Promoting the Health of Populations

Preface Unit 1. Introduction to Community Health Nursing

Chapter 1. Health: A Community View

Definitions of Health and Community

Determinants of Health and Disease



Indicators of Health and Illness

Definition and Focus of Public Health and Community Health

Preventive Approach to Health

Definition and Focus of Public Health Nursing, Community Health Nursing, and Community-Based Nursing

Population-Focused Practice and Community/Public Health Nursing Interventions

Community Health Nursing, Managed Care, and Health Reform

Learning Activities

Chapter 2. Historical Factors: Community Health Nursing in Context

Evolution of Health in Western Populations

Advent of Modern Health Care

Consequences for the Health of Aggregates

Social Changes and Community Health Nursing

Challenges for Community and Public Health Nursing


Learning Activities

Chapter 3. Thinking Upstream: Nursing Theories and Population- Focused Nursing Practice

Thinking Upstream: Examining the Root Causes of Poor Health

Historical Perspectives on Nursing Theory

How Theory Provides Direction to Nursing

Microscopic Versus Macroscopic Approaches to the Conceptualization of Community Health Problems



Assessing a Theory’s Scope in Relation to Community Health Nursing

Review of Theoretical Approaches

Healthy People 2020


Learning Activities

Chapter 4. Health Promotion and Risk Reduction

Health Promotion and Community Health Nursing

Determinants Of Health

Theories in Health Promotion

Risk and Health

The Relationship of Risk to Health and Health Promotion Activities


Learning Activities

Unit 2. The Art and Science of Community Health Nursing

Chapter 5. Epidemiology

Use of Epidemiology in Disease Control and Prevention

Calculation of Rates

Concept of Risk

Use of Epidemiology in Disease Prevention

Use of Epidemiology in Health Services

Epidemiological Methods




Learning Activities

Chapter 6. Community Assessment

The Nature of Community

Healthy Communities

Assessing the Community: Sources of Data

Needs Assessment

Diagnosing Health Problems


Learning Activities

Chapter 7. Community Health Planning, Implementation, and Evaluation

Overview of Health Planning

Health Planning Model

Health Planning Projects

Health Planning Federal Legislation

Nursing Implications


Learning Activities

Chapter 8. Community Health Education

Connecting with Everyday Realities

Health Education in the Community



Learning Theories, Principles, and Health Education Models

The Nurse’s Role in Health Education

Enhancing Communication

Framework for Developing Health Communications

Health Education Resources

Social Media


Learning Activities

Chapter 9. Case Management

Overview of Case Management

Origins of Case Management

Purpose of Case Management

Utilization Review and Managed Care

Trends that Influence Case Management

Education and Preparation for Case Managers

Case Manager Services

Case Manager Roles and Characteristics

Case Identification

The Referral Process

Application of Case Management in Community Health

Research in Case Management

International Case Management




Learning Activities

Unit 3. Factors that Influence the Health of the Community

Chapter 10. Policy, Politics, Legislation, and Community Health Nursing

Overview: Nurses’ Historical and Current Activity in Health Care Policy


A Major Paradigm Shift

Structure of the Government of the United States

Overview of Health Policy

Major Legislative Actions and the Health Care System

Public Policy: Blueprint for Governance

The Effective Use of Nurses: A Policy Issue

Nurses’ Roles in Political Activities

Health Care Reform and Restructuring of the Health Care Industry

Nurses and Leadership in Health Policy Development


Learning Activities

Chapter 11. The Health Care System

Overview: The Health Care System

Components of the Health Care System

Quality Care



Critical Issues in Health Care Delivery

Future of Public Health and the Health Care System


Learning Activities

Chapter 12. Economics of Health Care

Factors Influencing Health Care Costs

Public Financing of Health Care

Philanthropic Financing of Health Care

Health Care Insurance Plans

Cost Containment

Trends in Health Financing

Health Care Financing Reform

Roles Of the Community Health Nurse in the Economics of Health Care

Best Care at Lower Cost


Learning Activities

Chapter 13. Cultural Diversity and Community Health Nursing

Cultural Diversity

Transcultural Perspectives on Community Health Nursing

Population Trends

Cultural Perspectives and Healthy People 2020

Transcultural Nursing



Overview of Culture

Culture and Socioeconomic Factors

Culture and Nutrition

Culture and Religion

Culture and Aging

Cross-Cultural Communication

Health-Related Beliefs and Practices

Management of Health Problems: A Cultural Perspective

Management of Health Problems in Culturally Diverse Populations

Role of the Community Health Nurse in Improving Health for Culturally Diverse People

Resources for Minority Health


Learning Activities

Chapter 14. Environmental Health

A Critical Theory Approach to Environmental Health

Areas of Environmental Health

Effects of Environmental Hazards

Efforts to Control Environmental Health Problems

Emerging Issues in Environment Health

Approaching Environmental Health at the Population Level

Critical Environmental Health Nursing Practice




Learning Activities

Chapter 15. Health in the Global Community

Population Characteristics

Environmental Factors

Patterns of Health and Disease

International Agencies and Organizations

International Health Care Delivery Systems

Research in International Health

Health Initiatives Taking Place Throughout the World


Learning Activities

Unit 4. Aggregates in the Community

Chapter 16. Child and Adolescent Health

Issues of Pregnancy and Infancy

Childhood Health Issues

Adolescent Health Issues

Factors Affecting Child and Adolescent Health

Strategies to Improve Child and Adolescent Health

Public Health Programs Targeted to Children and Adolescents

Sharing Responsibility for Improving Child and Adolescent Health

Legal and Ethical Issues in Child and Adolescent Health




Learning Activities

Chapter 17. Women’s Health

Major Indicators of Health

Social Factors Affecting Women’s Health

Health Promotion Strategies for Women

Major Legislation Affecting Women’s Health

Health and Social Services to Promote the Health of Women

Levels of Prevention and Women’s Health

Roles of the Community Health Nurse

Research in Women’s Health


Learning Activities

Chapter 18. Men’s Health

Men’s Health Status

Use of Medical Care

Theories that Explain Men’s Health

Factors that Impede Men’s Health

Men’s Health Care Needs

Primary Preventive Measures

Secondary Preventive Measures

Tertiary Preventive Measures




Learning Activities

Chapter 19. Senior Health

Concept of Aging

Theories of Aging

Demographic Characteristics

Psychosocial Issues

Physiological Changes

Wellness and Health Promotion

Common Health Concerns

Additional Health Concerns

Elder Safety and Security Needs

Psychosocial Disorders


End-of-Life Issues


Learning Activities

Chapter 20. Family Health

Understanding Family Nursing

The Changing Family

Approaches to Meeting the Health Needs of Families

Approaches to Family Health

Assessment Tools



Family Health Assessment

Extending Family Health Intervention to Larger Aggregates and Social Action

Applying the Nursing Process


Learning Activities

Unit 5. Vulnerable Populations

Chapter 21. Populations Affected by Disabilities

Self-Assessment: Responses to Disability

Definitions and Models for Disability

A Historical Context for Disability

Characteristics of Disability

Disability and Public Policy

Costs Associated with Disability

Healthy People 2020 and The Health Needs of People with Disabilities

The Experience of Disability

Strategies for the Community Health Nurse in Caring for People with Disabilities

Ethical Issues for People Affected by Disabilities


Learning Activities

Chapter 22. Homeless Populations

Definitions, Prevalence, and Demographic Characteristics of Homelessness



Factors that Contribute to Homelessness

Health and Homeless Populations

Health Status of Homeless Population

Community Public Health Nursing: Care of Homeless Populations


Learning Activities

Chapter 23. Rural and Migrant Health

Rural United States


Rural Health Disparities: Context and Composition

Specific Rural Aggregates

Application of Relevant Theories and “Thinking Upstream” Concepts to Rural Health

Rural Health Care Delivery System

Community-Based Care

Legislation and Programs Affecting Rural Public Health

Rural Community Health Nursing

Rural Health Research

New Models of Health Care Delivery for Rural Areas


Learning Activities

Chapter 24. Populations Affected by Mental Illness



Overview and History of Community Mental Health: 1960 to the Present Day

HEALTHY PEOPLE 2020: Mental Health and Mental Disorders

Factors Influencing Mental Health

Mental Disorders Encountered in Community Settings

Identification and Management of Mental Disorders

Community-Based Mental Health Care

Role of the Community Mental Health Nurse


Learning Activities

Unit 6. Population Health Problems

Chapter 25. Communicable Disease

Communicable Disease and Healthy People 2020

Principles of Infection and Infectious Disease Occurrence

Chain of Transmission

Breaking the Chain of Transmission

Public Health Control of Infectious Diseases

Vaccines and Infectious Disease Prevention

Vaccine Needs for Special Groups

Healthy People 2020 Focus on Immunization and Infectious Diseases

Healthy People 2020 Focus on Sexually Transmitted Diseases

Healthy People 2020 Focus on HIV/AIDS

Prevention of Communicable Diseases




Learning Activities

Chapter 26. Substance Abuse

Etiology of Substance Abuse

Historical Overview of Alcohol and Illicit Drug Use

Prevalence, Incidence, and Trends

Adolescent Substance Abuse

Conceptualizations of Substance Abuse

Sociocultural and Political Aspects of Substance Abuse

Course of Substance-Related Problems

Legal and Ethical Concerns Related to Substance Abuse

Modes of Intervention

Social Network Involvement

Vulnerable Aggregates

Nursing Perspective on Substance Abuse


Learning Activities

Chapter 27. Violence

Overview of Violence

History of Violence

Interpersonal Violence

Community Violence



Factors Influencing Violence

Violence from a Public Health Perspective

Prevention of Violence


Learning Activities

Chapter 28. Natural and Man-Made Disasters

Disaster Definitions

Types of Disasters

Characteristics of Disasters

Disaster Management

Disaster Management Stages


Learning Activities

Unit 7. Community Health Settings

Chapter 29. School Health

History of School Health

School Health Services

School Nursing Practice

School-Based Health Centers

Future Issues Affecting the School Nurse


Learning Activities



Chapter 30. Occupational Health

Evolution of Occupational Health Nursing

Demographic Trends and Access Issues Related to Occupational Health Care

Occupational Health Nursing Practice and Professionalism

Occupational Health and Prevention Strategies

Skills and Competencies of the Occupational Health Nurse

Impact of Federal Legislation on Occupational Health

Legal Issues in Occupational Health

Multidisciplinary Teamwork


Learning Activities

Chapter 31. Forensic and Correctional Nursing

Subspecialties of Forensic Nursing

Correctional Nursing

Health Issues in Prison Populations

Mental Health Issues in Correctional Settings

Education and Forensic Nursing


Learning Activities

Chapter 32. Faith Community Nursing

Faith Communities: Role in Health and Wellness

Foundations of Faith Community Nursing



Roles or Functions of the Faith Community Nurse

Education of the Faith Community Nurse

The Faith Community Nurse and Spirituality

Issues in Faith Community Nurse Practice


Learning Activities

Chapter 33. Home Health and Hospice

Home Health Care

Types of Home Health Agencies

Certified and Noncertified Agencies

Special Home Health Programs

Reimbursement for Home Care


Nursing Standards and Educational Preparation of Home Health Nurses

Conducting a Home Visit

Documentation of Home Care

Application of the Nursing Process

Formal and Informal Caregivers

Hospice Home Care


Learning Activities




Special Features




3251 Riverport Lane St. Louis, Missouri 63043

COMMUNITY/PUBLIC HEALTH NURSING: PROMOTING THE HEALTH OF POPULATIONS ISBN: 978-0-323-18819-7 Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website:

This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).

Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding,



changes in research methods, professional practices, or medical treatment may become necessary.

Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility.

With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions.

To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

Library of Congress Cataloging-in-Publication Data

Community/public health nursing : promoting the health of populations / [edited by] Mary A. Nies, Melanie McEwen. — Edition 6. p. ; cm. Includes bibliographical references and index. ISBN 978-0-323-18819-7 (pbk. : alk. paper) I. Nies, Mary A. (Mary Albrecht), editor. II. McEwen, Melanie, editor. [DNLM: 1. Community Health Nursing. 2. Health Promotion. 3.



Public Health Nursing. WY 106] RT98 610.73’43–dc23 2014023359

Director, Traditional Education: Kristin Geen Senior Content Strategist: Nancy O’Brien Content Development Specialist: Jennifer Shropshire Publishing Services Manager: Deborah L. Vogel Project Manager: John W. Gabbert Design Direction: Karen Pauls

Printed in Canada Last digit is the print number: 9 8 7 6 5 4 3 2




To Phil Yankovich, my husband, companion, and best friend, whose love, caring, and true support are

always there for me. He provides me with the energy I need to pursue my dreams.

To Kara Nies Yankovich, my daughter, for whom I wish a happy and healthy life. Her energy, joy, and

enthusiasm for life give so much to me.

To Earl and Lois Nies, my parents, for their never- ending encouragement and lifelong support. They

helped me develop a foundation for creative thinking, new ideas, and spirited debate.

Mary A. Nies

To my husband, Scott McEwen, whose love, support, and encouragement have been my foundation for the past thirty-five years. I can’t wait to see what happens




Melanie McEwen



Author Biographies



Mary A. Nies

Mary A. Nies, PhD, RN, FAAN, FAAHB is the Dean and Professor School of Nursing, Joint Appointment MPH Program, Division of Health Sciences, Idaho State University. Dr. Nies received her diploma from Bellin School of Nursing in Green Bay, Wisconsin; her BSN from University of Wisconsin, Madison; her MSN from Loyola University, Chicago; and her PhD in Public Health Nursing, Health Services, and Health Promotion Research at the University of Illinois, Chicago. She completed a postdoctoral research fellowship in health promotion and community health at the University of Michigan, Ann Arbor. She is a fellow of the American Academy of Nursing and a fellow of the American Academy of Health Behavior. Dr. Nies co-edited Community Health Nursing: Promoting the Health of Aggregates, which received the 1993 Book of the Year award from the American Journal of Nursing. Her program of research focuses on the outcomes of health promotion interventions for minority and nonminority populations in the community. Her research is involved with physical activity and obesity prevention for populations, especially women. Her research is involved with physical activity and obesity prevention for vulnerable populations.



Melanie McEwen

Melanie McEwen, PhD, RN, CNE, ANEF is an Associate Professor at the University of Texas Health Science Center at Houston School of Nursing. Dr. McEwen received her BSN from the University of Texas School of Nursing in Austin; her Master’s in Community and Public Health Nursing from Louisiana State University Medical Center in New Orleans; and her PhD in Nursing at Texas Woman’s University. Dr. McEwen has been a nursing educator for more than 22 years and



is also the co-author of Community–Based Nursing: An Introduction (Elsevier, 2009) and co-author/editor of Theoretical Basis for Nursing (Lippincott, Williams and Wilkins, 2014).




Carrie Buch, PhD, RN, Associate Professor, Oakland University, School of Nursing, Rochester, Michigan

Chapter 13: Cultural Diversity and Community Health Nursing

Chapter 33: Home Health and Hospice

Patricia M. Burbank, DNSc, RN, Professor, College of Nursing, The University of Rhode Island, Kingston, Rhode Island

Chapter 7: Community Health Planning, Implementation, and Evaluation

Holly B. Cassells, PhD, MPH, RN, Professor, School of Nursing and Health Professions, University of the Incarnate Word, San Antonio, Texas

Chapter 5: Epidemiology

Chapter 6: Community Assessment

Stacy A. Drake, MSN, MPH, RN, Instructor, The University of Texas Health Science Center at Houston, School of Nursing, Houston, Texas

Nellie S. Droes, DNSc, RN, CS, Associate Professor, Emerita, School of Nursing, East Carolina University , Rivers Building, Greenville, North Carolina

Chapter 22: Homeless Populations



Anita Finkelman, MSN, RN, Visiting Faculty, School of Nursing, Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts

Chapter 10: The Health Care System

Chapter 11: The Health Care System

Chapter 12: Economics of Health Care

Susan Givens, RNC-OB, MPH, LCCE, Childbirth Educator, Mount Carmel St. Ann’s Hospital, Westerville, Ohio

Chapter 16: Child and Adolescent Health

Lori A. Glenn, DNP, CNM, RN, Assistant Professor, McAuley School of Nursing, University of Detroit Mercy, Detroit, Michigan, Nurse Midwife , Hurley Medical Center, Flint, Michigan

Chapter 17: Women’s Health

Deanna E. Grimes, DrPH, RN, FAAN, Professor, University of Texas Health Science Center at Houston, Houston, Texas

Karyn Leavitt Grow, MS, BSN, RN, CCM, Manager, Case Manager, Sierra Surgery Hospital, Carson City, Nevada

Chapter 9: Case Management

Diane C. Hatton, PhD, RN, Consultant, Reno, Nevada

Chapter 22: Homeless Populations

Jené M. Hurlbut, PhD, MSN, RN, CNE, Associate Professor, Roseman University of Health Sciences , Henderson, Nevada

Chapter 18: Men’s Health



Kim Jardine-Dickerson, RN, MSN, BC, CADC, Assistant Clinical Professor, Idaho State University, Pocatello, Idaho

Chapter 24: Populations Affected by Mental Illness

Chapter 26: Substance Abuse

Angela Jarrell, PhD, RN, Nurse Consultant, Duquesne University, Pittsburgh, Pennsylvania

Chapter 31: Forensic and Correctional Nursing

Jean Cozad Lyon, PhD, APN, Hospital Surveyor, The Joint Commission, Reno, Nevada

Chapter 9: Case Management

Diane Cocozza Martins, PhD, RN, Associate Professor, College of Nursing, University of Rhode Island, Kingston, Rhode Island

Chapter 3: Thinking Upstream: Nursing Theories and Population-Focused Nursing Practice

Chapter 7: Community Health Planning, Implementation, and Evaluation

Cathy D. Meade, PhD, RN, FAAN, Senior Member and Professor, Population Science, Health Outcomes & Behavior, Moffitt Cancer Center, University of South Florida, Tampa, Florida

Chapter 8: Community Health Education

Julie Cowan Novak, DNSc, RN, CPNP, FAANP, Professor and Vice Dean, Practice and Engagement, Executive Director, UT Nursing Clinical Enterprise, UTHSCSA Student Health Center and Employee Health and Wellness Clinic, UT Health Science Center San Antonio School of Nursing, San Antonio, Texas

Chapter 15: Health in the Global Community



Catherine A. Pourciau, MSN, RN, FNP-C, Family Nurse Practitioner, Internal Medicine and Pediatric Clinic, Baker, Louisiana

Chapter 27: Violence

Chapter 29: School Health

Bridgette Crotwell Pullis, PhD, RN, CHPN, Assistant Professor of Nursing, The University of Texas Health Science Center – Houston School of Nursing, Houston, Texas

Chapter 4: Health Promotion and Risk Reduction

Bonnie Rogers, DrPH, COHN-S, LNCC, Director, NC Occupational Safety and Health and Education and Research , Center and OHN Program, University of North Carolina , School of Public Health , Chapel Hill, North Carolina

Chapter 30: Occupational Health

Mary Ellen Trail Ross, DrPH, MSN, RN, GCNS-BC, Associate Professor of Clinical Nursing , Department of Nursing Systems, University of Texas Health Science Center, Houston, Texas

Chapter 19: Senior Health

Diane Santa Maria, MSN, RN, APHN-BC, Clinical Faculty, University of Texas School of Nursing, Houston, Texas

Chapter 14: Environmental Health

Beverly Siegrist, EdD, MS, RN, CNE, Professor, Department of Nursing, Western Kentucky University, Bowling Green, Kentucky

Chapter 20: Family Health

Chapter 32: Faith Community Nursing



Edith B. Summerlin, PhD, MSN, BSN, RN, CNS, Assistant Professor, University of Texas Health Science Center at Houston , School of Nursing, Houston, Texas

Chapter 19: Senior Health

Chapter 28: Natural and Man-made Disasters

Patricia L. Thomas, PhD, RN, Director, Nursing Practice & Research , Trinity Health, Livonia, Michigan

Chapter 23: Rural and Migrant Health

Meredith Troutman-Jordan, PhD, PMHCNS-BC, Associate Professor, University of North Carolina at Charlotte , College of Health and Human Services, School of Nursing, Charlotte, North Carolina

Chapter 21: Populations Affected by Disabilities

Elaine Vallette, DrPH, RN, Dean, Nursing and Allied Health, Baton Rouge Community College, Baton Rouge, Louisiana

Chapter 27: Violence

Chapter 29: School Health

Lori Wightman, MSN, DNP, RN, NEA-BC, Chief Nursing Officer, Mercy Hospital Grayling, Grayling, Michigan

Chapter 23: Rural and Migrant Health


Joanna E. Cain, BSN, BA, RN, President and Founder, Auctorial Pursuits, Inc., Atlanta, Georgia

NCLEX Review Questions



TEACH for RN-Case Studies

Penny Leake, PhD, RN, Professor Emerita of Nursing, Luther College, Decorah, Iowa

PowerPoint Slides

Tiffany M. Smith, MSN, RN, PhD student/Graduate Assistant, Roseman University of Health Sciences, University of Nevada , Las Vegas, Nevada

Case Studies

Anna K. Wehling Weepie, DNP, RN, CNE, COI, Assistant Dean, Undergraduate Nursing and Professor, Allen College, Waterloo, Iowa

Test Bank




Edna M. Billingsley, MSN, RN, PMHN-C, CLNC, GNP, Assistant Professor of Nursing , Bethel University , McKenzie, Tennessee

Barbara Broome, RN, MSN, PhD, FAAN, Associate Dean and Chair Community/Mental Health Nursing, Professor, University of South Alabama College of Nursing , Mobile, Alabama

Stephanie Chalupka, EdD, RN, PCHCNS-BC, FAAOHN, Associate Dean for Nursing, Worcester State University, Worcester, Massachusetts

Colleen L. Ciano, MSN, RN, PhD (c), Instructor of Nursing, The Pennsylvania State University, Middletown, Pennsylvania

Connie Cooper, EdD, RN, CNE, Assistant Professor, Bellarmine University, Louisville, Kentucky

Michelle T. Dang, PhD, RN, APHN-BC, Assistant Professor, California State University, Sacramento, Sacramento, California

Lisa Garsman, MS, FNP-BC, Director BSN Program, Saint Peter’s University, Jersey City, New Jersey

Scharmaine Lawson-Baker, DNP, FNP-BC, FAANP, CEO/Founder, Advanced Clinical Consultants, New Orleans, Louisiana

Lisa M. LeBlanc, RN, BSN, Instructor of Nursing, Wisconsin Lutheran College, Milwaukee, Wisconsin



Patricia S. Martin, RN, MSN, Assistant Professor, University of Louisville, Louisville, Kentucky

Nancy N. Menzel, PhD, RN, PHCNS-BC, CPH, Associate Professor, Nursing, University of Nevada, Las Vegas , Las Vegas, Nevada

Lynn M. Miskovich, DNP, ANP-BC, APRN, Associate Professor of Nursing , Purdue University Calumet, Hammond, Indiana

Patti Moss, MSN, RN, Assistant Professor, Nursing, Lamar University, Beaumont, Texas

Jill M. Nocella, MSN, RN, Professor of Nursing, William Paterson University, Wayne, New Jersey

Vicky L. O’Neil, DNP, APRN, FNP-BC, Associate Professor, Dixie State College of Utah, St. George, Utah

Laura Opton, MSN, RN, CNE, Second Degree BSN Program Director, Texas Tech University Health Sciences Center, Lubbock, Texas

Susan Palmer, MSN, RN, Lecturer, Fairleigh Dickinson University, Teaneck, New Jersey

Fay Parpart, MS, RN, ANP-BC, Assistant Clinical Professor, Virginia Commonwealth University, Richmond, Virginia

Keevia Porter, DNP, MSN, NP-C, RN, Assistant Professor BSN/MSN Programs, University of Tennessee Health Science Center, College of Nursing , Memphis, Tennessee

Cynthia Portman, MSN, RN, Assistant Clinical Professor in Nursing, Department of Nursing and Rehab Sciences, Angelo State University, San Angelo, Texas



Joann Sands, ANP-BC, MSN, RN, Clinical Instructor, The State University of New York – University at Buffalo, Buffalo, New York

Charlotte Sortedahl, DNP, MPH, MS, BSN, RN, Assistant Professor, University of Wisconsin – Eau Claire, Eau Claire, Wisconsin

Marnie Lynn Sperling, DMD, MSN, RN, FN-CSA, Assistant Professor, Nursing, Caldwell College , Caldwell, New Jersey

Debbie Sweeney, RN, DNSc, Associate Professor, Nursing, Baptist College of Health Sciences, Memphis, Tennessee

Virginia Teel, DHSc, RN, Assistant Professor, Nursing, College of Coastal Georgia, Brunswick, Georgia

Julie B. Willardson, DNP, FNP-C, Assistant Professor of Nursing, Roseman University of Health Sciences, College of Nursing, South Jordan, Utah




More money is spent per capita for health care in the United States than in any other country ($8400 in 2010). However, many countries have far better indices of health, including traditional indicators such as infant mortality rates and longevity for both men and women than does the United States. The United States is one of the few industrialized countries in the world that lacks a program of national health services or national health insurance. Although the United States spent 17.9% of its gross domestic product on health care expenditures in 2010, a record high of $2.6 trillion, before full implementation of the Affordable Care Act, nearly 18.0% of the population had no health care coverage.

The greater the proportion of money put into health care expenditures in the United States, the less money there is to improve education, jobs, housing, and nutrition. Over the years, the greatest improvements in the health of the population have been achieved through advances in public health using organized community efforts, such as improvements in sanitation, immunizations, and food quality and quantity. The greatest determinants of health are still equated with factors in the community, such as education, employment, housing, and nutrition. Although access to health care services and individual behavioral changes are important, they are only components of the larger determinants of health, such as social and physical environments.



Upstream Focus The traditional focus of many health care professionals, known as a downstream focus, has been to deliver health care services to ill people and to encourage needed behavioral change at the individual level. The focus of public/community health nursing has traditionally been on health promotion and illness prevention by working with individuals and families within the community. A shift is needed to an upstream focus, which includes working with aggregates and communities in activities such as organizing and setting health policy. This focus will help aggregates and communities work to create options for healthier environments with essential components of health, including adequate education, housing, employment, and nutrition and provide choices that allow people to make behavioral changes, live and work in safe environments, and access equitable and comprehensive health care.

Grounded in the tenets of public health nursing and the practice of public health nurses such as Lillian Wald, this sixth edition of Community/Public Health Nursing: Promoting the Health of Populations builds on the earlier works by highlighting an aggregate focus in addition to the traditional areas of family and community health, and thus promotes upstream thinking. The primary focus is on the promotion of the health of aggregates. This approach includes the family as a population and addresses the needs of other aggregates or population subgroups. It conceptualizes the individual as a member of the family and as a member of other aggregates, including organizations and institutions. Furthermore, individuals and families are viewed as a part of a population within an environment (i.e., within a community).

An aggregate is made up of a collective of individuals, be it family or another group that, with others, make up a community. This text emphasizes the aggregate as a unit of focus and how aggregates that make up communities promote their own health. The aggregate is



presented within the social context of the community, and students are given the opportunity to define and analyze environmental, economic, political, and legal constraints to the health of these populations.

Community/public health nursing has been determined to be a synthesis of nursing and public health practice with goals to promote and preserve the health of populations. Diagnosis and treatment of human responses to actual or potential health problems is the nursing component. The ability to prevent disease, prolong life, and promote health through organized community effort is from the public health component. Community/public health nursing practice is responsible to the population as a whole. Nursing efforts to promote health and prevent disease are applied to the public, which includes all units in the community, be they individual or collective (e.g., person, family, other aggregate, community, or population).



Purpose of the Text In this text, the student is encouraged to become a student of the community, learn from families and other aggregates in the community how they define and promote their own health, and learn how to become an advocate of the community by working with the community to initiate change. The student is exposed to the complexity and rich diversity of the community and is shown evidence of how the community organizes to meet change.

The use of language or terminology by clients and agencies varies in different parts of the United States, and it may vary from that used by government officials. The contributors to this text are a diverse group from various parts of the United States. Their terms vary from chapter to chapter and vary from those in use in local communities. For example, some authors refer to African-Americans, some to blacks, some to European-Americans, and some to whites. The student must be familiar with a range of terms and, most important, know what is used in his or her local community.

Outstanding features of this sixth edition include its provocative nature as it raises consciousness regarding the social inequalities that exist in the United States and how the market-driven health care system contributes to prevention of the realization of health as a right for all. With a focus on social justice, this text emphasizes society’s responsibility for the protection of all human life to ensure that all people have their basic needs met, such as adequate health protection and income. Attention to the impact of implementation of the Affordable Care Act as well as the need for further reform of the systems of health reimbursement has enhanced the recognition of the need for population-focused care, or care that covers all people residing within geographic boundaries, rather than only those populations enrolled in insurance plans. Working toward providing health promotion and population-focused care to all requires a dramatic shift in thinking from individual-focused care for the



practitioners of the future. The future paradigm for health care is demanding that the focus of nursing move toward population-based interventions if we are to forge toward the goals established in Healthy People 2020.

This text is designed to stimulate critical thinking and challenge students to question and debate issues. Complex problems demand complex answers; therefore, the student is expected to synthesize prior biophysical, psychosocial, cultural, and ethical arenas of knowledge. However, experiential knowledge is also necessary and the student is challenged to enter new environments within the community and gain new sensory, cognitive, and affective experiences. The authors of this text have integrated the concept of upstream thinking, introduced in the first edition, throughout this sixth edition as an important conceptual basis for nursing practice of aggregates and the community. The student is introduced to the individual and aggregate roles of community health nurses as they are engaged in a collective and interdisciplinary manner, working upstream, to facilitate the community’s promotion of its own health. Students using this text will be better prepared to work with aggregates and communities in health promotion and with individuals and families in illness. Students using this text will also be better prepared to see the need to take responsibility for participation in organized community action targeting inequalities in arenas such as education, jobs, and housing and to participate in targeting individual health-behavioral change. These are important shifts in thinking for future practitioners who must be prepared to function in a population-focused health care system.

The text is also designed to increase the cultural awareness and competency of future community health nurses as they prepare to address the needs of culturally diverse populations. Students must be prepared to work with these growing populations as participation in the nursing workforce by ethnically and racially diverse people continues to lag. Various models are introduced to help students understand the growing link between social problems and health status, experienced disproportionately by diverse populations in the



United States, and understand the methods of assessment and intervention used to meet the special needs of these populations.

The goals of the text are to provide the student with the ability to assess the complex factors in the community that affect individual, family, and other aggregate responses to health states and actual or potential health problems; and to help students use this ability to plan, implement, and evaluate community/public health nursing interventions to increase contributions to the promotion of the health of populations.



Major Themes Related to Promoting the Health of Populations This text is built on the following major themes:

• A social justice ethic of health care in contrast to a market justice ethic of health care in keeping with the philosophy of public health as “health for all”

• A population-focused model of community/public health nursing as necessary to achieve equity in health for the entire population

• Integration of the concept of upstream thinking throughout the text and other appropriate theoretical frameworks related to chapter topics

• The use of population-focused and other community data to develop an assessment, or profile of health, and potential and actual health needs and capabilities of aggregates

• The application of all steps in the nursing process at the individual, family, and aggregate levels

• A focus on identification of needs of the aggregate from common interactions with individuals, families, and communities in traditional environments

• An orientation toward the application of all three levels of prevention at the individual, family, and aggregate levels

• The experience of the underserved aggregate, particularly the economically disenfranchised, including cultural and ethnic groups disproportionately at risk of developing health problems.

Themes are developed and related to promoting the health of populations in the following ways:

• The commitment of community/public health nursing is to an equity model; therefore, community health nurses work toward the provision of the unmet health needs of populations.

• The development of a population-focused model is necessary to close the gap between unmet health care needs and health resources on a geographic basis to the entire population. The contributions of



intervention at the aggregate level work toward the realization of such a model.

• Contemporary theories provide frameworks for holistic community health nursing practice that help the students conceptualize the reciprocal influence of various components within the community on the health of aggregates and the population.

• The ability to gather population-focused and other community data in developing an assessment of health is a crucial initial step that precedes the identification of nursing diagnoses and plans to meet aggregate responses to potential and actual health problems.

• The nursing process includes, in each step, a focus on the aggregate, assessment of the aggregate, nursing diagnosis of the aggregate, planning for the aggregate, and intervention and evaluation at the aggregate level.

• The text discusses development of the ability to gather clues about the needs of aggregates from complex environments, such as during a home visit, with parents in a waiting room of a well-baby clinic, or with elders receiving hypertension screening, and to promote individual, collective, and political action that addresses the health of aggregates.

• Primary, secondary, and tertiary prevention strategies include a major focus at the population level.

• In addition to offering a chapter on cultural influences in the community, the text includes data on and the experience of underserved aggregates at high risk of developing health problems and who are most often in need of community health nursing services (i.e., low and marginal income, cultural, and ethnic groups) throughout.



Organization The text is divided into seven units. Unit 1, Introduction to Community Health Nursing, presents an overview of the concept of health, a perspective of health as evolving and as defined by the community, and the concept of community health nursing as the nursing of aggregates from both historical and contemporary mandates. Health is viewed as an individual and collective right, brought about through individual and collective/political action. The definitions of public health and community health nursing and their foci are presented. Current crises in public health and the health care system and consequences for the health of the public frame implications for community health nursing. The historical evolution of public health, the health care system, and community health nursing is presented. The evolution of humans from wanderers and food gatherers to those who live in larger groups is presented. The text also discusses the influence of the group on health, which contrasts with the evolution of a health care system built around the individual person, increasingly fractured into many parts. Community health nurses bring to their practice awareness of the social context; economic, political, and legal constraints from the larger community; and knowledge of the current health care system and its structural constraints and limitations on the care of populations. The theoretical foundations for the text, with a focus on the concept of upstream thinking, and the rationale for a population approach to community health nursing are presented. Recognizing the importance of health promotion and risk reduction when striving to improve the health of individuals, families, groups, and communities, this unit concludes with a chapter elaborating on those concepts. Strategies for assessment and analysis of risk factors and interventions to improve health are described.

Unit 2, The Art and Science of Community Health Nursing, describes application of the nursing process—assessment, planning, intervention, and evaluation—to aggregates in the community using selected theory bases. The unit addresses the need for a population



focus that includes the public health sciences of biostatistics and epidemiology as key in community assessment and the application of the nursing process to aggregates to promote the health of populations. Application of the art and science of community health nursing to meeting the needs of aggregates is evident in chapters that focus on community health planning and evaluation, community health education, and case management.

Unit 3, Factors That Influence the Health of the Community, examines factors and issues that can both positively and negatively affect health. Beginning with an overview of health policy and legislation, the opening chapter in this unit focuses on how policy is developed and the effect of past and future legislative changes on how health care is delivered in the United States. This unit examines the health care delivery system and the importance of economics and health care financing on the health of individuals, families, and populations. Cultural diversity and associated issues are described in detail, showing the importance of consideration of culture when developing health interventions in the community. The influence of the environment on the health of populations is considered, and the reader is led to recognize the multitude of external factors that influence health. This unit concludes with an examination of various aspects of global health and describes features of the health care systems and patterns of health and illness in developing and developed countries.

Unit 4, Aggregates in the Community, presents the application of the nursing process to address potential health problems identified in large groups, including children and adolescents, women, men, families, and seniors. The focus is on the major indicators of health (e.g., longevity, mortality, and morbidity), types of common health problems, use of health services, pertinent legislation, health services and resources, selected applications of the community health nursing process to a case study, application of the levels of prevention, selected roles of the community health nurse, and relevant research.

Unit 5, Vulnerable Populations, focuses on those aggregates in the



community considered vulnerable: persons with disabilities, the homeless, those living in rural areas including migrant workers, and persons with mental illness. Chapters address the application of the community health nursing process to the special service needs in each of these areas. Basic community health nursing strategies are applied to promoting the health of these vulnerable high-risk aggregates.

Unit 6, Population Health Problems, focuses on health problems that affect large aggregates and their service needs as applied in community health nursing. These problems include communicable disease, violence and associated issues, substance abuse, and a chapter describing nursing care during disasters.

Unit 7, Community Health Settings, focuses on selected sites or specialties for community health: school health, occupational health, faith community health, and home health and hospice. Finally, forensic nursing, one of the more recently added sub-specialty areas of community health nursing, is presented in this unit, combined with correctional nursing content.



Special Features The following features are presented to enhance student learning:

• Learning objectives. Learning objectives set the framework for the content of each chapter.

• Key terms. A list of key terms for each chapter is provided at the beginning of the chapter. The terms are highlighted in blue within the chapter. The definitions of these terms are found in the Glossary located on the book’s Evolve website.

• Chapter outline. The major headings of each chapter are provided at the beginning of each chapter to help locate important content.

• Theoretical frameworks. The use of theoretical frameworks common to nursing and public health will aid the student in application of familiar and new theory bases to problems and challenges in the community.

• Healthy People 2020. Goals and objectives of Healthy People 2020 are presented in a special box throughout the text. (The updated Healthy People 2020 information is new to this edition and based on the proposed objectives.)

• Upstream thinking. This theoretical construct is integrated into chapters throughout the text.

• Case studies and application of the nursing process at individual, family, and aggregate levels. The use of case studies and clinical examples throughout the text is designed to ground the theory, concepts, and application of the nursing process in practical and manageable examples for the student.

• Research highlights. The introduction of students to the growing bodies of community health nursing and public health research literature are enhanced by special boxes devoted to specific research studies.

• Boxed information. Summaries of content by section, clinical examples, and other pertinent information are presented in colored text to aid the students’ learning by focusing on major points, illustrating concepts, and breaking up sections of “heavy” content.



• Learning activities. Selected learning activities are listed at the end of each chapter to enable students to enhance learning about the community and cognitive experiences.

• Photo novellas. Numerous stories in photograph form depicting public health care in a variety of settings and with different population groups.

• Ethical insights boxes. These boxes present situations of ethical dilemmas or considerations pertinent to particular chapters.

• Veterans’ Health boxes. New to this edition, these boxes present situations and considerations pertinent to the care of veterans.



New content in this edition • New and timely information on emerging infections (e.g., H1N1,

SARS, West Nile virus) and changing recommendations (e.g., pediatric immunization schedule) are given in the Communicable Disease chapter.

• Reflecting the need for enhanced education and information related to the specific needs and issues for our country’s veterans, most chapters include at least one box highlighting veteran’s health care in relation to the chapter’s topic.

• Most chapters contain new or updated Research Highlights boxes highlighting timely, relevant examples of the topics from recent nursing literature and Ethical Insights boxes that emphasize specific ethical issues.



Teaching and Learning Package Evolve website: The website at is devoted exclusively to this text. It provides materials for both instructors and students.

• For Instructors: PowerPoint lecture slides, image collection, and more than 900 test bank questions with alternative item questions as well as the new TEACH for Nurses, which contains detailed chapter Lesson Plans including references to curriculum standards such as QSEN, BSN Essentials and Concepts, BSN Essentials for Public Health, and new and unique Case Studies.

• For Students: Quiz with multiple-choice questions with answers and correct answer rationales, Case Studies with questions and answers, a Glossary, and Resource Tools (supplemental material).



Acknowledgments Community/Public Health Nursing: Promoting the Health of Populations could not have been written without sharing the experiences, thoughtful critique, and support of many people: individuals, families, groups, and communities. We give special thanks to everyone who made significant contributions to this book.

We are indebted to our contributing authors whose inspiration, untiring hours of work, and persistence have continued to build a new era of community health nursing practice with a focus on the population level. We thank the community health nursing faculty and students who welcomed the previous editions of the text and responded to our inquiries with comments and suggestions for the sixth edition. These people have challenged us to stretch, adapt, and continue to learn throughout our years of work. We also thank our colleagues in our respective work settings for their understanding and support during the writing and editing of this edition.

Finally, an enormous “thank you” to Elsevier editors Jennifer Shropshire, Nancy O’Brien, and Johnny Gabbert. Their energy, enthusiasm, encouragement, direction, and patience were essential to this project.

Mary A. Nies

Melanie McEwen



UNIT 1 Introduction to Community Health Nursing

OUTLINE Chapter 1. Health: A Community View Chapter 2. Historical Factors: Community Health Nursing in Context Chapter 3. Thinking Upstream: Nursing Theories and Population- Focused Nursing Practice Chapter 4. Health Promotion and Risk Reduction







A Community View Melanie McEwen, and Mary A. Nies


Definitions of Health and Community Health Community

Determinants of Health and Disease Indicators of Health and Illness Definition and Focus of Public Health and Community Health Preventive Approach to Health

Health Promotion and Levels of Prevention Prevention versus Cure Healthy People 2020

Definition and Focus of Public Health Nursing, Community Health Nursing, and Community-Based Nursing

Public and Community Health Nursing Community-Based Nursing Community and Public Health Nursing Practice

Population-Focused Practice and Community/Public Health Nursing Interventions

Community Health Interventions



The Public Health Intervention Wheel Community Health Nursing, Managed Care, and Health Care Reform


Upon completion of this chapter, the reader will be able to do the following: 1. Compare and contrast definitions of health from a public health

nursing perspective. 2. Define and discuss the focus of public health. 3. Discuss determinates of health and indicators of health and illness

from a population perspective. 4. List the three levels of prevention, and give examples of each. 5. Explain the difference between public/community health nursing

practice and community-based nursing practice. 6. Describe the purpose of Healthy People 2020, and give examples

of the topic areas that encompass the national health objectives. 7. Discuss community/public health nursing practice in terms of public

health’s core functions and essential services. 8. Discuss community/public health nursing interventions as

explained by the Intervention Wheel.

KEY TERMS aggregates community community health



community health nursing disease prevention health health promotion population population-focused nursing primary prevention public health public health nursing secondary prevention tertiary prevention

As a result of recent and anticipated changes related to health care reform, community/public health nurses are in a position to assist the U.S. health care system in the transition from a disease-oriented system to a health-oriented system. Costs of caring for the sick account for the majority of escalating health care dollars, which increased from 5.7% of the gross domestic product in 1965 to 17.9% in 2010 (National Center for Health Statistics [NCHS], 2013). Alarmingly, national annual health care expenditures reached $2.6 trillion in 2010, or an astonishing $8400 per person.

U.S. health expenditures reflect a focus on the care of the sick. In 2010, $0.31 of each health care dollar supported hospital care, $0.20 supported physician services, and $0.10 was spent on prescription drugs (double the proportion since 1980). The vast majority of these funds were spent providing care for the sick, and only $0.03 of every health care dollar was directed toward preventive public health activities (NCHS, 2013). Despite high hospital and physician expenditures, U.S. health indicators rate considerably below the health indicators of many other countries. This situation reflects a



relatively severe disproportion of funding for preventive services and social and economic opportunities. Furthermore, the health status of the population within the United States varies markedly across areas of the country and among groups. For example, the economically disadvantaged and many cultural and ethnic groups have poorer overall health status compared with middle-class Caucasians.

Nurses constitute the largest group of health care workers; therefore, they are instrumental in creating a health care delivery system that will meet the health-oriented needs of the people. According to a survey of registered nurses (RNs) conducted by the Health Resources and Services Administration, about 62% of approximately 2.6 million employed RNs in the United States worked in hospitals during 2008 (down from 66.5% in 1992). This survey also found that about 14.2%, approximately 400,000, of all RNs worked in home, school, or occupational health settings; 10.5% worked in ambulatory care settings; and 5.3% worked in nursing homes or other extended care facilities (U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions [USDHHS, HRSA, BHP], 2010).

Between 1980 and 2008, the number of nurses employed in community, health, and ambulatory care settings more than doubled (USDHHS, HRSA, BHP, 2010). The decline in the percentage of nurses employed in hospitals and the subsequent increase in nurses employed in community settings indicate a shift in focus from illness and institutional-based care to health promotion and preventive care. This shift will likely continue into the future as alternative delivery systems, such as ambulatory and home care, will employ more nurses (Rosenfeld and Russell, 2012; Way and MacNeil, 2007).

Community/public health nursing is the synthesis of nursing practice and public health practice. The major goal of public health nursing is to preserve the health of the community and surrounding populations by focusing on health promotion and health maintenance of individuals, families, and groups within the community. Thus community/public health nursing is associated with health and the identification of populations at risk rather than with an episodic



response to patient demand. The mission of public health is social justice, which entitles all

people to basic necessities such as adequate income and health protection and accepts collective burdens to make it possible. Public health, with its egalitarian tradition and vision, often conflicts with the predominant U.S. model of market justice that largely entitles people to what they have gained through individual efforts. Although market justice respects individual rights, collective action and obligations are minimal. An emphasis on technology and curative medical services within the market justice system has limited the evolution of a health system designed to protect and preserve the health of the population. Public health assumes that it is society’s responsibility to meet the basic needs of the people. Thus there is a greater need for public funding of prevention efforts to enhance the health of our population.

Current U.S. health policies advocate changes in personal behaviors that might predispose individuals to chronic disease or accident. These policies promote exercise, healthy eating, tobacco use cessation, and moderate consumption of alcohol. However, simply encouraging the individual to overcome the effects of unhealthy activities lessens focus on collective behaviors necessary to change the determinants of health stemming from such factors as air and water pollution, workplace hazards, and unequal access to health care. Because living arrangements, work/school environment, and other sociocultural constraints affect health and well-being, public policy must address societal and environmental changes, in addition to lifestyle changes, that will positively influence the health of the entire population.

With ongoing and very significant changes in the health care system and increased employment in community settings, there will be greater demands on community and public health nurses to broaden their population health perspective. The Code of Ethics of the American Nurses Association (ANA) (2001) promotes social reform by focusing on health policy and legislation to positively affect accessibility, quality, and cost of health care. Community and public health nurses, therefore, must align themselves with public health programs that promote and preserve the health of populations by



influencing sociocultural issues such as human rights, homelessness, violence, disability, and stigma of illness. This principle allows nurses to be positioned to promote the health, welfare, and safety of all individuals.

This chapter examines health from a population-focused, community-based perspective. Therefore it requires understanding of how people identify, define, and describe related concepts. The following section explores six major ideas: 1. Definitions of “health” and “community” 2. Determinants of health and disease 3. Indicators of health and disease 4. Definition and focus of public and community health 5. Description of a preventive approach to health 6. Definition and focus of “public health nursing,” “community health nursing,” and “community-based nursing”



Definitions of Health and Community Health The definition of health is evolving. The early, classic definition of health by the World Health Organization (WHO) set a trend toward describing health in social terms rather than in medical terms. Indeed, the WHO (1958, p. 1) defined health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.”

Social means “of or relating to living together in organized groups or similar close aggregates” (American Heritage College Dictionary, 1997, p. 1291) and refers to units of people in communities who interact with one another. “Social health” connotes community vitality and is a result of positive interaction among groups within the community with an emphasis on health promotion and illness prevention. For example, community groups may sponsor food banks in churches and civic organizations to help alleviate problems of hunger and nutrition. Other community groups may form to address problems of violence and lack of opportunity, which can negatively affect social health.

In the mid-1980s, the WHO expanded the definition of health to emphasize recognition of the social implications of health. Thus health is:

the extent to which an individual or group is able, on the one hand, to realize aspirations and satisfy needs; and, on the other hand, to change or cope with the environment. Health is, therefore, seen as a resource for everyday life, not the objective of living; it is a positive concept emphasizing social and personal resources, and physical capacities. (WHO, 1986, p. 73)

Saylor (2004) pointed out that the WHO definition considers several dimensions of health. These include physical (structure/function), social, role, mental (emotional and intellectual), and general perceptions of health status. It also conceptualizes health from a macro perspective, as a resource to be used rather than a goal in and of itself.

The nursing literature contains many varied definitions of health.



For example, health has been defined as “a state of well-being in which the person is able to use purposeful, adaptive responses and processes physically, mentally, emotionally, spiritually, and socially” (Murray, Zentner, and Yakimo, 2009, p. 53); “realization of human potential through goal-directed behavior, competent self-care, and satisfying relationships with others” (Pender, Murdaugh, and Parsons, 2011, p. 22); and a state of a person that is characterized by soundness or wholeness of developed human structures and of bodily and mental functioning (Orem, 2001).

The variety of characterizations of the word illustrates the difficulty in standardizing the conceptualization of health. Commonalities involve description of “goal-directed” or “purposeful” actions, processes, responses, or behaviors and the possession of “soundness,” “wholeness,” and/or “well-being.” Problems can arise when the definition involves a unit of analysis. For example, some writers use the individual or “person” as the unit of analysis and exclude the community. Others may include additional concepts, such as adaptation and environment, in health definitions, and then present the environment as static and requiring human adaptation rather than as changing and enabling human modification.

For many years, community and public health nurses have favored Dunn’s (1961) classic concept of wellness, in which family, community, society, and environment are interrelated and have an impact on health. From his viewpoint, illness, health, and peak wellness are on a continuum; health is fluid and changing. Consequently, within a social context or environment, the state of health depends on the goals, potentials, and performance of individuals, families, communities, and societies.

Community The definitions of community are also numerous and variable. Baldwin and colleagues (1998) outlined the evolution of the definition of community by examining community health nursing textbooks. They determined that, before 1996, definitions of community focused on geographic boundaries combined with social attributes of people.



Citing several sources from the later part of the decade, the authors observed that geographic location became a secondary characteristic in the discussion of what defines a community.

In recent nursing literature, community has been defined as “a collection of people who interact with one another and whose common interests or characteristics form the basis for a sense of unity or belonging” (Allender, Rector, and Warner, 2013, p. 6); “a group of people who share something in common and interact with one another, who may exhibit a commitment with one another and may share a geographic boundary” (Lundy and Janes, 2009, p. 16); and “a locality-based entity, composed of systems of formal organizations reflecting society’s institutions, informal groups and aggregates” (Shuster, 2012, p. 398).

Maurer and Smith (2013) further addressed the concept of community and identified three defining attributes: people, place, and social interaction or common characteristics, interests, or goals. Combining ideas and concepts, in this text, community is seen as a group or collection of individuals interacting in social units and sharing common interests, characteristics, values, and goals.

Maurer and Smith (2013) noted that there are two main types of communities: geopolitical communities and phenomenological communities. Geopolitical communities are those most traditionally recognized or imagined when the term community is considered. Geopolitical communities are defined or formed by natural and/or man- made boundaries and include cities, counties, states, and nations. Other commonly recognized geopolitical communities are school districts, census tracts, zip codes, and neighborhoods. Phenomenological communities, on the other hand, refer to relational, interactive groups. In phenomenological communities, the place or setting is more abstract, and people share a group perspective or identity based on culture, values, history, interests, and goals. Examples of phenomenological communities are schools, colleges, and universities; churches, synagogues, and mosques; and various groups and organizations, such as social networks.



FIGURE 1-1 Model: Healthy People 2020. (From US Department of Health and Human Services Office of Disease

Prevention and Health Promotion. Federal Interagency Workgroup: The Vision, Mission, and Goals of Healthy People

2020. Retrieved July 2013 from

A community of solution is a type of phenomenological community. A community of solution is a collection of people who form a group specifically to address a common need or concern. The Sierra Club, whose members lobby for the preservation of natural resource lands, and a group of disabled people who challenge the owners of an office building to obtain equal access to public buildings, education, jobs, and transportation are examples. These groups or social units work together to promote optimal “health” and to address identified actual and potential health threats and health needs.

Population and aggregate are related terms that are often used in public health and community health nursing. Population is typically used to denote a group of people having common personal or environmental characteristics. It can also refer to all of the people in a defined community (Maurer and Smith, 2013). Aggregates are



subgroups or subpopulations that have some common characteristics or concerns (Harkness, 2012). Depending on the situation, needs, and practice parameters, community health nursing interventions may be directed toward a community (e.g., residents of a small town), a population (e.g., all elders in a rural region), or an aggregate (e.g., pregnant teens within a school district).



Determinants of Health and Disease The health status of a community is associated with a number of factors, such as health care access, economic conditions, social and environmental issues, and cultural practices, and it is essential for the community health nurse to understand the determinants of health and recognize the interaction of the factors that lead to disease, death, and disability. It has been estimated that individual behaviors are responsible for about 50% of all premature deaths in the United States (Orleans and Cassidy, 2011). Indeed, individual biology and behaviors influence health through their interaction with each other and with the individual’s social and physical environments. Thus, policies and interventions can improve health by targeting detrimental or harmful factors related to individuals and their environment. Figure 1-1 shows the model of Healthy People 2020, which depicts the interaction of these determinants and shows how they influence health.

In a seminal work, McGinnis and Foege (1993) described what they termed “actual causes of death” in the United States, explaining how lifestyle choices contribute markedly to early deaths. Their work was updated a decade later (Mokdad et al, 2004). Leading the list of “actual causes of death” was tobacco, which was implicated in almost 20% of the annual deaths in the United States—approximately 435,000 individuals. Poor diet and physical inactivity were deemed to account for about 16.6% of deaths (about 400,000 per year), and alcohol consumption was implicated in about 85,000 deaths because of its association with accidents, suicides, homicides, and cirrhosis and chronic liver disease. Other leading causes of death were microbial agents (75,000), toxic agents (55,000), motor vehicle crashes (43,000), firearms (29,000), sexual behaviors (20,000) and illicit use of drugs (17,000). Although all of these causes of mortality are related to individual lifestyle choices, they can also be strongly influenced by population-focused policy efforts and education. For example, the prevalence of smoking has fallen dramatically during the past two decades, largely because of legal efforts (e.g., laws prohibiting sale of



tobacco to minors and much higher taxes), organizational policy (e.g., smoke-free workplaces), and education. Likewise, later concerns about the widespread increase in incidence of overweight and obesity have led to population-based measures to address the issue (e.g., removal of soft drink and candy machines from schools, regulations prohibiting the use of certain types of fats in processed foods).

Public health experts have observed that health has improved over the past 100 years largely because people become ill less often (Russo, 2011; McKeown, 2003). Indeed, at the population level, better health can be attributed to higher standards of living, good nutrition, a healthier environment, and having fewer children. Furthermore, public health efforts, such as immunization and clean air and water, and medical care, including management of acute episodic illnesses (e.g., pneumonia, tuberculosis) and chronic disease (e.g., cancer, heart disease), have also contributed significantly to the increase in life expectancy.

Community and public health nurses should understand these concepts and appreciate that health and illness are influenced by a web of factors, some that can be changed (e.g., individual behaviors such as tobacco use, diet, physical activity) and some that cannot (e.g., genetics, age, gender). Other factors (e.g., physical and social environment) may require changes that will need to be accomplished from a policy perspective. Community health nurses must work with policy makers and community leaders to identify patterns of disease and death and to advocate for activities and policies that promote health at the individual, family, and population levels.



Indicators of Health and Illness A variety of health indicators are used by health providers, policy makers, and community health nurses to measure the health of the community. Local or state health departments, the Centers for Disease Control and Prevention (CDC), and the National Center for Health Statistics (NCHS) provide morbidity, mortality, and other health status–related data. State and local health departments are responsible for collecting morbidity and mortality data and forwarding the information to the appropriate federal-level agency, which is often the CDC. Some of the more commonly reported indicators are life expectancy, infant mortality, age-adjusted death rates, and cancer incidence rates.

Indicators of mortality in particular illustrate the health status of a community and/or population because changes in mortality reflect a number of social, economic, health service, and related trends (Shi and Singh, 2011). These data may be useful in analyzing health patterns over time, comparing communities from different geographic regions, or comparing different aggregates within a community.

When the national health objectives for Healthy People 2020 were being developed, a total of 12 leading health indicators were identified that reflected the major public health concerns in the United States (See Healthy People 2020 box). They are individual behaviors (e.g., tobacco use, nutrition, physical activity, and obesity), physical and social environmental factors (e.g., environmental quality, injury, and violence), and health systems issues (e.g., access to health services). Each of these indicators can affect the health of individuals and communities and can be correlated with leading causes of morbidity and mortality. For example, tobacco use is linked to heart disease, stroke, and cancer; substance abuse is linked to accidents, injuries, and violence; irresponsible sexual behaviors can lead to unwanted pregnancy as well as sexually transmitted diseases, including human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS); and lack of access to health care can contribute to poor



pregnancy outcomes, untreated illness, and disability.


Leading Health Indicator Topics • Access to Health Services • Clinical Preventative Services • Environmental Quality • Injury and Violence • Maternal, Infant and Child Health • Mental Health • Nutrition, Physical Activity, and Obesity • Oral Health • Reproductive and Sexual Health • Social Determinants • Substance Abuse • Tobacco From U.S. Department of Health and Human Services: Healthy People 2020 leading health indicator topics. Retrieved July 2013 from <>.

Community health nurses should be aware of health patterns and health indicators within their practice. Each nurse should ask relevant questions, including the following: What are the leading causes of death and disease among various groups served? How do infant mortality rates and teenage pregnancy rates in my community compare with regional, state, and national rates? What are the most serious communicable disease threats in my neighborhood? What are the most common environmental risks in my city?

The community health nurse may identify areas for further investigation and intervention through an understanding of health, disease, and mortality patterns. For example, if a school nurse learns that the teenage pregnancy rate in their community is higher than regional and state averages, the nurse should address the problem with school officials, parents, and students. Likewise, if an



occupational health nurse discovers an apparent high rate of chronic lung disease in an industrial facility, the nurse should work with company management, employees, and state and federal officials to identify potential harmful sources. Finally, if a public health nurse works in a state-sponsored AIDS clinic and recognizes an increase in the number of women testing positive for HIV, the nurse should report all findings to the designated agencies. The nurse should then participate in investigative efforts to determine what is precipitating the increase and work to remedy the identified threats or risks.



Definition and Focus of Public Health and Community Health C. E. Winslow is known for the following classic definition of public health:

Public health is the Science and Art of (1) preventing disease, (2) prolonging life, and (3) promoting health and efficiency through organized community effort for: (a) sanitation of the environment, (b) control of communicable infections, (c) education of the individual in personal hygiene, (d) organization of medical and nursing services for the early diagnosis and preventive treatment of disease, and (e) development of the social machinery to ensure everyone a standard of living adequate for the maintenance of health, so organizing these benefits as to enable every citizen to realize his birthright of health and longevity. (Hanlon, 1960, p. 23)

A key phrase in this definition of public health is “through organized community effort.” The term public health connotes organized, legislated, and tax-supported efforts that serve all people through health departments or related governmental agencies.

The public health nursing tradition, begun in the late 1800s by Lillian Wald and her associates, clearly illustrates this phenomenon (Wald, 1971; see Chapter 2). After moving into the immigrant community in New York City to provide care for individuals and families, these early public health nurses saw that neither administering bedside clinical nursing nor teaching family members to deliver care in the home adequately addressed the true determinants of health and disease. They resolved that collective political activity should focus on advancing the health of aggregates and improving social and environmental conditions by addressing the social and environmental determinants of health, such as child labor, pollution, and poverty. Wald and her colleagues affected the health of



the community by organizing the community, establishing school nursing, and taking impoverished mothers to testify in Washington, DC (Wald, 1971).

In a key action, the Institute of Medicine (IOM) (1988) identified the following three primary functions of public health: assessment, assurance, and policy development. Box 1-1 lists each of the three primary functions and describes them briefly. All nurses working in community settings should develop knowledge and skills related to each of these primary functions.

The term community health extends the realm of public health to include organized health efforts at the community level through both government and private efforts. Participants include privately funded agencies such as the American Heart Association and the American Red Cross. A variety of private and public structures serves community health efforts.

Public health efforts focus on prevention and promotion of population health at the federal, state, and local levels. These efforts at the federal and state levels concentrate on providing support and advisory services to public health structures at the local level. The local-level structures provide direct services to communities through two avenues:

BOX 1-1 CORE PUBLIC HEALTH FUNCTIONS Assessment: Regular collection, analysis, and information sharing

about health conditions, risks, and resources in a community. Policy development: Use of information gathered during

assessment to develop local and state health policies and to direct resources toward those policies.

Assurance: Focuses on the availability of necessary health services throughout the community. It includes maintaining the ability of both public health agencies and private providers to manage day- to-day operations and the capacity to respond to critical situations



and emergencies. From Institute of Medicine: The future of public health, Washington, DC, 1988, National Academy Press.

BOX 1-2 ESSENTIAL PUBLIC HEALTH SERVICES • Monitor health status to identify and solve community health

problems • Diagnose and investigate health problems and health hazards in

the community • Inform, educate, and empower people about health issues • Mobilize community partnerships and actions to identify and

solve health problems • Develop policies and plans that support individual and

community health efforts • Enforce laws and regulations that protect health and ensure safety • Link people to needed personal health services and assure the

provision of health care when otherwise unavailable • Assure a competent public health and personal health care

workforce • Evaluate effectiveness, accessibility, and quality of personal and

population-based health services • Research for new insights and innovative solutions to health

problems From Centers for Disease Control and Prevention, Office of the Director, Office of the Chief of Public Health Practice, National Public Health Performance Standards Program: 10 essential public health services, Atlanta, 2012. Retrieved July 2013 from <>.

• Community health services, which protect the public from hazards such as polluted water and air, tainted food, and unsafe housing

• Personal health care services, such as immunization and family planning services, well-infant care, and sexually transmitted disease (STD) treatment Personal health services may be part of the public health effort and



often target the populations most at risk and in need of services. Public health efforts are multidisciplinary because they require people with many different skills. Community health nurses work with a diverse team of public health professionals, including epidemiologists, local health officers, and health educators. Public health science methods that assess biostatistics, epidemiology, and population needs provide a method of measuring characteristics and health indicators and disease patterns within a community. In 1994 the American Public Health Association drafted a list of ten essential public health services, which the U.S. Department of Health and Human Services (USDHHS, 1997) later adopted. This updated list (CDC, 2010) appears in Box 1-2.



Preventive Approach to Health Health Promotion and Levels of Prevention Contrasting with “medical care,” which focuses on disease management and “cure,” public health efforts focus on health promotion and disease prevention. Health promotion activities enhance resources directed at improving well-being, whereas disease prevention activities protect people from disease and the effects of disease. Leavell and Clark (1958) identified three levels of prevention commonly described in nursing practice: primary prevention, secondary prevention, and tertiary prevention (Figure 1-2 and Table 1- 1).

FIGURE 1-2 The three levels of prevention.

Primary prevention relates to activities directed at preventing a



problem before it occurs by altering susceptibility or reducing exposure for susceptible individuals. Primary prevention consists of two elements: general health promotion and specific protection. Health promotion efforts enhance resiliency and protective factors and target essentially well populations. Examples include promotion of good nutrition, provision of adequate shelter, and encouraging regular exercise. Specific protection efforts reduce or eliminate risk factors and include such measures as immunization and water purification (Keller et al, 2004a; McEwen and Pullis, 2009).

Secondary prevention refers to early detection and prompt intervention during the period of early disease pathogenesis. Secondary prevention is implemented after a problem has begun but before signs and symptoms appear and targets those populations that have risk factors (Keller et al, 2004a). Mammography, blood pressure screening, scoliosis screening, and Papanicolaou smears are examples of secondary prevention.


AIDS, Acquired immunodeficiency syndrome; HIV, human immunodeficiency virus; STD, sexually transmitted disease; VDRL, Venereal Disease Research Laboratory. ∗ Note that terms are used differently in literature of various disciplines. There are not any clear-cut definitions; for example, families may be referred to as an



aggregate, and a population and subpopulations may exist within a community.

Tertiary prevention targets populations that have experienced disease or injury and focuses on limitation of disability and rehabilitation. Aims of tertiary prevention are to keep health problems from getting worse, to reduce the effects of disease and injury, and to restore individuals to their optimal level of functioning (Keller et al, 2004b; McEwen and Pullis, 2009). Examples include teaching how to perform insulin injections and disease management to a patient with diabetes, referral of a patient with spinal cord injury for occupational and physical therapy, and leading a support group for grieving parents.

Much of community health nursing practice is directed toward preventing the progression of disease at the earliest period or phase feasible using the appropriate level(s) of prevention. For example, when applying “levels of prevention” to a client with HIV/AIDS, a nurse might perform the following interventions: • Educate students on the practice of sexual abstinence or “safer sex”

by using barrier methods (primary prevention) • Encourage testing and counseling for clients with known exposure

or who are in high-risk groups; provide referrals for follow-up for clients who test positive for HIV (secondary prevention)

• Provide education on management of HIV infection, advocacy, case management, and other interventions for those who are HIV positive (tertiary prevention) (McEwen and Pullis, 2009).

The concepts of prevention and population-focused care figure prominently in a conceptual orientation to nursing practice referred to as “thinking upstream.” This orientation is derived from an analogy of patients falling into a river upstream and being rescued downstream by health providers overwhelmed with the struggle of responding to disease and illness. The river as an analogy for the natural history of illness was first coined by McKinlay (1979), with a charge to health providers to refocus their efforts toward preventive and “upstream” activities. In a description of the daily challenges of



providers to address health from a preventive versus curative focus, McKinlay differentiates the consequences of illness (downstream endeavors) from its precursors (upstream endeavors). The author then charges health providers to critically examine the relative weights of their activities toward illness response versus the prevention of illness.

A population-based perspective on health and health determinants is critical to understanding and formulating nursing actions to prevent disease. By examining the origins of disease, nurses identify social, political, environmental, and economic factors that often lead to poor health options for both individuals and populations. The call to refocus the efforts of nurses “upstream, where the real problems lie” (McKinlay, 1979) has been welcomed by community health nurses in a variety of practice settings. For these nurses, this theme provides affirmation of their daily efforts to prevent disease in populations at risk in schools, work sites, and clinics throughout their local communities and in the larger world.


Inequities: Distribution of Resources In the United States, inequities in the distribution of resources pose a threat to the common good and a challenge for community and public health nurses. Factors that contribute to wide variations in health disparities include education, income, and occupation. Lack of health insurance is a key factor in this issue and a major rationale for passage of the Patient Protection and Affordable Care Act, as about 20% of nonelderly adults and 25% of children in the United States are uninsured. Lack of insurance is damaging to population health, as low-income, uninsured individuals are much less likely than nonpoor insured individuals to receive timely physical examinations and preventive dental care.

Public health nurses are regularly confronted with the consequences of the fragmented health care delivery system. They



diligently work to improve the circumstances for populations who have not had adequate access to resources largely because of who they are and where they live.

Ethical questions commonly encountered in community and public health nursing practice include the following: Should resources (e.g., free or low-cost immunizations) be offered to all, even those who have insurance that will pay for the care? Should public health nurses serve anyone who meets financial need guidelines, regardless of medical need? Should the health department provide flu shots to persons of all ages or just those most likely to be severely affected by the disease? Should illegal aliens or persons working on “green cards” receive the same level of health care services that are available to citizens?

Social justice in health care is a goal for all. To this end, community and public health nurses must face the challenges and dilemmas related to these and other questions as they assist individuals, families, and communities dealing with the uneven distribution of health resources. From Ervin NE, Bell SE: Social justice issues related to uneven distribution of resources, J N Y State Nurses Assoc 35:8-13, 2004.

Prevention versus Cure Spending additional dollars for cure in the form of health care services does little to improve the health of a population, whereas spending money on prevention does a great deal to improve health. Getzen (2010) and others (Shi and Singh, 2011; Russo, 2011) note that there is an absence of convincing evidence that the amount of money expended for health care improves the health of a population. The real determinants of health, as mentioned, are prevention efforts that provide education, housing, food, a decent minimal income, and safe social and physical environments. The United States spends more than one sixth of its wealth on health care or “cure” for individuals, likely diverting money away from the needed resources and services that would make a greater impact on health (Shi and Singh, 2011; NCHS, 2012).



U.S. policy makers must become committed to achieving improved health outcomes for the poor and vulnerable populations. With a limited health workforce and monetary resources, the United States cannot continue to spend vast amounts on health care services when the investment fails to improve health outcomes. In industrialized countries, life expectancy at birth is not related to the level of health care expenditures; in developing countries, longevity is closely related to the level of economic development and the education of the population (Russo, 2011; Shi and Singh, 2012).

A continued overexpansion of the current health care system following passage of the Affordable Care Act (ACA) could actually be detrimental to the health of the population. The focus on obtaining health insurance for more people may defer a large investment of the country’s wealth from education and other developmental efforts that would positively affect health. Managed care organizations (MCOs) focus on prevention; therefore, they have determined that the rate of health care cost increases have slowed among employees of large firms (Shi and Singh, 2012). Prevention programs may help reduce costs for those enrolled in MCOs, but it remains unclear who will provide services for those who are required to purchase insurance, those who are currently uninsured and may remain so, the poor, and other vulnerable populations. In addition, still to be determined is who will provide adequate schooling, housing, meals, wages, and a safe environment for the disadvantaged. Increasing health care spending may negatively impact efforts to address economic disparities by reducing investments in sufficient housing, jobs, education, nutrition, and safe environments.

Healthy People 2020 In 1979, the U.S. Department of Health and Human Services published a national prevention initiative titled Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention. The 1979 version established goals that would reduce mortality among infants, children, adolescents and young adults, and adults and increase independence among older adults. In 1990, the mortality of



infants, children, and adults declined sufficiently to meet the goal. Adolescent mortality did not reach the 1990 target, and data systems were unable to adequately track the target for older adults (USDHHS, 2000).

Published in 1989, Healthy People 2000 built on the first Surgeon General’s report. Healthy People 2000 contained the following broad goals (USDHHS, 1989): 1. Increase the span of healthy life for Americans. 2. Reduce health disparities among Americans. 3. Achieve access to preventive services for all Americans.

The purpose of Healthy People 2000 was to provide direction for individuals wanting to change personal behaviors and to improve health in communities through health promotion policies. The report assimilated the broad approaches of health promotion, health protection, and preventive services and contained more than 300 objectives organized into 22 priority areas. Although many of the objectives fell short, the initiative was extremely successful in raising providers’ awareness of health behaviors and health promotional activities. States, local health departments, and private sector health workers used the objectives to determine the relative health of their communities and to set goals for the future.

Healthy People 2010 emerged in January 2000. It expanded on the objectives from Healthy People 2000 through a broadened prevention science base, an improved surveillance and data system, and a heightened awareness of and demand for preventive health services. This change reflects changes in demographics, science, technology, and disease. Healthy People 2010 listed two broad goals: Goal 1: Increase quality and years of healthy life. Goal 2: Eliminate health disparities.

The first goal moved beyond the idea of increasing life expectancy to incorporate the concept of health-related quality of life (HRQOL). This concept of health includes aspects of physical and mental health and their determinants and measures functional status, participation, and well-being. HRQOL expands the definition of health—beyond simply opposing the negative concepts of disease and death—by



integrating mental and physical health concepts (USDHHS, 2000). The final review and analysis of the Healthy People 2010 objectives

showed decidedly mixed progress for the nation. Some 23% of the objectives were met or exceeded, and another 48% “moved toward target.” Conversely, 24% of the objectives “moved away from target” (i.e., the indicators were worse than in the previous decade), and another 5% showed no change. Particularly concerning were the poor responses in two of the Focus Areas: Arthritis, Osteoporosis and Chronic Back conditions (Focus Area 2) and Nutrition and Overweight (Focus Area 19) “moved toward” or “achieved” less than 25% of their targets (USDHHS, 2013).

The fourth version of the Nation’s health objectives, Healthy People 2020, was published in 2010. Healthy People 2020 is divided into 42 Topic Areas and contains numerous new objectives and updates for hundreds of objectives from the previous editions. The Topic Areas are listed in the Healthy People 2020 box. The objectives and related information and materials can help guide health promotion activities and can be used to aid in community-wide initiatives (USDHHS, 2013). All health care practitioners, particularly those working in the community, should review the Healthy People 2020 objectives and focus on the relevant areas in their practice. Practitioners should incorporate these objectives into programs, events, and publications whenever possible and should use them as a framework to promote healthy cities and communities. Selected relevant objectives are presented throughout this book to acquaint future community health nurses with the scope of the Healthy People 2020 initiative and to enhance awareness of current health indicators and national goals (see for more information).


Topic Areas • Access to health services • Adolescent health



• Arthritis, osteoporosis, and chronic back conditions • Blood disorders and blood safety • Cancer • Chronic kidney disease • Dementias, including Alzheimer’s • Diabetes • Disability and health • Early and middle childhood • Educational and community-based programs • Environmental health • Family planning • Food safety • Genomics • Global health • Health communication and health information technology • Healthcare-associated infections • Health-related quality of life and well-being • Hearing and other sensory or communication disorders • Heart disease and stroke • HIV • Immunization and infectious diseases • Injury and violence prevention • Lesbian, gay, bisexual and transgender health • Maternal, infant, and child health • Medical product safety • Mental health and mental disorders • Nutrition and weight status • Occupational safety and health • Older adults • Oral health • Physical activity • Preparedness • Public health infrastructure • Respiratory diseases • Sexually transmitted diseases



• Social determinants of health • Substance abuse • Tobacco use • Vision From U.S. Department of Health and Human Services: Healthy People 2020 topics & objectives —objectives A-Z. Retrieved July 2013 from <>.



Definition and Focus of Public Health Nursing, Community Health Nursing, and Community-Based Nursing The terms community health nursing and public health nursing are often used synonymously or interchangeably. Like the practice of community/public health nursing, the terms are evolving. In past debates and discussions, definitions of “community health nursing” and “public health nursing ” have indicated similar yet distinctive ideologies, visions, or philosophies of nursing. These concepts and a third related term—community-based nursing—are discussed in this section.

Public and Community Health Nursing Public health nursing has frequently been described as the synthesis of public health and nursing practice. Freeman (1963) provided a classic definition of public health nursing:

Public health nursing may be defined as a field of professional practice in nursing and in public health in which technical nursing, interpersonal, analytical, and organizational skills are applied to problems of health as they affect the community. These skills are applied in concert with those of other persons engaged in health care, through comprehensive nursing care of families and other groups and through measures for evaluation or control of threats to health, for health education of the public, and for mobilization of the public for health action. ( p.34)

Through the 1980s and 1990s, most nurses were taught that there was a distinction between “community health nursing” and “public health nursing.” Indeed, “public health nursing” was seen as a subspecialty nursing practice generally delivered within “official” or governmental agencies. In contrast, “community health nursing” was considered to be a broader and more general specialty area that encompassed many additional sub specialties (e.g., school nursing,



occupational health nursing, forensic nursing, home health). In 1980, the ANA defined community health nursing as “the synthesis of nursing practice and public health practice applied to promoting and preserving the health of populations” (ANA, 1980, p. 2). This viewpoint noted that a community health nurse directs care to individuals, families, or groups; this care, in turn, contributes to the health of the total population.

The ANA has revised the standards of practice for this specialty area (ANA, 2013). In the updated standards, the designation was again “public health nursing,” and the ANA used the definition presented by the American Public Health Association (APHA) Committee on Public Health Nursing (1996). Thus, public health nursing is defined as “the practice of promoting and protecting the health of populations using knowledge from nursing, social, and public health sciences” (ANA/APHA, 1996, p. 5). The ANA (2013) elaborated by explaining that public health nursing practice “is population-focused, with the goals of promoting health and preventing disease and disability for all people through the creation of conditions in which people can be healthy” (p. 5).

Some nursing writers will continue to use community health nursing as a global or umbrella term and public health nursing as a component or subset. Others, as stated, use the terms interchangeably. This book uses the terms interchangeably.

RESEARCH HIGHLIGHTS Public Health Nursing Research Agenda In 2010, a national conference was held to set a research agenda that would advance the science of public health nursing (PHN). The conference employed a multistage, multimethod, participatory developmental approach, involving many influential PHN leaders. Following numerous meetings and discussions, an agenda was proposed. The agenda was structured around four “High Priority Themes”: (1) public health nursing interventions models, (2) quality



of population-focused practice, (3) metrics of/for public health nursing, and (4) comparative effectiveness and public health nursing outcomes. The aim of the agenda is to help PHN scholars contribute to an understanding of how to improve health and reduce population health disparities by advancing the evidence base regarding the outcomes of practice and by influencing related health policy. The group encouraged the agenda’s use to guide and inform programs of research, to influence funding priorities, and to be incorporated into doctoral PHN education through course and curriculum development. Ultimately, it is anticipated that PHN research will proactively contribute to the effectiveness of the public health system and create healthier communities. Data from Issel LM, Bekemeier B, Kneipp S: A public health nursing research agenda, Public Health Nurs 29:330-342, 2012.

Community-Based Nursing The term community-based nursing has been identified and defined in recent years to differentiate it from what has traditionally been seen as community and public health nursing practice. Community-based nursing practice refers to “application of the nursing process in caring for individuals, families and groups where they live, work or go to school or as they move through the health care system” (McEwen and Pullis, 2009, p. 6). Community-based nursing is setting-specific, and the emphasis is on acute and chronic care and includes such practice areas as home health nursing and nursing in outpatient or ambulatory settings.

Zotti, Brown, and Stotts (1996) compared community-based nursing and community health nursing and explained that the goals of the two are different. Community health nursing emphasizes preservation and protection of health, and community-based nursing emphasizes managing acute or chronic conditions. In community health nursing, the primary client is the community; in community-based nursing, the primary clients are the individual and the family. Finally, services in community-based nursing are largely direct, but in community health nursing, services are both direct and indirect.



Community and Public Health Nursing Practice Community and public health nurses practice disease prevention and health promotion. It is important to note that community health nursing practice is collaborative and is based in research and theory. It applies the nursing process to the care of individuals, families, aggregates, and the community. Box 1-3 provides an overview of the Standards for Public Health Nursing (ANA, 2013).

BOX 1-3 THE SCOPE AND STANDARDS OF PRACTICE FOR PUBLIC HEALTH NURSING The Scope and Standards of Practice for Public Health Nursing is the result of the collaborative effort between the American Nurse Association and the Quad Council of Public Health Nursing Organizations. The Standards were originally developed in 1999 and were updated in 2013. The Scope and Standards of Practice, which are divided into Standards of Practice and Standards of Professional Performance, describe specific competencies relevant to the public health nurse and the public health nurse in advanced practice.

The Standards of Practice include six standards that are based on the critical thinking model of the nursing process, with competencies addressing each nursing process step. The implementation step is further broken down into specific public health areas including coordination of services, health education and health promotion, consultation, and regulatory activities. The Standards of Professional Performance include the leadership competencies necessary in the professional practice of all registered nurses, but with additional standards specific to the public health nurse and advance public health nurse roles. These standards including evidence-based practice and research, collaboration, resource utilization, and advocacy, with competencies specific to public health, such as building coalitions and achieving consensus



in public health issues, assessing available health resources within a population, and advocating for equitable access to care and services. Data from American Nurses Association: Public health nursing: Scope and standards of practice, ed 2, Silver Spring, MD, 2013, Author. The Standards can be purchased at < 2nd.aspx>.

As discussed, the core functions of public health are assessment, policy development, and assurance. In 2003, the Quad Council of Public Health Nursing Organizations (Quad Council) closely examined the core functions and used them to develop a set of public health nursing competencies. These competencies were updated in 2011 and are summarized in Table 1-2 (Quad Council, 2011). Current and future community health nurses should study these competencies to understand the practice parameters and skills required for public health nursing practice.



Population-Focused Practice and Community/Public Health Nursing Interventions Community/public health nurses must use a population-focused approach to move beyond providing direct care to individuals and families. Population-focused nursing concentrates on specific groups of people and focuses on health promotion and disease prevention, regardless of geographic location (Baldwin et al, 1998). The goal of population-focused nursing is “provision of evidence-based care to targeted groups of people with similar needs in order to improve outcomes” (Curley, 2012, p. 4). In short, population-focused practice (Minnesota Department of Health, 2003): • Focuses on the entire population • Is based on assessment of the populations’ health status • Considers the broad determinants of health • Emphasizes all levels of prevention • Intervenes with communities, systems, individuals, and families

Whereas community and public health nurses may be responsible for a specific subpopulation in the community (e.g., a school nurse may be responsible for the school’s pregnant teenagers), population- focused practice is concerned with many distinct and overlapping community subpopulations. The goal of population-focused nursing is to promote healthy communities.

Population-focused community health nurses would not have exclusive interest in one or two subpopulations, but instead would focus on the many subpopulations that make up the entire community. A population focus involves concern for those who do, and for those who do not, receive health services. A population focus also involves a scientific approach to community health nursing. Thus a thorough, systematic assessment of the community or population is necessary and basic to planning, intervention, and evaluation for the individual, family, aggregate, and population levels.