship between cigarette smoking and a number of diseases and conditions, many of which were not, initially, seen as smoking-attributable diseases or conditions. The report documents the devas- tating effects and explains how tobacco causes disease.71

In addition, those who consume both alcohol and tobacco may be at greater risk for adverse health outcomes.72

Tobacco users are directly exposed through three routes: (1) smoking cigarettes, pipes, or cigars; (2) chew- ing smokeless tobacco; and (3) inhaling snuff. Tobacco use through any of these routes is a major public health issue for the entire community. Secondhand smoke exposure occurs when nonsmokers are exposed to a mixture of the smoke produced from the end of the cigarette, cigar, or pipe as well as the smoke exhaled by the smoker. Because exposure to secondhand smoke is an environmental issue, it is also referred to as environ- mental tobacco smoke (ETS) as well as involuntary or passive smoking. According to the American Cancer Society, ETS contains more than 7,000 chemicals, 70 of which cause cancer.73

Based on data from the National Drug Use and Health Survey for 2016, tobacco use within the previous year was higher among males (35.6%) compared to females (21.8%).2 Tobacco use was higher in the lesbian, gay, bisexual, transgender population; among those living below the poverty level; and among the disabled.74 The South and Midwest regions of the country also reported higher tobacco use.75 Tobacco use is more prevalent in persons with a mental health disorder at 36.5%.76

Differences exist in the prevalence of current tobacco use across ethnic groups, with American Indians/Alaska Natives having the highest prevalence of 42.6%, up from 35.8% in 2010, followed by Non-Hispanic whites (31.3%), African Americans (27.8%), Nonblack Hispanics (23.8%), Hawaiian/Pacific Islanders (26.1%), and Asians (15%).2

Globally, differences in the prevalence of tobacco use also exist among countries. Although tobacco use is declining in the U.S., it is increasing globally, especially in low-income countries. According to the WHO, “The tobacco epidemic is one of the biggest public health threats the world has ever faced.” 69 Almost 80% of smok- ers live in middle- or low-income countries.69

Tobacco product use in the U.S, which includes cigarettes, smokeless tobacco, cigars, and pipe tobacco, generally, is on the decline. In 2017, approximately 24% of adults were current consumers of tobacco products (used within the last 30 days). Youth cigarette use has also steadily declined. In 2017, 4.9% of those aged 12-17 were current cigarette smokers, compared with 5.3% in 2016.2 Tobacco use varies by state and region. The preva- lence of tobacco use ranges from 11.3% in Utah to 32% in West Virginia.75 Despite the decline in use, 44% of the 68 measurable objectives related to tobacco use in HP 2020 showed little or no detectable change and three were getting worse (Fig. 11-6). 77

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The 10 areas for national action are:

1. Leadership, awareness, and commitment 2. Health services’ response 3. Community action 4. Drunk-driving policies and countermeasures 5. Availability of alcohol 6. Marketing of alcoholic beverages 7. Pricing policies 8. Reducing the negative consequences of drinking and

alcohol intoxication 9. Reducing the public health impact of illicit alcohol

and informally produced alcohol 10. Monitoring and surveillance

The four priority areas for global action are:

1. Public health advocacy and partnership 2. Technical support and capacity building 3. Production and dissemination of knowledge 4. Resource mobilization

BOX 11–3 n World Health Organization Global Strategy to Reduce Harmful Alcohol Use

Source: (9)

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Consequences of Tobacco Use The adverse health consequences experienced by to- bacco users include cardiovascular disease, cancer, chronic obstructive pulmonary disorders, adverse effects on the oral cavity and teeth, and adverse maternal and neonatal outcomes.70,72 For nonsmokers exposed to ETS, the adverse effects are similar but also include other serious health risks, especially in children, including in- creased risk for asthma, sudden infant death syndrome (SIDS), middle-ear infections, and lower respiratory tract infections.71,72

Vulnerable Populations Across the Life Span Those who are most vulnerable to the adverse effects of tobacco use are in many cases children of smokers. From conception, children of smokers are at higher risk. Mothers who smoke during pregnancy are more apt to have children who are small for their gestational age. In addition, fetal exposure to tobacco increases the risk for SIDS. Children exposed to ETS in their home have higher rates of asthma and upper respiratory infections.73

This fact has resulted in a public service announcement campaign from the CDC to inform the public of the risk.

Another concern is that youth are the most vulnerable population for initiation of tobacco use. According to the National Cancer Institute, initiation of tobacco use be- gins for most smokers prior to the age of 18.79 Based on this, of the six objectives in HP 2020 related to tobacco, three were focused on adolescents. The tobacco use objective aimed at the reduction of the initiation of tobacco use among children, adolescents, and young adults has eight targets. For objectives centered around initiation of use of tobacco products in those aged 12 to 17, by 2017 there was a decline across all products exceeding the 2020 target.70

Screening and Treatment for Tobacco Use Like other substance use, screening for tobacco use in- cludes assessment of quantity and frequency. It is also standard to ask what type of tobacco is used and history of past use. Most current users of tobacco are daily users, thus the standard screening question asks the person if they use tobacco products, if so, how much on average

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12%

3%

37%

44%

4% Baseline only Target met or exceeded Getting worse Little or no change Improving

Healthy People 2020 Midcourse Review: Tobacco Usen HEALTHY PEOPLE AND

TOBACCO USE Goal: Reduce illness, disability, and death related to tobacco use and secondhand smoke exposure. Overview: Scientific knowledge about the health effects of tobacco use has increased greatly since the first Surgeon General’s report on tobacco was released in 1964.78

Midcourse Review: Of the 77 objectives in the Tobacco Use Topic Area, 9 were developmental and 68 were measurable. Eight objectives had met or exceeded their 2020 targets, 25 objectives were improving, 30 objectives had demonstrated little or no detectable change, 3 objectives were getting worse, and 2 objectives had baseline data only (Fig. 11-6).77 Adolescent tobacco use continued to decline from 26% in 2009 to 22.4 % in 2016.77

Healthy People Leading Health Indicator Relevant to Tobacco Use Reduction Objective: Reduce tobacco use by adolescents past month TU-2.1. Target: 21.0% Baseline: 26.0% of adolescents in grades 9 through 12 used cigarettes, chewing tobacco, snuff, or cigars in the past 30 days in 2009.30

Progress: The proportion of students in grades 9–12 who used tobacco products in the past 30 days de- creased from 26.0% in 2009 to 22.4% in 2013, moving toward the 2020 target.77 By 2017, prevalence of tobacco use in high school students dropped to 7.6%.70

In 2013, there were statistically significant disparities in the rates of adolescent tobacco use by sex, race, and ethnicity.74 By 2017, the gender gap had narrowed related to any tobacco use.70

Figure 11-6 HP 2020 Midcourse Status of the Tobacco Use Objectives. (Data from Source: [75])

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per day. The key is how the question is framed. The question should be “Have you ever used tobacco?” rather than “Do you smoke cigarettes?” Because tobacco use includes smokeless tobacco, cigars, pipes, and other forms of inhaling tobacco, it is important to identify those with a history of tobacco use. A good screening tool is to use the single-question approach recom- mended by the National Institute on Drug Abuse (NIDA), which can be combined with screening for al- cohol, tobacco use, and other drug use by asking a single question related to at-risk use.80 Because any current use of tobacco is considered at-risk, if the person is a current tobacco user, the next step in the screening process is to determine the person’s readiness to quit. If they are, the next step is to assist the person. If they are not willing to quit, you can provide support to help motivate them to quit by offering information on smoking cessation. Finally, arrange for follow up. If the person is not a cur- rent tobacco user, it is important to determine if they are a former user of tobacco and if they are at risk for relapse. It is also important to determine if they are exposed to secondhand smoke.73

Smoking cessation can occur for some without any intervention. However, over the past 2 decades, strides have been made in the development of methods to as- sist those who wish to stop smoking. Most former smokers quit without using one of the treatments that scientific research has shown can work. According to the CDC, there are a number of evidence-based ap- proaches to smoking cessation. They include: brief help by a health-care provider; counseling, including indi- vidual, group, or telephone; behavioral therapies; mo- bile phone-assisted treatment; and medications.81

Medications used for smoking cessation include over- the-counter and prescription nicotine replacement products and prescription non-nicotine medications such as bupropion SR (Zyban®) and varenicline tartrate (Chantix®). A combination of some form of counseling and medication is more effective than using either one by itself.81,82,83

Policy Level Intervention to Reduce Tobacco-Related Harm: Local to Global There are a number of events in U.S. history that coin- cided with changes in the smoking behavior of the American public, many of them associated with policy. Tobacco use in the U.S. rose steadily from the great depression, through World War II, and then peaked during the 1960s and 1970s. The period from 1934 to the end of World War II (1945) saw a consistent, almost 300% increase in number of cigarettes consumed.

Consumption dropped off again in the mid-1950s when the first evidence of the association of cancer and cigarette smoking was found. Both of those periods of reduced cigarette consumption were followed by a rebound to levels higher than they were before. In 1964, this phenomenon ceased.84

With the release of the first Surgeon General’s report on Smoking and Health, a period began of reduced cigarette consumption that has continued over the past 3 decades. In addition, the Federal Communication Commission (FCC) applied the Fair-Trade Act of 1949 to tobacco advertising. The point of this was to offer a no-cost opportunity to present health information that was directed toward smoking cessation. The application of the Fair-Trade Act would have given the same amount of time to the anti-smoking initiatives (at no cost) as was purchased by the cigarette industry for advertising. Application of the Fair-Trade Act seemed to be associated with a marked decrease in number of cigarettes smoked. Shortly following the ban on televi- sion advertising, however, the resulting elimination of free anti-smoking advertising, and the smoker’s rights movement in the 1970s, cigarette smoking increased again. The Great American Smoke Out of 1977 hosted by the American Cancer Society appears to be the beginning of a fairly consistent decline in cigarette con- sumption. This provided opportunities to encourage people to commit and quit smoking while increasing public awareness of harms associated with smoking. In the 1980s, nonsmokers’ rights movements began with eventual changes in policies related to smoking in public places, advertising restrictions, and increased taxes.84

Currently, global public health efforts include both individual and population-level strategies with the objective of reducing tobacco related harm. The WHO’s Report on the Global Health Epidemic 2017 uses the acronym MPOWER to lay out policy steps needed to reduce tobacco use and includes interventions at the in- dividual and the population level (Table 11-3).85 Since MPOWER was released, the number of countries that have implemented at least one of the recommended measures has risen from 42 to 121. Eight countries have implemented four or more of the measures. In tandem with adoption of these measures has been a global decline in current tobacco use globally from 24% in 2007 to 21% in 2015. One example of these types of population-level actions is smoke-free environments. Two cities in China, Shanghai and Shenzhen, instituted a smoking ban that included indoor public places, work- places, and public transport as well as many outdoor public places. These measures require support at the

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national level.85 In the U.S., the CDC has published Best Practices for Comprehensive Tobacco Control Pro- grams.86 The five areas presented by the CDC include state and community interventions, mass-reach health communication interventions, cessation interventions, surveillance and evaluation, and infrastructure, admin- istration, and management.

Drug Use The opioid overdose epidemic brought the issue of drug use to the national forefront. In addition to opioid use, the use of stimulants such as methamphetamine and cocaine continues with subsequent adverse effects on individuals and communities, resulting in what has been called a public health crisis. Drug use affects individuals, families, and communities because it can cause serious health consequences, environmental pollution, increased crime, and, due to potential overdose, a significant increase in mortality.87

In 2017, it was estimated that a little more than 11% of Americans reported illicit drug use during the past 30 days, up from a little more than 8% in 2010.2 The most prevalent illicit drug used was marijuana (9.6%) followed by nonmedical use of psychotherapeutics (sedatives, painkillers, stimulants) (2.2%), cocaine (0.8%), and hallucinogens (0.5%).2 Males were more apt to report current illicit drug use. Illicit drug use varies across age groups with those 18 to 25 reporting the highest current use (24.2%).2 There was an overall decline in current il- licit drug use among 12 to 17-year-olds from a high of 11.6% in 2002 to 7.9% in 2017.2 Those aged 65 years or older reported the lowest use at 3%.2 However, current illicit drug use is higher among adults aged 50 to 59 with an increase from 2.7% in 2002 to 9.5% in 2009.2 It is

worth noting that rates of illicit use may be higher and likely to be underreported due to the illegality of these substances.

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TABLE 11–3 n World Health Organization MPOWER: Effective Tobacco Control

Monitor

Protect

Offer

Warn

Enforce

Raise

Source: (84)

Monitor tobacco use and prevention policies

Protect people from tobacco smoke

Offer help to quit tobacco use

Warn about the dangers of tobacco

Enforce bans on tobacco advertising, promotion and sponsorship

Raise taxes on tobacco

w SOLVING THE MYSTERY The Case of the Morgue Pile Up: New Hampshire and the Opioid Epidemic Public Health Science Topics Covered: • Epidemiology • Surveillance • Program Planning

Up to this point, we have largely been talking about SUDs in relation to individuals or populations. The fact is, however, that substance abuse is a community- wide problem, affecting not just individuals but also the community and health-care providers confronted with the grim reality of the impact drug use has on a community.

In 2018, New Hampshire led the nation in per capita overdose deaths.6,88 Reporter Katharine Seeley from the New York Times wondered why New Hampshire, one of the wealthier states in the country, was experiencing such a high prevalence of opioid use and subsequent high overdose mortality rate. She discovered a report that helped explain the multiple factors that contributed to the crisis.88 The two main factors were access to opioids and lack of access to treatment. On the supply and demand side, New Hampshire borders Massachusetts, which has a large illicit drug distribution network, making access to opioids easier. In addition, the state has higher rates of prescribing opioids. On the treatment side, there are limited resources for those in need of treatment. Barriers to treatment include lengthy waitlists and trouble navigating the system. There is also little fund- ing for treatment on the consumer and program side. There are also staffing shortages.88

Using the steps in program planning, the HotSpot report89 demonstrates completion of the first step in the process, assessment. Based on their assessment, they found that overdoses increased in New Hamp- shire by almost 1,600% from 2010 to 2015. Based on these statistics, a number of groups partnered to do a Rapid “HotSpot” study in two phases. Phase one was with stakeholders and phase two was a survey con- ducted with opioid users (n = 76) and with first re- sponders/emergency department personnel (n=36).

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Based on data from this study, preliminary considerations for New Hampshire’s approach to tackling the opioid overdose crisis include:

• Increase public health funds targeting substance use • Expand prevention programs in elementary and middle

schools • Strengthen treatment to include broader availability,

non-prohibitive cost, and inclusion of medication- assisted options and holistic approaches

• Incentivize physicians to become buprenorphine- waivered providers

• Assist physicians with prudent prescribing of opioids, educating patients, and alternatives to pain management

• Support first responder and emergency department personnel with vicarious trauma associated with responding to overdoses

• Initiate needle exchange programs • Collaborate with Massachusetts on addressing the

manufacturing and trafficking of fentanyl and other opioids

• Launch programming to dispel stigma and fear: • Educate consumers (e.g., Narcan and Good

Samaritan Law) • Educate physicians and pharmacists (e.g., chronic

disease management and value of Narcan) • Educate law enforcement (e.g., alternative

approaches to punitive measures) • Educate the public (e.g., opioid crisis is not isolated

to one demographic/area and breaking the intergen- erational cycle of addiction)

BOX 11–4 n HotSpot Report: Understanding Opioid Overdoses in New Hampshire: Next Steps

Source: (87)

The collected data helped them identify the next steps in the process (Box 11-4).

The challenge in the program planning part is to decide what recommendations to act on and what barriers may further impede the ability to act on those recommendations. One barrier is the culture of New Hampshire, the state whose motto is “live free or die” with an emphasis on self-sufficiency. For example, the state does not have laws that require using seat belts and allows liquor stores to be next to major highways. Other issues include the lack of health-care providers in the field of substance use and the lack of needle exchange programs.

In alignment with the harm reduction recommenda- tion from the report, in 2017, two Dartmouth medical students opened a needle exchange program in a soup kitchen.90 The program uses a harm reduction model built on community partnerships including working with the fire chief, the police chief, the mayor, and community organizers such as Hope for Recovery within the county. The program is located in the Southwestern Shelter, across the street from a soup kitchen, and is open at the same time the kitchen is providing meals. The students distribute supplies such as clean needles and sharps containers for safe disposal. They also distribute naloxone and teach how to recognize signs of overdose and how to use naloxone.

One of the recommendations listed in the HotSpot Report was to increase the number of health-care providers able to deliver medication-assisted treatment. Placing those with an opioid use disorder on a similar acting medication has been controversial, yet evidence points to this approach as more effective in reducing re- lapse than an abstinence-based approach.

n EVIDENCE-BASED PRACTICE Medication Assisted Treatment (MAT)

The use of medications to treat an SUD has been in practice for many decades. With the opioid epidemic, there has been an increased focus on using MAT in conjunction with other treatments as an effective treatment for both opioid use disorders and AUDs. The use of MAT has also increased as a means to treat a nicotine use disorder. Some medications, especially buprenorphine and methadone, opioid agonists, result

in long term maintenance while other medications, such as those used to treat a nicotine use disorder are used with the ultimate goal of abstinence. Practice Statement: Increase availability of MAT to adults suffering from a SUD with FDA-approved effec- tive medications. Targeted Outcome: Reduction in health risks asso- ciated with substance use and to achieve abstinence from use. Supporting Evidence: For an opioid use disorder in adults, MAT has been shown to be effective not only in reducing overdose deaths but also improving social functioning, reducing the risk of transmitting

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In addition to opioids, methamphetamines (meth) have also negatively impacted communities. Persons who use meth present in a number of ways. They can appear euphoric, tremulous, anorexic, with dilated pupils, or with diaphoresis. Continued use results in weight loss, strong body odor, dry mouth, and tactile hallucinations that often take the form of imagined insects under the skin. These tactile hallucinations can result in infections and lesions on the skin where the user scratches or tries to remove the insects. In an attempt to relieve dry mouth, the user often drinks copious amounts of sugary beverages, which contributes to tooth decay in addition to other dental manifestations associated with methamphetamine use such as bruxism, gingival inflammation, decreased saliva production, and lower pH values.91 Long-term use can result in cachexia, alopecia, corneal ulcerations, repetitive behavior pat- terns, and severe mental illness symptoms. Harm done to the family is predictably similar to the harm done by the use of other substances. Meth is less expensive than cocaine or heroin, so it appeals to those in the lower so- cioeconomic groups, that is, those who can least afford it financially.92

Meth is easily manufactured, particularly in states lacking laws regulating the sale of the key components for manufacture. Interestingly, the early centers of man- ufacture were the farming communities of the Midwest and Western U.S. The ease with which meth is manufac- tured and its increasing popularity facilitated the spread of meth “labs” throughout the U.S. and Mexico. These labs can be located in homes, apartments, trailers, campers, caves, or any place of shelter.93

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Mortality risk during and after opioid substitution treatment: Systematic review and meta-analysis of cohort studies. British Medical Journal, 26, 357:j1550. doi: 10.1136/bmj.j1550.

4. National Institute on Drug Abuse. (2017). Principles of adolescent substance use disorder treatment: A research-based guide. Retrieved from https://www. drugabuse.gov/publications/principles-adolescent- substance-use-disorder-treatment-research-based- guide/evidence-based-approaches-to-treating-adoles cent-substance-use-disorders/addiction-medications.

5. Vashishtha, D., Mittal, M.L., and Werb, D. (2017). The North American opioid epidemic: Current challenges and a call for treatment as prevention. Harm Reduction Journal, 14, 7. Retrieved from https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC5427522/ doi: 10.1186/s12954-017-0135-4.

communicable disease, reducing criminal behavior, and for pregnant women improving neonatal out- comes.1 The two medications approved for use by the FDA are buprenorphine and methadone. Both medications are opioid agonists and long-acting medications, thus reducing cravings and likelihood of subsequent relapse; both medications exemplify a harm reduction approach. In addition, both medica- tions were associated with substantial reductions in mortality in people being treated for an opioid use disorder.2 For an AUD, acamprosate calcium, disulfi- ram, oral naltrexone, and extended-release injectable naltrexone are approved for use in the treatment and have established effectiveness.3 For nicotine use disorders, bupropion, nicotine replacement therapies (NRTs), and varenicline are approved for use and have established effectiveness.4 For other sub- stances such as cannabis, cocaine, or methampheta- mine, there are no FDA-approved medications to treat an SUD. There is insufficient evidence on the effectiveness of MAT with adolescents or the possible negative impact on the developing adolescent brain.5 Recommended Approaches: The use of MAT is seen as part of a more comprehensive treatment plan that includes behavioral treatment. Access to MAT is an issue especially with the opioid epidemic.4 Methadone clinics must comply with federal regulations. Physicians, nurse practitioners, and physician assistants who have completed the required training may now dispense Buprenorphine in primary care settings, yet few actu- ally complete training. Social stigma related to SUDs can also impact the ability to open methadone clinics or for practitioners to complete the training and work with patients with a SUD.

References 1. Volkow, N.D., Frieden, T.R., Hyde, P.S., &

Cha, S.S. (2014). Medication-assisted therapies — Tackling the opioid-overdose epidemic. New England Journal of Medicine, 370, 2063-2066. DOI: 10.1056/NEJMp1402780.

2. Substance Abuse and Mental Health Services Admin- istration and National Institute on Alcohol Abuse and Alcoholism. (2015). Medication for the treatment of alcohol use disorder: A brief guide. HHS Publication No. (SMA) 15-4907. Rockville, MD: Substance Abuse and Mental Health Services Administration.

3. Sordo, L., Barrio, G., Bravo, M.J., Indave, B.I., Degenhardt, L., … Pastor-Barriuso, R. (2017).

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Some of the chemical components of meth are quite caustic in their own right. They can include pool acid/muriatic acid, lye, acetone, brake fluid, brake cleaner, iodine crystals, lithium metal/lithium batteries, lighter fluid, drain cleaners, cold medicine containing pseudoephedrine or ephedrine, ethyl ether (in engine starting fluid), anhydrous ammonia (stored in propane tanks or coolers), sodium metal, and red phosphorous. Often, manufacturers of meth are either careless or lack knowledge regarding the proper handling of the compo- nents, which often leads to fires and explosions.94

Some “superlabs” can manufacture up to 100 pounds of meth per day. For every pound of meth produced, there are 5 to 6 pounds of toxic waste produced as well. This is an environmental disaster in the making. The manufacturers of meth dispose of the waste in a number of ways; flushing down the toilet, pouring into drains, burying, and pouring on the ground.93

Unlike other illicit drugs, pollution of the environ- ment with a hazardous chemical is a major issue con- nected to the production of meth. The threat to the water supply, health of the soil, and people in the sur- rounding areas is clear. Toxic waste byproducts from meth production can be in suspension in the air and settle on furniture, carpeting, floors, tables, food, and toys, creating a serious threat to those who reside where the labs are located, especially children. Children in such environments not only suffer from neglect but also are exposed to hazardous materials.95 When a meth lab is seized by law enforcement officials, assuming welfare of the children and treatment and/or incarceration for the users/manufacturers is only the beginning. For first responders, there are occupational health hazards that need to be addressed. Hazmat teams must be summoned to decontaminate and clean up the area where the lab was located. This process usually costs thousands of dollars or more, depending on the size of the lab.93

Consequences of Drug Use The consequences of drug use for individuals vary based on the pharmacokinetics of the drug used. For example, cocaine is a stimulant; thus, while under the effect of the drug, the individual experiences a stimulation of the CNS. These effects include an increase in energy, a de- creased need for sleep, and increased mental alertness. It also has a stimulant effect on the cardiovascular system including constriction of the blood vessels, dilated pupils, and increased heart rate and blood pressure. Once the drug has left the system, the person experiences a rebound effect, an understimulation of the CNS that can result in depression and decreased energy.96 Persons who

use drugs are at increased risk for comorbid mental disorders, sexually transmitted infections (STIs), and other adverse effects on health secondary to the use of the specific drug.97

Vulnerable Populations Across the Life Span As with alcohol and tobacco, the portions of the popula- tion most vulnerable to the effects of drugs are the fetus, youth, and the young adult. Use of drugs has been asso- ciated with adverse maternal and infant outcomes. The variation of the adverse effects again relates to the pharmacokinetics of the drug used. Adverse effects include prematurity, small for gestational age, neonatal withdrawal, and birth defects. In addition, women who use illegal drugs during pregnancy are at higher risk for poor nutrition, are more apt to engage in prenatal care later during the gestational period or not at all, and are at greater risk for STIs.98

For youth and the young adult, the focus is on prevention of use. In 2015, 10.1% of youth age 12 to 17 reported current use of an illicit drug. In young adults, the rate increased to a little over one-fifth (22.3%) of those ages 18 to 25 reporting current illicit drug use. Three of the HP 2020 objectives related to substance abuse focused on the adolescent, specifically increasing the proportion who report never using substances, who disapprove of substance use, and who perceive great risk associated with substance use.6

To address the issue of adolescent drug use, the NIDA published two guides, Principles of Substance Abuse Prevention in Early Childhood99 and Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide,100 both aimed at preventing drug use and providing guidance for providers to help adolescents identified with a drug use disorder. Issues associated with drug use in adolescents include not only social consequences but cognitive development.101

Researchers are beginning to identify possible adverse effects of marijuana on brain development.101, 102, 103

These findings underscore the need for prevention of drug use and the importance of screening and offering age appropriate treatment when indicated.

Screening and Treatment for Drug Use A number of screening instruments are available to screen for drug use. One widely used is the Drug Abuse Screen- ing Test (DAST-10). It screens for drug use excluding alcoholic beverages. The DAST-10 has been shown to be reliable and valid with both English-speaking and Spanish-speaking populations, and with those individuals seeking treatment for Attention-Deficit/Hyperactivity

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Disorder (ADHD).104 Another tool is the NIDA ASSIST tool. It is available online and covers the different types of drugs of abuse.105, 106

As with alcohol and tobacco, there is a clinician’s guide that incorporates both screening and interven- tions.106 The guide gives the health-care provider an ex- cellent overview of interventions that can be instituted at the individual level including pharmacological ap- proaches, the use of self-help groups, and behavioral therapies. SAMHSA also recommends using the SBIRT framework to address drug use in the same way used for those with at-risk alcohol use.107

Policy Level Intervention to Reduce Drug Use–Related Harm Policy related to drug use has been a hot topic for decades. Most policy has focused on controlling drug use through criminal means. In the U.S., drug policy has come under the title of a “war on drugs” complete with a federal level drug “czar.” The Office of National Drug Control Policy (ONDCP) is the national level organization focused on drug policy. The purpose of the office is to “… reduce drug use and limit its consequences by leading and coordinating the develop- ment, implementation, and assessment of U.S. drug policy.” This office also provides administrative and financial support to special commissions at the federal level such as the President’s Commission on Combating Drug Addiction and the Opioid Crisis, established by Executive Order on March 29, 2017.108 Under President Obama, the focus of the ONDCP shifted from prosecu- tion to increasing access to treatment. Under President Trump, the focus has shifted back to a focus on crimi- nalization of drug use and a “just say no” approach to prevention.

Substance Use and Communicable Diseases A prime example of how substance use contributes to the burden of disease is the association between sub- stance use and communicable diseases. This occurs across multiple levels starting with the increased the risk of transmission of a communicable disease down to the cellular level.

Many communicable diseases such as hepatitis, HIV/AIDS, sexually transmitted infections, and tuber- culosis are associated with substance use. Since the beginning of the HIV epidemic, substance use and in- creased risk of transmission of HIV have been strongly

correlated. In a landmark study, McKusick, Horstman, and Coates (1985) examined the relationship between sexual behavior and HIV.109 Subsequent research over the past 30 years has established that substance use often leads to impulsive behaviors, as a result of altered judgment, and engagement in high-risk sexual behavior (i.e., sexual intercourse without a condom, transactional sex, or sex-work) thus placing persons at risk for sexually transmitted infections.

Other issues also contribute to an increased risk of poorer outcomes. People living with HIV and who have been diagnosed with an SUD are also less likely to be en- gaged in care, to be adherent to antiretroviral treatment, and to achieve viral suppression, and are thus more likely to spread HIV to others.110 Additionally, particular sub- stances such as methamphetamine have also been linked to increased HIV viral load in the brain as well as neuronal damage, which leads to the development of HIV-associated neurocognitive disorders (HAND).110,111

Substance Use and Stigma Substance use has a long history of being viewed from a moral standpoint. Moral views of substance use vary based on ethnic culture, social practices, the specific substance in question, and the gender of the substance user. Often the person who engages in risky substance use suffers stigma. Stigma is defined as a mark of dis- grace or reproach. The person who is suffering from stigma often experiences shame, which in turn impacts their engagement in treatment.

Stigma has not always been experienced with sub- stance use if the use is seen as a social norm. For example, tobacco use was a culturally acceptable practice for men in the United States, especially during the early to mid- 20th century. However, women who smoked before World War II were perceived negatively. Many of the early tobacco ads aimed at getting women to smoke sug- gested that women should defy this moral stand and smoke. By the 1960s and early 1970s, some tobacco com- panies took this one step further and created a specific brand for women, such as Virginia Slims, and created ads that linked cigarette use to the feminist movement. By the 1990s, cigarette smoking shifted from acceptable social practice to a culturally reprehensible practice. The scientific evidence that ETS resulted in adverse effects for the nonsmoker, coupled with a growing intolerance of the odor of tobacco smoke in public places, resulted in bans against public smoking with a subsequent benefit to the population as a whole. But has this shift also resulted in a moral shunning of the tobacco user?

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The stigma related to alcohol use has, for the most part, focused on risky use or those with an AUD. One exception is the temperance movement in the late 1800s and early 1900s that resulted in the passing of the 18th amendment in 1919. This amendment, also known as Prohibition, effectively turned alcohol into an illicit drug. It was repealed in 1933, and alcohol use once again became a socially acceptable and normative practice. However, the judgment that a person who had an AUD was morally reprehensible did not change. The stigma associated with being an “alcoholic” resulted in the creation of confiden- tiality as a core principle in 12 step programs.

An example of a cultural shift related to alcohol use is the banning of drinking and driving. In the 1950s, the phrase “one for the road” was socially acceptable. Although law enforcement attempted to deal with drunk driving, it was hard to determine what constituted drunkenness. A number of events contributed to a cul- tural shift in our view of driving under the influence (DUI).112 These include the advent of the Mothers Against Drunk Driving movement, technological ad- vances in measuring BAC, and evidence related to what constituted impaired driving. A cultural shift began in relation to public tolerance of the drunk driver. Today, all states have laws that restrict impaired driving in some capacity. Most states have laws that stipulate a precise BAC that, when present, constitutes proof that the in- dividual is too impaired to drive. In addition, the law has evolved to the point that most states allow for proof of impairment through other means, such as specific field sobriety tests. All of these laws represent an attempt to discourage individuals from driving when they have been drinking or using drugs because it is often difficult for an individual to determine when they have had too much to drink.

Stigma is a continuing concern for persons who engage in risky drug use, especially when it becomes a barrier to treatment.113-115 Stigma is pervasive in the general and medical community. Examples of stigma in the nursing literature can be found, including articles about pregnant women engaged in illicit drug use or nurses who may be impaired.115-119 Stigma arises from the perception that risky substance use is a personal choice and the consequences are self-inflicted. The ONDCP support of midstream interventions reflects a growing emphasis on educating the national population on the benefits of treatment and the potential cost of continuing to treat substance use from a legal “war on drugs” approach. In addition, people with a SUD often experience discrimination and health inequities that fur- ther impede access to quality health-care services.118,119

Improving care delivery to this population by imple- menting a patient-centered approach and harm reduc- tion interventions will address the issue of stigma and advance health outcomes.120

n Summary Points • At-risk substance use affects the overall health of

the individual, family, and the community. • Substance use results in adverse consequences

from the cellular to the global level. • Substance use varies across the life span with

increased vulnerability for youth, young adults, and pregnant women.

• Evidence-based practices exist in relation to preven- tion programs, screening, brief intervention, and treatment.

• Substance use, especially use of tobacco and alcohol, are serious public health issues, and policy initiatives exist at the global, national, state, and local levels aimed at reducing the harm associated with at-risk substance use.

• Cultural context for substance use has shifted over time, but stigma continues to be a barrier for entrance into treatment for the person with at-risk use or an SUD.

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t CASE STUDY Implementing an Opioid Overdose Prevention Program

Learning Outcomes • Apply program planning to the development and

implementation of a health program. • Examine current standards of care related to opioid

overdose treatment • Identify strategies for training the public in recogniz-

ing opioid overdose and steps need to prevent over- dose death.

You have been asked to work with a community group to address the opioid epidemic. You suggest implementing a program in your county based on the program implemented by the medical students at Dartmouth College that combined a clean needle exchange program with a program for distribution of Naloxone.

• Outline the basic steps for building this program (see Chapters 4 and 5) and who you would involve in each step.

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114. Weine, E.R., Kim, N.S., & Lincoln, A.K. (2015). Under- standing lay assessments of alcohol use disorder: Need for treatment and associated stigma. Alcohol and Alcoholism, 51(1), 98-105.

115. Van Boekel, L.C., Brouwers, E.P., Van Weeghel, J., & Garretsen, H.F. (2013). Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: Systematic review. Drug & Alcohol Dependence, 131(1), 23-35.

116. Savage, C.L. (2009). Clinical reviews: A proposed frame- work related to the care of addicted mothers. Journal of Addictions Nursing, 19(3), 158-160.

117. Savage, C.L. (2016). Substance use and substance abuse – What’s in a name? Journal of Addictions Nursing, 27(1).

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118. Neville, K., & Roan, N. (2014). Challenges in nursing prac- tice: Nurses’ perceptions in caring for hospitalized medical- surgical patients with substance abuse/dependence. Journal of Nursing Administration, 44(6), 339-346.

119. Pauly, B.B., McCall, J., Browne, A.J., Parker, J., & Mollison, A. (2015). Toward cultural safety: Nurse and patient perceptions of illicit substance use in a hospitalized setting. Advances in Nursing Science, 38(2), 121-135.

120. McNeil, R., Kerr, T., Pauly, B., Wood, E., & Small, W. (2016). Advancing patient-centered care for structurally vulnerable drug-using populations: A qualitative study of the perspectives of people who use drugs regarding the potential integration of harm reduction interventions into hospitals. Addiction, 111(4), 685-694.

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n Introduction School shootings. Motor vehicle crashes. Suicide bombings. War. It seems almost daily these events end up in the headlines creating a stir on social media. Every one of them contributes to increased mortality and morbidity. How do we address injury and violence from a public health perspective? What are the implications for nursing? Injury, both intentional and unintentional, results in both long-term health consequences and in- creased risk for death, and is a major reason for an emergency department (ED) visit. Of the 136.9 million ED visits annually, 39 million (28%) are injury related.1

Overview of Injury Injury is a serious public health issue that kills more than 5 million people globally and causes harm to many more. Injury occurs as the result of a wide variety of events, including motor vehicle crashes (MVC), drowning,

poisoning, falls, burns, assault, self-inflicted violence, or acts of war. According to the World Health Organization (WHO), 9% of global mortality is attributable to injury, which is 1.7 times the deaths attributable to AIDS/HIV, tuberculosis, and malaria combined.2

Globally, road injury was the 10th leading cause of death in lower-income countries and lower-middle- income countries, and the eighth leading cause of death in upper-middle-income countries.3 In the U.S., in 2016, unintentional injury (accidents) was the fourth leading cause of death, and intentional injury (suicide) was the 10th leading cause of death. In contrast to the U.S., injury is not one of the top 10 leading causes of death in other high-income countries.3,4

Unintentional injury disproportionately affects the young and the impoverished, and in the United States is the number one cause of death for those aged 1 to 44.5 In addition, intentional injury (suicide and homicide) were in the top five causes of death for those ages 10 to 44, and

Chapter 12

Injury and Violence Christine Savage

LEARNING OUTCOMES

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

KEY TERMS

1. Describe the impact of injury and violence on the health of a population.

2. Define the burden of disease related to injury and violence using current epidemiological frameworks.

3. Use appropriate frameworks in the assessment of injury and violence.

4. Understand the role of policy in injury and violence prevention.

5. Apply current evidence-based population interventions to the prevention of injury and violence.

Acquaintance violence Alcohol-impaired driving Child maltreatment Collective violence Community violence Emotional abuse Emotional neglect Family violence Fire-related injury Haddon Matrix

Injury Intentional injury Interpersonal violence Intimate partner violence Motor vehicle crashes

(road traffic injuries) Physical abuse Physical neglect Physical violence Poison

Post-traumatic stress disorder (PTSD)

Psychological/emotional violence

Road traffic injury (RTI) Self-directed violence Sexual abuse Sexual violence Stalking Stranger violence

Suicide Threat of physical/sexual

violence Unintentional injury Unintentional poisoning Violence War Youth violence

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homicide was the third leading cause of death for those aged 1 to 9.5 Injury not only affects the person who is injured but also can have an effect on family members, friends, coworkers, employers, and communities.6 Injury is a serious public health issue due to mortality, disability, health-care costs, and the need for emergency care.

Types of Injuries An injury is damage or harm done to or suffered by a person or thing. There are two types of injury, uninten- tional and intentional.7 An unintentional injury is an injury to a person that occurs in a short period of time for which there is no predetermined intent to injure another or oneself.8 Unintentional injuries include motor vehicle traffic injuries, drowning, falls, poisoning, burns, and other injuries. Although the media use the term ac- cident when referring to unintentional injuries, these in- juries are often predictable and preventable, and not the result of random unavoidable accidental events.

In the United States, unintentional injuries account for more than 146,000 deaths and more than 30 million ED visits annually. Among unintentional injuries, the highest number of deaths are related to poisonings followed by motor vehicle traffic deaths and falls (Box 12-1).9 The population most at risk is males under the age of 45. More than a third (37%) of all deaths for children aged 1 to 19 are related to injury, making it the leading cause of death in this age group. For infants under the age of 1 year and newborns, it is the fifth leading cause of death.10

Unintentional injuries not only contribute to premature death, but nonfatal injuries also have consequences that range from temporary pain to long-term disability, chronic pain, and a diminished health-related quality of

life. Following a serious injury, a person often requires hospitalization and/or rehabilitation services.

Intentional injuries are injuries that occur because of a deliberate act that causes harm either to the self or to others.11 Violence refers to physical force used to violate, damage, or abuse others or oneself. It is a broader term and is used in conjunction with intentional injury in the public health literature. According to the WHO, violence is among the leading causes of death for those aged 15 to 44 years.12 Violence constitutes a serious threat to a community and often occurs along with mental illness and/or substance use (Chapters 10 and 11). In 2016 in the United States, more than 19,000 people were victims of homicide and nearly 45,000 people died by suicide.13 Of the $671 billion price tag for injuries in the United States, suicide accounted for $50.8 billion and homicide for $26.4 billion.14

Types of Violence The WHO presented a topology that separates violence into two contexts, family violence and community violence, and three categories, self-inflicted violence, interpersonal violence, and collective violence. Self- inflicted violence is violence in which the perpetrator and victim are one and the same and includes suicide and self-inflicted injury. Interpersonal violence occurs between individuals and includes two different contexts in which the violence occurs. The first is family vio- lence, which includes intimate partner violence (IPV), child abuse/maltreatment, and elder abuse. The second is community violence, which occurs in the context of the community and includes acquaintance violence, violence between individuals who know each other, and stranger violence, violence that occurs between individuals who do not know each other. Collective violence occurs when a large group of people engage in violent behavior and covers various types of violent acts such as conflicts between nations and groups, terrorism instigated by groups or states, rape as a weapon of war, and gang warfare.12

Violent acts are broken out into four types of violence: (1) neglect, (2) psychological violence, (3) physical vio- lence, and (4) sexual assault. The topology proposed by the WHO helps demonstrate the context in which vio- lence occurs and the four types of violence that can occur (Fig. 12-1).12

Injury and violence are of major concern worldwide, and in the United States Healthy People 2020 (HP 2020) health topics included prevention of unintentional injury and violence. This topic area was included because of the mortality and disability associated with injury. Under

284 U N I T I I n Community Health Across Populations: Public Health Issues

Unintentional injury deaths:

1. Poisoning 14.8 deaths per 100,000 population 2. Motor vehicle injury 11.7 deaths per 100,000 population 3. Falls 10.4 deaths per 100,000 population

Intentional injury deaths:

1. Suicide 13.7 deaths per 100,000 population 2. Homicide 5.5 deaths per 100,000 population

Note: Crude death rate for the U.S. in 2015 was 844 per 100,000 population

BOX 12–1 n Top Three Causes of Unintentional Mortality and Intentional Mortality, All Ages, 2015

Source: (9)

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this topic, there were a total of 43 objectives: 28 related to unintentional injury and 15 related to violence.15

Surveillance of Injury and Violence Injury surveillance is conducted via various reporting mechanisms at the local, state, and national levels. In relation to unintentional injury, various tracking meth- ods exist. For example, motor vehicle traffic incidents are tracked through the department of motor vehicles,

C H A P T E R 1 2 n Injury and Violence 285

Interpersonal

Family/Partner

Physical

Sexual

Psychological

Deprivation or Neglect

Child Partner Elder StrangerAcquaintance

Community

Figure 12-1 The topology of violence. (From the World Health Or- ganization, Violence Prevention Alliance. [2018]. Definition and typology of violence. Retrieved from http://www. who.int/violenceprevention/approach/ definition/en/)

Figure 12-2 HP 2020 Injury and Violence Prevention Midcourse Review.

n HEALTHY PEOPLE Injury and Violence Prevention

Goal: Prevent unintentional injuries and violence and reduce their consequences Overview: Injuries and violence are widespread in society. Both unintentional injuries and those caused by acts of violence are among the top 15 killers for Americans of all ages.1 Many people accept them as accidents, acts of fate, or as part of life. However, most events resulting in injury, disability, or death are predictable and preventable. The Injury and Violence Prevention Objectives for 2020 represent a broad range of issues that, if adequately addressed, will improve the health of the nation.15

Midcourse Review: Of the 65 objectives, 1 was archived, 9 were developmental, and 55 were measurable. Of those that were measurable, 9 met or exceeded the goal, 11 were improving, 26 had little or no change from baseline, and 9 were getting worse (Fig. 12-2).16

17%16%

47%

20%

Getting worse Little or no change Improving Met or exceeded

Healthy People 2020 Midcourse Review: Injury and Violence Prevention

department of transportation, and, for fatal motor vehi- cle incidents, through vital statistics. Some categories of injury, such as poisoning, are tracked through the department of public health. Some injuries are not rou- tinely tracked at the governmental level, such as injury due to falls, but are tracked by institutions for patient- related falls and through public health departments and child protective services for child-related falls.

Tracking of intentional injury became more central- ized in 2002 when the Centers for Disease Control and Prevention (CDC) received funding to establish the National Violent Death Reporting System. This system collects data on violent deaths from various state-level databases to create an anonymous database that could

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help states develop programs and monitor outcomes. Sources of data include death certificates, police reports, medical examiner reports, and other available data.17

Thus, multiple sources of data can be used to examine the impact of injury at the population level.

Determining Risk for Injury or Violence Tracking the incidence of injury is only one part of the puzzle. A key step in prevention of injury is to determine who is at greater risk for incurring an injury. The risk fac- tors for injury vary based on the type of injury but come under the same main categories as chronic disease, be- havioral, environmental, and socioeconomic risk factors. For example, in an MVC, several factors come into play. The behavioral level assessment includes evaluation of such issues as wearing seat belts, texting while driving, or driving under the influence of alcohol. In addition, en- vironmental factors such as weather conditions and traf- fic control may play a role. Socioeconomic factors also play a role; for example, those with fewer economic re- sources may have older cars that may not be adequately maintained, and poorer countries, states, or municipali- ties may not be able to maintain safe roads. Analysis of risk for a particular injury requires a complex evaluation of a number of factors.

The Haddon Matrix A common method used to determine injury risk is the Haddon Matrix. This matrix was developed based on the epidemiological triangle (see Chapter 3) and incor- porates the three constructs in the triangle: (1) agent, (2) host, and (3) environment. It was designed by William Haddon, Jr., the first head of what is now the National Highway Traffic Safety Administration (NHTSA). The original purpose was to examine the problem of traffic safety.18

The Haddon Matrix has a minimum of 12 empty boxes to be filled in. The rows reflect the time around the event—”pre-event,” “event,” and “post-event”—and the columns are related to the host, agent, and environment (Fig. 12-3). Filling in the boxes provides a method of viewing the factors that contributed to the event and helps in the planning of injury interventions and preven- tion strategies. The matrix can also help set up the process for data collection. The process helps identify interventions that could occur at multiple points by preventing the injury (pre-event) or by mitigating the impact of the event (event or post-event).

Although this matrix was originally developed for the evaluation of MVCs, it can be used for any category of

injury. Because it uses a classic epidemiological frame- work, it has applicability across settings. For example, it could be useful in an acute care setting to evaluate patient falls. It also provides needed information to develop primary prevention strategies (prevention of the event) and mitigation of the impact of the event, both during the event and following the event (secondary and tertiary prevention).

Figure 12-3 includes a blank Haddon Matrix and a partially filled-out matrix related to motor vehicle crashes (MVCs) that can be used with your own county or city data. If you continue filling out the partially com- pleted form, you can begin to identify areas where interventions could be developed at all three levels: pre- crash, crash, and following the crash. The first part of the matrix provides vital information on what con- tributes to the injury and the consequences of the injury, and the second dimension provides vital information to help planners compare possible interventions on a va- riety of dimensions. The matrix becomes three dimen- sional by adding decision criteria for each level and includes consideration of the effectiveness, cost, feasi- bility, and other identified criteria used to decide what would be the best intervention.18 This can help planners choose from a variety of possible interventions.

Prevention of Injury and Violence Prevention of injury and violence is a major public health initiative. The CDC has a national center dedi- cated to injury prevention. The homepage for this center illustrates the current main areas for prevention including suicide, opioid overdose prevention, trau- matic brain injury, home and recreation safety, motor vehicle safety, and violence prevention. The injury center not only collects surveillance data on injury, it also provides leadership and funds research aimed at reducing injury.19

Nursing Role in Prevention Nurses play a key role in addressing the issue of injury and violence through the care they provide, the interven- tions they develop, and their active role in policy making. There is constant national attention from the media on injury issues that help raise awareness and, in many cases, result in policy-level interventions. For example, the issue of violence against women has received inter- national attention, especially with the #metoo move- ment. Nurses directly helped shape policy here in the United Sates to help prevent violence against women. For example, public health nurse researchers, such

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Dr. Jacquelyn Campbell, and nursing organizations, especially the American Nurses Association (ANA), were actively involved in the passing of the 2013 Violence Against Women Act. Nurses also play a role on the front lines every day providing care for persons following in- jury, especially in trauma centers. Dr. Nancy Glass used results from her research to develop an evidence-based

app, myPlan, that women can use to help prevent rela- tionship abuse.20 Nurses like Dr. Glass and Dr. Campbell have championed the cause of preventing violence against women not only here in the U.S. but globally.

Other nursing organizations also focus on injury prevention. The Society of Trauma Nurses (STN) in- cludes injury prevention and education in its mission

C H A P T E R 1 2 n Injury and Violence 287

Phases Host/Human

Poor vision Texting/Cell phone Reaction time Alcohol Risk taking Driving experience

Failed brakes Missing lights

Narrow shoulders Rain storm

Malfunctioning seat belts

Failure to wear seat belt

High susceptibility Alcohol

Agent Vehicle/Equipment

Physical Environment

Social Environment

Pre-Event

Event

Post-Event

Phases Host/Human Agent Vehicle/Equipment

Physical Environment

Social Environment

Pre-Event

Event

Post-Event

Partially Filled-In Haddon Matrix: Analysis of a Motor Vehicle Crash

Complete the matrix by filling in possible factors for agent and environment based on

the time phases.

Assess the contributing factors or characteristics from the perspective of:

1. Host/Human: What were the Host or Human Factors that contributed to the event?

2. Agent Vehicle/Equipment: What was the crash worthiness of the vehicle?

3. Physical Environment: What was the status of the roadway design or safety features?

4. Social Environment: For example, passage and enforcement of seat belt laws.

Combine with time phases:

1. Pre-Event: What factors affect the host before the event occurs?

2. Event: What are factors related to the crash phase?

3. Post-Event: What are the factors related to the post-event crash phase?

Figure 12-3 Twelve boxes of the Haddon Matrix.

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statement. It has an active committee dedicated to injury prevention.21 In line with the STN priorities, trauma nurses at Cincinnati Children’s Hospital Medical Center (CCHMC) initiated an injury prevention program. The nurses developed and implemented a child passenger safety program. The program was offered to low-income families and was conducted at 46 “fitting” stations located in the community, including fire stations and health departments, so that parents could receive help on car seat installation, which is “fitting” the seats into their cars. These nurses also initiated a bike safety program, conducted community health fairs, and participated in leadership of the Safe Kids Coalition.

Because injury prevention is an essential component of what nurses provide to their communities, how would you begin? A good place to start is to examine the injury data related to the setting in which you work and the population for whom you care. If you work in the ED, you are most likely confronted with injury on a daily basis. As almost all injury is preventable, it is important to take an upstream approach while tending to the victims downstream, as did the nurses at CCHMC. To review from Chapter 2, the upstream metaphor in public health refers to the following: peo- ple are drowning in a river and rescue workers are pulling them out to save them from drowning. Pretty soon, the rescuers realize that, no matter how hard they work at pulling people out, more keep floating down- stream. They decide to walk upstream to find out why people are falling into the river in the first place. Effort is then put into fixing the problem upstream that is causing people to fall into the river.

The problem for the individual nurse is that it feels as though there is no time to walk upstream. There are just too many patients coming for nursing care who have already fallen into the water. Luckily, the upstream ap- proach is done as a collaborative effort across disciplines and entities. Take, for example, the child safety initiative at CCHMC.22 The programs were offered in community settings and included nurses at the hospital, the public health department, the fire department, and the police department. The key is to have someone ask the question, “What is happening upstream?” and then have a team not only ready to find out but also committed to fixing the issues upstream.

Policy Aimed at Prevention of Injury and Violence Many examples of policies aimed at preventing injury exist at the state and local levels. For example, most local municipalities require that a fence be placed around a

swimming pool to prevent accidental drowning. Pedes- trian laws and signs at crosswalks are in place to prevent injury to pedestrians. The list is long and demonstrates that policy efforts are effective in reducing injury. Seat belt laws alone have resulted in a reduction in fatal motor vehicle injuries and death. Policies aimed at reducing violence often come through the judicial system. How- ever, other approaches are also effective, such as creating neighborhood watch groups, increasing lighting on streets at night, and reducing density of alcohol outlets. Policy initiatives often arise from the grassroots, and effectiveness is often contingent on neighborhood buy- in (Chapter 4).

Epidemiology of Unintentional Injury: Motor Vehicle Crashes Motor vehicle crashes (MVCs) are a major public health concern worldwide, particularly for the young. An MVC is the collision of a motor vehicle with another vehicle, a stationary object, or a person that results in injury or death. The term crash has been substituted for the term accident because most MVCs are not random accidental events but are related to preventable causes. To help encompass the broader issue of road-related injury, the WHO uses the term road traffic injury (RTI). The WHO’s definition of an RTI is similar to the definition of an MVC, but it includes the term public road. Thus, its definition is an injury that occurs as the result of a collision on a public road with involvement of at least one vehicle.23,24

In the United States, for persons aged 15 to 24, MVCs are the leading cause of unintentional injury deaths.25

The annual number of MVC deaths in the U.S. is 32,000 and there are more than 2 million MVC-related nonfatal injuries.26 There has been a decline over time in MVC- related injury, which may reflect an increase in the use of seatbelts, car seats, and booster seats.26 Policy can help reduce MVC-related injury and death. For example, variation in alcohol-related MVC deaths are associated with alcohol policies.27

Risk Factors for Motor Vehicle Crashes As noted earlier, when considering motor vehicle traffic, a number of factors come into play. The behavioral level includes such issues as wearing seat belts, texting while driving, or driving under the influence of alcohol. In addition, environmental factors may play a role, for exam- ple, weather conditions and traffic control. Socioeconomic factors also play a role; for example, those with fewer

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economic resources may have older cars that may not be adequately maintained, and poorer countries, states, or municipalities may not be able to maintain safe roads.

The CDC uses data from the National Vital Statistics System (NVSS) to estimate the economic burden of both fatal and nonfatal injuries.28 The annual cost of medical care and productivity losses associated with injuries and deaths from MVCs exceeds $63 billion.29,30 Other sources of data that can help determine which risk fac- tors are associated with MVC injuries are the Fatality Analysis Reporting System (FARS) and the Behavioral Risk Factor Surveillance System (BRFSS).31 In one study, Beck, Downs, Stevens, and Sauber-Schatz ex- plored the underlying risk factors related to the higher MVC rate in rural areas versus urban areas. In 2015, al- though an estimated 19% of the U.S. population lived in rural areas, 57% of passenger-vehicle–occupant deaths occurred on rural roads, with a higher proportion of rural MVCs resulting in death. Based on their review of the data, they concluded that, because there was a lower rate of seat belt use in rural areas, efforts to reduce MVC mortality should focus on improving seat belt use in rural areas.31

Two major risk factors for MVCs are alcohol use and distracted driving. Alcohol-impaired driving is driving with a blood alcohol level at 0.08 or above, and laws have been enacted that make it illegal to drive impaired. Distracted driving is defined as diversion of attention from activities critical for safe driving. There are three main types of diversions: visual (taking your eyes off the road), manual (taking your hands off the wheel), or cognitive (taking your mind off of driving).32,33 Distrac- tion can include use of handheld devices, eating, driver drowsiness, and adjusting the radio, and in 2015, these accounted for 10% of fatal crashes and 15% of injury crashes.33,34

Speed is another major contributing factor to the severity of the injury associated with MVCs. Speed con- tributes more than any other factor because of its impact on reaction time, the amount of kinetic energy created, and ability to control the vehicle.35 Other contributing factors include weather, road conditions, and vehicle safety features.35 Once again, behavioral and environ- mental factors and socioeconomic status play roles. Other injury issues exist when the broader context of all RTIs is considered. Passengers and operators of other vehicles such as all-terrain vehicles, motorcycles, and bicycles are at risk for injury in the case of an RTI. Pedestrians are also at risk. Potential injuries in these circumstances are major public health issues, especially because of the high mortality rates associated with these

types of injuries. The same risk factors apply across all RTIs.

Prevention of Motor Vehicle Crashes Reduction in MVC-associated injury has, in part, occurred due to changes at the policy level. Laws related to the use of seat belts, car seats, booster seats, and handheld phones have helped reduce injury and mor- tality. A case in point is the issue of texting while driv- ing. Under the Haddon Matrix, this risk factor would come under the Host/Human column as a pre-crash factor (see Fig. 12-3). This risk factor came to the fore- front of media attention in 2009 based on data indicat- ing that an increasing number of motorists were texting while driving prior to an MVC. The CDC now includes texting as one of the examples of distracted driving often equated with driving while intoxicated. Response to this risk factor has been reflected in laws making texting while driving illegal.

Much of the prevention efforts at the primary level in the United States have focused on reducing risky behav- iors such as alcohol-impaired driving and on increasing public education about the importance of using proper safety measures. Back in the late 1970s, hospitals enacted policies that all parents must have a car seat in place prior to taking their newborns home from the hospital. An- other approach has been to put in place a graduated driver licensing system aimed at reducing MVCs where teenagers are the drivers.

Other prevention efforts are aimed at the environ- ment: improving roads, installing traffic lights, and installing pedestrian walkway signs. These types of pre- vention approaches are more difficult to put in place in low- and middle-income countries (LMICs) that lack the resources and that have not placed a strong emphasis on injury prevention.24 The WHO adopted a global plan for road safety for the decade 2011–2020. The plan has five pillars, or categories, of prevention efforts. These include: “1) building road safety management capacity; 2) im- proving the safety of road infrastructure and broader transport networks; 3) further developing the safety of vehicles; 4) enhancing the behavior of road users; and 5) improving post-crash care.”24

In the United States, there have been dramatic im- provements in post-crash care, resulting in a reduction in MVC-associated mortality and morbidity. Much of this is due to the development of Level I trauma units, use of flight teams to bring helicopters to the crash site and transport victims directly to a trauma center, and the de- velopment of interventions aimed at decreasing the time from initial trauma to initiation of treatment. Such efforts

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to improve post-crash care help reduce long-term disabil- ity and survival rate of injury associated with MVCs.

Epidemiology of Unintentional Injury: Burn-Related Injuries Burn-related injuries include “… an injury to the skin or other organic tissue primarily caused by heat or due to radiation, radioactivity, electricity, friction, or contact with chemicals. Skin injuries due to ultraviolet radiation, radioactivity, electricity, or chemicals, as well as respira- tory damage resulting from smoke inhalation, are also considered to be burns.”36 Globally, the annual estimate of burn-related deaths from fires is 265,000. This figure does not include deaths that occur from burns that occurred due to scalding, electrical burns, and other non-fire-related forms of burns.36 More than 96% of the fatal burns occur in LMICs, with more than half occur- ring in Southeast Asia.36 Burns are among the most devastating of all injuries and are almost always prevent- able. They are difficult to treat even in high-income coun- tries and, with limited resources, even more difficult to treat in LMICs.37, 38

In the United States, an estimated 486,000 people received medical treatment for burns in 2016. Fires and smoke inhalation accounted for 3,275 deaths. Of those burned, 40,000 required hospitalization. Seventy- three percent of burn injuries occurred in the home. The

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n HEALTHY PEOPLE Injury and Violence (IVP)

Objective: IVP-13 IVP-13.1: Reduce MVC-related deaths: deaths per 100,000 population Baseline: 13.8 deaths per 100,000 population were caused by MVCs in 2007 (age adjusted to the year 2000 standard population) Target: 12.4 deaths per 100,000 population Target-Setting Method: 10% improvement15

Midcourse Review: “The age-adjusted rate of MVC deaths per 100,000 population declined from 13.8 in 2007 to 10.5 in 2013, exceeding the 2020 target. In 2013, 33 states and the District of Columbia had achieved the national 2020 target for MVC deaths. In 2013, there were statistically significant disparities by sex, race and ethnicity, and geographic location in the age-adjusted rate of MVC deaths.”16

Source: 15, 16

majority (68%) of those burned were male. According to the American Burn Association, one civilian death due to burns occurs every 2 hours and 41 minutes.39 More than 300 children and adolescents are treated in emer- gency rooms for burn-related injuries each day, and two of those die.40

Younger children are more likely to sustain injuries from scald burns caused by hot liquids or steam, whereas older children are more likely to sustain injuries from flame burns caused by direct contact with fire.40 How- ever, in LMICs, the epidemiology of pediatric burn injury is different from what it is in high-income coun- tries in that burn mortality is often higher. Burn mortal- ity among children is closely associated with maternal deprivation and varies by region and income level, with the highest mortality burden in Sub-Saharan Africa.41, 42

Risk Factors for Burn Injuries Using the epidemiological data, the associated risk fac- tors for burn injuries are influenced by behavioral, social, cultural, and economic factors. Women and children in LMICs are at greatest risk because they spend more time at home using open fires to cook food and heat water. In LMICs in colder climates, there is exposure to heaters and stoves to keep homes warm.42 Behavioral risk factors include alcohol use, tobacco use, history of seizures, and history of a psychiatric disorder. Environmental risk fac- tors include the safety of the built environment, popula- tion density, the work environment, and the natural environment. To address these risk factors, in 2008, the WHO published a burn prevention plan (see Box 12-2) that addresses the main risk factors for burns, and it is still relevant today.42,43

Prevention of Burn Injuries Prevention is an essential component in any burn man- agement program, especially with the high incidence in LMICs.41,42 As in all injuries, the main focus is on reduc- tion of risk. For burns, primary prevention focuses on environmental measures in the home and behavioral changes. In the United States, many of the public health interventions focus on children and on measures that can be taken to reduce risk. In LMICs, the challenge for prevention is greater, where there is less governmental emphasis on prevention of injury as well as limited re- sources.37,38,42

In the United States, policy has played a large role in reducing fire-related morbidity and mortality. In 1911, a devastating fire in the Triangle Shirtwaist factory in New York City took the lives of 146 garment workers, most of them women. Based on that event, laws were put in place

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to improve safety of the workplace. Another fire, the Coconut Grove fire that occurred in Boston in 1942, resulted in the deaths of 462 people, the deadliest night- club fire in U.S. history. The club was decorated in a South Pacific motif using decorations made of flammable materials that covered exit signs. The fire spread rapidly, engulfing the club within 5 minutes of the first flame. The main entrance was a single revolving door that quickly became jammed as panicked customers tried to escape. This fire resulted in the institution of fire code regula- tions that are in place today, such as restriction on the use of flammable materials as decorations and require- ments for clearly marked exit signs. It also resulted in the mandate that two regular doors equipped with panic bars flank all revolving doors. The next time you go through a revolving door, you will notice that this safety measure is always in place.

Secondary prevention focuses on what to do in the event of a fire. Stop, Drop, and Roll is an example of a suc- cessful campaign to teach children, workers, and others what to do if their clothes or hair are on fire (Fig. 12-4). The purpose is to mitigate the extent of the burns by using a technique that is effective in extinguishing the flames. Strides have also been made in the management of burns, resulting in a worldwide decline in fire-related mortal- ity.42 Care of a fire-related injury must also consider the issues of disability, disfigurement, emotional impact, and pain.

C H A P T E R 1 2 n Injury and Violence 291

Specific recommendations for individuals, communities, and public health officials to reduce burn risk:

• Enclose fires and limit the height of open flames in domestic environments.

• Promote safer cookstoves, fewer hazardous fuels, and educate regarding loose clothing.

• Apply safety regulations to housing designs and materi- als and encourage home inspections.

• Improve the design of cookstoves, particularly with re- gard to stability and prevention of access by children.

• Lower the temperature in hot water taps. • Promote fire safety education and the use of smoke

detectors, fire sprinklers, and fire-escape systems in homes.

• Promote the introduction of and compliance with in- dustrial safety regulations, and the use of fire-retardant fabrics for children’s sleepwear.

• Avoid smoking in bed and encourage the use of child-resistant lighters.

• Promote legislation mandating the production of fire-safe cigarettes.

• Improve treatment of epilepsy, particularly in develop- ing countries.

• Encourage further development of burn-care systems, including the training of health-care providers in the appropriate triage and management of people with burns.

• Support the development and distribution of fire-retardant aprons to be used while cooking around an open flame or kerosene stove.

BOX 12–2 n A WHO Plan for Burn Prevention and Care

Sources: (42, 43)

w SOLVING THE MYSTERY The Case of the Exploding Barrel Public Health Science Topics Covered: • Assessment • Epidemiology • Health planning

In May 2020, Ben Smith, RN, moved from a large metropolitan area to a rural region of the country. He took a job working in the ED in a regional medical center serving six counties. After working there for 2 months, he became concerned about the number of injuries from firecrackers that he saw, especially injuries to teenagers. His concern grew when two teenagers were admitted to the ED. They had sus- tained eventually fatal injuries after placing a 50-gallon metal barrel over a sparkler bomb. After this event, Ben approached his supervisor about his concerns, and the supervisor commented that this was something they saw every summer, especially in July. Ben wanted to know whether the number of injuries was up this year and whether their ED had been involved in any prevention efforts. His supervisor thought that was a good question and suggested that Ben look into the issue.

Ben applied basic public health principles that he had learned in his undergraduate community health courses to begin investigating the problem. He began

Stop Drop Roll

Figure 12-4 Stop, Drop, and Roll.

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by reviewing their records for the number of fire- works-related injuries treated in the ED during the past 5 years, including age of the patient, month the injury occurred, and the severity of the injury based on triage level. This first phase of his investigation required a basic understanding of epidemiology (see Chapter 3), specifically how to calculate incidence rates, track the rates over time, and compare them with national rates. It also required basic community assessment skills. In this case, he did a focused assessment (see Chapter 4), that is, he started with a specific focus of fireworks- related injury. He found that the Consumer Product Safety Commission (CPSC) had a fireworks safety page and a three-step guide to fireworks safety.44 This helped guide his investigation because the site provided information on the most common risk factors, current laws and regulations, and possible solutions. Through a link to firework injury data available on the CPSC site, Ben found that in 2016 there were an estimated total of 11,100 injuries in the U.S that required medical treatment at an ED.45

Using 5 years of data from their own hospital, Ben found that the two deaths he had encountered in the ED were the only deaths in the past 5 years, but various fireworks-related injuries had been treated during that time period that were similar to national data; most of the injuries had occurred to the fingers, hands, and eyes, and the majority were burns. He cal- culated incidence rates for the entire population living in the region served by the medical center, using popu- lation estimates for each of the 5 years (Box 12-3). He then looked at the frequency of injuries based on sepa- rate age groups including children under the age of 5, children aged 6 to 12, youths aged 13 to 18, and adults over the age of 18, and for each county. Based on that information, he determined that the overall incidence rate for the five-county region was higher than the national rate. He also found that the injury rate had decreased in children under the age of 6 but had increased in those aged 6 to 18. Starting in 2014, the majority of cases were between the ages of 13 and 18.

Ben then looked into community information that might help explain the decreased incidence rate in one age group and the increased rate in the other age group. After talking with his colleagues in the pediatric units, he discovered that the community had introduced a fire- works safety initiative with new parents in 2014. The health departments in all five counties had developed a brochure that was handed out at all the well-baby clinics and was provided to the pediatricians as well. For

children less than 5 years of age, the prevention program from the public health departments appeared to have been effective. But why was the rate going up in the older children, especially among teenagers?

Ben did some further research on the laws sur- rounding the sale of fireworks. He found that there was a wide variance in the state laws. The state in which he was working had strict laws that went beyond the Federal Hazardous Substances Act, which prohibits the sale of highly dangerous fireworks and the components used to make them. However, the region his hospital served was close to the border of another state that had more lax laws and allowed the sale of fireworks that were just under the legal limit of no more than 50 milligrams of explosive powder and no more than 130 milligrams of flash powder. In 2015, two new fireworks stores had opened right across the state border. This increased availability was a possible factor in the increased incidence.

He then applied the Haddon Matrix to the problem. He started with the incident that had resulted in the death of the two teenagers and filled out the Haddon Matrix using factors related to the two boys, pre-event, event, and post-event. He accessed local news reports, police reports, and fire department reports on fire- works-related injuries and filled in the matrix. He found that the social environment pre-event played a

The populations of the following five counties are consid- ered here when estimating injury rates:

County Q 44,516 County R 42,316 County X 40,383 County Y 17,934 County Z 28,093

• The total population for the preceding counties in 2012 = 173,242.

• The total number of ED visits for fireworks injuries = 25.

• Rate of fireworks-related injury for the region = 12.9 per 100,000.

• The 2012 population for the United States as a whole = 313,780,968.

• The estimated number of ED visits in the United States for fireworks-related injury in 2012 = 9,300.

• Rate of fireworks-related injury in the United States = 2.9 per 100,000.

BOX 12–3 n Estimating Injury Rates

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big role, with a growing peer-related interest in using more dramatic fireworks. He also found that most of the injuries were clustered in the counties closest to the state border.

The Haddon Matrix assisted Ben in his assessment in another way. It helped him examine whether there were factors during the event or post-event that also influenced the outcome of the injury. The two counties that were closest to the state border were also far- thest from the regional medical center and were quite rural. For some of the events, the time for emergency personnel to arrive on the scene was 20 minutes or more. Transportation to the regional medical center averaged 25 minutes from the time the emergency personnel arrived on the scene to the time the victim arrived at the medical center.

Following his assessment, Ben identified possible ac- tion that could be taken by the hospital in conjunction with the public health departments, the schools, the emergency providers, and other stakeholders to re- duce the number of these incidents. The actions he recommended included prevention at the three levels of pre-event (e.g., public service announcements on firework safety), event (e.g., increasing safety measures at the county firework displays, emergency personnel preparedness), and post-event (e.g., a formal process for the evaluation of each event to identify contributing factors at the individual and community level). In some cases, his information opened the door for a discussion on injury prevention in the region at a higher level. Ben felt that the post-event issue related to emergency response time was bigger than just the fireworks injury issue. Ben’s approach to a problem led to the develop- ment of a comprehensive fireworks prevention pro- gram spearheaded by the regional hospital that built on the work done with the preschool children. Ben now had baseline data to track the effectiveness of the inter- vention. Based on his work, the community put an injury prevention committee in place.

Epidemiology of Unintentional Injury: Drowning Drowning is defined by the WHO as “… the process of experiencing respiratory impairment from submersion/ immersion in liquid.” The end result of drowning includes death, morbidity, or no morbidity.46 The WHO estimates that there are 3,536 deaths from drowning annually, or 10 per day. Drowning is among the top 10

leading causes of death in children and young adults globally. This holds true in the U.S., with 10 deaths asso- ciated with unintentional drowning per day. Children ages 1 to 4 have the highest drowning rates. Those who receive emergency care for nonfatal submersion fre- quently require a high level of hospitalization, and if they suffer brain damage, they can become a heavy burden to society.47

Risk Factors for Drowning We know that age is a risk factor for drowning. This is true in the U.S. and globally. Age plays a role for the older adult as their swimming ability declines. For young chil- dren, risk is tied to multiple issues. Their inquisitiveness and their lack of coordination make them susceptible to falls into bodies of water such as swimming pools, lakes, ponds, ditches of water, bathtubs, and buckets. Children aged 1 to 4 have the highest drowning rate. In the United States, young males are 10 times more likely to drown than young females, with 80% of all drowning victims being male.47 In the United States, the most common sites for drowning are home swimming pools. Drowning rates for all rural residents are three times higher than for urban residents with drowning usually occurring in open water such as ponds, rivers, irrigation canals, and lakes. Children usually die of drowning in sites where they are without adequate supervision.47 Another risk factor is hair or body entrapment in drains of pools or spas. There are multiple risk factors associated with drowning (Box 12-4) that help guide development of prevention programs including swimming lessons, use of barriers around swimming pools, increased supervi- sion especially of children, and use of life jackets. Alcohol also increases the risk of drowning among adolescents and adults due to impairment of balance, coordination, and judgment. These effects of alcohol increase with sun exposure and heat.47

What factors influence drowning risk?

• Lack of swimming ability • Lack of barriers, such as pool fencing • Lack of close supervision • Location: people of different ages drown in different

locations • Failure to wear life jacket • Alcohol use • Seizure disorders

BOX 12–4 n Risk Factors for Drowning in the U.S.

Source: (47)

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require medical attention.50 In the U.S., falls are the leading cause of nonfatal injury in children under 19 years of age. 51

Risk Factors for Falls in Children In the U.S., the majority of falls in children occur on the playground, from windows, from beds or other furniture, from baby carriers or with baby walkers/riders that allow an infant to independently move from place to place, including ride-on toys and circular walkers.51,52,53 Age, socioeconomic status, and gender play roles as well. The type of fall changes based on the age and stage of devel- opment of the child. When examining the contributing factors that increase the risk for falls in children, it is important to consider the evolving developmental stages of children and adolescents. These include the innate curiosity of children in relation to their surroundings and increasing levels of independence. In addition, other fac- tors include inadequate adult supervision, poverty, being a single parent, and hazardous environments.50 Fall risk increases once an infant becomes mobile. In mobile infants and toddlers, falls are usually from furniture or on the stairs. Preschool and school-age children are at risk for playground-related falls.51,52 As children enter middle school and engage in athletics, sports-related falls predominate. Window-related falls are perhaps the most dramatic, as underscored by Eric Clapton’s song “Tears in Heaven.” In 1991, his 4-year-old son Conor fell

Not having the ability to swim is a significant risk fac- tor and is more common in females than males, and more common in African Americans than whites.47 The tragic event that occurred on the Red River near Shreveport highlights this issue when six teens from two African- American families drowned. One unknowingly stepped off the shallow edge and slipped into the deep river, and six more teens went in to rescue him. Only one made it back. None of them knew how to swim and neither did their parents, watching from the shore.48 In the United States, African-American children aged 5 to 19 are five times more likely to drown in swimming pools than white children.47 Thus, the fact that no one in a family knows how to swim increases the risk, because family members often are the only ones supervising children when they swim.

Prevention of Drowning Prevention requires a concerted effort on the part of health-care providers, public health officials, and family members. The American Academy of Pediatrics (APA) policy statement issued in 2010 remains the standard for prevention. The policy is aimed at increasing the role that pediatricians can play in preventing drowning in children and serves as a guide to nurses. The policy statement focuses on prevention interventions aimed at both pri- mary and secondary levels of prevention. The scope is broad and includes supervising, learning to swim (both caretakers and children), and making changes to the environment such as installing fences and drain covers.49

The CDC breaks down primary prevention into the fol- lowing categories: barriers, supervision, learning to swim, life jacket use, and alcohol use.47 From a secondary pre- vention viewpoint, both the APA and CDC recommend learning cardiopulmonary resuscitation (CPR). The CDC also includes recommendations to help prevent drowning in natural bodies of water. There is a clear consensus on the actions that can be taken to prevent drowning and, in the event of a drowning, to provide early and effective treatment to prevent mortality (Box 12-5).

Epidemiology of Unintentional Injury: Falls in Children The WHO defines a fall as “… an event which results in a person coming to rest inadvertently on the ground or floor or other lower level”.50 The two populations at greatest risk for fall-related injuries are children and older adults (see Chapter 19). Globally each year there are 646,000 fall-related deaths and 37.3 million falls that

294 U N I T I I n Community Health Across Populations: Public Health Issues

Tips to help you stay safe in the water:

• Pool fencing on all four sides at a 4-foot height would reduce drowning by 83%.

• Supervise when in or around water. • Use the buddy system. • Seizure disorder safety. • Learn to swim. • Learn cardiopulmonary resuscitation (CPR). • Air-filled or foam toys are not safety devices. • Avoid alcohol. • Don’t let swimmers hyperventilate before swimming

underwater or try to hold their breath for long periods of time.

• Know how to prevent recreational water illnesses. • Know the local weather conditions and forecast before

swimming or boating. • Do not use personal flotation devices, as they are not

designed to keep people safe.

BOX 12–5 n Primary Prevention for Drowning in the United States

Sources: See reference (47).

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from a 53rd floor apartment window in New York City. Window falls occur most often in urban, low-income, and multidwelling settings.

Prevention of Falls in Children Prevention efforts begin with home safety interventions. Parents are encouraged to put stair and window guards in place to prevent falls and, as with drowning preven- tion, maintain supervision of children in the home and on the playground.54 Product regulation has also played a role in increasing the safety of baby walkers and play- ground equipment. The U.S. Consumer Product Safety Commission has a playground equipment safety guide- line publication that clearly outlines how to prevent playground-related injury.55 Window guards, baby walkers, and other nursery products must meet product safety requirements.

C H A P T E R 1 2 n Injury and Violence 295

n EVIDENCE-BASED PRACTICE Use of Window Guards

Practice Statement: Window guards should be placed on all windows in multidwelling buildings. Targeted Outcome: Reduction in incidence of window-related falls in children Evidence to Support: The majority of the evidence is linked to surveillance data tracking the incidence of window-related falls in children before and after the enactment of window guard laws. In New York City, the incidence dropped 35% in the 2 years following the enactment of the requirement for window guards. Recommended Approaches: Legislative approaches that require landlords and owners of multidwelling buildings to install window guards, provide access to window guards for those who may not be able to purchase them, and distribute public information on preventing window-related falls in children (Box 12-6).

Source: (56)

Epidemiology of Unintentional Injury: Poisonings According to the CDC, “A poison is any substance, in- cluding medications, that is harmful to your body if too much is eaten, inhaled, injected, or absorbed through the skin. An unintentional poisoning occurs when a person taking or giving too much of a substance did not mean to cause harm.”57 Globally, more than 80% of all uninten- tional poisonings occur in LMICs with a resulting loss

In 1976, the New York City Board of Health enacted leg- islation known as Health Code Section 131.15, the window guard law. It requires owners of multiple dwellings (build- ings of three or more apartments) to provide and prop- erly install approved window guards on all windows, including first floor bathroom and windows leading onto a balcony or terrace in an apartment where a child (or chil- dren) 10 years of age or younger reside and in each hall- way window, if any, in such buildings.

The exceptions to this law are:

• Windows that open onto fire escapes • A window on the first floor that is a required second-

ary exit in a building in which there are fire escapes on the second floor and up

If tenants or occupants want window guards for any reason, even if there are no resident children in the covered age category, they should request them in writing, and they may not be refused. Examples:

• Grandparents who have visiting children • Parents who share intermittent custody • Occupants who provide childcare

If required or requested and window guards have not been installed, if they appear to be insecure or improperly installed, or if there is more than 4.5 inches of open, unguarded space in the window opening, a complaint should be made immediately to 311.

For more information on Window Guards, call 311.

BOX 12–6 n New York City Window Guard Program

Source: (56)

of more than 10.7 million years of healthy life (disability- adjusted life years [DALYs]).57

In 2015, in the U.S., 47,478 persons died from uninten- tional poisoning, a mortality rate of 14.8 per 100,000.58

Most concerning has been the rise in drug poisoning mor- tality, attributable to the rise in opioid drug overdoses (see Chapter 11). From 1999 to 2016, for all ages, the mortality rate for drug poisoning rose from 6.1 to 19.8 per 100,000 (Fig. 12-5).59 However, for non-Hispanic whites, the rate for all ages went from 8.7 in 1999 to 48.7 per 100,000. For non-Hispanic white males aged 25-34 the rate rose from 12.2 to 68.4 per 100,000. By comparison, for non-Hispanic black males during the same time period, the rate rose from 12.2 to 27.2 per 100,000 (Fig. 12-6).59

The National Poison Data System, an electronic surveil- lance system documenting all calls made to poison centers across the United States, is a source for data to monitor poisonings. In 2016, analgesics (11.2%), household

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cleaning substances (7.54%), cosmetics/personal care products (7.20%), sedatives/hypnotics/antipsychotics (5.84%), and antidepressants (4.74%) were the top five poison exposures in the U.S.60 For children 5 years of age and under, the top five poison exposures were cosmetics/ personal care products (13.3%), household cleaning substances (11.1%), analgesics (9.21%), foreign bodies/ toys/miscellaneous (6.48%), and topical preparations (5.07%).61 From a global perspective, lead poisoning, especially in children, is a leading cause of poisoning.

According to the WHO, 494,550 deaths annually are due to lead exposure. Furthermore, there is a loss of 9.3 mil- lion DALYs due to the long-term effects that exposure to lead has on health, with the highest burden occurring in LMICs.61 In the U.S., the Flint, Michigan, water crisis demonstrated the real threat of lead poisoning due to the built environment (see Chapter 6).

Risk Factors for Unintentional Poisonings As noted earlier, there are differences in unintentional poisoning mortality rates based on demographic charac- teristics such as age, gender, and ethnicity. Children younger than 6 years of age account for most poisoning events (46%), followed by adults (39%) and teens (7%).62

The most common poisoning in adults age 20 or older was related to pain medication and, in children, the most common poisonings were related to cosmetics and per- sonal care products.62

A major issue related to children and poisoning is the home environment. Most childhood poisonings occur in the home.63,64 Children who live in older homes are at greater risk for lead poisoning as a result of the presence of lead-based paint or carbon monoxide poisoning from older heating systems. The other issue is ingestion of poi- sonous substances found in the home such as chemicals and medications.

Prevention of Unintentional Poisoning With the predominant problem of overdose related to prescription medications, the most obvious approach to prevention is a focus on proper use and labeling of

296 U N I T I I n Community Health Across Populations: Public Health Issues

Year

D ea

th s

pe r

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9.69.18.98.88.2 7.36.96.4

5.8 4.6

4.13.9

Age-Adjusted Drug Overdose Death Rate per 100,000, 1999–2017

Figure 12-5 Age-Adjusted Drug Poisoning Rate U.S. 1999–2016. (Data from https://www.cdc. gov/nchs/data-visualization/drug-poisoning-mortality/)

Figure 12-6 Age-adjusted drug poisoning by race. (Data from https://www.cdc.gov/nchs/data-visualization/ drug-poisoning-mortality/)

30

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1999 2003 2008 2011 2017

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C H A P T E R 1 2 n Injury and Violence 297

medications, not sharing medications, proper storage of medications, and proper disposal of medications.63,64

Due to the opioid overdose epidemic, much of the focus has been on reducing prescription of opioids for the treatment of pain (see Chapter 11). With children at greatest risk, prevention efforts related to poisoning reduction in children are also important. The American Association of Poison Control Centers provides valuable guides to prevention that cover a wide range of potential poisons as well as environmental issues related to expo- sure.65 The United States Consumer Product Safety Commission also has a Web site that provides guidance for prevention and highlights current hazards such as single load liquid laundry packets and tiny button batteries. They also provide a link to recent recalls.66

Another major mechanism for prevention of morbidity and mortality is the network of poison control centers throughout the U.S. 65

Prevention efforts globally include efforts to reduce lead poisoning and poisoning from pesticides. The WHO has an International Program on Chemical Safety (IPCS). Their work includes promoting and establishing poison centers, providing information on poisoning, and developing peer-reviewed guidelines on the prevention and management of poisoning.67

Epidemiology of Self-Directed Violence: Suicide Self-directed violence (SDV), both fatal and nonfatal, is a serious public health issue and is defined as “… any- thing a person does intentionally that can cause injury to self, including death”.68 It includes suicide, defined as “death caused by self-directed injurious behavior with an intent to die as a result of the behavior.”69 Other suicidal acts include suicide attempt, defined as “a non- fatal, self-directed, potentially injurious behavior with an intent to die as a result of the behavior; might not result in injury”, and suicidal ideation, defined as “think- ing about, considering, or planning suicide.”69 SDV also includes non-suicidal acts such as cutting, head banging, self-biting, and self-scratching with some non-suicidal acts being unintentional and occurring in response to something environmental.68

Currently, due to a rise in the suicide rate, prevention of suicide has become a primary public health focus. In the U.S., there has been an alarming statistically significant rise in the suicide rate from 1999 to 2016 from 10.5 to 13.4 per 100,000. By 2016, suicide was the 10th leading cause of death in the U.S. Breaking it down by age group,

suicide was the second leading cause of death for persons aged 10 to 34, and the fourth leading cause of death among persons aged 35 to 54.70

There were more than twice as many suicides (44,965) in the United States as there were homicides (19,362).70,71 The media helped focus national atten- tion on the problem, especially with the high-profile celebrity deaths in 2018 of Anthony Bourdain and Kate Spade. One of the frequently referenced risk factors for suicide has been a history of mental health problems, but in a recent study of state surveillance data, 54% of those who committed suicide in 27 states had no known mental health condition.71

Globally, suicide is the 17th leading cause of death ac- counting for 1.4% of all deaths with an annual suicide rate of 10.7 per 100,000. It is also the second leading cause of death worldwide for persons aged 15-29. Almost a third (30%) are due to ingestion of pesticides. The other two most common methods globally are death by use of a firearm and hanging.72 There is no clear pattern globally with socioeconomically diverse countries in the top five: Guyana, Lithuania, South Korea, Kazakhstan, and Sri Lanka.73

Overall, in 2016, 4% of the U.S. population reported suicidal ideation (Fig. 12-7), and 0.5% reported a suicide attempt. Women and young people are more likely to attempt suicide than men and older adults. For that same year, 1.3 million adults attempted suicide, and 1 million reported making suicide plans.70

Risk Factors for Suicide Although in the United States suicide has been viewed as a moral problem or a sign of personal weakness by some (see Chapter 10), the underlying risk factors are complex and often multifactoral.71 Based on an analysis of suicide surveillance data, half of all persons who die by suicide had not been diagnosed with mental health disorder at the time of death. This brings into question limiting pre- vention to persons with a known mental health disorder. Those with mental health disorders often have other risk factors as well such as job or relationship problems or physical health issues.71 According to the WHO, some suicides are an impulsive action in a time of crisis with the person losing the ability to cope with life stressors. Other triggers “… experiencing conflict, disaster, vio- lence, abuse, loss, or a sense of isolation are strongly associated with suicidal behavior.”72 In addition, specific groups that experience discrimination are at increased risk including refugees; migrants; indigenous peoples; prisoners; Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ+) persons; and prisoners.72 There are a

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298 U N I T I I n Community Health Across Populations: Public Health Issues

10%

All other groups are non-Hispanic or Latino NH/OPI = Native Hawaiian/Other Pacific Islander AI/AN = American Indian or Alaska Native

* **

***

8%

6%

4%

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0% Overall Male Female

Gender Race/Ethnicity Age Group

Hispanic or Latino*

White AsianBlack NH/ OPI**

AI/AN*** 2 or more

18–25 26–49 50+

4.0 4.0 4.1 3.5

2.5

7.5

4.3 3.9

2.3

3.5

8.8

4.2

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Figure 12-7 Past Year Prevalence of Suicidal Thoughts Among U.S. Adults. (2016) (Data courtesy of SAMHSA; figure source https://www.nimh.nih.gov/health/statistics/suicide.shtml)

n CULTURAL AWARENESS AND COMPETENCY AROUND SUICIDE PREVENTION

Taking into account the cultural context of different communities is central to the building of effective suicide prevention programs as evidenced by the Substance Abuse and Mental Health Services Administration’s publication To Live to See the Great Day that Dawns: Preventing Suicide by American Indian and Alaska Native Youth and Young Adults – 2010. The publication utilizes culturally appropriate guidance to American Indian and Alaska Native communities drawing on cultural strengths and narratives to address suicide risk.75

According to the Indian Health Service, “Factors that protect AI/AN youth and young adults against suicidal behavior are a sense of belonging to one’s culture, a strong tribal/spiritual bond, the opportunity to discuss problems with family or friends, feeling connected to family, and positive emotional health.”76

Building a prevention program should not only address risk factors but build on cultural strengths within a community.

Suicides are preventable. There are a number of meas- ures that can be taken at population, subpopulation, and individual levels to prevent suicide and suicide at- tempts. These include:

• Reducing access to the means of suicide (e.g., pesticides, firearms, certain medications)

• Reporting by media in a responsible way • Introducing alcohol policies to reduce the harmful use

of alcohol • Early identification, treatment, and care of people with

mental and substance use disorders, chronic pain, and acute emotional distress

• Training of non-specialized health workers in the assessment and management of suicidal behavior

• Follow-up care for people who attempted suicide and provision of community support

BOX 12–7 n World Health Organization: Prevention of Suicide

Source: (72)

Veterans are another vulnerable group at higher risk for suicide in the U.S., especially those experiencing

number of protective factors as well including both family and community support (Box 12-7).

homelessness. The attempted suicide rate among vet- erans who are housed is 1.2% compared to 6.9% of those experiencing homelessness.77 The rate of suicidal ideation in the past 2 weeks is also higher among those experiencing homelessness (19.8% versus 7.4%). In Montana, between 2013 and 2016, veterans accounted for 20% of all suicides.78 Comparing suicide rates

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among veterans versus civilian populations is compli- cated, and recent statistics can be misleading because it is important to be clear about who is counted as a veteran. In addition, suicide rates for the general popu- lation includes adolescents to older adults. Thus, when comparing the suicide rate in veterans to the adult pop- ulation, it is important to use an age-adjusted rate as well as a clear definition of who is classified as a veteran.

Place of residence also plays a role. Both veterans and non-veterans living in rural areas in Montana and in the U.S. are at increased risk for suicide.73,79 Also, states with stricter gun laws have lower suicide rates as well as states with gun seizure laws.80 Nevada, a state that put in place suicide prevention programs, has seen a drop in the sui- cide rate, although the rate remains high.

Prevention of Suicide Prevention occurs from the individual to the policy level. As evidenced by the reduction of suicide rate in states with stricter gun control laws, upstream polices that address a risk factor, in this case easy access to guns, can help reduce the suicide rate. One set of authors recommended the use of the socioecological model (Chapter 2) in the development of suicide prevention programs using access to guns as the targeted risk factor. Using this approach, prevention occurs across the

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continuum of societal, community, relationship, and individual interventions.81 Examples of societal ap- proaches include policy and system level strategies. Novel approaches such as social networking for youth are emerging to address specific populations within the context of their daily lives. This is an example of a rela- tionship approach.82

The Zero Suicide (ZS) model is an example of a health systems-level approach. ZS uses a multilevel approach to help implement evidence-based practices for suicide prevention in the behavioral health setting. The compo- nents of the program include four aspects of clinical care (Identify, Engage, Treat, and Transition) and three components on the administrative level (Lead, Train, and Improve).83 The CDC published a guide to suicide prevention programs that illustrates that multiple evidenced-based prevention programs exist.84 From a global perspective, prevention requires attention to the multiple factors that contribute to suicide (Table 12-1). Suicide was listed in HP 2020 under mental health rather than injury and violence.85 Given that approxi- mately 50% of persons who commit suicide in the U.S. had not been diagnosed with a mental health disorder,71 suicide is relevant to both the mental health topic and to the violence and injury topic in Healthy People 2030.

TABLE 12–1 n Suicide: Risk Factors and Protective Factors

Risk Factors

• Family history of suicide • Family history of child maltreatment • Previous suicide attempt(s) • History of mental disorders, particularly clinical

depression • History of alcohol and substance abuse • Feelings of hopelessness • Impulsive or aggressive tendencies • Cultural and religious beliefs (e.g., belief that suicide is

noble resolution of a personal dilemma) • Local epidemics of suicide • Isolation, a feeling of being cut off from other people • Barriers to accessing mental health treatment • Loss (relational, social, work, or financial) • Physical illness • Easy access to lethal methods • Unwillingness to seek help because of the stigma attached

to mental health and substance abuse disorders or to suicidal thoughts

Protective Factors

• Effective clinical care for mental, physical, and substance abuse disorders

• Easy access to a variety of clinical interventions and support for help seeking

• Family and community support (connectedness) • Support from ongoing medical and mental health care

relationships • Skills in problem solving, conflict resolution, and

nonviolent ways of handling disputes • Cultural and religious beliefs that discourage suicide and

support instincts for self-preservation • Substance abuse disorders or suicidal thoughts

Source: (74)

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Epidemiology of Violence Against Children and Women Violence against women and children occurs both within and outside of the family context. Family violence includes violence between intimate partners (IPV), maltreatment of children, and elder abuse. The context of the violence is the family and occurs between individ- uals. The victims and the perpetrators have an established family-based relationship and can include violence against children and women. Violence against children that occurs outside the family includes community-based violence (see later), bullying, and school-based violence (see Chapter 18). Violence against women other than IPV includes stalking and sexual assault by persons other than intimate partners.

Child Maltreatment Child maltreatment is defined by the federal Keeping Children and Families Safe Act of 2003 (P.L. 108-36) as “any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emo- tional harm, sexual abuse or exploitation” or “an act or failure to act which presents imminent risk or serious harm.”87 The WHO points out that maltreatment of a child can lead to serious adverse consequences both im- mediately and long term. Violence against children not only leads to death, serious injury, and potential disabil- ity but also causes stress that negatively impacts brain de- velopment with damage to the nervous and immune systems. Thus, victims of child maltreatment may have “… delayed cognitive development, poor school per- formance and dropout, mental health problems, suicide attempts, increased health-risk behaviors, revictimiza- tion, and the perpetration of violence.”88

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n HEALTHY PEOPLE 2020 Mental Health and Mental Disorders: Mental Health Status Improvement

Objective: MHMD-1 Reduce the suicide rate Baseline: 11.3 suicides per 100,000 population occurred in 2007 (age adjusted to the year 2000 stan- dard population) Target: 10.2 suicides per 100,000 population85

Midcourse Review: The objective, MHMD-1, wors- ened, with a significant increase in the suicide rate from baseline to 12.6 per 100,000 in 2013 moving away from the target of 10.2.86 In 2016, the rate continued to climb to 15.6 per 100,000.71

Child neglect is the most prevalent form of child mal- treatment and includes both physical neglect and emo- tional neglect. Physical neglect includes the withholding of food, shelter, clothing, and/or medical or dental care, whereas emotional neglect involves the omission of caring, nurturing, and acceptance. Emotional abuse is defined as extreme debasement of feelings, whereas physical abuse is nonaccidental physical harm such as bruising, bites, thermal burns or cigarette burns, severe fractures, and even death. Sexual abuse defined by the federal Child Abuse Prevention and Treatment Act87 and as amended by the Keeping Children and Families Safe Act of 2003 is “the employment, use, persuasion, induce- ment, enticement, or coercion of any child to engage in, or assist any other person to engage in, any sexually explicit conduct or simulation of such conduct for the purpose of producing a visual depiction of such conduct; or the rape, and in cases of caretaker or inter-familial relationships, statutory rape, molestation, prostitution, or other form of sexual exploitation of children, or incest with children.”87

At both the global level and in the U.S., one in four adults have a history of physical abuse as a child.89,90 The National Child Abuse and Neglect Data System is the surveillance system that monitors trends of child maltreatment by collecting child protective service re- ports from 50 states, Puerto Rico, and the District of Columbia.91 In 2016, in the U.S., child protective services received reports of 676,000 victims of child maltreatment of whom an estimated 1,750 died.91 Also in 2016, chil- dren younger than a year old had the highest rate of child maltreatment at 24.8 per 1,000. American Indian or Alaska Native children had the highest rate (14.2 per 1,000) followed by African-American children (13.9 per 1,000). The fatality rate was highest in African-American children at 4.65 per 100,000, which is twice as high as the rate for white children (2.10 per 100,000) and three times as high as Hispanic children (1.58 per 100,000).91 Be- cause these data represent only those cases reported to child protective services, the actual incidence may be higher. The estimated cost of child maltreatment in the U.S. is $124 billion each year.90

Risk Factors for Child Maltreatment Risk factors for childhood maltreatment include three levels of risk: individual, family, and community (Table 12-2).92 Parental socioeconomic factors play a role. For example, the level of mother’s education and poverty, and parental behavioral issues such as mental health disorders or substance use place a child at higher risk.90, 92,93 For some, a parent’s history of child

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TABLE 12–2 n Child Maltreatment: Risk Factors and Protective Factors

Risk Factors for Victimization

Individual Risk Factors

• Children younger than 4 years of age • Special needs that may increase caregiver burden (e.g., disabilities, mental health issues, and chronic physical illnesses)

Risk Factors for Perpetration

Individual Risk Factors

• Parents’ lack of understanding of children’s needs, child development, and parenting skills • Parental history of child abuse and or neglect • Substance abuse and/or mental health issues including depression in the family • Parental characteristics such as young age, low education, single parenthood, large number of dependent children, and

low income • Nonbiological, transient caregivers in the home (e.g., mother’s male partner) • Parental thoughts and emotions that tend to support or justify maltreatment behaviors

Family Risk Factors

• Social isolation • Family disorganization, dissolution, and violence, including intimate partner violence • Parenting stress, poor parent-child relationships, and negative interactions

Community Risk Factors

• Community violence • Concentrated neighborhood disadvantage (e.g., high poverty and residential instability, high unemployment rates, and high

density of alcohol outlets), and poor social connections.

Protective Factors

Family Protective Factors

• Supportive family environment and social networks • Concrete support for basic needs • Nurturing parenting skills • Stable family relationships • Household rules and child monitoring • Parental employment • Parental education • Adequate housing • Access to health care and social services • Caring adults outside the family who can serve as role models or mentors

Community Protective Factors

• Communities that support parents and take responsibility for preventing abuse

Source: (90)

abuse in the family of origin is significant,93 whereas for other families current substance abuse and/or men- tal health issues including depression in the family are predictors of child maltreatment.90,92 Other risk factors include parents’ lack of understanding of children’s needs, child development, and parenting skills, or parental thoughts and emotions that tend to support

or justify maltreatment behaviors.90 Maternal IPV (see later) is another strong risk factor for child maltreat- ment.94 The presence of a nonbiological, transient care- giver in the home is another risk factor for sexual abuse in particular (e.g., mother’s male partner).90

Community-level risk factors include low socioeconomic status and living in an impoverished community.90,92

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A history of childhood maltreatment can lead to lifelong health issues in adults.90

Prevention of Child Maltreatment The focus of childhood maltreatment prevention pro- grams is often on parental education, support, and/or public awareness campaigns in an effort to strengthen the protective factors within the home and community (Table 12-3).92,95 Tertiary prevention is also important to prevent recurrence of abuse or to decrease impair- ment. Home visitation (see Chapter 17) in particular has been implemented for the prevention of child maltreat- ment. Focusing on selective protective factors is the focus of many of these programs. Protective factors for child maltreatment include nurturing parenting skills, pro- moting stable family relationships, promoting household rules and child monitoring, and assisting with parental employment, adequate housing, or access to health care and social services.95 Home visitation programs include the Nurse Family Partnership Model, which has under- gone rigorous evaluations and shows promise for the prevention of child maltreatment.96 Examples of other programs aimed at reinforcing protective factors in

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TABLE 12–3 n Childhood Maltreatment Prevention Programs

Strategy

Teach safe and healthy relationship skills

Engage influential adults and peers

Disrupt the developmental pathways toward partner violence

Create protective environments

Strengthen economic supports for families

Support survivors to increase safety and lessen harms

Approach

• Social-emotional learning programs for youth • Healthy relationship programs for couples

• Men and boys as allies in prevention • Bystander empowerment and education • Family-based programs

• Early childhood home visitation • Preschool enrichment with family engagement • Parenting skill and family relationship programs • Treatment for at-risk children, youth and families

• Improve school climate and safety • Improve organizational policies and workplace climate • Modify the physical and social environments of

neighborhoods

• Strengthen household financial security • Strengthen work family supports

• Victim-centered services • Housing programs • First responder and civil legal protections • Patient-centered approaches • Treatment and support for survivors of IPV

Source: (112)

families and communities include the Triple P program and Family Connections.97,98

Violence Against Women and Intimate Partner Violence Intimate partner violence is violence that occurs be- tween two people in an intimate relationship. It includes physical violence, sexual violence, and/or psychological/ emotional violence as well as threats of physical and/or sexual violence. It can occur between both heterosexual and same sex partners.99 Globally, more than one-third of women (38%) have experienced either physical and/or sexual violence with 30% of them experiencing IPV. In addition, 38% of all homicides of women are perpetrated by an intimate partner.100

Physical violence is the intentional use of physical force with the potential for causing death, disability, in- jury, or harm. Physical violence includes, but is not lim- ited to, scratching, pushing, shoving, throwing, grabbing, biting, choking, shaking, slapping, punching, burning, use of a weapon, and use of restraints or one’s body, size, or strength against another person. Sexual violence is divided into three categories: (1) use of physical force to

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compel a person to engage in a sexual act against his or her will, whether or not the act is completed; (2) at- tempted or completed sexual act involving a person who is unable to understand the nature or condition of the act, to decline participation, or to communicate unwillingness to engage in the sexual act (e.g., because of illness, disabil- ity, the influence of alcohol or other drugs, or because of intimidation or pressure); and (3) abusive sexual contact. Threat of physical or sexual violence is the use of words, gestures, or weapons to communicate the intent to cause death, disability, injury, or physical harm. Psychological/ emotional violence involves trauma to the victim caused by acts, threats of acts, or coercive tactics. Psychological/ emotional abuse can include, but is not limited to, humil- iating the victim, controlling what the victim can and cannot do, withholding information from the victim, de- liberately doing something to make the victim feel diminished or embarrassed, isolating the victim from friends and family, and denying the victim access to money or other basic resources. Stalking is defined as “… a pattern of harassing or threatening tactics used by a perpetrator that is both unwanted and causes fear or safety concerns in the victim.”101,102

About 1 in 4 American women and about 1 in 10 males reported a lifetime impact of contact sexual violence, physical violence, and/or stalking.102 Surveil- lance of IPV occurs through various databases. This abuse can start early in dating relationships.102 LGBTQ+ persons also experience IPV at levels equal to or higher than the heterosexual population.103

IPV has significant negative effects on health. These effects are both short- and long-term and include phys- ical, mental, sexual, and reproductive adverse health con- sequences for women and their children.100,104 There are also serious negative social and economic consequences for women, their families, and their communities.100,104

Abused women are also more likely to use medical serv- ices including outpatient primary care, EDs, and mental and substance abuse services.105 Femicide (Box 12-8) is the most extreme negative outcome.106

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n CULTURAL CONTEXT As part of a series on violence prevention, the WHO examined how cultural and social norms can encourage violence, including IPV. Some examples of cultural norms from different countries provided by the WHO include the following: “a man has a right to assert power over a woman and is socially superior (India, Nigeria, Ghana); a man has a right to ‘correct’ or disci- pline female behavior (India, Nigeria, China); a woman’s

freedom should be restricted (Pakistan); and physical violence is an acceptable way to resolve conflicts within a relationship (South Africa, China).”107 Devia- tion from norms results in disgracing the entire family, which can then lead to honor killings such as the honor killing of a couple who married for love in Pakistan in 2018. The role culture plays in violence against women has been in the spotlight with calls to stand up against a cultural acceptance of men perpetuating violence against women, especially sexual violence. Thus, at the global level, a cultural shift is occurring to not only accept women who speak out and report perpetrators but also to make violence against women unacceptable. Time magazine choosing the founders of the #metoo movement as their Person of the Year in 2017 is evidence of the cultural shift.

Femicide is the intentional murder of women.

• Femicide is usually perpetrated by men, but sometimes female family members may be involved.

• Femicide differs from male homicide in specific ways. For example, most cases of femicide are committed by partners or ex-partners, and involve ongoing abuse in the home, threats or intimidation, sexual violence, or situations where women have less power or fewer resources than their partner.

BOX 12–8 n World Health Organization Definition of Femicide

Source: (106)

Risk Factors for Intimate Partner Violence Risk for IPV occurs at many levels. At the individual level, risk factors include female gender, young age, being un- married, being uninsured or on medical assistance, low income, and having a history of child maltreatment.100,108

In addition, at-risk alcohol use by either partner or both is associated with IPV perpetration.100,108 Other risk factors include low self-esteem, mental health problems, unemployment, or desire for power and control in rela- tionships.100,108 At the family level, exposure as an ado- lescent to severe IPV between caregivers increases the risk for relationship violence in early adulthood.100,108 At the community level, residence in an area characterized by poverty and social disadvantage as well as by an increased density of alcohol outlets are factors associated with IPV–related ED visits.100,108,109

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Epidemiology of Community Violence Community violence is an event that includes crime, weapons use, and violence or potential violence, and is perpetrated in a public place by individuals who do not have a relationship with the vicitms.116 Examples of com- munity violence include violent acts or victimization by strangers perpetrated by one or more individuals, sniper attacks, gang wars, and drive-by shootings.117

The impact of violence on a community is widespread. Exposure to the constant stress of living within an unsafe community takes its toll on all of its citizens. It can lead to a sense of isolation for older adults who limit their activity outside their home because of violence. It can lead to a lack of physical activity in children and families because parents are concerned about the safety of their children. It can lead to psychiatric sequelae because of the feelings of fear and stress.116,117

Community violence can also occur in towns and neighborhoods where violence is not the norm, such as the killing of 20 children and 6 adults at Sandy Hook Elementary School in Newtown, Connecticut; the killing of church members in South Carolina; or the school shootings in Parkland, Florida. These events sent shock waves through the nation and brought calls for stricter gun control laws. Understanding the causative factors behind community-level violence is complex and can include individual level factors such as a history of men- tal illness or terrorism, as was the case in the Boston Marathon bombing and the events on September 11, 2001.

In 2016, in the U.S., 5.7 million people aged 12 or older experienced violent victimization at a rate of 21.2 per 1,000. The rate of violent victimization by a stranger was higher than the rate for IPV (8.2 per 1,000 versus 2.2 per 1,000).118,119 These statistics reflect actual reported events of violent crime. At the community level, violence not only affects the victim(s), it also affects those who witness the violence and can create a community-level reaction of concern for safety. For some communities, it is an unexpected event that takes a community unaware, and in others, the violence is part of everyday life. In the case of war, one expects to be exposed to death, trauma, and stress. Unfortunately, certain neighborhoods in our cities have often been compared to war zones where it is not uncommon to be exposed to severe violence on a regular basis.

Exposure to community violence (i.e., seeing some- one shot; someone being stabbed, molested, raped, mugged, threatened with a knife, gun or weapon; or someone being beaten up or hurt) is often associated

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The majority of studies have focused on risk factors in relation to the female victim. Globally, there is a lack of research related to the perpetrator. In addition, outside of the U.S., there is little research on the community level related to IPV.110 In a ground-breaking study by Camp- bell et al., risk factors for femicide included a history of prior abuse, a history of perpetrator unemployment, availability of guns, and presence of the victim’s child from another relationship in the home.111

Prevention of Intimate Partner Violence In 2017, the CDC published Preventing Intimate Partner Violence Across the Lifespan: A Technical Package of Programs, Policies, and Practices, an evidence-based re- view of prevention strategies across the continuum aimed at reducing IPV and reducing negative conse- quences in persons who have experienced IPV.112 The main categories of prevention include: (1) Teach safe and healthy relationship skills, (2) Engage influential adults and peers, (3) Disrupt the developmental pathways to- ward partner violence, (4) Create protective environ- ments, (5) Strengthen economic supports for families, and (6) Support survivors to increase safety and lessen harms. This broad overview of prevention requires promoting change at all levels of the socioecological model (Chapter 2): individual, relationship, community, and society. Examples of evidence-based prevention strategies presented in the CDC technical program package include early childhood visitation programs, organizational and workplace policies, and family-based programs.112

At the secondary prevention level, screening and re- ferral for treatment are two key steps for prevention of further IPV in women who have a history of prior IPV or are at risk for IPV.110 Nurses have advocated for universal screening for IPV.110,111,113 A number of screening tools are available, such as the DOVE tool de- veloped by a nurse and tailored for screening during a home visit. DOVE is an evidence-based screening tool developed to help identify women who may be at risk for perinatal IPV and includes steps for implementing interventions during a perinatal home visit aimed at re- ducing violence.114 Disclosure of IPV requires action by the provider, further assessment, appropriate referrals, and discussion of a safety plan. To help practitioners, the Agency for Healthcare Research and Quality re- viewed the evidence to support screening for IPV in women who did not have signs of abuse. Their fact sheet provides the evidence to support screening as well as for resources for implementing screening in health- care settings.115

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with psychiatric sequelae including post-traumatic stress disorder (PTSD).115,116 Post-traumatic stress disorder is a type of anxiety disorder in children and adults who witness horrific events. PTSD can develop in response to a variety of traumatic events such as witnessing a violent act or crime, experiencing a natural or unnatural disaster, and experiencing physical or sexual abuse.116

Other comorbid psychiatric symptoms include anxiety and major depressive episodes. Substance use and behavior problems are also seen in children exposed to violence.116

Risk and Protective Factors for Community Violence For the most part, economically depressed and disorgan- ized communities with fewer resources and an increased access to guns are at greater risk for community-level violence.120 Truly understanding risk and protective factors for community violence continues to be a challenge. Risk factors often not addressed include racism, discrimination, prisoner reentry, and other conditions of vulnerability and invisibility.121 Protective factors at the community level include norms supporting gender equity and robust economic/job opportunities in communities.

A particular concern with violence in the community is youth violence, which occurs when youths hurt peers unrelated to them that they may or may not know well.122

Young people perpetrate violent acts at a higher rate than any other age group. The risk factors for youth violence occur at the individual, family, peer, and community level. They include low socioeconomic status, poor parental supervision, delinquent peers, and harsh par- enting. At the community level, risk factors for violence are similar and include living in disorganized communi- ties with fewer resources, lower socioeconomic status, and a higher rate of transiency.122

Promoting youth development is one strategy used to decrease youth violence within the community. This is based on the fact that social connectedness is a pro- tective factor inversely associated with rates of crime at the community level.122 Resilience is the ability to suc- cessfully adapt and function despite exposure to chronic stress and adversity. Resilience is achieved through sup- port from a family, school, or peer group. The CDC has published a guide to evidence-based programs aimed at reducing youth violence. The recommendations include six areas: (1) promote family environments that support healthy development, (2) provide quality education early in life, (3) strengthen youth skills, (4) connect youth to caring adults and activities, (5) create protective community environments, and (6) intervene to lessen

harms and prevent future risk. This technical prevention package provides links to evidence-based programs, many of which can be implemented at the community level.123

Epidemiology of War: An Example of Collective Violence War as defined by the online Merriam Webster diction- ary is “a state of usually open and declared armed hostile conflict between states or nations.”124 This excludes individuals or families fighting, gangs fighting, and other smaller community entities. Traditional war is thought of as the fighting between two political states or coun- tries, but just as common is the fighting between two groups within a state (civil war) that are aspiring to be- come the political entity for the state. War is a violent way of determining who will govern. War and its vio- lence create serious social consequences that affect all the political communities involved. These consequences can be a result of a prolonged conflict, extreme aggres- sion, excessive mortality and morbidity, and/or high financial cost, all of which reduce resources for social needs.

In their book On War and Public Health, Levy and Sidel write:

War accounts for more death and disability than many major diseases combined. It destroys families, communities, and sometimes whole cultures. It directs scarce resources away from protection and promotion of health, medical care, and other human services. It destroys the infrastruc- ture that supports health. It limits human rights and con- tributes to social injustice. It leads many people to think that violence is the only way to resolve conflicts—a mindset that contributes to domestic violence, street crime, and other kinds of violence. And it contributes to the destruction of the environment and overuse of nonrenewable resources. In sum, war threatens much of the fabric of our civilization (p. 3, 138).125

War affects more than the combatants. In the 20th century, it was estimated that 136.5 to 148.5 million people died in war and conflict.126 However, the largest death toll comes not from the direct conflict but from both the short- and long-term residual effects of the war such as disease and malnutrition.127,128

Worldwide, in 2018, examples of ongoing wars in- cluded those in Afghanistan, Syria, Yemen, Somalia, and Myanmar. More than 40 wars (both between nations and civil wars) began in the 1990s compared with fewer than

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10 in the first decade of this century. There also were fewer deaths caused directly by war-related violence. For example, the number of all battle-related deaths in conflicts in 2016 was 87,432.129 One contributing factor to lower mortality is that the nature of war has changed. There are no longer huge armies in battle with massive human destruction. However, more countries have access to weapons of mass destruction, and the number of countries with active nuclear warheads has grown from two in the 1940s to nine by 2013.

With the use of social media, there has also been more reporting of wars and their atrocities. The reporting occurs almost at the moment they occur. It makes the violence seem greater, because of the immediacy with which it is being reported. When traditional reporting by journalists is impeded, as occurred in the Syrian con- flict, social media has provided an alternative source of news for those inside and outside the country.

Even with fewer wars and numbers of deaths, the war- related effects of current conflicts are enormous. There is an obvious breakdown in public health systems with the displacement of resources to war and away from health services including prevention services, increases in disease transmission, and other changes in the social systems that had previously kept the population healthy. There are many other examples of the destructiveness of war: the use of child soldiers resulting in severe physical and emotional abuse of the children, making it very difficult for them to reintegrate into civil society; the forced movements of refugees and displaced persons from their own homes to areas with decreased health and safety; and the increased acceptability of violence as a solution to problems.

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section of the world flows over into other countries, especially with the current crisis related to war refugees coming into western countries and ensuing resistance from citizens of western countries to accept refugees (see Chapter 7). Hogopian argued that war should be reframed as a public health issue due to the serious consequences to the health of populations that result during war and its aftermath.130 White took a global view and proposed that collaboration among nations was essential in the prevention of war.131

Advances in treating injury resulting from war at the cellular level has improved survival rate for combatants, yet a global international approach may be needed to reduce the short- and long-term impacts on non- combatants including those who stay and those who are forced to seek refuge from a war zone.

n CELLULAR TO GLOBAL The Impact of War

Advances in health care have reduced the immediate impact of combat injuries, reducing mortality and long- term morbidity substantially in the time between the American Civil War and today. So, on the surface, it appears we have vastly improved our ability to address the impact of war on combatants at the cellular level. Taking the wider view of the impact of war on the communities where the conflict occurs demonstrates the more complex relationship between armed conflict and health not only due to injury but malnutrition, destruction of community infrastructure, housing, and access to clean water. On the psychological level, both combatants and non-combatants suffer from short- and long-term PTSD. On the global level, war in one

Role of the Nurse in War Starting with primary prevention, the nurse can sup- port actions to prevent war. If war ensues, the nurse may try to minimize the effects of the war as part of secondary prevention. After the war is over, the nurse, at the tertiary level, may help treat the victims of the war and minimize the political, economic, social, and environmental destruction. Nurses can help in surveil- lance and documentation of what happens during the war and report it to the appropriate agencies, advocate for the use of nonviolence, advocate to minimize the re- sults of war, and work with the refugees and displaced persons from the war, either in the United States or in other countries, to improve their health and social rein- tegration into society. With additional training, nurses can provide the emergency relief frequently needed during and immediately at the end of the war. Nurses can also help document and understand the most ap- propriate interventions for refugees and displaced persons, which are frequently specific to the affected population. Using this additional information, the reintegration of individuals into post-war social systems can be facilitated.

n Summary Points • Injury is a major public issue that includes both in-

tentional and unintentional injury, most of which is preventable.

• Risk factors associated with injury and violence are complex and include a combination of individual behaviors, environment, socioeconomic status, and culture.

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t SUICIDE AND VULNERABLE POPULATIONS Learning Outcomes

At the end of this case study, students will be able to:

• Compare dependent rates (Chapter 3). • Compare the effectiveness of different approaches

to prevention based on the target population. • Explain the role of health-care providers and key

stakeholders in prevention program planning. • Discuss the benefits of incorporating cultural

components into a health program. • Compare and contrast different levels of prevention

as well as the applicability of the socioecological model when developing a health program.

Suicide rates are rising in the U.S. with a rate of 15.6 per 100,000 in 2016, up from 11.3 per 100,000 in 2007. Split into teams and have each team choose a different specific subpopulation (e.g., adolescents, older adults, veterans). Subpopulations can be further divided based on demographic variables such as race and gender. Examine the most recent statistics on suicide rates in this population as well as the most recent sta- tistics at the national and global level. Then examine the current evidence-based approaches to prevention and decide on a specific prevention approach. As part of your assessment and program planning:

1. Compare the suicide rate in your chosen population with the suicide rate in the general population and decide if there is a significant difference.

2. Examine possible evidence-based approaches to sui- cide prevention within the context of a particular health-care setting (e.g., ED, primary care, public health department) and the chosen population. Choose one to implement.

3. Determine the level of intervention based on whether it is primary, secondary, or tertiary as well as whether it is universal, selective, or indicated.

4. Develop a draft plan of the program. Be sure to ad- dress possible cultural concerns, key stakeholders, and access to care.

5. Compare plans between teams. If you could only implement one program, which would you chose? Support your choice using a public health perspective.

REFERENCES

1. Centers for Disease Control and Prevention. (2017). Emergency department visits. Retrieved from https://www. cdc.gov/nchs/fastats/emergency-department.htm.

2. World Health Organization. (2014). Injury and violence: The facts. Geneva, Switzerland: Author.

3. World Health Organization. (2018). Top ten causes of death. Retrieved from http://www.who.int/mediacentre/factsheets/ fs310/en/index1.html.

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

5. Centers for Disease Control and Prevention. (2018). Leading causes of death by age group, United States 2016. Retrieved from https://www.cdc.gov/injury/images/lc-charts/leading_ causes_of_death_age_group_2016_1056w814h.gif.

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313

Public Health Planning

Chapter 13

Health Planning for Local Public Health Departments Susan Bulecza, Laurie Abbott, and Barbara Little

LEARNING OUTCOMES

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

KEY TERMS

1. Describe the historical development of public health departments (abbreviated in this chapter as PHDs).

2. Describe the structure and services of PHDs. 3. Describe the interdisciplinary workforce in PHDs. 4. Analyze key roles and responsibilities of public health

nurses (PHNs) in PHDs. 5. Discuss current issues related to delivery of essential

public health services by PHDs.

6. Investigate the role of PHDs in community assessment and planning for health needs of the community.

7. Identify the most frequent activities and services provided by PHDs.

8. Discuss financial and information technology resources needed to support PHDs.

9. Describe the challenges facing PHDs. 10. Discuss accreditation and evaluation of services

provided by PHDs.

Behavioral Risk Factor Surveillance System (BRFSS)

Categorical funding Centralized system Community health

assessment

Decentralized system Directly observed therapy Geographic information

system (GIS) Federally qualified health

centers (FQHCs) Fetal death

Healthy Start Medication electronic

monitoring system Public health department

(PHD) Public health informatics Public health system

Public health systems and services research

Shared or mixed system Vital statistics Women, Infants, and

Children (WIC)

n Introduction An official governmental body responsible for assuring the health of citizens residing within a county, municipality, township, or territory is called a public health department (PHD). PHDs are considered trusted conveners that fa- cilitate partnerships and coalitions to assess and address local public health issues.

The basic mandate of the PHD is to protect and improve health in partnership with the community (see Chapter 1). Citizens generally think that the PHD

is responsible for providing services related to commu- nicable diseases or immunization services. However, they may not be aware of the overarching mission of the PHD to promote and protect the health, defined more broadly than communicable diseases, of all peo- ple in the community. This mission can only be ac- complished through a host of health-care providers and community partners who pool together resources and coordinate services. These partners and their serv- ices make up the public health system.1 Although the PHD is not responsible for providing all health services

U N I T III

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for a population, governmental agencies are responsi- ble for assuring essential community health services.2

The purpose of this chapter is threefold. It is important for all nurses to be aware of the role of local health depart- ments to (1) facilitate linkages between clients and serv- ices, (2) describe the role of the public health nurse in a PHD, and (3) discuss current challenges affecting PHDs.

History of Public Health Departments Local official agencies in the United States developed out of local boards of health in the late 18th century.3 The first city to form a board of health was Philadelphia (1794), followed by Baltimore (1797), Boston (1799), Washington, DC (1802), New Orleans (1804), and New York City (1805).4 The concerns at that time were fo- cused on communicable diseases within densely popu- lated cities. In part because of a growing understanding of the connection between proper sanitation and disease, there was an expansion of municipal health departments in the 1880s and early 1900s.5 Another major growth pe- riod occurred with the passage of the Social Security Act in 1935, which provided millions of dollars for maternal and child health services for public health.4

The delivery of public health services in rural commu- nity settings presented unique challenges. Prior to the es- tablishment of formalized governmental units in rural areas, district nurses provided much of the work of public health.5 The progression of time and population growth within rural communities influenced the formation of county health departments, which provided public and en- vironmental health services including sanitation. In 1908, the first PHD to provide public health services was estab- lished in Jefferson County, Kentucky, and in 1911, two oth- ers were formed. Guilford County, North Carolina, expanded school health programs, and Yakima County, Washington, responded to a typhoid epidemic.5 The first exclusively rural county health department was in Robeson County, North Carolina.5 By 1921, the county movement had spread to 186 counties in 23 states, often with the help of private foundations.6,7 The Rockefeller Foundation de- veloped rural programs between 1910 and 1913 to:5

• Educate medical professionals and the public about hookworm disease;

• Provide funds to sanitize communities for protection against hookworm and typhoid diseases;

• Fund the employment of personnel to continue work in the counties.

The financial support from the Rockefeller Founda- tion and other private foundations including the

Commonwealth Fund, W.K. Kellogg Foundation, and, eventually, the Public Health Service (PHS) contributed to the rapid increase in county health departments during the early 20th century, from 1 in 1908 to 610 in 1932.5

Mission of Public Health The mission of public health had its beginnings in the mid- 19th century when physicians, housing reformers, advo- cates for the poor, and scientists trained in housing and civil engineering came together to target health problems associated with urbanization, industrialization, and immi- gration.8 The focus was largely on housing conditions and communicable diseases. The work of social reformers at Hull House in Chicago or the Henry Street Settlement with Lillian Wald (Chapter 1) are examples of this work.

Beginning in the 1920s, the Committee on Adminis- trative Practice of the American Public Health Associa- tion (APHA) sought to define the mission of public health agencies.3,9 In 1933, the Committee on Administrative Practice of APHA listed two primary goals for local public health agencies:3

• Control of communicable diseases • Promotion of child health

These goals reflected the basic public health needs of the time, recognizing that children suffered the most from communicable diseases. By 1940, another APHA statement produced a clearer listing of the six minimum functions of local health departments:10

• Vital statistics • Environmental sanitation • Communicable disease control • Public health laboratories • Maternal and child health • Public health education

The mission of public health was revisited with the In- stitute of Medicine (IOM) report in 1988. At that time, public health was redefined (see Chapter 1), and the mis- sion was defined as fulfilling society’s interest in assuring conditions in which people can be healthy.11 The three core functions of assurance, assessment, and policy for- mation evolved from this work.

Structure of Public Health Departments As hospitals have different corporate and organizational structures, so does the infrastructure for public health agencies vary on the state and local levels. Thus, the adage, “When you have seen one health department, you have seen one health department,”1 means that no two health departments are alike. Knowing how the PHD is

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organized is of key importance for nurses to understand how public health services are delivered in their state and community. Generally, PHDs are organized by one of three major delivery modes:

• Centralized (state) system: PHDs are operated by a state health agency or board of health, and the PHD functions under the state agency (five states).

• Decentralized (local) system: PHDs are operated by local government with or without a board of health (27 states).

• Shared or mixed system: PHDs are operated under shared or combined authority of the state health agency, board of health, and local government (16 states).12,13

• Hawaii and Rhode Island have state, not local, PHDs.12

Similar to the size of the hospital (number of beds) and nurse-to-patient ratio, the size of the population the PHD serves is a critical factor in local public health service delivery. Figure 13-1 illustrates the percentage of small, medium, and large PHDs and the percentage of the U.S. population served by these PHDs. It is interest- ing to note that 51% of the population is served by only 6% of large PHDs, whereas 62% of small PHDs cover 10% of the population.12

The type of jurisdiction or territory served by the PHD is another organizational factor. The majority of PHDs

C H A P T E R 1 3 n Health Planning for Local Public Health Departments 315

(69%) are county-based with smaller percentages serving a city or town (20%) as well as city/county (3%) areas such as Miami-Dade in Florida12 (Fig. 13-2). Proposed as a method for strengthening public health services in rural areas, multicounty or regional jurisdictions encom- pass 8% of all PHDs.12,13

PHDs located in rural areas are challenged by infra- structural issues related to limited resources and isola- tion.14 And yet, they are often called upon to address widening health disparities and worsening health out- comes than those in urban areas.15 For example, mor- bidity and mortality rates reported for rural areas are often higher, and the environmental health challenges related to agricultural pollution and unsafe mining and logging practices contribute to the problem. People liv- ing in rural areas are typically older, poorer, and more likely to have been diagnosed with chronic diseases.15 In fact, the more remote the rural area is, the lower the life expectancy.15

Public Health Workforce The PHD workforce is interdisciplinary, and the majority of PHDs have fewer than 100 employees. The types of oc- cupations typically found in PHDs include physicians, environmental health specialists, dietitians, social work- ers, pharmacists, epidemiologists, information technol- ogy (IT) specialists, health educators, public information specialists, and nurses. The 2016 National Association of City and County Health Officials (NACCHO) survey re- ported that registered nurses comprised 18% of the pub- lic health workforce composition, a notable decrease from 24% in 2005 (Fig. 13-3).12 Depending on the juris- diction, some PHDs employ mental health service providers (2%), physicians (1%), and licensed practical nurses (2%).12 Staffing patterns vary depending on the size and services provided by the PHD.

Historically, the sociodemographic characteristics of the public health workforce have not adequately repre- sented the diversity of the communities served. The re- ported findings of a study by NACCHO were that the local health department workforce is predominately Cau- casian (72.2%).16 The PHD employees belonging to spe- cific racial and ethnic minority groups (overall, 27.8%) were African American (15.8%), American Indian/Alaska Native (0.5%), Asian (3.8%), Native Hawaiian/Other Pacific Islander (1.9%), and Some Other Race/Two or more Races (5.8%).16 Regarding ethnicity, a small per- centage of all PHD employees are Hispanic (10.5%), but most are Not Hispanic or Latino (89.5%).16 The larger the size of the population served, the greater the percentage of diverse workers employed by the PHD.16

Small

(<50,000) 62%

33%

6% 51%

10%

39%

0

N = 2,533

10 20 30 40 50

Percent

Percent of U.S. Population Served by PHDs

60 70

Medium

(50,000–499,999)

Large

(500,000+)

Percent of all PHDs

Percent of population served by PHDs

Figure 13-1 Percentage of PHDs and percentage of U.S. population served, by size of population served. (© 2017. National Association of County and City Health Officials. The 2016 national profile of local health departments. Retrieved from http://nacchoprofilestudy.org/wp-content/uploads/2017/10/ ProfileReport_Aug2017_final.pdf)

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Role of Public Health Nurses in Public Health Departments Nurses who work within a PHD are usually considered public health nurses (PHNs). PHNs make up one of the largest professional groups within the health department. Not all PHNs work within an official agency.

The relevance of nursing to public health was rec- ognized in the early 1920s when C.E. Winslow’s defi- nition of public health highlighted the role of nursing services:17

Public health is the science and art of preventing disease, prolonging life, and promoting physical and mental health well-being through organized community effort for the san- itation of the environment, the control of communicable infections, the organization of medical and nursing services for the early diagnosis and prevention of disease, the education of the individual in personal health, and the

development of social machinery to assure everyone a stan- dard of living adequate for the maintenance or improve- ment of health.

In addition, APHA’s 1933 and 1940 statements of the mission of public health emphasized the role of public health nursing in several functions of the health depart- ment, especially communicable disease and maternal- child health.3

Core Functions Today, PHNs who work in PHDs promote and protect the health of the entire population in a community through the three core public health functions:11

• Population assessment • Assurance of a well-coordinated system of health

promotion and health-care services • Policy development to support the health of the

community

316 U N I T I I I n Public Health Planning

City or town County Multi-city Multi-county

Geographic Jurisdictions Served by PHDs

Figure 13-2 Percentage distribution of PHDs by type of geographical jurisdiction. (© 2017. National Association of County and City Health Officials. The 2016 national profile of local health departments. Retrieved from http://nacchoprofilestudy. org/wp-content/uploads/2017/10/ProfileReport_Aug2017_final.pdf)

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C H A P T E R 1 3 n Health Planning for Local Public Health Departments 317

Figure 13-3 Percentage distribution of occupations in the PHD workforce. (© 2017. National Association of County and City Health Officials. The 2016 national profile of local health departments. Retrieved from http://nacchoprofilestudy.org/ wp-content/uploads/2017/10/ProfileReport_Aug2017_final.pdf)

Agency Leadership (5%)

Business Operations Staff (5%)

Preparedness Staff (2%)

Nutritionists (4%)

Health Educators (4%)

Community Health Workers

(4%)Nursing or Home Health Aide

(2%)

Oral Health Care (1%)

Info Systems

(1%)

Lab Workers

(1%)

Animal Control (1%)

Physicians (1%)

Epi/stats (1%)

Office Support Staff (18%)

Estimates shown (detail lost due to rounding). Public information professional (0.4%) not shown. n = 1,611–1,828

Registered Nurses (18%)

Other Occupations Not in Profile

(18%)

Licensed Practical or Vocational Nurse

(2%)

Behavioral Health Staff (2%)

Environmental Health Workers (10%)

Workforce Composition

These functions and their related essential services18

were introduced in Chapter 1 (see Box 1-1), and their rel- evance for guiding local health departments is further explored in this chapter.

We can apply the core functions to public health nursing within a PHD setting using immunization as

an example of an intervention to promote the health of a population/community. Assessment is illustrated when PHNs working in PHDs gather epidemiological data to determine the rate of children fully immunized against specific communicable diseases (e.g., measles, H1N1 influenza). A high immunization rate (>70%) is

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and assuring the provision of health care when otherwise unavailable.18 Continuing with the immunization exam- ple, PHD PHNs refer college students to their primary care provider, college health center, or local health de- partment to obtain needed immunizations.

Public Health Interventions A useful conceptual framework for understanding how a health department provides population-based care is the Intervention Wheel, which was introduced in Chapter 2.21

The Intervention Wheel depicts 17 PHN interventions provided on the individual, community, or systems level to affect the health of individuals and families that make up the community.

PHD PHNs usually provide several types of interven- tions to address a single issue and these interventions may be directed at different levels of care. The Interven- tion Wheel model depicts three levels of care: (1) indi- vidual, (2) community, and (3) systems.21 For example, interventions for reducing tobacco use can be provided for all three levels of care. On the individual level, a PHD PHN may counsel a pregnant woman about ways to stop smoking. A community-level intervention may be used to have an impact on more smokers through group edu- cation. The PHD PHN may teach tobacco cessation classes that target teens. Nurses working in PHDs also direct interventions at the systems level, which affects the health of the populations and may have the greatest

318 U N I T I I I n Public Health Planning

needed to provide a community level of immunity (herd immunity) to protect the population (see Chapter 8).19

Another example of the application of core functions by PHNs in PHDs is their involvement in writing and implementing policies that require immunizations for entry into day care, schools, and colleges to help ensure that herd immunity level is obtained for the protection of students, staff, and families. If the rate is lower, PHNs assure immunization services are provided by mobiliz- ing community partners to target specific groups that have low immunization rates and by providing easily accessible immunizations in pediatric clinics and schools. This example demonstrates the role of PHD PHNs in assessment, assurance, and policy develop- ment to decrease the risk of communicable disease transmission in their community. Underlying these three functions is the assumption that the PHN work- ing in the PHD will provide ethical and moral leader- ship in providing public health services as outlined by the Public Health Leadership Society20 (Box 13-1).

Essential Services The core functions of a PHD are further delineated in the 10 essential public health services that illustrate to legis- lators and the general public what public health does (see Chapter 1) (Fig. 13-4). For example, the assurance func- tion is further defined in the essential public health serv- ice of linking people to needed personal health services

• Public health should principally address the fundamental causes of disease and requirements for health, aiming to prevent adverse health outcomes.

• Public health should achieve community health in a way that respects the rights of individuals in the community.

• Public health policies, programs, and priorities should be developed and evaluated through processes that ensure an opportunity for input from community members.

• Public health should advocate and work for the empow- erment of disenfranchised community members, aiming to ensure that the basic resources and conditions neces- sary for health are accessible to all.

• Public health should seek the information needed to implement effective policies and programs that protect and promote health.

• Public health institutions should provide communities with the information they have that is needed for deci- sions on policies or programs and should obtain the community’s consent for their implementation.

• Public health institutions should act in a timely manner on the information they have within the resources and the mandate given to them by the public.

• Public health programs and policies should incorporate a variety of approaches that anticipate and respect diverse values, beliefs, and cultures in the community.

• Public health programs and policies should be imple- mented in a manner that most enhances the physical and social environment.

• Public health institutions should protect the confidential- ity of information that can bring harm to an individual or community if made public. Exceptions must be justified on the basis of the high likelihood of significant harm to the individual or others.

• Public health institutions should ensure the professional competence of their employees.

• Public health institutions and their employees should engage in collaborations and affiliations in ways that build the public’s trust and the institution’s effectiveness.

BOX 13–1 n Principles of the Ethical Practice of Public Health

Source: (18)

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potential for improving health-care outcomes. For ex- ample, in considering a population, intervening on the systems and policy levels to levy tobacco taxes is likely more effective for tobacco cessation at a community level than individually counseling people to quit smoking22

(see Chapter 11). What does intervening at a systems level mean?

For at least 10 years, the Tobacco Control Research Branch of the National Cancer Institute studied a trans- disciplinary initiative to explore systems thinking approaches and methods in tobacco prevention and control, resulting in a 2007 monograph titled Greater Than the Sum: Systems Thinking in Tobacco Control.23

The complexity involved in systems thinking was dis- cussed, for example, by presenting a framework for investigating the social ecology of tobacco use. The mul- tiple factors at play included actions of the tobacco in- dustry, regulatory systems (smoke-free laws, taxation levels), and the tobacco use control subsystem (quit lines, social marketing, multilevel networks).24,25 One can address any of these factors from a systems perspective.

Ideally, PHD PHNs and community partners work to- gether to implement the core functions, essential services, and public health nursing interventions to ultimately

meet the Healthy People 2030 (HP 2030)-proposed vision of a “society in which all people achieve their full potential for health and well-being across the life span.”26 To help illustrate how this is done, the next section describes how a PHD implements core functions, essentials services, and interventions to address high infant mortality rates in their community (Fig. 13-5).

C H A P T E R 1 3 n Health Planning for Local Public Health Departments 319

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 13-4 Essential services and core functions of public health. (From the Public Health Functions Steering Committee, 1995. Retrieved from http://www.health.gov/ phfunctions/public.htm)

w SOLVING THE MYSTERY The Case of the Dying Babies Public Health Science Topics Covered: • Assessment • Epidemiology • Surveillance • Rates

Health problems are identified in a variety of ways, often simultaneously. In hypothetical Beach County, the death of a 5-month-old infant of a 14-year-old mother was highly publicized in the local media, and community members were outraged that this occurred in their “backyard.” A nurse leader at the PHD was asked to convene a community work group to assess the issues, especially because this was not viewed as an isolated case, and to make recommendations for addressing infant mortality in her community.

The nurse leader decided to begin by conducting an assessment on the population level. Community health assessments (see Chapter 4) are ongoing activities by PHDs, and formal community health as- sessments are usually conducted every 3 to 5 years.25

There are several frameworks for conducting a com- munity health assessment, including the Community Health Assessment and Group Evaluation tool (CHANGE) (see Chapters 4 and 5). Beach Health Department selected the Mobilizing for Action Through Planning and Partnerships (MAPP) because of its emphasis on a community-driven process facili- tated by the PHD.25 This framework, which consists of four different types of assessments, allows commu- nities to apply strategic thinking to prioritize public health issues and identify resources to address them (see Chapters 4 and 5). In this case, the PHD was very concerned about the infant mortality issue and decided to focus its assessment on a specific popula- tion: mothers and babies. Because a comprehensive assessment was due in approximately 2 years, this phase was viewed as a narrower perspective for identifying the issues surrounding the infant mortality problem.

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320 U N I T I I I n Public Health Planning

Local health departments

Partners in the local public health system: •Churches •Civic groups •Community centers •Corrections •Drug treatment •Economic development •Elected officials •Emergency medical services/Hospitals •Environmental health •Employers •Federally funded community health centers •Fire department •Health care providers •Home health •Laboratory facilities •Mass transit •Mental health •Nursing homes •Schools •Parks and recreation •Police •Tribal health •And many more!

“A society in which all people live long, healthy lives” – Healthy People, https://www.healthy people.gov/2020/ About-Healthy-People

Core Functions • Assessment • Assurance • Policy Development 10 Essential services • Monitor health status • Diagnose and investigate health problems and health hazards • Inform, educate & empower people about health issues • Mobilize community partnerships • Develop policies & plans • Enforce laws & regulations • Link people to needed services & assure provision of services • Ensure a competent workforce • Evaluate effectiveness, accessibility & quality of health services • Research for new insights and innovative solutions Public Health Nursing Interventions • Surveillance • Disease & Health Event Investigation • Case Finding • Outreach • Screening • Referral & Follow-up • Case Management • Delegated Functions • Health Teaching • Counseling • Consultation • Collaboration • Coalition Building • Community Organizing • Advocacy • Social Marketing • Policy Development & Enforcement

Inputs Strategies

Vision: A healthy and safe community where individuals can thrive and prosper Mission: Collaborate with community partners to promote and assure high quality,

accessible health and human services for local residents

Outcomes

Figure 13-5 Framework for the delivery of population-focused health services on the local level. (Created by B. Little and S. Bulecza, 2013.)

There were several steps involved in the assess- ment, all exhibiting evidence of the essential services. The nurse leader contacted the state department of health and arranged for training on MAPP, thus assur- ing a competent workforce, the eighth essential public health service. A MAPP committee was formed to guide the health planning process, with broad repre- sentation of the community and local public health system including community members, nurses, and health-care providers from the local hospital, schools, and private practices. Elected officials were asked to join as well as a pregnant woman and teen mothers.

This committee is an example of the fourth essential public health service: mobilizing community partner- ships to identify and solve health problems. The assessment was initiated by the PHD in this case, bringing not only a public health perspective to the issue but also a governmental legitimacy and sense of urgency.

The committee began with a brainstorming activity to formulate a shared community vision and values statements to guide the community-driven planning process. A timeline was established, and a preliminary plan was written that identified the work to be done.

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C H A P T E R 1 3 n Health Planning for Local Public Health Departments 321

As explained in Chapter 4, MAPP is divided into four assessments:25

1. The Community Themes and Strengths As- sessment provides a deep understanding of the is- sues that residents feel are important by answering the open-ended questions about what is important to the community. In this case, it might involve some key informant interviews or focus groups as- sessing the strengths and problems surrounding the care of mothers in the community.

2. The Local Public Health System Assessment focuses on the organizations and entities that con- tribute to the public’s health. In this case, it would be important to assess the organizations providing services to mothers and babies.

3. The Community Health Status Assessment identifies priority community health and quality of life issues. It includes identifying the indicators fo- cused on maternal-child health and gathering sec- ondary and primary data related to these indicators.

4. The Forces of Change Assessment focuses on identifying forces such as legislation, technology, and other impending changes that affect the context in which the community and its public health system operate. In this case, a key question was focused on the impending changes regarding funding for maternal-child services in the county.

The members of the core steering committee di- vided themselves according to interest or expertise into one of four groups. The nurse and the PHD epi- demiologist provided support to each of the subcom- mittees. This assessment illustrates how the PHD implements the essential services of monitoring health status to identify, diagnose, and investigate health prob- lems and health hazards in the community.

During the next several months, subcommittees met on a regular basis and periodically reported on progress and findings to each other. For example, the Forces of Change subcommittee reported on a newly funded grant for the development of a federally funded health center in a neighborhood where there was a high infant mortality rate. The Community Health Status subcom- mittee asked the PHD epidemiologist for additional vital statistics and geographic information systems (GIS) data, described later in this chapter, and assistance with ana- lyzing the rate of infant mortality and teen births by ZIP code, race, and age. The committee also gathered secondary data from the state and county Behav- ioral Risk Factor Surveillance System (BRFSS)

survey data about high-risk behaviors as well as county data about neonatal mortality, infant mortality, per- centage low birth weight, percentage very low birth weight, percentage of prenatal care initiated in the first trimester, percentage of mothers who smoke, and the prevalence of sudden infant death syndrome (SIDS). BRFSS is a behavioral and noncommunicable disease surveillance system sponsored by the Centers for Disease Control and Prevention (CDC).26 The surveys are conducted via land line telephones and recently expanded to include cell phones. The Community Themes and Strengths Assessment group decided to focus on a series of listening or focus groups with mi- nority residents and youth, whereas the Local Public Health System Assessment group focused on identify- ing resources within the community addressing health concerns. They conducted an Inventory of Resources (see Chapter 4).

After the subcommittees completed their assess- ments, the nurse leader compiled the results and pre- pared a presentation and agenda for the next MAPP committee meeting. The report consisted of county- specific data, health status compared with state objectives, trends, disparities, assets, and summary con- clusions. The results showed that the infant mortality rate was 9.6 deaths per 1,000 live births compared with 7.1 for the state. There were racial differences, also: a rate of 12.7 deaths per 1,000 live births for African Americans and a rate of 6.2 for the white population. Only 68.4% of the African American population re- ceived prenatal care in the first trimester compared with 80% for the total population. Fifteen percent of pregnant women smoked in Beach County compared with 12% statewide. The percentage of low birth weight was much higher for the minority population (12%) compared with that of the white population (7.8%). Low birth weight was similar to the state findings. The teen birth rate was 71 per 1,000 live births compared with 67 per 1,000 live births only 2 years earlier.

The core committee met to review the data. Com- munity issues were discussed and a list of four issues were identified and arranged by priority. In Beach County, some of the issues directly related to infant mortality were delayed prenatal care, increased low birth weight, high birth rates among teens, and tobacco use during pregnancy. Each issue was further re- searched for best practices, and goals and strategies were developed. In addition, the committee estab- lished a community goal for reducing infant mortality to 6 per 1,000 live births within 3 years.

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Local Health Department Activities In 2016, PHDs were surveyed by NACCHO to identify not only structure but also function and capacity of local PHDs. The role of PHDs has changed during the past century and has been shaped by historical events. The events of September 11, 2001, brought to the forefront an awareness of the role of PHDs in disasters. The recent natural disasters in the United States including hurri- canes, wildfires, and floods as well as manmade tragedies such as mass shootings have emphasized the necessity of public health services to an even greater degree.

The following section describes a contemporary view of the activities of PHDs and recognizes that separating out activities solely performed by local health departments is indeed difficult. The 2016 NACCHO survey asked PHDs to report those activities performed only by the PHD, those done in concert with the state, and those done by contracting out to other members of the public health system. The 10 most frequent activities and services pro- vided by PHDs directly are found in Table 13-1.12 It is clear that more than three-fourths of PHDs provide these serv- ices. Other services are provided through contractual re- lationships with other organizations such as lab services, by other governmental agencies (animal control), or through nongovernmental organizations (NGOs). The contractual agreements are one way for PHDs to assure that needed health services are available to its citizens.29

There are five categories used to summarize the major activities of PHDs:30

1. Environmental health services 2. Data collection and analysis: health and vital

statistics 3. Individual and community health 4. Disease control, epidemiology, and surveillance 5. Regulation, licensing, and inspection

322 U N I T I I I n Public Health Planning

This MAPP example illustrates the PHD role in conducting community assessments, facilitating health planning, and collaborating with partners to target high- priority issues. During the next year, the MAPP com- mittee entered the action cycle and sought funding from public and private donors to establish a Nurse- Family Partnership27,28 community health program with nurse home visits for low-income, first-time mothers. Through administration of the home visitation program, the PHD addressed the essential service of linking people to needed personal health services and assuring the provision of health care when otherwise unavailable.

n EVIDENCE-BASED PRACTICE The Nurse-Family Partnership Model for Providing Home-Visiting for Low-Income, First-Time Mothers and Their Children

Practice Statement: Nurses provide prenatal and child health education, care coordination, and life coaching during home visits that begin during pregnancy and continue through the child’s second birthday. Targeted Outcome: Improved prenatal health, fewer childhood injuries, fewer subsequent pregnancies, increased intervals between births, increased maternal employment, improved school readiness Evidence to Support: Randomized controlled trials and economic analysis suggest improved long-term outcomes for mothers and children in the nurse-family partnership home visitation program. Nurse-family partnership programs are available in 43 states and participate in a web-based data collec- tion and evaluation system that allows programs to measure progress toward meeting nurse-family part- nership benchmarks for maternal and child health outcomes. Recommended Approaches: The nurse-family relationship is the cornerstone of the home- visiting program that is based on a client-centered, strengths-based approach to support personal and family functioning. Nurses are equipped with tools, education, and resources to improve family out- comes. The nurse-family partnership agency provides the infrastructure to ensure high quality implementa- tion and ongoing program evaluation in local communities.

Sources: 1. Nurse-Family Partnership.27 (2018a). Overview. Retrieved

from https://www.nursefamilypartnership.org/wp- content/uploads/2017/07/NFP_Overview.pdf

2. Nurse-Family Partnership.28 (2018b). Research trials and outcomes. Retrieved from https://www.nursefamily partnership.org/wpcontent/uploads/2017/07/NFP_ Research_Outcomes_2014.pdf

3. Nurse-Family Partnership.29 (2018c). Nurses and mothers. Retrieved from https://www.nursefamily partnership.org/wpcontent/uploads/2017/07/NFP_ Nurses_Mothers.pdf

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Environmental Health Services Environmental health services are focused on ensuring that communities have safe water, safe food, and sanitary environments. For example, local health de- partments located near beaches are responsible for conducting periodic water sampling to ensure that the water does not contain high levels of contaminants or bacteria. If bacteria or contaminants are found at levels out of the normal range that pose a risk to persons swimming at the beach, then local health departments have the authority to close the beach until levels return to an acceptable range.

Environmental services are the backbone of public health infrastructure in developed countries and have eliminated such problems as cholera and diarrheal dis- ease. In fact, in 1940, environmental sanitation was viewed as a minimum function of local health depart- ments to address proper public and private water sup- ply systems and sewage disposal, restaurant inspections, insect and rodent control, housing inspections, and environmental complaints.3 The development of solid waste management is interesting. At the time of the infectious epidemics in the 1800s, funding was not

available for a regional approach to solid waste man- agement, which resulted in municipal approaches to dealing with the problems.30 Today, solid waste man- agement is largely handled by municipalities and oper- ated by private companies.

Environmental concerns today are often seen as the responsibilities of both local and state agencies as well as other local governmental agencies or NGOs. In the most recent NACCHO 2016 survey, food safety educa- tion and vector control activities were most often con- nected with the PHD as the resource. State health departments were most often listed as resources for indoor air quality, groundwater protection, noise pollu- tion, hazardous waste disposal, air pollution, and radia- tion control.12 With any of these activities, there is a great deal of variability, with many agencies often assuming some level of responsibility. In another study examining the combined roles of state and local health departments, the PHD was typically found to oversee private water supplies and septic systems.31 A list of typ- ical environmental concerns is found in Box 13-2 (see also Chapter 6).

C H A P T E R 1 3 n Health Planning for Local Public Health Departments 323

TABLE 13–1 n Percentage of Public Health Department Jurisdictions With 10 Most Frequent Activities and Services

Available Through PHDs Directly

Percentage of Activity or Service Jurisdictions

Adult Immunization Provision

Communicable/Infectious Disease Surveillance

Child Immunizations Provision

Tuberculosis Screening

Food Service Establishment Inspection

Environmental Health Surveillance

Food Safety Education

Tuberculosis Treatment

Schools/Day Care Center Inspection

Population-Based Primary Prevention: Nutrition

Source: (12)

90%

93%

88%

84%

79%

85%

77%

79%

74%

74%

• Inspect and investigate food service and outlets, from wholesale to retail.

• Inspect and investigate wastewater management systems, either community or individual homes (septic tanks).

• Inspect and investigate solid and hazardous waste site investigations.

• Conduct sanitary surveys of potential or existing water systems and watersheds.

• Conduct investigations of facilities, institutions, and licensed establishments.

• Inspect swimming pools and recreational facilities. • Investigate hazardous materials and radiation hazards

or spills. • Manage occupational health and safety programs. • Investigate and analyze potential toxic exposures. • Conduct community education and provide expertise

on environmental conditions. • Assure animal and vector control including rabies

surveillance. • Address sanitary nuisances.

BOX 13–2 n Environmental Health Services Potentially Provided by Public Health Departments

Source: Centers for Disease Control and Prevention. (2014). Environmental public health performance standards. Retrieved from http://www.cdc.gov/nceh/ehs/ envphps/Docs/EnvPHPSv2.pdf

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Data Collection and Analysis: Health and Vital Statistics Most data collection and analysis activities are state-level functions, although the process of collecting statistics be- gins at the local level. Vital statistics are data collected regarding births, deaths, marriages, and divorces. Data are forwarded to the state, where they are compiled and sent to the CDC National Vital Statistics System.32 This is the oldest process for sharing public health data across governmental agencies. It requires that these agencies share standards and procedures so that the National Center for Health Statistics can monitor, store, and disseminate the nation’s official vital statistics.

When a baby is born, the hospital completes a birth form that is submitted to the PHD. The PHD then issues the official birth certificate to the child’s parents. The birth record includes data that can be found on the offi- cial birth certificate such as the birth date, place of birth, and parents’ names. It also includes a wealth of other in- formation not listed on the official birth certificate. These data include neonatal outcomes, risk factors related to adverse outcomes, and protective factors related to pos- itive outcomes.33 Information is included on parental de- mographic and behavioral variables such as age, level of education, race, and maternal use of alcohol, tobacco, and other drugs during pregnancy. Information is also collected related to the pregnancy and delivery, such as the number of prenatal visits, when the trimester prena- tal care began, and the type of delivery. Finally, data are collected on the newborn. In addition to weight, head circumference, and length, data are collected on infor- mation related to the neonate’s weeks of gestation and congenital defects. Data are obtained from the medical record, the health provider of record, and from family members. These data provide important information needed to understand population-level trends related to birth and facilitates evaluation of how well Healthy People objectives are being met.

Likewise, PHDs collect mortality data based on the in- formation obtained from death records. The first part of the document includes basic demographic information about the deceased that is completed by the funeral direc- tor or other person in charge of internment. This same person is also responsible for filing the certificate with the registrar in the location where the death occurred. The medical examiner or coroner certifying the death com- pletes the second section of the document that specifies the cause of death. The certificate contains essential de- mographic data as well as date and time of death, where the death occurred, and the primary cause of death. Like the birth record, the death record includes more data than

what is contained in the death certificate. The death record includes information about the conditions that contributed to the death, history of tobacco use, race, and other variables.33 These data are used to evaluate mortality trends at the population level. If the death was due to an injury, information related to the injury is also collected. Data regarding causes of death are compiled from death certificates and used to determine specific disease, injury, or mode of death rates within communities and the state. For example, death data are used to determine the num- ber of cancer deaths in a community and to help during community assessments and health system planning. For infants aged less than 1 year, linked birth and death cer- tificate files provide information to determine significant risk factors that influenced fetal mortality.

Another required vital record is fetal death. Fetal death is a spontaneous intrauterine death of a fetus at any time during pregnancy. Again, the record includes a section to complete the basic information related to parental demographic data, time and date of delivery, and gender of the fetus. The second section relates to the cause of death and conditions contributing to the fetal death. The data not only provide an official record of the death, the additional information also facilitates population-level assessments and program planning. Most states report fetal deaths of at least 20 weeks of ges- tation and/or birth weight of 350 grams or more.

Although states are responsible for the analysis of most data, the PHD is typically responsible for the col- lection and analysis of data regarding the Reportable Dis- eases category.12 In addition, in some states with local boards of health, morbidity data are sometimes collected at the local level.

There are many uses for vital statistics. Birth and death certificates are used to legally establish citizenship and ob- tain drivers licenses and Social Security cards, and are required in the probating of a will. Vital statistics help genealogists conduct family research and establish ties be- tween individuals. Most importantly, vital statistics from a global perspective are vital to understanding the health of populations, determining life expectancy, and helping to guide interventions aimed at improving health.

324 U N I T I I I n Public Health Planning

n CULTURAL CONTEXT The Future of the Public’s Health in the 21st Century35

“A healthy community is a place where people pro- vide leadership in assessing their own resources and needs, where public health and social infrastructure and policies support health, and where essential public

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Individual and Community Health The role of some PHDs in assuring the health of popula- tions sometimes involves providing direct individual care as well as providing care at the community level. Direct individual care provided by PHDs can include a variety of services such as prenatal and well-baby clinics, clinics for communicable diseases (e.g., tuberculosis [TB], sexually transmitted infections [STIs]), primary care clinics, school health services, and vaccination clinics. Comparing PHDs, there is probably no area within the local public health sys- tem with as much diversity in programs for the provision of direct individual care. Some health departments provide no direct care at all, whereas others provide a wide variety of care. The City of Cincinnati Health Department, for example, includes home-care services, pharmacy, school nursing, and multiple clinics.34 Other PHDs contract out services or the services are available only through NGOs.

At one time, the provision of primary care services (see Chapter 15), particularly to underserved and eco- nomically disadvantaged citizens (and areas), was part of the mainstream of public health activities. There has been a national effort to have governmental public health services return their attention to more population-based public health services.35 Consequently, a transfer of services has taken place, and this has been done in many different formats. PHDs have contracted or networked with their local hospital system to fund primary care services as a more cost-effective alternative to emergency room visits for the same service. In some cases, the most recent 2016 NACCHO survey found that certain activi- ties were exclusively provided through contracts:12

• Laboratory services, 14% • HIV/AIDS treatment, 9% • HIV/AIDS screening 8% • STI screening, 8% • STI treatment 7% • Population-based tobacco prevention services, 7% • TB treatment, 7%

• Cancer screening, 6% • Oral health, 6%

Another process for PHDs to obtain funding for providing care is through federally qualified health centers. Federally qualified health centers (FQHC) are funded through the Health Resources and Service Administration (HRSA) under section 330 of the Pub- lic Health Service Act. There are multiple benefits for having a FQHC, including enhanced reimbursement from Medicare and Medicaid. FQHC must serve an underserved area or population, offer a sliding fee scale, and provide comprehensive services.36 They must also have an ongoing quality assurance program with a governing board of directors.

Maternal and Child Health Maternal-child services have traditionally been a key component of any PHD (see Chapter 17). This goes back to the early 20th century as evidenced in the APHA mis- sion statements.9,10 The overall goal of maternal-child services has been to improve the health of mothers and children through the delivery of preventive interven- tions. Although these efforts have changed over time, they are still an important aspect of PHD services. PHDs either provide these services directly or help to link their constituents with available services. For maternal-child health services overall, the 2016 NACCHO survey shows that the current services provided most often in PHDs are Women, Infants, and Children (WIC) services (66%), MCH home visits (60%), and family planning (53%).12 The importance of these programs was under- scored by HRSA in 2017 when they provided $342 mil- lion in funding to 55 states, territories, and nonprofit organizations through the Maternal, Infant, and Child- hood Home Visiting Program.37 The money is awarded to provide evidence-based home visiting services to preg- nant women and families with young children from birth until entry into kindergarten.37

One example of a comprehensive maternal-child health program is Healthy Start, which focuses on reducing in- fant mortality and low birth weight. The Healthy Start ini- tiative was signed into law in 1991 and is funded through HRSA.38 In this program, nurses working at PHDs engage in multiple services from group-level activities, such as health education for expectant and new mothers to indi- vidual care in prenatal and well-baby clinics or home vis- iting. Healthy Start addresses multiple issues such as providing adequate prenatal care, meeting basic health needs, reducing barriers to access, and empowering clients. There is growing evidence that these programs have been successful in reducing infant mortality rates,

C H A P T E R 1 3 n Health Planning for Local Public Health Departments 325

health services, including quality health care, are avail- able. In a healthy community, communication and col- laboration among various sectors of the community and the contributions of ethnically, socially, and eco- nomically diverse community members are valued. In addition, the broad array of determinants of health is considered and addressed, and individuals make in- formed, positive choices in the context of health- protective and supportive environments, policies, and systems.”

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increasing access to early prenatal care, and providing community services to lower preterm delivery and inci- dence of low birth weight.39

In addition to maternity care programs, PHDs provide nutritional support for pregnant women and children through the federally funded WIC programs.12 WIC was established as a pilot program in 1972, made permanent in 1974, and is administered at the federal level by the Food and Nutrition Service of the U.S. Department of Agriculture. In April 2014, there were 9.3 million women, infants, and children enrolled in the WIC program, and almost three-quarters of them (74.2%) were at or below the poverty line.40 Nurses and dietitians work collabora- tively to provide nutrition counseling and breastfeeding support.

Family planning programs are a third example of ma- ternal-child health care in PHDs. Family planning pro- grams in the United States were implemented in the 1960s and 1970s in response to the reproductive needs of populations at some level. Family planning grew out of federal legislation, originally the Office of Economic Opportunity in 1965 and then the enactment of Family Planning Services and Population Research Act of 1970, or Title X.41 Family planning programs did not share a universal acceptance upon their inception. These pro- grams coincided with the approval of oral contraceptives and were associated with the changing societal attitudes regarding sexual activity. Many communities initially re- sisted the provision of these services. Over the years, lev- els of acceptance of these programs have risen and fallen, with most of the controversy focusing on whether there should be public financing of family planning. This demonstrates the role that public opinion plays in public health policy. Core family planning services have centered on individual counseling regarding contracep- tive method selection, annual physicals, and follow-up services.

An example of comprehensive family planning serv- ices can be found at the New York State Department of Health website: http://www.health.state.ny.us/health_ care/medicaid/program/longterm/familyplanbenprog. htm. The purpose of the program is to “…increase access to confidential family planning services and to enable teens, women, and men of childbearing age to prevent and/or reduce the incidence of unintentional pregnancies.”42

School Health School health is concerned with assuring the health of the entire school population, students, and staff

(Chapter 18). As the health-care expert in the school setting, school nurses take a leadership role in devel- oping policies and providing clinical care activities that promote health and assure safe health-care practices in a nonmedical setting. School nursing services include medication administration, immunizations, and re- sponse to emergencies during medical crises and dis- asters. School-based screening programs identify children with potential health problems associated with vision, hearing, and obesity that may be barriers of academic achievement. When underlying medical conditions are detected, the school nurse will make re- ferrals to specialists and other health-care providers and conduct follow-up activities to assure access to care and adherence to treatment (see Chapter 18).43 By delivering case management services, school nurses co- ordinate care and help families locate resources for medical, social, and mental health services. School- based wellness programs are designed to address com- mon childhood issues such as obesity; dental caries; asthma; and health education needs related to growth and development, communicable diseases, and sexual- ity. Funding and staffing patterns for school nurses employed by PHDs and school districts vary between states and counties. Not every school has a school nurse, and for the 5% of children without health insur- ance, the school nurse may be their only access to health screening and care.44

Immunization and Health Protection Programs Providing immunizations to protect a population from communicable diseases is an essential component of public health. Vaccinations are mandated by school dis- tricts and in some cases employers, especially in health- care settings. If an outbreak of disease occurs, the PHD is often the entity responsible for mass immunization, as occurred in the H1N1 influenza outbreak in 2009.

Immunization practices have been in place for cen- turies. For example, variolation (the exposure of well per- sons to material from an infected person such as pus or scabs) was used to prevent smallpox. Although variola- tion resulted in death for some, the overall death rate re- lated to smallpox fell. In the late 1700s, Edward Jenner, a physician, discovered that milkmaids exposed to cow- pox, a less deadly disease, developed immunity to small- pox. The term vaccine comes from the word vaca, which means “cow” in Latin. He exposed a small boy to pus from a milkmaid with cowpox and then exposed him to smallpox. The boy did not contract the disease. Although it took a while for vaccinations to enter into mainstream

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practice, by 1800, the use of vaccines spread across Eu- rope and to other parts of the globe.45 Today, through the successful efforts of a global campaign, smallpox has been eradicated worldwide.

Immunizations are a major responsibility of PHDs. PHDs manage the program requirements associated with administration and utilization of vaccines for pre- ventable diseases. Immunization administration may be integrated into the PHD clinical service program. Immunization program components include ordering and tracking vaccines, ensuring that individual immu- nizations are recorded into registries if used in that ju- risdiction, and coordinating special immunization clinics. In addition, immunization programs coordinate the Vaccine for Children program. This program facil- itates the delivery of adequate supplies of vaccines to health-care providers who provide services and vac- cines to children. This ensures that all children, regard- less of ability to pay, have access to immunizations for vaccine-preventable diseases.

In addition to childhood vaccination programs, PHD immunization programs provide services to other populations at risk. This includes international travel vaccinations and the rabies postexposure prophylaxis vaccine. PHDs often work with community partners to provide clinics where anyone can come for immuniza- tions for diseases such as influenza. These types of clin- ics help increase a community’s level of immunity from these diseases. PHNs often coordinate the planning and implementation of these open clinics. Schools have often been a place where immunizations and other child-focused services are provided. Through these ac- tivities, not only does the PHD protect individuals who receive the vaccine, but it also reduces the overall preva- lence of communicable diseases, thus reducing the op- portunity for the spread of disease and providing herd immunity (see Chapter 8).

Role of Nurses in Providing Individual Care Nurses are often employed by PHDs to provide the direct individual care at the clinics. The nursing care provided often includes one-on-one clinical interventions such as vaccinations, prenatal care, and dispensing of medica- tions for STIs or TB. In addition, PHNs often provide home visiting and a focus on high-risk families as part of these services.46 Establishing working relationships with these families has been a strength of public health nurs- ing, and home visitations by registered nurses has been associated with improved outcomes.47,48 A recent qualitative study illustrates that PHNs are flexible and

especially adept at recognizing the sociohistorical factors that influence families while simultaneously focusing on strengths and chaotic life situations.46

Community Health Primary Prevention Efforts As described in Chapter 2, primary prevention is a strategy used to avert occurrences of illness or injury. In addition to services focused on individuals, PHDs provide a wide array of primary prevention services aimed at health pro- motion and protection at the community level. Health promotion includes activities that focus on improving the ability of individuals and populations to practice healthy living. Health protection interventions involve protecting individuals and populations from disease by improving the immune system through vaccination for individuals or providing protective barriers such as the use of personal protective equipment by health-care providers.

Health promotion efforts at the community level in- clude educating about healthy lifestyles. Examples of health education include HIV prevention education for teens or Back to Sleep campaigns for reducing SIDS. The Back to Sleep campaigns began in 1994 and focused on educating parents, caregivers, and health-care providers about ways to reduce the risk of SIDS. Since the cam- paign started, there has been a 50% reduction in SIDS deaths, and the percentage of babies being placed on their backs to sleep has increased significantly.49 Unfor- tunately, health promotion interventions and the latest advances in primary prevention and screening activities are less likely to be delivered among vulnerable popula- tions having lower socioeconomic status, racial and eth- nic minorities, and people living in rural and remote areas of the United States.50,51 Culturally relevant, evidence- based health promotion interventions can be especially useful for improving health and reducing disease risk among at-risk populations.

Communication is a key component to the provision of primary prevention programs for PHDs. In today’s world, there are multiple methods for communicating important health data and health promotion informa- tion. For example, during the H1N1 influenza outbreak in 2009, PHDs used multiple methods to communicate with communities regarding the locations where im- munizations were available as well as potential public health priorities associated with vaccinating certain groups, such as pregnant women and children, before the general population. Technological strategies tradi- tionally used to communicate public health messages in- clude television, radio, newspapers, and sending printed information home with school-aged children. During

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this century, PHDs are increasingly using computer- mediated technologies, including social media such as YouTube, Twitter, and Facebook, as effective avenues for providing health information.

A Healthy Community: Sarasota, Florida: An ex- ample of a community-wide health promotion initiative is the Community Health Improvement Partnership in Sarasota, Florida.52 The Sarasota PHD led this partner- ship and brought together many stakeholders from the community. Partners included community organiza- tions, individual citizens, and health-care professionals. Together, they identified evidence-based strategies and chose those that had the most applicability to their com- munity. These strategies were multipronged; that is, they used different venues and methods to engage the com- munity in a healthier lifestyle. They developed Healthy Living kiosks throughout the community. These kiosks provided information about health insurance options, health-care resources, and consumer tips. Users were able to access a county health scorecard that provided data on health status and linkage to a community pharmacy where those who were uninsured or underinsured could have access to needed medications. The development of this required that PHD nurses understand the basics of public health science so that they could develop an intervention based on the community priority health needs and service gaps within the community. It also required understand- ing implementation and evaluation strategies to determine whether the kiosk was an effective intervention. PHDs provide essential leadership and skills in the promotion of the health of the community they serve.

Disease Control, Epidemiology, and Surveillance Disease Control Because communicable disease is a primary concern of PHDs, their ability to provide necessary training and services surrounding communicable diseases is important. This will vary depending on the size of the public health system. Many small health departments gather private physician case reports and provide the information to a regional or central office for analysis and compilation. Larger PHDs may have internal units devoted to the communicable disease program, includ- ing core epidemiological services and biostatistical analysis of the determinants of diseases in animals and man.

Tuberculosis Management: TB management is one of public health’s oldest communicable disease programs for one of the oldest diseases noted in history. With the advent of effective therapies, elimination of TB was

considered a possibility. However, this remarkable or- ganism continues to be a major threat to public health both globally and in the United States. A resurgence of the disease is sometimes now accompanied by a rise in multidrug-resistant TB (MDR-TB), which is defined as TB resistant to the two most effective first-line therapeu- tic drugs, isoniazid and rifampin. The CDC established a task force to develop a plan of action to address the issue of drug-resistant TB.53 TB is a complex interaction of medical, societal, behavioral, and economic factors.

Because of the communicability of TB, PHDs and PHNs take a leading role in both the prevention and treatment of TB. One approach by state and PHDs is to provide TB clinics that include screening assessment, di- agnosis, and treatment components. Efforts at the local, state, and national levels have resulted overall in a re- duced incidence of TB.54 It is possible that TB could be eliminated in the United States. It will take continued ef- forts on the part of PHDs to continue to screen those at risk, assess persons with positive screens, and treat those with active disease.

328 U N I T I I I n Public Health Planning

l APPLYING PUBLIC HEALTH SCIENCE The Case of the Tuberculosis Neighborhood Investigation Public Health Science Topics Covered:

• Surveillance • Disease investigation • Prevention

Sara Johnson, communicable disease nurse at Creek County Health Department, received a call from the infection control nurse at Providence Hospital report- ing a newly diagnosed case of TB in a hospitalized pa- tient. The patient was a 40-year-old male (Mr. H.) who worked for the grounds maintenance unit of the local college. Sara advised the infection control nurse that she would come to the hospital that day to review the chart and interview the patient. She remembered that there had been another university employee from the same unit diagnosed a year ago and that all of the em- ployees had received appropriate TB testing. No other cases had been identified during that case follow-up, so she was somewhat concerned about the appearance of this case.

Sara learned the following from her chart review and patient interview:

• The patient had only been employed with the univer- sity for 4 months.

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C H A P T E R 1 3 n Health Planning for Local Public Health Departments 329

• He lived with his girlfriend and her two daughters. • He presented with classic TB symptoms—night

sweats, weight loss, no appetite, and persistent cough. His sputum was acid-fact bacillus (AFB) posi- tive and his chest x-ray was indicative of pulmonary TB. Pharmacological therapy was consistent with the CDC’s TB treatment protocols. He would be hospi- talized in isolation until three consecutive AFB sputum smears were negative.

• Names of coworkers, family, and friends were obtained.

• He wasn’t sure whether he had been around anybody with TB. One of his neighbors had been sick a few months ago with similar symptoms, but the patient didn’t know what the neighbor had.

Based on this information, Sara ruled out that he had been exposed from the previous case and began to prioritize the contact list for follow-up. What crite- ria should Sara use to prioritize the contacts? To answer this question and the rest of the questions related to this case, see Box 13-3.53–55

Sara contacted the patient’s girlfriend and arranged for her and her daughters to come to the health de- partment for evaluation and tuberculin skin testing be- cause they had closest contact with the patient. Then, she contacted the patient’s supervisor to advise him of the situation and the need to interview coworkers. To minimize disruption to the workers, Sara agreed to bring a small interview team to the site to conduct evaluations and provide tuberculin skin testing. She agreed to go back to the site to read the tests 72 hours later so the workers would not have to miss work.

After about a week, Sara received notification from the hospital that the patient was ready for discharge and he would need to be on directly observed therapy for several months to ensure adherence to the medication regimen. It was decided that Sara would meet the patient at his home the next day after he was discharged. During this meeting, Sara reviewed activity restrictions and the medication plan, explained the process of directly observed therapy, and told him that she would be coming to his home each day to watch him take the medications.

Two key issues in the treatment of TB are the length of treatment and the emergence of MDR-TB. For the most part, MDR-TB occurred because of nonadherence to recommended treatment. That is, those with an active infection did not complete the

required drug regimen, and the bacterium became resistant to the drug. Today, the World Health Organization (WHO) recommends treatment to continue for 6 months or longer.56 In the United States, the populations most at risk for active TB are often those hardest to reach (e.g., foreign-born persons from countries with a high TB prevalence, those exposed to persons with active TB, those who are immune-compromised, persons with alcohol or substance abuse, and persons with latent TB infections [they are infected but do not have active disease]).55 To assist with this, nurses working in PHDs often function as case

1. How is the infectious period for TB defined? 2. What is the difference between active and latent

TB infection? 3. What factors had an impact on the decision to

initiate a contact investigation? What are the goals of a contact investigation?

4. What groups are most at risk for TB infection? How should the nurse prioritize contact for follow-up?

5. What factors would require a contact be placed on chemoprophylaxis?

6. Directly observed treatment is a resource-intensive intervention. How should the nurse prioritize contacts for it?

7. If the neighborhood had been different, what other interventions could have been used to reach the neighbors?

8. Discuss challenges with and solutions for providing directly observed therapy with someone who is homeless.

9. This investigation may attract the attention of the media. What strategies should the nurse use for communicating with the media?

The following are recommended sources for answering the preceding questions:

Centers for Disease Control and Prevention. (2005). Guidelines for the investigation of contacts of persons with infectious tuberculosis. Morbidity and Mortality Weekly Report, 54(RR15), 1-37. Retrieved from http:// www.cdc.gov/mmwr/preview/mmwrhtml/rr5415a1. htm CDC TB Web site: http://www.cdc.gov/tb/

BOX 13–3 n Questions Related to the Neighborhood Investigation of Tuberculosis

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approved, she identified a Saturday for the event, recruited health department staff to assist, and solicited other health department programs to participate or provide information or give-away items. The event was very successful, with many of the neighbors receiving testing and information. Fortunately, no new cases were identified, but several people with latent TB infection were placed on prophylaxis therapy.

Sexually Transmitted Infections: Communities also rely on PHDs to provide surveillance, prevention, and treatment of STIs. Most STIs are reportable diseases and the PHD reports each case to the state department of health, which then reports to the CDC. PHDs also com- bine clinical care for the diagnosis and treatment of the disease with a strong field investigative component needed to identify and notify contacts. Many PHDs conduct primary prevention programs, especially with teens, aimed at preventing STIs with outreach to schools, correctional facilities, bathhouses, and other community settings.

There is an enormous burden of STIs in the United States with more than 1.5 million cases of chlamydia in- fections, 468,514 cases of gonorrhea, 27,814 cases of syphilis, and 39,782 new cases of HIV infection in 2016.58 With a disease burden of this magnitude in ad- dition to the costs for society, the investigative role of PHDs is critical. The investigation of STIs includes three steps: 1. Screening for possible infection. Persons with sus-

pected STIs are screened using appropriate tests. Depending on the STI, a positive screen may require further laboratory confirmation.

2. Treatment. 3. Screening all known sexual contacts of the person

with the confirmed STI and treat if necessary. PHNs often conduct the follow-up investigations for

persons diagnosed with an STI such as syphilis. The PHN follows up with the patient to ensure he has adhered to the prescribed medications and obtain contact informa- tion for any sexual contacts before he was treated.

In 2012, NACCHO published a policy statement about the prevention and control of STIs.59 PHDs have traditionally fulfilled a critical role in this arena but there is a current threat to this coverage because of dwindling funds. In 2011, 57% of PHDs had to make cuts in their core programs, which in some cases resulted in an elim- ination of programs and services.60

330 U N I T I I I n Public Health Planning

managers to help ensure that patients with TB follow through with the required treatment. Nurses apply their holistic approach to care and are able to appreciate and mitigate factors that exist in the patient’s life.

A key function of TB case management is ensuring adherence to the medication regimen. As noted ear- lier, one of the oldest ways of ensuring adherence is through the use of directly observed therapy, in which the patient takes the required daily medication in the presence of a public health-care provider, often a nurse. Either the patient goes directly to the PHD, or the public health-care provider comes to the patient’s home. As with other areas of health care, technology has been developed that enhances the ability to monitor medication adherence. One example is a medica- tion electronic monitoring system, which tracks adherence to a medication regimen through a chip placed in the medication bottle cap that up- loads the date and time the cap is opened.57 Other examples include use of text messaging, phone call reminders, and e-mail reminders.

With case management under way in the case of Mr. H., it was critical to continue to investigate for additional exposures. In trying to determine how he may have been exposed, Sara began reviewing pre- vious cases. She found that the case from the prior year lived on the same street as the patient, and there had been several contacts who could not be found. She also determined that there had been another earlier case on the same street. Based on this information, should Sara expand the contact investigation? Sara determined that there needed to be outreach to all the neighbors to ensure there were not any additional undiagnosed cases. She decided to learn more about the neighborhood by conducting a windshield survey of the street. Her findings were the following: (1) The street was isolated and not connected to a larger neighbor- hood; (2) there were about 15 houses; (3) there appeared to be children of all ages living on the street; and (4) there were several open, grassy areas on the street.

Sara decided that a community information fair and testing clinic would be the best way to provide outreach services to the neighbors without com- promising the patient’s privacy. She developed the plan and presented it to the health department administrator for approval. After the plan was

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C H A P T E R 1 3 n Health Planning for Local Public Health Departments 331

l APPLYING PUBLIC HEALTH SCIENCE The Case of the Unintended Death Public Health Science Topics Covered:

• Surveillance • Community Organizing • Advocacy • Policy Development and Enforcement

Community members seek assistance from PHDs for a variety of health issues. In hypothetical Beach County, Mrs. McIntire requested a meeting with the director of the PHD to discuss her concern about misuse of prescription drugs by young adults in the county. She shared that her son accidently died from an overdose of prescription pain drugs and alcohol. She explained her concern that this was a growing problem in the county and that she wasn’t the only person in the community that lost their son or daughter. The PHD director listened to her and agreed to take a look at the data on prescription drug misuse and overdose.

Data analysis by the PHD epidemiologist revealed the county had the highest rates in the state. The director called a meeting with Mrs. McIntire and the PHD leader- ship team to discuss what to do next. They decided to bring up the issue at the next meeting of the Behavioral Health Consortium to see if they were aware of this dis- turbing trend and if this was something that the Consor- tium could address as a community concern. The Consortium consisted of a variety of community agen- cies including social services, law enforcement, health care, mental health, substance use, as well as advocacy groups. During the meeting, Mrs. McIntire told the story of her son’s accidental overdose. PHNs from the Healthy Start program also shared stories of young fami- lies with at-risk substance use issues and children who were orphaned as a result of their parent’s unintentional deaths. The epidemiologist presented data on mortality rates related to substance abuse.

The Numbers Deaths caused by drugs, medications, and biological substances are categorized as unintentional poisoning. Mortality data showed the county experienced a 22% increase in unintentional poisonings, which was twice that of the state rate. The crude death rate for ages 15-29 due to unintentional poisoning steadily increased over the previous 4 years from a rate of 7.3 (N=3) to 52.9 (N=24). In comparison to the state rate, the county rate was statistically higher (52.9 county, 15.7 state). In addition, there was a 90% increase in patients admitted

to local Addictions Receiving Facilities for prescription drug misuse over the previous 4 years. The epidemiol- ogist explained these rates reflect the health and well- being of this age group as well as the quality of the health care available, particularly mental health and substance abuse counseling.

Collaboration The Consortium members agreed to work together to address this urgent public health problem by col- laborating with local governments and organizations to identify existing services and designate available resources. The next steps involved making a similar presentation to local hospital administrators. The medical examiner in attendance reported that approx- imately 40% of the deaths were related to the com- bined use of prescription opioids and alcohol. The hospital agreed to join in the effort to educate the public, police, and local governmental officials and to develop solutions.

Meetings with the Sheriff’s Office revealed that several new pain management clinics had recently opened in the county and were thought to be con- tributing to increased access to prescription pain medications. The Sheriff reported a pattern of illegal drug use and distribution associated with clinics that dispense narcotics on-site and were trafficked by users from other states. Increased arrests for drug trafficking near some of these clinics were also re- ported. Addressing the source of prescription drugs through regulation of pain management clinics was proposed as a solution and presented to the Board of County Commissioners.

Implementation of Strategies The PHD Consortium and community partners imple- mented an array of strategies to address the epidemic including the following.

The PHD and Sheriff’s Office worked with the county government to develop legislation that regu- lated pain clinics and placed a moratorium on new oc- cupational licenses for pain management clinics. The PHD Community Health Improvement Project (CHIP) worked with local hospitals and medical providers to present educational programs for clinicians regarding the epidemic. This included the need to inform patients of the risks of opioids and to monitor them closely. A public awareness campaign was implemented by CHIP to inform the public of the problem and available com- munity resources. A local database was established to

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Epidemiology and Surveillance Emerging or Re-emerging Infections: As we move

ahead into the 21st century, PHDs will face two signif- icant challenges: increased mobility due to globaliza- tion and emergence of new human pathogens. Joshua Lederberg coined the term emerging infections for the IOM in 2000.61 Morens and Fauci (2013) define emerg- ing infections as “diseases that are recognized in the human host for the first time “and re-emerging dis- eases as “diseases that historically have infected hu- mans, but continue to appear in new locations or in drug-resistant forms, or that reappear after apparent control or elimination (p. 1).”62

Our global society and rapid transit around the globe can result in the rapid dissemination of pathogens throughout the world. Examples of emerging infectious diseases include the 2009 H1N1 pandemic influenza, se- vere acute respiratory syndrome (SARS), and Middle East Respiratory Syndrome (MERS). SARS originated in China and was rapidly spread across the globe as infected persons traveled by airplane from China to other coun- tries. As noted in Chapter 8, SARS infected 8,437 people with a case fatality rate of 9.6% (813 people).63 Other recent examples of rapid global dissemination of a com- municable disease are that of H1N1 and H7N9 (see Chapter 8). For H1N1, the Mexican government dissem- inated a wide array of pamphlets and posters to alert their population about mitigating the impact of H1N1 by slowing the transmission and lowering mortality.64

Besides globalization, there are a number of factors that influence emergence and re-emergence of disease. These factors include climate/natural disasters, economic devel- opment/urbanization, poverty, limited or lack of public health services, war/social disruption, and famine. Popu- lation movement has been associated with the re- emergence of Dengue virus and West Nile virus in the United States and Caribbean countries. Likewise, the global emergence of antibiotic resistant organisms is linked to antibiotic overuse and inadequate antibiotic steward- ship, medical tourism, and economic globalization. This has resulted in multidrug-resistant TB and malaria, and bacterial diseases like vancomycin-resistant enterococci.62

Zoonotic Diseases: Another challenge in the modern world is the growth of cities and suburbia, which en- croaches on the natural habitats of wild animals. Across the United States, deer, fox, and other wild animals are now living in suburbia and even in urban settings, in- creasing the likelihood of the transmission of zoonotic disease. Zoonotic diseases are diseases transmitted from animals to humans in the community through direct con- tact, as with rabies, or indirect contact through a vector,

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track narcotic prescriptions by patients and providers. This was later implemented on the state level.

Conclusion The rates of unintended poisonings declined over the next few years. This case illustrates the role of the PHD in:

• Being open to early identification of problems facing the community

• Using data to validate the depth and breadth of the problem

• Bringing key community leaders to work together to create a comprehensive array of solutions

• Utilizing public health practices related to surveil- lance, community organizing, policy development, and advocacy (see Box 13-4 for discussion questions)

1. What are the rates for deaths caused by unintentional poisoning in your community?

2. How is your local and state PHD involved in address- ing the issue? What other community agencies are addressing the issue?

3. What types of substance abuse services are provided in your community? Is there a waiting list for inpatient services?

4. How is the community informed about the problem and community resources?

5. What types of prevention programs are offered in the schools?

6. What are the challenges to addressing substance abuse in your community?

7. Would the strategies in Beach County work in your community? Review the literature on best practices for addressing the opioid crisis. What additional strategies would you recommend for your community?

The following are recommended sources:

1. National Institute on Drug Abuse. Opioid crisis. https://www.drugabuse.gov/drugs-abuse/opioids/ opioid-overdose-crisis

2. National Institute on Drug Abuse. Opioid summaries by state. https://www.drugabuse.gov/drugs-abuse/ opioids/opioid-summaries-by-state

3. Department of Health & Human Services. National opioids crisis-help, resources & information. https:// www.hhs.gov/opioids/

BOX 13–4 n Questions Related to The Case of the Unintended Death

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such as Lyme disease65 (see Chapter 8). PHDs are called on to conduct surveillance of zoonotic disease and insti- tute prevention programs.

Rabies is a preventable viral disease of mammals usu- ally transmitted through the bite of a rabid animal such as a dog or a raccoon. Efforts from PHDs, both at the local and state levels, have reduced the incidence of rabies in the United States dramatically during the past 100 years.66

Through public health campaigns to vaccinate domestic animals, 90% of all cases reported to the CDC are now in bats and wild carnivores. Human deaths due to rabies rarely occur because of effective and early intervention with post-bite exposure prophylaxis. The PHD provides education to health-care providers; tracks and reports all known cases to the state department of health, both ani- mal and human; and works in partnership with animal control programs and veterinarians

Disaster Preparedness: An increasingly prominent role of PHDs, especially PHNs, is public health prepared- ness for responding to emergencies and disasters. Prior to the events of 2001, the preparedness functions were dictated by the regularity of events that affected the pop- ulation and the health-care systems. Southeastern coastal states regularly face hurricanes. Midwestern states con- tinually experience tornados. West Coast states are con- stantly threatened by earthquakes and fires. All have created robust emergency response systems. However, the realities of the 21st century have placed an additional responsibility on these systems because of threats caused by humans. Disaster planning programs evolved into “all hazards” planning. For example, a biological event, whether it is an anthrax attack or a widely distributed Escherichia coli contamination, calls for a concerted re- sponse action. Preparedness has five major requirements PHDs need to address (see Chapter 22):

• Preparedness • Mitigation • Response • Recovery • Evaluation

In 2002, the Bioterrorism and Emergency Readiness Competencies for All Public Health Workers was devel- oped and became the standard for ensuring the public health workforce was prepared and ready to respond to emergencies and disasters.67 As more experience has been gained through public health response and more discipline-specific competencies have been devel- oped, these initial competencies have evolved into the Public Health Preparedness & Response Core Compe- tency Model.67b The Association of Public Health Nurses

integrated this model into its 2013 The Role of Public Health Nurses in Emergency and Disaster Preparedness, Response, and Recovery position paper, which provides guidance to PHNs on how to work in a disaster or emergency.67

Preparedness functions and planning rely heavily on the use of partners and data sets to achieve success. Each community is different in the resources it can bring to bear in dealing with an emergency or disaster. Consis- tently, the PHD is looked to as the community lead, in collaboration with local emergency management, for health and medical response activities in an emergency or disaster. PHNs have key roles to play in disaster plan- ning and preparedness efforts. A key preparedness func- tion uses a basic public health nursing skill, community assessment. By knowing the aspects of the community, plans can be written to meet the unique needs of that community during an emergency or disaster. During the disaster, the PHN’s role may center on staffing emer- gency shelters for persons with special health and med- ical needs or providing tetanus immunizations in the community for persons engaged in clean-up activities. During the recovery phase of a disaster, the PHN may be assigned to go into the community to assess the current and long-term needs of the area. Identification of these needs is essential to ensure the delivery of services to the community so that normal functioning may return.

Regulation, Licensing, and Inspection Regulatory, licensing, and inspection activities are common roles for a PHD. The 2016 NACCHO survey of PHDs revealed that the areas of particular focus in PHD were food service, schools/daycare centers, swimming pools, septic systems, and smoke-free ordinances.12 Other areas in- cluded private drinking water, body art (tattoos/piercings), camps, campgrounds, and, in some cases, housing.

Public Health Department Challenges for the Future Healthy People As one thinks about the future, the objectives for HP provide some insight into the issues of importance to the functioning of local health departments. HP’s goal is to increase public health infrastructure. It is this in- frastructure that provides the foundational capacity for national, state, and local actions to prevent disease and promote health. An example of an objective is “to in- crease the proportion of tribal and state public health agencies that provide or assure comprehensive laboratory services to support essential public health services.”68

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Other objectives relate to assuring the workers’ compe- tencies, monitoring performance, and assuring practice is guided by standards. In an effort to highlight the need to strengthen the public health workforce, increased workforce diversity and reducing the shortage are critical and are reflected in the objectives added to HP 2020 that targeted public health education and competencies.

Other challenges of PHDs include issues of relevance to the public health workforce, IT, quality improvement and PHD accreditation, and PHD financing, especially as it relates to the economic recession.

Public Health Workforce Currently, there is a shortage of public health workers, and this shortage is projected to increase in the coming years. In 2016, the Association of State and Territorial Health Officials conducted a survey of state agencies. It

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n HEALTHY PEOPLE Healthy People 2020 Objectives Relevant to Public Health Department Infrastructure

Selected Objectives: PHI-1: Increase the proportion of federal, tribal, state, and local public health agencies that incorporate core competencies for public health professionals into job descriptions and performance evaluations.

PHI-2: Increase the proportion of Tribal, State, and local public health personnel who receive continuing education consistent with the Core Competencies for Public Health Professionals.

PHI-3: Increase the proportion of Council on Educa- tion for Public Health (CEPH) accredited schools of public health, CEPH accredited academic programs, and schools of nursing (with a public health or commu- nity health component) that integrate Core Competen- cies for Public Health Professionals into curricula.

PHI-4: Increase the number of public health or re- lated graduate degrees, post-baccalaureate certificates, and bachelor’s degrees awarded.

PHI- 5: (Developmental) Increase the proportion of 4-year colleges and universities that offer public health or related majors and/or minors consistent with the core competencies of undergraduate public health education.

PHI-6: Increase the proportion of 2-year colleges that offer public health or related associate degrees and/or certificate programs.

PHI-11: Increase the proportion of tribal and state public health agencies that provide or assure compre- hensive laboratory services to support the essential public health services.

PHI-12: Increase the proportion of public health laboratory systems (including state, tribal, and local)

which perform at a high level of quality in support of the 10 Essential Public Health Services.

PHI-13: Increase the proportion of tribal, state, and local public health agencies that provide or assure comprehensive epidemiology services to support essential public health services.

PHI-14: Increase the proportion of state and local public health jurisdictions that conduct a public health system assessment using national performance standards.

PHI-15: Increase the proportion of tribal, state, and local public health agencies that have developed a health improvement plan and increase the proportion of local health jurisdictions that have a health improve- ment plan linked with their state plan.

PHI-16: Increase the proportion of tribal, state, and local public health agencies that have implemented an agency-wide quality improvement process.

PHI-17: Increase the number or proportion of tribal, state and local public health agencies that are accredited. Midcourse Review: Of the 61 objectives for this topic, 2 were archived, 6 were developmental, and 53 were measurable. Of the measurable objectives, 12 met or ex- ceeded their 2020 targets, 9 improved, 4 demonstrated little or no change, 7 were getting worse, 17 only had baseline data, and 4 were informational (Fig. 13-6).68b

32.1% 13.2%

7.5%

22.6% 7.5%

Baseline only Informational Target met or exceeded Getting worse Little or no change

Healthy People 2020 Midcourse Review: Public Health Infrastructure

Figure 13-6 HP 2020 Midcourse Status of the Public Health Infrastructure Objectives.

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found an average of 14% of state health agency positions were vacant, an average of 365 positions per state health agency. There are a number of factors contributing to this shortage, including budget reductions and hiring freezes, a rapidly aging workforce whose average age was 47, and 25% of the workforce eligible to retire by 2020.69 All of these issues raise concern for PHDs as well.

The U.S. public health workforce has been of suffi- cient interest to policy makers during the past 4 decades to lead to regular efforts to enumerate it. In 1980, there was a ratio of public health workers to the general pop- ulation of 220/100,000, and in 2000 that had dropped to 158/100,000.70 Although there is an overall shortage, the critical shortage of PHNs is a threat to the public’s health and of great concern because they make up a large sector of the public health workforce.71,72 Execu- tive leadership for PHDs is also a major concern, espe- cially in light of the aging public health workforce and projected shortages.73

Core competencies for various public health workers or in specific functions have been developed to enhance the public health workforce capacity. These include the Public Health Nursing: Scope and Standards of Practice,74

Public Health Preparedness and Response Core Compe- tencies,75 Council on Linkages: Core Competencies for Public Health Professionals,76 and Competencies for Pub- lic Health Informaticians.77

Because the public health workforce comprises a broad range of educational backgrounds and training, these competencies provide a common framework for measuring and improving public health workforce skills and abilities (Box 13-5). To further support public health workforce competency, public health workers

have the ability to become certified in public health through the National Board of Public Health Examiners.78

Sustainment of the public health workforce is a major concern and is influenced by several factors. First, many of the health-care professions have experienced shortages in available workers, thus many health-care facilities are competing for the same candidates. Second, many PHD jurisdictions are located in rural or remote areas, making recruitment of qualified personnel difficult. Third, limited financial resources may make it difficult for PHDs to pro- vide compensation that is competitive with private-sector entities. Finally, there are faculty shortages within the ac- ademic setting that limit the ability of colleges and univer- sities to graduate large numbers of qualified individuals.79

Currently, there are critical PHN nursing faculty shortages that have significantly limited the exposure to and special- ization in public health nursing.80

Information Technology IT is a key infrastructure component within a PHD, from clinical records management to supporting a PHD Web site. IT is used in every aspect of operations. All persons working in a PHD use IT at varying degrees. The level of use and knowledge required is position-dependent. For example, an administrative assistant would require just basic knowledge and skills to use IT for general office functions, whereas an epidemiologist will need more ad- vanced knowledge and skills for data collection and analysis. IT is much more than just using computer equipment and programs. The field of public health in- formatics focuses on the use of IT by public health pro- fessionals. There are several definitions for public health informatics, all of which essentially define it as public health information systems and infrastructure that are population-based and used for surveillance, program outcome evaluation, quality assurance, systems analysis, and evidence-based disease management.81

In 2002, the CDC created a work group of subject matter experts to define overarching public health infor- matics competencies for all persons working in public health. These competencies focused on three areas: (1) information for public health practice, (2) use of IT by the public health professional to enhance personal performance, and (3) utilization of IT projects to im- prove PHD effectiveness.77 These competencies provide the framework to ensure that PHDs have the capacity to adequately perform in today’s technologically demand- ing environment.

Although PHDs use IT to support general business operations, new regulations and technology create new demands on PHDs to enhance IT use. Two key examples

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• Core Competencies for Public Health Workers. http://www.phf.org/resourcestools/Documents/Core_ Competencies_for_Public_Health_Professionals_ 2014June.pdf

• Public Health Preparedness and Response Core Competencies https://www.cdc.gov/phpr/documents/perlcpdfs/ preparednesscompetencymodelworkforce-version1_ 0.pdf

• PHN Scope and Standards of Practice http://www.nursesbooks.org/Main-Menu/Standards/ O—Z/Public-Health-Nursing.aspx

• Public Health Informatics Competencies https://www.cdc.gov/informaticscompetencies/

BOX 13–5 n Public Health Core Competencies

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of this are geographic information system (GIS) appli- cation and electronic health records. Both of these activ- ities have required PHDs to expand staff knowledge and hardware capacity to effectively integrate these applica- tions into daily operations.82 The use of GIS has trans- formed a number of functions within PHDs. It can be used to visualize data geographically within a designated area. For example, in a disease outbreak, the case data can be entered into a GIS program and maps can then be created to show various characteristics of the cases. An epidemiology nurse can easily identify where cases may be clustering geographically or identify density of cases through a color-coding system. Likewise, the PHN can use GIS to identify potential exposure risk from en- vironmental hazards by applying layers of demographic data to environmental data layers. GIS technology is a very effective tool for understanding the dynamics be- tween health status, health system access, and physical environment.

Regulations and requirements to move health records from paper-based systems to electronic systems have re- sulted in a paradigm shift for medical record management. PHDs have faced unique challenges in implementing these systems because public health practitioners’ health focus is much broader than that in clinical care. Public health electronic systems need to (1) integrate clinical data from all providers for public health use, such as disease surveil- lance and investigation, and (2) include expanded capacity for psychosocial, behavioral, and environmental client data collected by PHDs. The impact of electronic health record implementation affects public health systems in two ways: (1) There is a need to implement an electronic system for individual patient care, and (2) PHDs need to maintain the ability to conduct population-based core functions such as assessment, policy development, and assurance through interfaced integration of electronic data from providers. This will require public and private providers to come together to ensure electronic health record systems include a public health orientation. By ef- fectively integrating this focus, reporting duplication can be reduced and community decision making can be en- hanced through more comprehensive data availability.83

Quality Improvement and Public Health Department Accreditation The emerging areas of PHD accreditation and public health systems and services research expand our knowledge about the relationship between characteris- tics of PHDs, local public health system performance, and public health outcomes. Continuous quality im- provement initiatives are led by multidisciplinary teams

to systematically apply evidence-based practice, im- prove service delivery, and achieve the best outcomes. In the NACCHO 2016 survey of PHDs, 89% of PHDs reported conducting some type of quality improvement activities.12 The Public Health Accreditation Board has developed a national voluntary accreditation program for state and PHDs to formalize and advance quality and performance of PHDs and improve population health outcomes. In early 2018, more than 200 state and local PHDs had received national accreditation.84 Ac- credited PHDs have reported many benefits from the accreditation process. These benefits include increased transparency, stronger management processes, and in- creased ability to identify organizational weaknesses. However, the most significant benefit identified was the increased use of quality improvement information in decision making and a more robust quality improve- ment culture.85,85b

Studies show that the strongest predictor of PHD per- formance is the size of the jurisdiction population.73,85 In general, PHDs serving larger populations with greater numbers of staff and higher funding per capita perform better than PHDs serving populations of less than 50,000.2 PHD leadership structure also influences the staffing model and service focus. Bekemeier and Jones86 found there were distinct differences between programmatic service delivery and the core functions of assessment and planning in PHDs led by nurse executives and non-nurse executives. PHDs under nurse executive leadership had stronger prevention programs to address unintended pregnancy, obesity, injury prevention, immunization, and maternal-child health than non-nurse-led PHDs. How- ever, assessment and planning functions were performed less by nurse executives than by medical or nonclinical senior executives, indicating the need for additional train- ing in these areas.86

Public Health Department Financing Public health systems have historically been designed as a function of local (county or city) government opera- tions. The structure of PHDs previously described has an impact on PHD financing. The vast majority of states have county-operated systems, usually governed by local boards of health, but large metropolitan areas, such as Los Angeles or New York City, may have city structures as well. Some states (e.g., Florida) have a state-centered program with contractual agreements with counties for provision of public health services. The financing of PHD operations can become very complex, related to dispar- ities in county size, needs, and local community capabil- ities to provide services. There is an inverse relationship

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between per person expenditures and revenues and size of population served. Small PHDs have higher per per- son expenditures ($49) and revenues ($51) compared to large PHDs ($31 expenditures and $33 revenues). Due to decreasing funding, PHD per person expenditures have declined from an average of $63 in 2008 to $48 in 2016. This translates into fewer services available to pop- ulations the PHD serves.12 However, the 2016 NACCHO survey noted that more PHDs reported higher budget amounts than in any previous survey. Hopefully, this increasing revenue trend will continue.

The three primary funding streams for PHDs are fed- eral (24%), state (21%), and local (55%)12. There is not an overriding formula for any of these financing layers. However, there are guidelines developed to assure that allocations are used appropriately and may be designated for specific programs or services. These funds, often called categorical funds, are usually federal funds either directly disbursed to PHDs from the federal government through grants or received by the states and reallocated to the PHDs. Either way, budgets must show the expen- ditures by category (personnel, expenses, fixed capital) and require annual reporting back to the federal govern- ment.87 An example of this might be a PHN position that performs family planning, STI, and school-based health services. The PHN will then need to record her time spent in each service area to ensure her time is allocated to the appropriate funding source. This is a common oc- currence in PHDs; therefore, tracking systems and re- porting procedures have been developed to manage the funding reporting requirements.

A significant part of PHDs clinical service funding is through insurance billing such as Medicaid or Medicare. The amounts generated through billing will vary greatly among PHDs depending on the types of services provided and the robustness of their billing process to fully leverage the revenue return. For exam- ple, Alabama PHDs have been able to generate 29.5% of their total revenue through Medicare and Medicaid billing. Whereas, Georgia only generated 1.3% of rev- enue from Medicaid or Medicare billing.91 Maximizing billing opportunities allows PHDs to utilize other pub- lic funds to provide more clinical services to uninsured or underinsured populations.

The 2016 NACCHO survey of PHDs found a loss of 43,000 employees since 2008. The economic recession had a significant impact on jobs, budgets, and programs. Many of the PHDs reported that the cuts are most often in local and state funding, and that the dramatic cuts threaten the general use funds that enable PHDs to respond to urgent community needs not covered by specific disease grants.10

One way the PHDs have survived these changes has been through one-time funding for diseases, such as the H1N1 influenza outbreak and Ebola virus prepared- ness. What is needed, however, is stable, long-term funding. The key to funding the PHD in the future will be the ability to clearly articulate its mission. Policy makers will need to support PHDs by ensuring an ade- quate investment in public health by assuring that pre- vention dollars do go to PHDs to help build their capacities. This is critical, considering the important role that PHDs play in keeping communities safe. “[PHDs] have been described as the country’s ‘best kept secret.’ As one PHD official states, ‘Unless there is an outbreak, no one even knows that we exist. We operate diligently and quietly in the background, keeping our community healthy and safe.’”88

Additional Challenges Keeping the community healthy and safe is key. Although there is a growing emphasis on emerging or re-emerging communicable diseases or on disaster preparedness, a major threat to the health of populations is noncommu- nicable disease. PHDs often lack structure as well as money to address noncommunicable disease and con- tributing factors like obesity. This challenge raises issues of what strategies to use in addressing multiple health is- sues as well as how to finance new initiatives. Some health departments provide an exemplar of what can be done. In a local collaboration between the PHD, the school board, and city of Anchorage, a multiyear project was ini- tiated to reduce childhood obesity using a broad set of policies. These policies included increased weekly physical education in public schools and day care centers, no sodas sold during school hours, healthier school lunches, and increased healthier food options in campus vending machines as well as a public awareness campaign on the consequences of childhood obesity. Because of these efforts, elementary and middle school obesity rates de- clined by 2.2%.89

In an effort to engage communities more effectively within a limited funding environment, 12 Utah PHDs collaborated to initiate a month long social media cam- paign to promote healthy family meals and family dinner together. They used a variety of social media platforms with videos, competitions, and a designated interactive Web site. Some of the results were an average of 121 in- dividuals visited the Web site daily, Facebook likes had reached 1,454, and Twitter followers were 255 by the month’s end. The authors estimate between 10% and 12% of the target population was reached. Additionally, the campaign was cost effective at an overall cost of

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the services being provided and the level of expert- ise needed.

• Challenges for PHDs include the shortage of public health workers, using IT to enhance care, quality improvement, and financing efforts in the future.

• PHD accreditation is a voluntary program to advance quality and performance of PHDs.

• The mission of public health is to assure conditions in which people can be healthy. Although there are emerging and re-emerging infections from a global concern that affects population health, noncom- municable diseases, which are additional challenge for PHDs, are the major threats to the health of populations.

27 cents per engagement.90 The PHDs built their capacity by relying on categorical funding supplemented by flex- ible funding and sometimes the use of state revenue as well as creative community collaborations.

n Summary Points • The basic mandate of the PHD is to protect and im-

prove health in partnership with the community. • PHDs are organized by three major delivery modes:

centralized system, decentralized system, and shared or mixed system.

• The PHD workforce is interdisciplinary, with nurses making up 17% of it.

• The 10 most frequent activities and services available through the direct services of the PHD are: adult immunization provision, communicable disease surveillance, child immunization provision, TB screening, food service establishment inspection, environmental surveillance, food safety education, TB treatment, schools/day-care center inspections, and population-based nutrition services.

• PHDs also work in collaboration with the state or contract with other partners to fulfill the core functions of public health.

• The major responsibilities of PHDs lie with environ- mental health services, data collection and analysis (which includes the collection of vital statistics), assurance of individual and community health, communicable diseases, epidemiology and surveil- lance, and licensing.

• Nurses’ roles within health departments include providing primary prevention efforts, making health policy, designing health programs, and pro- viding care at the individual and community levels. The role of the nurse in a PHD varies depending on

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n CELLULAR TO GLOBAL Multidimensional interventions, such as those previ- ously discussed, are frequently implemented by PHDs in communities across this country. However, middle- to low-income countries are challenged to implement even the most basic interventions, such as directly observed therapy for TB control or bed net distribu- tion for malaria prevention, due to the lack of re- sources and public health infrastructure. Lack of a robust public health workforce with high quality train- ing and strong leadership at local and national levels significantly affects a nation’s ability to provide basic services or response to expanding disease threats.92

t CASE STUDY Collaborating with Community Partners

Learning Outcomes At the end of this case study, the student will be able to:

• Investigate the role of PHDs in community assessment and planning for health needs of the community.

• Describe the structure and services of your PHD. • Identify the major partners involved in community

health planning.

You have been asked by your hospital to be the rep- resentative on a community needs assessment. This will involve measuring and evaluating health status and developing collaborative programs that will address the health needs of your community. You realize that you need to learn more about your local health department and the population that it serves. Research your local health department and answer the following questions:

1. What type of public health system is used in your state (centralized, decentralized, mixed, shared)?

2. What type of jurisdiction does your PHD serve (city, town, county, multiple county, district, region)?

3. Is there a local board of health and, if so, what is its role and function?

4. What types of assessment and planning are under way? Who are the main community partners?

5. Where is the PHD located? Are there branch offices?

6. What types of services are provided? What services exist that (a) ensure a safe environment; (b) provide

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REFERENCES

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preventive and/or primary health care; (c) monitor, detect, and investigate disease outbreaks; (d) track and record health data about the community; (e) promote healthy behaviors; and (f) prepare the health department to support communities during times of disasters or emergency?

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35. Institute of Medicine. (2003). The future of the public’s health in the 21st century. Washington, DC: National Academies Press.

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37. Maternal and Child Health Bureau. (2017). HRSA awards $342 million to support families through the maternal, infant and early childhood home visiting program. Retrieved from https://www.hrsa.gov/about/news/press-releases/ hrsa-awards-342-million-miechiv-program.html.

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45. Riedel, S. (2005). Edward Jenner and the history of smallpox and vaccination. BUMC Proceedings, 18, 21-25.

46. Browne, H., Reimer, J., MacLead, M., & McLellan, E. (2010). Public health nursing practice with “high priority” families: The significance of contextualizing “risk.” Nursing Inquiry, 17, 27-38.

47. Sama-Miller, E., Akers, L., Mraz-Esposito, A., Zukiewicz, M., Avellar, S., Paulsell, D., & DelGrosso, P. (2016). Home visiting evidence of effectiveness review: Executive summary. Washington, D.C.: Office of Planning, Research and Evalua- tion, Administration for Children and Families, U.S. Depart- ment of Health and Human Services.

48. Olds, D., Robinson, J., O’Brien, R., Luckey, D., Pettitt, L., Henderson, C., … Talmi, A. (2002). Home visiting by para- professionals and by nurses: A randomized, controlled trial. Pediatrics, 110, 486-496.

49. Safe to Sleep. (n.d.). National Institutes of Health, Eunice Kennedy Shriver National Institute of Child Health and Human Development. Retrieved from http://www.nichd.nih.gov/sids/.

50. Havranek, E.P., Barr, D.A., Cruz-Flores, S., Davey-Smith, G., Dennison-Himmelfarb, C.R., Lauer, M.S., … Yancy, C.W. (2015). Social determinants of risk and outcomes for cardio- vascular disease: A scientific statement from the American Heart Association. Circulation, 132(9), 873-898

51. Howard, G., Kleindorfer, D.O., Cushman, M., Long, D.L., Jasne, A., Judd, S.E., … Howard, V.J. (2017). Contributors to the excess stroke mortality in rural areas in the United States. Stroke 48(7), 1773-1778.

52. Sarasota County Health Department. (n.d.). Community health improvement partnership. Retrieved from http:// www.chip4health.org/whatwedo/index.htm.

53. LoBue, P., Sizemore, C., & Castro, K.G. (2009). Plan to combat extensively drug-resistant tuberculosis: Recommen- dations of the federal Tuberculosis Task Force. Morbidity and Mortality Weekly Report, 5(RR03), 1-43. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5803a1. htm?s_cid=rr5803a1_e.

54. Jeffries, C., LoBue, P., Chorba, T., Metchock, B., & Kashef, I. (2017). Role of the health department in tuberculosis preven- tion and control-Legal and public health considerations. Microbiology Spectrum, 5(2). doi:10.1128/microbiolspec. TNMI7-0034-2016.

55. Centers for Disease Control and Prevention. (2016). Tuberculosis. Retrieved from http://www.cdc.gov/tb/.

56. World Health Organization. (2009). Treatment of tuberculo- sis guidelines. Retrieved from http://whqlibdoc.who.int/ publications/2010/9789241547833_eng.pdf.

57. van Heuckelum, M., van den Ende, C., Houterman, A., Heemskerk, C., van Dulmen, S., & van den Bemt, B. (2017). The effect of electronic monitoring feedback on medication adherence and clinical outcomes: A systematic review. Plos ONE, 12(10). https://doi.org/10.1371/journal.pone.0185453.

58. Centers for Disease Control and Prevention. (2017). Sexually transmitted disease surveillance, 2016. Atlanta, GA: U.S. Department of Health and Human Services.

59. National Association of County and City Health Officials. (2010). Statement of policy prevention and control of sexually transmitted infections. Retrieved from http://www.naccho. org/advocacy/positions/upload/09-10-Prevention-and- Control-of-STI.pdf.

60. National Association of County and City Health Officials. (2012). Statement of policy-Sexually transmitted infections. Washington, DC: Author.

61. Davis, J.R., & Lederberg, J. (Eds.). (2000). Public health systems and emerging infections: Assessing the capabilities of the public and private sectors. Washington, DC: National Academies Press.

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62. Morens, D.M., & Fauci, A.S. (2013) Emerging infectious diseases: Threats to human health and global stability. PLoS Pathog, 9(7): e1003467. doi:10.1371/journal.ppat.1003467

63. World Health Organization. (2003). Summary of probable SARS cases with onset of illness from 1 November 2002 to 31 July 2003. Retrieved from http://www.who.int/csr/sars/ country/table2004_04_21/en/index.html.

64. Stern, A.M., & Markel, H. (2009). What Mexico taught the world about pandemic influenza preparedness and commu- nity mitigation strategies. JAMA, 302(11), 1221-1222.

65. Centers for Disease Control and Prevention. (2018). National center for emerging and zoonotic infectious diseases. Retrieved from https://www.cdc.gov/ncezid/index.html.

66. Centers for Disease Control and Prevention. (2011). Public health importance of rabies. Retrieved from https://www. cdc.gov/rabies/location/usa/index.html.

67. Centers for Disease Control and Prevention. (2002). Bioter- rorism & emergency readiness: Competencies for all public helath workers. Retrieved from http://training.fema.gov/ emiweb/downloads/BioTerrorism%20and%20Emergency% 20Readiness.pdf.

67b. Association of Schools of Public Health (ASPH). (2010). Public health preparedness & response core competency model. Retrieved from http://www.asph.org/userfiles/ PreparednessCompetencyModelWorkforce—Version1.0.pdf

67c. Association of Public Health Nurses. (2013). The role of public health nurses in emergency and disaster preparedness, response, and recovery. Retrieved from http://www.achne. org/files/public/APHN_RoleOfPHNinDisasterPRR_ FINALJan14.pdf.

68. Department of Health and Human Services. (2014). Healthy People 2020 topics & objectives-public health infrastructure. Retrieved from https://www.healthypeople.gov/2020/ topics-objectives/topic/public-health-infrastructure.

68b. National Center for Health Statistics. (2016). Chapter 35: Public health infrastructure. Healthy People 2020 midcourse review. Hyattsville, MD: National Center for Health Statistics.

69. Association of State and Territorial Health Officials. (2017). Profile of state public health (Vol. 4). Retrieved from http:// www.astho.org/Profile/Volume-Four/2016-ASTHO- Profile-of-State-and-Territorial-Public-Health/.

70. Merrill, J., Btoush, R., Gupta, M., & Gebbie, K. (2003). A history of public health workforce enumeration. Journal of Public Health Management, 9(6), 459-470.

71. Beck, A.J., Boulton, M.L., & Coronado, F. (2014). Enumera- tion of the governmental public health workforce, 2014. American Journal of Preventive Medicine, 47(5S3), S306-S313.

72. Beck, A. J., & Boulton, M. L. (2016). The public health nurse workforce in U.S. State and local health departments, 2012. Public Health Reports, 131, 145-152.

73. Little, R.G., Greer, A., Clay, M., & McFadden, C. (2016). Profile of public health leadership. Journal of Public Health Management and Practice, 22(5), 479-481.

74. American Nurses Association. (2013). Public health nurs- ing: Scope and standards of practice (2nd ed.). Silver Spring, MD: Author.

75. Centers for Disease Control & Prevention. (2010). Public health preparedness & response core competency model. Retrieved from https://www.cdc.gov/phpr/documents/ perlcpdfs/preparednesscompetencymodelworkforce- version1_0.pdf.

76. Public Health Foundation. (2014). Council on linkages: Core competencies for public health professionals between acade- mia and public health practice. Retrieved from http://www. phf.org/resourcestools/Documents/Core_Competencies_ for_Public_Health_Professionals_2014June.pdf.

77. U.S. Department of Health and Human Services. (2009). Competencies for public health informaticians. Retrieved from http://www.cphi.washington.edu/resources/ PHICompetencies.pdf.

78. National Board of Public Health Examiners. (n.d.) Credentialing public health leaders. Retrieved from: https:// www.nbphe.org/.

79. Council on Linkages Between Academia and Public Health Practice. (2016). Recruitment and retention: What’s influ- encing the decisions of public health workers? Washington, DC: Public Health Foundation.

80. Collier, J., Davidson, G., Allen, C.B., Dieckmann, J., Hoke, M.M., & Sawaya, M.A. (2010). Academic faculty qualifica- tion for community/public health nursing: An association of community health nursing educators position paper. Public Health Nursing, 27(1), 89-93.

81. Baker, E.L., Fond, M., Hale, P., & Cook, J. (2016) What is “informatics”? Journal of Public Health Management & Practice, 22(4), 420-423.

82. Centers for Disease Control and Prevention. (2016). GIS and public health at CDC. Retrieved from https://www. cdc.gov/gis/index.htm.

83. Tomines, A., Readhead, H., Readhead, A., & Teutsch, S. (2013). Applications of electronic health information in public health: Uses, opportunities & barriers. EGEMS, 1(2). DOI: http://dx.doi.org/10.13063/2327-9214.1019.

84. Public Health Accreditation Board. (2018). Public health department accreditation. Retrieved from http://www. phaboard.org./

85. Laymon, B., Shah, G., Leep, C., Elligers, J. & Kumar, V. (2015). The proof’s in the partnerships: Are affordable care act and local health department accreditation practices influencing collaborative partnerships in community health assessment and improvement planning? Journal of Public Health Management and Practice, 21(1), 12-17.

85b. Kronstadt, J., Meit, M., Siegfried, A., Nicolaus, T., Bender, K., & Corso, L. (2016). Evaluating the impact of national public health department accreditation-United States, 2016. Morbidity and Mortality Weekly Report, 65, 803-806.

86. Bekemeier, B., & Jones, M. (2010). Relationship between local public health agency functions and agency leadership and staffing: A look at nurses. Journal of Public Health Management and Practice, 16(2), E8-E16.

87. Leider, J., Resnick, B., Sellers, K., Kass, N., Bernet, P., Young, J., & Jarris, P. (2015). Setting budgets and priorities at state health agencies. Journal of Public Health Manage- ment and Practice, 21(4), 336-344.

88. National Association of County and City Health Officials. (2010). Research brief: Local health department job losses and program cuts. Retrieved from http://www.naccho.org/ topics/infrastructure/lhdbudget/upload/Job-Losses-and- Program-Cuts-5-10.pdf.

89. National Collaborative on Childhood Obesity Research. (2015). Signs of progress in childhood obesity declines-site

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summary report Anchorage, Alaska. Retrieved from https:// www.nccor.org/downloads/CODP_Site%20Summary% 20Report_Anchorage_public_clean1.pdf.

90. Lister, C., Royne, M., Payne, H., Cannon, B., Hanson, C. & Barnes, M. (2015). The laugh model: Reframing and rebrand- ing public health through social media. American Journal of Public Health,105(11), 2245-2251.

91. Meit, M., Knudson, A., Dickman, I., Brown, A., Hernandez, N., & Kronstadt, J. (2013). An examination of public health

financing in the United States. (Prepared by NORC at the University of Chicago) Washington, DC: The Office of the Assistant Secretary for Planning and Evaluation.

92. Yamey, G. (2012). What are the barriers to scaling up health interventions in low- and middle-income countries? A quali- tative study of academic leaders in implementation science. Globalization and Health, 8, 11. https://doi.org/10.1186/ 1744-8603-8-11.

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Chapter 14

Health Planning for Acute Care Settings Kathleen Ballman, Christine Savage, and Mary Nicholson

LEARNING OUTCOMES

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

KEY TERMS

1. Describe the relationship between acute care and population health.

2. Identify the role of population-level data in the development of the discipline of critical care.

3. Discuss the relevance of cohort studies to the delivery of tertiary care.

4. Explain the application of health planning in an acute care setting.

5. Recognize the basic steps in the quality improvement process.

6. Identify key infection control issues related to the acute care setting.

Acute care Acute coronary syndrome

(ACS) Acute myocardial ischemia Cardiopulmonary

resuscitation (CPR) Critical care nursing Critically ill/injured patients Door-to-balloon time Electronic medical record

(EMR)

Epidemiology Health care-associated

infections (HAIs) Hospital-associated

pneumonia (HAP) Hospital discharge rate Hospital recidivism Institutional review board International Classification

of Diseases, 9th Revision (ICD9)

International Classification of Diseases, 10th Revision (ICD10)

Major diagnostic category (MDC)

Multiple drug-resistant organisms

Plan-Do-Study-Act (PDSA) cycle

Patient populations Polio

Performance improvement

Quality improvement Sepsis ST-elevation myocardial

infarction (STEMI) Surgical site infection (SSI) Survival rate Ventilator-associated

pneumonia (VAP)

n Introduction Sixty-one percent of the nursing workforce works in an acute care setting.1 Acute care is care provided during a severe episode of illness, following surgery, or following a traumatic injury. Acute care usually occurs in a hospital setting and requires skilled care provided by health-care providers. Acute care is provided for a short time during the severe episode and may be followed by chronic care in the home or a long-term care facility.2

Acute care occurs mostly at the tertiary prevention level (see Chapter 2), and the focus of the care is to pre- vent further morbidity and reduce disability related to the disease or injury. The majority of the care is clinical rather than environmental or even behavioral. Although an effort is made during the hospital stay to provide ed- ucation on behavioral changes that will increase the chances of return to a healthier state and reduce the

chances of death or disability, the primary focus of the hospital stay is direct clinical interventions.

Hospitals provide care to persons who are acutely ill, many of them critically ill. Adults who seek care in a hos- pital setting require highly skilled nurses competent to provide care to the individual addressing the acute episode of illness or aftermath of an injury. It would seem at first glance that the public health sciences have little to con- tribute to the acute care setting. However, the high level of care now available to patients experiencing an acute episode of illness or injury is based on a clear understand- ing of the natural history of disease that evolved out of cohort and case control studies (see Chapter 3). Our knowledge of the effectiveness of interventions is based on the findings from rigorous clinical trials (see Chapter 3). These research designs have their basis in epidemiology.

Nurses have a long history of applying population- level research and an understanding of determinants of

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health to their delivery of care at both the macro (popu- lation) level and the micro (individual) level. As hospitals strive to meet criteria for accreditation and recognition of excellence, the role of the staff nurse in improving pa- tient outcomes includes actively applying public health science to the evaluation and improvement of the care they provide.

The Acute Care Setting and Population Health Often, the distinction between the community/public health nurse (PHN) and the nurse working in a hospital is based on the concept of direct and indirect care as pre- sented in the Essentials of Doctoral Education for Ad- vanced Nursing Practice.3 However, that distinction becomes blurred because many nurses who define them- selves as PHNs provide direct care to individuals, for ex- ample, administering flu vaccines, whereas hospital-based nurses frequently tackle problems from a public health perspective, for example, reducing the rate of health care- associated infections (HAIs) (see following section on HAIs) or improving targeted patient outcomes for a par- ticular population.

If, instead of a dichotomous concept of direct and in- direct care, nursing practice is viewed across the contin- uum of care from micro/individual health to macro/ population health, it is easier to demonstrate the applica- tion of public health science to nursing practice in acute care settings. Nurses in acute care settings are continu- ously involved in efforts to improve care for the popula- tions they serve, not just for each individual. If nurses on a unit are working on a performance improvement proj- ect, they have moved along the continuum to look at an issue at the group level, the group they serve. Development of an understanding of the patient data they collect for the project requires the application of epidemiology such as computing discharge rates, establishing odds ratios (see Chapter 3), or looking at HAI rates. In most hospitals, the performance improvement committee provides frequent updates on care issues within the hospital and evidence to demonstrate whether efforts to address specific problems have resulted in improved patient outcomes.

The challenge is differentiating the term population used in public health and the term population used in a hospital setting. In Chapter 1, the term was defined as a mass of people that make up a definable unit to which measurements pertain. Chapter 1 explains that population health occurs within the context of the social, economic, cultural, and environmental influences on populations

and, thus, on individuals. This implies that, from a public health perspective, population includes persons who share a similar social setting, culture, and/or geographical com- munity over a period of time. In a hospital setting, popu- lations are instead grouped based on a particular health issue or a hospital unit with individuals rapidly entering and exiting the population. For example, within the hos- pital the concern may be the diabetic population being treated at the hospital, or it may be the patient population on a specific unit. Thus, the term population within a hos- pital context does not usually refer to a group of persons who share other attributes other than being admitted to the hospital on a certain unit and/or having a specific diagnosis.

344 U N I T I I I n Public Health Planning

w SOLVING THE MYSTERY The Case of the Nurse Who Wanted to Know “Who, Why, What, Where, and When?” Public Health Science Topics Covered: • Assessment • Epidemiology

• Computing rates • Comparing rates with national rates

• Health planning • Conducting a setting-specific assessment • Population-level conclusions: Identifying priorities

A large midwestern teaching hospital contracted with a college of nursing to have a faculty member with research experience provide mentorship to the staff engaged in nursing practice research. A nurse researcher who was also a PHN, Cheryl, was assigned to the project. She found that the hospital had a history of nurses on the units initiating small nursing-practice studies; they also reviewed the literature to examine the evidence related to a particular nursing intervention. These projects were conducted by individual nurses and typically culminated in a brief report on their findings from the literature. The projects did not nec- essarily result in a change in practice. There was no in- formation on the effect any of these activities had on patient outcomes. The newly appointed chief nursing officer (CNO), Janet, stated that she wanted to change the process to seek evidence that demonstrated whether these studies or projects resulted in a change in how nursing care was delivered and if there was a positive impact on patient outcomes. Janet asked Cheryl how to change the process so it was clear what

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patient outcomes should be targeted, how to plan change, and how to evaluate the impact of the change.

Cheryl explained to Janet that a good starting point was to take a public health perspective. When Janet asked her to explain, Cheryl replied that a health- planning model that included an assessment phase and health program phase was the best approach (Chapters 4 and 5). Cheryl said the best place to begin was to answer the questions related to who, why, what, where, and when; that is, to find out who was being admitted to their hospital, why were they being admitted (diagnosis), what were their outcomes, where were they coming from, and whether there was a vari- ation in these variables over the months and years.

As explained in Chapter 4, there are different types of community/population assessments. Cheryl pro- posed to Janet that the nursing department conduct a setting-focused assessment. In addition, Cheryl explained that this assessment would be conducted using an epidemiological model; that is, the assessment would focus on quantifying hospital-based data using existing data sources and would then compare these data with national data such as that available from the Healthcare Cost and Utilization Project (HCUP).4 The purpose of the assessment would be to determine what patient issues were priorities for nursing practice research in the hospital. The choice of priorities would be based on the discharge diagnostic category with the highest volume, longest mean length of stay, and high- est mean charges as well as trends over time.

The CNO liked this approach and, together with Cheryl, assembled a small team of graduate student nurses and nurses familiar with the nursing units. They were able to use a de-identified database (no patient names or other means of identification) that included all hospital discharges during a 5-year period. For each discharge, they had information on gender, diagnoses (including primary diagnosis and all other diagnoses applied during the hospital stay), procedures, length of stay, hospital charges, ZIP code, and payer source. They used the HCUP Web site4 to access national- level data to compare these parameters with national statistics.

The team first calculated hospital discharge rates for each diagnostic category. A hospital discharge rate is the rate of a particular discharge diagnosis divided by the total number of discharges times a constant, and is computed in the same way other rates are computed (see Chapter 3). Thus, a hospital discharge rate repre- sents the number of discharges for that diagnosis in

comparison with all other discharges for that time pe- riod. It is calculated using the number of discharges for the diagnostic category or group divided by all dis- charges times a constant, usually per 100 discharges (Box 14-1).

While doing the assessment, one of the students asked Cheryl to explain the difference between International Classification of Diseases, 10th Re- vision (ICD-10) codes and the Major Diagnostic Cat- egories (MDC) used by HCUP. Cheryl explained that the major diagnostic category (MDC) is a taxon- omy that groups the principal diagnosis of patients into similar diagnosis-related groups. There are 25 categories based on systems designed to be mutually exclusive.4 Conversely, although ICD-10 is also a taxonomy, it was developed to code very spe- cific diagnoses related to the discharge rather than categories of diagnoses, although the codes can be collapsed into broader categories based on systems such the circulatory system or disease group such as neoplasms. A person with diabetes who has heart failure (HF) may be admitted primarily to treat an acute episode of HF. Therefore, the primary diagno- sis coded using an ICD-10 code would be specific to HF. They may have subsequent secondary and terti- ary ICD-10 codes entered related to the circulatory system and would have an ICD-10 code for diabetes listed as the fourth or fifth diagnosis. ICD-10 allows the hospital to code for billing a very specific diagno- sis under the broader ICD-10 category that indicates exactly what particular diagnoses were related to this admission. To help illustrate this for the student, Cheryl took the data for one admission from the data- base and demonstrated what ICD-10 categories were entered for that patient including the primary diag- nosis and all other diagnoses related to the admission

The total number of discharges assigned to the MDC Cardiovascular System was 4,179, and the total number of discharges was 29,585.

The discharge rate per 100 discharges is as follows:

4,179/25,585 × 100

and is read as

14.1 per 100 discharges in 2009

Note: This reflects discharges, not patients.

BOX 14–1 n Calculating a Discharge Rate

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346 U N I T I I I n Public Health Planning

TABLE 14–1 n Comparison of Major Diagnostic Category Listing and ICD10 Codes for a Discharge

MDC

Discharge

Diagnoses

Major Diagnostic Category

6

Diseases of the digestive system

ICD10 Primary Diagnostic Category

D21.4

Neoplasm of the abdomen

ICD10 Tertiary Diagnostic Code

I11.2

Hypertensive disease

ICD10 Secondary Diagnostic Category

172

Diseases of arteries, arterioles, and capillaries

TABLE 14–2 n Top 10 Major Diagnostic Categories for Nonmaternal Nonneonatal Hospitalizations

Rank Rank All Rank All Rank All Rank Males Females Genders Genders Genders

Major Diagnostic Category Aged 0–85+ Aged 0–85+ Aged 18–44 Aged 45–64 Aged 65+

Diseases of the circulatory system

Diseases of the respiratory system

Diseases of the digestive system

Diseases of the musculoskeletal system and connective tissue

Diseases of the nervous system

Diseases of the kidney and urinary tract

Mental disorders

Infectious and parasitic diseases

Diseases of the hepatobiliary system

Endocrine, nutritional, and metabolic systems

Diseases of the female reproductive system

1

2

3

4

5

6

7

8

9

10

1

2

4

3

5

6

7

8

11

9

10

1

2

4

3

5

6

12

7

9

8

15

1

4

3

2

5

6

8

9

7

10

12

4

6

2

3

5

10

1

14

7

8

9

(Table 14-1). She then pointed out that only one MDC category was applied to that specific admission. In this case, the MDC was used to identify the princi- pal diagnosis for admission and was a broader cate- gory, whereas the ICD-10 code identified for what specific diseases the patient was being treated during the admission (Table 14-1).

The team ran frequencies on the discharge data to determine the top five MDCs, which MDC had the highest mean length of stay, and which had the highest mean charges. They also calculated hospital discharge rates for each MDC. The MDC with the highest dis- charge rate was the circulatory system. They con- structed a table that displayed the top 10 MDC discharge rate bases on gender and age (Table 14-2).

They then compared these data with the available na- tional data related to hospital discharges. They found that although their discharge rate was higher, when compared with the national data, the hospital had a lower mean length of stay and mean charges for that MDC. Despite the evidence that they were better than the national norms on these two indicators, they con- cluded that, because of the high discharge rate, the pa- tients admitted with an MDC related to the circulatory system would be a focus area for development of health programs aimed at improving outcomes.

The team had now answered the “why” question. They went on to answer the rest of the questions. They used gender, payer source, and place of residence to answer the “who” and “where” questions. They

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C H A P T E R 1 4 n Health Planning for Acute Care Settings 347

completed the analysis for each of the 5 years of data and trending discharge rates during the 5 years and by month. They then used the discharge status variable to examine outcomes. This was an extensive project, but it provided answers to their questions and, most im- portantly, provided a clear picture of the patients they served and the subpopulations most at risk for poorer outcomes. They also identified other information that they wished to add to the assessment such as hospital recidivism, that is, readmission to the hospital within 30 days of discharge.

The assessment project not only helped the nursing department establish these priorities, but also provided baseline data from the past 5 years. In this way, the nursing department could track discharge rates and other quality indicators such as length of stay and charges over the next 5 years to help determine whether institution or revision of nursing interventions resulted in any changes in patient outcomes. At this hospital, the nursing department moved from focusing on the evaluation of effectiveness of nursing interven- tions on individual patient outcomes to an inclusion of the population-level perspective and the evaluation of the outcomes for both levels.

n CULTURAL CONTEXT AND ACUTE CARE SETTINGS

Culture is an important aspect of nursing care within an acute care setting. Nurses understand the need for culturally relevant care for individuals and families, but it also helps if nurses working in an acute care setting are aware of the different cultures represented in their community. An excellent hypothetical example based on an actual story is the issue of the Burundian refugees who settled in a midwestern city. In this ex- ample, a total of 106 Burundian refugees came to the city with support from the Catholic Archdiocese of the city. They were able to find housing in one of the poorer sections of the city and faced multiple chal- lenges, including obtaining health care. They had lived in refugee camps since the 1970s and were unable to speak English, with low literacy in their own language.

To address the challenges faced by these refugees, the parish nurse employed by a large urban hospital as part of their community outreach project began to work with the Burundians to help establish a means for them to access care and communicate with health-care providers. This required that she learn their culture and normative health-care practices. The parish nurse

located an interpreter and began meeting with the women in the community on a regular basis. Together they learned from one another: The Burundians learned the culture of their new country, and the parish nurse learned the culture of the Burundians. She was able to use this cultural knowledge to provide the hospital with key cultural insights into Burundian cul- ture, especially in relation to health beliefs, so that the physicians and nurses providing care would understand health from a Burundian perspective. Without the work of the parish nurse, the hospital would have had difficulty not only in understanding the Burundians when they came for care but also in understanding their cultural perspective on the care received.

The Epidemiology of Populations Treated in Acute Care Settings in the United States As defined in Chapter 3, epidemiology is the study and quantification of illness and disease within human and animal populations. From an acute care perspective, epidemiology provides the framework for the study of the frequency, distribution, cause, and control of dis- eases or injury in persons who receive care in an acute care setting. Thus, epidemiology revolves around sev- eral factors, including patients with noncommunicable diseases, communicable diseases, violence, abuse, and injury. Its purpose is to assist public health officials as well as the registered nurse (RN) to understand the causes of disease, the distribution and impact of disease, and the groups at risk so that prevention efforts along the continuum from primary to tertiary levels can be developed. Hospital morbidity and mortality rates are published each year by the Centers for Disease Control and Prevention (CDC) and the Agency for Healthcare Research and Quality (AHRQ). PHNs as well as nurses working in the acute care setting may access any of these databases to determine specific health risk factors based on age group, gender, and residence. This infor- mation may then be used to target interventions to im- prove the health of those they care for in acute care settings.

According to the CDC, in 2016 the top two leading causes of death in the United States were heart disease and cancer for both males and females. There were differ- ences between genders; the third leading cause of death for males was unintentional injuries, and for females, it was chronic lower respiratory diseases (Table 14-3). Fol- lowing cancer and chronic respiratory diseases were stroke, Alzheimer’s disease, unintentional injury, diabetes,

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influenza and pneumonia, kidney disease, and sepsis.5 In 2016, 6.4% of the U.S. population aged 1 and older had at least one hospital stay, down from 7.8% in 1997. When broken down by age, 15.2% of those over the age of 64 had at least one hospital stay and for those over the age of 84, almost a quarter (22.5%) had at least one hospital stay.6 The average length of stay was 6.1 days.7 In 2015, The most common diagnosis for inpatient stays after live birth was septicemia (Table 14-4).8

Discharge Status of Hospitalized Patients The goal on discharge is to return the patient to his op- timal state of health and, if possible, to independent liv- ing. Return to independent living is attainable for the majority of all hospitalized adults in the U.S. Others are able to return to their home environment with home health-care services or are transferred to an extended care facility for both short-term and long-term stays. Fi- nally, patients may have been discharged to another hos- pital, died, or left against medical advice.8 Assessing patients at the time of admission and developing indi- vidual discharge plans will make the postdischarge tran- sition easier for all of those involved. Tracking discharge status is another indicator of patient outcomes and could easily be added to an ongoing hospital population assessment such as the one conducted by Janet and Cheryl.

Inpatient Populations Understanding public health science and its daily role in the hospital setting is an essential competency for all nurses working across various units including critical care, emergency departments (EDs), and medical- surgical units. They participate through their daily ac- tivities in the improvement of health for the patients for whom they care, the patients’ families, and the commu- nities to which those patients return. Understanding the patients they care for within the broader context of the community served by the hospital can be a challenge. As the nation takes its slow march toward health promo- tion and disease prevention, as evidenced in the Afford- able Care Act of 2010,9 the need for more health-care activities on the population end of the continuum con- tinues to increase. Nurses working in acute care settings have an important role to play.

348 U N I T I I I n Public Health Planning

TABLE 14–3 n 2015 Differences in Top 10 Leading Causes of Death by Gender

Leading Causes of Death Males Percentage Leading Causes of Death Females Percentage

1. Heart disease 2. Cancer 3. Unintentional injuries 4. Chronic lower respiratory diseases 5. Stroke 6. Diabetes 7. Suicide 8. Alzheimer’s disease 9. Influenza and pneumonia

10. Chronic liver disease

22.3 21.2 6.2 6.1 5.7 4.0 2.7 2.3 1.8 1.6

1. Heart disease 2. Cancer 3. Chronic lower respiratory diseases 4. Stroke 5. Alzheimer’s disease 6. Unintentional injuries 7. Diabetes 8. Influenza and pneumonia 9. Kidney disease

10. Septicemia

24.4 22.8 6.8 5.3 4.2 3.1 2.5 2.0 2.0 1.9

TABLE 14–4 n 2015* U.S. National Inpatient Stays

Rate of Stays Principal Diagnosis per 100,000

Liveborn

Septicemia (except in labor)

Osteoarthritis

Congestive heart failure; nonhypertensive

Pneumonia (except that caused by tuberculosis or sexually transmitted disease)

Mood disorders

Cardiac dysrhythmias

Complication of device; implant or graft

Acute myocardial infarction

Other complications of birth; puerperium affecting management of mother

*Maternal/Neonatal Stays Included Source: (8)

1,195

552

339

297

276

267

212

203

196

195

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Within hospitals, there are numerous settings that are usually referred to as units. These units vary based on the type of services required (e.g., surgery, medical, emer- gency care) and the severity of the patients’ condition (e.g., intensive care, trauma, step-down units). Hospitals also vary in relation to the level of care they provide, the communities they serve, and whether or not they are teaching hospitals. Some services, such as infection con- trol, are provided across all units of the hospital. Com- munity hospitals located in suburban or rural areas are less apt to provide care to high-level-of-acuity patients such as those requiring complex surgical procedures or trauma level-one care. By contrast, a large urban medical center, especially one affiliated with a large university, has a wide array of units, many of which provide com- plex or specialized services.

Critical Care An excellent example of the relationship between public health science and acute care settings is the role that public health science has played in the development of critical care as a specialty in the acute care setting. Crit- ical care nursing requires specialized skills related to human responses to life-threatening health problems,9 and is usually provided within an area in the hospital designed to provide care to the most critically ill or in- jured patients. Critically ill or injured patients are patients who are at high risk for actual or potential life-threatening health-care problems.10 Critical illness can result from a progressive disease such as chronic obstructive pulmonary disease or may occur in an acute situation such as myocardial infarction (MI). Acute illness can involve a rapid change in condition for the worse or a condition that arises quickly, such as an exacerbation of fluid overload in the patient with HF. Patients in the critical care arena have varied disease eti- ologies, background demographics, socioeconomic sta- tus, and complexities. Also, a patient may be in critical condition from blood loss due to an acute injury sus- tained in motor vehicle crash. The more critically ill the patient is, the more vulnerable they are for instability and threat to life, requiring intense and highly skilled nursing care.

The care of the critically ill patient takes place in sev- eral different arenas within the hospital setting. This pa- tient population can be found in the intensive care units (ICUs), step-down or transitional care units, EDs, postanesthesia care units (PACU), cardiac catheter lab- oratories (cardiac cath lab), and cardiac care units. The focus of the critical care nurse is not only on the patient’s responses to illness and optimal care but also on the

family’s response. Almost two-thirds of all working RNs work in the hospital setting (61%). Of those, more than a third work in the critical care area.1,10,11 Critical care nurses rely on a vast body of knowledge, skill, and expe- rience so that they can provide care to the patient and the patient’s family while performing as a patient advo- cate and liaison. Included in the body of knowledge is public health science.

Although nurses working in critical care settings spend the majority of their time providing individual care to patients and families, hospital-based, population- level data are needed to evaluate the effectiveness of that care. Nurses use well-established epidemiological models to guide their health prevention activities, mostly at the tertiary prevention level. These activities include health education and careful discharge plan- ning to promote recovery and reduce the risk of disabil- ity and mortality. In addition, over time critical care nurses actively engage in population-level care through performance improvement activities and participation in research studies aimed at gathering evidence to demonstrate the effectiveness of interventions for improving the outcomes of the patient populations they serve.

Evolution of Critical Care: Population Driven Over the past few decades, critical care nursing has been recognized as a distinct and essential specialty, providing care to those who are the most severely ill or injured.10 The origin and development of the critical care field occurred in response to several different factors, each of which was population driven. The initiating factors first occurred in response to wartime injury. The progression of critical care can be attributed to the advancement in technology and the utilization of an improvement process shaped by evidence-based practice (EBP).

War: Critical care, in part, was developed using knowl- edge and skill obtained during wartime efforts. The true origin has been difficult to establish, but Florence Nightingale12 is considered to be the first to have used an ICU approach to help focus care on those who were in the need of the highest level of nursing care. She served with the British during the Crimean War from 1854 to 1856. In her book Notes on Hospitals, she wrote about the advantages of establishing a separate area of the hos- pital for the sickest or most severely injured soldiers. She maintained this area close to her nursing station where she could keep a close watch on their condition and pro- vide quick help when needed. The next report of a similar effort was in 1929, when Dr. Walter Dandy of Johns Hopkins Hospital in Baltimore developed a specialized

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postoperative unit containing three beds for neurosurgi- cal patients.13

Advancements in care for the critically ill also oc- curred as a consequence of wartime injuries. During World War I, the importance of recognizing shock and treating it with the intravascular volume replacement using saline and colloid solutions was demonstrated. Early in World War I, before the United States entered into the war, Bruce Robertson first introduced blood transfusion. He was a Canadian physician who, while training in the U.S., became convinced that whole blood was superior to saline infusions. The blood was collected from soldiers on the battlefield who were willing and ready to donate. It was not until World War II that the technique of blood transfusion was widely used. This war provided the stimulus for organized blood collection; as the war progressed, a national blood program was estab- lished, which provided massive quantities of blood for overseas use.14

Also, during World War II, advances in surgical tech- niques led to survival after injuries that were previously considered lethal. These injured soldiers subsequently needed prolonged supportive care for recovery. Shock wards were developed to resuscitate and care for soldiers injured in battle or undergoing surgery, and postopera- tive patients were admitted to recovery rooms to facilitate nursing care.15

With each subsequent war, advances have been made in the care of the critically ill and injured. In the Iraq and Afghanistan wars, significant advances were made in the treatment of traumatic brain injuries that resulted from roadside bomb explosions. These have translated into ad- vances in caring for civilian injuries both unintentional, such as motor vehicle crashes (MVCs) and football in- juries, and intentional, such as the mass shooting event that occurred at a high school in Parkland, Florida. These advances occurred because of the focus on the care of a population, in this case soldiers, and the particular type of injuries they were experiencing. This has resulted in a steady improvement in the mortality rate of soldiers in U.S. conflicts.16,17 During the American Civil War, the chance of dying was about one in four (250 per 1,000). Only a fraction actually died during battle because much of the deaths were attributable to disease and infections of wounds sustained during battle.17 By the time of the war in Vietnam, the death rate dropped to 21.8 per 1,000, which was five times higher than the death rate during the war in Iraq as measured between the beginning of the war under George Bush in 2003 and the functioning of the new Iraq government in 2006.19 Some of these advancements were a result of innovations not that dissimilar to what

Florence Nightingale did in the Crimean War. For exam- ple, in Iraq, medical teams were deployed closer to combat areas, and evacuation times were greatly improved.19

All of these innovations in care were driven by population-level data. In particular, these changes were made to improve the health outcomes of soldiers who had sustained life-threatening injuries or contracted dis- eases on the battlefield. The practices continued to be re- fined and used because population-level data demonstrated that survival rates improved. Survival rate is defined as the number of persons who survive an event divided by the total number of persons who experience an event. Thus, these innovative clinicians, including Florence Nightingale (see Chapter 1), effectively used public health science to improve the health of the critically ill.

Polio and Intensive Care: Critical care has evolved not only through the care of those injured during war but also through advances related to communicable dis- eases (see Chapter 8) and noncommunicable chronic dis- eases (see Chapter 9). Innovations in the delivery of care to those who are critically ill have developed in response to communicable disease outbreaks. In other cases, pub- lic health science findings have resulted in changes in how we care for chronic diseases.

A good example of how a communicable disease out- break changed practices in critical care is the po- liomyelitis (polio) epidemic that started in the late 1940s. Polio, one of the most dreaded diseases of childhood during the 20th century, is caused by the poliovirus, a human enterovirus member of the family Picornaviridae. It is transmitted from person to person via the fecal-oral route. Until the 20th century, the virus was readily trans- mitted via water, and most exposures to the virus oc- curred during infancy. At this young age, when most have at least partial protection via maternal antibodies, the resulting infection was subclinical. This asympto- matic infection in turn gave lifelong immunity. Only a few suffered from paralysis, which was labeled infantile paralysis. As advancements in water treatment took place, the early childhood exposure to the poliovirus de- creased. As a consequence of better hygiene, the first ex- posure to the virus was more apt to occur during late childhood or young adulthood. In this older age group, the infection caused more severe sequelae: a paralysis syndrome. At the peak of the epidemic in 1952, there were more than 21,000 cases. With the introduction of the Salk vaccine, the incidence rapidly decreased. By 1965, there were only 61 cases, and the last known case caused by wild poliovirus was in 1993.20

Prior to the introduction of the vaccine, the epidemic in the late 1940s and early 1950s resulted in an increased

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demand on the health-care system. More than 90% of poliovirus infections are asymptomatic, however, in cases that do show symptoms, the most severe potential effect of the virus is paralysis. The paralytic syndromes range from paralysis of one or more limbs to respiratory muscle paralysis. The mortality rate from respiratory polio was greater than 90%. Boston Children’s Hospital was the first to use a mechanical respiratory machine called the iron lung to prevent likely death (Fig. 14-1). Use of this respiratory therapy resulted in a significant reduction of mortality but was found to be cumbersome and expensive, which made it difficult to provide nursing care. As years passed, improvements were made to this mechanical respiratory unit, and it was broadly used throughout North America and Europe during severe polio outbreaks.

In 1952, during a large polio outbreak in Denmark, Bjorn Ibsen, an anesthesiologist in Blegdam Hospital, used the positive pressure ventilation concept used in the operating room for the respiratory support for the polio victims. Dr. Ibsen had his medical students hand-ventilate dozens of patients through tracheostomy tubes until the worst of the paralytic phase had passed. For efficiency and convenience, the patients who needed the respiratory support were placed in a single location within the hos- pital. This is often cited as the world’s first ICU, “a ward where physicians and nurses observe and treat ‘desper- ately ill’ patients 24 hours a day.”13,21 It is considered the

origin of today’s ICU. Again, improved outcomes and de- creased mortality for this particular hospital-based pop- ulation drove the development of these interventions.

Despite the innovative use of an iron lung and an ICU concept, the polio pandemic spurred public health re- search aimed at primary prevention. Based on the epi- demiological triangle reviewed in Chapters 3 and 8, clinicians had the choice to eradicate the virus, change the environment, or protect the host (humans). There was a major public health program using public service an- nouncements that warned parents about the risk of polio with a focus on public swimming areas. Polio outbreaks often occurred during the summer months as a result of children swimming in contaminated water. Thus, initial efforts were to alter the chance of exposure. However, public health research concentrated on protecting the host through the development of a vaccine that would boost human resistance to the virus. It was the introduc- tion of the Salk vaccine in 1952 and the Sabin vaccine in 1962 that dramatically reduced the incidence of polio to less than one per 100,000 persons annually in the early 1960s. Thus, public health science can often help bring solutions to health issues which result in the need for crit- ical care. Since the initiation of the ICU concept during the polio pandemic, ICUs have come to provide care for many different kinds of patients, from the neonate to adults with specific intensive care needs (Box 14-2).

C H A P T E R 1 4 n Health Planning for Acute Care Settings 351

• Neonatal intensive care unit (NICU) • Special care nursery (SCN) • Pediatric intensive care unit (PICU) • Psychiatric intensive care unit (PICU) • Coronary care unit (CCU) • Cardiac surgery intensive care unit (CSICU) • Cardiovascular intensive care unit (CVICU) • Medical intensive care unit (MICU) • Medical surgical intensive care unit (MSICU) • Surgical intensive care unit (SICU) • Overnight intensive recovery (OIR) • Neurotrauma intensive care unit (NICU) • Neurointensive care unit (NICU) • Burn wound intensive care unit (BWICU) • Trauma intensive care unit (TICU) • Surgical trauma intensive care unit (STICU) • Trauma-neuro critical care (TNCC) • Respiratory intensive care unit (RICU) • Geriatric intensive care unit (GICU) • Mobile intensive care unit (MICU)

BOX 14–2 n Specialized Types of Intensive Care Units

Figure 14-1 A 1960 historical photograph of a nurse caring for a victim of a Rhode Island polio epidemic, who is inside an Emerson respirator, also sometimes referred to as an “iron lung” machine. (From Centers for Disease Control and Prevention, Public Health Image Library, No. 12009. Retrieved from http://phil.cdc.gov/phil/details.asp)

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Technology and Acute Care: Cardiopulmonary Resuscitation: Advances in technology have also re- sulted in changes in the delivery of critical care. The use of these technologies demonstrates a combination of population data, advances in the understanding of human physiology, and technological advances. As in the field of pharmacy, the randomized clinical trial (Chapter 3) is the gold standard for determining the effectiveness and efficacy of technological interventions in critical care. These advances often began with bench science; in the end, however, they translate into how care is provided because of positive changes in the outcomes of the patient populations involved. One of the most dramatic examples is the whole issue of cardiopulmonary resus- citation (CPR), an emergency procedure that includes the use of external cardiac massage and artificial respira- tion for persons who experience sudden cardiac arrest. The technique was developed within the acute care set- ting and adopted for use by the general public. Overall, CPR has dramatically reduced mortality attributed to a variety of events that result in cessation of breathing, heartbeat, or both.

Peter J. Safar, the “father” of CPR, converted the method of CPR used in the hospital for use by the general public. He promoted the development of life-supporting first aid, which is known as basic life support. In 1957, he pub- licized the “A” (airway), “B” (breathing), and “C” (circula- tion system). Safar was a public health advocate who gave the first step to the general public to aid others in an emer- gency. He worked hard to popularize the procedure around the world and collaborated with a Norwegian company to create “Resusci Anne,” the first CPR training mannequin. His contribution to life-saving medical technique has earned him a reputation as one of the pioneers of critical care medicine and has saved countless lives.22

In 1960, the American Heart Association (AHA) started a program to acquaint physicians with closed- chest cardiac resuscitation, and it became the forerunner of CPR training for the general public. Although only 40 communities in the United States regularly measure and report survival rates, these population-level data have proved invaluable in the evaluation of the success of CPR and the development of changes aimed at improvement of survival rates. Initially, it was recommended that laypersons administering CPR first clear the airway (A), then administer breaths (B), and then initiate chest compressions (C). In 2010, dramatic revisions were made to the CPR guidelines. The recommendations were for the three steps of CPR to be rearranged: the new first step is now chest compressions instead of first es- tablishing the airway, and then administering breaths.

Newborns are an exception to the change. Thus, for the single rescuer, A-B-C has become C-A-B for compres- sions, airway, and breathing (Fig. 14-2). For laypersons, the AHA states that the most effective approach is to im- mediately deliver chest compressions at a rate of greater than 100 compressions per minute “the same rhythm as the beat of the Bee Gees’ song, ‘Stayin’ Alive.’”24 Although it is difficult to determine the exact outcomes associated with long-term survival, according to 2014 data, nearly 45% of out-of-hospital cardiac arrest victims survived when bystander CPR was started.23 Using the AHA in- formation to guide the administration of CPR, supportive programs such as public access defibrillation programs were implemented aimed at improving survival rates.24,25

Role of Cohort Studies in the Delivery of Acute Care Population data have not only been gathered from within the hospital to help improve patient outcomes but have also been gathered from general populations. A longitu- dinal cohort study (see Chapter 3) provides valuable ev- idence on who will potentially develop disease based on different risk factors. At baseline, information is collected about the health of the individuals in the cohort and then these individuals are tracked over time to determine who develops disease and who does not. A cohort study can be focused on a particular disease, for example, the Fram- ingham Health Study (FHS),26 or a particular population, such as the Nurses’ Health Study.27

The Framingham Heart Study and Cardiovascular Disease As reported in Chapter 9, the leading cause of death in the United States is cardiovascular disease (CVD). Nearly 2,300 Americans die of CVD each day, an average of one death every 38 seconds. CVD claims more lives each year than all forms of cancer and chronic lower respiratory diseases combined. There are an estimated 92,100,000 American adults (more than one in three) with CVD.28

The FHS is directly responsible for the remarkable ad- vances made in the prevention of heart disease in the United States and throughout the world.

In 1948, the town of Framingham, Massachusetts, was selected as the study site by the U.S. Public Health Serv- ice, and 5,209 healthy residents between 30 and 60 years of age, both men and women, were enrolled as the first cohort of participants. It was the first major cardiovas- cular study to recruit women participants. At the time, little was known about the general causes of heart disease

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C H A P T E R 1 4 n Health Planning for Acute Care Settings 353

Figure 14-2 C-A-B for cardiopulmonary resuscitation. (See [24]. Used with permission.)

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and stroke, but the death rates for CVD had been in- creasing steadily since the beginning of the 20th century and had become an American epidemic. The FHS be- came a joint project of the National Heart, Lung, and Blood Institute (NHLBI) and Boston University.27

The objective of the FHS was to identify the common risk factors that contribute to CVD by following its de- velopment over a long period of time in a large group of participants who had not yet developed overt symptoms of CVD or suffered a heart attack or stroke. Since 1948, the subjects have continued to return to the study every 2 years for a detailed medical history, physical examina- tion, and laboratory tests. In 1971, the study enrolled a second generation, 5,124 of the original participants’ adult children and their spouses, to participate in similar examinations. In 1994, the need to establish a new study including a more diverse community of Framingham was recognized, and the first Omni cohort (OMNI1) of the FHS was enrolled. Due to the predominantly white population in the first cohorts, the OMNI cohorts were enrolled as a way of representing the growing diversity of Framingham from a racial and ethnic perspective. In

April 2002, the study entered a new phase, the enroll- ment of a third generation of participants, who were the grandchildren of the original cohort. In 2003, a second group of Omni participants was enrolled.26

The FHS continues to make important scientific con- tributions by enhancing its research capabilities and cap- italizing on its inherent resources. Some of the more recent data from the FHS, from the original and offspring cohorts (1980–2003), show that the average annual rate of first major cardiovascular events is on the rise. Events have gone from 3 per 1,000 in men at ages 35 to 44, to 74 per 1,000 at ages 85 to 94. For women, comparable rates occur 10 years later in life, and the gap narrows with ad- vancing age. Before age 75, men suffer a higher propor- tion of CVD events due to coronary heart disease (CHD) than do women, and a higher proportion of events due to stroke occur in women. From 1996 to 2006, death rates from CVD declined 29.2%. Data from the FHS in- dicate that the lifetime risk for CVD is two in three for men and more than one in two for women at age 40.26

Over time, the impact of the study on heart health is substantial (Box 14-3).28,29

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1960 1961 1967 1970 1976 1978 1988 1994 1996 1998

1999 2001

2002 2002 2004 2005 2006

2007

2008

Cigarette smoking found to increase the risk of heart disease. Cholesterol level, blood pressure, and electrocardiogram abnormalities found to increase the risk of heart disease. Physical activity found to reduce the risk of heart disease, and obesity found to increase the risk of heart disease. High blood pressure found to increase the risk of stroke. Menopause found to increase the risk of heart disease. Psychosocial factors found to affect heart disease. High levels of high-density lipoprotein cholesterol found to reduce risk of death. Enlarged left ventricle (one of two lower chambers of the heart) shown to increase the risk of stroke. Progression from hypertension to heart failure described. Development of simple coronary disease prediction algorithm involving risk factor categories to allow physicians to predict multivariate CHD risk in patients without overt CHD. Lifetime risk at age 40 years of developing CHD is one in two for men and one in three for women. High-normal blood pressure is associated with an increased risk of CVD, emphasizing the need to determine whether lowering high-normal blood pressure can reduce the risk. Lifetime risk of developing high blood pressure in middle-aged adults is 9 in 10. Obesity is a risk factor for heart failure. Serum aldosterone levels predict future risk of hypertension in non-hypertensive individuals. Lifetime risk of becoming overweight exceeds 70%; risk for obesity approximates one in two. The NHLBI of the National Institutes of Health announced a new genome-wide association study at the FHS in collaboration with Boston University School of Medicine to be known as the SHARe project (SNP Health Associ- ation Resource). Based on evaluation of a densely interconnected social network of 12,067 people assessed as part of the FHS, network phenomena appear to be relevant to the biological and behavioral trait of obesity, and obesity appears to spread through social ties. Based on analysis of a social network of 12,067 people participating in the FHS, researchers discover that social networks exert key influences on decision to quit smoking.

BOX 14–3 n Framingham Heart Study Milestones

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Women and Cardiovascular Disease CVD is the leading cause of death in women.30 Initially CVD was perceived by many health-care providers as a predominately male disease linked to stress and lifestyle. It was thought that women had a low risk for developing CVD and were protected by female sex hormones. Since the 1990s, there has been an effort to increase the amount of research done to help understand heart disease in women. This research is leading to a better understanding of risk factors, early signs and symptoms, and treatment.31,32

As mentioned earlier, the FHS is one of the few long- term prospective studies of CVD that has included both men and women. Women participated from the very be- ginning, and investigators recognized that CVD occurs later in life and with lower frequency in females. With follow-up of 5,209 original study participants (2,873 women and 2,336 men), researchers have documented information about the incidence of CVD in the FHS women and risk factors unique to women.29

There are specific physiological, pathophysiological, clinical, and socioeconomic issues that differentiate women and men with CVD. Because of these differences, symptoms of an acute myocardial infarction (AMI) are different between genders. Women are more likely to ex- perience atypical chest pain, abdominal pain, dyspnea, nausea, and fatigue during a cardiovascular event. Be- cause these symptoms are different from the “elephant sitting on the chest” type of pain that males often expe- rience, the atypical presentation may be missed or be at- tributed to another etiology. If the suspicion of CVD has not been raised by symptoms, underinvestigation and undertreatment may occur. Women typically wait longer to seek medical assistance; this may be due to the atypical presentation of symptoms.32,33 Delay of treatment has a devastating effect on the outcome of a cardiovascular event, which certainly may be seen in the mortality rate for a woman following an AMI (Box 14-4). The risk of

CVD increases with age, and as the baby boomers age, the morbidity and mortality rate related to CVD in women will grow. Because of this increasing number, it is important to raise awareness of this major public health issue for older women.

C H A P T E R 1 4 n Health Planning for Acute Care Settings 355

Source: (29)

2008

2009

2009

2009 2010s

Discovery by FHS and publication of four risk factors that raise probability of developing precursor of heart failure; new 30-year risk estimates developed for serious cardiac events. FHS cited by the AHA as being among the top 10 cardiovascular research achievements of 2009, “Genome-wide Association Study of Blood Pressure and Hypertension: Genome-wide Association Study Identifies Eight Loci Associated With Blood Pressure.” A new genetic variant associated with increased susceptibility for atrial fibrillation, a prominent risk factor for stroke and heart failure, is reported in two studies based on data from the FHS. FHS researchers find parental dementia may lead to poor memory in middle-aged adults. Sleep apnea is tied to increased risk of stroke; Additional genes identified that may play a role in Alzheimer’s disease; and hundreds of genes were discovered that are underlying major heart disease risk factors.

BOX 14–3 n Framingham Heart Study Milestones—cont’d

• CVD, particularly coronary heart disease (CHD) and stroke, remain the leading causes of death of women in America and most developed countries, with nearly 37% of all female deaths in the United States occurring from CVD.

• CVD is a particularly important problem among minority women. The death rate due to CVD is higher in black women than in white women.

• One in 2.7 females who die, die of heart disease, stroke, and other CVD compared with one in 30 who die of breast cancer.

• At age 40 and older, 23% of women compared with 18% of men will die within 1 year after a heart attack.

BOX 14–4 n Facts About Women and Cardiovascular Disease

Source: (30)

l APPLYING PUBLIC HEALTH SCIENCE The Case of the Waiting Women Public Health Science Topics Covered:

• Health planning • Conducting a setting-specific assessment • Population-level conclusions: Identifying priorities

Two nurses, Susan and Maria, work together in a cardiac catheterization laboratory (cath lab) in a large urban tertiary center. The cath lab is a very busy area within this medical center. This specialized area holds

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diagnostic imaging equipment used to support diagnos- tic and interventional procedures. The cath lab is staffed by a multidisciplinary team including physicians (interventional cardiologists, vascular surgeons, or radi- ologists), nurses, and radiology technicians.

A diagnostic procedure called a cardiac catheteriza- tion is performed in the cath lab to determine the ex- tent of disease present in the vascular system. Left heart catheterization (arterial) is performed to deter- mine blockages in the coronary vascular system. Right heart catheterization (venous) is performed to deter- mine how well the heart valves are functioning and how effectively the heart is pumping blood to the lungs. The method involves threading a catheter through a femoral artery or vein or the radial artery and then threading it into the heart. During cardiac cath, a radio- opaque dye is injected through the catheter to highlight the coronary arteries. This test is called a coronary angiogram or coronary arteriogram.

Depending on what is found during the coronary an- giogram, different interventions may be necessary dur- ing the cardiac cath. For example, an angioplasty that uses a balloon on the end of the catheter is able to open narrowed coronary arteries. Stents, which are small, mesh-like devices that act as supports, or scaf- folds, inside of a vessel, may be placed at the time of angioplasty.

During one particularly busy shift in the cath lab, Susan relieved Maria for lunch and received a report on a patient who was coming from the ED with a diag- nosis of a suspected AMI. The patient was a 60-year- old woman with no known history of CVD who arrived in the ED about an hour before with vague complaints of fatigue, shortness of breath, and chest pressure. After a detailed history and physical, this pa- tient was found to have an ST-elevation myocardial infarction (STEMI), a heart attack caused by a pro- longed period of blocked blood supply.33 While Susan was with this patient in the cath lab, the coronary an- giogram showed a severely occluded left main coronary artery, a surprising discovery given her atypical com- plaints. Knowing that this type of obstructive disease holds an increased mortality risk, Susan wanted to know why this patient was in the ED for such a long time before the diagnosis was made. She was also con- cerned because the door-to-balloon time was just at the 90-minute mark.

Door-to-balloon time is defined as the amount of time between a patient’s arrival at the hospital and the time he/she receives percutaneous coronary

intervention, such as angioplasty.33 Because “time is muscle,” meaning that delays in treating an AMI in- creases the likelihood and amount of myocardial damage resulting from localized hypoxia, the Ameri- can College of Cardiologists and the AHA guidelines recommend a door-to-balloon time of no more than 90 minutes. A national Door-to-Balloon Initiative was launched in November 2006 and has become a core quality measure for The Joint Commission.

When Maria returned from her lunch break, she and Susan discussed the circumstances of the patient with the STEMI. Susan voiced her concerns about the sever- ity of the CVD in the presence of atypical complaints and the length of door-to-balloon time despite the suc- cess of the intervention. Maria was equally concerned in light of the fact that she had just cared for a post- menopausal patient with a STEMI who also presented with vague complaints earlier in the day that had gone beyond the 90-minute door-to-balloon time. After much discussion and a review of the recorded door- to-balloon times during the past several months, which showed other cases of women with prolonged times, both nurses felt strongly that they needed to take ac- tion so that they could make a difference in the care of women with CVD.

Unsure of what to do next, Susan and Maria decided to consult Karen, the director of nursing research at the hospital. They knew that their short-term goal was to discover the red flags that could be used to alert the ED personnel to the possibility of CVD in postmenopausal woman with atypical symptoms. After educating the ED staff, Susan and Maria then wanted to use this information to educate women at risk.

Karen encouraged the two nurses to learn more about the population at risk. Was the event that Susan witnessed unusual or more the norm in the ED? What was the evidence to support the door-to-balloon time frame? Were women at greater risk than men? Susan and Maria had hunches but no real data on the issue. Karen suggested that they conduct a retrospective chart review to answer these questions. She reminded them that they would have to follow the hospital poli- cies related to chart reviews. The two nurses, with Karen’s help, wrote up a proposal for doing the review.

Focused Assessment

The purpose of their review was not only to determine the length of time between arrival in the ED and treat- ment but also to determine the length of time between the point at which the women first had symptoms and

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C H A P T E R 1 4 n Health Planning for Acute Care Settings 357

their arrival at the ED. Thus, the team embarked on a focused assessment (Chapter 4) that allowed them to examine the population of women who arrived in the ED over a specified period of time. They collected data on all adult women who arrived with a non-trauma event and then compared the presenting symptoms for those who actually had STEMI with those who did not. They collected information on time from first symp- toms to arrival at the ED and what those first symp- toms were. All of these assessment data were needed not only to determine whether indeed the door-to- balloon time standard was or was not being met, but also to more accurately describe the presenting symp- toms of the women with a STEMI compared with those without a STEMI. This vital information helped in the development of an intervention for health-care providers and for the educational program the nurses wanted to develop for women at risk for a STEMI. Both centered on how to recognize a possible STEMI, and both interventions used a population approach.

Ethics in an Acute Care Setting

One issue Susan and Maria faced was how to address the privacy of the patient information they obtained during their chart review. Karen showed them how to write a proposal, which they would then send to the institutional review board for approval. Karen ex- plained to them that they could not access patient data without going through this process. In that way, they would design the review so that they would ensure the privacy of the patients and also allow them to dissemi- nate their findings at an aggregate level with no per- sonal identifiers.

Nurses interested in using population-level data to improve patient outcomes must be fully aware of the ethics of utilizing individual patient-level data for pur- poses other than what they were intended. There are two legal areas that nurses must remember at all times when conducting assessments or doing health program evaluations using patient data. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 was designed to protect the use of electronic patient data. It set national standards for the security of electronic protected health information such as the electronic medical record. An EMR is a digital version of the patient chart that has replaced paper charts in most acute care settings. HIPAA also in- cludes rules on the use of identifiable confidential pa- tient information to analyze patient safety events and improve patient safety.34

Although patient information obtained during a hos- pital stay is protected under HIPAA, there are times when the information can be or must be shared. This represents the conflict between the individual’s right to privacy and the public health perspective of pro- tecting the health of the whole. The law includes regulations that recognize the need for public health authorities, and others mandated to protect the public safety, to have access to patient data. Thus, a physician may report information on dog bites or gunshot wounds to those with authority without violating HIPAA. Agencies with such authority include state and local health departments, the Food and Drug Adminis- tration (FDA), the CDC, and the Occupational Safety and Health Administration (OSHA). Situations in which individual information may be shared to help protect the public include child abuse or neglect, ad- verse events associated with an FDA-approved activity or product, and reportable communicable diseases. It is important to note that the information may only be released to agencies with recognized authority as stipulated in the law.34

HIPAA is an important factor for nurses who plan to collect patient data to conduct a study related to their care. For example, in some cases, nurses make changes to practice based on existing evidence and do this within the scope of their practice. They do not report the assessment data or the success of their program outside of their hospital because it is not a research study. Susan and Maria remembered cover- ing human subjects’ research in their research class but were not sure how to proceed. Their hospital had a policy that all projects that involved obtaining data from patient records and/or collecting patient data from patients must be reviewed by the institutional review board (IRB) prior to collecting any data. An institutional review board is a committee formally charged with reviewing biomedical and behavioral re- search conducted with human subjects to ensure the protection of research participants. These commit- tees must comply with federal regulations related to conducting research with human subjects. The two nurses worked with the hospital nurse researcher to delineate exactly what their process was and then provided the information as required to their institu- tion’s IRB. They clarified that, when collecting the data from the medical records, they would include information on the residence of the patient and that they would need to link medical records from the two different areas. Although they were planning to

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Thus, nurses working in acute care settings are faced with multiple ethical issues. From a public health per- spective, the nurse must be aware of the need to protect the health of the public while protecting the right to in- dividual privacy. In addition, as more hospitals encour- age nurses working in acute care settings to engage in research, they must become aware of the ethical dilem- mas posed in the collection of patient data. Improving patient outcomes requires a constant review of the evi- dence and health planning to improve practice. During this process, human subjects must always be protected from unnecessary risk.

The Nurses’ Health Study The Nurses’ Health Study is similar to the FHS but fo- cuses on the health of women rather than on incidence of a particular disease. It started in 1976 and has ex- panded to include two more cohorts, one in 1989 and one in 2008. Initially, the primary objective was to study the long-term consequences related to the use of oral contraceptives. However, the findings from the studies are providing insights into a broad array of health issues including breast cancer, diabetes, and CVD in women. Based on the results of the studies, researchers have con- cluded that diet, physical activity, and other lifestyle fac- tors promote better health and reduce risk for disease to a significant degree.35

Health Planning and Acute Care The first case study in this chapter, Solving the Mystery, is an example of a health planning approach to the de- livery of nursing care in a hospital setting. The team com- pleted the first step in heath planning, the assessment (see Chapter 4). The data from that step helped to iden- tify populations at risk for poorer outcomes. Armed with

these data, the nursing department could now move to the next steps, the development, implementation, and evaluation of a health program aimed at improving pa- tient outcomes (see Chapter 5). For Cheryl, who wanted to know the who, what, why, when, and where, the final results of the assessment identified the areas in need of nursing activities related to searching for the evidence to support practice, as well as conducting research studies aimed at improving outcomes. For the CNO, the assess- ment provided her with the outcomes-focused approach and the baseline data she needed to evaluate change over time from an organizational perspective. The results were distributed to the nursing staff as a whole, and nursing units were encouraged to explore opportunities to de- velop population-level interventions that would improve outcomes for patients admitted with a diagnosis that matched those included in Table 15-2.

Noncommunicable Diseases and Acute Care Settings Chapter 9 provided an overview of noncommunicable dis- eases and their contribution to the overall burden of dis- ease. Acute care settings provide care to persons with noncommunicable diseases when they are experiencing an acute stage of the disease. They may come to the hos- pital when they have first been diagnosed, or the admis- sion may be one of many related to the noncommunicable disease. Providing acute care for a disease process that will not result in a cure leaves the care provider focused on de- creasing disease-related morbidity and disability, and re- ducing the risk of premature death. Thus, the nurse in the acute care setting who is caring for a person with a non- communicable disease is providing tertiary prevention (see Chapter 2). This can be challenging for the nurse be- cause of short hospital stays. The nurse must adapt the plan of care to fit the individual’s needs. However, devel- opment of a program that addresses population-level barriers to care and improves the ability of patients to self-manage their disease upon discharge can make a big difference. This again requires using a population approach and often requires the identification of subpopulations within the patient population who may be experiencing significant barriers to self-management of their diseases.

The first step for the nurse working on a hospital unit who wishes to develop an intervention program is to identify the level of prevention involved in the interven- tion. For example, if a nurse wanted to develop a pro- gram focused on acute coronary syndrome (ACS), she would have to begin with an understanding of the dis- ease. ACS is defined by the AHA as any set of clinical symptoms associated with acute myocardial ischemia.

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use the information for an internal change in practice, they wished to also examine whether there was a dif- ference between those patients who actually had a STEMI and those who did not, and then report those findings in a journal article or at a conference. Thus, they wished to generalize the findings of their assess- ment. They submitted their proposal with specific in- formation on how they would protect the privacy of the patient’s medical record. The IRB determined that it did constitute human subjects’ research but met the requirements for an expedited review because it in- volved a review of medical records only, with minimal risk to the patients.