Community DQ6
Read chapters 10 and 12 of the class textbooks and review the PowerPoint presentations located in the PowerPoint folder. Once done answer the following questions.
1. Discuss the meaning of culture and its effect on transcultural nursing.
2. Discuss the term subcultures and give some examples.
3. In your own words describe what is case management and care management? Mention the similarities and differences between the two concepts.
4. Identify and discuss the role of the home care nurse as part of the interdisciplinary team.
PLAGIARISM FREE
APA format (intext citations and references)
A minimum of 3 evidence-based references no older than 5 years must be used.
A minimum of 800 words not to exceed 1,000 are required without counting the first and last page.
1
Community and
Public Health
Nursing | 3rd edition
EVIDENCE FOR PRACTICE
Rosanna F. DeMarco, PhD, RN, FAAN
Chair and Professor
Department of Nursing
College of Nursing and Health Sciences
University of Massachusetts Boston
Boston, Massachusetts
Judith Healey-Walsh, PhD, RN
Clinical Associate Professor
Director of the Undergraduate Program
Department of Nursing
College of Nursing and Health Sciences
University of Massachusetts Boston
Boston, Massachusetts
2
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3rd Edition
Copyright © 2020 Wolters Kluwer.
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rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form
or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information
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9 8 7 6 5 4 3 2 1
Printed in China.
Library of Congress Cataloging-in-Publication Data
Names: DeMarco, Rosanna F., author. | Healey-Walsh, Judith, author. | Preceded by (work): Harkness, Gail A.
Community and public health nursing.
Title: Community and public health nursing : evidence for practice / Rosanna F. DeMarco, Judith Healey-Walsh.
Description: 3. | Philadelphia : Wolters Kluwer, [2020] | Preceded by Community and public health nursing / Gail A.
Harkness, Rosanna F. DeMarco. Second edition. [2016]. | Includes bibliographical references
and index.
Identifiers: LCCN 2018058862 | eISBN 9781975144500
Subjects: | MESH: Community Health Nursing | Public Health Nursing | Evidence-Based Nursing | Nursing Theory |
United States
Classification: LCC RT98 | NLM WY 108 | DDC 610.73/43—dc23
LC record available at https://lccn.loc.gov/2018058862
Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices.
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application of the information in this book and make no warranty, expressed or implied, with respect to the currency,
completeness, or accuracy of the contents of the publication. Application of this information in a particular situation
remains the professional responsibility of the practitioner; the clinical treatments described and recommended may not
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text are in accordance with the current recommendations and practice at the time of publication. However, in view of
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Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for
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each drug or device planned for use in his or her clinical practice.
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Contributors
Stephanie M. Chalupka, EdD, RN, PHCNS-BC, FAAOHN, FNAP
Associate Dean for Nursing
Department of Nursing
Worcester State University
Worcester
Visiting Scientist
Environmental and Occupational Medicine and Epidemiology Program
Department of Environmental Health
Harvard T. H. Chan School of Public Health
Boston, Massachusetts
(Chapter 9, Planning for Community Change)
Susan K. Chase, EdD, RN, FNAP
Professor
College of Nursing
University of Central Florida
Orlando, Florida
(Chapter 23, Faith-Oriented Communities and Health Ministries in Faith
Communities)
Sabreen A. Darwish, RN, BScN, MScN
Second Year PhD Student/Research Assistant
College of Nursing and Health Sciences
University of Massachusetts
Boston, Massachusetts
(Chapter 3, Health Policy, Politics, and Reform)
Karen Dawn, RN, DNP, PHCNS, CDE
Assistant Professor
School of Nursing
George Washington University
Ashburn, Virginia
(Chapter 4, Global Health: A Community Perspective)
Pamela Pershing DiNapoli, PhD, RN, CNL
Associate Professor of Nursing and Graduate Programs
College of Health and Human Services
University of New Hampshire
Durham, New Hampshire
(Chapter 22, School Health)
4
Merrily Evdokimoff, PhD, RN
Consultant
Clinical Associate Lecturer
Department of Nursing
University of Massachusetts
Boston, Massachusetts
(Chapter 20, Community Preparedness: Disaster and Terrorism)
Barbara A. Goldrick, MPH, PhD, RN
Epidemiology Consultant
Chatham, Massachusetts
(Chapter 8, Gathering Evidence for Public Health Practice; Chapter 14, Risk of
Infectious and Communicable Diseases; Chapter 15, Emerging Infectious
Diseases)
Patricia Goyette, DNP-PHNL, RN
Educational Consultant
Everett, Massachusetts
(Chapter 25, Occupational Health Nursing)
Cheryl L. Hersperger, MS, RN, PHNA-BC, PhD Student
Assistant Professor
Department of Nursing
Worcester State University
Worcester, Massachusetts
(Chapter 9, Planning for Community Change)
Anahid Kulwicki, PhD, RN, FAAN
Dean and Professor
School of Nursing
Lebanese American University
Beirut, Lebanon
(Chapter 3, Health Policy, Politics, and Reform)
Carol Susan Lang, DScN, MScN(Ed.), RN
Associate Director of Global Initiatives
Assistant Professor of Global and Population Health
George Washington University School of Nursing
Washington, DC
Annie Lewis-O’Connor, PhD, NP-BC, MPH, FAAN
Senior Nurse Scientist and Founder and Director of C.A.R.E Clinic
Brigham and Women’s Hospital
Boston, Massachusetts
(Chapter 16, Violence and Abuse)
5
Patricia Lussier-Duynstee, PhD, RN
Assistant Dean
Assistant Professor
School of Nursing
MGH Institute of Health Professions
Boston, Massachusetts
(Chapter 6, Epidemiology: The Science of Prevention; Chapter 7, Describing
Health Conditions: Understanding and Using Rates)
Kiara Manosalvas, MA
Reseach Assistant II The Following & Mental Health Counselor
Teachers College
Columbia University
Chestnut Hill, Massachusetts
(Chapter 16, Violence and Abuse)
Patrice Nicholas, DNSc, DHL (Hon.), MPH, MS, RN, NP-C, FAAN
Professor
School of Nursing
MGH Institute of Health Professions
Director, Global Health and Academic Partnerships
Brigham and Women’s Hospital
Boston, Massachusetts
(Chapter 6, Epidemiology: The Science of Prevention; Chapter 7, Describing
Health Conditions: Understanding and Using Rates)
Christine Pontus, RN, MS, BSN, COHN-S/CCM
Associate Director in Nursing and Occupational Health
Massachusetts Nurses Association (MNA)
Canton, Massachusetts
(Chapter 25, Occupational Health Nursing)
Joyce Pulcini, PhD, RN, PNP-BC, FAAN, FAANP
Professor
Director of Community and Global Initiatives
Chair, Acute and Chronic Care Community
School of Nursing
George Washington University
Washington, DC
(Chapter 4, Global Health: A Community Perspective)
Teresa Eliot Roberts, PhD, RN, ANP
Clinical Assistant Professor
College of Nursing and Health Sciences
University of Massachusetts Boston
Boston, Massachusetts
6
(Chapter 10, Cultural Competence: Awareness, Sensitivity, and Respect)
Judith Shindul-Rothschild, PhD, MSN, RN
Associate Professor
Connell School of Nursing
Boston College
Chestnut Hill, Massachusetts
(Chapter 17, Substance Use; Chapter 21, Community Mental Health)
Joy Spellman, MSN, RN
Director, Center for Public Health Preparedness
Mt. Laurel, New Jersey
(Chapter 20, Community Preparedness: Disaster and Terrorism)
Tarah S. Somers, RN, MSN/MPH
Senior Regional Director
Agency for Toxic Substances and Disease Registry, New England Office
US Public Health Service Commissioned Corps
Boston, Massachusetts
(Chapter 19, Environmental Health)
Patricia Tabloski, PhD, GNP-BC, FGSA, FAAN
Associate Professor
Connell School of Nursing
Boston College
Chestnut Hill, Massachusetts
(Chapter 24, Palliative and End-of-Life Care)
Aitana Zermeno, BS
Research Assistant
Connors Center for Women’s Health and Gender Biology
Division of Women’s Health
Brigham and Women’s Hospital
Boston, Massachusetts
(Chapter 16, Violence and Abuse)
7
Reviewers
Elizabeth Armstrong, DNP, MSN, RN, CNE
Assistant Professor
School of Nursing
University of Bridgeport
Bridgeport, Connecticut
Karen Cooper, MS, RN
Clinical Assistant Professor
Department of Nursing
Towson University
Towson, Maryland
Teresa E. Darnall, PhD, MSN, RN, CNE
Assistant Dean
Assistant Professor
May School of Nursing and Health Sciences
Lees-McRae College
Banner Elk, North Carolina
Florence Viveen Dood, DNP, MSN, BSN, RN
RN-BSN Program Coordinator
Assistant Professor
School of Nursing
Ferris State University
Big Rapids, Michigan
Aimee McDonald, PhD, RN
Assistant Professor
Department of Nursing
William Jewell College
Liberty, Missouri
Rita M. Million, PhD, RN, PHNA-BC, COI
Nursing Faculty
School of Nursing
College of Saint Mary
Omaha, Nebraska
8
Deanna R. Pope, DNP, RN, CNE
Professor
School of Nursing
Marshall University
Huntington, West Virginia
Kendra Schmitz, RN, MSN
Assistant Professor
School of Nursing
D’Youville College
Buffalo, New York
Kathleen F. Tate, MSN, MBA, CNE, RN
Assistant Professor
School of Nursing
Northwestern State University
Natchitoches, Louisiana
9
W
Preface
“If you want to go quickly, go alone. If you want to go far, go together.”
African Proverb
“The idea that some lives matter less is the root of all that is wrong in the world.”
Paul Farmer
“No matter what people tell you, words and ideas can change the world.”
Robin Williams
e are experiencing extraordinary changes in healthcare in this new century; changes
that call upon the most creative, analytical, and innovative skills available. While the
world has the resources to reduce healthcare disparities and eliminate the differences
in healthcare and health outcomes that exist between various population groups across the globe,
accomplishing this is a long-term and complicated task. Improvement in the social structure
within which people live, and a redistribution of resources so that all people have access to the
basic necessities of life, require an unprecedented global consciousness and political
commitment.
Ultimately, reducing health disparities and promoting health equity occur within the local
community where people reside. Nurses are by far the largest group of healthcare providers
worldwide and, as such, have the ability and responsibility to be change agents and leaders in
implementing change in their communities. They can be the primary participants in the
development of health policy that specifically addresses the unique needs of their communities.
Through implementation and evaluation of culturally appropriate, community-based programs,
nurses can use their expertise to remedy the conditions that contribute to health disparities.
People need to be assured that their healthcare needs will be assessed and that healthcare is
available and accessible.
In the United States, public health has resurged as a national priority. Through Healthy
People 2020, national goals have been set to promote a healthy population and address the issue
of health disparities. The process of implementing the Healthy People 2020 objectives rests with
regional and local practitioners, with nurses having a direct responsibility in the implementation
process. The nurse practicing in the community has a central role in providing direct care for the
ill as well as promoting and maintaining the health of groups of people, regardless of the
circumstances that exist. Today, there are unparalleled challenges to the nurse’s problem-solving
skills in carrying out this mission.
Whether caring for the individual or the members of a community, it is essential that nurses
incorporate evidence from multiple sources in the analysis and solution of public health issues.
Community and Public Health Nursing: Evidence for Practice focuses on evidence-based
practice, presenting multiple formats designed to develop the abstract critical thinking skills and
complex reasoning abilities necessary for nurses becoming generalists in community and public
health nursing. The unique blend of both the nursing process and the epidemiologic process
provides a framework for gathering evidence about health problems, analyzing the information,
generating diagnoses or hypotheses, planning for resolution, implementing plans of action, and
evaluating the results.
10
“To every complex question there is a simple answer…and it is wrong.” H. L. Mencken
(writer and wit, 1880–1956)
CONTENT ORGANIZATION
It is the intention of Community and Public Health Nursing: Evidence for Practice to present the
core content of community and public health nursing in a succinct, logically organized, but
comprehensive manner. The evidence for practice focus not only includes chapters on
epidemiology, biostatistics, and research but also integrates these topics throughout the text.
Concrete examples assist students in interpreting and applying statistical data. Healthy People
goals and measurable objectives serve as an illustration of the use of rates throughout the text.
Additionally, we have added brief learning activities and questions throughout the text to allow
students to apply the Healthy People goals to real-life scenarios. Groups with special needs,
such as refugees and the homeless, have been addressed in several chapters; however, tangential
topics that can be found in adult health and maternal-child health textbooks have been omitted.
A chapter on environmental health concerns has been included, along with a chapter on
community preparedness for emergencies and disasters. Also, a global perspective has been
incorporated into many chapters.
Challenges to critical thinking are presented in multiple places throughout each chapter.
Case studies are integrated into the content of each chapter and contain critical thinking
questions imbedded in the case study content. Also, a series of critical thinking questions can be
found at the end of each chapter. (Please see the description of features below.) Considering the
onus presented by Mark Twain: “Be careful about reading health books. You may die of a
misprint,” every attempt has been made to present correct, meaningful, and current evidence for
practice.
Part One presents the context within which the community or public health nurse practices.
An overview of the major drivers of healthcare change leads to a discussion of evolving trends,
such as the emphasis on patient/client-centered care, the effects of new technology upon the
delivery of care, and the need for people to assume more responsibility for maintaining their
health. Community and public health nursing as it presently exists is analyzed and reviewed
from a historical base, and issues foreseen for both the present and immediate future are
discussed. The nursing competencies necessary for competent community and public health
practice are also presented.
A more in-depth discussion of the complex structure, function, and outcomes of public
health and healthcare systems follows. National and international perspectives regarding
philosophical and political attitudes, social structures, economics, resources, financing
mechanisms, and historical contexts are presented, highlighting healthcare organizations and
issues in several developed countries. The World Health Organization’s commitment to
improving the public’s health in developing countries follows, with an emphasis on refugees and
disaster relief. With the burden of disease growing disproportionately in the world, largely due
to climate, public policy, socioeconomic conditions, age, and an imbalance in distribution of risk
factors, the countries burdened by disease often have the least capacity to institute change. Part
One concludes with examination of the indicators of health, health and human rights, factors that
affect health globally, and a framework for improving world health.
Part Two provides the frameworks and tools necessary to engage in evidence-based practice
focused on the population’s health. Concepts of health literacy, health promotion, disease
prevention, and risk reduction are explored, and a variety of conceptual frameworks are
presented with a focus on both the epidemiologic and ecologic models. Epidemiology is
presented as the science of prevention, and nurses are shown how epidemiologic principles are
11
applied in practice, including the use of rates and other statistics as community health indicators.
Specific research designs are also explored, including the application of epidemiologic research
to practice settings.
Part Three is designed to develop the skills necessary to implement nursing practice
effectively in community settings. Since healthcare is in a unique state of transformation,
planning for community change is paramount. The health planning process is described, with
specific attention given to the social and environmental determinants of change. Lewin’s change
theory, force-field analysis, and the effective use of leverage points identified in the force-field
analysis demonstrate the change process in action.
Changes directed at decreasing health disparities must be culturally sensitive, client-
centered, and community-oriented. A chapter on cultural diversity and values fosters the
development of culturally competent practitioners, and the process of cultural health assessment
is highlighted. Frameworks of community assessment are presented and various approaches are
explored. Management of care and the case management process follows. The role and scope of
home care nursing practice and the provision of services is presented along with the challenges
inherent with interdisciplinary roles, advances in telehealth, and other home care services.
Although content on family assessment can be found in other texts, it is an integral
component of community and public health practice. Therefore, theoretical perspectives of
family, and contemporary family configurations and life cycles are explored. Family Systems
Nursing and the Calgary Family Assessment and Intervention Model are provided as guides to
implementing family nursing practice in the community. Evidence-based maternal-child health
home visiting programs and prominent issues related to family caregiving are also highlighted.
Part Four presents the common challenges in community and public health nursing. The
chapter addressing the risk of infectious and communicable diseases explores outbreak
investigation with analysis of data experience provided by the case studies. Public health
surveillance, the risk of common foodborne and waterborne illnesses, and sexually transmitted
diseases are followed by a discussion of factors that influence the emergence/reemergence of
infectious diseases, examples of recent outbreaks, and means of prevention and control.
The challenge presented by violence in the community is presented with an emphasis on
intimate partner violence and the role of the healthcare provider. Because of the cultural
variations in substance use disorder, multifaceted approaches to the problem are discussed with
the recommendation that evidence-based prevention and treatment protocols for substance use
disorder are incorporated by community health nurses in all practice settings. Meeting the
healthcare needs of vulnerable and underserved populations is another challenge. Health
priorities for people who live in rural areas; are gay, lesbian, bisexual, or transgender; are
homeless; or live in correctional institutions are reviewed.
The issues of access to quality care, chronic disease management, interaction with health
personnel, and health promotion in hard-to-reach populations among these populations are also
presented.
The environmental chapter demonstrates how to assess contaminants in the community by
creation of an exposure pathway. The health effects of the exposure pathway can then be
ascertained. Individual assessment of contaminant exposures, interventions, and evaluations are
also explored, ending with a focus on maintaining healthy communities. The final chapter in
Part Four presents the issue of community preparedness. The types of disasters along with
classification of agents are described, disaster management outlined, and the public health
response explained. The role and responsibility of nurses in disasters and characteristics of the
field response complete the content.
Part Five describes five common specialty practices within community and public health
nursing. All have frameworks that define practice and reflect the competencies necessary for
competent practice in a variety of community settings. These include application of the
12
principles of practice to community mental health, school health, faith-oriented communities,
palliative care, and occupational health nursing.
Features Found in Each Chapter
CHAPTER HIGHLIGHTS
Brief outline of the content and direction of the chapter
OBJECTIVES
Observable changes expected following completion of the chapter
KEY TERMS
Essential concepts and terminology required for comprehension of chapter content
CASE STUDIES
Vignettes presented throughout the content of each chapter, designed to stimulate critical thinking and
analytic skills
Evidence for Practice
Examples of objective evidence obtained from research studies that provide direction for
practice
Practice Point
Highlighting of essential facts relevant to practice
Student Reflection
Student stories of their own experience and reflections
KEY CONCEPTS
Summary of important concepts presented in the chapter
CRITICAL THINKING QUESTIONS
13
Problems requiring critical analysis that combines research, context, and judgment
COMMUNITY RESOURCES
List of resources that support the content of selected chapters
I didn’t fail the test, I just found 100 ways to do it wrong. Benjamin Franklin
14
Acknowledgments
It is difficult to embark on the development of a new textbook without the support of colleagues,
family, and friends. A special thanks belongs to our contributors, both returning and new, who
were willing to share their expertise by writing chapters filled with the passion and commitment
to community and public health. In addition, we are thankful for the invaluable experiences we
obtained from our community and public health work that interfaced and informed the
production of this book. Those experiences ranged from developing interventions with and for
women living with HIV/AIDS in Boston, to implementing community-based programs that
addressed the health needs of diverse populations, to teaching students about the social
determinants of health, and to assuming leadership roles on local boards that are responsible for
the health of our local communities. Our editorial coordinator, John Larkin, was very helpful in
answering questions, calming frustrations, and solving problems. Greg Nicholl, our development
editor, provided the consistency found throughout the chapters. Thank you all for helping us
create this unique approach to community and public health nursing!
Rosanna F. DeMarco
Judith Healey-Walsh
A Special Thanks in Memoriam to Dr. Gail A. Harkness, DPH, FAAN
The first and second editions of this textbook were led by the efforts of Dr. Gail Harkness. Gail
was a mentor and friend. While she is no longer with us to help support, guide, and enliven this
newest edition, we wanted to take time to honor her memory and produce this edition in her
honor.
Gail was such an intelligent, warm, and wise public health expert who was most passionate
about population health and epidemiology, and particularly infectious diseases past, present, and
evolving. She was a prolific writer and teacher. When I met her, she reached out to me, asking if
I could help her with her vision of a community health and public health textbook for nursing
15
students that was affordable and succinct and did not just “rattle on” with facts but situated
public health ideas in the context of evidence, student stories, and current disease prevention and
health promotion innovations. She brought to my mentorship opportunity her global experiences
from the UK (University of Leeds) to Japan (Osaka), as well as her own local work on a town
Board of Health in Massachusetts. Gail loved public health research and the evidence it yielded
to inform policy decisions toward all our health. She was a graduate of the University of
Rochester (undergraduate and graduate programs) in Nursing and received her Doctorate in
Public Health from the University of Illinois, School of Public Health in Epidemiology and
Biometry (the application of statistical analysis to biologic data).
More than being an epidemiologist, she loved the opportunity as an academician to teach
nursing students at all levels to be as passionate about public health as she was. She was a
professor emerita from University of Connecticut. We know her family and friends miss Gail
very much, but her energy and spirit will always be in this textbook.
Rosanna F. DeMarco
16
Contents
PART ONE
The Context of Community and Public Health Nursing
Chapter 1
Public Health Nursing: Present, Past, and Future
Healthcare Changes in the 21st Century
Public Health Nursing Today
Roots of Public Health Nursing
Challenges for Public Health Nursing in the 21st Century
Chapter 2
Public Health Systems
Importance of Understanding How Public Health Systems are Organized
Structure of Public Healthcare in the United States
Functions of Public Health in the United States
Trends in Public Health in the United States
Healthcare Systems in Selected Developed Nations
Public Health Commitments to the World: International Public Health and Developing Countries
Chapter 3
Health Policy, Politics, and Reform
Healthcare Policy and the Political Process
Healthcare Finances and Cost–Benefit
Access to Care and Health Insurance
Healthcare Workforce Diversity
Nursing’s Role in Shaping Healthcare Policy
Advocacy Activities of Professional Nursing Organizations
Current Situation of Nursing Political Involvement: Challenges and Barriers
Quality of Care
Information Management
Equity in Healthcare Access and Quality
Community-Based Services Associated With Healthcare Reform
Ethical Consideration
Health Advocacy and Healthcare Reform
Overview of the ACA Prior to the End of Obama Presidency
Health Services Research
Conclusion
Chapter 4
Global Health: A Community Perspective
Definitions of Health
Global Health Concepts
Women, Poverty, and Health
Sustainable Development Goals
Other Factors That Affect Global Health
Role of Nurses
17
PART TWO
Evidence-Based Practice and Population Health
Chapter 5
Frameworks for Health Promotion, Disease Prevention, and Risk Reduction
Introduction
Health Promotion, Disease Prevention, and Risk Reduction as Core Activities of Public Health
Healthy People Initiatives
Road Maps to Health Promotion
Behavior Models
Use of the Ecologic Model: Evidence for Health Promotion Intervention
Health Promotion and Secondary/Tertiary Prevention for Women Living With HIV/AIDS
Health Literacy
Health Literacy and Health Education
Health Literacy and Health Promotion
Role of Nurses
Chapter 6
Epidemiology: The Science of Prevention
Defining Epidemiology
Development of Epidemiology as a Science
Epidemiologic Models
Applying Epidemiologic Principles in Practice
Chapter 7
Describing Health Conditions: Understanding and Using Rates
Understanding and Using Rates
Specific Rates: Describing by Person, Place, and Time
Types of Incidence Rates
Sensitivity and Specificity
Use of Rates in Descriptive Research Studies
Chapter 8
Gathering Evidence for Public Health Practice
Observational Studies
Intervention (Experimental) Studies
PART THREE
Implementing Nursing Practice in Community Settings
Chapter 9
Planning for Community Change
Health Planning
Community Assessment
Systems Theory
Working With the Community
Social Ecologic Model
Health Impact Pyramid
Multilevel Interventions
Social Determinants of Health
Change Theory
Planning Community-Level Interventions
Collaboration and Teamwork
Evaluating Community-Level Interventions
18
Funding Community-Level Intervention Programs
Social Marketing
Nurse-Managed Health Centers
Chapter 10
Cultural Competence: Awareness, Sensitivity, and Respect
Culture and Nursing
Western Biomedicine as “Cultured”
Aspects of Culture Directly Affecting Health and Healthcare
Cultural Health Assessment
Chapter 11
Community Assessment
Introduction
Defining the Community and Its Boundaries
Frameworks for Community Assessment
Chapter 12
Care Management, Case Management, and Home Healthcare
Care Management
Case Management
Home Healthcare
Case Management, Home Healthcare, and Current Healthcare Reform
Chapter 13
Family Assessment
Introduction
Family Nursing Practice
Understanding Family
Family Nursing Theory
How Community Health Nurses Support Families
Community Health Nurses’ Responsibility to Families
PART FOUR
Challenges in Community and Public Health Nursing
Chapter 14
Risk of Infectious and Communicable Diseases
Introduction
Epidemiology of the Infectious Process: The Chain of Infection
Outbreak Investigation
Healthcare-Associated Infections
Public Health Surveillance
Specific Communicable Diseases
Other Sexually Transmitted Diseases
Prevention and Control of Specific Infectious Diseases
Chapter 15
Emerging Infectious Diseases
Introduction
Factors That Influence Emerging Infectious Diseases
Recent Emerging and Reemerging Infectious Diseases
Reemerging Vaccine-Preventable Diseases
Antibiotic-Resistant Microorganisms
Conclusions
19
Chapter 16
Violence and Abuse
Overview of Violence
Intimate Partner Violence
Mandatory Reporting of Abuse
Intervention
Human Trafficking
Model of Care for Victims of Intentional Crimes
Forensic Nursing
Chapter 17
Substance Use
International Aspects of Substance Abuse
Health Profiles and Interventions for High-Risk Populations
Impact on the Community
Public Health Models for Populations at Risk
Treatment Interventions for Substance Abuse
Goals of Healthy People 2020
Chapter 18
Underserved Populations
The Context of Health Risks
Rural Populations
Correctional Health: Underserved Populations in Jails and Prisons
Gay, Lesbian, Bisexual, Transgender, and Queer Community
Veterans and Health
Human Trafficking
Homeless Populations
Chapter 19
Environmental Health
Introduction
Human Health and the Environment
Assessment
Interventions
Evaluation
Environmental Epidemiology
Working Toward Healthy Environments
Children’s Health and the Environment
Environmental Justice
Global Environmental Health Challenges
Chapter 20
Community Preparedness: Disaster and Terrorism
Introduction
Emergencies, Disasters, and Terrorism
Disaster Preparedness in a Culturally Diverse Society
Disaster Management
MRC and CERT Groups
Roles of Nurses in Disaster Management
Bioterrorism
Chemical Disasters
Radiologic Disasters
Blast Injuries
Public Health Disaster Response
20
PART FIVE
Specialty Practice
Chapter 21
Community Mental Health
Cultural Context of Mental Illness
Definitions of Mental Illness
Scope of Mental Illness
Some Major Mental Illnesses
Evolution of Community Mental Health
Legislation for Parity in Mental Health Insurance Benefits
Roles and Responsibilities of the Community Mental Health Practitioner
Psychological First Aid
Chapter 22
School Health
Introduction
Historical Perspectives
Role of the School Nurse
Common Health Concerns
The School Nurse as a Child Advocate
The Future of School Health: Whole School, Whole Community, Whole Child (WSCC) Model
Chapter 23
Faith-Oriented Communities and Health Ministries in Faith Communities
Nursing in Faith Communities
History of Faith Community Nursing
Models of Faith Community Practice
The Uniqueness of Faith Communities
Roles of the Faith Community Nurse
Healthy People 2020 Priorities
Scope and Standards of Practice
The Nursing Process in Faith Community Nursing
Ethical Considerations
Education for Faith Community Nursing
Chapter 24
Palliative and End-of-Life Care
Nursing and Persons With Chronic Disease
Death in the United States
Nursing Care When Death Is Imminent
Palliative Care
Hospice Care
Caring for Persons at the End of Life
Nursing Care of Persons Who Are Close to Death
Complementary and Alternative Therapies
Chapter 25
Occupational Health Nursing
Introduction
The Worker and the Workplace
Occupational Health Nursing
Conceptual Frameworks
Occupational Health Nursing: Practice
Implementing Health Promotion in the Workplace
21
Implementing a Program: Example, Smoking Cessation
Epidemiology and Occupational Health
Emergency Preparedness Planning and Disaster Management
Nanotechnology and Occupational Safety and Health
Index
22
Part 1
The Context of Community
and Public Health Nursing
23
Chapter 1
Public Health Nursing:
Present, Past, and Future
Judith Healey-Walsh
For additional ancillary materials related to this chapter. please visit thePoint
Nursing is based on society’s needs and therefore exists only because of society’s need for
such a service. It is difficult for nursing to rise above society’s expectations, limitations,
resources, and culture of the current age.
Patricia Donahue, Nursing, the Finest Art: An Illustrated History
I believe the history of public health might be written as a record of successive redefinings of
the unacceptable.
George Vicker
Some people think that doctors and nurses can put scrambled eggs back into the shell.
Dorothy Canfield Fisher, social activist and author
The only way to keep your health is to eat what you don’t want, drink what you don’t like, and
do what you’d rather not.
Mark Twain
CHAPTER HIGHLIGHTS
Healthcare changes in the 21st century
Characteristics of public health nursing
Public health nursing roots
Challenges for practice in the 21st century
OBJECTIVES
Outline three major changes in healthcare in the 21st century.
Identify the eight principles of public health nursing practice.
Explain the significance of the standards and their related competencies of professional public health
nursing practice.
Discuss historical events and relate them to the principles that underlie public health nursing today.
Consider the challenges for public health nurses in the 21st century.
24
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KEY TERMS
Aggregate: Population group with common characteristics.
Competencies: Unique capabilities required for the practice of public health nursing.
District nurses: Public health nurses in England who provide visiting nurse services; historically,
they cared for the people in the poorest parish districts.
Electronic health records: Digital computerized versions of patients’ paper medical records.
Epidemiology: Study of the distribution and determinants of states of health and illness in
human populations; used both as a research methodology to study states of health and
illness, and as a body of knowledge that results from the study of a specific state of health or
illness.
Evidence-based nursing: Integration of the best evidence available with clinical expertise and
the values of the client to increase the quality of care.
Evidence-based public health: A public health endeavor wherein there is judicious use of
evidence derived from a variety of science and social science research.
Health disparities: Differences in healthcare and health outcomes experienced by one
population compared with another, frequently associated with race/ethnicity and
socioeconomic status
Health information technology: Comprehensive management of health information and its
secure exchange between consumers, providers, government and quality entities, and
insurers.
Public health: What society does collectively to ensure that conditions exist in which people can
be healthy.
Public health interventions: Actions taken on behalf of individuals, families, communities, and
systems to protect or improve health status.
Public health nursing: Focuses on population health through continuous surveillance and
assessment of the multiple determinants of health with the intent to promote health and
wellness; prevent disease, disability, and premature death; and improve neighborhood quality
of life (American Nurses Association [ANA], 2013).
Telehealth: Use of electronic information and telecommunications technologies to support long-
distance clinical healthcare, patient and professional health-related education, public health,
and health administration.
Social determinants of health: Social conditions in which people live and work.
CASE STUDY
References to the case study are found throughout this chapter (look for the case study icon).
Readers should keep the case study in mind as they read the chapter.
The Department of Health and Human Services (HHS) in a southeastern state has begun
implementing the recommendations from both the U.S. Institute of Medicine’s publication The
Future of the Public’s Health in the 21st Century and the 10-year national objectives for promoting
health and preventing disease in the United States established by Healthy People 2020. A task
force is developing a new vision for public health in the state. Sandy is a program developer in the
state’s Department of Public Health, with the primary responsibility of assisting local public health
departments in developing, implementing, and evaluating public health nursing initiatives. Sandy
represents public health nursing on the task force. (Adapted from Jakeway, Cantrell, Cason, &
Talley, 2006).
HEALTHCARE CHANGES IN THE 21ST CENTURY
25
A worldwide phenomenon of unprecedented change is occurring in healthcare. There are new
innovations to test, ethical dilemmas to confront, puzzles to solve, and rewards to be gained as
healthcare systems develop, refocus, and become more complex within a multiplicity of settings.
Nurses, the largest segment of healthcare providers in the world, are on the frontline of that
change.
Demographic characteristics indicate that people in high-income countries are living longer
and healthier lives, yet tremendous health and social disparities exist. The social conditions in
which people live, their incomes, their social statuses, their educations, their literacy levels, their
homes and work environments, their support networks, their genders, their cultures, and the
availability of health services are the social determinants of health. These conditions have an
impact on the extent to which a person or community possesses the physical, social, and
personal resources necessary to attain and maintain health. Some population groups, having
fewer resources to offset these effects, are affected disproportionately. The results are health
disparities, or differences in healthcare and health outcomes experienced by one population
compared with another.
For example, the World Health Organization (WHO) estimates that almost half of all
countries surveyed have access to less than half the essential medicines they need for basic
healthcare in the public sector. These essential medicines include vaccines, antibiotics, and
painkillers. Children in low-income countries are 16 times more likely to die before reaching the
age of 5 years, often because of malnourishment, than children in high-income countries. The
double burden of both undernutrition and overweight conditions causes serious health problems
and affects survival (WHO, 2017). Globally, resources exist to remedy these circumstances, but
does the political commitment exist?
The development of society, rich or poor, can be judged by the quality of its population
health, how fairly health is distributed across the social spectrum, and the degree of
protection provided from disadvantage as a result of ill health. World Health
Organization
Role of the Government in Healthcare
A government has three core functions in addressing the health of its citizens: (1) it assesses
healthcare problems; (2) it intervenes by developing relevant healthcare policy that provides
access to services; and (3) it ensures that services are delivered and outcomes achieved. The
United States, the United Kingdom, the European community, and some newly industrialized
countries have embraced these principles. However, governments in other countries struggle to
build any semblance of a health system. Unstable governments struggle with mobilizing the
concern, motivation, or resources to address healthcare issues.
There were unprecedented public health achievements in the United States during the 20th
century. The Centers for Disease Control and Prevention (CDC) has listed the Ten Great Public
Health Achievements as the legislature amends the law based on supportive epidemiologic
analyses and comparisons of health factors over 30 years (Box 1.1). However, healthcare
expenditures are now more than $3.2 trillion per year (CDC, 2016). Infant mortality, longevity,
and other health indicators still fall behind those of many other industrialized nations. The
current U.S. healthcare system faces serious challenges on multiple fronts. Although the United
States is considered the best place for people to obtain accurate diagnoses and high-quality
treatment, until 2014 nearly 45 million Americans lacked health insurance and therefore access
to care. These uninsured Americans were primarily young people, low-income single adults,
small-business owners, self-employed adults, and others who did not have access to employer-
sponsored health insurance.
26
1.1 Ten Great Public Health Achievements in the United States, 1900 to 1999
Vaccination
Motor vehicle safety
Safer workplaces
Control of infectious diseases
Decline in coronary heart disease and stroke deaths
Safer and healthier foods
Healthier mothers and babies
Family planning
Fluoridation of drinking water
Recognition of tobacco as a health hazard
Source: Centers for Disease Control and Prevention. (1999). Ten great public health achievements—United States, 1900–1999. Morbidity Mortality Weekly
Report, 48(12), 241–243.
The Patient Protection and Affordable Care Act (PPACA) was signed into law by President
Barack Obama in 2010. The goal of the PPACA is to help provide affordable health insurance
coverage to most Americans, lower costs, improve access to primary care, add to preventive care
and prescription benefits, offer coverage to those with pre-existing conditions, and extend young
adults’ coverage under their parents’ insurance policies. It is estimated that 95% of legal U.S.
residents will ultimately be covered by health insurance, although implementation will evolve
over time (Doherty, 2010). The passage of the PPACA was the first step in providing Americans
with the security of affordable and lifelong access to high-quality healthcare. More information
about the Affordable Care Act is found in Chapter 3.
It is cheaper to promote health than to maintain people in sickness. Florence Nightingale
Practice Point
Making healthcare a right rather than a privilege has global implications.
The United States assesses and monitors people’s health through an intricate system of
surveillance surveys conducted by the HHS, the CDC, and the state and local governments.
Health policy development focuses on cost, access to care, and quality of care. Access is defined
as the ability to get into the healthcare system, and quality care is defined as receiving
appropriate healthcare in time for the services to be effective. Outcomes are ensured by a
continual evaluation system linked in part with the CDC surveys. Despite this elaborate
healthcare system, health disparities related to race, ethnicity, and socioeconomic status still
pervade the healthcare system. Health disparities vary in magnitude by condition and
population, but they are observed in almost all aspects of healthcare, in quality, access,
healthcare utilization, preventive care, management of chronic diseases, clinical conditions, and
settings, and within many subpopulations.
The National Healthcare Quality and Disparities Report (NHQDR) measures trends in the
effectiveness of care, patient safety, timeliness of care, patient centeredness, and efficiency of
care. The report presents, in chart form, the latest available findings on quality of and access to
healthcare (Agency for Healthcare Research and Quality [AHRQ], 2018). For example, Figure
1.1 indicates that quality of healthcare improved overall from 2000 to 2014, although the pace of
improvement varied based on priority area. In addition, as Figure 1.2 demonstrates, that
although some gaps in measures by race/ethnicity are improving, health disparities in quality
27
healthcare remain.
FIGURE 1.1 Number and percentage of all quality measures that were improving, not changing, or
worsening, total and by priority area, from 2000 through 2014.
The challenge for the United States in the 21st century is to create a dynamic, streamlined
healthcare system that produces not only the finest technology and research, but also the most
accessible, efficient, low-cost, and high-quality healthcare in the world. The current healthcare
system also must be transformed to become one of the most competitive and successful systems
in the world. Innovative and creative changes will be needed to create a patient/client-centered,
provider-friendly healthcare system that is consumer-driven. The political will does exist to
create a better future: patient/client-centered care is evolving, new technology is shaping
delivery of care, and people are assuming more responsibility for maintaining their health.
Patient/Client-Centered Care
Healthcare has been evolving toward a multifaceted system that empowers patients and clients
28
rather than providers, as was common in the past. This transformation is considered the best way
to ensure that patients have access to high-quality care, regardless of their income, where they
live, the color of their skin, or how old or ill they are.
Patient/client-centered care considers cultural traditions, personal preferences, values,
families, and lifestyles. People requiring healthcare, along with their families or significant
others, become an integral part of the healthcare team, and clinical decisions are made
collaboratively with professionals. Clients become active participants in their own care, and
monitoring health becomes the client’s responsibility. Support, advice, and counsel from health
professionals are available, along with the tools that are needed to carry out that responsibility.
The shift toward patient/client-centered care means that a broader range of outcomes needs
to be measured from the patient’s perspective to understand the true benefits and risks of
healthcare interventions.
Practice Point
The AHRQ has developed a series of tools to assist clients in making healthcare decisions.
29
FIGURE 1.2 Number and percentage of quality measures with disparity at baseline for which
disparities related to race and ethnicity were improving, not changing, or worsening (2000 through
2014 to 2015).
To help clients and their healthcare providers make better decisions, the AHRQ has
developed a series of tools that empower clients and assist providers in achieving desired
outcomes. Tools include questionnaires to help determine important treatment preferences and
decisions, symptom severity indexes, client fact sheets, client-reported functional status
indicators, and other helpful decision-making guidelines. AHRQ (2016) developed the SHARE
Approach, a model to promote shared decision-making between a healthcare provider and
patient/client. The model has five steps that encourage a conversation between the provider and
patient in order to gain a clear understanding of the benefits, harms, and risks of the care options
and to identify the patient’s values and preferences. The steps include:
1. Seek the patient’s participation
2. Help the patient to review and compare care options
3. Assess the patient’s values and preferences
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4. Reach a consensus decision with the patient
5. Evaluate the decision
These tools are available to both consumers and healthcare providers at the AHRQ website.
For the system to work effectively, transitions between providers, departments, various
healthcare settings, and the home must be coordinated and efficient so that unneeded or
unwanted services can be reduced. Americans are sophisticated, empowered consumers in
almost every aspect of their lives and will make the best decisions both for themselves and
collectively for the healthcare economy and society itself.
Technology
Rapidly advancing forms of technology are dramatically improving lives. Thousands of new
ideas are investigated each year, with hundreds of new medical devices submitted to the U.S.
Food and Drug Administration annually. Medical devices vary considerably, such as computer-
assisted robotic surgical techniques, artificial cervical disks, new diagnostic techniques,
implantable microchip-containing devices that control dosing from drug reservoirs, continuous
glucose-monitoring systems for detecting trends and tracking patterns in people with diabetes,
and many more.
The benefits of biomedical progress are obvious, clear, and powerful. The hazards are
much less well appreciated. Leon Kass, physician
Although massive investments in medical research have been made, there has been an
underinvestment in both research and the infrastructure necessary to translate basic research into
results. For example, studies indicate that it takes physicians an average of 17 years to adopt
widely the findings from basic research. The healthcare sector invests nearly 50% less in
information technology than any other major sector of the U.S. economy. More comprehensive
knowledge bases of healthcare information, computerized decision support, and a health
information technology (HIT) infrastructure with national standards of interoperability to
promote data exchange are necessary.
Health Information Technology
Health information technology is defined as the comprehensive management of health
information and its exchange between consumers, providers, government, and insurers in a
secure manner. HIT makes it possible for healthcare providers to better manage patient care
through secure use and sharing of health information. It is viewed as the most promising tool for
improving the overall quality, safety, and efficiency of the health delivery system.
Health information technology and electronic health information exchange have emerged
as a primary means of shaping a healthcare system that is effective, safe, transparent,
and affordable. When linked with other health system reforms, technology can support
better quality healthcare, reduce errors, and improve population health. State Alliance for
e-Health
Health information technology includes the use of electronic health records (EHRs), digital
computerized versions of patients’ paper medical records, to maintain people’s health
information. EHRs and other HIT systems are powerful tools that are having a significant impact
on healthcare. Consumers are empowered with more information, choices, and control, and
providers have reliable access to complete personal health information that can help them make
31
the right decisions. All necessary health information, from medical histories to billing
information, will be accessible from the internet and readily available to all appropriate
healthcare facilities and providers of care (with permission of the client). With faster diffusion of
medical knowledge through the internet, decision-making will be expedited, medical errors
reduced, and duplication of tests and misdiagnosis decreased. However, to protect these records
from unauthorized, inappropriate, or unethical use, national privacy laws must be in place.
In the United States, the Office of the National Coordinator for Health Information
Technology (ONC) is the principal federal entity responsible for the coordination and safety of
information technology issues. It is a resource to the entire health system to support the adoption
of HIT and to promote nationwide health information exchange to improve healthcare. ONC is
organizationally located within the Office of the Secretary for the U.S. HHS. The ONC has
developed SAFER guides for EHRs, consisting of nine guides organized into three broad groups
that enable healthcare organizations to address EHR safety in a variety of areas. The guides
identify recommended practices to optimize the safety and safe use of EHRs and can be found
on the ONC website (see web Resources on ).
The ONC funds the Nationwide Health Information Network (NwHIN, 2013), a
collaborative organization of federal, local, regional, and state agencies. Its mission is to develop
the envisioned secure, nationwide, interoperable health information infrastructure to connect
providers, consumers, and organizations involved in supporting health and healthcare. The
major goals of NwHIN are to enable health information to follow the consumer, to be available
for clinical decision-making, and to support appropriate use of healthcare information beyond
direct client care to improve the health of communities. The conceptual model that guides
NwHIN is illustrated in Figure 1.3. The NwHIN has developed a set of standards, services, and
policies that enable the secure exchange of health information nationwide over the internet.
Health information will follow the patient and be available for clinical decision-making as well
as for uses beyond direct patient care, such as measuring quality of care. It is proposed that the
NwHIN will be the vehicle through which health information will be exchanged.
Telehealth
Telehealth is the use of electronic information and telecommunications technologies to support
long-distance clinical healthcare, patient and professional health-related education, public
health, and health administration (Health Resources and Services Administration, 2014).
Telehealth is becoming a necessity, due in part to the aging population, the rising number of
people with chronic conditions, and the need to increase healthcare delivery to medically
underserved populations. Findings from the 2015 National Nursing Workforce Survey indicated
that nearly half of the registered nurses surveyed had provided nursing services through the use
of telehealth products (Budden, Moulton, Harper, Brunell, & Smiley, 2016).
32
FIGURE 1.3 The nationwide health information network conceptual model. (From Nationwide
Health Information Network [NwHIN]. Retrieved from
http://www.ahrq.gov/research/findings/nhqrdr/nhdr12/highlights.html.)
Advances in technology, specifically those involving videoconferencing, medical devices,
sensors, high-speed telecommunication networks, store-and-forward imaging, streaming media,
and terrestrial and wireless communications have made it possible to assess clients’ conditions
remotely in their homes. Information can be stored for later access or assessments can be
performed in real time using internet video systems. It is also possible to obtain the advice of
expert specialty consultants without meeting in person. The increasing complexity of telehealth
requires ongoing communication, training, cultural sensitivity, and customization for individual
clients. However, access, availability, and cost issues can be barriers to use of this technology
(Standing, Standing, McDermott, Gururajan, & Mavi, 2016; Tuckson, Edmunds, & Hodgkins,
2017).
Evidence for Practice
The use of home telehealth devices as an alternative for chronic disease management by
nurses has the potential to assist many older people in their homes with the goal of
decreasing hospital readmission, and improving the quality of life through early detection
and prompt treatment of symptoms. However, long-term outcomes and sustainability have
been a concern and challenge. Radhakrishnan, Xie, and Jacelon (2015) studied a
telehealth program at a home health agency (HHA) in Texas that ended the program after
10 years of service. The researchers designed a descriptive qualitative study using
semistructured interviews to explore the reasons for starting the program, the progressive
decline, and the barriers to and facilitators for sustainability of home telehealth programs.
The sample included 13 home health staff, including six visiting nurses, two telehealth
33
http://www.ahrq.gov/research/findings/nhqrdr/nhdr12/highlights.xhtml
nurses, four nursing administrators, and nine adult patients, all of whom were over 55 years
of age.
Of them, 77% were over 60, and all had Medicare benefits. The service was provided on
average for 60 days to patients who were dealing with self-management of chronic
diseases, such as cardiovascular disease, respiratory conditions, and diabetes. The
telehealth system used at the agency transmitted the patient’s biometric and symptom
status data to the HHA, but it did not have audio or video capacity. A technician and LVN
trained the patient on the use of the device. The telehealth nurse would review the data,
and if they were above or below the pre-determined parameters, the nurse would call the
patient and the visiting nurse, who would call or visit the patient or contact the MD.
Data on telehealth utilization and patient outcomes were tracked by the HHA. The
researchers used conventional content analysis (reading and coding) of the interview
transcripts, from which five themes emerged. Subthemes and the barriers and facilitators
toward program sustainability were identified. The five themes and aligned subthemes
included (a) impact on patient-centered outcomes (self-management, quality of life, and
patient characteristics); (b) impact on cost-effectiveness (return on investment), impact on
healthcare utilization, and telehealth update and maintenance costs; (c) patient–clinician
and interprofessional communication (nurse–patient, nurse–physician, and patient–
physician communication); (d) technology usability (cumbersome installation process,
device usability); and (e) home health management culture (top-down decision-making,
support for supplementary telehealth resources.)
The major barriers were lack of reimbursement, fewer than expected referrals from MDs,
minimal impact on re-hospitalization rate, nurses’ caseloads usability of the device, high
maintenance time and costs, poor interoperability with MD offices, frustration with the
amount and delays in communication, lack of administrative and technical support, and
patient preference for in-person interaction. Positive features and outcomes that could
support sustainability included early identification of a problem and ability to intervene
quickly, at-home convenience and ability to remain at home, family caregiver support,
feeling of security and support for the patient and family, cost-sharing with other institutions,
understanding and buy-in at all levels of management, ease of use and communication to
the nurse, and MD involving end users in decision-making in all aspects of program
development.
The study’s findings support the complexity of a telehealth program, as having
potentially positive and negative features. Program design and implementation needs to be
intentionally addressed with involvement of the end users nurses, patients, and MDs. The
program also must have an ongoing assessment and quality improvement approach, so
that barriers are identified early and solutions found to maximize the benefits and
sustainability of the program.
Personal Responsibility for Health
Increased personal responsibility for preventing disease and disability is a vital component of
healthcare change. The underlying premise holds that if people have a vested interest in their
health, they will do more to maintain it. However, if a person is healthy, he or she may not focus
on maintaining individual health, yet no one is more seriously affected when illness or disability
occurs. Preventing or modifying unhealthy behaviors can save both lives and money, but can
personal responsibility regarding one’s health be truly mandated and regulated?
1.2 Healthy People 2020 Overarching Goals
1. Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death.
2. Achieve health equity, eliminate disparities, and improve the health of all groups.
3. Create social and physical environments that promote good health for all.
4. Promote quality of life, healthy development, and healthy behaviors across all life stages.
34
Personal responsibility for health involves active participation in one’s own health through
education and lifestyle changes. It includes responsibility for reviewing one’s own medical
records, including laboratory test results, and monitoring both the positive and negative effects
of prescription and over-the-counter medications. It means showing up for scheduled tests and
procedures, following dietary recommendations, losing weight if needed, avoiding tobacco and
recreational drug use, engaging in exercise programs, and educating oneself about one’s own
conditions. Ultimately, people must take the responsibility for making their own choices and
healthcare decisions.
The patient should be made to understand that he or she must take charge of his own life.
Don’t take your body to the doctor as if he were a repair shop. Quentin Regestein,
psychiatrist, Harvard University
U.S. government initiatives have been implemented to encourage personal responsibility for
health. Healthy People 2020 is a national, science-based plan designed to reduce certain
illnesses and disabilities by reducing disparities in healthcare services in people of different
economic groups. Since 1979, Healthy People programs have measured and tracked national
health objectives to encourage collaboration, guided people toward making informed health
decisions, and assessed the impact of prevention activity. Specific objectives with baseline
values for measurement are developed, setting specific targets to be achieved by 2020. The four
major overarching goals that incorporate these objectives are listed in Box 1.2 (Healthy People
2020, n.d.).
PUBLIC HEALTH NURSING TODAY
The shorter length of stay in acute care facilities, as well as the increase in ambulatory surgery
and outpatient clinics, has resulted in more acute and chronically ill people residing in the
community who need professional nursing care. Fortunately, these people can have their care
needs met cost-effectively outside of expensive acute care settings. As a result, demand has
increased for nurses in ambulatory clinics, home care, and care management.
Hospitals remain the most common workplace for RNs in the United States (54%) (Budden
et al., 2016). However, the number of RNs working in home health service units or agencies is
increasing (13%) (U.S. Department of Labor, 2017). Public health, ambulatory care, and other
noninstitutional settings have historically had the largest increases in RN employment. These
statistics indicate a shift in the roles of nurses, particularly for those working in public health
settings.
Nursing is the protection, promotion, and optimization of health and abilities, prevention of
illness and injury, alleviation of suffering through the diagnosis and treatment of human
response, and advocacy in the care of individuals, families, communities, and populations.
American Nurses Association
Public Health Nursing
A decades-long debate about terminology has fostered confusion regarding the roles of nurses
who serve the community. However, public health professionals nationwide have come together
to define the principles of public health (Box 1.3). Embracing these fundamental principles for
all public health professionals, the Quad Council of Public Health Nursing Organizations
established eight principles of public health nursing practice (Box 1.4). The Quad Council of
35
Public Health Nursing Organizations is an alliance of four national nursing organizations that
address public health nursing issues in the United States, comprising the following:
Association of Community Health Nurse Educators (ACHNE)
ANA’s Congress on Nursing Practice and Economics (CNPE)
American Public Health Association (APHA)—Public Health Nursing Section
Association of State and Territorial Directors of Nursing (ASTDN)
Public health is what we, as a society, do collectively to assure the conditions in which
people can be healthy. Institute of Medicine, 1988
1.3 Principles of Public Health
Focus on the aggregate.
Promote prevention.
Encourage community organization.
Practice the ethical theory of the greater good.
Model leadership in health.
Use epidemiologic knowledge and methods.
1.4 Principles of Public Health Nursing: The Public Health Nurse Is Guided by
Adherence to All of the Following Principles
The client or unit of care is the population.
The primary obligation is to achieve the greatest good for the greatest number of people or number of
people as a whole.
Public health nurses collaborate with the client as an equal partner.
Primary prevention is the priority in selecting appropriate activities.
Public health nursing focuses on strategies that create healthy environmental, social, and economic
conditions in which populations may thrive.
A public health nurse is obligated to actively identify and reach out to all who might benefit from a
specific activity or service.
Optimal use of available resources and creation of new evidence-based strategies is necessary to assure
the best overall improvement in the health of populations.
Collaboration with other professions, populations, organizations, and stakeholder groups is the most
effective way to promote and protect the health of the people.
Source: American Nurses Association (ANA). (2013). Public health nursing: Scope and standards of practice. Silver Spring, MD: Nursesbooks.
Scope and Standards of Practice
The ANA sets the scope and standards for all professional nursing practice. The publication
Public Health Nursing: Scope and Standards of Practice establishes the characteristics of
competent public health nursing practice and is the legal standard of practice. It defines the
essentials of public health nursing, the activities, and the accountabilities that are characteristics
of practice at all levels and settings. An important component of this document is the
designation of competencies required to meet each standard of practice. This scope and
standards document can be used by PHNs from entry-level to senior management in a variety of
practice settings and is an indispensable publication reference for every practicing PHN (ANA,
2013).
36
Competencies for Public Health Nursing Practice
The core competencies for public health nurses (CCPHN) defined in the ANA (2013)
publication are aligned with core competencies developed by other public health organizations.
The CCPHN reflect the unique capabilities required for the practice of public health nursing.
Three tiers of practice are defined, along with competencies associated with that level of
practice. Tier 1 core competencies apply to entry-level public health professionals at the basic or
generalist level. For example, individuals who have limited experience working in the public
health field and are not in management positions would be considered practicing at Tier 1. Tier 2
core competencies apply to individuals with management and/or supervisory responsibilities and
are considered specialists or mid-level practitioners. Tier 3 core competencies apply to senior
managers and leaders at the executive level who deal with multisystems. Essentially, these
competencies underlie the wide variety of roles and responsibilities that PHNs accept in the
workplace.
The CCPHN are integrated into the Standards of Practice for Public Health Nursing (ANA,
2013). Each standard of practice is followed by the essential competencies required to meet that
standard. Following each standard of practice, additional competencies are presented for practice
as an advanced PHN.
Public Health Nursing Interventions
The public health intervention (wheel) model illustrated in Figure 1.4 is (1) a population-based
model that (2) is applied to individuals, families, communities, or within systems and (3) defines
17 public health interventions focusing upon prevention. It is a way of defining public health
nursing by the type of actions taken on behalf of clients to protect or improve health status. The
interventions in the wheel model complement the competencies that each PHN must
demonstrate for safe practice. The competencies define what should be done while the
interventions provide a means to accomplish those actions. Table 1.1 describes the 17
interventions illustrated in the wheel. Other interventions have been suggested, such as that of
change agent, culture broker, and researcher. The wheel creates a structure for identifying and
documenting interventions, thereby capturing the nature of public health nursing practice.
Two years ago, Sandy participated in a statewide survey of both the public health nurses
in the state as well as their employers. The purpose of the survey was to determine the
characteristics of public health nursing practice, especially the use of principles of
population health. Results indicated that the majority of the public health nurse’s time is
spent in the provision of primary care and clinical services to individual clients. The major
factors that contribute to this finding include the number of uninsured people (16%) and a
large population of medically underserved people.
Define the type of practice (tier) that the public health nurses were performing.
37
FIGURE 1.4 Public health intervention wheel.
The new vision for public health being designed by the task force promotes a shift from a
predominantly individual and clinic-based care model to a population health practice model. The
public health nurses in the state were unprepared for this transition and lacked a strong
understanding of population health concepts and competencies. Using the standards of practice
and associated competencies outlined in Public Health Nursing: Scope and Standards of
Practice, and with assistance from faculty members at the state university, the task force is
helping to develop an online population-based health course to meet the needs of the public
health nurses in the state. The priorities of the online course are as follows:
Community assessment and diagnosis
Interpreting and presenting health information
Using computer technology in health planning and policy development
Building community coalitions
Using Public Health Nursing: Scope and Standards of Practice, choose the appropriate
standards and competencies that the public health nurses should demonstrate to meet these
priorities.
Education for Public Health Nursing Practice
38
The educational credential for entry into public health nursing practice is the baccalaureate
degree in nursing. This can be a baccalaureate in nursing (BS or BSN) or a generalist master’s
degree as a clinical nurse leader (CNL). Public health nursing specialists in population health
may have a master of science in nursing (MSN), master of public health (MPH), a joint
MSN/MPH, or a doctoral degree. Doctoral degrees may be doctor of philosophy (PhD), doctor
of nursing practice (DNP), or doctor of public health (DrPH). Diploma- and associate degree-
prepared RNs and licensed practical nurses may practice in some public health settings. In these
positions, nurses provide care for individuals or families but not for populations (ANA, 2013).
TABLE 1.1 Public Health Nursing Interventions
Intervention Definition
Surveillance Monitors health events through ongoing, systematic collection, analysis and
interpretation of health data for planning, implementing, and evaluating public
health interventions
Investigation of disease and
other health events
Systematically gathers and analyzes data about threats to population health,
determines the source, identifies cases and those at risk, and determines
control measures
Outreach Locates populations at risk, provides information, identifies possible actions,
and identifies access to services
Screening Identifies individuals with unrecognized risk factors or asymptomatic conditions
Case-finding Locates individuals and families with identified risk factors and connects them
with resources
Referral and follow-up Assists in identifying and accessing necessary resources to prevent or resolve
concerns
Case management Coordination of a plan or process to bring health services and the self-care
capabilities of the client together as a common whole in a cost-effective way
Delegation Direct care tasks an RN entrusts to other appropriate personnel
Teaching Develops a health education plan and teach clients and other caregivers
leading to behavior change
Counseling Develops an interpersonal relationship with the client to increase his or her
capabilities to address or solve issues
Consultation Seeks information and generates solutions to health problems or issues through
interactive problem-solving
Collaboration Works with people or representatives of organizations to achieve a common
goal
Coalition-building Fosters, mobilizes, and participates in community-wide alliances to achieve a
specific goal
Community organizing Helps community groups to identify common problems or goals, mobilizes
resources, and develops and implements strategies for reaching those goals
Advocacy Acts on behalf of clients who have lost control of factors that affect their health
and a need is unmet; strengthens clients’ capacity to act
Social marketing Uses marketing principles and technology to design programs to address needs
of the client
Policy development Promotes beneficial social changes that influence the health of groups and
populations
Policy enforcement Compels others to comply with the laws, rules, regulations, and ordinances
created in conjunction with policy development
Source: Adapted from Public Health Interventions: Application for Nursing Practice. Retrieved from www.health.state.mn.us/divs/opi/cd/phn/wheel.html.
ROOTS OF PUBLIC HEALTH NURSING
Exploring the roots of the healing professions provides the background for understanding the
characteristics of nursing practice today (Table 1.2). Since the beginning of civilization, people
in all cultures have focused on birth, health, illness, and death. Historical records indicate that
early societies engaged in public health measures by burying wastes away from water supplies,
39
http://www.health.state.mn.us/divs/opi/cd/phn/wheel.xhtml
developing sewage systems, and draining marshes to control communicable disease. In these
times, people spent their lives with their family and community, especially when they were ill
and needed care. Early caregivers, usually women, cultivated healing herbs, applied poultices,
applied heat and cold, immobilized fractures, delivered babies, and attended the dead.
In the Middle Ages, care of ill people was based in the household. Care was haphazard. The
few hospitals that existed were run by monks and nuns, primarily for residents of monasteries,
and only the wealthy could afford assistance with their care. Changes in social structures
encouraged the development of cities, but overcrowding, lack of sanitation, and an ever-
increasing susceptible population contributed to recurring epidemics. During the 14th century,
the Black Plague alone killed approximately one fourth of the population of Europe. From the
1500s through the 1700s, the Renaissance in Europe stimulated the rise of scientific thought and
inspired social consciousness.
The English Poor Law of 1601 marked the beginning of state-provided relief for the poor,
placing a legal responsibility on each district to care for people within its boundaries who, either
because of age or infirmity, were unable to work. The Sisters (or Daughters) of Charity, known
as the “Grey Sisters,” was founded in 1617 in France, with members taking vows to provide care
to the sick poor. The organization was so successful that it spread from the rural districts to
Paris, and a training program was established in 1633 for young women who were devoted to
serving people in need. From that time through the 19th century, this nursing community spread
throughout the world. Today, the mother house is located in Paris.
TABLE 1.2 Milestones in Public Health and Public Health Nursing
1601 Poor Law instituted in England; beginning of state-supported assistance for the
poor
1617 Sisters (or Daughters) of Charity founded in France
1789 First local permanent health department in the United States founded in
Baltimore, MD
1798 Marine Hospital Service established in the United States; later became the
Public Health Service
1809 Sisters of Charity founded by Elizabeth Ann Seton in Maryland
1813 Ladies’ Benevolent Society of Charleston, SC, established to provide home
care to the sick
1825 154 hospitals had been established in England
1836 Training school for deaconesses established by Theodore Fliedner, a German
Lutheran pastor
1840/1841 Dorothea Dix began her lifelong campaign to improve the life of the mentally ill
1850 Shattuck Report published by the Massachusetts Sanitary Commission;
recommended the establishment of a state health department and local
health boards in every town, collection of vital statistics, sanitation, disease
control, health education, town planning, and teaching of prevention in
medical schools
1851 Florence Nightingale attended Fliedner’s school for deaconesses
1859 William Rathbone established district nursing in England
1860 Florence Nightingale established the first school for nurses at St. Thomas
Hospital in London
1861 Soldiers in the American Civil War attended by visiting nurses
1870s First nursing schools opened in the United States based on the Nightingale
model
1872 American Public Health Association established
1882 Clara Barton convinced the U.S. Congress to establish the American Red Cross
with an extended mission to provide aid for natural disasters
1885/1886 Visiting nurse associations established in Boston, Philadelphia, and Buffalo
1893 Lillian Wald established the Henry Street Settlement in New York City for the
sick poor
1895 Ada Steward employed by Vermont Marble Works as the first occupational
health nurse
40
1898 Significant use of trained nurses in military hospitals
1901 U.S. Army Nurse Corps established
1908 U.S. Navy Nurse Corps established
1912 National Organization for Public Health Nursing established, with Lillian Wald
the first President; U.S. Children’s Bureau established; Marine Hospital
Service changed to U.S. Public Health Service
1914 First postgraduate program in public health nursing at Teachers College in New
York City, affiliated with the Henry Street Settlement, established by Mary
Adelaide Nutting
1920 90% of the ill were cared for at home with assistance from the community
1925 Frontier Nursing Service in the United States established by Mary Breckinridge
to provide access to healthcare in remote Appalachian regions of
southeastern Kentucky
1933 Pearl McIver became the first nurse employed by the U.S. Public Health Service
1935 U.S. Social Security Act passed
1943 Frances Payne Bolton was instrumental in founding the Cadet Nurse Corps as
a part of the Public Health Service to train nurses during World War II
1953 U.S. Department of Health, Education, and Welfare established
1957 Nationalized Canadian healthcare system established
1965 Public health pediatric nurse practitioner program established at University of
Colorado
1966 Medicare for the elderly established in the United States
1967 Medicaid for the medically indigent established in the United States
1970 Occupational Safety and Health Administration established
1974 National Health Planning and Resources Development Act passed
1975 Certification for community health nurses established by the American Nurses
Association (ANA)
1979 Smallpox eradication worldwide certified by the WHOa
1980 First national health objectives for the United States established: Promoting
Health/Preventing Disease: Objectives for the Nation
1980 Direct reimbursement through Medicaid for nurse practitioner in rural health
clinics, United States
1984 Behavioral Risk Factor Surveillance System (BRFSS) established
1989 Guide to Clinical Preventive Services (standardizing screening and prevention
strategies) published by the U.S. Public Health Services Task Force
1990 Healthy People 2000: National Health Objectives for Health Promotion and
Illness Prevention published
1991 Nursing’s Agenda for Health Care Reform published by a coalition of more than
60 nursing organizations
1998 The Public Health Workforce: An Agenda for the 21st Century published by U.S.
Public Health Service
2000 Healthy People 2010 published
2002 European region of WHO declared free of polio
2002 U.S. Office of Homeland Security established
2003 U.S. Institute of Medicine recommends that undergraduate nursing students
understand the ecological model of health and core competencies of
population-based practice
2010 Patient Protection and Affordable Care Act (PPACA) passed
aWHO, World Health Organization.
In the 1800s, a variety of reforms were initiated to care for the sick poor throughout Europe
that interacted and built on one another. Hospitals were established. By 1825, there were 154 in
England alone. However, the fatality rates in these institutions were high, particularly for
newborns and people with open wounds; the hospitals were called “death houses.” So-called
“ward maids,” equivalent to housekeepers, provided care.
In Holland, Mennonites recruited women of the church to form deaconess groups to care for
the poor. In 1836, Theodore Fliedner, a German Lutheran pastor, established a three-year
training school for deaconesses, which was associated with a new hospital. Fliedner also
founded parish districts by dividing towns geographically into smaller areas to provide care to
41
residents.
In Victorian times, poorhouses or workhouses existed for chronically ill poor people who
were often elderly, without families. The primary reason for poverty was illness, and
tuberculosis was rampant. Each parish had its own poorhouse. “Pauper nurses” were poor
residents themselves, given the responsibility to care for the destitute. Conditions in many of
these poor houses were deliberately harsh and often abysmal. Unfortunately, some pauper nurses
were illiterate, irresponsible drunks who were vicious to residents, prolonging their illness (The
Public Health [Scotland] Act, 1897). One of the most famous comical, fictional characters in
Charles Dickens’s works is Nurse Sairey Gamp in The Life and Adventures of Martin
Chuzzlewit. She was a nurse of sorts who dealt with the “lying in and the laying out” extremities
of life, representing some of the more questionable characteristics of the so-called nurses at the
time (Fig. 1.5).
During the latter part of the 19th century, when district nursing was established, meeting the
needs of the ill became more organized in England. At that time, William Rathbone, a Quaker
merchant and philanthropist in Liverpool, England, organized help for the poor. In 1859, he
hired Mary Robinson, a nurse who previously had cared for his terminally ill wife, to provide
care for the people in one of the poorest parish districts in Liverpool. Mary became the first
district nurse in England. Box 1.5 lists the duties of district nurses in Liverpool. District
nursing soon sprang up in other towns, cities, and rural areas in England, funded by local
philanthropists.
Rathbone devoted the rest of his life to expanding services for the sick poor, with assistance
from his friend Florence Nightingale and others. Nightingale, the daughter of a wealthy English
landowner, devoted her life to the prevention of needless illness and death. In 1851, she attended
Theodore Fliedner’s program for deaconesses—for nurse training—in Kaiserswerth, Germany.
She formed a team of nurses that assisted soldiers during the Crimean War (1854 to 1856) and
statistically documented her successes saving lives through prevention of infections and
improving environmental conditions (Fig. 1.6). In 1860, following the war, Nightingale opened
the first school of nursing, and Rathbone hired several graduates as district nurses. Two years
later, with Nightingale’s assistance, he established a nursing school in Liverpool.
42
FIGURE 1.5 Dickens’s character, Sairey Gamp. (From Kalisch, P. A. & Kalisch, B. J. [2004].
American nursing: A history. Philadelphia, PA: Lippincott Williams & Wilkins.)
1.5 Duties of District Nurses in Liverpool, England: 1865
Investigate new referrals as soon as possible.
Report to the superintendent situations in which additional food or relief would improve recovery.
Report neglect of patients by family or friends to the superintendent.
Assist physicians with surgery in the home.
Maintain a clean, uncluttered home environment and tend fires for heat.
Teach the patient and family about cleanliness, ventilation, giving of food and medications, and
obedience to the physician’s orders.
Set an example for “neatness, order, sobriety, and obedience.”
Hold family matters in confidence.
Avoid interference with the religious opinions and beliefs of patients and others.
Report facts to and ask questions of physicians.
Refer the acutely ill to hospitals and the chronically ill, poor without family to infirmaries.
Source: Brainard, M. (1985). The evolution of public health nursing (pp. 120–121). New York: Garland. (Original work published in 1922. Philadelphia, PA:
W.B. Saunders.)
43
Public Health Initiatives in Early America
American social values were strongly influenced by British traditions, including care for the sick
poor. Care of destitute and infirm residents was the responsibility of the town or county, similar
to the English Poor Law of 1601. In the 1700s, early public health efforts in the colonies were
focused on sanitation, collection of vital statistics, and control of infectious diseases. People
with contagious diseases were isolated in “pesthouses,” and home quarantines were instituted.
Women of the house were responsible for care of the ill, and treatments consisted of home
remedies that were often passed down through generations.
Occasionally, a board of health would be established to address a specific problem, but it
was then disbanded. In 1789, the first local health department with a permanent board of health
was formed in Baltimore, MD. In 1798, the Marine Hospital Service was established by
Congress to provide for the temporary relief and maintenance of sick and disabled seamen, as a
means to protect the public from contagious diseases brought into port by the sailors. This was
the first prepaid medical care program in the United States, financed through compulsory
employer tax and federally administered.
At the beginning of the 1800s, people recognized that they needed a more organized public
health system. In 1809, Elizabeth Ann Seton founded the Sisters of Charity in Maryland. The
Sisters of Charity (also called Daughters of Charity) established and operated many hospitals,
orphanages, and educational institutions over the years. In 1813, the Ladies’ Benevolent Society
of Charleston, SC, was established to provide organized home care to the sick. Knowing the
threats that sick merchant seamen posed to the general population, Congress passed the Act for
the Relief of Sick and Disabled Seamen in 1798 (amended in 1802) to establish hospitals for
merchant seamen. However, conditions in many cities remained nearly intolerable.
The Industrial Revolution resulted in the transformation of primarily agricultural economies
to large industrial centers. Large numbers of people migrated into cities, living in crowded
tenement houses. Working conditions were poor, people were overworked and underpaid, and
child labor was prevalent. Poor nutrition and overcrowded living conditions led to the rapid
spread of communicable diseases. For example, New York City’s streets were piled with
garbage and sewage, and tenements were filthy and crowded, providing breeding grounds for
tuberculosis, smallpox, and typhus. Although initial attempts were made to protect residents
from infectious diseases by providing healthcare to merchant seamen, diseases became epidemic
and quarantine became inadequate. Few advances in public health were made other than
scattered smallpox regulations until the Shattuck Report was published.
44
FIGURE 1.6 Florence Nightingale, the “Lady with the Lamp.” (From Kalisch, P. A. & Kalisch, B. J.
[2004]. American nursing: A history. Philadelphia, PA: Lippincott Williams & Wilkins.)
Lemuel Shattuck
Lemuel Shattuck prepared a report for the Massachusetts Sanitary Commission that pointed out
that much of the ill health and disability in American cities in 1850 could be traced to unsanitary
conditions. The report is now considered one of the fundamental documents in public health in
the United States. It provided for the first systematic use of birth and death records and
demographic data to describe the health of a population. The recommendations became the
foundation of the sanitation movement in the United States, which laid the framework for the
dramatic increase in life expectancy that occurred in the next 150 years. In 1850, the average
lifespan was 25 years, and by 2000, it was more than 75 years. The Shattuck Report
recommended the establishment of a state health department and local health boards in every
town, and resulted in the first attempt to write a comprehensive public health code. Following
the Civil War, many states and localities adopted these recommendations, ultimately resulting in
the public health system that exists today.
Perhaps the most significant single document in the history of public health—I know of no
single document in the history of that science quite so remarkable in its clarity and
completeness and in its vision of the future. C. E. A. Winslow, bacteriologist and public
health expert, on the Shattuck Report
Dorothea Dix
Dorothea Dix was also an American political activist in the 19th century who became aware of
the dreadful conditions in prisons and mental hospitals, and she vigorously lobbied state and
federal officials to remedy the situation. She had traveled to England in 1836, and during her
time there, she met William Rathbone, who was spending a year as a guest at the family estate in
45
Liverpool. In addition, she met political activists who believed that government should take an
active role in social welfare. The lunacy reform movement was underway in England at the time,
and the detailed investigations of the madhouses were published, resulting in legislative
changes. After returning from England in 1840, Dix traveled the state of Massachusetts, visiting
jails and insane asylums. She was appalled by conditions there and compiled a report that she
presented to the Massachusetts Legislature. Considered the most progressive state in the union,
Massachusetts quickly allocated funds to establish the first hospitals for the mentally ill. After
making changes in Massachusetts, Dorothea moved on to other states and other countries,
establishing hospitals and improving life for the mentally ill.
I proceed, Gentlemen, briefly to call your attention to the present state of Insane Persons
confined within this Commonwealth, in cages, stalls, pens! Chained, naked, beaten with
rods, and lashed into obedience. Dorothea Lynde Dix
Clara Barton
Clara Barton achieved widespread recognition during the Civil War, distributing supplies to
wounded soldiers and caring for the casualties with the help of her team of nurses. As a result of
these experiences, she recognized the need for a neutral relief society in the United States that
could be activated in times of war, similar to the International Committee of the Red Cross that
was founded in 1863 in Geneva, Switzerland, by Henry Dunant. Barton lobbied tirelessly, and in
1882, she convinced Congress to ratify the Treaty of Geneva, and the American Red Cross was
established with an extended mission—to provide aid for natural disasters.
Lillian Wald
In the 1880s, 20 years following the establishment of district nursing in England, a similar
movement began in the United States. Urban tenement houses in the large American cities
across the country were crowded and unsanitary, and infectious diseases such as tuberculosis,
typhoid fever, smallpox, and scarlet fever were prevalent. A number of initiatives were
undertaken in the major cities to improve the life of residents. An increased understanding of
communicable disease indicated that education about prevention of infections would reduce
these illnesses. Teaching methods to prevent infectious disease, implementing sanitary reforms,
and fostering better nutrition became the foundations of community nursing practice in the
United States.
Lillian Wald, the founder of public health nursing, was born into a life of privilege (as was
Florence Nightingale) (Fig. 1.7). At the age of 22, Wald attended the New York Hospital School
of Nursing. While taking classes at the Women’s Medical College, she became involved in
organizing a class in home nursing for poor immigrants on New York’s Lower East Side.
Distressed by the living conditions in the dingy multistorey flats, Wald moved to the
neighborhood, and she and her classmate Mary Brewster volunteered their services. With the aid
of several patrons, they founded the Henry Street Settlement in 1893; fees were based on the
patient’s ability to pay. In addition to providing acute and long-term care for the sick, Wald and
Brewster taught health and hygiene to the immigrant women, stressing the importance of
preventive care. Wald called her services “public health nursing.” Similar settlement houses in
other American cities developed rapidly.
46
FIGURE 1.7 Lillian Wald (center, second row) and nurses of the Henry Street Settlement. (From
Kalisch, P. A. & Kalisch, B. J. [2004]. American nursing: A history. Philadelphia, PA: Lippincott
Williams & Wilkins.)
The vermin in these old houses are terribly active at night…there is nothing harder to
endure than to watch by a night sickbed in these old worn houses and see the crawling
creatures, and the babes so accustomed to them that their sleep is scarcely disturbed.
Lillian Wald, The House on Henry Street
Wald devoted herself full time to the Lower East Side community, ultimately becoming one
of the most influential and respected social reformers and humanitarians of the 20th century.
Within a decade, the Henry Street Settlement included a team of 20 nurses, and it offered an
astonishing array of innovative and effective social, recreational, and educational services.
Eventually, the organization incorporated housing, employment, educational assistance, and
recreational programs. It also placed nurses in public schools and businesses. Later, the Henry
Street Settlement became the Visiting Nurse Association of New York City (Henry Street
Settlement, 2004).
Nursing is love in action, and there is no finer manifestation of it than the care of the poor
and disabled in their own homes. Lillian Wald
In 1912, Wald helped found the National Organization for Public Health Nursing, which set
the first professional standards for the practice of public health nursing. These standards were a
precursor to ANA’s Public Health Nursing: Scope and Standards of Practice, which guides the
practice of public health nursing today. As a founder of Columbia University’s School of
Nursing, she persuaded the administration to appoint the first professor of nursing in the
country, laying the foundation for nursing education in institutions of higher learning. Wald also
was an advocate for children and women’s rights, helping with the establishment of the United
States Children’s Bureau, National Child Labor Committee, and the National Women’s Trade
Union League (Ruel, 2014).
47
Public Health Initiatives in the 20th Century
Public Health in the First Half of the Century
Public health and nursing initiatives grew exponentially in the 1900s, a century dominated by
two world wars and an astounding increase in scientific knowledge. Recognition of public health
nursing as a necessary function of government came about gradually in the early part of the 20th
century. Local health departments, charged with control of communicable diseases, sanitation,
maintaining a safe water supply, food inspection, health education, and other functions, began
hiring more nurses. Although there was a rapid growth in the number of hospitals, few resources
were available to people who had to be cared for in their homes. The first PHNs focused on care
at the bedside, but they soon realized that their efforts had little effect if conditions were
unsanitary and if there was no food in the house. PHNs effectively served as sanitary inspectors,
tenement house inspectors, probation officers, and social welfare service workers. Before long,
it was clear that nursing practice demanded psychosocial and political skills, along with a broad
understanding of the community.
As demand for services grew, the role of PHNs became more focused on teaching and
counseling, showing others how to care for the sick, instructing them on how to prevent illness,
and promoting maternal and child health (Kalisch & Kalisch, 1978). Health promotion and
disease prevention began with the need for health education during home visits to the poor living
in large cities and expanded over time to schools, employees, and the rural population.
Mary Breckinridge
An innovation in the provision of health services occurred when Mary Breckinridge founded the
Frontier Nursing Service in 1925 (Fig. 1.8). Following the death of her two children, she decided
to devote her life to improving the health of children and developing a system of rural healthcare
in the remote regions of Kentucky and throughout the world. Traveling on horseback,
Breckinridge studied the health needs of the mountain people. She found that women lacked
prenatal care, gave birth to an average of nine children, and primarily had self-taught midwives
in attendance at their delivery. Maternal and infant mortality were high. Breckinridge realized
that children’s healthcare must begin before birth with care of the mother and continue
throughout childhood, while including care for the entire family (Schminkey & Keeling, 2015).
She founded the Frontier Nursing Service, which continues to provide family-oriented
healthcare to rural and underserved populations today. In 1939, she helped establish the Frontier
Graduate School of Midwifery, one of the first midwifery programs in the country (Frontier
Nursing Service Inc., n.d.)
Our aim is to see ourselves surpassed. Mary Breckinridge
Early 20th Century Federal Healthcare Initiatives
The Spanish–American War of 1898 led to a significant use of trained nurses in military
hospitals. For the first time, the graduates of nearly 200 nurse training schools throughout the
country were incorporated into a single nursing corps. These nurses were the forerunners of
women in the armed services. A permanent Army Nurse Corps was established in February,
1901, followed by creation of a Navy Nurse Corps in 1908 (Kalisch & Kalisch, 1978).
48
FIGURE 1.8 Mary Breckinridge and a frontier nursing visit. (From Kalisch, P. A. & Kalisch, B. J.
[2004]. American nursing: A history. Philadelphia, PA: Lippincott Williams & Wilkins.)
Prior to the 20th century, government involvement in healthcare was left to the states. By
1900, health departments had been established in the majority of states, but their function was
limited. By 1912, there was a growing acceptance that the U.S. government should take an
active role in the health and welfare of the people. The need for a permanent federal agency that
was responsible for the health of citizens was recognized, and the Marine Hospital Service,
originally established in 1798 for seamen, was reorganized to form the U.S. Public Health
Service (USPHS). The office of the U.S. Surgeon General was also founded that year. Federal
programs focused on the health of mothers and children, the poor, the mentally ill, and those
with sexually transmitted diseases were implemented. For example, the Maternal and Infancy
Act (Sheppard–Towner Act), passed in 1921, provided matching funds to states that developed
maternal and child divisions in their health departments. Home visits by PHNs encouraged
prenatal care and health promotion for mother and child, and maternity centers and child health
clinics were established (Kalisch & Kalisch, 2004).
World War I (1914 to 1918) was a military conflict centered in Europe that involved most of
the world’s great powers. Although the Army Nurse Corps and the Navy Nurse Corps had
expanded, care of the wounded was still insufficient, and civilian nurses were in short supply.
The types of wounds from modern weapons and the use of poisonous gases required new
nursing skills, and wound infections were rampant. Then, in late 1918, when the armistice
occurred, an influenza pandemic spread throughout the world, with soldiers becoming vectors of
the viral infection.
By 1920, there was a significant shortage of nurses, and patient care suffered. It was
estimated that 90% of ill people were cared for at home with assistance from the community
(Kalisch & Kalisch, 1978). The Great Depression began in 1929, resulting in widespread
unemployment, including nurses. At the same time, the need for health services expanded,
especially for charity cases. The federal government became even more active in health and
social welfare programs, employing nurses through the Federal Emergency Relief Act, the Civil
Works Administration, and other agencies. In 1933, Pearl McIver became the first nurse to be
49
employed by the USPHS. Her primary role was to provide consultation services to state public
health departments, resulting in an increase in local PHN employment.
The Social Security Act of 1935 was passed to help prevent a recurrence of the problems
associated with the Depression, especially for poor elderly people. It provided a system of
federal old-age benefits and enabled states to make more adequate provision for elderly people,
the blind, dependent and crippled children, maternal and child welfare, public health, and the
administration of state unemployment compensation laws. Financial support was provided to
increase public health programs, particularly for mothers and children in rural areas. Local
health departments designed their programs on the basis of the funding that was available, rather
than directing their efforts toward a comprehensive community health program. A component of
the federal approach to health policy today still directs funding to special population groups or to
the prevention and control of specific diseases.
With the onset of the United States’ involvement in World War II, it became clear that the
United States would soon face a critical shortage of nurses nationwide. Through the work of
Congresswoman Frances Payne Bolton, the Cadet Nurse Corps was founded as a part of the
USPHS to train nurses during World War II. Applicants were granted subsidization of nursing
school tuition and associated expenses, and schools were funded to provide expedited training.
In exchange, applicants agreed to provide nursing services to the military or other essential
civilian industries for the duration of the war. The number of PHNs employed by industry
almost doubled during this time. Public health nursing also expanded in rural areas during World
War II, and some official agencies began to offer bedside care.
Public Health in the Second Half of the Century
After the war, the increased demand for healthcare services led to increased opportunities for
PHNs, changes in healthcare delivery and financing, and the growth of health insurance. Local
health departments faced increases in demand for services related to community problems such
as alcoholism and mental illness. Their services increased to include screening for tuberculosis
and sexually transmitted diseases as well as treatment of infectious diseases, and services were
extended to rural areas.
By mid-century, a number of social improvements resulted in an increased lifespan. Public
health measures such as improved sanitation, provision of potable water, better nutrition, and
better housing contributed to this phenomenon, along with medical developments such as
immunizations and antibiotics. Childhood mortality decreased, and more Americans lived into
middle and old age. Infectious diseases were the leading causes of mortality in 1900; by 1950,
the leading causes of death were heart disease, cancer, and cerebrovascular disease, as they
remain today. With the increased lifespan, new challenges related to chronic diseases emerged.
In 1966, the Social Security Act was amended and Medicare was created to provide
healthcare funding to the elderly. The next year, Medicaid was established to provide funding
for the indigent (see Chapter 2). These programs contributed to the continued increase in
demand for services, and costs of healthcare escalated. Some people perceived these programs to
be the first step toward universal healthcare coverage in the United States. To address increased
demands, the federal government passed health planning legislation to meet differing needs
throughout the country. Although this legislation had merit, it failed to produce expected results.
Federal efforts to reform healthcare continued to focus on organization of services and
financing, rather than implementing changes in the social conditions that led to health
disparities.
The roles and responsibilities of PHNs continued to expand during the 1970s, and they
contributed significantly to the improvement of the health of communities. A wide variety of
programs were implemented according to need. Hospice services, day care centers for the
disabled, alcohol and drug abuse programs, halfway houses, and rehabilitation centers are just a
50
few of the public health initiatives that nurses helped create. Home nursing visits increased
following Medicare’s implementation of diagnosis-related groups (DRGs) that were designed to
lower costs through reduced hospital stays. Medicaid also reimbursed some home care services,
as did the Veterans Administration and private medical insurance. More and more acutely ill
people were cared for in the home, creating an ongoing demand for PHNs.
Despite the increased need for nursing services, public health as a whole declined in the
1980s. The economic recession resulted in decreased funding for social programs. The Institute
of Medicine (IOM) published The Future of Public Health in 1988, finding that public health
services varied considerably across the United States. The system was in disarray, controlled
more by the political system than by public health professionals. This study set the stage for the
development of the Healthy People initiative that designed a national strategy to improve the
health of Americans. Healthy People 2020, discussed earlier in this chapter, is the most recent
vision for the next decade. Many of these measurable objectives (see Box 1.2) are discussed
throughout this text.
The task force decides that a written and pictorial presentation on the historical roots of
public health nursing practice will be a component of the online course.
Describe three characteristics of population-based nursing practice that have been
present since the first district nurse was appointed in England.
The First Decade of the 21st Century
The Department of Homeland Security (DHS) was created by the Department of Homeland
Security Act of 2002 and is an outgrowth of the Office of Homeland Security established by
President George W. Bush shortly after the terrorist attacks of September 11, 2001. The primary
mission of DHS is to lead the unified national effort to secure the United States, reducing the
vulnerability of the United States to terrorism and protecting against and responding to threats
and hazards to the United States.
The DHS fosters an all-hazards, all-disciplines approach to emergency management that
allows effective response to all emergencies, whether natural or human-made, or caused by
terrorists. To meet this mission, the DHS builds collaboration and partnerships with all levels of
government, the private sector, academia, and the general public. Because all disaster response
begins at the local level, all cities and towns in the United States are now required to have all-
hazards local emergency preparedness plans (see Chapter 20). The National Response
Framework, established by DHS, guides the overall conduct and coordination of all-hazards
incident responses when the scope of a disaster extends beyond the capability of local and state
governments to respond.
Through education and outreach, homeland security expertise is fostered across multiple
disciplines to serve as an indispensable resource for the United States. The Federal Emergency
Management Agency, as the lead agency for emergency management, offers courses for first
responders. The CDC also offers many online training sessions, and many states and localities
have developed their own training programs.
The aftermath of the destruction of the World Trade Center in 2001 also identified a lack of
trained leaders and workers in all areas of public health service. In an era in which public health
threats range from pandemics of emerging infectious diseases to obesity epidemics to the opioid
epidemic to bioterrorism, the need for an effective public health workforce is paramount. PHNs
constitute the single largest group of professionals practicing public health; however, all nurses,
to some degree, are involved in public health. Therefore, the IOM (2003) has recommended that
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undergraduate nursing students have an understanding of the ecological model of health (see
Chapter 5) and the core competencies of population-based practice discussed earlier in this
chapter.
Some of the issues that were characteristic of public health nursing in the past are still
prevalent today, and a multitude of new challenges exists. To provide the most comprehensive
care to clients, whether individual people, families, or groups, PHNs must be flexible, be
politically active, embrace change, and refresh their knowledge of public health issues on a
continual basis.
CHALLENGES FOR PUBLIC HEALTH NURSING IN
THE 21st CENTURY
Many yet-unknown challenges will develop during the 21st century. Communities will evolve
and change, cultures will merge, environments worldwide will undergo transformation, and
advances in technology and therapeutic techniques will result in dramatic changes to healthcare.
The following are some of the challenges for PHNs foreseen at present.
Engaging in Evidence-Based Practice
Nurses have always used the knowledge gained through education and experience in making
decisions about the care of clients—accentuated by a dose of intuition. The challenge today and
for the future is to document and use the best evidence available in making decisions with
clients about their care. Evidence-based nursing is the integration of the best evidence
available with clinical expertise and the values of the client to increase the quality of care.
Similarly, evidence-based public health is a public health endeavor in which there is judicious
use of evidence derived from a broad variety of science and social science research. In addition
to published research, PHNs can gather information from interviews and through observation of
specific population groups and gather pertinent information about the geographic locale.
Epidemiology is the science of prevention. Epidemiologic research has provided knowledge
of the natural history of diseases and identified the (risk) factors that increase a person’s
susceptibility to illness. Nurses use the evidence that epidemiologic research has established
when assessing clients and using data for planning and implementing interventions. Using the
epidemiologic body of knowledge that has been developed for specific conditions, nurses can
determine the stage of the illness in question and decide with the client what type of
interventions are most appropriate for preventive or therapeutic purposes (see Chapters 5 and 6
for discussions of primary, secondary, and tertiary prevention strategies). Nurses engaging in
community assessment also use epidemiologic methods to determine the assets and health needs
of populations, and the evidence is used to create a variety of intervention programs. The public
health approach to problem-solving is illustrated in Figure 1.9.
Sandy and other members of the task force think that evidence-based practice should be
part of the online population-based health course.
What activities could be assigned that would foster evidence-based practice?
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Practice Point
Systematic reviews of research evidence, such as those included in the Cochrane Database
of Systematic Reviews, are instrumental in implementing evidence-based practice.
Helping Eliminate Health Disparities in Underserved
Populations
Eliminating health disparities is a combined effort of health professionals in all settings, but
PHNs deal directly with these issues, often on a personal basis. Ultimately, the most important
changes occur at the local level. By participating in the development, implementation, and
evaluation of culturally appropriate, community-based programs, nurses use their expertise to
remedy the conditions that contribute to health disparities.
Demonstrating Cultural Competence
Countless cultures in the world are constantly changing. The shared cultural symbols and
meanings that are a part of people’s daily social interactions have an impact on their acceptance
or rejection of actions taken to promote their health. Therefore, nursing strategies that are
focused on people with little attention as to how they think, feel, and interact with their world
are not sufficient.
FIGURE 1.9 The public health approach to problem-solving.
Cultural competency is an expected component of nursing practice, but it will become even
more essential as interaction and integration among cultures increases. The characteristics of the
major cultural groups that make up a community must be understood, along with those aspects
of the community that give it its own unique subculture. It is necessary for nurses to be aware of
cultural interpretations of healthcare activities so that they know what questions to ask and
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interventions to suggest. To achieve cultural competence, nurses should respect differences,
understand their own beliefs, and not let personal beliefs have an undue influence on others.
Nurses need to communicate curiosity and openness to others’ ideas and ways of life, respect
their decisions, and demonstrate patience and humility (see Chapter 10).
Misunderstanding a culture’s symbols is a common root of prejudice. Dan Brown, The
Lost Symbol
Evidence for Practice
The delivery of culturally competent public health nursing that can address health disparities
depends on competent nursing practice. Understanding the nurse characteristics, care
situations, and training associated with culturally competent awareness and behavior
provides a basis for planning and developing interventions to ensure competent nursing
care. To meet this objective, a cross-sectional, descriptive, and exploratory study was
conducted among 31 PHNs in a southeastern U.S. public health department using a cultural
competence assessment tool with an internal consistency reliability of 0.90.
The self-reported study findings showed moderate competence in awareness and
sensitivity. Although nursing care was consistent with guidelines and mandates found in the
National Standards for Culturally and Linguistically Appropriate Services in Healthcare (U.S.
Office of Minority Health), the nurses did not assess their behaviors at comparable levels.
While providing care, the nurses encountered multiple racial/ethnic and special population
groups, including many that are at risk for or experiencing health disparities and poor
outcomes. Therefore, being culturally competent in both thought and actions is necessary
and important for these nurses. These nurses felt frustrated in their attempts to provide care
that was consistent with their perceptions of culturally competent care. Lack of human or
financial resources, interpreters, gender-specific providers, and time were the most
common barriers. In addition, the nurses expressed a desire for additional diversity training.
To meet the goals of a culturally competent workforce, formal courses, continuing education
programs, and practical experiences should focus on awareness, sensitivity, and behaviors
consistent with culturally competent care. To develop additional evidence-based knowledge
for practice, additional studies of clients’ perceptions and evidence of culturally competent
care are needed. This information is necessary for the development of practice
interventions with measurable outcomes that can be evaluated for effectiveness in
addressing health disparities (Starr & Wallace, 2009).
Planning for Community Change
Change in healthcare at all levels can occur through behavior change, or through modifications
in the environment, public policy, social or cultural norms, or healthcare delivery. Often,
interventions at institutional or societal levels may lead to significant changes in public health
without the need for behavior change on the part of individual people; fluoridation of water is an
example. Even small changes in health behavior at the community or population level have the
potential to significantly affect health status. The use of gel alcohol in hospitals and the
availability of disinfectant wipes in grocery stores and other public places are examples.
Change should be planned and should meet specific needs to be the most effective. The
impetus for change varies considerably. For example, installation of home monitoring devices
may require new responsibilities, an influx of immigrants may increase the healthcare needs of a
community, data may indicate that substance use disorder and violence are increasing in specific
groups, or new state regulations may require the establishment of new programs. On a
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community basis, health planning occurs on both an ongoing and an episodic basis depending on
the need and usually is a collaborative effort between multiple groups and organizations. A good
example is the development of emergency preparedness plans in cities and towns (see Chapter
20).
Monitoring and evaluating the health status of individual people, families, and community
groups are primary components of nursing practice in the community, as is the investigation of
emerging health and environmental problems. Therefore, accepting responsibility for
contributing to community health change as a policy advocate and political activist is essential.
Few practitioners are as well prepared to address community health issues as PHNs. See Chapter
9 for more information on planning for community change.
The state department of public health recognizes that increasing the knowledge base of
PHNs in population-based practice is just one step in implementing the new vision of public
healthcare delivery. Knowledge alone cannot change practice from a clinical focus to a
population-based focus if the work environment does not support the transition. Sandy is
preparing another survey to determine current practices that need to be discontinued,
strengthened, or developed within the next five years. Although the new vision for PHNs will
include primary care, the majority of skills in the new model of practice will focus on
population-based competencies.
Design a simple public health nursing model that incorporates the basic principles of
population-based nursing.
Evidence for Practice
Intimate partner violence (IPV) is a serious and prevalent public health issue. Given the
complexity of IPV, there have been efforts to integrate social and healthcare services.
Public health nurses are well positioned to work collaboratively with social service agencies
to provide health education and assistance in accessing healthcare services. Providing
health education at social service agencies gives public health nurses access to IPV
survivors and is also convenient for the IPV survivors, who typically spend significant
amounts of time at the agencies. Prior to developing any educational offering it is imperative
that the nurse assess the perceived needs of the survivors. Ferranti, Lorenzo, Munoz-
Rojas, and Gonzalez-Guarda (2017) studied the health education needs and learning
preferences of female IPV survivors who were receiving assistance at a social service
agency in South Florida. Using an exploratory two-phase sequential mixed method, the
researchers first conducted semistructured interviews with 10 service providers to gain their
perspective on the health needs of women they served. The interviews were analyzed to
extract themes, and the themes guided the development of a survey that contained 10
close-ended questions. Three themes were identified: (a) multidimensional health needs of
families (primary care, mental health, reproductive/sexual health, chronic disease
management); (b) complexities of navigating the health system, including structural barriers
(insurance, transportation, finances, and immigration status) and health literacy (finding a
doctor); and (c) self-improvement specific to IPV survivors (empowerment and vocational
skills).
There were 122 female IPV survivors who completed the survey. The sample was
primarily Hispanic, ranging in age from 19 to 65, with a mean age of 34.8 and the majority
having a high school education or higher (81%). Of them, 57% were born outside of the
United States. Physical health proved to be a lower priority for the participants, as almost
70% of them identified depression as the top health education need. Over 50% of the
women chose abuse and mental health as the next greatest concerns, with anxiety selected
by 45%. For health topics, over half of the women selected self-esteem, nutrition, and
women’s health, with 45% identifying children’s health as an important health topic. With
respect to learning preference, hands-on activities and talking to an expert were the top two
55
choices, with 50% of the participants selecting them. The relationships between most
learning preferences and demographic factors, as analyzed using chi-square and t-tests,
were nonsignificant. However, age was significantly related to learning preference of
brochures/books. Those who selected brochures/books were significantly older (mean =
37.6) compared to those who did not. Also, language preference (English vs. another
language, Spanish or Creole) was significantly associated with presentation preference and
group discussion. The women who preferred English were more apt to select both
presentation and group discussion when compared with those who preferred another
language.
The study highlights the importance of health education in the continued recovery of IPV
survivors. The differences that were found between the service providers and recipients
supports the critical importance of public health nurses including the IPV survivors prior to
planning any health education program so that it targets the participants’ priorities and
learning preferences. The strong emphasis on mental health acknowledges the
psychological toll that IPV has on the survivors.
Contributing to a Safe and Healthy Environment
Where people live, work, and spend their time can have direct consequences on their health. In
every community in the world, clients are part of the environment, which has a direct impact on
their health and well-being. The WHO (2016) reports that 23% of the global burden of disease is
attributable to the environment. There are two ways to examine the effects of the environment
on human health. The first focuses on how contaminants in the environment, such as asbestos,
lead, or radon, influence human health. The second focuses on how the entire environment
surrounding the community, such as the climate, neighborhood safety, access to grocery stores,
and the physical layout of the community, affects health. Often, the two types of environmental
effects interact.
The challenge for environmental health nurses is to use the best science available to assess
how the local environment affects human health, to formulate evidence-based or best-practice
interventions, and to evaluate the effectiveness of those interventions. Nurses are in a strong
position to advocate for healthier environments in both the workplace and community (see
Chapter 19).
Responding to Emergencies, Disasters, and Terrorism
All disaster response begins at the local level, and PHNs have always responded to community
emergencies and disasters. They play an important role in all phases of the disaster management
continuum, whether anticipating potential emergencies, developing appropriate community
preparedness plans, building system-wide partnerships, practicing implementation of disaster
management plans and skills on a regular basis, or evaluating outcomes (see Chapter 20).
Disaster preparedness plans are proactive planning efforts that are developed in anticipation
of disaster scenarios, providing structure to a response before the disaster occurs. In an all-
hazards event plan, the response must be a coordinated community effort in which members of
the community are engaged in ongoing preparedness activities focused on a variety of disaster
situations. The capacity to respond to threats depends in part on the ability of healthcare
professionals and public health officials to rapidly and effectively detect, manage, and
communicate during an event. The terrorist attacks in 2001 identified a lack of workers in all
areas of public health, as well as a growing appreciation of the first responders, primarily
firemen, police, and healthcare personnel. Increased competency in disaster response added a
new dimension to nursing practice. The public health workforce continues to be mobilized to
ensure the training and education of communities across the nation regarding biological,
56
chemical, and radiological attacks. It is necessary to learn how to prepare for events that are
difficult to imagine, and it is even more challenging to mount a response.
Responding to the Global Environment
The burden of disease is growing disproportionately in the world and is largely affected by
climate, public policy, age of the population, socioeconomic conditions, and factors that place
people at risk for illness. Most of the countries burdened by disease have the least amount of
human and economic capacity to effect change. Extreme poverty is the driving force behind
increased mortality, and women are disproportionately affected.
Although maternal deaths have dropped worldwide by almost 50% in the last decade,
maternal mortality is still unacceptably high. On any given day, approximately 800 women die
from preventable causes related to pregnancy and childbirth, nearly all (99%) occurring in low-
income countries. Many of the complications resulting from childbirth can be prevented by
skilled care before, during, and after childbirth by midwives and nurses. When a mother dies or
is disabled, her children may be forced to live in poverty. Presently, about 6.6 million children
younger than 5 die each year; poor nutrition is the underlying cause of death (WHO, 2017).
FIGURE 1.10 The top 10 global causes of death in 2016.
The leading causes of mortality and global burden of disease worldwide have shifted from
communicable to noncommunicable chronic diseases as a result of population aging and better
control of infectious diseases. Cardiovascular disease is already the leading cause of death in the
world, followed by stroke. Figure 1.10 shows the 10 leading causes of death worldwide. Only
57
lower respiratory infections, diarrheal diseases, and tuberculosis are infectious diseases
remaining in the top 10. Chronic diseases such as COPD; Alzheimer disease; tracheal, broncial,
and lung cancers; and diabetes mellitus are causing increased numbers of deaths worldwide.
Traffic injuries worldwide are expected to grow from the eighth leading cause of death in 2016
to the fifth in 2030. The global burden of disease and methods to improve global quality of care
are discussed in Chapter 4.
With the world becoming a global village, problems that affect people in other countries also
affect people in their own countries. Nurses and community healthcare providers need to be
knowledgeable about the needs of all people, as well as their patients, in the global society.
Opportunities have expanded for nurses to work internationally in a wide variety of roles:
working side by side with local people in healthcare, initiating health education programs,
establishing local primary healthcare programs, and participating in countless other activities.
Advanced technology and knowledge transfer techniques will allow rapid transfer of
information from electronic monitoring equipment, presenting exciting opportunities to improve
health in remote locations. New cooperative healthcare ventures will occur throughout the world
in the 21st century.
Practice Point
In this dynamic time, care will be transformed as needs rapidly evolve. Newly prepared
nurses will experience events never before thought possible.
Student Reflection
Over the spring vacation, a group of eight undergraduate nursing students, three graduate
students, and three faculty members flew to Nicaragua to work in a clinic for the week.
There was one person who stands out in my mind. She was a 25-year-old woman who
came to the clinic complaining of diarrhea, accompanied by her 6-year-old son and 3-year-
old daughter. One of our nurse practitioners (NPs) cared for her while I observed. After the
NP determined that the woman had a gastrointestinal parasite that was common in
Nicaragua and prescribed treatment, the nurse asked the client about her wishes to have
more children. The woman responded quietly that she did not want more children, but that
her husband was adamant that she did not use birth control. When the NP asked if birth
control was a sensitive subject between them, the woman began to cry. She told us that
after the birth of her daughter, she began birth control without consulting her husband, and
when he found out, he became verbally and physically abusive. Since that point, their
relationship had become increasingly violent and the woman said she feared for her life,
along with the lives of her children. Her husband felt that if she used birth control she was
cheating. He told her that he was not going to use a condom, and if she did not want to
have his children, she didn’t love him.
This situation made me realize just how dismal it can be for women in violent
relationships. Because of lack of resources, it is very difficult for abused women to find help,
and many lose hope, believing that nothing can be done. Their situation is complicated
since the majority of women are financially dependent on their partners. Our client was in a
similar situation. She was afraid of her husband, vulnerable financially, and had two children
to protect. Her situation would be further complicated if she continued without birth control.
During the visit, the NP and I listened and provided the emotional support that she so
desperately needed. We began to discuss some options and actions that she might be able
to take. Just as we would in the United States, we discussed the necessity of formulating a
58
plan before acting, helping to ensure success and safety. We talked about the possibility of
staying with a family member and reviewed the important documents and birth certificates
that she should take with her. Also, I told her about a domestic violence support group that
the clinic provided. Finally, we discussed multiple forms of birth control that she could use,
such as the hormone injection that lasts for three months to prevent pregnancy, if she were
unable to leave for any reason. I think the woman left feeling relieved and somewhat
hopeful for what the future held for her family. Even if I was only able to get my client
thinking about her options, I feel that our time together was a success.
KEY CONCEPTS
Three major changes in healthcare in the 21st century include the development of patient/client-centered
care, increased use of technology, and increased personal responsibility for health.
The practice of public health nursing is defined in the ANA (2013) publication Public Health Nursing: Scope
and Standards of Practice. It defines the essentials of public health nursing, the activities, and the
accountabilities that are characteristic of practice at all levels and settings. It is the legal standard of
practice set by the profession.
In the ANA (2013) publication, each standard of practice is followed by the essential competencies required
to meet that standard.
The Public Health Intervention Wheel defines 17 interventions—actions taken on behalf of individuals,
families, communities, and systems to protect or improve health status.
Entry into public health nursing practice requires a baccalaureate degree.
The historical roots of public health nursing have set the framework for current nursing practice in the
community.
Multiple challenges face PHNs in the 21st century:
Engaging in evidence-based practice
Helping eliminate health disparities in underserved populations
Demonstrating cultural competence
Planning for community change
Contributing to a safe and healthy environment
Responding to emergencies, disasters, and terrorism
Responding to the global environment
CRITICAL THINKING QUESTIONS
1. Review the public health milestones presented in Box 1.1. What potential health successes might be cited
in the next decade?
2. Identify a new role for nursing that will most likely evolve in the first half of the 21st century.
3. Analyze the roots of public health nursing and its influence on practice today.
HEALTHY PEOPLE 2020 LEARNING ACTIVITY
Social Determinants of Health
Healthy People 2020 provides a blueprint which identifies nationwide health improvement priorities. This
national consensus plan includes 42 topics, with a subset of 12 leading health indicators (LHI) and over 1,200
objectives. It offers a framework for strategic planning to promote health improvement and achieve health
equity through measurable objectives and deliberate actions. The Healthy People 2020 website is dense with
important information on the development, implementation, and progress of this national plan. Learning to
59
navigate the website, to access the rich materials offered is vital to gain a deep understanding of the national
health improvement priorities, specific objectives, and initiatives seeking to achieve the national goals and
objectives.
Social Determinants of Health is a new topical area identified as a priority in Healthy People 2020. To learn
more about this topic go to: https://www.healthypeople.gov.
Click on Topics & Objectives: Topics are listed alphabetically, scroll down to “S” and click on Social
Determinants of Health.
Click on “Overview” and find the answers to the following questions:
What is the goal for this topic?
What are some examples of social and physical determinants of health?
What are the five determinants selected for Healthy People 2020?
Click on “Objectives” and select one objective from each of the five determinants: Analyze the data,
looking specifically at any disparities, progress made, and thinking about continued barriers to achievement.
Click on “Resources and Interventions” and select one resource from the national, state, and local
groupings:
Review the resource to explore how community and public health groups are working to address and improve
the social determinants of health across the nation.
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WEB RESOURCES
• Please visit thePoint for up-to-date web resources on this topic.
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Chapter 2
Public Health Systems
Rosanna F. DeMarco
For additional ancillary materials related to this chapter. please visit thePoint
It is no measure of health to be well adjusted to a profoundly sick society.
Jiddu Krishnamurti
Without health, life is not life; it is only a state of languor and suffering—an image of death.
Buddha
America’s healthcare system is neither healthy, caring, nor a system.
Walter Cronkite
Everyone should have health insurance? I say everyone should have healthcare. I’m not selling
insurance.
Dennis Kucinich
CHAPTER HIGHLIGHTS
Public health and healthcare systems as a complex organization of institutions and structures
National and international perspectives on public health structure, function, and outcomes differ by fiscal
support and philosophical attitudes concerning health
Public health administration as a reflection of health, politics, economics, and social structures
Influences of history, resources, financing mechanisms, interest groups, and environmental conditions on
public health
Governmental and nongovernmental organizations and public health
OBJECTIVES
Understand and describe the challenges in reducing the gap between healthcare expenditures and
healthcare disparities.
Compare and contrast differences across international public health systems.
Explain the different contributions of governmental and nongovernmental structures in public health
systems in different countries.
KEY TERMS
Bilateral agency: Refers to two agencies that conduct business within one country.
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Department of Health and Human Services: U.S. branch of government responsible for health
and welfare of citizens.
Health disparities: Difference in the quality of healthcare delivered or obtainable, often tied to
race or ethnicity or socioeconomic status.
Healthy People 2020: A U.S. national consensus plan with specific health goals.
International Council of Nurses (ICN): A federation of more than 130 national nurses
associations (NNAs), representing the more than 16 million nurses worldwide.
Millennium Development Goals (United Nations): Eight goals that all 191 UN member states
have agreed to try to achieve by the year 2015 to combat poverty, hunger, disease, illiteracy,
environmental degradation, and discrimination against women.
Multilateral agencies: Agencies that use both governmental and nongovernmental resources.
National Health Expenditure Accounts (NHEA): Comprised of measures of costs of healthcare
goods and services in the United States.
Nongovernmental organization (NGO): Agency that acquires resources to help others from
private (vs. public) sources.
Organization for Economic Cooperation and Development (OECD): A group that collects
data related to healthcare use across a variety of professional and service parameters.
Philanthropic organization: An organization that uses endowments or private funding to
address the needs of individuals, families, and populations.
Refugee: Person who leaves his or her place of origin and cannot return because of a well-
founded fear of being persecuted for reasons that include race, religion, nationality,
membership of a particular social group, or political opinion.
United Nations Educational, Scientific, and Cultural Organization (UNESCO) Sustainable
Development Goals: A global framework of 17 goals to coordinate efforts from 193 nations
represented by the United Nations around ending poverty and hunger, combating inequality
and disease, and building a just and stable world.
World Bank: International organization that uses funds from developed countries to help
initiatives of developing countries.
World Health Organization (WHO): International center that collects data, advances initiatives,
and offers support related to public health.
CASE STUDY
References to the case study are found throughout this chapter (look for the case study icon).
Readers should keep the case study in mind as they read the chapter.
When Clara arrived in the United States as a refugee* after surviving many years of violence and
brutality in her native Sudan, she was barely 20 years of age (an estimate). Many girls like Clara do
not know their age; they often do not know the year in which they were born. Clara represents a
community or population of women who have experienced hard realities related to the genocide in
Sudan. War between the North and the South, which still continues, results from different religious
views and ethnicity, and it puts all people, particularly some young women, in a vulnerable position.
In their commitment to ethnic cleansing, men in the army have raped young girls without hesitation,
leaving them to face pregnancy with no women’s healthcare and with very little support to change
their future circumstances in a patriarchal society.
Clara has found asylum in the United States through the generosity of a nongovernmental
health organization. She now enters a healthcare system that offers screening, care, follow-up, and
support as she learns that she and her child are human immunodeficiency virus (HIV)-seropositive.
Although Clara and her young child face the prospect of a life-threatening illness, she is supported
by a system that seems to care about her progress and future health, as well as the health of the
entire population.
*The United States provides refuge to persons who have been persecuted or have well-founded fear of persecution through two
programs: one for refugees (persons outside the United States and their immediate relatives) and one for asylees (persons in the
United States and their immediate relatives) (https://www.dhs.gov/sites/default/files/publications/Refugees_Asylees_2015 ).
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C omparing healthcare systems allows for an examination of how these systems, whichhelp ensure the health or wellness of populations, are organized and financed; costcontrol is important. Comparing helps develop standards and initiatives directed by
organizations discussed in this chapter, such as the World Health Organization (WHO), the
World Bank, and the Organization for Economic Cooperation and Development (OECD).
In addition, such comparisons aid researchers who study specific healthcare interventions and
outcomes internationally. The fundamental challenge in making comparisons is the difficulty in
finding universal measures of health which can be compared fairly. In the final analysis, what
should be of most interest is learning which healthcare system yields the highest quality of care
and universal access at a reasonable cost.
IMPORTANCE OF UNDERSTANDING HOW PUBLIC
HEALTH SYSTEMS ARE ORGANIZED
Public health involves organized efforts to improve the health of communities rather than
individual people. Thus, the central goal of public health is the reduction of disease through
prevention and the improvement of health in the community, both nationally and internationally
(Schnieder, 2017). As shown in Chapter 1, it has been the characteristics of population health
and illness over time that have directed how public health is defined, organized, delivered, and
evaluated. But it would be naive to believe that these characteristics are the only things that
contribute to the ways in which public health initiatives and the structure behind them have
developed. So, to understand how public health systems are organized in a city, state, or country,
it seems logical and necessary to explore a variety of components to fully realize why public
health systems exist and how they function. To that end, the following section explores a variety
of general health and public health systems ranging from those in industrialized countries to
those in developing countries. The text discusses the role of public health personnel in the
context of how local and global communities organize their efforts to keep the population
disease- and injury-free. For people who are committed to the ideals of prevention and access to
care for all, public health is not without challenges.
STRUCTURE OF PUBLIC HEALTHCARE IN THE
UNITED STATES
In the midst of many successes and challenges related to health and illness, the public health
delivery system in the United States supports efforts to address significant healthcare concerns
that affect both citizens and refugees/asylees through government agencies, nongovernmental
organizations (NGOs), and philanthropic organizations (Office for Refugees and Immigrants
[ORI], 2017). The following section describes the complexity of relationships among the
agencies devoted to public health delivery at the local and state levels. The activities of these
agencies vary widely because local priorities and values influence availability and operations.
Government Agencies and Public Health
Through public efforts, the U.S. government becomes involved with providing services that
benefit the social welfare of citizens in terms of health at national, state, and local levels. The
federal government creates policy, financing, and regulatory enforcement when a service that
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would benefit citizens is identified and available (Shi & Johnson, 2014). Good examples of
government efforts to improve public health include providing free drug information on
government published databases, establishing disaster preparedness plans, and creating quality
indicators for child health (Agency for HealthCare Research and Quality [AHRQ], 2017a;
American Red Cross, 2017; National Library of Medicine, 2017).
The federal government plays an important role in regulation. Public health entities of
regulation are often related to (1) food, (2) drugs, (3) devices, (4) occupation health, and (5) the
environment through the Centers for Disease Control and Prevention (CDC) Public Health Law
Program (2017) and Department of Health and Human Services, National Prevention
Strategy created by the National Prevention Council (2011). However, out of concern related to
the quality of healthcare, the government can “step in” to assist private citizens on different
occasions. Two examples are federal regulations related to women delivering children who need
at least 48 hours of inpatient care and making sure that mental healthcare is in parity with
medical care (Harwood et al., 2017).
The federal government allocates tax funds to state governments in support of specific public
health programs. For example, block grants give money to specific programs and providers
based on state health needs (Urban Institute, 2013). Some examples of block grants include
Maternal and Child Health Services and Prevention and Treatment of Substance Abuse Block
Grants. Entitlement programs to support the healthcare needs of low-income families come from
the federal government. Three important examples of entitlement programs are Medicare,
Medicaid, and the Special Supplemental Food Program for Women, Infants, and Children (WIC)
(Jackson & Mayne, 2016). The Medicaid program requires matching funds from the states to
provide for the healthcare needs of citizens (Fig. 2.1) (Centers for Medicare and Medicaid
Services [CMS], 2018).
State governments also play a large role in public health regulatory activities, program
responsibility, and resource allocation—to varying extents. Local governments implement the
public health activities within communities.
Generally, from either an economic or theoretical perspective, the private sector often does
not provide services that would improve social welfare, although in many ways, private
organizations often directly assist the common good of populations through their endowment
funds (endowed with monies often directly assists the common good of populations); they direct
their efforts to key initiatives that are altruistic and very helpful to community dwellers.
Examples include philanthropies such as the Kellogg Foundation and the Robert Wood Johnson
Foundation (Kellogg Foundation, 2017; Robert Wood Johnson Foundation, 2017).
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FIGURE 2.1 Sample configuration of health department structures in the United States. USDHHS,
U.S. Department of Health and Human Services. (From http://www.hhs.gov/about/orgchart.)
Clara is a good example of a person who came to the United States with no resources.
She has no income and is trying to find a way to sustain herself and her child while
dealing with the trauma of her past life, and her future life with a chronic life-threatening
illness. She is receiving Medicaid from the state in which she now lives in the United
States, WIC for her child, and support from the Ryan White HIV/AIDS Program. Since
1991, this program has provided supplemental support for medical care, medications,
housing, and public health services for those living with HIV.
Evidence for Practice
The Ryan White Program funds networks of care, which include medical care providers and
support services, for people living with HIV or acquired immunodeficiency syndrome (AIDS)
(PLWHA) in 51 eligible metropolitan areas (EMAs). Researchers created a survey to
measure characteristics of care networks and the quality, accessibility, and coordination of
services from the perspective of case management and medical providers, administrators,
and consumers (Hirschhorn et al., 2009), and they administered the surveys in 42 EMAs.
The investigators then rated the care networks highly on access, quality, and
coordination between case management and primary care providers. However, there were
frequent differences in ratings of quality and barriers by the type of respondents (consumer
representatives, grantees, and providers). There were also substantial variations across
EMAs in network characteristics, perceived effectiveness, performance measurement, and
quality improvement activities. The results indicated that the Ryan White Program has been
somewhat successful in developing networks of care. However, support is needed to
strengthen the comprehensiveness and coordination of care.
Specific Agencies
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United States Department of Health and Human Services
The U.S. Department of Health and Human Services or USDHHS (USDHHS, 2017a) is the
federal agency that is directly involved with the health and healthcare of U.S. citizens or
refugees/asylees. The Office of the Secretary of Health and Human Services oversees the work
of 11 agencies (Fig. 2.2). These agencies work in collaboration with state and local governments
in the United States to provide (1) assessment information regarding the level of health or illness
in the nation; (2) assurance that the infrastructure, including trained personnel, is available to all
citizens and refugees/asylees; and (3) legislation and implementation of health policy. The
federal government makes public health policy. By producing information gathered through
research, it provides evidence that can effectively change public health practice (Bekemeier,
Zahner, Kulbok, Merrill, & Kub, 2016). Thus, the federal government supports research efforts
that can help citizens improve their health significantly, and promotes ways to implement the
evidence from a culturally relevant and sensitive perspective. For example, the National
Institutes of Health (NIH, 2017), Agency for Healthcare Research and Quality (AHRQ, 2017b),
and the Centers for Disease Control and Prevention (CDC, 2017a) are three important
organizations in which research is undertaken and used effectively to address healthcare
concerns such as HIV screening and care, adverse events in hospital settings, and measures to
decrease the rates of emerging infectious diseases (USDHHS, 2017a).
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FIGURE 2.2 Federal agencies with public health responsibilities. (Redrawn from U.S. Department
of Health and Human Services organizational chart.) *Designates components of the Public Health
Service. (From http://www.hhs.gov/about/orgchart.)
State and Local Health Departments
State agencies, which administer specific federal public health activities throughout a particular
state, are influenced from a structural and functional perspective by the federal government.
However, state departments of health can be diverse for political and environmental reasons
(CDC, 2017a), and they influence NGOs as well as local health departments.
According to Schneider (2017), there are several types of models of health department
structure. Most commonly, a state health department is an independent organization that is in
communication with the head of the executive branch of the state government (governor).
(Within the health department are core public health areas, such as infectious disease control,
preventive health, health institution licensing, and epidemiology, but they may relate to a
political agenda or worldview of the state leadership.) The head of the state health department
can be, but is not necessarily, a physician, although in some states, this is a statutory
requirement. The state governor may choose the head of the department of health, or members
of a state board of health may make the appointment. These boards of health are representative
of the state demographics and may include residents who may be health professionals or may
simply be healthcare consumers.
Another model is the state department of health and human services. This model focuses on
public health, social service, and medical assistance programs. This relationship between public
health and social services often helps bring together related expertise to address complex
problems that frequently require coalition building with the public (Janosky et al., 2013).
Although local health departments (city or county) can be governed by state health
departments, the local departments often create their own structure based on the needs of the
local community, and these local health departments implement programs that serve local
citizens. In a county health department, it would not be unusual to see a functioning tuberculosis
clinic and tuberculosis surveillance program that works in collaboration with the state health
department to care for patients exposed to or infected with the tuberculosis bacillus.
Finally, many other contributors to public health initiatives have strong relationships and
interagency affiliations with state and local health departments. They include social service
agencies, elementary and secondary schools, housing departments, police and fire departments,
parks and recreation departments, libraries, public transportation systems, and water and sewer
authorities. Government authorities are often involved in these areas within the context of public
health. Generally, localities create relationships and lines of authority that make sense for the
particular needs of their citizens (see Fig. 2.1).
FUNCTIONS OF PUBLIC HEALTH IN THE UNITED
STATES
In the chapters that follow, there are specific explanations with examples of the functions that
public health offers to people in the United States. However, it is important to review several
key components of the function public health serves, including a national consensus on goals
(USDHHS, 2017b); provision of systems of health insurance based on risk, not necessarily on
health; and the role of nongovernmental entities in disease prevention and health promotion. In
the United States, public healthcare includes disease prevention and health promotion based on
science and cultural relevance. It is not focused on the health of the individual person, but on the
population as a whole. The goal of public healthcare is to keep populations healthy through a
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broader “reach” than connection at the individual level.
One way to develop a system that advises people with backgrounds similar to Clara’s
involves strategically putting language-sensitive notices in places where these people
live, congregate, or travel. They need to (1) go to their local healthcare centers to get
tested for the HIV virus and (2) receive appropriate care. This “reach” may help more at-
risk members of a community than discussing the HIV-testing program with people at
healthcare facilities. This approach uses broad strategic planning, including the voices of
community members, multidisciplinary teams, and nongovernmental not-for-profit sectors
of health organizations, which focuses on key target objectives.
Public health goals and focused target objectives are identified and promulgated by a
national publication called Healthy People 2020. Healthy People 2020 is a national consensus
plan identifying focal areas which need active and specific plans and implementations, based on
levels of illness (morbidity) and death (mortality) that account for the physical, psychosocial,
and financial suffering of citizens (USDHHS, 2017a). Healthy People 2020 is mentioned
throughout this book as a source of goals and indicators that should direct community healthcare
at the local, state, and federal level. However, the United States and its system of healthcare
have historically given, and continue to give, stronger support to (1) individual rather than
community care and (2) cure rather than prevention. It involves highly specialized healthcare
providers who have little contribution to community outreach.
Funding for the healthcare system in the United States comes primarily from privately
owned health insurance companies. Exceptions include programs that are publicly funded, such
as Medicare, Medicaid, TRICARE (civilian health benefits for military personnel, retirees, and
dependents), Children’s Health and Insurance Program (CHIP), and Veterans Health
Administration (Centers for Medicare and Medicaid Services, 2017; Children’s Health Insurance
Program, 2017; U. S. Department of Veterans Affairs Health Benefits, 2017). At least 15.7% of
the U.S. population is completely uninsured (Kaiser Foundation, 2013), and a substantial portion
of the population (35%) is underinsured. More is spent on healthcare in the United States than in
any other nation in the world. Even though not all citizens have health insurance, according to
the OECD, the United States has the third highest public healthcare expenditure per capita, and
still lags behind in measures to decrease infant mortality and raise life expectancy, as compared
with other nations in the world (Table 2.1) (OECD, 2017a). Active debate about healthcare in
the United States includes serious ethical questions about whether health is a right or a privilege,
and whether all people should have equal access to quality healthcare. In 2010, controversial
federal legislation took positive steps to give access to healthcare to all citizens through private
and public funding through health insurance. This effort evolved into a federal program called
Obamacare after then President Barack Obama and has since been evolving into a new health
coverage program that seems to hold a difficult political road ahead. Taking into account the
expense and the assurance of efficiency, effectiveness, access, and quality for all to be insured
will be the challenge of the current White House administration (The White House, 2017).
TABLE 2.1 Measures of Healthcare in Selected Developed Countries
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Beyond the system of public and private control and ownership of healthcare services in the
United States, a vast array of NGOs helps keep people healthy through voluntary and
philanthropic services. For example, private community hospitals are sometimes supported by
community groups which ensure that vulnerable populations have access to healthcare. The care
may be free. In addition, the community facility may sponsor community health education
programs and prevention/screening clinics for underserved populations. Although many states
provide communities with (community) municipal or neighborhood health centers and
ambulatory/outpatient services through local or federal funding, health services can be offered
through private groups who are interested in supporting specific areas of need, such as migrant
or school-based health programs (McGuire, 2014). These programs are often run by altruistic,
nonprofit organizations. Examples of some NGOs in the United States include the American
Diabetes Association, Citizens for Global Solutions, AmeriCorps, and the U.S. Fund for
UNICEF (United Nations Children’s Fund, 2017).
TRENDS IN PUBLIC HEALTH IN THE UNITED STATES
In the United States, the federal government expends time and effort every year to create a
report of the trends in the following areas: (1) health status and what determines health
(determinants), (2) how communities use healthcare services (health utilization) and healthcare
resources to help communities stay healthy, (3) how much money is spent on healthcare
(expenditures), and (4) which citizens are the most vulnerable. The following sections explain
these four areas more specifically.
Health Status and Its Determinants
Measuring the health status of citizens in communities helps the U.S. public health system
determine how to direct resources (money and services) to keep people healthy. Despite the fact
that life expectancy is higher for both men and women in countries such as Japan, the overall
health of people in the United States has improved over the years. However, in the United
States, current data show a downward shift related to malignancies, obesity, and dental care
(Organization of Economic Cooperation and Development [OECD], 2017a). It is believed that
the health successes found in the United States result from money spent on health education
programs, public health programs, health research, and healthcare itself. The trend has been
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toward using larger sums of money to help Americans keep healthy. Much of the funding
currently spent on healthcare is spent on prescription drugs and care of chronic conditions,
which often affect the elderly or disabled. A good example of how increases in funding have
improved health is the significant improvement in mortality (numbers of deaths) and morbidity
(numbers of recorded illnesses) statistics in a variety of health-related actions, such as the use of
corticosteroids in acute lung injury or disease (Tang, Craig, Eslick, Seppelt, & McLean, 2009).
Mortality (death rates) and morbidity (illness rates) have improved for many reasons, but a
primary reason is that an organized effort on the part of the American public health system has
injected resources to study certain prominent problems in the United States. A good example is
the provision of services to prevent progression of cardiac illness. Thus, the death rate from
heart disease has decreased, primarily because health education has emphasized a healthier
lifestyle and cholesterol screening (Speroni, Williams, Seibert, Gibbons & Early, 2013). Another
example is the decrease in mortality and morbidity rates of individuals living with HIV/AIDS.
The use of highly active antiretroviral therapy, including protease inhibitors, has dramatically
changed patterns of survival; these patterns now assume the trajectory of a chronic illness.
Regardless of inequalities in gender, race, and socioeconomic status, people who once lived for
five years after being diagnosed with HIV now live for 15 years, and children born with HIV
infection from perinatal transmission are now teens who deal with HIV, safe sex behaviors, and
disclosure issues with sexual partners (Regidor et al., 2009).
Practice Point
It is easy to receive morbidity and mortality information in the United States by going to the
CDC website and electronically subscribing to the Morbidity and Mortality Weekly Report
(MMWR) for free. The MMWR reports are very informative about trends in assessing the
public health status of the United States. More specifically, the MMWR reports publicly, in a
systematic way, the frequencies of diseases, disabilities, or health-related events, and it
supplies information about trends provided by the CDC and other health officials.
Despite these successes, key social and behavioral determinants of health still need to be
addressed. For example, obesity, diabetes, and cigarette smoking are significant risk factors for
diseases that may interfere with healthy brain functioning (Lal, Strange, & Bachman, 2012).
Although much effort has been given to preventive education in these areas, a high percentage
of adults and adolescents continue to make no effort to change their exercise, smoking, or eating
patterns. In addition, rates of reportable childhood infectious diseases have decreased and cancer
has declined in men, but there has been no significant change in the rates for women’s cancers.
In fact, many believe that there has been an epidemic of breast cancer in non-Hispanic white
women in recent years (Sexton et al., 2011).
Utilization of Healthcare Resources
Changes in payment policies, which are intended to decrease direct and indirect costs, as well as
losses from billing fraud/abuse, continue to change healthcare delivery in the United States.
There is less use of institutions (i.e., hospitals). Highly complex diagnostic procedures and
surgical interventions like cardiac surgery are more likely to take place in hospitals. However,
emergency departments and office-based physician and physician-group visits, as well as
ambulatory surgical procedures, have increased. In particular, emergency department admissions
have increased for those citizens who are asthmatic, especially children (Banda et al., 2013). At
the same time, there has been a significant decrease in Medicare-certified home health agencies.
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In 1997, there were 10,800 agencies, and in 2002, there were 6,800 agencies, primarily because
the Balanced Budget Act of that year forced either consolidations or closing of existing services
(Center of Budget and Policy Priorities, 2017).
Prevention-oriented approaches and services decrease morbidity and mortality rates (Friis &
Sellers, 2014). For example, distribution of flu or pneumonia vaccines as a form of prevention
and a common public health campaign demonstrates a commitment of public health to
decreasing morbidity and mortality. However, the funding for such programs is often slashed
when fiscal constraints cause fiscal intermediaries to (address) pay for treatment of well-known
illnesses and disabilities, rather than provide funding for prevention programs which have the
potential to impact large populations. Despite decreases in financial support for vaccination
programs, there have been increases in the number of children 19 to 35 months of age who have
received combined vaccinations (Chidiac & Ader, 2009). In addition, the number of women
older than 18 obtaining a Papanicolaou (Pap) smear screen has also increased. However, there is
a link between this preventive intervention, some college training, and the vaccine that counters
certain strains of human papillomavirus (HPV) (CDC, 2017b).
Practice Point
Assurance is a word used in public health to identify an important concept: that individual
people, families, and populations have the healthcare personnel and systems needed to
address their respective healthcare needs. Assurance as a goal is highly related to the goal
of maintaining healthcare professionals in the work force who are competent and stay in the
work force. It is possible to think about schools of nursing as a way in which nursing
programs are supporting assurance. To understand the level of commitment to healthcare
education for nursing professionals in the state in which you live, determine the number of
schools of nursing in the state, which ones specifically offer advanced practice specialties in
community/public health, the number of schools of public health, and the number of medical
schools. In addition, check labor statistics related to trends in the retirement of health
professionals. Each of these efforts can help make it possible to understand trends in the
preparation of healthcare providers and also help assess needs for the future from the local
perspective. Comparison among states gives a larger perspective and can be obtained by
accessing the Health Resources and Services Administration (HRSA) website, which is the
federal organization specifically responsible for health professional resources in the United
States.
Expenditures and Health: Trying to Improve Public Health
Economically
Access to healthcare is critical for prevention and treatment of illness and injury. Health
insurance and appropriate coverage often determine access. Lack of health insurance is related
to poverty, and puts residents in a position of vulnerability. The United States spends more on
healthcare than any industrialized country. Although hospital care accounts for the largest share
of healthcare spending, prescription drugs are the fastest growing healthcare expenditure.
Medicare pays for only a little of this expense, even though citizens aged 65 and older, who are
the primary recipients of Medicare, have the greatest need for therapeutic drugs. Thus, people
whose income is reduced through retirement, or death of a family member, may have a
substantial out-of-pocket expense (Baird, 2016).
National Health Expenditure Accounts (NHEAs) are a measure of expenditures on
healthcare goods and services in the United States. These accounts are prepared by the National
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Health Statistics Group. Government public health activity constitutes an important service
category in NHEAs. In the most recent set of estimates, expenditures totaled $56.1 billion in
2004, or 3.0% of total U.S. health spending (CMS, 2017). What becomes challenging is
specifically identifying what is considered “public health” in an expenditure.
Vulnerable Populations and Healthcare
Key indicators in the United States reveal a healthcare gap between the overall American
population and people of different genders and ethnicities. There is also a healthcare gap for
those who have less education, lower socioeconomic status, and live in certain geographic areas
in the United States. These disparities are characteristic of people who have been marginalized
and oppressed. Marginalization often occurs in people who live below the poverty level in the
United States, and these people frequently are poorly educated. In the chapters that follow,
higher rates of morbidity, mortality, difficulty in accessing care, and negative outcomes when
receiving care will be seen as key issues in such populations.
Clara is a good example of someone who has been courageous in coming to the United
States but is compromised in terms of literacy and socioeconomic needs. She also is
unfamiliar, at a basic level, with how healthcare systems work, and how to access them
effectively. She needs someone to advocate for her. Even if there are services available
to help her, she may not know how to gain access to these services.
Historically, in 2002, the Institute of Medicine released a document called Unequal
Treatment: Confronting Racial and Ethnic Disparities in Healthcare (Institute of Medicine,
2002). The report defines health disparities as “racial or ethnic difference in the quality of
healthcare which is not due to access-related factors or clinical needs, preferences, and
appropriateness of intervention” (Institute of Medicine, 2002, p. 3). Disparities are found in
certain types of illness, such as cardiovascular disease, cancer, HIV, diabetes, end-stage renal
disease, and certain surgical procedures. Surgical procedures such as amputations have been
found to be more common within minority groups.
The Department of Health and Human Services has identified six areas for which it has
oversight. These areas are (1) infant mortality, (2) cancer screening, (3) cardiovascular disease,
(4) diabetes, (5) HIV/AIDS, and (6) immunizations. In addition, there are also several areas that
need special emphasis, including mental health, hepatitis, syphilis, and tuberculosis.
HEALTHCARE SYSTEMS IN SELECTED DEVELOPED
NATIONS
Overall, the commitment to prevention and the cost savings, whether a personal commitment or
an economic commitment, is yet to become effective in the United States across a variety of
parameters. However, other countries have been able to achieve success with their healthcare
system structure, function, and outcomes. Figure 2.3 provides an overview of selected healthcare
indicators of 17 countries including the United States. For purposes of comparison and contrast,
the following section discusses how Canada, France, Germany, the Netherlands, and the United
Kingdom keep their citizens healthy and well. These countries were chosen because they
historically have had healthcare philosophies that are based on inclusivity of all citizens, lower
cost, quality, and a perspective that healthcare is a right. No country is perfect, and many face
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the same escalating costs as the United States. However, a key international source, the OECD
(OECD, 2017a), presents comparative data that demonstrate that these countries have better
morbidity and mortality rates, as well as other health-related factors, than the United States. The
approaches of these countries to the healthcare of their citizens can serve as important examples
of goals which other countries may want to pursue. Key components to advancing public health
and public health systems are (1) identifying indicators of health, (2) being committed to
providing healthcare professionals and the public with a system that works, and (3) generating
policy that allows for the production of positive outcomes. The following countries have been
selected because of unique positive contributions they have made in healthcare outcomes,
through creative funding and infrastructure adjustments to meet the unique needs of their
respective populations. In many cases, comparisons have been made to these countries because
of the positive experiences that have been reported from health outcome data as it relates to
costs.
FIGURE 2.3 Overall ranking of countries according to various healthcare indicators (2007). *2003
data. (From The Commonwealth Fund. [2013]. International Health Policy Survey, the
Commonwealth Fund 2005; International Health Policy Survey of Sicker Adults; the 2006
Commonwealth Fund International Health Policy Survey of Primary Care Physicians; and the
Commonwealth Fund Commission on a High-Performance Health System National Scorecard.)
Canada
According to Health Canada (2017) and the OECD Canada (2017b), Canada is the second
largest country in the world, with 10 provinces and two territories. Its 31.5 million people have a
life expectancy of 78 years (men) and 82 years (women). Seventeen percent of the population is
older than 60 years of age. Cancer is the leading cause of mortality, followed by congestive
heart failure.
Canada’s healthcare system is a national health program; it is considered a single-payer
system with universal coverage. This means that all Canadian citizens are covered for healthcare
by one government-run system. Canadian Medicare, the healthcare insurance coverage for all,
began in 1968 to eliminate financial barriers to care and to allow citizens to have choice in what
physician they chose for their care (Health Canada, 2017). Culturally, Canada is made up of
multicultural and multilingual populations because of high immigration rates over the years.
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Canadians view healthcare as a right, not a privilege, and more specifically, as a social
responsibility.
Funding for the Canadian healthcare system comes from personal, sales, and corporate taxes,
and federal transfer payments (<25%). The federal government provides healthcare only for
special populations (military personnel, native Canadians, and federal prisoners [<2% of the
population]). The government of Canada has the responsibility for what are considered the
public health arms of the National Institutes of Health, occupational and environmental health,
health promotion, Indian Health Service, and health protection.
Despite a single-payer reimbursement system, the 12 provinces determine the management,
delivery, and financial arrangements for the Canadian Medicare services. Private insurance
exists to cover services not covered under Medicare, such as vision needs, dental services, and
pharmaceuticals for nonelderly people. This type of private insurance is acquired through
employment contributions, and represents a small portion of total health expenditures (15%).
Provinces raise money specifically for Medicare through taxes, corporate contributions, personal
income, fuel taxes, and lottery profits.
The money allocated through these approaches supports the individual health costs of
citizens in each unique province or territory, hospital payments, and physician salaries which are
capped and negotiated, drugs, long-term care and mental health institutions, and provincial
healthcare planning. At the national level, there is oversight of the development and safety of
pharmaceuticals and reviews that survey physician production, practice, and quality.
The most powerful individuals in the healthcare system are health administrators, not
physicians. These health administrators put an emphasis on cost, efficiency, and social
responsibility. Unlike in the United States, most of the physicians are generalists who are
reimbursed by provincial health plans (99%) through fee-for-service, capitation (maximal
amount of money based on patient caseload), or salaries in health centers. Nevertheless, the
majority of care occurs in the private physician’s office. Nurses have little autonomy and often
migrate to the United States to practice in order to gain higher salaries (Health Canada, 2017).
Capital expenditures are separate from operating expenditures, which gives provinces
control over facility development and renovation. There is a trend toward delivering healthcare
and performing medical and surgical procedures outside of hospital settings, with an increasing
focus on health promotion and disease prevention. Most procedures are scheduled in advance
and take place in outpatient or ambulatory areas. Although there may be long waits for care, it is
important to remember that the wait time is not for emergency or life-threatening conditions. It
is a way to distribute care more evenly and to control costs.
Individual provinces closely monitor quality of care, with strong emphasis on decreasing
duplication of services across all levels of care. Hospitals, in particular, are used not just for
acute care, but for long-term care of patients (23% of hospital beds). There have been reports of
inequities between provinces (Health Canada, 2017) and fear that cost containment may limit
the use of newer and developing technologies. The balanced benefit of this approach is that
Canada has better health outcomes than the United States (30th vs. 37th) in OECD rankings
(OECD Canada, 2017b) while spending less money per person on healthcare. Many people
believe that it is far better to wait for nonemergent care than to be uninsured (see Table 2.1).
Evidence for Practice
Brehaut and colleagues (2009) used population-based data to evaluate whether caring for a
child with health problems had implications for caregiver health after controlling for relevant
covariants. They used data on 9,401 children and their caregivers from a population-based
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Canadian study to analyze and compare 3,633 healthy children with 2,485 children with
health problems. Caregiver health outcomes included chronic conditions, activity limitations,
self-reported general health, depressive symptoms, social support, family functioning, and
marital satisfaction. Covariants included family (single-parent status, number of children,
income adequacy), caregiver (gender, age, education, smoking status, biologic relationship
with child), and child (age, gender) characteristics. Their findings showed that caregivers of
children with health problems had more than twice the odds of reporting chronic conditions,
activity limitations, and elevated depressive symptoms, and had greater odds of reporting
poorer general health than did caregivers of healthy children. This study points out that
caregivers of children with health problems had substantially greater odds of also having
health problems than did caregivers of healthy children. From a public health assurance
perspective, this indicates that healthcare initiatives need be directed not only to individual
children who are chronically ill but also to families. There is an important link between those
with chronic illness and those who care for them.
Student Reflection
We were asked in clinical seminar to think about and discuss the prejudices we may have
heard about other healthcare systems in the world, and I immediately thought of Canada
because it is our next-door neighbor. Everybody says that healthcare is rationed, there
aren’t enough doctors, the quality of care is poor, and that it is “socialized medicine.” I have
realized that although there may be a wait for specialist care, there is no wait for the most
common need for care…primary care. There is rationing related to immediate need versus
needs that can be delayed. The most important thing is that everybody has insurance, and
nobody is denied care because they can’t pay for it. Although there are some shortages of
physicians, there is more of a sense of balance in having more physicians available to take
care of the common illnesses of the population (primary care). From what I have read, the
quality of care is acceptable, especially in light of the fact that in our own country some have
no ability to obtain care. I guess the bottom line is, as I prepare to practice nursing, I am
keenly aware of the need to ensure all populations of having access to get help for common
problems and to have, most importantly, equal access to quality care.
France
Despite the French people’s dissatisfaction with their healthcare system, many consider their
system one of the best in the world (Bourdelais, 2010). According to the OECD (OECD, 2017c),
France, a republic with a population of 61,000,000, is a healthy country in terms of infant
mortality, life expectancy, and healthcare-related costs (see Table 2.1).
The Ministry of Health runs two large organizations that cover the funding and provision of
health services in 22 regional services agencies: (1) General Health Management and (2)
Hospital and Healthcare Management. The structure of the healthcare system in France includes
the National Institute of Health, established in 1998; the French Agency of Health Safety of
Health Products, which functions similarly to the Food and Drug Administration (FDA) of the
United States, also established in 1998; the Agency of Environmental Health Safety (established
in 2000); French Institute of Blood, established in 1992; French Institute of Transplants
(established in 1994); and the Ministry for Health, Family and the Disabled.
The government presents a law to the parliament every year as a way to use public policy to
finance a social security fund, which includes the national expenditure on health insurance. This
public policy effort also specifies goals for the healthcare system, similar to the Healthy People
2020 effort in the United States. The Ministry of Health delegates the planning and
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implementation of health initiatives to regions that make up the country in order to decentralize
and make care plans specific to each region. A national health insurance guarantees universal
access to 80% of the French people by offering health coverage to wage earners through what is
called the CNAMTS (Caisse Nationale de l’Assurance Maladie des Travailleurs Salariés or
French National Health Insurance Agency for Wage Earners). The rest of the national funding is
divided among other funds that are occupationally specific (physicians, agricultural workers, and
students). Therefore, the French population is 100% covered by a public mandatory health
insurance. Funds are financed by payroll taxes (60%) and since 1990, by a proportional income
tax (40%) called the CSG (“contribution sociale généralisée”). The funds are governed by
boards with representatives of the government, the main workers unions, and the association of
French manufacturers. France has an essential single-payer system. More than 80% of French
people carry a supplemental form of private insurance often linked to employment. Public
payment covers 76% of French health expenditure. Patients pay physicians directly and apply
for reimbursement, and 21% of expenditures are on pharmaceuticals. For 96% of the population,
healthcare is entirely free; it is reimbursed up to 100%. Users of this system can select any
physician—even a specialist and hospital (public or private)—with the belief that choice leads to
successfully managed competition and quality care.
In France, there are more than 1.2 million employees in the health service sector. Physicians
consider public hospital jobs undesirable, and often foreign physicians fill these positions. The
majority of physicians in private practice participate in a government-fixed fee-for-service
scheme, and the remainder charge what they wish. Physicians accept what the government pays,
and the patient pays the difference. French general practitioners earn the equivalent of about
$55,000 per year. Other characteristics of physicians working in France are presented in Box
2.1.
2.1 Characteristics of Physicians in France
Physicians are unevenly distributed between rural and urban areas.
About 50% of physicians are women.
Physician visits can take 15 to 30 minutes.
Physicians see about 10 patients per day.
Medical education for physicians is publicly funded.
Ratio of generalists to specialists is 1:1.
Ranking system of hospital practitioners is nationwide.
Physicians, biologists, and dentists are all salaried hospital practitioners.
Advancement is based on seniority.
Source: Organization of Economic Cooperation and Development. (2006). The supply of physician services in OECD countries (OECD health working
papers No. 21). Retrieved from http://www.oecd.org/els/health-systems/35987490 .
The French healthcare system is made up of public, private, and not-for-profit sectors, which
avoids the long waiting lists characteristic of other socialized medicine systems. Health
insurance supplies a large majority (91%) of the funds for the 1,032 (85% of total) public
hospitals, which account for 65% of all hospital beds in France. Private, not-for-profit hospitals
account for 15% of all hospital beds, and specialize in medium- to long-term care. Private, for-
profit hospitals account for 20% of all hospital beds. The private hospitals conduct 50% of
surgeries and 60% of cancer care.
A key ethic of this system is individual choice of physician and place of service, including a
tradition of long-term care in the private home. France maintains strict boundaries between
health and social services, and outcomes and performance are benchmarks for both home
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http://www.oecd.org/els/health-systems/35987490
healthcare and nursing homes. Financial aid is given to people in the form of allocation
personnalisée d’autonomie, or allocation for loss of autonomy, to purchase care—even from
family members or other unskilled labor—as a way to promote employment.
Evidence for Practice
The following two survey studies are examples of this commitment to the health of the
French population.
1. Constant, Salmi, Lafont, Chiron, and Lagarde (2009) investigated behavioral changes in
a cohort of car drivers to understand why there was a decrease in motor vehicle road
casualties in France. Researchers offered self-report survey questions to more than
11,000 people between 2001 and 2004 to explore attitudes related to road safety and
driving behaviors. Investigators found that adequate sleep was related to positive
outcomes in road safety. Decreases in cell phone use and speeding over this time period
demonstrated decreases in road mortality in France.
2. Nayaradou, Berchi, Dejardin, and Launoy (2010) elicited preferences of the population
for willingness to participate in a mass colorectal cancer screening initiative in northwest
France. (The implementation of a mass colorectal cancer screening program is a public
health priority.) They interpreted the results of a survey conducted by mail from June
2006 to October 2006 on a representative random sample of 2,000 inhabitants, aged 50
to 74 years. On the questionnaire, each person made three or four discrete choices
between hypothetical tests that differed in eight ways: how screening is offered, process,
test sensitivity, rate of unnecessary colonoscopy, expected mortality reduction, method
of screening, test result transmission, and cost. Results from the 32.8% of respondents
indicated that expected mortality reduction, sensitivity, cost, and process were among
the population preferences. Researchers found that the sensitivity of the test was most
important in respondents with higher financial resources. Key implications included how
adherence to screening could be accomplished in light of these data.
Clients in nursing homes pay for their room and board separately from nursing/healthcare,
and these costs come from pension funds or welfare funds. The residents of nursing homes are
legally entitled to be involved in the governance of their home, and in France, this system is
highly respected and well run with little inefficiency. Finally, there is a strong emphasis on
prevention as a priority.
Germany
Germany, the largest country in Europe, is made up of 82.4 million people divided into 16
states. From a vital statistics perspective, life expectancy varies between men and women (76
and 82 years, respectively), and 19% of the population is older than 65 years of age. The leading
causes of death include heart disease and lung cancer (OECD, 2017d).
Germany has a universal healthcare system (OECD, 2017d). Historically, health insurance
was a requirement and directed at low-income workers and certain government employees.
Eventually, all people were able to obtain insurance. Currently, physicians in private practice
provide ambulatory care, and centralized nonprofit hospitals offer the majority of inpatient care.
Most of the population has health insurance; individuals can obtain coverage from a variety of
“sickness funds” financed by public and private sources. Funds for standard insurance come
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from a combination of employee/employer contributions and government subsidies, which are
scaled on the basis of need. An option exists for individuals to choose to pay a tax and opt out of
the standard plan in favor of “private” insurance. Many people with higher salaries choose this
option, but their premiums are linked to health status, not to income level.
Regional physicians’ associations negotiate provider reimbursement for specific services. A
commission composed of representatives of business, labor, physicians, hospitals, and insurance
and pharmaceutical industries meets annually. The commission takes into account government
policies and makes recommendations on overall expenditure targets to regional associations.
Although reimbursement of providers is on a fee-for-service basis, including co-payments, the
amount to be reimbursed for each service is determined retrospectively to ensure that spending
targets are not exceeded. The average length of hospital stay in Germany has decreased in recent
years from 14 to nine days, still considerably longer than the five- to six-day average in the
United States (OECD, Health Statistics, Definitions, Sources, and Methods, 2016). Drug costs
have increased substantially each year, despite attempts to contain costs. Overall healthcare
expenditures have risen, but costs are substantially less than those in the United States (OECD,
2017d).
The reunification of East and West Germany, which occurred in 1990, did increase variation
in health statistics by lowering infant mortality and increasing life expectancy. However,
differences continue to exist between the two parts of the country because of differences in
philosophy and distribution of care in the past. Philosophically, the idea that all people should
have health insurance and that the nation is responsible to provide systems of healthcare to its
citizens is common to both regions. Health insurance coverage is maintained by all citizens
sharing in the effort to have an insurance pool, and payment is based on income, not risk. The
healthcare benefits are extremely comprehensive and include medications, dental, vision,
medical treatments, and even health spas. Decentralization of healthcare administration includes
a federal institute for communicable and noncommunicable disease similar to the CDC in the
United States. The organizations of a variety of institutes are grouped across a regional
healthcare system which is managed by the sickness funds and physician associations.
Prevention has an important role in the German system, not only as an effort toward cost
saving but also in increasing the quality of life of citizens. Public health efforts include not only
primary prevention but also health screening with a special emphasis on youth development.
Evidence for Practice
Stolle, Sack, and Thomasius (2009) have expressed concern about episodic excessive
alcohol consumption (binge drinking) in children and adolescents as a serious public health
problem in Germany because of its associated risks with further morbidities and mortality.
An extensive literature search for evidence related to binge drinking from 1998 to 2008
revealed that episodic excessive alcohol consumption is associated not only with somatic
complications, but also with traffic accidents and other types of accidents, violent behavior,
and suicide. The more frequently a child or adolescent drinks to excess, and the younger he
or she is, the greater is the risk of developing an alcohol-related disorder (alcohol misuse or
dependence syndrome). Although in the United States, brief motivational interventions have
been shown to have a small to medium-sized beneficial effect in reducing further binge
drinking and its complications, the Germans use an intervention called HaLT (“stop,” also an
acronym for hart am limit—“near the limit”). Further types of brief motivating intervention
could be integrated in this approach as another variable to decrease binge drinking
behavior and prevent the development of alcohol-related disorders.
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Nurses in the German healthcare system are mostly diploma-educated individuals working
with a physician. There has been a protracted history of shortages of nurses in the 831 public
hospitals, 835 independent nonprofit hospitals, and 374 private hospitals. As a final comparison,
Germany’s healthcare system is sixth in financial fairness, 14th in overall goal attainment, and
14th in terms of overall performance. America’s system is 54th in financial fairness, 15th in goal
attainment, and 37th in overall performance.
Student Reflection
It is stunning to me that when you explore different healthcare systems in the United States,
the systems seem so wasteful or greedy or just not inclusive enough to allow everyone to
have the same healthcare opportunities. One of the things I was thinking about is that, in the
United States, we have accepted for a long time the necessity of education. Whether the
quality of the education is there or not…the idea is that education is a significant predictor of
success and gainful employment in life. Well, if that is the case why would we not have the
same perspective for health? Isn’t good health a predictor of future good health? Recently,
some people in the United States were very worried about the effort to create opportunities
for all people to have access to healthcare…not necessarily effective or efficient healthcare
but healthcare, period. My sense was that people were divided about using tax money for
healthcare. Some felt that the United States was becoming “socialized.” I guess it made me
sad to think about so many people I have met in poor, run-down neighborhoods who could
use the benefits of a philosophy that does not forget them, that cares for them, and wants
them to have an equal share of a quality life.
The Netherlands
According to the OECD (2017e), total health spending in the Netherlands accounted for 9.8% of
the GDP, slightly more than the average of other OECD countries. The Netherlands also ranks
above the OECD average in terms of health spending per capita, with current spending of
U.S.$3,52 (adjusted for purchasing power parity), compared with an OECD average of
U.S.$2,964. Health spending per capita in the Netherlands remains much lower than in the
United States, Norway, Switzerland, and Luxembourg.
The Netherlands has a dual-level healthcare payment system. All primary and acute care is
financed from private mandatory insurance. Long-term care for the elderly, dying, long-term
mentally ill, and so on is covered by money acquired from taxation and is considered a “social
insurance.” Insurance companies must offer a core universal insurance package for universal
primary, curative care, which includes the cost of all prescription medicines at a fixed price
without discrimination by age or levels of health or illness. Otherwise, they are considered to be
operating illegally.
According to OECD health data (2017e), for people whose health expenses are higher
because of illness, insurance companies receive more compensation if they have to pay out more
than might be expected. This allows them to accept all patients in an ethically sound way and
take care of their needs, rather than strategizing savings by not insuring those who have
expensive, long trajectories of needed care. Insurance companies compete with each other on
price for insurance premiums and negotiate deals with hospitals to keep costs low and quality
high. There is formal regulation that includes checking for abuse and for acts that are against
consumer interests. An insurance regulator ensures that all basic policies have identical coverage
rules so that no person is medically disadvantaged by his or her choice of insurer.
Payroll taxes paid by employers and a fund controlled by the health regulator, or the
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“regulator’s fund,” finance the healthcare system. The government contributes 5% to the
regulator’s fund. The remaining money needed to cover the country’s health expenses is
collected as premiums paid by those insured. Insurance companies, many of which are private,
can offer additional services, such as dental care, at extra cost over and above the universal
system. The standard monthly premium for healthcare paid by individual adults is about €100
(currently about U.S.$129) per month, and people with low incomes can get help from the
government to pay for the premiums. The regulator’s fund pays for all children’s healthcare in
the country.
Hospitals in the Netherlands, which have been advancing in quality over time, are regulated
and inspected regularly. They are privately run and for-profit. People can choose where they
want to be treated; on the internet, they can obtain access to information about the performance
and waiting times at each hospital. Those who are dissatisfied with their insurer and choice of
hospital can cancel at any time, but they must make a new agreement with another insurer.
The Netherlands primarily funds what is considered one of the best long-term care systems
through non–means-tested social insurance programs financed by national premiums. The
programs cover a broad range of institutional and noninstitutional services (OECD, 2017e). This
system includes mental health and substance abuse care. Prescriptions are covered by insurers
who use specific cost formularies. Generally, co-payments, with options to pay more for certain
drugs, are available.
Evidence for Practice
Investigators in the Netherlands examined the association between dairy product intake and
the risk of bladder cancer in 120,852 men and women 55 to 69 years of age (Keszei,
Schouten, Goldbohm, & Van Den Brandt, 2009). By using a 150-item food frequency
questionnaire, several researchers studied a cohort for 16 years and identified and
examined 1,549 people. The findings suggested a positive correlation in women between
butter intake and bladder risk.
United Kingdom
The National Health Service (NHS), which provides healthcare in the United Kingdom, began in
1948 (U.K. Department of Health, 2017). The system operates across the four countries that
make up the United Kingdom (England, Scotland, Wales, and Northern Ireland). Although there
are differences in how the health system is implemented, its basic organization and functions are
detailed in a constitution which includes specific rights and governance.
The NHS constitution states that healthcare will be provided for all permanent residents of
the United Kingdom, regardless of age, gender, disability, race, sexual orientation, religion, or
belief, and access to healthcare is based only on need. People are able to choose their own
physician; if necessary, this may involve traveling outside the United Kingdom to see other
medical professionals for healthcare. About 36% of clients wait for hospital admission for
treatment of nonacute conditions, and emergencies are addressed immediately. Two-thirds of
patients are treated in less than 12 weeks (OECD, 2017f).
The NHS system is decentralized, with access to care and prevention provided by the
Strategic Health Authorities. The primary treatment centers are structured like departments of
health in the United States and are responsible for (1) assessing healthcare needs of
communities, (2) commissioning health services needed by these communities based on this
assessment, (3) identifying goals for improving the health of communities, (4) ensuring access to
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care, (5) assessing the interaction between healthcare organizations and social services
organizations, and (6) assessing the quality of healthcare personnel.
Each of the foundation trusts, which are decentralized departments whose goal is the health
of specific sectors of the population, acts as a department of health (U.K. Department of Health,
2017). There is also a central Department of Health which is not involved in day-to-day
decision-making and implementation of care. This department makes policy decisions on a large
scale, and local governments can define how they will uniquely carry out those policies for their
citizens. The NHS provides primary, inpatient, long-term, psychiatric, and eye care free to many
people, including children, the elderly, the unemployed, and low-income residents. Private
healthcare does exist in the United Kingdom, but only a small percentage of the population use
it, generally for specialty care. Private insurance does not cover the cost of pre-existing
conditions, chronic conditions, or pregnancy.
Access to medications and healthcare personnel and facilities include prescriptions which are
paid by either a flat rate or through annual capped charges. Physicians contract with the NHS to
provide services and receive a salary. The majority of the hospitals are owned and run by the
NHS trusts. Of the 2.1 physicians per 1,000 population, most are general practitioners. They can
have both a public and private practice. They are paid by a mix of capitation, salary, and fees.
Those physicians who are specialists are called “consultants,” and they are based in hospitals.
Nurses make up the largest group of NHS staff and are paid from 40% of the NHS budget. As in
most parts of the world, there is a nursing shortage. Although most nurses work in hospital
systems, they are educated as specialists, and focus on particular specialty areas such as
maternal health.
Revenues for all NHS health services come from taxes (83%), employer–employee
contributions (13%), and user fees or co-payments (4%). Expenditures come from the NHS
(88%) and private insurance (12%). All people in the United Kingdom have health insurance; in
comparison, 44 million in the United States are uninsured, with no access to healthcare.
Although there are questions about the level of quality of care in the NHS when compared to the
United States, there is much better cost control, and access to care for all people, which
translates into better health for the U.K. population.
Evidence for Practice
The Royal College of Paediatrics and Child Health (RCPCH) in the United Kingdom
introduced guidelines for re-immunization of children after completion of standard-dose
chemotherapy and after hematopoietic stem cell transplantation (HSCT) (Patel, Chisholm, &
Health, 2008). To understand if the guidelines were properly applied and whether they
created a positive standard, researchers offered an online anonymous survey to pediatric
principal treatment center (PTC) consultants and shared care (SC) consultants. Results
from 55 PTC consultants and 54 SC consultants demonstrated that most PTC and SC
consultants recommend initiating re-immunization at six months after completion of
standard-dose chemotherapy. Between 93% and 100% of respondents reported re-
immunization at the recommended time after HSCT for each transplant type. (Physicians
recommended pneumococcal conjugate vaccine after chemotherapy by 58.3% (35/60) of
respondents and by 51.7% (30/58) after HSCT.) There were distinct differences between
PTC and SC consultants in their choice of varicella postexposure prophylaxis.
PUBLIC HEALTH COMMITMENTS TO THE WORLD:
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INTERNATIONAL PUBLIC HEALTH AND DEVELOPING
COUNTRIES
The following section addresses public health commitment from an organizational perspective.
The WHO will be discussed, especially in relation to its current health goals, and the structures
and processes which are intended to yield positive outcomes. Initiatives to address refugees
internationally through the United Nations and other organizations across the globe (bilateral,
multilateral, NGOs) will also be considered. In addition, the international face of nursing will be
discussed with its focus on offering nursing science and evidence-based practice internationally.
World Health Organization
When the United Nations was established in 1945, a key directive and commitment was to
protect human rights, security, and the social development of all countries. The WHO was
established in 1946 as part of the United Nations to maximize health and wellness for all (World
Health Organization [WHO], 2017a). The WHO is located in Geneva, Switzerland, and has six
regional offices, including a U.S. branch located in Washington, DC (Pan American Health
Organization, PAHO). The relationship of the United Nations to the WHO is similar to that of
the USDHHS and the NIH to the CDC. For example, there is a keen focus on supplying current
information about disease and disability and establishing standards of care on the basis of
evidence found in health research. In the WHO, efforts are directed primarily to safely conquer
disease and to help advance professionals and healthcare systems which allow this to occur with
efficiency and effectiveness. In addition, the WHO, led by Director General Adhanom
Ghebreyesus (Fig. 2.4), focuses on policy development through a process of supporting annual
commissions and assemblies (e.g., World Health Assembly) as a means of advancing policies
and guidelines to countries with common, or uniquely specific, healthcare problems (WHO,
2013b). The development of the WHO’s Child Growth Standards used data collected in the
WHO Multicentre Growth Reference Study. The WHO provides international access to
documentation on how physical growth curves and motor-skill milestones of achievement were
developed, as well as application tools to support implementation of the standards (WHO,
2013c).
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FIGURE 2.4 World Health Organization Director General Adhanom Ghebreyesus (Image courtesy
of the World Health Organization).
The 63rd session of the World Health Assembly in Geneva in May 2010 (WHO, 2017d)
discussed a number of public health issues, including (1) implementation of the International
Health Regulations (IHR), (2) monitoring of the achievement of the health-related Millennium
Development Goals (MDGs), (3) strategies to reduce the harmful use of alcohol, and (4)
counterfeit medical products.
The IHR document is a legal brief that addresses transnational control of infectious diseases
and was developed as a response to the increase in international travel and trade. On June 15,
2007, the IHRs became international law; 194 countries have agreed to implement the
regulations. The IHR requires nations to strengthen core surveillance and response capacities to
infection control at the primary, intermediate, and national level, as well as at designated
international ports, airports, and ground crossings. The regulations further introduce a series of
health documents, including ship sanitation certificates and an international certificate of
vaccination or prophylaxis for travelers. The document is available at the WHO website.
Historically, the United Nations MDGs were eight goals that all 189 UN member states at
the time agreed to try to achieve by the year 2015 (WHO, 2017d). The United Nations
Millennium Declaration, signed in September 2000, committed world leaders to combat poverty,
hunger, disease, illiteracy, environmental degradation, and discrimination against women. The
MDGs were derived from this Declaration, and all have specific targets and indicators. The
following are the specific goals:
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1. To eradicate extreme poverty and hunger
2. To achieve universal primary education
3. To promote gender equality and empowering women
4. To reduce child mortality rates
5. To improve maternal health
6. To combat HIV/AIDS, malaria, and other diseases
7. To ensure environmental sustainability
8. To develop a global partnership for development
The UN MDGs have, overall, been remarkably successful in focusing attention and
mobilizing resources to address the major gaps in human development. Some of the MDGs’ key
targets, such as halving the poverty rate were met; however, achieving the health goals continues
to look very challenging (Center for International Governance Innovation, 2017).
These goals are now further empowered with the United Nations Educational, Scientific,
and Cultural Organization (UNESCO) Sustainable Development Goals. The Sustainable
Development Goals, or SDGs, are a global framework to coordinate efforts around ending
poverty and hunger, combating inequality and disease, and building a just and stable world.
There are 17 goals in all, and all 193 nations represented at the United Nations agreed to them
(UNESCO, 2017).
The World Bank, the International Monetary Fund, and the African Development Bank
agreed to cancel debt of the poorest countries so that resources could be used to improve health.
Key criticisms about this monetary support has been related to the fact that much of the money
(at least 50%) was diverted to disaster relief and military aid, areas for which it was not intended
(World Bank Annual Report, 2010).
Refugee and Disaster-Relief Assistance
A refugee is defined as “any person who is outside his or her country of origin and who is
unwilling or unable to return there or to avail him or herself of its protection because of a well-
founded fear of being persecuted for reasons of race, religion, nationality, membership in a
particular social group, or political opinion or a threat to life or security as a result of armed
conflict and other forms of widespread violence which seriously disturb the public order”
(Office of the United Nations High Commissioner for Human Rights [UNHCR], 2017). The
United Nations High Commissioner for Refugees (UNHCR) was established by the International
Refugee Organization, an organization that was founded on April 20, 1946, to deal with the
massive refugee problem created by World War II.
Internally displaced persons are people who have been forced to flee their homes suddenly
or unexpectedly in large numbers because of armed conflict, internal strife, systematic violations
of human rights, or natural disasters, and who are within the territory of their own country
(Office of the United Nations High Commissioner for Human Rights [OHCHR], 2017).
Most conflicts occur within rather than between countries. Compared with other continents,
Africa and Asia have consistently registered high numbers of civil armed conflicts (Relief Web,
2013). Some of the countries that have experienced violent conflicts and prominent
humanitarian interventions in the past two decades include Liberia, Angola, Sierra Leone,
Rwanda, Sudan, Chechnya, Bosnia and Herzegovina (formerly Yugoslavia), Somalia, Sri Lanka,
Azerbaijan, Armenia, Democratic Republic of Congo (DRC), Kosovo, East Timor, Afghanistan,
and Iraq (Relief Web, 2017).
The health consequences experienced by populations affected by armed conflict are
generally similar in nature. War-induced displacement is psychologically and physically
traumatizing to everyone affected. People are rarely prepared for flight and have no time to
85
gather clothes, food, or anything that can sustain their lives during displacement. Their search
for safety can last for long periods, depending on the nature of war, prevailing geographical
conditions, and the willingness of host communities to welcome them. Relatives and family
members are often separated. Some are lost to capture, displacement, and/or death (Brown,
deGraaf, Annan, & Betancourt, 2016).
The health effects of armed conflict may be direct or indirect. The direct effects include
injuries (e.g., due to land mines, weapons), sexual violence, human rights violations,
psychological trauma, and death. Indirect effects include food scarcity, population displacement,
high levels of morbidity and mortality, infectious disease, complications of chronic disease,
reproductive health morbidities, malnutrition, and disruption of health services (Levy & Sidel,
2016). It is significant that the United Nations, in its human rights activities, works with bilateral
and multilateral agencies, NGOs, and the World Bank to offer health assistance in addition to
the many other competing direct and indirect needs related to refugees.
Multilateral, Bilateral, and Nongovernmental Organizations as
International Organizations for Health
International health organizations are classified on the basis of their relationships with other
distinguished organizations which match their commitment to specific aspects of population-
based health, the specific implementation of health goals both directly and indirectly, and their
particular resources, including financial contributions. Multilateral agencies and organizations
receive funding from both governmental and nongovernmental sources. Examples of these
multilateral agencies include the United Nations and the WHO, which were discussed
previously. The World Bank is another multilateral organization. Its major goal is to lend money
to countries in need of developing their infrastructure on a variety of fronts. Some of the projects
undertaken by the World Bank and related to health include addressing access to safe drinking
water, soil development so that healthy foods can be grown and eaten, building sanitation
systems so that water drainage is not connected directly to sewage, and promotion of vaccination
programs, as well as promoting primary healthcare, which includes screening programs. Specific
programs include Roll Back Malaria, the Joint United Nations Programme on HIV/AIDS, the
Global Alliance for Vaccines and Immunizations, Onchocerciasis Control Program (river
blindness control), and the Global Water Project (World Bank, 2017). (See the earlier discussion
of WHO, United Nations, and MDGs for a critique of the use of promised monies to assist with
health goals by World Bank and other funding organizations.)
Bilateral agencies and organizations conduct their services within one specific country. The
U.S. Agency for International Development (USAID) is a good example in the United States. It
is a committed initiative which works with developing countries to enhance systems to fortify
the health and welfare of international populations. USAID focuses specifically on support
directed to sub-Saharan Africa, Asia, Latin America, the Caribbean, Eurasia, and the Middle
East. Key health prevention initiatives focus on larger areas of child, maternal, and reproductive
health, and have specific interests in HIV/AIDS, malaria, and tuberculosis care (USAID, 2017).
Many of the healthcare systems in countries described earlier in this chapter have parallel
organizations to USAID.
NGOs, discussed earlier in this chapter, are private agencies that voluntarily use their
resources to address a variety of healthcare initiatives in the United States. Some of these
organizations have specific goals or roles in global health. For example, the International
Committee of the Red Cross (2017) is known most for its role in disaster relief. Some groups,
such as Catholic Relief Services, (2017), have a particular religious affiliation, and others, such
as Oxfam International (2017), are directed specifically to issues related to hunger and
nutritional health. Philanthropies are organizations that are similar to NGOs, but they receive
86
funding through personal endowments. For example, the Bill and Melinda Gates Foundation
(2017) focuses on health, poverty, and development in Africa, South America, Asia, and
Australia. Specifically, The Living Proof Project supports vaccine and nutrition programs, as
well as decreasing the incidence of diseases such as polio, HIV/AIDS, and tropical illnesses. In
all cases, NGOs and philanthropies view human rights as a fundamental (motivation) basis for
addressing the unseen and unfelt pain of many people in the world who suffer needlessly.
Practice Point
The United States offers a process of applying for tax-exempt status for not-for-profit NGOs,
which are focused on national or international public health. This process requires filing
specific forms with the Internal Revenue Service (IRS) and a fee, and there must be no
involvement with or by any political campaigns. The organizational status acquired through
this process is a tax-exempt, nonprofit corporation or association (a 501c3). It requires a
board of directors be formed, with a stipulation in its by-laws which states the work intended
to be done by the organization. In return, the IRS gives the organization tax exemption for
purchases aligned with the mission of the organization, as well as other benefits and
protections. Donations and contributions made to nonprofit organizations may be claimed as
tax deductions on individual or corporate tax returns. Check out your local rules and
regulations, or discuss this idea with any legal consultant you may know (perhaps a law
student at your university or town).
International Council of Nurses
The International Council of Nurses (ICN) is a federation of more than 130 national nurses
associations (NNAs), representing more than 13 million nurses worldwide. Founded in 1899,
ICN is the world’s first and widest-reaching international organization for health professionals.
Operated by internationally prominent nurses, ICN works to ensure quality nursing care for all,
sound health policies globally, the advancement of nursing knowledge, and the presence
worldwide of a respected nursing profession and a competent and satisfied nursing work force
(International Council of Nurses [ICN], 2017).
ICN advances nursing, nurses, and health through its policies, partnerships, advocacy,
leadership development, networks, congresses, and special projects, and by its work in the
arenas of professional practice, regulation, and socioeconomic welfare. ICN is particularly
active in the following:
International classification of nursing practice
Advanced nursing practice
Entrepreneurship
HIV/AIDS, tuberculosis, and malaria
Women’s health
Primary healthcare
Family health
Safe water
Despite the variation in healthcare structures between countries, and the varying degrees of
both fiscal and health outcomes, nurses continue to advance the health of the public. Through (1)
assessment of health across a variety of specialties and patient groups, (2) education of other
nurses in health promotion and disease prevention, and (3) contributions to health policy
development, nurses represent the voice of patients and clients worldwide.
87
KEY CONCEPTS
Healthcare systems are organized based on philosophies of care and are culturally influenced.
The United States healthcare system includes structure and functions to support assessment, assurance,
and health policy related to the health of populations.
Despite the economic strength of the United States and other industrialized nations, many countries have
found more efficient and effective ways to care for all by decreasing health disparities and giving equal
access to care.
Public, philanthropic, and nongovernmental agencies all contribute to the health of populations through
diverse structures, financing, and personnel approaches to the health needs of citizens.
CRITICAL THINKING QUESTIONS
1. Give three reasons why you think that comparing healthcare systems between countries is an important
approach to serving the healthcare needs of people.
2. In thinking about multilateral, bilateral, and nongovernmental organizations, where would you see the role
of a community/public health nurse? Give some examples, and explain why public health nurses provide a
unique contribution.
3. How do cultural and philosophical factors play an important role in how healthcare systems are developed
and supported? Give explicit examples.
COMMUNITY RESOURCES
Local philanthropies and foundations with goals focused on healthcare
State Department of Health
Organizational chart of the (state house) legislative governance in your state (look for Health and Human
Services)
Insurance companies (private, HMOs)
Departments of Social Services (Medicaid Division)
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Chapter 3
Health Policy, Politics, and
Reform
Anahid Kulwicki and Sabreen A. Darwish
For additional ancillary materials related to this chapter. please visit thePoint
Healing is a matter of time, but it is sometimes also a matter of opportunity.
Hippocrates
Disruptive innovation is not about pushing out the incumbent, it’s about giving the consumer a
choice.
Dr. Jason Hwang, co-author of The Innovator’s Prescription: A Disruptive Solution for Healthcare
CHAPTER HIGHLIGHTS
Healthcare policy and the political process
Healthcare finance and cost–benefit in relation to health policy
Access to healthcare and insurance facts in the United States
Healthcare workforce diversity and its effects on the quality of healthcare
Nursing’s role in shaping healthcare policy
Quality of care and evaluation
Information management facts
Equity in healthcare access
Ethical consideration in health policy
Political advocacy, how to be politically active and advocate
Health advocacy and healthcare reform
Affordable Care Act (ACA) overview and updates
Community-based services and healthcare reform
Health services research application to healthcare policy
OBJECTIVES
Define public health, policy, and politics while identifying the relationships between concepts.
Explain the effect of politics in healthcare policy.
Identify the steps of policymaking and understand them comprehensively.
Apply the process of policymaking to explain daily decisions regarding health and health choices.
92
http://thepoint.lww.com/vitalsource/ebook/9781975111694
Understand facts regarding the healthcare system, access to care, and insurance issues.
Identify the basic economic and financial concepts in relation to healthcare services.
Identify the definition and determinants of quality of care.
Understand the critical role of nurses in healthcare reforms through political advocacy.
Explain the importance of workforce diversity, and the concept of cultural competency.
Understand the information management involved in the healthcare system.
Explain the ethical and legal considerations in the policymaking process.
Explain the major reforms in the healthcare system in the United States.
Understand the main foundations and premises of the Affordable Care Act (ACA), community health
services, and the role of the ACA
Understand the value of health services research in the healthcare system.
KEY TERMS
Affordable Care Act (ACA): The comprehensive healthcare reform law enacted in March 2010
(sometimes known as the Patient Protection and Affordable Care Act [PPACA], the Health
Care and Education Reconciliation Act, or “Obamacare”) designed to improve the quality and
accessibility of healthcare while reducing its cost.
Centers for Medicare and Medicaid Services (CMS): Federal agency that runs the Medicare,
Medicaid, and Children’s Health Insurance Programs, and the federally facilitated marketplace
that was designed to enact and achieve the goals of the ACA, which were first articulated by
the Institute for Healthcare Improvement.
Cost–benefit: An economic approach or analysis tool used to evaluate the effectiveness of a
treatment or intervention. Mathematically speaking, the net economic benefit can be
calculated by subtracting the costs for a service from the benefits of this service. If this value
is positive, it implies that the benefit from a specific intervention exceeds its cost. An
intervention is judged to be unworthy if its cost exceeds the benefits gained from carrying it
out.
Cost sharing: The arrangement that defines how you and an insurer pay for insured services or
items. Coinsurance, copayment, and deductibles are all forms of cost sharing. Premiums,
payments for uncovered healthcare supplies or services, or fees paid to out-of-network
providers are not shared costs.
Cultural competency: The knowledge, skills, attitudes, and behaviors that are learned in order
to provide the optimal health service to individuals from a variety of ethnic, racial, and cultural
backgrounds.
Deductibles: The amount you pay in a calendar year before your health plan begins to pay. For
instance, if your deductible is $2,000, you must pay that amount out-of-pocket for covered
health services before your insurer begins paying your healthcare costs.
Economics: The study of how individuals, groups, organizations, and society allocate and utilize
finances, personnel, time, and physical space as components of resources. Economic tools
and other quantitative financial measures are used as a method of evaluating the existing
governmental, private programs or public, and private policy alternatives.
Equity: As applied to healthcare, the notion that healthcare does not vary in quality because of
gender, race, age, ethnicity, geographic location, or socioeconomic status.
Gross domestic product (GDP): The main economic indicator used to evaluate the degree of
economic growth in the United States. It is defined as the final and total output of goods and
services produced in 1 year by labor input within the United States. The figure of GDP is
reported quarterly.
Health policy: Policy that has an impact on the health of an individual, a family, a population, or
a community and is created by the government, institution(s), or professional association(s).
National health expenditure: The total spending in dollars for the costs of healthcare goods and
services in a 1-year period. National health spending is one of the many parts that constitute
the GDP, and the growth in health expenditure is usually compared to the GDP growth.
Out-of-pocket costs: The costs that aren’t covered by your health plan. Deductibles,
coinsurance, copayments, and some supplies or services are examples.
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B
Patient advocacy: A vital nursing professional duty of supporting actions that are in the best
interest of patients’ health and that defend patient rights via speaking on patients’ behalf.
Such support is targeted toward the overall well-being and the contribution to the healing
process.
Policy: Principles that govern an action to achieve a given outcome. Policies are guidelines that
direct individuals’ behavior toward a specific goal. They are deliberate courses of action
chosen by an individual or group to confront problems.
Politics: Process of influencing the allocation of resources (financial, human, time, or physical
space). Additionally, politics represents how conflicts are expressed and resolved in a society.
Politics also may be a factor in deciding who participates or who influences governmental
decision-making.
Public health policy: A set of policies (governing principles) that has a health-related mission
and has an impact on the health and well-being of the population.
Political advocacy: Being involved in the legislative process and influencing decision-making in
relation to healthcare to best serve the public interest as well as the profession by enacting
the advocacy role to influence a change in policies, laws, or regulations that govern the larger
healthcare system.
Quality of care: A concept used to evaluate the extent of how efficiently and effectively
healthcare systems provide safe patient care at a reasonable cost to people in need. It is the
degree to which health services for individuals and populations increase the likelihood of a
desired health outcome.
Reform: Form again; improvement of what is wrong or unsatisfactory. It is for the better,
especially as a result of improvement of legal or political abuses or malpractices.
Workforce diversity: The presence of a variety of ethnic, religious, age, gender, sexual
orientation, socioeconomic status, nationality, disability, geographic location, racial, and
cultural backgrounds of the workers in a specific area such as the health sector.
CASE STUDY
References to the case study are found throughout this chapter (look for the case study icon).
Readers should keep the case study in mind as they read the chapter.
You are caring for an 8-year-old African American female patient on the general pediatrics floor.
She was transferred from the PICU, where she was admitted for respiratory failure and status
asthmaticus. She has a history of “wheezing” but has never been diagnosed with asthma. She
receives the majority of her care in the emergency department (ED) and urgent care centers. She
has never been on asthma medications. She lives at home with her mother and two siblings. Her
mother is employed as a clerk at a hospital and earns $29,942 per year. Her mother’s employer
provides health insurance. However, she cannot afford to add all three of her children to her health
insurance plan. As you read through the chapter, consider the following questions.
Lack of health insurance limits this patient’s access to quality asthma care. Barriers to quality
care exist even for those who are insured. What are some of those barriers? Are there differences
in asthma prevalence by race and income? Are there differences in how children in minority groups
access medical care? How do these differences affect asthma care? How are most children in the
United States insured? Do you think it is common for a person to have a job yet not have health
insurance coverage for their children? What are other health insurance options available to this
family? How can you advocate for this child? How can you help ensure improved asthma care for
all?
eing engaged in the healthcare system as a healthcare professional providing care, as an
administrator, or even as a client, it is important to have a general understanding of how
the healthcare system works. What are the guiding principles that affect individuals’
daily decisions regarding their health and health choices? Who is involved in the process of
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decision-making? What are the steps that are followed during this process? How can nurses be
an active part in the process of developing or changing healthcare policies? Do patients have
input into these policies? How does a healthcare policy affect an individual’s access to
healthcare? Are politics different from healthcare policies? Are politics isolated from any ethical
or legal considerations? As healthcare providers, how can nurses be involved in reforming the
healthcare system? How can they do so by using research or evidence in reforming healthcare?
This chapter will answer these questions. Moreover, it will give the reader the opportunity to
start thinking about the challenges and problems in the healthcare system in a broad and
comprehensive manner, to analyze these problems critically, and to find solutions by
considering the political process and policy actions. In other words, the reader will be able to
better understand challenges addressed by health policies and understand researcher input that
may improve the U.S. healthcare system.
HEALTHCARE POLICY AND THE POLITICAL
PROCESS
Policy can be created in the form of a law or a guideline of public and private institutions
(Centers for Disease Control and Prevention [CDC], 2015). Health policy refers to decision-
making to reach health goals and these decisions are made to direct future health planning and
outcomes within a framework of time (World Health Organization [WHO], 2017).
Porche (2012) defines policies as a set of principles that govern an action to achieve a given
outcome, or guidelines that direct individuals’ behavior toward a specific goal. Kraft and
Furlong (2013) define policy as decisions characterized by behavioral consistency, which reflect
the values and beliefs of two parties, namely, policymakers and policy followers. Moreover,
they claim that policy refers to the goals, plans, and specific strategies or programs used in
achieving a given outcome. Public policies address community problems and are developed by
public or government officials (Kraft & Furlong, 2013). Health policy broadly describes the
actions taken by governments—national, state, and local—to advance the public’s health (Acuff,
2017).
Health policies are those policies that have an impact on the health of an individual, a
family, and a population or community and are created within the government, institution, or
professional association (Porche, 2012). Health policies are crafted to alleviate issues of health
or healthcare (Mason, Leavitt, & Chaffee, 2012). “States use health policies to specify
requirements for licensure in the health professions, to set criteria for eligibility for Medicaid,
and to mandate immunization requirements for public university students” (Mason et al., 2012,
p. 3). Furthermore, U.S. states are involved with healthcare policy in many ways; some directly
operate public hospitals and mental health facilities, while others administer public health
departments that operate public health clinics (Acuff, 2017). In addition to the state level,
policies can be separated into local or national. An example of a state-level policy would be a
school board crafting a policy in regard to contraceptive care, whereas an example of national
policies would include laws and regulations in regard to access to care and reimbursement for
advanced practice nurses (Leavitt, 2009). In times of emergency at the local, state, or national
levels there is concentration of effort through the Federal Emergency Management
Administration (FEMA). The FEMA addresses through organized coordination of a variety of
key services assistance when natural and man-made disasters occur but they also do this work
successfully by being responsible in getting all of these levels of services prepared in light of a
disaster or any kind (Acuff, 2017).
Moreover, three main components of public health policy are reported consistently in the
literature, namely, (1) health-related decisions guided by the stated laws written by legislators,
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(2) rules and regulations designed to operate the health-related activities and programs, and (3)
the judicial decisions related to health, which involve both federal and state governments
(Porche, 2012).
Practice Point
As was previously discussed, politics cannot be separated from the process of policymaking.
There are many different ways to describe the impact of politics. First, politics are concerned
with the exercising of power and decision-making in a society (Kraft & Furlong, 2013).
Second, politics are usually studied as the process of formulating and adopting policies along
with focusing on the role of both governmental institutions and the public.
Involving Politics
Politics are the process of influencing the allocation of resources needed to enable policies, and
involves the strategies needed to achieve the desired goals (Mason et al., 2012). Politics also
reflects how conflicts and problems are expressed and resolved in the context of society, and
involves choices and influences based on power dynamics (Leavitt, 2009). Additionally, politics
helps in answering questions regarding who participates or who influences governmental
decision-making, and who benefits or who does not. Therefore, it is impossible to understand
health policy or any type of public policy without considering political factors, which affect
every level of policy formulation.
Kraft and Furlong (2013) discussed many reasons to involve the government in the
policymaking process. These reasons usually reflect political, moral, ethical, and economical
responsibilities. The two latter reasons will be discussed later in this chapter. In reference to a
political issue, the government should be interested in problems that affect a specific group or a
whole population. This interest usually takes the form of legislations that provide substantial
solutions for the health problems that threaten the safety of the citizens and/or their environment.
There are many examples of the positive role that governments play through policies and
legislations—to name a few: providing equal opportunity through universal provision of
education, healthcare, and often, housing and nutrition programs (Grogan, 2012).
Solutions can be achieved by working at either the federal or the state level. However, Rice
and team (2013) explain that there is little agreement between the two major U.S. political
parties (Democrats and Republicans) when it comes to how, when, to whom, and what kind of
healthcare should be provided, and who should pay for it. Rice and colleagues (2013) concluded
that in attempting to answer healthcare-related critical questions, disagreement between the two
major political parties can create difficulty in finding solutions to the problems of the society,
and hence to policies, including those of healthcare. Consequently, this can influence access to
healthcare and the possibility of improving the quality of care provided (Rice et al., 2013).
Additionally, politics interacts with every aspect of healthcare in the United States (Morone,
Litman, & Robins, 2008). Accordingly, U.S. politicians are interested in making decisions for
the society that can be enforced by rules, laws, and regulations. Politics is sometimes perceived
as a negative and unfavorable way to deal with social issues. However, politics provides the
power needed to influence critical decisions regarding the allocation and distribution of
resources in a society. Moreover, political actions are the tools used by politicians and the
official representatives of the citizenry to shape decisions.
In summary, Mason and colleagues (2012) identified three common themes, which can be
extracted from the different definitions of politics. First, the power of influence implies there is
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room for shaping desired outcomes by having an impact on the decisions made by governments,
communities, or associations. Second, the most critical process for politics is to make decisions
regarding the distribution and allocation of resources. Third, resources vary and include
financial, human (personnel), time, and physical space. These resources are often found to be
scarce. It is argued by Brownson, Fielding, and Maylahn (2009) that the availability of adequate
resources can strongly affect the decision-making process. Accordingly, resources are believed
to affect the desired outcome and outputs from a given policy.
While the previous themes of governmental power, decision-making, and resources are vital
in understanding the political role in decision-making, it is crucial to acknowledge the fact that
healthcare professionals, namely nurses, have political skills and active roles in healthcare
leadership. As highlighted by Mason and colleagues (2012), those skills are as follows:
1. Having social skills and the ability to understand, interpret, and represent one’s own and
others’ behaviors
2. Having the ability, qualifications, and power to influence others and make changes
3. Networking ability to develop, connect, and use different social networks
4. Having a high level of integrity, sincerity, and genuineness
Des Jardin (2001) notes that nurses, in the role of negotiating and finding moderating points
of agreement in political charged areas of concern, are very skilled in negotiating,
communicating clearly, solving problems and creating consensus (Boswell, Cannon, & Miller,
2005). Nurses are trusted nationally and internationally and trust is a significant ingredient to
assisting with agendas focused on change and consequently to help in making improvements in
healthcare and the healthcare system (Boswell et al., 2005; Williams, 1993). Because nurses are
active at the point of care with many patients and families it brings them to see their role and act
in the capacity to influence changes in policies, laws, or regulations that govern the larger
healthcare system (Oestberg, 2013).
Politics are interconnected with policymaking because politicians can control and determine
the allocation of resources. To put health policies in place, politicians must agree on the most
prevalent health issues and on how to address these issues, as they greatly impact the nation’s
health (Porche, 2012). To best serve their patients and best understand their field, nurses and
other healthcare professionals are encouraged to be involved in the political process and in the
development of health policies.
For the previously mentioned reasons, it is important for healthcare professionals to
understand some of the important terms and concepts that are related to healthcare politics and
policy. Putting policies in place is a process. Policymaking takes a great deal of effort, time, and
commitment. Porche (2012) laid out a dynamic series of events that take place in the
policymaking process (Fig. 3.1).
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FIGURE 3.1 Policy cycle.
Setting an agenda: the crucial basic phase when the problem of common interest is identified for a
specific community or a group. Three factors were found to play a role in this stage and were identified
by Porche (2012): (1) the significance of the problem, (2) the political support for addressing the
problem, and (3) the ability to perceive the viability of proposed alternative solutions for the problem. For
example, tobacco use is a major contributor to morbidity and mortality, which threaten populations
globally. Consequently, governments play a critical role in encouraging or discouraging smoking
behavior through different policies along with the role of nurses as political advocates for achieving
health improvements.
Policy formulation: the stage in which the possible and available alternative policies are identified and a
specific policy is selected. Continuing the discussion on tobacco use, all possible and effective policy
measures, such as smoke-free indoor air laws, tobacco industry–regulating policies at all levels—state,
local, and national—should be addressed and discussed to select the most effective policy in reducing the
prevalence of smoking.
Policy adoption: the process of selecting the policy that should gain support, power, and directions for the
legislators. In order to proceed in the process of fighting tobacco use, all proposed policies need to gain
support from stakeholders at the different levels starting from state level and ending at the local level,
along with nursing’s role in reflecting and directing the selection of policies.
Policy implementation: the stage in which the actual carrying out of the policy takes place by using the
available human and financial resources. In terms of tobacco use, in this stage, real application of the
anti-tobacco policies takes place when representatives at different political levels, including nurses, start
to enhance and reinforce the application of smoke-free environments using all possible resources. Law
enforcement is critical in this stage.
Policy assessment: evaluation of the implemented policy in terms of being compliant or congruent with
the statutory requirements, and whether it really serves the goal of solving the problem. Because the goal
of anti-tobacco policies and regulations is to prevent tobacco-related diseases through reducing smoking
prevalence, the success of these policies can be evaluated mainly by assessing the extent of achieving
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these goals, along with consideration for cost containment and effectiveness of policy-based
interventions.
Policy modification: depending on the prior step, the policy can be maintained, changed, or eliminated,
according to its level of appropriateness. In this step, a decision takes place either to maintain working
according to the anti-tobacco policies or to modify them and replace them, considering other alternative
policies, and the process of policymaking repeats itself.
Evidence for Practice
Tobacco use is a major global contributor to illness and is projected to kill more than 1
billion people during this century if present trends continue (WHO, 2008). Nurses are
increasingly engaged in community- and policy-level activities to improve health and
prevent disease and disability by conducting research that focuses on the tobacco industry
and related policies. Malone (2009) conducted a literature review on research studies
conducted by nurses on the tobacco industry. The epidemic of tobacco and its health
consequences result primarily from the industry’s promotion through marketing to groups
who already struggle with health challenges and may have literacy challenges. These
approaches undermine public health interventions to address smoking behavior. The notion
that smoking is a behavioral choice of individuals creates further barriers to understanding
the larger social and political context within which individuals use and attempt to quit
tobacco.
Nurses have been among the researchers worldwide who are studying tobacco industry
activities and their role in policy and public health. Much of the nursing research to date
focuses on four broad areas: (1) the tobacco industry’s influence on policy, (2) its strategic
responses to public health efforts, (3) its targeting of marginalized groups, and (4) its
influence on research processes and outcomes.
Recommendations:
1. Traditional tobacco prevention and cessation efforts must accompany understanding of
the role of the tobacco industry in shaping and contextualizing counseling programs.
2. Nurses need to be prepared to intervene as clinicians, community health proponents,
policy advocates, researchers, and educators.
3. Nurses have the political power to influence perceptions about tobacco and the tobacco
industry because they are highly trusted by the public and respected by policymakers for
their numbers and political savvy.
4. Innovative archival research on the tobacco industry can help nurses reframe tobacco as
a nursing issue, and link practices and government policies to their clinical practice.
5. Finally, nurses working in public health and policy arenas can help educate the public
about the tobacco industry’s ongoing efforts to encourage tobacco use, with major health
consequences.
In the United States, both state legislatures and the U.S. Congress are responsible for
determining appropriate healthcare policies. These state and national government representatives
work on creating policies to solve problems affecting a specific group, a geographic area, or the
entire population (Kraft & Furlong, 2013). These policies usually take the form of legislation,
which provides substantial solutions for the health problems that threaten the health and safety
of the citizens. This legislation can be achieved by working at either the federal or the state
level. Health policy is not a single action but needs a range of legislative and regulatory efforts
from ensuring air and water quality to supporting health-related research (Acuff, 2017).
Although state legislatures and members of Congress can work collaboratively to solve
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problems and distribute resources, there is often much delay and disagreement between major
political parties such as the Democratic and Republican parties (Rice et al., 2013). Because of
such disagreements, it is difficult to build an effective collaboration in healthcare policymaking,
and this can influence the individual’s access to care and the possibility of improving the quality
of care (Rice et al., 2013).
HEALTHCARE FINANCES AND COST–BENEFIT
Economics is the study of how individuals, groups, organizations, and society allocate and
utilize resources (Porche, 2012). Consequently, it is critical to apply economic tools and various
quantitative measures as a method of evaluating the existing governmental programs or public
policy alternatives (Kraft & Furlong, 2013). Politics and economics interact at either the
microeconomic level, which concerns the allocation of resources at the individual decision-
making level, or the macroeconomic level (Porche, 2012). Economically speaking, any process
of allocating fiscal resources is usually directed to best meet the human need and to improve
their well-being (Kraft & Furlong, 2013). In the health context, for example, if the government
spends more on medical visits than is needed to benefit its populations, this will lead to a
decrease in resources available for other services such as education. Hence, the role of
economics is extremely vital to enforce appropriate, effective, and efficient allocation of
resources on the different areas of services provided for populations, and to achieve balance and
justice reinforced by policies, laws, and regulation.
In studying health finance, it is critical to understand key terms. In the United States, the
gross domestic product (GDP) is the main economic indicator used in the processes of
evaluating policies in terms of their contribution to the economic growth. GDP is defined as the
final and total output of goods and services produced by labor input within the United States in 1
year as determined by the Bureau of Economic Analysis (USBEA, 2013) in the U.S. Department
of Commerce. The GDP figure is reported and released quarterly each year by the BEA.
National health expenditure is one of the many components of the GDP, and the growth in
health expenditure is usually compared to the GDP. As highlighted by Hartman, Martin, Benson,
and Catlin (2013), the total U.S. healthcare spending reached $2.7 trillion in 2011, representing a
3.9% increase from 2010.
There is a set of economic analysis processes used to evaluate economic policy outcomes.
The cost–benefit approach has been considered pivotal in evaluating the effectiveness of a
treatment or intervention (Sorbello, 2008). It is the most frequently used approach because it
serves to illustrate both the strengths and weaknesses of a given policy (Kraft & Furlong, 2013).
Consequently, economists were found to be continuously interested in finding answers for the
questions such as who gets the benefit and who bears the burden of a policy? How should we
measure the values, costs, and benefits of a specific policy? In this type of analysis, economists
are concerned with measuring the relative costs (in actual monetary value) against the benefits
(both monetary and quality-of-life value) of a given program or any aspect of healthcare
(Sorbello, 2008).
Practice Point
Mathematically speaking, the net economic benefit can be calculated by subtracting the costs
from the benefits. If this value is positive, this implies that the benefit from a specific
intervention exceeds its cost, so a decision is made to adopt such intervention. In contrast,
an intervention is judged to be ineffective in terms of its costs if its cost exceeds the benefits
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gained from carrying it out. Although this process seems to be easily accomplished, it is a
complicated process when it involves the healthcare system.
As described by Sorbello (2008), cost can be direct, in which the patient as a consumer is
supposed to pay these costs at the time of service. For example, direct costs can be supplies or
medications. Indirect costs are costs that are not assigned directly to the patient, but are related
to the provision of services at the organizational level. Similarly, health benefits or outcomes
can vary from simple, direct benefits to more complicated benefits. Outcomes should be
objective, measurable, and representative of the treatment interventions, which is not an easy
task to calculate, especially if the outcomes need to be expressed in dollars (Kraft & Furlong,
2013). However, less tangible outcomes, such as prevention of long-term suffering or disability,
and quality of life, are more difficult to quantify. On the other hand, hospital days or dollars
spent in a specific health service, for example, can be easily measured and evaluated.
There is one important process, which should not be ignored in cost–benefit analysis.
Economists in their analysis of the costs and benefits must involve the perspectives of the
different healthcare components that are participants in providing or receiving this service.
Morone and colleagues (2008) explain there are many perspectives that should be considered
and satisfied when providing a specific healthcare service. In other words, it is crucial for
economists to consider the costs of the people who are counted, the type of costs involved, and
the type of outcome that is desired. From the patients’ perspectives, patients usually are more
interested in their own costs and benefits. In other words, they are interested in their own
expenses and out-of-pocket (OOP) expenses. Patients are also concerned about other types of
costs, such as their psychological costs, suffering, and pain, which are difficult to quantify yet
have long-lasting negative effects. Regarding the payer’s perspective, the actual payment for the
service is usually what matters. The providers are usually concerned with the actual and direct
cost of providing a service.
Finally, it is critical to consider the societal concern, which usually includes all direct and
indirect costs and benefits at the broader community level regardless of who benefits from or
pays for the services. However, using the cost–benefit analysis as the only criterion in evaluating
the efficiency and effectiveness of a policy is restricted by the fact that cost and benefits are not
distributed evenly among individuals, consumers, or providers (Kraft & Furlong, 2013). In other
words, the economic analysis should involve the distribution of costs and accessibility of the
benefits in their analysis. Equity will be discussed in the following sections.
In summary, health spending is a product of services and the cost associated with those
services. When a policy is evaluated for its effectiveness, there is an interest in keeping the cost
of a specific health program within reason. Moreover, there is consideration for the overall costs
and benefits of the existing program, in the event a more efficient and effective service is
identified.
ACCESS TO CARE AND HEALTH INSURANCE
Before discussing access to care and health insurance, it is important first to understand the
nature of the U.S. healthcare system, which is a unique system of independent and collaborative
powers of both federal and state governments (Morone et al., 2008).
Evidence for Practice
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In a large exploratory study comparing the U.S. healthcare system with that of other
countries, Rice and colleagues (2013) highlighted the following facts about the U.S. system:
1. Private sector stakeholders play a stronger role in the U.S. healthcare system than in
other high-income countries.
2. The major federal government health insurance programs Medicare and Medicaid were
established in the mid-1960s.
3. Medicare provides coverage for seniors and the disabled, while Medicaid covers
healthcare services for qualified low-income individuals (also covering limited care needs
for qualifying seniors).
4. Public sources constitute 48% of healthcare expenditures in the United States.
5. Private third-party payers pay 40%, with the remaining 12% being paid OOP by
individuals.
6. Only a minority (30%) of the U.S. population is covered by the public financing system,
mainly through Medicare and Medicaid. Currently, 54% of Americans receive their
coverage from private health insurance, with most (36%) privately insured individuals
obtaining coverage through an employer.
7. One in six Americans is uninsured and over 17% of the population are without health.
Because of the Affordable Care Act, the number of nonelderly who was at 10.3% in
2016.
8. Even among those with coverage, high OOP costs can be a barrier to receiving timely
care and medications. Many others face high OOP expenses due to underinsurance.
9. The underinsured include elderly individuals who receive Medicare but cannot afford
supplemental insurance or the OOP expenses associated with Medicare.
10. Those covered by Medicaid have insurance, but may experience problems accessing
primary care due to their inability to find a private physician who accepts Medicaid
patients. OOP expenses may also be a factor in inability to access care.
11. Patients in rural areas may find it impossible to get to primary care facilities. Medical
costs are responsible for over 60% of personal bankruptcies in the country.
Concerns regarding racial/ethnic minorities, low-income groups, and uninsured groups
overlap because of similar barriers these populations experience in accessing healthcare and
obtaining quality services. Many low-income and uninsured populations are from diverse racial
and ethnic minorities. National programs for improvement of access to quality healthcare for
low-income and ethnic and racial minorities in United States are often addressed simultaneously.
There are, of course, special issues within each population that need to be taken into
consideration. Frequently, community health agencies play an important role in providing access
to healthcare for underserved groups, especially those who are uninsured and with low income.
HEALTHCARE WORKFORCE DIVERSITY
The United States is a home for individuals from different ethnic backgrounds. Although the
numbers are not growing as rapidly as the immigration of ethnically diverse populations, the
United States has had an increase in the number of healthcare professionals immigrating to the
United States from other countries (Hohn, Lowry, Witte, & Fernadez-Pena, 2016). Workforce
diversity can address two important areas of outreach and support to communities affected by
health disparities by reducing health disparities themselves and encouraging minority health
professionals to work in these areas of underrepresented racial and ethnic minority groups
(White, Zangaro, Kepley, & Camacho, 2014). However, the shortage of healthcare providers in
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the United States and the higher pay of health professionals in high-income countries have led to
the migration of healthcare professionals from developing countries. In addition to the higher
wages in United States, the opportunities for advancement are an incentive for health
professionals’ migration to the United States. Although healthcare professionals emigrating from
other countries have filled critical vacancies, helped improve culturally competent care, and
played important roles in innovations to substantially improve healthcare for hard to reach
populations, they have created global challenges to low-resource countries. When nurses’
education was publicly funded or subsidized and then those nurses moved to work in wealthier
countries, their countries of origin suffer the loss of intellectual and practice evolution (Li, Nie,
& Li, 2014).
Evidence for Practice
The 2016 American Association of Colleges of Nursing policy brief and the 2015 National
Council of State Board of Nursing (NCSBN) survey reported that minority nurses represent
19% to 19.5%, respectively, of the total of all registered nurses (RNs) in the United States.
The Office of Health Resource Service Administration’s (HRSA) brief on gender and
racial/ethnic diversity in U.S. health occupations for 2010 to 2012 describes a rate of ethnic
minorities of 21.4% (HRSA, 2015). These estimates are below the almost 40% of ethnic
minorities in the U.S. population (U.S. Census Bureau, 2015). According to the 2016
National Healthcare Quality and Disparities Report, released by the Agency for Health
Quality and Research (AHQR, 2016), it was reported that in 2015, there were also 2.7
million RNs. In terms of nursing workforce, current estimates show that men are
approximately 9% to 11% of the nursing workforce (Budden, Shong, Moulton, & Cimiotti,
2013; HRSA, 2013), while racial and ethnic minorities compose 33% of the U.S. workforce.
However, only 25% of the nursing workforce shows a modest increase in racial and ethnic
minority nurses (HRSA, 2013). RNs in a recent national workforce survey by the NCSBN
were 83% white/Caucasian, 6% black/African American, 6% Asian, 3% Hispanic/Latino, 1%
Native Hawaiian or Pacific Islander ethnicity, and 1% other (Budden et al., 2013). The
difference in the proportion of white RNs in this study and the 75% proportion reported by
HRSA in a recent report (HRSA, 2013) was attributed to the different sampling method, in
which the NCSBN drew its sample from RN licensing data and represents all RNs licensed
in the United States. Meanwhile, the HRSA sample included currently employed RNs and
those seeking employment as RNs (National Advisory Council on Nurse Education and
Practice [NACNEP], 2013).
Reports indicate that while 6.7% of the RN workforce was made up of foreign-educated
nurses, some states like California, Hawaii, Nevada, New Jersey, New York, and
Washington, D.C., were found to have an amount greater than 10% of foreign-educated
nurses who are currently practicing (NCSBN, 2015). There has been an incremental
increase in nursing workforce diversity for RNs. HRSA reported in a survey that the number
of RNs from minority or ethnic backgrounds has grown from 119,512 in 1980 to 513,860 in
2008 (HRSA, 2010). The survey also revealed that while only 65.6% of the U.S. population
is white and non-Hispanic, 83.3% of RNs were white and non-Hispanic. RNs from Asian
backgrounds were overrepresented at 5.8%, compared to 4.5% of the U.S. population. This
imbalance of RNs from Asian ethnicity in the United States can be explained by the U.S.
recruitment efforts directed toward RNs primarily from the Philippines and/or India as shown
in Figure 3.2. In this survey, in terms of languages spoken, most RNs spoke only English.
Only 5.1% spoke Spanish, 3.6% spoke Filipino languages, 1.1% spoke French, and less
than 1% spoke Chinese, German, or other languages. There are 165,539 RNs living in the
United States who were educated in other countries. This number accounts for 5.6% of the
entire licensed RNs workforce in the United States.
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FIGURE 3.2 National Sample Survey of Registered Nurses (HRSA, 2010). (From U.S.
Department of Health and Human Services, Office of Health Resources and Services
Administration. [2010]. Findings From the 2008 National Survey of Registered Nurses [Chap 8, p.
192]. Retrieved from
http://www.hrsa.gov/About/News/Pressreleases/2010/100922nursingworkforce.html.)
Practice Point
In the NCSBN survey, an examination of RNs by job title showed that “nurse executive” and
“nurse faculty” roles had the least diversity, while “staff nurse” had the most diversity (Budden
et al., 2013). Additionally, newly licensed nurses had a more diverse racial/ethnic
composition (NCSBN, 2015). These data illustrate the need for diversity programs that focus
on educational and career advancement for underrepresented minority RNs.
As minority populations increase at rapid rates, there is an increasing need for a diverse
workforce of healthcare providers who can provide culturally competent care.
Transcultural and cultural competency is very important when addressing needs of diverse
multicultural populations. Leininger (1999) defined transcultural nursing as a formal area of
study, research, and practice focused on culturally based care beliefs, values, and practices to
help achieving the goal of well-being, and prevention of disability in a culturally congruent and
beneficial ways. Culture encompasses human beings, religion, kinship, education, technology,
language, environmental context, and worldviews, and needs to be integrated into nursing care
(Leininger, 1999). As defined by Bearskin (2011), cultural competence refers to the skills,
knowledge, and attitudes required to provide care with consideration for various cultural
differences. HRSA acknowledged that the most dominant determinant in RN cultural
competency is the language used to communicate with the population being served by the RN.
Similarly, a number of critical cultural competency interventions were proposed by Betancourt,
Green, Carrillo, and Ananeh-Firempong (2003), which included minority recruitment into health
professions, development of interpreter services and language-appropriate health educational
materials, and education of healthcare providers on cross-cultural issues in order to best address
health and healthcare disparities.
Consistently, Purnell has emphasized that healthcare providers must recognize, respect, and
integrate clients’ cultural beliefs and practices into health prescriptions allowing for the provider
to be culturally aware, culturally sensitive, and have some degree of cultural competence to be
effective in integrating health beliefs and practices into plans and interventions (Purnell, 2002;
2012). Purnell added that while cultural awareness has more to do with an appreciation of the
external signs of diversity (e.g., arts, music, dress, etc.), cultural sensitivity has more to do with
personal attitudes and not saying things that might be offensive to someone from a cultural or
ethnic background different from what is considered normal.
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http://www.hrsa.gov/About/News/Pressreleases/2010/100922nursingworkforce.html
FIGURE 3.3 A, B: Surrounded by registered nurses and legislators, on July 2, 2010, Gov. Deval
Patrick signed into law a bill. C: Nurses testifying for one of the bills. (Adopted from the
Massachusetts Nurse Newsletter July/August 2010.)
Practice Point
Purnell (2002) has identified cultural competence as having several characteristics that
include knowledge and skills as well as the following:
Exploring one’s culture in a context of not trying to change others’ cultures
Making the effort to learn about others’ cultures and cultural meanings
Tolerating and embracing different ways of knowing and experiencing life by others
Making no assumptions about what others believe
Avoiding judgements around differences
Opting to be available and being comfortable to experience other cultural interactions in persons or
events
Being versatile with other cultures
Cultural competence is an individualized plan of care that begins with performing an assessment
through a cultural lens.
It is also clear that cultural competency is required for achieving the aims of public health in
the context of the client, individual, family, or community. Because healthcare professionals are
involved in the process of policy formation, it is logical that the less diverse the workforce is, the
less appropriate and effective the healthcare policies will be for disadvantaged populations.
Healthcare professionals continue to report that marginalized (minority) populations experience
greater healthcare needs and receive lower quality of care (Bearskin, 2011). As a result, the U.S.
Health and Human Services and the Office of HRSA have taken bold steps to increase
workforce diversity by providing funds for programs that address this important issue.
Despite all national efforts to improve the diversity of the healthcare workforce, Hunt (2007)
reported that managing a racially and culturally diverse workforce is complex and challenging
for nurses. He stated, “There are no ready-made tools to show them how to do so…Achieving
effective management of a culturally diverse workforce comes from an intrinsic motivation to
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develop the cultural competence to engage with them” (Hunt, 2007, p. 2252).
NURSING’S ROLE IN SHAPING HEALTHCARE
POLICY
Historical Highlights on Nursing Political Involvement
Nurses have long been recognized as patient advocates. Today, more than ever, nurses need to
be politically involved personally and professionally in the complex healthcare arena (Fig. 3.3).
The process of gaining a position of influence in the legislative arena takes time.
William (1993) argues that the history for nurses being involved in political endeavors
started in the mid-’70s and early ’80s when nursing scholars and leaders advocated for political
involvement of nurses. Furthermore, debate about nursing involvement in political issues within
the profession and in societal issues occurred during 1976 (Powell, 1976). Nursing education
efforts focused on legislative involvement at all government levels in this important year of
advocacy (Williams, 1977). While Leininger (1978) described the need for political activism
within the instruction of nursing students, Cowart and Allen (1981) described the rationale for
curricular inclusion of politics and health policy content. Successful legislative lobbying toward
healthcare policy formation included the voices of nurses in the 1990s (Milstead, 2013). Since
then, organized nursing is included in the debates about healthcare reform. Nursing’s presence in
these debates was credited to the many years of public involvement by selected leaders in the
nursing profession (Magnussen, Itano, & McGuckin, 2005.) There are many examples of the
tremendous influence of nurses on healthcare. Nursing has a rich history of political activists in
Florence Nightingale, Lillian Wald, and many others (Selanders, Louise, Crane, & Patrick,
2012).
Evidence for Practice
In a historical literature review of political activism in nursing conducted by Rubotzky (2000),
it has been stressed that the years 1992 to 1994 were very influential.
1. Nursing in the United States started 1992 as an assertive, organized professional
discipline with the intention of influencing national public policy. Such organized
movement resolve was a clear break from the traditional, historical role of this
traditionally women’s profession.
2. The subsequent events of 1992 to 1994 illustrate a pivotal story of a discipline becoming
an advocate of political signicance, overcoming the barriers of traditional views,
organizing as an identiable political interest group, and speaking out with clarity as an
advocate for the health of all Americans.
3. In 1993, the newly elected President of the United States, William Clinton, directed the
formation of a national Task Force for Health Care Reform, including professional nurses
in its membership.
In the modern era, there have been outstanding examples of individual nurses as well as
associations throughout the history of the profession who have demonstrated their capacity
to shape healthcare by being active in directing healthcare through legislation. Nurses have
done this through initiating/revising healthcare goal policy proposals and influencing the
implementation of health policy. For example, nurses who wanted to secure state
registration for Michigan nurses created the Michigan Nurse Association. It took them over 5
years of lobbying to accomplish their goal and that was before women could even vote
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(Nault & Sincox, 2014).
What Does It Mean to Be Politically Active and Involved?
It’s been argued that being personally involved in politics means being active in the political
process as a citizen of the country. A good example of personal involvement is voting (Boswell
et al., 2005). Nurses have long been recognized as patient advocates. Today, more than ever,
nurses need to be politically involved personally as well as professionally in the complex
healthcare arena. However, being politically involved means being knowledgeable about issues,
laws, and health policy. Nurses need to be both personally and professionally involved but they
need to be involved in an informed way more than ever today.
Oestberg (2013) highlighted many important reasons why nurse-informed political
involvement is necessary: (1) nurses are direct caregivers, who spend more time with patients
than other healthcare providers; (2) nurses come face to face with issues associated with patient
safety and satisfaction, access to services, clinical outcomes, and health disparities and (3)
nurses are positioned on a daily basis to see not only the impact of health policy on individual
patients but also the need for more comprehensive changes in the policies that address many
health-related issues. Nursing exists to serve the public. It is a duty to be active politically and
work to influence public policy especially when nurses are in a position to be aware of injustices
in the healthcare system and the political arena. Nurses have a duty to set an example and
become involved (Des Jardin, 2001; King, 2015).
In addition to their clinical expertise, nurses are being sought out to serve in a variety of
leadership positions and develop policy recommendations related to a wide range of healthcare
policy issues (Dean, 2011). Accordingly, policymakers need to hear nurses articulate their
perceptions of needed change in policy or the need to create policy anew because they are in the
best position to communicate citizens’ problems and be advocates for individual, family, and
community rights and healthcare needs.
As highlighted by Porche (2012), nurses and other healthcare professionals have a rich
preparation in knowledge and personal and professional experiences within the healthcare
system that enable them to influence the development of health policy. Nurses are experts as
clinicians, educators, researchers, and administrators and need to acknowledge and use the
power they have in numbers in public policy. Nurses are experts and should use their expertise
to translate new worldviews into the policy arena. In the policy arena, they can utilize their
knowledge, perspective, experiences, and skills to be change agents for public policy at all levels
of government (Leavitt, 2009). Nurses also represent communities and speak as trusted and
respected professionals, evidenced by annual surveys, which indicate that the public continues to
rate RNs as the most trusted profession on the basis of their professional honesty and ethical
standards (Norman, 2016; Williamson, 2017).
Nursing Advocacy and Policy Participation
“Nurses are natural advocates, but this advocacy does not stop at the patient and family level.
Every nurse has a voice and can lead change locally and globally” (Carol Ann King, 2015, p.
13). Nurses consistently play the role of advocate as they support each patient’s emotional well-
being, contribute to the healing process and speak on their patients’ behalf. On the other hand,
nurses can use their patient advocacy and political advocacy skills to work in supporting each
other and for the nursing profession as a whole (Krischke, 2011). Fulfilling the role of patient
and public advocate, requires nurses to support actions that are in the best interest of public
health and also that defend patient as well community rights. Therefore, nurses have a
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professional duty to protect many interests (Des Jardin, 2001; King, 2015). As indicated by
Milstead (2008, 2013), nurses are experts who can address both the rational shaping of the
policy, and the emotional aspects of the process, and should feel morally obligated to advocate
for their patients.
“As nursing advocates, we start with the foundation that we are servants to others and
stewards of our profession. We choose to lead from that servant position, making sure peoples’
needs are being met through wise and thoughtful interactions.” (Noel, in Krischke, 2011). When
nurses act as patient advocates, many of them are referencing to what happens at the point of
care. It is often not the case to see oneself as a nurse equipped of able to discuss concerns related
to health and healthcare with legislators (Nault & Sincox, 2014). Many nurses today are inspired
to take on some form of advocacy to bring about change in the current policies, laws, or
regulations that govern the larger healthcare system (Abood, 2007).
How to Be Politically Involved?
Nursing as an organized labor force makes up the largest group of healthcare professionals.
Because of the extent of their knowledge of health principles and their ability to shape
healthcare policy, nurses have a valuable part to play. According to Catalano (2015), political
involvement comprises activities, methods, tactics, and behaviors that shape or have the
possibility to affect governmental and/or legislative strategies and outcomes. Dealing with
numerous concerns daily and other workplace issues, nurses have the choice to motivate
themselves to act and find opportunities to bring about change in the healthcare system itself
(Abood, 2007). Additionally, nurses can play a leading role in influencing their elected
representatives to enact needed changes in healthcare and nursing policy and electing pro-
nursing politicians to make sure that nurses and patients have partners at the state level and
federal levels in gaining quality, affordable, and accessible healthcare (Artz, 2006).
Practice Point
Oestberg (2013) indicates that nursing and nurses can only be effective if they not only have
deep knowledge about how the health system functions (structure and process) but also
understand who are the decision-makers in the context of structure and process that can
impact policy. In being knowledgeable in these areas, nurses can strategize effectively to
impact policy development and change at the local, state, and federal level.
Nurses continuously demonstrate evidence-based care, and they share decision-making with
patients and families, resulting in improved quality and reduced cost. Nurses have also been
active in the development of public policies as members of the legislative and executive
branches at national and state levels (Dean, 2011; Leavitt, 2009). Furthermore, elected officials
are selected as representatives and they make decisions based on the information that is shared
with them. Therefore, it is critical for nurses to become one of the key sources of information to
legislators when the issues with which they deliberate on impact healthcare and the well-being
of our population (King, 2015).
Oliver (2012) argued that legislators must make decisions about a large number of issues in a
short time frame as they cannot be experts in every field, so they rely heavily on their staffers to
research issues and on the experts in those fields with whom they have developed. In the
research arena, all nurses engaged in research usually consider the policy implications of their
work, and even if the researcher is not the advocate, those who are engaged in workplace,
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organizational policy, or public policy can use research studies to propose policy alternatives
and enhance policy modification accordingly (Leavitt, 2009). Evidence-based practice is the
gold standard for the interventions used in individual, family and community care efforts.
Evidence-based practice examples are needed in nursing advocacy efforts because through
research evidence can be gathered to be presented to decision makers about the changes nurses
want to see and strive to accomplish (Oestberg, 2013). Nurses have many milestones in policy
development as addressed by Leavitt (2009) through their practice and research, which have
contributed to (1) quality outcomes, (2) decreases in cost, (3) expanded access, and (4) major
differences to the health of the nation. To name a few:
1. The magnet process, which was originated by the American Academy of Nursing (AAN), has
been integrated into The Joint Commission’s standards.
2. School-based health centers, as demonstrated by advanced practice and public health nurses,
can improve access for underinsured and uninsured children and can reduce some of the
disparities in healthcare access.
3. Linda Aiken and colleagues’ groundbreaking research on nurse staffing and the effect on
patient outcomes has resulted in laws and regulations that created guidelines for staffing
criteria of hospital units in many states (Aiken, Xue, Clarke, & Sloane, 2006).
In terms of policymaking, nurses have the basic vital evidence either supporting or opposing
a policy. Nurses can also serve on a personal and professional level in the process of political
election to be instrumental in serving the nation’s health (Porche, 2012). They can be members
of an organization or a group, which enables them to be involved in agenda setting and the
introduction of a specific problem into the national agenda, identifying the goals and tools, and
advocating and disseminating health issues through the media (Milstead, 2008).
ADVOCACY ACTIVITIES OF PROFESSIONAL
NURSING ORGANIZATIONS
Central to all nursing practice is the role of nurses as advocates. Advocacy allows nurses to use
their voice of experience to represent patients, families, causes, and professional issues. Nurses
who are advocates in these areas often use their moral and ethical decision-making based on
principles of fairness and equity and use them to influence political process that can lead to
decisions in resource allocation (Matthews, 2012).
The Role of Professional Nursing Organizations
The American Nurses Association (ANA) is the only full-service professional organization
representing the interests of the nation’s 3.1 million registered nurses through its constituent
member nursing associations and its organizational affiliates (Mathews, 2012). The ANA has
issued Nursing’s Agenda for Health Care Reform, endorsed by over 60 other nursing groups
(ANA, 2010a). Myers (2010) pointed out that the ANA which serves as the strongest nursing
organization in the United States, has been engaged in helping its members play a significant
role in advocating for their patients by closing the gaps in the healthcare access for patients and
their families through testifying at congressional hearings, healthcare summits, and regional
forums. For example, nurses who are members of the ANA and their state nurses’ association
can apply to participate in the American Nurses Advocacy Institute (ANAI) which focuses on
advocacy initiatives and political strategies (Vencill & Lemmons, 2015). Furthermore, ANA
works with other health coalitions and advocates for nurses to serve as members of governing
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boards in each state, to advance the role of and recognition of nurses, to prevent potential
declines in quality, and to communicate with the Congress in the prevention of harmful changes
in Medicare actions (Dean, 2011; Spring, 2013). However, Myers (2010) stated there is a
concern that too many nurses have been absent from policy deliberations despite ANA’s calls
for advocacy, minimizing the collective power of nurses in the legislative process.
Nursing organizations with legislative departments provide analysis on current issues in
health policy and tips on how to communicate with legislators. Many also offer workshops on
nursing advocacy, or legislative days at the state house, both excellent opportunities to begin an
advocacy career (Oestberg, 2013). For example, the National League for Nursing (NLN)
advocates a curriculum revolution and incorporates political activism in their strategic plan
(Williams, 1993). The International Council of Nurses (ICN) is a federation of more than 130
national nursing associations where the ANA is the U.S. representative, along with other nursing
associations, representing more than 13 million nurses worldwide. The ICN was founded in
1899 as an international center for nurses and other health professionals. The goal of the
organization is to assure that quality nursing care is rooted in reasonable and effective health
policies through the generation of nursing knowledge (research). The primary focus of this work
is to benefit patients, families, communities, and the professional nurse workplace on the global
stage (ICN, 2011).
CURRENT SITUATION OF NURSING POLITICAL
INVOLVEMENT: CHALLENGES AND BARRIERS
Among the challenges that have been identified as negatively affecting nursing’s political
involvement include (1) living a fast-paced stressful life in today’s world with not enough time
to get involved; (2) heavy workloads with understaffing; (3) a perception of powerlessness; (4)
gender issues that often support not being direct but indirect with upset and concerns; (5) fear
that political action will create a breach of family time; (6) anxiety with public speaking; (7)
complex public policy coupled with lack of knowledge in the legislative process; and (8) fear of
retaliation for raising controversial positions related to justice and parity (Des Jardin, 2001).
Furthermore, Boswell and colleagues (2005) added that time constraints, lack of resources,
political awareness, role modeling, peer support, frustration, and burnout may also lead to
minimal political involvement. Last, political involvement is further weakened by role
ambiguity, role issues, and role incongruity (Des Jardin, 2001; Oliver, 2012).
Strategies for Nursing Involvement in Policy and Politics
There have been many co-authors in the policy arena who have developed strategies to guide
nurses to find the best opportunity for policy involvement. Oestberg (2013) highlighted that
nurses can make phone calls to elected representatives about bills under consideration, testify
before committees, become involved in practice councils or boards at the workplace, and even
run for elected office. Oestberg (2013) added that other strategies can include (1) establishing a
mentor relationship with an experienced nurse advocate; (2) seeking formal education on health
policy or public health, (3) searching for an internship with one’s local or state representative to
work on health-related legislation to understand how the system works and gain networking
contacts; (4) using local and state resources or national nursing advocacy groups to gain an
understanding of current issues and learn about involvement; (5) networking with other nurses to
create a unified voice in addition to the elected representatives and their staff by first building
credibility with them; and (6) avoiding underestimating personal experiences because legislators
like to hear how legislative issues would affect their constituents. An example of nursing
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involvement in policy and passing laws that had a direct impact on the nursing profession is
when Governor Patrick signed the Assault Bill announcing a zero tolerance for violence against
healthcare professionals, namely nurses.
Practice Point
Nurses as educators have a particular responsibility to teach students how to translate issues
into health policy. They can serve as both role models and teachers when there is a need to
include political competence and citizenship in the education system (Carnegie & Kiger,
2009). Because nursing roles are interrelated, educators can work with researchers, and
administrators can work with clinicians to share their perspectives and diverse knowledge to
make tremendous contributions to policy development (Hewlett et al., 2009). Whitehead
(2003) highlighted the vital role of the nursing education curriculum as an integral part in
achieving many goals for nurses early on in their careers. These goals are: (1) reinforcing
and ensuring nursing’s active role in initiating and developing health policy; (2) creating
politically involved nurses; and (3) developing nurses who are health policy experts and
entrepreneurs. However, he observed that the available literature suggests that the majority
of nursing curricula are yet to fulfil this role.
In summary, the nursing profession is one of the largest sectors of the healthcare industry
in the United States and has a rich history as a unique profession with its own values, ethics,
respect, integrity, and responsibility. Nurses’ opportunities for contributions to healthcare
policies are unlimited. As Fyffe (2009) pointed out, there is a need for greater coordination of
action to ensure that nursing is represented and actively supported in influencing and
shaping health and healthcare policy.
QUALITY OF CARE
The healthcare system in the United States is very complex, made up of diverse patients,
healthcare providers, and healthcare payers. With patients, providers, and payers constantly
interacting for varying reasons and in a variety of environments, it is extremely difficult to
evaluate the complexities of the quality of care for the U.S. population. Despite the difficulties
in evaluating the quality of healthcare, much is being done by the federal government, U.S.
Department of Health and Human Services, the Centers for Medicaid and Medicare Services
(CMS), and private institutions and organizations to examine the healthcare system in terms of
quality, access, and cost. Mason and colleagues (2012) report several examples as to how
efficiently and effectively healthcare systems provide safe patient care to people in need at a
reasonable price and with equal distribution. Mason and colleagues (2012) reference the Institute
of Medicine report (2001), which lists the following dimensions of healthcare systems that
should be considered when quality, cost, and access are examined:
1. Safety: avoiding injury and harm from care that is meant to aid patients
2. Effectiveness: assuring that “evidence-based” care is actually delivered by avoiding overuse
of medically unproven care and underuse of medically sound care
3. Patient-centeredness: involving patients thoroughly in the decision-making process about their
care, thereby respecting their cultures, social circumstances, and needs
4. Timeliness: avoiding unwanted delays in treatment
5. Equality: closing racial, ethnic, gender, and socioeconomic gaps in care and outcomes
Quality of care is defined by the Institute of Medicine (2001) as the degree to which health
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services for individuals and populations increase the likelihood of desired outcomes and are
consistent with current knowledge. Additionally, the U.S. Department of Health and Human
Services (HHS) defines quality improvement efforts as “systematic and continuous actions that
lead to measurable improvement in healthcare services and the health status of targeted patient
groups” (AHRQ, 2016).
In demonstrating quality care, patients receive correct assessment and diagnosis, are given
appropriate and effective treatment, and are monitored closely.
The Commonwealth Fund Commission on a High Performance Health System (Mongan,
2006) states the following six drivers of high performance in healthcare systems: (1) patient
information is available to patients and all providers through health record systems; (2) patient
care is coordinated among multiple providers and managed accurately; (3) all providers have
accountability to each other and to the patient and collaborate to reliably deliver high-quality
care; (4) patients have access to appropriate and culturally competent care and information; (5)
accountability is present for the care of patients; and (6) the system is working to improve the
quality of healthcare.
In an update on U.S. healthcare quality improvement efforts cited by Harvard School of
Public Health, it has been reported that “Healthcare quality in the United States is improving,
but there is still a lot that needs to be done. The National Healthcare Quality and Disparities
Report (NHQDR) gives one benchmark we can use to assess the impact of current improvement
efforts on healthcare outcomes” (Berger, 2015). The report added that the ACA mandated that
the National Strategy for Quality Improvement in Health Care established in March 2011 by the
Agency for Healthcare Research and Quality (AHRQ) to guide quality improvement efforts at
the local, state, and national levels through three key aims (below) and six priorities:
1. Improving overall quality by making healthcare more patient-centered, reliable, accessible,
and safe
2. Improving the health of the population by supporting proven interventions to address
behavioral, social, and environmental determinants of health
3. Reducing the cost of quality care for individuals, families, employers, and government
Priority 1: Making care safer by reducing harm caused in the delivery of care
Priority 2: Ensuring that each person and family are engaged in care
Priority 3: Promoting effective communication and care coordination
Priority 4: Promoting the most effective prevention and treatment practices for the leading
causes of mortality, starting with cardiovascular disease
Priority 5: Working with communities to promote wide use of best practices to enable healthy
living
Priority 6: Making quality care more affordable for individuals, families, employers, and
governments by developing new healthcare delivery models
Evidence for Practice
On the global level, quality of care is tracked based on attainment, equity of health
outcomes across populations, and fairness of financial contributions. Additional measures
include how investments in public health impact social objectives like reducing health
disparities, improving health, and providing responsive services that best assist patients
(Murray & Frenk, 2010). On the basis of these measures, the World Health Organization
(WHO) public health leaders (2010) explained that governments including the Americas on
average allocate more to health than the other regions. Americans spend a significant
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amount for health insurance but receive little in terms of quality of care. As described in
Chapter 2, comparative evidence has shown that the U.S. healthcare system is gradually
slipping behind less-industrialized countries each year, and improvements in healthcare
have been slower when compared to other industrialized or developed countries (Murray &
Frenk, 2010). Furthermore, the U.S. healthcare system has been deemed broken by many
people, with skyrocketing costs and plummeting coverage for middle-class and low-income
families (Jacobs & Skocpol, 2012).
In evaluating the extent that the goals and priorities addressed by the AHRQ have been
achieved, in 2013 (Berger, 2015), the NHQD found the following:
Half of all patient safety measures improved, with a median improvement of 3.6% per year.
There was a 17% reduction in hospital-acquired conditions (including pressure ulcers, falls,
and infections), resulting in approximately 50,000 fewer patient deaths and $12 billion in
healthcare cost savings.
A significant reduction in adverse drug reactions
Patient–provider communication improved from 2005 to 2012, with the percentage of adults
who reported poor communication with health providers decreasing.
Parents also reported a significantly lower degree of poor communication with their
children’s health providers.
Healthcare facilities saw improved discharge processes and care coordination, facilitated by
the adoption of health information technologies such as electronic medical records.
A significant increase in the percentage of patients with serious conditions who received
complete written discharge instructions. For example, the percentage of heart failure
patients who received full discharge instructions increased by 35%.
Half of effective treatment measures improved for life-threatening conditions. For instance,
from 2005 to 2012, the percentage of heart attack sufferers treated within 90 minutes of
their arrival to a hospital increased.
The overall performance of 10 other treatment measures improved, leading to better
outcomes in cancer, pneumonia, and HIV care.
Half of measures of healthy living improved. Adolescent vaccines were among notable
improvements from 2008 to 2012—including increases in the percentage of adolescents
receiving the meningococcal and tetanus-diphtheria-acellular pertussis vaccines. The
recent anti-vaccination movement seems to be reversing this trend.
Access and cost barriers to health insurance are being targeted through tax credits, more
coverage options within the Health Insurance Marketplace, and cost-sharing reductions.
According to the Kaiser Family Foundation, the average U.S. insurance premium increased
by 3% in 2014, which is the smallest increase since 1999.
However, the NHQD reported several areas where disparities and gaps were evident in
quality: (1) the development of special efforts is under way to address disparities; for
instance, only 70% of people with high blood pressure are receiving the recommended level
of care; (2) disparities in two areas—hospice care and chronic disease management—
increased; (3) healthcare affordability is not yet decreasing; and (4) across all six priorities,
disparities still exist according to income, race, and ethnicity.
To overcome this downward spiraling of quality and access to healthcare, it is essential
that the United States better evaluate performance of healthcare and compare results with
other countries (refer to Chapter 2 comparisons for data supporting this key point) (Murray
& Frenk, 2010).
INFORMATION MANAGEMENT
As highlighted earlier in this chapter, information management of the U.S. healthcare system
must be improved to advance the overall delivery of healthcare. Healthcare experts and the U.S.
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Congress overwhelmingly agree that implementing electronic information systems could greatly
improve the efficiency of the healthcare system and the health of Americans (Blumenthal,
2009). In such efforts, U.S. policymakers have adopted the health information technology (HIT),
labeled HITECH in law, a high priority through the American Recovery and Reinvestment Act
(ARRA) (Jha, DesRoches, Kralovec, & Joshi, 2010). The ARRA offers significant incentives
through Medicare and Medicaid funding to physicians and hospitals if they adopt effective HIT
and electronic health records (EHRs). Through ARRA, $17 billion in financial aid was used as
incentive for doctors and hospitals to utilize EHRs. Physicians who adopt and use EHRs
meaningfully can be reimbursed for their services up to $44,000 over 5 years. Similarly,
hospitals that effectively utilize EHRs earn an incentive of $2 million through a one-time bonus.
Furthermore, HITECH provides $2 billion in assistance to put systems in place and offers grants
that assist providers’ installation of EHRs. Physicians and hospitals refusing to implement EHRs
face penalties, such as losing a percentage of their Medicare fees (Blumenthal, 2009; Fonkych &
Taylor, 2005). HITECH “provisions created an essential foundation for restructuring healthcare
delivery and for achieving the key goals of improving healthcare quality; reducing costs; and
increasing access through better methods of storing, analyzing, and sharing health information”
(Buntin, Jain, & Blumenthal, 2010, p. 1).
The Office of the National Coordinator for Information Technology (Charles, Gabriel, &
Searcy, 2015, OCN Data Brief) reported that in 2014, three out of four (76%) of hospitals had
adopted at least a basic EHR system which represents an increase of 27% from 2013 and an
eightfold increase since 2008 (Charles, Gabriel, & Searcy, 2015, OCN Data Brief). Nearly all
reported hospitals (97%) possessed a certified EHR technology in 2014, increasing by 35%
since 2011. Fewer hospitals are using basic EHRs without clinical notes, while the systems with
more advanced functionality have increased significantly. Additionally, hospital adoption of
comprehensive EHR systems has increased 11-fold since 2009, rising to a third (34.4%) of
hospitals in 2014 (Charles et al., 2015, OCN Data Brief). Barriers to adopting systems include,
but are not limited to, high costs, technical challenges in implementing and maintaining the
system, and concerns of privacy (Blumenthal, 2009; Fonkych & Taylor, 2005). Providers who
have not implemented an EHR system have difficulty in coordinating care, evaluating quality of
care, and avoiding medical errors.
EQUITY IN HEALTHCARE ACCESS AND QUALITY
Equity is defined by the Institute of Medicine (2001) as healthcare that does not vary in quality
because of gender, race, ethnicity, geographic location, or socioeconomic status. The U.S.
Department of Research and Quality (USDHHS, AHRQ, 2007) indicates that significant
healthcare disparities exist and the progress in eliminating health disparities is limited.
Eliminating health disparities has became a priority of the Barack Obama administration as the
U.S. population became increasingly diverse (Mason et al., 2012). Furthermore, insurance rates
are rising more rapidly than wages, and middle- and low-income families and employers are
having great difficulty affording insurance (Institute of Medicine, 2003).
Schoen, Davis, How, and Schoenbaum (2006) developed a scoring system of equity in the
U.S. healthcare system and concluded that there were major inequities in health, quality, access,
and efficiency. More researchers have reported that individuals living in low-income
communities are associated with significant disparities. For example, researchers found that
whites, blacks, and Hispanics with cancer who lived in high-poverty geographic areas,
experienced a systematically lower 5-year survival rate. In addition to disparities due to poverty,
there were disparities found in terms of race and ethnicity as well. In terms of getting effective
and appropriate care, white patients were more likely to receive timely, patient-centered care
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than African Americans and Hispanics. Additionally, African Americans and Hispanics had
higher mortality rates than were whites. Researchers went further to explain, “black, Hispanic,
low-income and uninsured patients are less likely to have primary care providers to coordinate
care, are more likely to experience test results/records delays and duplication, are more likely to
go to the emergency departments when other care was not available, and more likely to be
admitted to the hospital for potentially preventable conditions, than white, higher-income, and
insured patients” (Schoen et al., 2006, p. 472). In summary, because there is an abundance of
evidence indicating increased disparities in healthcare delivery when assessed by income,
insurance, and race, it is imperative that appropriate efforts continue in reducing health
disparities in the United States.
Because of such vast disparities in healthcare access and quality, President Obama made
healthcare a priority issue. In March of 2010, President Obama signed the Patient Protection and
Affordable Care Act (ACA) into law (Jacobs & Skocpol, 2010). As of late 2018, different
measures of the law had been diminished and were being challenged by the Trump
administration and a majority-Republican Congress.
COMMUNITY-BASED SERVICES ASSOCIATED WITH
HEALTHCARE REFORM
Efforts put forth through the ACA, such as the Community Transformation Grant (CTG)
program, provide funds to organizations, health centers, and initiatives with goals of creating
healthy communities and assisting vulnerable populations (Hennrikus, 2013). The CTG grants
fund programs that promote tobacco-free living, physical activity, healthy eating, services to
prevent and control high blood pressure and high cholesterol, social and emotional wellness, and
healthy and safe environments. It is estimated the CTG program will affect 40% of the U.S.
population with health promotion and disease prevention efforts with vast opportunities for
nurses to get involved.
Achieving health equity is and must continue to be a priority for this country to move
forward. It is critical that nurses stay involved and offer their expertise. Nurses’ involvement
with research, advocacy, community outreach, and policy efforts will help underserved
populations receive the care that they need and deserve (Mason et al., 2012). Community-based
prevention commonly refers to a range of prevention strategies including upstream interventions
that address underlying social and economic factors; public policies, including regulations and
legislation, that support healthy behaviors; and interventions directed at high-need, low-income
neighborhoods (Goodman, 2009).
There is also a critical need to increase the prevention resources available in impoverished
communities to achieve the breadth and depth of influence necessary to shift the distribution of
risk factors, exposures, and chronic diseases to healthier patterns. Finally, there needs to be
better alignment with and support for community programs that have been traditionally viewed
as outside of the public health sector but which nonetheless exert a fundamental influence on
population health (e.g., early childhood development, income support for families living in
poverty, and access to quality schools and educational opportunities). Such interventions create
an infrastructure in public health departments to support and implement community-based
prevention programs aimed at improving population health (Goodman, 2009).
The website, Healthcare.gov referred to home and community-based services (HCBS) as the
services and support provided by most state Medicaid programs in a home or community that
give help with such daily tasks as bathing or dressing where such care is covered when provided
by care workers or by a family member if permitted. Calman, Golub, and Shuman (2012) have
highlighted four vital models that are congruent with the ACA Triple Aim that includes: (1)
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better healthcare for individuals; (2) better health outcomes in the community; and (3) lower
healthcare costs. Healthcare reform was designed to address both the quality and accessibility of
healthcare while reducing its cost. This article by Calman and colleagues (2012) provides an
overview of models that are considered as foundations for healthcare reform and are supported
by the ACA and its core principles of primary care: comprehensive, coordinated and continuous
primary care; preventive care; and the sophisticated implementation of HIT designed to promote
communication between healthcare providers, enhance coordination of care, minimize
duplication of services, and permit reporting on quality. These models included:
1. Federally qualified health centers: also, known as community health centers, have been a key
component of the primary care safety net in the United States since 1965 and became a focus
of the Obama administration’s health-reform plan.
2. Patient-centered medical home (PCMH): describes the model of care in the most advanced
primary care centers, focus is on the provision of primary and preventive care by qualied
primary care providers, supported by an interdisciplinary team of health professionals. Care
must be accessible, high-quality, safe, and efcient, as well as continuous, comprehensive,
and coordinated with other healthcare providers as needed. The basic requirements to achieve
PCMH recognition include measures in the following areas: (1) access and communication,
(2) patient tracking and registry functions, (3) care management, (4) patient self-management
and support, (5) electronic prescribing, (6) test tracking, (7) referral tracking, (8) performance
reporting and improvement, and (9) advanced electronic communication.
3. Accountable care organizations (ACOs): an initiative supported by the ACA. ACOs are based
in part on the models developed between 2005 and 2010 by the CMS demonstration project,
the Physician Group Practice Demonstration. Like PCMHs and health homes, ACOs provide
a structure for reforms in the way that healthcare is nanced in order to incentivize
collaborating organizations to provide better care at lower costs, with the goal of generating
both overall savings and greater earnings for the provider organization.
4. Meaningful use: The goals of the meaningful use (MU) initiative are to (1) improve the
quality, safety, and efciency of care and to reduce health disparities; (2) engage patients and
their families; (3) improve care coordination; (4) improve population and public health; and
(5) ensure adequate privacy and security protection for personal health information.
Evidence for Practice
A program designed and implemented in collaboration with a Certified Home Healthcare
Agency and regional hospital addresses the serious issue of increasing hospital
readmission rates by focusing on transitional care needs of patients and families. The
researchers who designed this experiment to see how re-hospitalization could be affected
compared the odds of re-hospitalization among patients who received the transitional care
services (n = 223) and a similar group of patients who received usual home care services (n
= 224). Findings indicate that patients who received the transitional care services were
significantly less likely to be readmitted to the hospital than the patients in the control group
who received usual care (Russell, Rosati, Sobolewski, Marren, & Rosenfeld, 2011).
ETHICAL CONSIDERATION
Nursing has an ethical obligation to society to improve quality of life by maximizing the
potential of the individual patient according to his or her needs (Des Jardin, 2001). In that
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capacity, nurses have a duty to support professional nursing goals that relate to healthcare for
consumers; yet, each distinct group of healthcare professionals has its own priorities that might
not be congruent with the institutional values (Indiana State Nurse Association, 2013). This
section will explain how the Nursing Code of Ethics strengthens nursing’s position as an
advocate and will describe how professional associations advocate for the nursing profession,
nurses, and healthcare for the citizens of the United States.
Practice Point
Des Jardin (2006) states clearly that differences in stakeholder interests puts parties such as
nurses, patients, and institutions into a political-ethical clash at times. Guidelines are
available to help nurses know how they can be involved in the political process.
By using these guidelines and an ethical framework for political decision-making, nurses
can evaluate issues while assessing problems, planning for action, and evaluate the
effectiveness and benefits of those strategies effectively.
Individuals have their own moral lens through which they view the world, and where they
can judge what is right and wrong. No matter what a nurse’s personal moral views may be,
employers establish policies regarding appropriate behavior in the workplace and these
expectations are known as organizational ethics, which are defined as expectations about the
“right” behaviors for healthcare professionals in the work setting (Indiana State Nurse
Association, 2013). An example of such ethics are the standards provided in the Code of Ethics
for Nurses (ANA, 2010a). Advocacy by the profession of nursing developed within the United
States as visionaries, leaders, and nurses from across the nation formulated the first (and
subsequent) revisions of the Code of Ethics for Nurses with Interpretive Statements, often
referred to as the Code of Ethics (ANA, 2001). The concluding statement of the Code of Ethics
preface states: “…the Code of Ethics is the ethical standard for all members of the profession.
No one outside of nursing can alter it” (Mathews, 2012). The ANA Code of Ethics with
Interpretive Statements has been updated in later versions (ANA, 2015a, 2015b) and have
addressed nine main nursing ethical principles or known as provisions:
1. Provision 1: The nurse practices with compassion and respect for the inherent dignity, worth,
and unique attributes of every person.
2. Provision 2: The nurse’s primary commitment is to the patient, whether an individual, family,
group, community, or population.
3. Provision 3: The nurse promotes, advocates for, and protects the rights, health, and safety of
the patient.
4. Provision 4: The nurse has authority, accountability, and responsibility for nursing practice;
makes decisions; and takes action consistent with the obligation to promote health and to
provide optimal care.
5. Provision 5: The nurse owes the same duties to self as to others, including the responsibility to
promote health and safety, preserve wholeness of character and integrity, maintain
competence, and continue personal and professional growth.
6. Provision 6: The nurse, through individual and collective effort, establishes, maintains, and
improves the ethical environment of the work setting and conditions of employment that are
conducive to safe, quality healthcare.
7. Provision 7: The nurse, in all roles and settings, advances the profession through research and
scholarly inquiry, professional standards development, and the generation of both nursing and
health policy.
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8. Provision 8: The nurse collaborates with other health professionals and the public to protect
human rights, promote health diplomacy, and reduce health disparities.
9. Provision 9: The profession of nursing, collectively through its professional organizations,
must articulate nursing values, maintain integrity of the profession, and integrate principles of
social justice into nursing and health policy.
It’s noteworthy to address the role of the ANA in the following:
1. The Code of Ethics for Nurses—asserts the values and commitment to excellence for patients,
society, and nurses individually and collectively as a profession (ANA, 2015a, 2015b);
2. The Social Policy Statement—details the authority based on the social responsibility of the
profession to society. It serves as nursing’s contract between the profession of nursing and
society to uphold the highest values and standards in delivering its service of nursing care
(ANA, 2010a); and
3. The Scope and Standards of Practice in Nursing—delineates the scope of nursing practice
and then defines the standards of professional nursing practice and accompanying
competencies (ANA, 2010b).
Healthcare workers encounter complicated ethical issues in their practice, however, and
nursing particularly is involved in infinite judgments regarding the morality and immorality of
their actions or interventions toward their patient. This has resulted mainly from the radical
progress in biomedical sciences and the technological piece of the healthcare, which affects the
lives of billions of people throughout the world. Consequently, nurses are required to hold the
responsibility of both safeguarding the values of their society and developing their own moral
framework for dealing with the moral dilemmas. The role of the nurse as a member of the
interprofessional care team is to identify potentially ethics-related situations, work with others to
address these issues, and provide holistic support for patients, families, and colleagues. Thus, in
order to guide the process of moral decision-making, for example, the Ohio Nurses Association
(2013) developed a process to guide RNs in the process of working through ethical ambiguity or
dilemmas, which includes the following:
1. Identifying the existence of the ethical dilemma (conflict in values)
2. Gathering and analyzing relevant information—including identification of stakeholders,
interdisciplinary team members, and other sources of relevant information
3. Clarifying personal values and moral position, including the moral perspectives of other
“players” in the scenario
4. Determining options, based on careful consideration of alternatives’ benefits and risks
5. Making responsible decisions about actions or recommendations, in collaboration with other
interested parties
6. Evaluating the impact of the action and outcomes
Evidence for Practice
Technological and societal changes have created both ethical issues and new requirements
for nursing education in the context of ethics (Ramos et al., 2013). However, a lack of
ethical confidence is reported among newly graduated nurses (Park, 2009). In a qualitative
case study conducted by Ramos and colleagues (2013), the participants, who were nursing
teachers, expressed that reflection on nurses’ ethics education should take place and that
this reflection should not be limited to discussing content or instructional methods but
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should be extended to engage the student in critical analysis of moral scenarios. Students
should actively pursue the building of their professional values (Ramos et al., 2013).
As concluded by Park (2009), nursing students have not been prepared to encounter
ethical dilemmas in their nursing practice. The author also proposes the need for pragmatic
teaching methods as a solution. In other words, planned ethics content in the nursing
curriculum is necessary to improve moral sensitivity and moral reasoning of students (Park
et al., 2012). Students must also be prepared to adopt different ways of thinking, to be open
to the ethical issues by utilizing their absolute professional values and their professional
code of ethics, and to apply them by using the lenses of their clients in order to achieve
moral sensitivity.
HEALTH ADVOCACY AND HEALTHCARE REFORM
The concept of advocacy is both a morally and professionally important duty in nursing practice.
This implies that nurses are required to help the patient make decisions according to their
personal beliefs and values and to protect the patient’s right through communicating with other
healthcare providers (Leavitt, 2009; Park, 2009). Advocacy is a requirement for nurses.
Advocacy is collaborating with colleagues or other healthcare professionals and engaging in
conversations with decision-makers (Carnegie & Kiger, 2009). Because nurses have the position
of communicating, interacting with, and caring for individuals and communities, it is extremely
important that they listen to the experiences of individuals, and offer them the opportunity to
address, and contribute to policies that affect their health (Carnegie & Kiger, 2009).
Healthcare systems are dynamic. Overall, they have been changing worldwide for decades,
particularly in the United States. O’Grady (2009) made it clear that as communities are engaging
in complex and dynamic health reforms, nurses are required to develop the language for a
healthcare delivery system that is patient-centered, longitudinal and sustainable, relationship-
based, and evidence-based. RNs are increasingly being recognized as leaders in transforming the
healthcare system to meet the demand for illness prevention, wellness, and primary care
services, with special attention to improving quality and managing costs (Dean, 2011).
Prior to the signing of the ACA in 2010, efforts were made for universal health insurance
coverage dating back to the 1910s during the presidential campaign of Theodore Roosevelt.
Even though such coverage has been established in all other industrial or industrializing nations,
healthcare reformers have faced daunting political opposition in attempts at universal coverage
in the United States (Jacobs & Skocpol, 2010). Although halted on universal coverage in the
1960s, reformers were able to establish Medicare to help cover costs for the elderly and
Medicaid to help cover costs for low-income individuals. After incredible efforts that lasted over
a decade, the ACA of 2010 became a monumental milestone but currently may be in jeopardy of
being repealed under a new presidential administration and worldview as mentioned previously.
OVERVIEW OF THE ACA PRIOR TO THE END OF
OBAMA PRESIDENCY
Generally speaking, health insurance is a contract that requires the health insurer to pay some or
all of one’s healthcare costs in exchange for a premium (Centers for Medicare and Medicaid
Services [CMS], 2017; Healthcare.gov, 2017). The comprehensive healthcare reform law
enacted in March 2010 (sometimes known as ACA, PPACA, or Obamacare), has two parts: (1)
the Patient Protection and Affordable Care Act and (2) the Health Care and Education
Reconciliation Act. The ACA is designed to address these concerns by improving the quality
and accessibility of healthcare while reducing its cost. First articulated by the Institute for
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Healthcare Improvement as the Triple Aim and later by the CMS as the Three-Part Aim, the
goal of the ACA is to achieve better healthcare for individuals, better health outcomes in the
community, and lower healthcare costs.
In May 2017, among the 48 states reporting both total Medicaid and CHIP enrollment and
child enrollment data for the current period, total enrollment was comprised of 50.3% enrolled
in the Medicaid child and CHIP, while 49.7% of adults were enrolled in Medicaid. Medicaid
provides health coverage to millions of Americans, including eligible low-income adults,
children, pregnant women, elderly adults and people with disabilities. Medicaid is administered
by states according to federal requirements. The program is funded jointly by states and the
federal government. Sixty-nine million people are covered. On the other hand, Medicare is a
health insurance program for people age 65 or older, people under age 65 with certain
disabilities, and people of all ages with end-stage renal disease (permanent kidney failure
requiring dialysis or a kidney transplant). Medicare has three parts:
1. Part A hospital insurance—Most people don’t pay a premium for Part A because they or a
spouse already paid for it through their payroll taxes while working. Medicare Part A
(hospital insurance) helps cover inpatient care in hospitals, including critical access hospitals,
and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care
and some home healthcare. Beneficiaries must meet certain conditions to get these benefits.
2. Part B medical insurance—Most people pay a monthly premium for Part B. Medicare Part B
(medical insurance) helps cover doctors’ services and outpatient care and some other medical
services that Part A doesn’t cover (e.g., services of physical and occupational therapists)
while Part B helps pay for these covered services and supplies when they are medically
necessary.
3. Prescription drug coverage—Most people will pay a monthly premium for this coverage
while everyone with Medicare can get this coverage that may help lower prescription drug
costs and help protect against higher costs in the future. Medicare prescription drug coverage
is insurance that is provided by private companies. Beneficiaries choose the drug plan and pay
a monthly premium.
Through the Patient Protection and ACA, the Obama administration’s goals in improving the
overall healthcare system and the quality of care included expanding health insurance coverage,
shifting the focus of the healthcare delivery system from treatment to prevention, and reducing
the costs and improving the efficiency of healthcare (Hellerstedt, 2013). The ACA was put in
place to improve the quality, access, and affordability of healthcare. “The American College of
Physicians hopes that the legislation will advance key priorities on coverage, workforce, and
payment and delivery system reform” (Doherty, 2010, p. 679).
Additionally, the ACA expanded healthcare access to children (Oberg, 2013). Through the
ACA, youth are allowed to remain on their parents’ healthcare plan to the age of 26, insurers are
no longer allowed to exclude children from coverage because of preexisting conditions, and
access had been expanded through state-based health insurance exchanges for uninsured families
(Oberg, 2013). Medicaid and Children’s Health Insurance Program (CHIP) provisions have been
administered through the ACA with goals of enrolling uninsured children. Such reforms will
work to insure vulnerable childhood populations like children aging out of the foster care system
(Oberg, 2013). Furthermore, reforms in healthcare for children will help reduce the cost of
healthcare for families so that more children will be covered.
The U.S. Department of Health and Human Services, AHRQ (2012) reported that although
indicators have shown that quality of healthcare for the general population is improving, quality
of care is still not up to par for minorities and low-income communities. Furthermore, although
the ACA has made strides for healthcare for all, an estimated 49 million Americans are still
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without health insurance (Hellerstedt, 2013).
Evidence for Practice
There has been considerable debate on repealing, replacing, or updating the ACA by
President Donald Trump and his administration as well as members of the Congress. The
proposed revised version of the ACA was reviewed by the Congressional Budget Office
(CBO) and concluded that the new proposed version of the ACA would reduce the deficit by
$337 billion in the next 10 years due to removal of premium tax credits and cuts in
Medicaid. However, if the revised bill is enacted, it is estimated that 24 million people will
lose health coverage by 2026. On March 24, 2017, the Speaker of the House of
Representatives withdrew the ACA repeal-and-replace bill and stated that the ACA will be
left intact for the time being. On March 6, 2017, House Republicans announced a bill to
partially repeal and replace the ACA. There remains disagreement among members of
Congress as to the details of the bill.
Next Steps
1. Elimination of additional Medicare taxes
There has been considerable discussion about repealing the additional Medicare tax,
which imposes additional tax to individuals with high incomes. The repeal of the current
bill will have considerable payroll implications. Effective January 2018, the bill would
repeal the additional Medicare tax that imposes an additional tax on income of $200,000
or more for individuals, $250,000 or more for joint returns, and $125,000 or more for
married taxpayers filing separate returns. This would have payroll implications as
employers have been required to withhold an additional 0.9% of Medicare subject wages
over $200,000 to support the additional tax.
2. Premium tax credits and subsidies repealed
The proposed bill would eliminate premium tax credits for individuals who obtain health
insurance through a federal or state health insurance marketplace (exchange) as of
January 1, 2020. It would also repeal cost-sharing reductions (and payments to issuers
for such reductions) for plan years beginning after December 31, 2019.
More changes have included the following areas as well:
3. Health insurance tax credit
4. Continuous coverage
5. Elimination of other ACA taxes
For more information on the ACA updates, please visit
https://www.paychex.com/articles/health-reform/aca-update-march-2017.
Evidence for Practice
In measuring the equity of healthcare and in working on reform, it is also important to review
the effects of social determinants of health, which include early childhood education,
employment opportunities, treatment of women, the effects of poverty, and individual
empowerment on humans’ health status and life expectancy (Wilensky & Satcher, 2009).
The WHO’s Commission on the Social Determinants of Health was created in 2005 to focus
on the social determinants as a means of reducing health disparities (Wilensky & Satcher,
2009). This group explains that healthcare reform must focus on nutrition, education,
reducing substance abuse, and access to care. In the United States, the following four
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components have been, or need to be, addressed in the following ways:
1. Nutrition: Over the years, the federal government has put in place systems that work to
improve nutrition for low-income communities such as the federal food stamp program
and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC
and SNAP, respectively).
2. Education: Programs like the No Child Left Behind Act and the Action for Healthy Kids
Program work to help low-income students by providing additional academic support and
proper nutrition and physical activity.
3. Reducing substance use: Because many children are born with medical challenges due
to their mother’s substance abuse, more aggressive intervention must be put in place to
help pregnant women deal with substance abuse. Programs for mothers should be free
to those who cannot afford them.
4. Access to care: Medicaid and the State Children’s Health Insurance Program (SCHIP)
were put in place to ensure low-income children were provided with appropriate care.
Although such systems were put in place, many children who are eligible are not
enrolled. More aggressive outreach campaigns must be established to educate families
on the care they are eligible to receive.
HEALTH SERVICES RESEARCH
Although the ACA has been passed and efforts to improve healthcare are increasing, the quality
of healthcare and services has not improved significantly. Researchers, healthcare professionals,
and other advocacy groups continue to push for an improved healthcare system in the United
States with appropriate health services for all, and to do this, the healthcare system needs an
accelerated transformation, which brings about quality care, proper information management,
insurance for all, and equity to access (Dougherty & Conway, 2008). Dougherty and Conway
(2008) proposed a model to transform the U.S. healthcare system, explaining how to deliver
high-quality healthcare. Their plan outlines the activities, participants, investments, and
fundamental shifts required to create and sustain a high-quality, patient-focused, healthcare
system. Porter (2009) lists the following steps that must take place to improve the U.S.
healthcare system:
1. Measurement and dissemination of health outcomes must be shared.
2. The delivery of prevention, wellness, screening, and routine health maintenance services must
be fundamentally restructured.
3. Care delivery must be reorganized around medical conditions.
4. A reimbursement program for healthcare professionals as incentives to achieve better
outcomes for patients should be introduced.
5. Providers must compete for patients based on the quality of the care provided.
6. All providers must establish electronic medical records.
7. Patients’ involvement in their health must improve and incentives for patient involvement
should be considered.
Porter explains that all items must happen simultaneously to build an effective healthcare
system. Conway and Clancy (2009), in speaking of improving the healthcare system on the front
line, emphasize the importance of improving measurements, adopting information technology,
accelerating the production and use of requisite research, improving collaborations and
networks, and increasing clinical training. Taking such action, Conway and Clancy claim, may
significantly improve clinician engagement and patient care.
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CONCLUSION
At this moment in history, healthcare is at the forefront of the public’s attention. As an item on
the President’s platform, as the most popular topic on the news and radio, and as an issue greatly
impacting individuals and employers, healthcare is an important topic, which is receiving
attention from everyone. During this significant moment in the history of healthcare, nurses play
an important role in providing quality healthcare, tracking patient progress, and being active
members in healthcare reform. It is important that nurses are knowledgeable about health policy,
politics, and healthcare reform because it will improve their understanding about where they
work, the patients they care for, and government efforts that will impact both.
KEY CONCEPTS
Because policy development and formulation is concerned with providing population-based interventions
which will greatly impact the nation’s health, the political process has a close relationship with health
policies.
Making health policy takes great time, effort, and commitment. This process is presented as a dynamic and
cyclic series of six events, namely, agenda-setting, policy formulation, policy adoption, policy
implementation, policy assessment, and finally policy modification.
When a policy is evaluated for its effectiveness, there is an interest in keeping the cost of a specific health
program within reason, and it is critical to consider the overall costs and benefits of an existing program
when a more efficient and effective service is identified and adopted.
The U.S. healthcare system is a unique system of both independent and collaborative power and action by
both federal and state governments.
Healthcare issues of racial and ethnic minorities, low-income individuals, and the uninsured overlap.
Community health agencies play an important role in providing access to healthcare for those who are
underserved, whether from uninsured or low-income communities.
The United States has an increasing healthcare professional immigration from other countries.
There is an increasing need for a diverse workforce of healthcare providers who can provide culturally
competent care for the growing minority population. The less diverse the workforce, the less representative
and influential will be the impact of the healthcare providers on healthcare policies.
Nursing has a rich history as a unique profession, with its own values, ethics, respect, integrity and
responsibility. Nurses’ contributions to the policies are unlimited; there is a need for greater coordination of
action to ensure that nursing is actively supported and involved in influencing and shaping health and
healthcare policy.
It is extremely difficult to evaluate the complexities of the quality of care for the U.S. population.
U.S. policymakers have made the adoption of HIT a priority so that health records can be kept
electronically, assisting patients, providers, and insurers.
Because of the vast disparities in healthcare access and quality, President Obama made healthcare his top
priority, promising affordable and adequate healthcare insurance for all Americans.
Healthcare is closely linked with ethical issues and decisions and has implications for patients, providers,
and healthcare leaders.
Although most politicians agree a reform must take place, many cannot agree on what the change should
look like. Consequently, healthcare reform in the United States has been a long political battle for quite
some time.
Research continues to be an influencing power by documenting the need for an accelerated reform in order
to achieve quality care, proper information management, and insurance for all, and equity to access.
CRITICAL THINKING QUESTIONS
123
1. Consider that you are a nurse working with a patient who is from a different cultural and ethnic
background from your own. Explain how you could translate the concept of cultural competency into
practice. Do not forget ethical considerations.
2. After reading this chapter, you have learned about the six stages of the process of policy. Give at least
one example showing how nurses can be engaged in each stage of the process.
3. You have read a lot about President Obama’s Patient Protection and Affordable Care Act:
a. What are the major milestones of this act that represent the healthcare reform?
b. Explain how this act helps in delivering better healthcare services.
c. Explain why this act has been considered a long political battle for a period of time.
4. You have learned about health information technology (HIT) in this chapter:
a. Give a few examples for the application of HIT in the clinical practice.
b. Explain the main barriers of using HIT in the healthcare system.
c. How has the American Recovery and Reinvestment Act (ARRA) reinforced the use of HIT in different
healthcare settings?
5. How can research help in improving the U.S. healthcare system?
6. After carefully reading about Rice’s exploratory study regarding the U.S. healthcare system, summarize in
a short paragraph the major problems in this system.
7. Please visit this website https://www.healthypeople.gov/2020/topics-objectives and answer the following
questions:
a. What is the role that the Healthy People 2020 initiative plays in healthcare reforms?
b. What are the objectives that include professional nursing activities?
c. How do you relate this to healthcare reforms and quality improvement?
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WEB RESOURCES
Please visit thePoint for up-to-date web resources on this topic.
Please watch the following YouTube video titled as: Governor Patrick Signs Assault Bill.
https://www.youtube.com/watch?v=bdsgDoS8amY. Massnurses Published on Jul 8, 2010.
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http://www.who.int/topics/health_policy/en/
http://thepoint.lww.com/vitalsource/ebook/9781975111694
https://www.youtube.com/watch?v=bdsgDoS8amY
Chapter 4
Global Health: A
Community Perspective
Joyce Pulcini and Karen Dawn
For additional ancillary materials related to this chapter. please visit thePoint
It is health that is real wealth and not pieces of gold and silver.
Mahatma Gandhi
Of all the forms of inequality, injustice in healthcare is the most shocking and inhumane.
Martin Luther King Jr.
CHAPTER HIGHLIGHTS
Definitions of global health and global burden of disease
Indicators of health
Health and human rights
Factors that affect health globally
Framework for improving world health
Sustainable Development Goals
OBJECTIVES
Identify critical determinants of global health and the intersection between health and the environment.
Describe the approaches to achieving maximum health outcomes in poor countries and affluent countries.
Define the concept of burden of disease, how it is measured, and the ultimate effect on a population’s
health.
Identify and explain the effects of political, economic, and sociodemographic factors on health.
Describe the purpose of the Sustainable Development Goals and their future impact on improving global
health.
Describe key indicators of health that can be measured or used as benchmarks to examine the health
outcomes of a population.
KEY TERMS
Communicable disease: An illness caused by an infectious agent or its toxins that occurs
through the direct or indirect transmission of the infectious agent or its products from an
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infected individual or by an animal, vector, or the inanimate environment to a susceptible
animal or human host (Centers for Disease Control and Prevention, 2010).
Demographic and epidemiologic transitions: Progressive improvement in health from a global
perspective.
Determinants of health: Factors that affect outcomes of health status, such as physical
environment, social environment, health behaviors, and individual health, as well as broader
factors such as access to health services and overall health policies and interventions.
Global burden of disease: The importance of risks to health and their outcomes in different
demographic populations and social settings.
Global health: “An area for study, research, or practice that places a priority on improving health
and achieving equity for all people worldwide. Global health emphasizes transnational health
issues, determinants, and solutions, involves many disciplines within and beyond the health
sciences, and promotes interdisciplinary collaboration, and is a synthesis of population-based
prevention with individual-level clinic care” (Koplan et al., 2009).
Health: A state of complete physical, mental, and social well-being, not merely the absence of
disease or infirmity.
Health indicators: Descriptors of the general health of a nation that are grouped into four
categories: morbidity and mortality, risk factors, health service coverage, and health system
resources.
Noncommunicable disease: Diseases that afflict a population which are chronic in nature and
may be due to lifestyle changes, sometimes as a result of modernization of societies.
Examples include cardiovascular diseases, cancers, diabetes, obesity, and chronic respiratory
diseases.
Risk factors: Personal habits and behaviors, social, and environmental conditions, or inborn or
inherited characteristics that are known to affect a health-related condition which could be
alleviated or managed.
Public health: Ensuring that every person in the community has a standard of living adequate for
the maintenance of health. This involves the science and art of preventing disease, prolonging
life, and promoting physical health and efficiency through organized community efforts.
CASE STUDIES
References to case studies are found throughout this chapter (look for the case study icon).
Readers should keep the case studies in mind as they read the chapter.
CASE 1
Haweeyo is a 30-year-old woman living in extreme poverty just outside Mogadishu. She is pregnant
by a man who sexually assaulted her several months ago. She reported the incident to the police
but they did nothing. In her culture, pregnancy without marriage carries great stigma and shame.
She and her family have become social outcasts in their community and are having difficulty finding
work and paying for food. Haweeyo received threats of violence repeatedly by people in her
community and was taken from her home and severely beaten 2 days ago. Haweeyo has received
no prenatal care and did not seek treatment for her injuries because she feared she would be
treated poorly by the health providers. A few hours after being attacked by her neighbors she went
into early labor and her sister called the birth attendant. As her labor continued, the community
health worker (CHW) birth attendant recognized the labor was complicated and needed to get
Haweeyo to the hospital to deliver her baby. Her family did not have funds or transportation to get
her to the city hospital. Haweeyo died in her own home a few hours later.
CASE 2
Vikram is a 68-year-old father of seven children, who shares a small home with his wife, three of
his adult children and their families, his mother, and older brother in India. He is recently recovering
from a third episode of diarrheal illness in the past 3 months. He experienced weight loss of almost
20 lb in 4 weeks, complained of feeling fatigued most of the time, shortness of breath, persistent
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cough, night sweats, and low-grade fever. Two years ago, he was diagnosed with tuberculosis. He
took medications for a short time, but due to lack of finances and availability of the medications he
stopped. Vikram visited the small health clinic where he was seen by the only medical practitioner
in the village. With no x-ray facilities available, a TB skin test (TST) was performed and he was sent
home. Three days later he returned to the clinic. The skin test was positive and TB was confirmed
by a sputum smear test. While at the health clinic he was also tested for HIV, which was negative.
He was started again on TB medications, but developed multidrug-resistant tuberculosis (MDR-TB)
and subsequently his condition deteriorated.
e live in a global environment. Recent examples of how health in one region of the
world affects other regions include both the Ebola epidemic and Zika infections.
News of both of these infections have spread rapidly through world news and are
exacerbated by widespread global migration.
What does it mean to be healthy in a global context? A person’s health status is highly
dependent on his or her living environment, social norms, gender, and age, specifically in low-
resourced settings. Access to and utilization of healthcare is highly dependent on where you live
in the world and the community definition of health. In addition, the health of individuals
depends on the social and economic conditions in which they live. Many factors affect the health
and well-being of individuals. This chapter explores an array of factors that affect health and the
global environment.
DEFINITIONS OF HEALTH
The World Health Organization (WHO) in 1947 defined health as “a state of complete physical,
mental, and social well-being and not merely the absence of disease or infirmity” (WHO, 1947,
p. 1). The WHO definition of health encompasses the highest level of health, involving self-
actualization or reaching one’s true potential. The more specific concepts of public health or
global health may be important when the concept of an individual’s health is considered. All are
interrelated in a global context.
Winslow (1920), often called the father of public health, defined public health as “the
science and art of preventing disease, prolonging life, and promoting physical health and
efficiency through organized community efforts for the sanitation of the environment, the
control of community infections, the education of the individual in principles of personal
hygiene, the organization of medical and nursing service for the early diagnosis and preventive
treatment of disease, and the development of the social machinery which will ensure to every
individual in the community a standard of living adequate for the maintenance of health” (p. 23).
The identification of nursing in 1923 as a key participant in the social construct of health
recognized the contribution that nurses could make to promote health and well-being of all
humankind.
Dunn (1959) placed health on a continuum, ranging from premature death to wellness to
high-level wellness, which can be equated to self-actualization. In this model, the environment
(i.e., factors outside of the person) plays a major role in health (Fig. 4.1)
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FIGURE 4.1 The health grid, its axes and quadrants. (From Dunn, H. [1959]. High-level wellness
for man and society. American Journal of Public Health, 49[6], 788.)
In her classic work, Smith (1981) identified four models of health:
1. Clinical model: elimination of disease or symptoms. Some people feel that they are well when
they have no symptoms or diagnosed diseases and would not classify themselves as sick
otherwise.
2. Role-performance model: health that involves a match between people and social roles. For
example, some people, even if they have symptoms of disease, would classify themselves as
unhealthy only if they could not fulfill their roles in life, such as parent or worker.
3. Adaptive model: health that involves adaptation to the environment. For example, some
people consider health to be determined by their ability to adapt in the face of adversity or
disease.
4. Eudaimonistic model: health that is the actualization or realization of human potential. In this
model, for example, people would consider themselves to be healthy if they are functioning
not only physically but also emotionally and socially. The WHO (1947) definition of health
actually strives for this level of health.
Global health was defined by the Institute of Medicine (IOM, 1997) as “health problems,
issues, and concerns that transcend national boundaries and may best be addressed by
cooperative actions and solutions” (p. 2). Each of Smith’s four models can be viewed within the
definition of the IOM and includes people’s definition of health based on their culture, role in
life, and environmental resources. A person’s definition of health determines how and when he
or she seeks assistance from the healthcare system and may ultimately affect the outcome of
long-term health.
The evolution of the definition of health clearly shows an increased appreciation of the
biophysical, sociodemographic, and environmental influences on individual, family, and
community health. Health is a complex concept that can be conceptualized in many ways, from
a broad to narrow disease-specific view. Further, complexity comes into play when the social,
political, and economic conditions are factored into the equation.
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In each of these case studies, internal factors—the way a person views health—and
external factors outside of the individual such as the environment, affect whether a person
is viewed as healthy, unhealthy, or at risk. The way women view health, in particular
pregnancy, can affect birth outcomes. Environment is key and ultimately changes the
context in which health or illness conditions are experienced or played out. When
dimensions of poverty, education, culture, lifestyle, norms, beliefs, and political and
economic instability are added to the equation, it is possible to further understand the
complexity of the concept of health and its determinants.
GLOBAL HEALTH CONCEPTS
Determinants of Health
Global health is a dynamic concept with many components. In examining this concept, several
factors need to be considered. Skolnik (2016) identifies the key determinants of health, which
encompass the following domains: (1) physical environment; (2) social environment; (3) health
behaviors and coping skills; (4) access to health services; (5) healthy child development; and (6)
employment and working conditions, in the context of the broader factors of access to health
services, as well as health policies and interventions (p. 21).
Demographic and Epidemiologic Transitions
When it comes to global health, there is no “them”…only “us.” Global Health Council
Demographic and epidemiologic transitions refer to the improvement in global health
indicators (WHO, 2013a). Changes in these demographic indicators signify improvement in
health over time. In addition, specific indicators provide a unique picture of community health:
life expectancy and morbidity and mortality, selected infectious diseases, health service
coverage, health systems expenditure and inequities, and demographic and socioeconomic
statistics (WHO, 2014a). They include many factors, such as age, gender, socioeconomic status,
and disease prevalence, and taken together, they can portray the health of a community and
identify areas in need of intervention.
In addition, these indicators are tracked by the demographic and health survey (DHS)
program, which is conducted at the household level to evaluate the health of a nation (United
States Agency for International Development, 2014). Every 3 to 4 years, a DHS is conducted to
describe the health of a country and define specific demographics that can be compared to each
other. These transitions are used as a measure of health improvement of a nation.
Demographic transitions may progress from low to high levels:
1. High fertility and high mortality, resulting in slow population growth
2. Improvement in hygiene and nutrition, leading to less infectious disease
3. Mortality declines, and later fertility declines
4. Elderly population increases
Epidemiologic transitions include the following:
1. High and fluctuating mortality, due to poor health, epidemics, and famine
2. Progressive declines in mortality, as epidemics become less frequent
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3. Further decline in mortality, increasing life expectancy, and predominance of
noncommunicable diseases (NCDs)
As a country becomes more developed, levels of demographic or epidemiologic transitions
shift upward. For example, as mortality rates decrease, more attention can be paid to increase the
quality of life of all citizens, including the elderly. As the number of children involved in
agrarian functions decreases and as the need for formal education increases, fertility rates tend to
decrease. As more members of a population are educated, indicators of health, such as higher
life expectancy and lower mortality rates, improve.
Global Burden of Disease
Every observer of human misery among the poor reports that disease plays the leading
role. Fisher (1909, p. 124)
Global burden of disease (GBD) is the risks to health and health outcomes in different
demographic populations and social settings related to a set of diseases and injuries. There are
18 components of GBD that are interrelated and create the changing picture of burden related to
specific communities (Institute for Health Metrics and Evaluation, 2014). The largest study of
these indicators was published in 2012, revealing that women and men are living longer but
spending more time living with illness and injury (Horton, 2013). The collection of specific data
related to risk factors, health indicators, and health outcomes of 291 diseases and injuries in 20
regions of the world determines the GBD (Murray et al., 2012). Indicators include lower
respiratory tract infection, diarrheal disease, malaria, and protein malnutrition as well as road
injuries and pollution (Institute of Health Metrics and Evaluation, 2014). Changes in these
factors can identify areas of improvement or the need for intervention. The goal of analyzing
these data is to summarize measures of a population’s health and to identify risk factors that
affect health. The concept of disease burden first occurred in the early 1980s, when the World
Bank signaled the need for a better understanding of disease control and mortality to set
priorities for resource-limited countries. In an era of unmet needs, economic divisions, and
health inequalities, the need for rigorous data for decision-making despite limited resources was,
and still is, vital (Lopez, Mathers, Ezzati, Jamison, & Murray, 2006). Examining the effects of
health indicators and risk factors on the overall health of a community can guide healthcare
planners and providers in choosing those services and interventions that can improve health.
As health policymakers and governments better understood the impact of disease, the need
for an analysis of the circumstances grew. In 1990, the World Bank commissioned the first study
on disease burden (World Bank, 1993). In 1994, Jamison and Jardel (1994) incorporated the
concept of cost–benefit analysis related to disease burden to assist countries in decision-making
about health interventions. Murray and Lopez (1996) edited a publication called The Global
Burden of Disease. All of these reports later influenced the ongoing analysis by the World Bank,
as well as work by the Fogarty International Center at the U.S. National Institutes of Health and
the Bill and Melinda Gates Foundation, to form the Disease Control Priorities Project (DCPP).
The project’s purpose has been “to review, generate, and disseminate information that
contributes to the scientific evidence base for improving population health in developing
countries” (DCPP, 2008, p. 1). Murray and colleagues (2012) compared data on disease and
injury from 1990 through 2010, providing a longitudinal assessment of effects of disease and
injury on specific populations. Integrating collected health data, using evidence that supports the
data, and applying to disease outcomes is paramount to improving global health.
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Noncommunicable Diseases
In 2012, the World Health Assembly endorsed an important new health goal: to reduce
avoidable mortality from noncommunicable diseases (NCDs) by 25% by 2025 (the 25 × 25
goal) (Alleyne et al., 2013). The Global Burden of Disease and Risk Factors study built upon
earlier versions, providing a comprehensive analysis of the health of the world’s population,
including health indicators for disease outcomes, as well as risk factors and monitoring
strategies that can be used for program planning to improve health outcomes (Murray et al.,
2012).
While communicable disease is still prevalent, 70% of all deaths globally are caused by
NCDs. Four common behavioral risk factors that occur globally—tobacco use, excessive alcohol
consumption, poor diet, and lack of physical activity—are associated with four health diseases—
cardiovascular disease, cancer, chronic pulmonary disease, and diabetes that account for 80% of
deaths from NCDs (Hunter & Reddy, 2013, WHO 2017a). Clearly, the leading causes of
mortality and burden of disease worldwide have shifted from communicable to NCDs. This
change represents an opportunity for communities to address behaviors that can affect overall
health (Fig. 4.2). When examining the GBD chart, many diseases can be ameliorated through
health promotion, education, and the provision of skilled healthcare (Box 4.1).
According to the WHO Global Status Report on Noncommunicable Diseases (2014b), of the
56 million global deaths in 2012, 38 million, or 68%, were due to NCDs, the most prominent of
which were cardiovascular diseases, diabetes, cancers, and chronic respiratory diseases. Nearly
15 million of all deaths attributed to NCDs occur between the ages of 30 and 69 years and 80%
of these deaths from NCDs occur in low- and middle-income countries (Lozano et al., 2012).
The report states that, “almost three quarters of all NCD deaths (28 million), and 82% of the 16
million premature deaths, occur in low- and middle-income countries” (WHO, 2015, p 1). Low-
income countries are mostly situated in middle Africa, but middle-income countries include
most of Central and South America, Eastern Europe, and Asia. While NCDs are still not the
most frequent causes of death in African nations, these diseases are rising rapidly and are
projected to exceed communicable, maternal, perinatal, and nutritional diseases as the most
common causes of death by 2030 (Southern African Development Community, 2012).
More than half of all cancer deaths occur in developing nations (Cancer Research U.K.,
2014). NCDs also cause death at younger ages in low- and middle-income countries. For
example, 29% of deaths due to NCDs in low- and middle-income countries occur among people
under the age of 60, compared to 13% in high-income countries. A WHO report (2011) stated
that the estimated percentage increase in cancer incidence by 2030, compared with 2008, will be
greater in low-income (82%) and lower–middle-income countries (70%) compared with the
upper–middle-income (58%) and high-income countries (40%).
Key factors in the rise of NCDs are similar in all countries, and the diseases are often
preventable (Box 4.2). In low- and middle-income countries that are now seeing increases in the
rate of NCDs, the process is accelerated by urbanization, culture change especially among the
young, increasing sedentary lifestyles, and corporate marketing that targets these populations.
One might see older populations still eating more healthy traditional foods, and younger
populations lured in by fast food marketing, for example. Recommendations are being made,
especially in low-resource settings, for increased surveillance and reporting of these diseases as
well as increased efforts to educate the public on this important health area. NCDs play an
important role not only on their effect on individuals but also on social, economic, and
environmental factors that affect human development (Alleyne et al., 2013; WHO, 2017a).
An important factor in the increase in NCDs is also the aging of the global population. As
we look to the future, the combination of aging and increased NCDs is likely to cause a higher
disease burden.
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The Impact of Disease Burden
The burden of disease is growing disproportionately in the world and is largely affected by
climate, public policy, aging of the population, socioeconomic conditions, and risk factors (Fig.
4.3). Most of the countries burdened by disease have the least amount of human and economic
capacity to effect change (Farmer, Furin, & Katz, 2004). Sub-Saharan Africa is unique in having
an overwhelming share of the disease burden related to poverty and people living with
HIV/AIDS (United Nations, 2012).
Women are disproportionately affected by the disease burden related to reproductive health
and HIV infection (Hawkes & Buse, 2013). Globally, an estimated 830 women die daily from
complications of childbirth (WHO, 2016a). Many of the complications resulting from childbirth
can be prevented with the use of skilled midwives and nurses at birth. When a mother dies or is
disabled, her children may be forced to live in poverty. Addressing the causes of these health
discrepancies with education, specifically education for girls, and creating integrated health
programs, such as HIV treatment and prenatal care, will improve the quality of care and thus
decrease the disease burden (Potter et al., 2008; UNAIDs, 2017). Girls and young women aged
15 to 24 years are twice as likely to become infected with HIV and account for 22% of new HIV
infections (United Nations AIDS, 2013). Women now comprise 51% of individuals infected
with HIV worldwide (amfAR, 2016). Of adults living with HIV in sub-Saharan Africa, 58% are
women, compared with 26% in North America. HIV/AIDS is the leading cause of death among
women of reproductive age (aged 15 to 44) (amfAR, 2016).
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FIGURE 4.2 The leading causes of death worldwide. (Institute for Health Metrics and Evaluation.
[2017]. University of Washington. Retrieved from https://vizhub.healthdata.org/gbd-compare.)
4.1 Top 10 Facts According to the Global Burden of Disease
Fact 1: Global average life expectancy increased by 5 years between 2000 and 2015, the fastest increase
since the 1960s.
Fact 2: Globally, healthy life expectancy (HLE) at birth in 2015 was estimated at 63.1 years.
Fact 3: In 2015, more than 16 000 children under age 5 died every day.
Fact 4: 45% of deaths among children under age 5 occur during the first 4 weeks of life.
Fact 5: In 2015, an estimated 2.6 million babies were stillborn.
Fact 6: 1.3 million deaths in 2015 were attributable to hepatitis.
Fact 7: Noncommunicable diseases (NCDs) caused 37% of deaths in low-income.
Fact 8: Ischemic heart disease and stroke killed 15 million people in 2015.
Fact 9: Diabetes is among the 10 leading causes of deaths and disability worldwide.
Fact 10: Injuries claimed nearly 5 million lives in 2015.
Source: World Health Organization. (2017c). 10 Facts on the State of Global Disease. Retrieved from http://www.who.int/features/factfiles/global_burden/en.
4.2 Key Factors in the Rise of Noncommunicable Diseases
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http://www.who.int/features/factfiles/global_burden/en
Noncommunicable diseases (NCDs) kill 40 million people each year, equivalent to 70% of all deaths globally.
Each year, 15 million people die from a NCD between the ages of 30 and 69 years; over 80% of these “premature”
deaths occur in low- and middle-income countries.
Cardiovascular diseases account for most NCD deaths, or 17.7 million people annually, followed by cancers (8.8
million), respiratory diseases (3.9 million), and diabetes (1.6 million).
These four groups of diseases account for over 80% of all premature NCD deaths.
Tobacco use, physical inactivity, the harmful use of alcohol, and unhealthy diets all increase the risk of dying from
a NCD.
Detection, screening, and treatment of NCDs, as well as palliative care, are key components of the response to
NCDs.
Source: World Health Organization. (2017b). Global status report on non-communicable diseases. Retrieved from
http://www.who.int/mediacentre/factsheets/fs355/en.
Children younger than 5 years who may be malnourished shoulder a significant portion of
the disease burden. Nutrition is related to access to a food source and the quality of the food. In
many countries, staple food such as rice, nshima, or millet, and other grain-based substances is
abundant but lacks basic nutrients. Undernutrition and a diet of foods with poor nutritional
content contribute to 45% of deaths in children younger than 5 years in developing countries
(WHO, 2014c). Optimal breast-feeding could save more than 800,000 lives of children younger
than 5 years each year. This primarily results from the lack of national infrastructure to
adequately measure the effects of ill health on the entire country. Women are often essentially
“invisible” to the healthcare system after childbirth. Compound this with poverty and lack of
access, and women and children will remain in a state of poor health.
FIGURE 4.3 Global healthy life expectancy at birth. (World Health Organization [2016e]).
The community response to outcast Haweeyo and her family because of her pregnancy
and unmarried status represents discrimination. As a woman, she suffers the triple stigma
of being “immoral,” pregnant, and poor because the cultural norm in her country is to
marry before conceiving a child. Why do you think stigma, shame, and social outcasting
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continue to be a challenge for women and their families in this region of the world? How
might you explain the relationship between culture and perceived women’s role and
behavior? As a nurse working in this community, what might be the best practice for
intervening and preventing violence and death toward young girls and women who find
themselves in a situation such as Haweeyo’s?
What Risk Factors Affect the Disease Burden?
In a health context, risk factors are defined as personal habits and behaviors, environmental
conditions, or inborn or inherited characteristics that are known to affect a health-related
condition. Many of these can be reduced or prevented. Addressing risk factors and how they
relate to the population can improve the health status of a nation. Risk factors occur in
combination and change with age, creating different risks over a lifetime. Risk factor categories
found to be associated with overall health include the following:
Childhood and maternal undernutrition: Underweight children and conditions related to iron, vitamin A,
and zinc deficiencies contribute to poor health outcomes.
Other nutrition-related risk factors and inactivity: Obesity and physical inactivity, coupled with
hypertension and hyperlipidemia, affect adults as well as children worldwide.
Addictive substances: Tobacco smoking, alcohol and illicit drug use affect the health of the world’s
population.
Sexual and reproductive health: Risk factors of unsafe sex and no use or ineffective use of contraception
contribute to decreased health of women and children.
Environmental risks: Unsafe drinking water, unsanitary conditions, poor hygiene, urban air pollution, and
indoor smoke created by burning solid fuels, contribute to poor health.
What Can Nurses Do?
The health of a nation is overwhelmingly affected by the presence of specific risk factors and the
nation’s capacity to support and implement health programs that will affect the major causes of
morbidity and mortality. Risk factors such as tobacco use, nutritional status, alcohol
consumption, and condom use can be modified with educational interventions and have an effect
on the overall quality of life (WHO, 2004). Nurses can have a profound effect on risk factors by
playing a major role in health promotion and education. The quality of health service coverage,
even in settings with few resources or ones where an extreme nursing shortage exists, can be
improved by nurses who target health promotion issues within their community. One example is
educating families on the daily use of insecticide-treated bed nets (ITNs) in regions where
malaria is highly endemic, and use of artemisinin-based combination therapies (ACTs) in high-
prevalence regions (WHO, 2013b). Artemisinin is a drug known for its ability to swiftly reduce
the number of Plasmodium parasites in the blood of patients with malaria. The 2016 WHO
Malaria Report (2016b) states that between 2010 and 2015, malaria incidence rates fell by 21%
globally and in the WHO African Region. During this same period, malaria mortality rates fell
by an estimated 29% globally and by 31% in the Region. During this same period, malaria
mortality rates fell by an estimated 29% globally and by 31% in the African region. However, as
cases of malaria have diminished, the use of ITNs has decreased. The public health sector needs
to advocate that the ITNs are essential for all areas, and that they be retreated annually for
efficacy. The Roll Back Malaria project of the WHO focuses on the community commitment to
fight malaria (WHO, 2013b), and ITNs are one method of prevention. Promoting the proper use
of ITNs would be an example of a program based on a specific demographic risk factor that
nurses, as trustees of health, could promote.
Risk factors can be addressed both at the individual and the societal level. Often, the way in
which various risk factors interact with one another, and the best approach to addressing each
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one, is not well understood or defined. If demographics and geographic patterns are applied to
each of the risk categories, different patterns of need emerge. Using risk factors as a guide to
which interventions will work (i.e., the package of interventions) greatly improves outcomes in
specific communities. Removal of major risk factors, could improve healthy life expectancy
worldwide.
Practice Point
Nurses can have a substantial effect on people’s health by focusing their teaching on
modifiable risk factors such as changing lifestyle behaviors.
Health Indicators
According to the WHO statistical information system, health indicators may be placed in four
categories: morbidity and mortality, risk factors, health service coverage, and health system
resources. Each category has a list of indicators and universal definitions. Morbidity and
mortality are measured by life expectancy at birth and health-adjusted life expectancy (HALE)
at birth. The effect of mortality on a population is reported as disability-adjusted life years
(DALYs) (Box 4.3). These three indicators reflect the general health of a population. Secondary
measures of mortality, such as maternal and neonatal rates, reflect at-risk groups that affect
overall mortality. Risk factor reduction focuses on healthy nutrition, improving health behaviors,
and ameliorating environmental factors such as clean water and burning solid fuels. Health
service coverage data identify uptake of specific services known to improve or promote health
and well-being, such as reproductive health services, infant and child health and immunization,
HIV, and tuberculosis (TB) care. Health system resources focus on the capacity and supply of
healthcare providers. These indicators in the aggregate provide valuable data that are used by
health ministries and nongovernmental organizations (NGOs) as benchmarks for measuring
target interventions.
4.3 Health Indicator Descriptions
Life expectancy at birth (years): average number of years a newborn is expected to live if the current
mortality rates continue to apply
HALE (health-adjusted life expectancy at birth [years]): average number of years that a person can
expect to live in “full health” by taking into account years lived in less than full health due to disease
and/or injury
DALYs (disability-adjusted life years): quantifying the burden of disease to a healthy life. The loss of
years related to burden of disease. The gap in years reflects the current state of health versus an
optimum state of health of a nation.
Source: World Health Organization. (2014). Health statistics and health information systems. Retrieved from http://www.who.int/healthinfo/en.
Box 4.4 reflects the 10 highlights of the WHO Health Statistics Report for 2016 (WHO,
2016d). These highlights indicate that health discrepancies continue, and that interventions and
benchmarks targeted at health indicators need to be based on the community-specific risk
factors. In addition, these highlights suggest that global health continues to have an immense
disease burden that is filled with opportunities for nurses to make a difference. Programs should
focus on areas that have high impact on the overall health and well-being of the population they
are intended to serve. The six lines of action (Box 4.5) of the WHO Health Statistics Report for
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2017 (WHO, 2017b) provide guidance in promoting health equity and sustainable development
through 2030.
4.4 Ten Highlights of the 2016 WHO World Health Statistics Report
Every year:
303,000 women die due to complications of pregnancy and childbirth
5.9 million children die before their fifth birthday
2 million people are newly infected with HIV, and there are 9.6 million new TB cases and 214 million malaria
cases
1.7 billion people need treatment for neglected tropical diseases
more than 10 million people die before the age of 70 due to cardiovascular diseases and cancer
800,000 people commit suicide
1.25 million people die from road traffic injuries
4.3 million people die due to air pollution caused by cooking fuels
3 million people die due to outdoor pollution
475,000 people are murdered, 80% of them men
Source: World Health Organization (2016d). World Health Statistics 2016. Retrieved from http://www.who.int/mediacentre/news/releases/2016/health-
inequalities-persist/en.
4.5 Six Lines of Action to Promote Health in the 2030 Agenda for Sustainable
Development
1. Monitoring the health-related Sustainable Development Goals (SDGs)
2. Health system strengthening for universal health coverage
3. Health equity—leave no one behind
4. Sustainable health financing
5. Innovation, research and development
6. Intersectoral action for health
Source: World Health Statistics Report. (2017c). World Health Statistics Report 2017. Retrieved from
http://apps.who.int/iris/bitstream/10665/255336/1/9789241565486-eng ?ua=1.
Practice Point
Culturally appropriate, community-driven, and community-based programs are critical for
eliminating disparities; strategies directed at individuals are not sufficient.
From what you know about global risk factors that affect burden of disease, in reviewing
the highlights of the WHO report (2017c) what nursing interventions should be implemented
to address improved health outcomes? What risk factors could be targeted that would
address some of the issues highlighted within the report? For example, we know that unsafe
sex practices is a major risk factor affecting reproductive health—maternal mortality is
declining too slowly and cases of HIV infection are still on the rise in young women. What
other factors would we need to know within a global setting before we could conduct a
community needs assessment about unsafe sex practices? For example, how should we
address unsafe sex practices for both men and women?
Statistics on population health indicators are used by governments and donor agencies.
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Health statistics will become vital to cost–benefit analysis for program development, with the
shift in the developing world toward implementing a sector-wide approach program for health
planning (WHO, 2008).
A sector-wide approach promotes the collective agreement of the government entity (e.g., a
ministry of health), donor countries, and other key stakeholders in the community such as
physician and nurse organizations, NGOs, and researchers. The process ensures that the
government assumes leadership in developing a common policy and program for health,
including monitoring arrangements and instituting more coordinated procedures for funding and
procurement (WHO, 2013c). The challenge for ministries of health will be to administer,
implement, and evaluate their annual healthcare goals and to work to identify ways and means to
address the shortcomings that most affect the communities.
Evidence for Practice
Deaths from injuries and car accidents are about as prevalent as HIV/AIDS in the world.
Bus accidents also cause many injuries in countries where safety laws are not well
enforced. More than 90% of injury deaths occur in low- and middle-income countries, where
preventive efforts are often nonexistent and healthcare systems are least prepared to meet
the challenge, according to the WHO (2009b). What interventions can nurses implement
that can reduce this problem?
Addressing the burden of highly infectious diseases such as TB is an urgent global health
priority. TB is one of the 10 leading causes of death worldwide. In 2015 alone, an estimated 1.8
million people died from the disease, including 0.4 million with a dual diagnosis of TB and HIV.
Despite a decrease in the incidence of the disease, approximately 10.4 million new cases were
diagnosed in 2015 alone with most infections occurring among people living in crowded
conditions in low-income countries. Treatment of TB involves following a strict drug regimen
for several months, and completing the full course of treatment is critical. Unfortunately, failure
to complete the drug regimen is very common, often attributed to cost and availability of
medications. One of the consequences when patients stop taking their medications is the
emergence of multidrug-resistant disease (MDR-TB). An estimated 480,000 people who started
treatment developed multidrug-resistant TB (MDR-TB) in 2015. Ending the TB epidemic by
2030 is a key health target among the Sustainable Development Goals (SDGs) (WHO, 2017c).
As you reflect upon Vikram, what are some of the important preventive measures Vikram
could have taken to reduce the risk of TB for himself and his family? What may have put
Vikram at risk for MDR-TB? As a nurse, what are some of the important teaching points
you should emphasize about taking TB medications? Why do you think Vikram was
tested for HIV when he presented to the clinic with symptoms of TB?
Poverty and Risk Factors
Only when (and if) the “haves” develop genuine empathy for the “have-nots,” and come to
acknowledge their own long-term interdependence with all other humans, will the global
economy be improved to any significant advantage for the desperately poor. SR Benatar
in PLOS Medicine (2005)
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Low- and middle-income countries have an increased burden of the risk factor of poverty.
Extreme poverty—the inability to meet the basic needs of adequate nutrition, safe drinking
water, basic education, and primary health services, and a livelihood that can generate the means
to secure these basic needs—is the driving force behind increased mortality. Unlike those who
are moderately and relatively poor, those who are extremely poor cannot access healthcare and
are chronically hungry (Sachs, 2010, 2015). With a substantial segment of the world population
existing on less than a dollar a day, the choices within the environment for sustenance create
health risks. Nearly half the world’s population and about 81% of sub-Saharan African
households rely on wood-based biomass energy (fuel wood and charcoal) for cooking (World
Bank, 2011). Continuous smoke from burning air-polluting solid fuels affects the population’s
health, and negatively impacts the economy. Attention to achieving sustainable energy sources,
particularly in Africa, will help to alleviate poverty, improve healthcare status, and address ever-
expanding greenhouse gas emissions (Venro, 2009). This continued reliance on air-polluting
fuels, such as in China, affects the population’s health (which, in turn, affects their economic
prospects).
Unclean water remains a major problem in reducing diarrheal illness and waterborne and
water-related illnesses and their health consequences. Between 1990 and 2011, 1.9 million
people gained access to improved sanitation facilities (United Nations, 2013a) and the
proportion of people using an improved water source rose from 76% to 89%. Developing basic
sanitation expectations for communities and decreasing reliance on traveling great distances to
acquire water will improve health overall.
WOMEN, POVERTY, AND HEALTH
“There are two powers in the world; one is the sword and the other is the pen. There is a
third power stronger than both, that of women.” Malala Yousafzai author of I Am Malala:
The Girl Who Stood Up for Education and was Shot by the Taliban
Gender impacts health, both biologically and socially. The health of women and girls is affected
by many social issues, particularly education. A lack of basic education worsens a female’s risk
of poverty, which impacts childhood marriage, early childbirth, lack of birth control, and
increased vulnerability to HIV/AIDS (Jackson, 2009; WHO, 2017b).
Some of the sociocultural factors that prevent women and girls from benefiting from quality
health services and attaining the best possible level of health include:
unequal power relationships between men and women;
social norms that decrease education and paid employment opportunities;
an exclusive focus on women’s reproductive roles; and
potential or actual experience of physical, sexual and emotional violence (WHO, 2017b).
Poverty is a barrier to health for both men and women, but it yields a higher burden on
women and girls’ health.
The burden of disease associated with reproductive health affects the health indicators of a
nation. Thompson (2007) described the deadly combination of poverty, the right to economic
development, and the poor health of women as barriers to improving the health of the world’s
families. If maternal and child healthcare is left unattended, the rates of maternal and neonatal
mortality will rise and national development in those nations with the fewest resources will be
limited. The continued low status of women, despite years of policy development, increases the
risk of disease and disability. The power imbalances within households around the world affect
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the health of women and young girls.
Maternal, newborn, and child health affect population mortality and health in profound
ways. An estimated 3 million unsafe abortions occur annually among girls and young women
age 15 to 19 years (WHO, 2014d). Despite evidence of low-cost interventions that would
improve reproductive health outcomes, scale-up for these interventions is lacking (Bhutta et al.,
2008). The known interventions are focused on recognizing maternal and neonatal
complications; procedures to prevent postpartum hemorrhage (PPH), such as active management
of the third stage of labor; neonatal care at birth, such as drying the infant off and wrapping the
infant immediately; and having a skilled provider examine the infant within 2 days of birth.
Each of these interventions relies heavily on education of the mother and community and should
be a primary focus of community-based programs to improve maternal and child health. As
education increases in the community, evaluating the use of such interventions still remains low.
Such low-cost, low-tech interventions can address the imbalances in maternal and child health, if
used for every pregnancy and birth, and evaluated for quality of delivery and effectiveness.
Refocusing efforts on the full cycle of quality improvement will greatly affect overall global
health (Houweling et al., 2014).
In Case 1, Haweeyo benefited from the presence of an experienced CHW birth attendant
and her ability to recognize the necessity for moving her to the hospital for advanced level
of care for both mother and baby. As the nurse, you recognize gender differences and
acceptable roles and behaviors for women are evident in this community. How might you
intervene to reduce gender discrimination and violence based on culturally specific
restrictive beliefs and taboo regarding women, moral behaviors, and role of women in a
community? How might you help women like Haweeyo allay their fear of stigma and
shame and become more aware of available services, transportation, and sensitive,
caring providers who will care for her emotional and physical well-being?
SUSTAINABLE DEVELOPMENT GOALS
“Two years ago, world leaders adopted the ambitious 2030 Agenda for Sustainable
Development, with 17 Sustainable Development Goals at its heart. The Agenda is our
shared plan to transform the world in 15 years and, crucially, to build lives of dignity for
all.” UN Secretary-General António Guterres
The Sustainable Development Goals (SDGs) were adopted by the United Nations in 2015 to
replace the Millennium Development Goals (MDGs) (Fig. 4.4). The SDGs are a universal set of
goals, targets, and indicators that the United Nations 191 member states are using to frame their
agendas and political policies through 2030 (United Nations, 2017). The SDGs aim to address
inequalities between nations, but also within nations. The SDGs contain 17 goals covering a
broad range of sustainable development issues for the world. In addition to the overarching
goals, there are targets within each goal for a total of 161 targets. Goal number 3: Good health
and well-being for all, specifically addresses health.
The 17 SDGs:
1. End poverty in all its forms everywhere
2. End hunger, achieve food security and improved nutrition, and promote sustainable
agriculture
3. Ensure healthy lives and promote well-being for all at all ages
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4. Ensure inclusive and equitable quality education and promote lifelong learning opportunities
for all
5. Achieve gender equality and empower all women and girls
6. Ensure availability and sustainable management of water and sanitation for all
7. Ensure access to affordable, reliable, sustainable, and modern energy for all
8. Promote sustained, inclusive, and sustainable economic growth, full and productive
employment, and decent work for all
9. Build resilient infrastructure, promote inclusive and sustainable industrialization, and foster
innovation
10. Reduce inequality within and among countries
11. Make cities and human settlements inclusive, safe, resilient, and sustainable
12. Ensure sustainable consumption and production patterns
13. Take urgent action to combat climate change and its impacts
14. Conserve and sustainably use the oceans, seas, and marine resources for sustainable
development
15. Protect, restore, and promote sustainable use of terrestrial ecosystems, sustainably manage
forests, combat desertification and halt and reverse land degradation, and halt biodiversity
loss
16. Promote peaceful and inclusive societies for sustainable development, provide access to
justice for all and build effective, accountable, and inclusive institutions at all levels
17. Strengthen the means of implementation and revitalize the global partnership for sustainable
development
FIGURE 4.4 United Nations Sustainable Development Goals. (WHO).
Over the past decade, significant improvements have occurred in global health outcomes, but
it is important to note that health inequalities are prevalent throughout the globe. According to
the International Counsel of Nurses (2017), the social determinants of health (SDH) are the
conditions and systems that shape health throughout the life cycle. The SDH are the conditions
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in which people are born, grow, live, work, and age (Marmot, 2016). These circumstances are
shaped by the distribution of money, power, and resources at the local, national, and global
levels. Social factors, including education, employment status, income level, gender, and
ethnicity have a direct influence on a person’s health. The SDH are mostly responsible for health
inequities—the unfair and avoidable differences in health status seen within and between
countries. Health equity and social determinants are acknowledged as an important component
of the SDGs agenda and of the achievement of universal health coverage (UHC). To reduce
health inequities, both SDH and UHC need to be addressed in an integrated and systematic
manner (WHO, 2016c).
Evaluating the SDGs
The United Nations has extensive and continuous targets for evaluating all 17 goals. The High-
Level Political Forum (HLPF) has a central role in the follow-up and review of the 2030 Agenda
and the 17 SDGs at the global level. The HLPF facilitates sharing successes, challenges, and
lessons learned, and provides political leadership, guidance, and recommendations for follow-
up. The HLPF also coordinates sustainable development policies, ensures that the 2030 Agenda
remains relevant and ambitious, assesses progress, achievements, and challenges faced by
developed and developing countries, and addresses emerging issues. A central feature of the
HLPF is the voluntary national reviews (VNRs) that it receives from member states on their
implementation of the 2030 Agenda and the SDGs. Regularly undertaken by both developed and
developing countries, the VNRs provide a platform for partnerships between groups and
stakeholders (United Nations, 2017). Global progress on meeting each SDG is summarized in
Table 4.1. Progress on SDG #3 (health), is summarized in Box 4.6.
How Can Nurses Help Implement the STGs?
Global health is encompassed in all the SDGs, and most prominently in SDG #3: Ensure healthy
lives and promote well-being for all and all ages. Our nursing role directly impacts this SDG.
While nurses seek to help people achieve their optimal health, our work frequently includes
addressing the SDH and nurses understand the links between wider conditions on individual and
population health. As nurses, we have a responsibility to care for our patients, communities,
country, and the globe, by staying informed and continually educating ourselves on how to
improve health for all. Suggestions on how to implement the SDGs from the International
Council of Nursing (2017) include (1) becoming a leader and (2) raising your voice at the policy
table. Becoming a leader involves working with groups within the healthcare system and larger
community. Leadership includes both social responsibility and good citizenship, which connects
to nurses’ professional and ethical responsibilities to improve health for all. According to the
Institute of Medicine (2011), “a shift must take place in how nurses view their responsibility to
those they care for; they must see themselves as full partners with other health professionals” to
be effectively involved in improving overall health.
Evidence for Practice
The 2015 countdown report for maternal, newborn, and child survival outlines the progress
that has been made in improving the lives of families. Yet more can be done with basic, low-
cost interventions (United Nations, 2013b; WHO, 2012b). Sustaining focused interventions
on early detection and treatment of diarrhea and pneumonia will decrease mortality (Walker
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et al., 2013). Four interventions known to affect both diarrhea and pneumonia include the
following (Bhutta et al., 2013):
Breast-feeding. Not breast-feeding resulted in a 165% increased risk of acquiring diarrhea
from 0 to 5 months of age (Lamberti, Walker, Noiman, Victora, & Black, 2011). Education
on exclusive breast-feeding. Significant results, as high as 90%, were attributed to
promotional interventions for children from 0 to 6 months of age (Bhutta et al., 2013).
WASH interventions. Water, sanitation, and hygiene (WASH) interventions demonstrated a
risk reduction of 17% with proper excreta disposal, and risk reductions of up to 48% with
water and soap handwashing (Cairncross et al., 2010).
Zinc supplementation. Supplementation resulted in a reduction in diarrhea and acute lower
respiratory tract infection mortality (Yakoob et al., 2011).
Postpartum hemorrhage. PPH is the leading cause of maternal death, claiming an
estimated 140,000 lives in low-resource settings, with an additional 2 million women left to
recover from anemia (Prata, Passano, Sreenivas, & Gerdts, 2010; Smith, Gubin, Holston,
Fullerton, & Prata, 2013). The use of uterotonics such as oxytocin or misoprostol can have
a profound effect on preventing and treating PPH. Several large randomized controlled
trials (RCTs) have shown that the use of such medications will improve delivery of the
placenta, decrease blood loss, and avert death and disability. Implementation of such
treatments as a standard of care requires a reliable supply chain for medications and the
support of nurse leaders to implement the procedures for every delivery, since we know that
long labors and multiple gestations increase the risk for PPH, but many women with no risk
factors suffer hemorrhage.
Creating political will is important to improving health. Countries that improved care by
strengthening their health system with education and deployment of midwives reduced their
maternal mortality rate by 2% to 5% and will have a median drop of maternal mortality ratio
by 63% over 20 years (Van Lerberghe et al., 2014). Countries with sustainable changes
focused on improving access as close to the family as possible, scaling up birth care in line
with the population, decreasing fees and financial barriers to care, and making quality care
a priority. In countries where these four elements have been most successful, nurse
midwifery has become more visible and accepted.
Preterm birth and stillbirth have been neglected in improving child mortality (WHO, 2012a).
Investing in low-cost interventions, such as universal kangaroo care, and high-cost
interventions, such as corticosteroid injections, could save up to 950,000 infants per year.
Education of skilled health personnel, specifically nurses and midwives, on tools to support
preterm care and access to essential equipment and education can have a profound effect
on neonatal survival. The global action report by WHO Born Too Soon (WHO, 2012a)
outlines steps that can improve preterm birth and prevent causes of stillbirth, such as
maternal malnutrition.
TABLE 4.1 Progress to Date: Sustainable Development Goals, 2017
Sustainable Development Goals Progress at Meeting Goal
1. End poverty in all its forms everywhere An estimated 767 million people lived below the extreme poverty
line in 2013, down from 1.7 billion people in 1999. This represents
a reduction in the global rate of extreme poverty from 28% in
1999 to 11% in 2013.
2. End hunger, achieve food security and
improved nutrition, and promote
sustainable agriculture
The proportion of undernourished people worldwide declined from
15% in 2000–2002 to 11% in 2014–2016. Globally, approximately
793 million people were undernourished in 2014–2016, down
from 930 million in 2000–2002.
3. Ensure healthy lives and promote well- See Box 4.6 for extensive progress at meeting this health goal.
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being for all at all ages
4. Ensure inclusive and equitable quality
education and promote lifelong learning
opportunities for all
Despite gains in primary school enrollment between 2000 and 2014,
9% of primary school–aged children worldwide were out of school
in 2014, with little progress since 2008.
5. Achieve gender equality and empower all
women and girls
Women’s participation in national parliaments worldwide were 23%
in 2017. In the majority of the 67 countries with data from 2009 to
2015, fewer than a third of senior- and middle-management
positions were held by women.
6. Ensure availability and sustainable
management of water and sanitation for all
In 2015, 5.2 billion people (71% of the global population) used a
safely managed drinking water source located on premises,
available when needed and free from contamination.
7. Ensure access to affordable, reliable,
sustainable and modern energy for all
In 2014, 85% of the global population had access to electricity, up
from 78% in 2000. However, 1.06 billion people still lived without
this basic service
8. Promote sustained, inclusive and
sustainable economic growth, full and
productive employment, and decent work
for all
The average annual growth rate of real gross domestic product
(GDP) per capita expanded from 0.9% in 2005–2009 to 1.6% in
2010–2015. Real GDP growth in the least developed countries
(LDCs) averaged 4.9% in 2010–2015, short of the target of at
least 7% annually.
9. Build resilient infrastructure, promote
inclusive and sustainable industrialization,
and foster innovation
Global investment in research and development increased at an
average annual rate of 4.5% between 2000 and 2014.
10. Reduce inequality within and among
countries
In 49 of 83 countries with data from 2011–2015, the per capita
incomes of the poorest 40% of the population grew more rapidly
than the national average, leading to a reduction in income
inequality.
11. Make cities and human settlements
inclusive, safe, resilient, and sustainable
In 2014, nine in 10 people living in urban areas breathed air that did
not meet the World Health Organization’s air quality guidelines
value for particulate matter.
12. Ensure sustainable consumption and
production patterns
Globally, the material footprint of human beings increased from 48.5
billion metric tons in 2000 to 69.3 billion metric tons in 2010. The
material footprint per capita increased from 8 metric tons per
person in 2000 to 10 metric tons per person in 2010.
13. Take urgent action to combat climate
change and its impacts
As of 2017, 148 parties ratified the Paris Agreement.
14. Conserve and sustainably use the oceans,
seas, and marine resources for
sustainable development
Of the 63 large marine ecosystems, 16% are in the “high” or
“highest” risk categories for coastal eutrophication (oxygen
depletion leading to animal death). By 2050, it is estimated that
coastal eutrophication will increase in 21% of large ecosystems.
15. Protect, restore and promote sustainable
use of terrestrial ecosystems, sustainably
manage forests, combat desertification
and halt and reverse land degradation,
and halt biodiversity loss
From 2010 to 2015, the annual net loss of forest area globally was
less than half that of the 1990s. The proportion of land area
covered by forest decreased from 32% in 1990 to 32% in 2010
and 31% in 2015.
16. Promote peaceful and inclusive societies
for sustainable development, provide
access to justice for all, and build effective,
accountable, and inclusive institutions at
all levels
Globally, the proportion of people held in detention without being
tried or sentenced for a crime was 31% in 2013–2015.
17. Strengthen the means of implementation
and revitalize the global partnership for
sustainable development
In 2016, approximately 80% of the population in developed regions
had internet access, compared to 40% in developing regions and
15% in LDCs.
Source: United Nations. (2017). Sustainable Development Goals Report 2017. Retrieved from
https://unstats.un.org/sdgs/files/report/2017/TheSustainableDevelopmentGoalsReport2017 .
4.6 Progress on SDG 3—Health
Goal 3 addresses all major health priorities and calls for improving reproductive, maternal and child
health; ending communicable diseases; reducing noncommunicable diseases and other health hazards;
and ensuring universal access to safe, effective, quality, and affordable medicines and vaccines as well
as health coverage. Between 2000 and 2015, global health indicator changes included:
Maternal mortality ratio declined by 37%, and the under 5 mortality rate fell by 44%. However, 303,000 women
died during pregnancy or childbirth and 5.9 million children under age 5 died worldwide in 2015; most from
preventable causes.
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https://unstats.un.org/sdgs/files/report/2017/TheSustainableDevelopmentGoalsReport2017
46% reduction in HIV incidence
17% decline in the incidence of tuberculosis
41% decrease in the incidence of malaria
21% drop in people requiring mass or individual treatment and care for neglected tropical diseases.
The risk of dying between the ages of 30 and 70 from one of four main NCDs—cardiovascular disease, cancer,
diabetes, or chronic respiratory disease—fell from 23% to 19% between 2000 and 2015, but not rapidly enough to
meet the 2030 target.
Nearly 800,000 suicides occurred worldwide in 2015, with men twice as likely to die by suicide as women.
In 2013, approximately 1.25 million people died from road traffic injuries, an increase of 13% since 2000.
Globally in 2012, household air pollution from cooking with unclean fuels and inefficient technologies led to an
estimated 4.3 million deaths; another 3 million deaths were attributed to ambient air pollution from traffic,
industrial sources, waste burning, and residential fuel combustion.
OTHER FACTORS THAT AFFECT GLOBAL HEALTH
Economics and Politics
The global environment is intricately intertwined with the economic and political status of a
nation. As one area improves, so do others, and vice versa. It is known that health and education
are clearly linked, in that the better educated the population is, the better the health of the
population (Ross & Wu, 1995). Political and economic instability, which leads to poverty, is a
major barrier to achieving health for a population. When economies and political systems are
stable, the health of a population generally improves.
Over the past 60 years, the world economy has increased, and yet has spawned greater
disparities. For example, the global economy increased sevenfold since 1950, whereas the
disparity in gross domestic product between the 20 richest and 20 poorest nations more than
doubled between 1960 and 1997 (British Medical Journal, 1999). Extreme poverty is decreasing
in every region of the world, according to the 2017 Sustainable Development Goals Report of
the United Nations. The proportion of people living on less than $1.25 a day fell from 43% in
1990 to 21% in 2010 (World Bank, 2014). An estimated 767 million people, or 10.7% of the
population lived on less than $1.90 a day in 2013, with decreasing numbers of people living in
conditions of extreme poverty. Yet living in poverty remains the driving economic condition
that significantly affects health and well-being in sub-Saharan Africa and in southern Asia
(United Nations, 2013a; World Bank, 2016).
The current economic and political instability of many parts of the world only exacerbates
the difficulties for the world’s poor. The effects of a slowdown of the world economy on the
incomes of other less wealthy nations have become evident. This ripple effect is felt by the
poorest people of the world.
The first wealth is health. Ralph Waldo Emerson
Even with these enormous disparities in health, poor countries can learn to become more
economically self-sufficient by producing enough basic commodities and foods for their
population to survive, and also by producing specific goods for export that are not readily
available in wealthier countries. Poor countries must grow staple foods that lead to nutritionally
balanced diets for the local people. It is possible to achieve high levels of health even without
high levels of income. Disparities between the wealthiest and poorest nations must be reduced;
in the end, each individual is inextricably linked as the world quickly becomes a global
community. Maintaining communities and honoring cultural norms and traditions can only help
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populations become more self-sufficient. It is inherently necessary for health planners to
understand this basic fact.
In Case 2, consider some of the social and economic factors that may influence the
health of Vikram and his family. How might access to healthcare services, education
about prevention, and treatment of communicable diseases prevent transmission of TB
from occurring in Vikram’s community and other rural, poorly resourced areas? How do
diagnoses and treatments of communicable and infectious diseases differ both globally
and culturally within different regions of the world?
Factors Associated With Healthcare Systems
Healthcare systems differ in terms of the degree to which they can adequately serve the
population and the degree to which they are centralized in the government. They range from
national healthcare systems, such as those in the United Kingdom or Spain, to pluralistic free-
market systems, such as those in the United States. National healthcare systems are highly
regulated, tend to have salaried physicians and other providers, are funded by governments, and
involve relatively high taxes. Free-market healthcare systems depend more on individual or
employer and employee contributions than on taxes. In between these two extremes are the
systems of various countries whose citizens have access to universal health insurance and pay
higher taxes for these services, such as the Scandinavian countries of Denmark, Norway, and
Sweden. Other health insurance funding methods include national health insurance programs
with single-payer systems, such as those in Canada, and programs with multipayer health
insurance systems that offer universal health insurance via sickness funds, such as those in
Germany and France.
The U.S. system, which is often characterized as highly fragmented and segmented,
depending on the individual’s insurance status or level of wealth, spends far more per capita on
health than any other country in the world. Although the United States spends the most on
healthcare per capita, it has the worst rating in preventable deaths (treatable cancer, diabetes,
childhood infections/disease, and complications from surgery); it ranked last among 16
industrialized nations. From 1997–1998 to 2006–2007, the United States lowered its preventable
mortality rate by only 20% compared to an average decrease of 31% in other nations (Nolte &
McKee, 2011). The United States ranked last among 11 industrialized countries in access,
administrative efficiency, equity, and healthcare outcomes in 2017 (Schneider et al., 2017).
Figure 4.5 compares countries of the world on these measures (Schneider et al., 2017)
The United States passed the Patient Protection and Affordable Care Act in March 2010, a
landmark national healthcare reform law that was expected to allow 94% of all Americans to
obtain health insurance, reduce the growth in healthcare costs, and decrease the federal budget
deficit by $143 billion over the next 10 years (Congressional Budget Office, 2010). This
legislation has had many hurdles and had gradually increased the number of insured individuals
in spite of opposition by many Americans and various states until 2017 when significant
challenges occurred. So how does this translate to poorer countries with less wealth than the
United States or Europe? Lessons learned from decades of work focusing on a specific disease
of a population have provided data to suggest that focusing on the system may garner better
health indexes for global health delivery (Kim, Farmer, & Porter, 2013). Care delivery value
chains (CDVCs) targeted at a specific problem can create a system that engages all aspects of
care toward one outcome. Creating a value-based delivery system which is focused on the value
it achieves for the patient and society, and which emphasizes best practice and includes the need
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to understand the combined effect of interventions over a cycle of care, is an important aspect of
CDVCs (Kim et al., 2013). The elements of the value chain include the following:
Monitoring and prevention
Diagnosing
Preparing
Intervening
Recovering and rehabilitation
Monitoring and managing overall outcomes
Integrating this model into health systems may move health indexes to the next level.
Strong healthcare systems are vital, yet they also need sustainable financial support. Some
countries are turning to insurance mechanisms. Smith and Sulzbach (2008) describe voluntary,
nonprofit health insurance schemes, organized and managed at the community levels, that they
call “community-based health insurance” (p. 2461). This concept is based on the principle of
risk pooling and involves regular payments of a small premium in exchange for reducing direct
payments at the point of service. These types of financing are also referred to as prepayment
schemes, private prepaid programs, microinsurance, and mutual health organizations (Dror et
al., 2016; Smith & Sulzbach, 2008). Although care in these poorer countries involves a
completely different paradigm than in developed countries, lack of the greatest resource—
healthcare providers—is one of the most compelling problems. Lack of financing either from the
government or from the population further exacerbates this problem.
FIGURE 4.5 Healthcare System Performance Rankings. (Schneider, E., Sarnak, D., Squires, D.,
Shah, A., Doty, M. [2017]. Mirror, Mirror 2017: International comparison reflects flaws and
opportunities for better U.S. healthcare. The Commonwealth Fund. Retrieved from
http://www.commonwealthfund.org/∼/media/files/publications/fund-
report/2017/jul/schneider_mirror_mirror_2017 .)
Extreme shortages of healthcare workers are an endemic problem in developing countries,
and yet again, these countries share the greatest burden of disease, spend the least on healthcare
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http://www.commonwealthfund.org/∼/media/files/publications/fund-report/2017/jul/schneider_mirror_mirror_2017
expenditures, and have the lowest number of healthcare workers. Fifty-seven countries, most of
them in Africa and Asia, face a severe health workforce crisis. With most recent data available,
the WHO (2006) estimated that at least 2,360,000 health service providers and 1,890,000
management support workers, or a total of 4,250,000 health workers, are needed to fill the gap.
Without prompt action, the shortage will worsen, especially in the poorest countries. Sub-
Saharan Africa, for example, had 11% of the world’s population and 24% of the GBD, and it
manages with only 3% of the world’s health workers (WHO, 2006). The number of health
workers is directly related to the health of global populations. Further, country-specific data can
be found at the website of Global Atlas of the Health Workforce, WHO, Geneva:
http://www.who.int/hrh/statistics/hwfstats/.
To add to this problem, many factors that affect the health of global populations are often
beyond the control of individual people. Wars, political instability, famine, ecologic factors such
as climate change and subsequent environmental disasters, and economic trends may lead
members of the local health workforce (such as nurses and physicians) to move to highly
developed countries where they can work in more favorable conditions.
What has occurred is a global shortage of nurses and physicians in areas of need, and
workforce migration leading to a “brain drain” of workers moving from lesser-developed
countries to more developed countries. In 2010, the WHO introduced the Global Code of
Practice of the Recruitment of Health Personnel (WHO, 2010). The code promotes the ethical
recruitment of personnel and provides a focus on health work force development and health
systems sustainability, and strengthening local health systems. Table 4.2 lists the key facts
related to health worker migration. The WHO (2011) assembly on strengthening nursing and
midwifery supported a continued focus on including nursing and midwifery in health system
planning and employment, and transforming education systems to meet the needs of each
country. Gostin (2008) states that the factors contributing to a shortage of healthcare workers are
globalization, which has increased over the past 20 to 30 years, and a decreased supply of
healthcare workers along with an increased demand for well-trained workers. He says that this
leads to a “push–pull” situation, in which healthcare workers are “pushed” from developing
countries and “pulled” to developed countries with the promise of a brighter future. Factors
leading to this problem include low wages, unsafe environments, the need for better living
conditions and facilities, lack of opportunity to be promoted, and unusually heavy workloads
and long working hours (Gostin, 2008). The WHO (2010) suggests that in-source countries need
to consider better health workforce retention by focusing on maldistribution of nurses and
quality of life. Health systems need to provide protection and better treatment of workers in
general, as often there are poor working conditions and poor pay. Finally, in accordance with the
WHO goal of improving nursing education, countries need to invest in improving the initial
education and training of midwives so that they are better prepared as professional healthcare
workers (WHO, 2009a). Because migration is a human right, the WHO supports destination or
receiving countries to act as responsible global citizens in recruiting migrant workers. This
includes building capacity in their own countries as well as treating expatriate workers with the
same dignity and respect as all healthcare workers.
TABLE 4.2 Background on Health Workforce Shortage
Globally, health workforce shortages are highest in sub-Saharan Africa, which bears 24% of the world’s disease
burden but has only 3% of health workers and less than 1% of the world’s financial resources to respond to this
burden (WHO, 2006).
Adding to the shortage and inequitable distribution of the health workforce, the past 20 years have seen an
increase in international health worker migration, with patterns of migration becoming increasingly complex (Nair
& Webster, 2013; Taylor & Dhillon, 2011). In this period, developed nations have become more and more reliant
on international migrants to fill health workforce positions—including nursing assistants, nurses, physicians, and
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medical specialists.
With rising life expectancy and expanding elderly populations, this reliance is expected to continue.
Migration, undeveloped health systems, and poor wages and working conditions are some of the factors that
impact limited health workers in countries with the poorest health indicators.
WHO estimates that the basic healthcare system of 57 countries is affected by shortage of human resources
and about 1/3 of these countries are the emerging market economies (Nair & Webster, 2013).
Gostin (2008) does suggest an upside to migration for the worker and the community:
workers who migrate also gain new skills in the receiving countries and can return to their native
countries revitalized with education and new outlooks on solving the problems—in other words,
“brain gain.” Those who leave may also come back with the skills to educate other workers. For
example, nurses may return with advanced practice nursing skills and become educators in their
respective countries.
When a country invests in its healthcare workers through improved training, improved
working conditions, career ladders, and allocation of financial resources toward improving
salaries and systems, workers are more likely to remain in that country. HIV protection and
treatment, as well as plans for emergency preparedness, are paramount if workers are to feel safe
in their environments. The “pull” to other countries is great, and healthcare workers must feel
that their contribution is valued and that their future will be improved if they resist the perceived
benefits of moving to more developed countries to live out their lives and careers.
ROLE OF NURSES
The world is now a global village. Problems that affect people in other countries also affect
people in their own countries. Nurses and community healthcare providers need to be
knowledgeable about the needs of all people, as well as of their patients, in the global society.
Knowledge of the goals for worldwide health can lead to new cooperative ventures and unique
solutions using technology and knowledge transfer techniques. Do all citizens of the world
deserve access to good health and a sense of well-being? It is expected that the answer to this
question will be “yes,” but such a goal can be accomplished only through international
cooperation, regardless of national boundaries. Larger questions of inequalities in wealth and
resources must be addressed, and as a new generation of providers emerge, they may have the
answers that have eluded societies before them.
Nurses are a major part of the solution to world health problems. The ability of nurses to
assess patients and communities, set realistic goals, develop interventions partnered with local
community resources, and continually evaluate progress toward meeting goals will move the
global environment on a path toward improved health. Nurses’ enlightenment about global
health issues will enable our valuable profession to be part of the solution toward a healthier
global population.
KEY CONCEPTS
Global health encompasses the behavioral and environmental risk factors of a community, which are
influenced by politics, economics, and culture.
Monitoring health indicators and ensuring the inclusion of vulnerable and invisible populations will improve
packaged interventions to affect health outcomes.
Global burden of disease is a term that reflects the health of a nation and the level of opportunity to improve
153
health.
The Sustainable Development Goals are a framework for achieving improved global health and outcomes.
Nurses should participate in both policy and leadership working toward meeting the SDGs.
The road map to achieving health relies on the participation of all individuals and nations to address the
basic needs of clean drinking water, sanitation, and alleviating poverty.
Education is the key to improving the community environment, which, in turn, will improve health.
Health worker migration increases the burden of care for a society and results in the need to shift tasks
primarily to nurses and community health workers.
CRITICAL THINKING QUESTIONS
1. Imagine the role that nurses can play in a more egalitarian world where all healthcare providers can
contribute equally to the pressing global problems presented here. What are some of your proposed
solutions?
2. How can nurses work within communities of interest to determine how the burden of disease is affected by
poverty?
3. How can nurses influence the major risk factors related to maternal mortality and HIV?
4. What health factors can nurses address to work with young males of a community to improve overall
health?
COMMUNITY RESOURCES
World Health Organization
International Council of Nurses
United Nations
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WEB RESOURCES
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Part 2
Evidence-Based Practice
and Population Health
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Chapter 5
Frameworks for Health
Promotion, Disease
Prevention, and Risk
Reduction
Rosanna F. DeMarco and Judith Healey-Walsh
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Perplexity is the beginning of knowledge.
Khalil Gibran
In theory there’s no difference between theory and practice. In practice there is.
Yogi Berra
If the facts don’t fit the theory, change the facts.
Albert Einstein
CHAPTER HIGHLIGHTS
Influences on health and well-being
Role of the nurse as an interdisciplinary team member in health promotion and prevention
Health promotion programs
Epidemiologic models of health promotion and public health science
Levels of prevention and pathogenesis
Immunizations
Screening
Behavior change theories
Ecologic model and women living with HIV/AIDS
Health literacy
Interactive health literacy and health education
Critical health literacy and health promotion
OBJECTIVES
Discuss the contribution of the Centers for Disease Control and Prevention to the health and well-being
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of people in the United States.
Explain three levels of prevention in relation to levels of pathogenesis.
Identify and define health behavior change models and their practical use in altering behavior to enhance
health and well-being.
Identify a multisystem prevention approach to people, families, and communities.
Describe epidemiologic models of health promotion and modifiable risk reduction.
Describe the relationship among health literacy, health education, and health promotion.
Compare the three levels of health literacy: functional, interactive, and critical.
Identify requisite health literacy knowledge and skills for self-management of health.
Describe essential health literacy practices for community health nurses.
KEY TERMS
Behavior change models: Models that assist clients, groups, and communities to redirect
activities toward health and wellness.
Ecologic model: Model that considers intrapersonal attributes, interpersonal dynamics,
person/environment interactions, cultural beliefs, and attitudes.
Health: A quality, an ability to adapt to change, or a resource to help cope with challenges and
processes of daily living.
Health belief model: A behavior change model that considers the severity of the potential illness
or physical challenge, the level of conceivable susceptibility, the benefits of taking preventive
action, and the challenges that may be faced in taking action toward the goal of health
promotion.
Health literacy: The degree to which individuals have the capacity to obtain, process, and
understand basic health information and services needed to make appropriate decisions.
Health literacy universal precautions: Practices that healthcare providers use to make all
health information easier to understand, to confirm client–provider comprehension, and to
reduce the difficulty of health-related tasks.
Health promotion: The process of enabling people to increase control over all modifiable
determinants of health to improve their health and well-being.
Learning model: A behavior change model emphasizing reinforcement of social competence,
problem solving, autonomy, and sense of purpose.
Modifiable risk: Susceptibility to disease or injury that can be controlled by individual people,
families, or communities.
Motivational interviewing: Client-centered communication style for eliciting behavior change by
helping clients and groups explore and resolve ambivalence to change.
Primary prevention: Maximizing health and wellness through strategies that are set in place
before illness or injury is present.
Relapse prevention model: A change model that is used primarily to assist people struggling
with relapse and recovery from substance use.
Risk reduction: Decreasing the chance of developing an illness, experiencing an injury, or being
faced with chronic consequences of both.
Secondary prevention: Maximizing health and wellness through strategies set in place at the
early and active chronic stages of illness and injury.
Social learning: A behavior change model that considers environmental influences, personal
factors, and behavior as key components to change.
Social support: A component of change in which community members, friends, neighbors, and
adjacent communities influence change by offering instrumental assistance, informational
support, emotional support, and appraising support.
Tertiary prevention: Maximizing health and wellness through strategies that are set in place at
the palliation and end stage of disease and injury trajectories.
Theory of reasoned action: A behavior model emphasizing that individual performance of a
given behavior is primarily determined by a person’s intention to perform that behavior.
Transtheoretical model: Sequential approach to behavior change on the basis of process
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across stages and timely readiness of the learner.
Well-being: A subjective perception of full functional ability as a human being.
CASE STUDIES
References to case studies are found throughout this chapter (look for the case study icon).
Readers should keep the case studies in mind as they read the chapter.
The following three case studies are examples of prevention research by the Centers for Disease
Control and Prevention (CDC) to address community health risk reduction and health promotion
initiatives in people of various ages. They illustrate how healthy behaviors and risk reduction can be
addressed through culturally relevant avenues using both epidemiologic evidence and the behavior
change models presented in this chapter. The key to success in promoting health and reducing risk
in these cases is the thoughtful, planned building of coalitions among individuals, communities, and
health professionals. For example, nurses who address a particular healthcare concern need to
involve members of communities in identifying goals, objectives, and solutions that can affect
lifelong health promotion. It is critical that the risk be modifiable (sometimes referred to as a
“modifiable risk”), which means that individual people or groups can actually do something about
the problem using social competence, problem solving, autonomy, and purpose.
CASE 1
At the CDC Prevention Research Centers’ (PRCs) annual program meeting, 300 participants
received a bag that was a product of community prevention research. The PRC program purchased
the bags from Threads of Hope, a small business developed by community partners and the Center
for Health Promotion and Disease Prevention of the University of North Carolina at Chapel Hill, one
of 33 CDC-funded PRCs. Threads of Hope is a spin-off of the center’s core research project, HOPE
Works, which trains community facilitators to run support groups enabling women to help each
other make health and lifestyle changes. The women, who are African American, Native American
(Coharie tribe), Latina, or white, live in Sampson and Duplin Counties in eastern North Carolina,
where unemployment has been high since the mid-1990s, when tobacco and textile production
ceased in the area. At the time, the poverty rate was close to 20%.
Fifteen years of researcher–community collaboration in the area has indicated that income,
education, occupation, and community factors are playing a greater role in health than individual
health behaviors or access to healthcare. The economic depression contributed to a sense of
hopelessness that made some women less motivated to address health behaviors. The women
who participate in this community-owned business receive a living wage, training in textile
production and business management, health insurance, a chance to pursue higher education, and
access to health promotion interventions primarily concerning nutrition and physical activity (CDC,
2017a; HOPE (Health Opportunity, Partnerships, Empowerment) WORKS, 2017).
CASE 2
An organization known as Program to Encourage Active, Rewarding Lives for Seniors (PEARLS)
was developed at the Health Promotion Research Center of the University of Washington to help
combat depression in seniors. The CDC provided funding for this program, which lasts for six
months and consists of eight in-home visits by a counselor.
Minor depression is characterized by loss of interest or pleasure in activities, and feelings of
sadness or hopelessness. It strikes about 14% of seniors, many of whom are dealing with isolation,
loss of friends and family, and debilitating chronic diseases. For example, seniors who have
diabetes are more than twice as likely as other people of the same age to have depression. One
client who had limited vision said, “I just can’t contribute anymore.” Another woman spent weeks
lying hopelessly in bed after recovering from pneumonia. Counselors help clients identify and write
down the factors contributing to their depression as well as develop and evaluate solutions. One
counselor said, “…just like the cold or the flu has symptoms, so does depression.…There is a close
connection between depression and unsolved problems. If the problem is, ‘I can’t do anything
worthwhile,’ the goal can be, ‘Find something I can do on a small scale that will be beneficial to
other people.’” Both the client with limited vision and the one recovering from pneumonia found
help in PEARLS, which uses structured behavioral therapy and positive events to resolve
depression. A counselor helped the woman with limited sight find ways to help others, such as
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knitting baby blankets and calling isolated people, which were activities suited to her skills,
interests, and personality. Other components of PEARLS include scheduling social and physical
activities and planning simple pleasures, such as taking a walk, calling a friend, or soaking in a hot
bath.
In its 3-year study phase, PEARLS eliminated depression completely for more than a third of
participants. Of seniors in a comparison group who received usual care, only 12% reportedly
eliminated depression completely. PEARLS also reduced depressive symptoms by half for 43% of
participants—with almost three times as many people achieving that result as in the comparison
group. Investigators have also found that PEARLS reduces hospitalizations, for any reason, among
participants. Researchers attribute the success of PEARLS to the behavioral therapy, which affects
the same parts of the brain as some antidepressant drugs. Behavioral therapy can be more
permanent than drugs, is less expensive, and can be used outside a clinical setting. Because the
clients come up with solutions of their own, they feel capable of following through on them (CDC,
2015e).
CASE 3
A project called Planet Health, developed by the Prevention Resource Center on Nutrition and
Physical Activity at Harvard University, combines important messages on nutrition and physical
activity with four academic subjects in public schools: social studies, math, science, and language
arts. Even though obesity affects many American children, officials still find they must eliminate
health classes, nurses, and physical education from public schools because of tight budgets.
The Planet Health curriculum meets Massachusetts academic standards and includes lessons
designed to fit into a teacher’s busy schedule. The program consists of 24 lessons a year, six in
each of the four main subjects—language arts, math, science, and social studies—plus special
activities for physical education classes. Planet Health also challenges students to turn off
televisions. Harvard researchers have shown that television viewing is directly related to obesity.
The curriculum encourages children to spend less time watching television, playing video games,
or using the computer—to reduce their “screen time” to two hours or less per day. The curriculum
also includes innovative exercises to learn more about food and the properties of food and styles of
eating that make kids healthy.
In a two-year study at 10 middle schools, Planet Health reduced the amount of time boys and
girls watched television and also lowered the prevalence of obesity among girls. According to
another study, the program will save money for children later in life; for every dollar spent on the
program in middle school, $1.20 in medical costs and lost wages will be saved by the time the
children reach middle age. Blue Cross Blue Shield of Massachusetts picked up Planet Health as
part of an overall school wellness program, and it is now used in more than 120 schools across the
state. The YMCA has also started offering a version of Planet Health during after-school programs
in Massachusetts. Since 2001, when the curriculum was put into book form, more than 4,000
copies have been sold. Researchers are working on a new edition that will add and update
information about sugar-sweetened beverages, the different types of fats, and whole grains.
Researchers and administrators say Planet Health’s greatest success can be seen in the
lifestyle changes it inspires—not just in the classroom, but in the community. Schools that use
Planet Health have begun to hold fitness days for families, and teachers have started yoga classes
for themselves (CDC, 2017f).
INTRODUCTION
According to Glanz, Rimer, and Viswanath (2015), health is a quality, an ability to adapt to
change, or a resource to cope with challenges and processes of daily living. Whether health is
defined as an attribute that helps individuals, families, and communities navigate the stormy sea
of life, or as an ideal state of physical, social, and mental well-being, the notion of health being
the absence of disease is superseded by a complex relationship between health and a person’s
sense of wellness. For example, it is true that people who make up neighborhoods, communities,
and populations can die from lack of health, but they can die well (i.e., with a sense of well-
being and at a high level of human functioning). This chapter explores models of health
promotion through public health science, with specific emphasis on models of risk prevention
and behavior change as vehicles to well-being. In this chapter, “disease” refers to illness or
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injury not just at the individual level, but also from the perspective of the larger community of
people in neighborhoods, cities, states, countries, and the world. An important underpinning to
every effort described in this chapter is the ethical imperative to address health as a proactive
approach to wellness. The chapter ends with the discussion of an inclusive and integrative
behavior change model that describes the need to consider multiple influences on positive health
outcomes. This is in contrast to single-focused measures that have been used in the past to
develop health promotion interventions and healthcare policy. The issue of African American
women living with human immunodeficiency virus/acquired immunodeficiency syndrome
(HIV/AIDS) in the United States is used as an example of how a formidable infectious and
communicable disease can be addressed using this model to identify key components that
influence behavior change. It also illustrates how interdisciplinary teams that include nurses
identify and foster health promotion and policy change.
Every human being is the author of his own health or disease. Buddha
HEALTH PROMOTION, DISEASE PREVENTION, AND
RISK REDUCTION AS CORE ACTIVITIES OF PUBLIC
HEALTH
Health has different meanings to individuals, families, and communities. Nurses working with
clients in communities with a focus on population-based health gain knowledge about subjective
well-being by observing individuals, families, and communities who are directly participating in
improving their health. Individuals and groups interact in partnership with public health
professionals to enhance their well-being and maximize their progress toward health, rather than
just avoid illness, such as in the case studies at the beginning of this chapter.
Improving health is a journey of discovery among health professionals, the science of public
health (epidemiology), and people who are motivated to effect change across varied and
complex influences on well-being. Ten key components of public health practice are central to
keeping populations healthy and safe. Nurses promote health through prevention efforts by
belonging to interdisciplinary teams that address the following core activities (American Public
Health Association, 2017):
1. Providing essential input to interdisciplinary programs that monitor, anticipate, and respond to
public health problems in population groups, regardless of which disease or public health
threat is identified
2. Evaluating health trends and risk factors of population groups and helping to determine
priorities for targeted interventions
3. Working with communities or specific population groups within the community to develop
public policy and targeted health promotion and disease prevention activities
4. Participating in assessing and evaluating healthcare services to ensure that people are
informed of available programs and services and are assisted in the utilization of available
services
It is important to understand that promoting health and wellness behaviors in individuals as
members of a group or population depends on addressing all 10 core activities of public health
simultaneously as an integrated whole. Each of these areas is addressed throughout this chapter
in more detail. In this chapter, health promotion is presented through frameworks or models that
can direct nursing practice to (1) focus on how to approach this complex and almost
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overwhelming concept of health at the population level; (2) become knowledgeable about how
and why behavior change needs to be addressed, related to disease prevention and health
promotion, depending on levels of control over an outcome; and (3) devise creative, cost-
effective interventions and policy changes related to levels of prevention.
HEALTHY PEOPLE INITIATIVES
The Healthy People initiatives and Healthy People 2000, 2010, and 2020 (HP 2000, HP 2010,
and HP 2020) are a set of health objectives established nationally to address keeping individuals,
families, and populations safe and healthy (Koh, Blakey, & Roper, 2014). Chapter 4 discusses
international approaches to public health issues on the global scale. In the United States, the
CDC promotes health at the global level by promoting the sharing of knowledge, tools, and
other resources as a global responsibility, as well as creating partnerships throughout the world
through health promotion, health protection, and health diplomacy (CDC, 2017b). From a
national perspective, HP 2020 is a guidepost for nurses and interdisciplinary teams in
community and public health. HP 2020 has historic roots in efforts by the U.S. Surgeon General
to establish a definitive plan for state and community organizations to address the health of
citizens. The effort to establish measurable objectives was developed through a planned process
that involves consulting healthcare experts locally and nationally, collecting data obtained from
studies of population illness (morbidity, natural progression of disease and injury, and mortality
patterns over time), engaging businesses in the process, and listening to the needs and barriers
identified by citizens in the United States. HP 2020 is designed to achieve two primary goals: (1)
to increase quality and years of healthy life and (2) to eliminate any barriers to accessing care,
specifically through health disparities. Currently, 42 topic areas with congruent objectives and
data are available for consideration. Of this current grouping, new seminal areas have been
identified that include genomics, global health, healthcare-associated infections, LGBT (lesbian,
gay, bisexual, and transgender) health, preparedness, and social determinants of health (HP
2020, 2017a). Box 5.1 lists all the new areas of interest in HP 2020. Please note that HP 2030 is
on the way (HP 2020, Development of the National Health Promotion and Disease Prevention
Objectives for 2030, 2017b).
Where would the first case study, about Threads of Hope, fit in terms of addressing HP
2020 indicators and focal areas? Identifying specific indicators and focal areas that
support health promotion means very little unless professionals in community or public
health practice, such as nurses, consider partnerships to be necessary in the promotion
of community health. Do you think that Threads of Hope addresses a particular focal point
that is missing from the HP 2020 project?
Knowing how to address the need for change and the actual change at a personal, family,
and community level must be based on science—evidence based on rigorous understanding of a
problem. Specific actions that can best achieve positive health outcomes can then be determined.
Consideration must be given to realistic availability of solutions, cost and benefits, and the
degree to which individual people will accept these approaches. It seems too simple to assume
that promoting identified HP 2020 goals and objectives in tandem with known scientific
methods will promote the health of the nation. Many complicated factors affect the process of
educating the public about health, such as people’s knowledge of their risk of disease,
subsequent health outcomes, and the personal or communal choice to be healthy. It is necessary
to consider individual and family perspectives about health and wellness, as well as community
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definitions of these concepts.
5.1 Healthy People 2020 New Focal Areas
1. Adolescent health
2. Blood disorders and blood safety
3. Dementias, including Alzheimer disease
4. Early and middle childhood
5. Genomics
6. Global health
7. Healthcare-associated infections
8. Health-related quality of life and well-being
9. Lesbian, gay, bisexual, and transgender health
10. Older adults
11. Preparedness
12. Sleep health
13. Social determinants of health
Source: http://www.healthypeople.gov/2020/about/new2020.aspx.
Student Reflection
I will never forget giving a presentation to a group of men and women in a senior center as
my first effort in trying to convince them that cholesterol was a silent killer. After sharing
age- and education-specific information from the American Heart Association and the CDC
demonstrating dietary and exercise choices to promote health, one man got up and said,
“What difference does it make; we all are going to die from something and I would rather eat
fried foods than not eat them.” Many people around him nodded their heads, and I realized
that until people are convinced that scientific evidence applies to them and that their choices
affect their personal well-being, family, and increasing costs in healthcare, we are stuck with
lofty goals by tradition rather than through transformation into something new.
The role of the community and the public health nurse in promoting health encompasses
advocacy, community organizing, health education, and political and social reform in
collaboration with agencies and community members (Kulbok, Thatcher, Park, & Meszaros,
2012).
Thus, it is critical to seek out health promotion and behavior change models to provide
direction in making health promotion, disease prevention, and risk reduction efforts meet the
realities of communities and the agencies serving communities.
ROAD MAPS TO HEALTH PROMOTION
Epidemiologic Model and Prevention
Although illness care is a primary component of the art and science of nursing, health promotion
and disease prevention are important, closely related public health efforts in achieving the goals
of nursing care. “Health Promotion is the art and science of helping people discover the
synergies between their core passions and optimal health, enhancing their motivation to strive
for optimal health, and supporting them in changing their lifestyle to move toward a state of
optimal health. Optimal health is a dynamic balance of physical, emotional, social, spiritual, and
intellectual health. Lifestyle change can be facilitated through a combination of learning
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http://www.healthypeople.gov/2020/about/new2020.aspx
experiences that enhance awareness, increase motivation, and build skills and, most important,
through the creation of opportunities that open access to environments that make positive health
practices the easiest choice” (O’Donnell, 2009, p. 4).
In this chapter, the word “disability” is replaced with the words “physically challenged” or
“differently abled” to emphasize that there is always “ability” to deal with structural and
functional problems (Smeltzer, Robinson-Smith, Dolen, Duffin, & Al Maqbali, 2010).
Community health nurses are focused specifically on modifiable risks of acquiring disease.
This requires nurses to analyze trends in risk surveillance data and consider the physical,
emotional, and psychosocial challenges people face when confronting disease, physical
stressors, and the possibility of premature death. Public health science uses in-depth processes of
data collection across the natural history of disease to define trends, and in this way assists
nurses and other public health officials in prioritizing the steps they need to take to minimize
risk and improve the quality of care in populations.
Practice Point
The Morbidity and Mortality Weekly Report (MMWR), published weekly by the CDC and
available online, contains useful public health information and guidelines that address trends
in illness and disease. MMWR readership predominantly consists of physicians, nurses,
public health practitioners, epidemiologists and other scientists, researchers, educators, and
laboratory-oriented professionals. The data provided in the MMWR come from state health
departments and compare morbidity and mortality rates annually. These records are very
helpful to public health clinicians because they supply information that promotes a proactive
approach to resource planning when the rates are increasing (CDC, 2017c).
Although the morbidity and mortality data reports are quantitative, it is important to
understand that in most cases, perceptions of health or well-being on the part of individuals,
families, and communities are subjective. The science of diagnosis and healthcare follow-up
may be present, but it is the subjective perceptions of others that often determine a person’s
willingness to participate in health promotion initiatives. For example, if people perceive that
health or “low risk” means the absence of acute symptoms or the absence of disease, many of
them may consider themselves healthy and in no need of making an effort toward health
promotion. In fact, they could actually be living with real, chronic morbid or comorbid
conditions such as diabetes, hypertension, congestive heart failure, or hepatitis C, or they may be
at risk for acquiring these conditions.
Keeping in mind the subjectivity of wellness, how would you develop outreach in the
PEARLS program to elderly members of the community who are isolated and may want
to preserve their privacy?
What would be a convincing argument to make to women who are not involved in
making bags with Threads of Hope? How could you convince them that doing so would
actually be an act of health promotion and would have a positive effect on their well-
being?
Health promotion is a strategy that is used in partnership with health professionals,
individuals, and communities. It includes all three levels of disease prevention and has the
potential to or can directly change health and well-being. Healthcare professionals or people in
communities can institute these strategies. In reality, disease and physical challenges can occur
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at any time. In many cases, predictions made from statistical conclusions (probabilities) through
the science of epidemiology are the basis for determining the possibility of getting a disease or
becoming physically or emotionally challenged (see Chapters 6 and 7). Analysis of
epidemiologic data occurs while health professionals consider what happens at the
prepathogenic, early pathogenic, and late pathogenic phases of diseases and physical or
emotional disorders. The basis of this scientific approach is the study of causal relationships that
yield pathology. Epidemiologists make conclusions about the direction of further study by
considering (1) relative risk of an agent causing a problem (e.g., smoking and lung cancer); (2)
consistency (i.e., similar results across other studies); (3) exposure (i.e., correlation with a
certain distinct pathologic condition, such as for asbestos and mesothelioma); (4) timing (i.e.,
cause and resulting condition both occurring within a short period of time, such as inhaled fumes
and an asthma attack); and (5) plausibility (i.e., existence of a biologic process) (Wakeford,
2015).
The central idea here is to prevent illness and physical or emotional challenges from
occurring. Or, if they do occur, the goal is to lessen their effects and enhance clients’ quality of
life. The science of epidemiology helps health professionals such as nurses, and coalitions of
interested citizens, develop interventions for the stages of illness or physical or emotional
challenges, which enhance the quality of life of individuals and communities. In Figure 5.1,
health and wellness change along a developmental timeline. After a disease or physical
challenge is identified, it progresses and eventually becomes life threatening. Although this
pattern appears to be linear, in reality the linearity is theoretical. Illness occurs erratically; there
are times of stability and times of acute and stressful exacerbation (Yohannes et al., 2017). At
each pathogenic level, health promotion is intimately linked to prevention.
FIGURE 5.1 Natural history of disease and levels of wellness/illness continuum.
Levels of Prevention
Activities classified as “preventive” are directed at eradicating, eliminating, or reducing the
impact of disease and injury on individuals and populations, thus promoting health instead of
disease (Gasink & Lautenbach, 2008). Disease in this context refers to communicable and
noncommunicable conditions. Examples of noncommunicable diseases (noninfectious diseases
or physical or emotional challenges) are substance abuse, obesity, depression, or workplace
injuries. Physical or emotional challenges, as well as genetic disorders, are conditions that are
generally noncommunicable in nature but cause structural and functional changes that are not
statistically normal in the general population. Some examples include glaucoma, scoliosis,
Down syndrome, neurofibromatosis, hearing loss, and learning disabilities. Communicable
diseases are caused by pathogens (e.g., viruses and bacteria) that multiply and enter hosts
through a variety of mechanisms and influences. These diseases have the capacity to cause
infections across living organisms, with life-threatening and potentially chronic effects.
Examples include HIV, malaria, swine flu, and smallpox (Webber, 2016).
What type of diseases (communicable or noncommunicable) do the programs in each case
study address? Could addressing noncommunicable diseases or physical or emotional challenges
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through these programs influence vulnerability or resistance to communicable diseases in these
populations?
To understand specific health promotion approaches, nurses should think in terms of three
levels: primary, secondary, and tertiary prevention. The individual person’s or the community’s
state of health and well-being, as studied within the science of identification, description, and
prediction of illness, serve as the basis for the levels.
Primary Prevention
When an individual or a group is considered in good health and shows no signs or symptoms of
disease or physical challenges, nurses in interdisciplinary teams and community partnerships are
involved in primary prevention. They seek to maximize health and wellness, using a variety of
strategies, at a time when they or the clients have some level of control over the trajectory of
health and wellness. Examples of primary prevention include the use of seat belts, hand
washing, proper preparation of food, exercise, and balanced nutrition (Box 5.2).
Surveillance of healthy populations is a continual, dynamic method of gathering data about
the health of the general public for the purpose of primary prevention of illness. The CDC and
individual states monitor emerging and endemic health hazards that occur in community settings
on an ongoing basis. Data are systematically collected, analyzed, interpreted, and disseminated
so that they can be used to develop activities and programs that will reduce morbidity and
mortality and improve health. The functions of public health surveillance are described in Box
5.3. In addition, local surveillance of community populations can be obtained by using various
records—from clinics, community health and visiting nurses, worker’s compensation
settlements, personnel files, and the like.
5.2 Examples of Primary Prevention
Immunizations
Driver’s safety classes
Healthy water quality
Healthy air quality
Health education classes
Improving safety designs of equipment
Fire safety
Decreasing exposure to sun
Use of environmentally safe products
Using seat belts
Using earplugs and safety glasses
5.3 Functions of Public Health Surveillance
Estimating the impact of a disease or injury
Portraying the natural history of a health condition
Determining the distribution and spread of illness
Generating hypotheses and stimulating research
Evaluating prevention and control measures
Facilitating planning for program activities
Detecting outbreaks
Source: Centers for Disease Control and Prevention. (2004). Framework for evaluating public health surveillance systems for early detection of outbreaks.
Morbidity and Mortality Weekly Report, 53(RR-05), 1–11.
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It is critical to understand that there are situations in which primary prevention is difficult to
achieve at the individual or community level. Sometimes, even with professional support and
healthcare information, clients are unable to avoid experiencing disease or physical challenges
because the causative agents are “not modifiable,” for example, genetic conditions, unexpected
tragedies (natural disasters such as floods or tornados), and situations in which there is no
developmental control, such as the effect of secondhand smoke. These would be considered
conditions for which primary prevention strategies are difficult to implement and not modifiable.
Great things are done by a series of small things brought together. Vincent Van Gogh
An important example of primary prevention is the availability and dispensing of vaccines
developed to enhance the body’s ability to create antibodies to either live or attenuated antigens.
This approach protects individuals and populations from getting communicable diseases or
lessens the severity of the disease. Immunization with vaccines is an effective way to promote
primary prevention. Nurses who actively participate in the immunization of children in well-
child clinics, young adults in university health clinics, and adults in international travel clinics
are promoting primary prevention of measles, human papillomavirus (American Cancer Society,
2017), and yellow fever, respectively. See Box 5.4 for a list of vaccine-preventable diseases
(CDC, 2017g).
According to the CDC (2017g), immunity to a disease results from the presence of
antibodies to that disease. Antibodies are proteins produced by the body to neutralize or destroy
toxins or disease-carrying organisms, and they are disease-specific. For example, antibodies to
measles protect a person who is exposed to measles but have no effect if the person is exposed
to mumps. There are two types of immunity: active and passive.
5.4 Vaccine-Preventable Diseases
Anthrax
Cervical cancer
Diphtheria
Hepatitis A
Hepatitis B
Haemophilus influenzae type b (Hib)
Human papillomavirus (HPV)
Influenza (flu)
Japanese encephalitis
Lyme disease
Measles
Meningococcal disease
Monkeypox
Mumps
Pertussis (whooping cough)
Pneumococcal pneumonia
Poliomyelitis (polio)
Rabies
Rotavirus
Rubella (German measles)
Shingles (herpes zoster)
Smallpox
Tetanus (lockjaw)
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Tuberculosis
Typhoid fever
Varicella (chickenpox)
Yellow fever
Active immunity results when exposure to a disease organism triggers the immune system to
produce antibodies to that disease. Exposure to the disease organism can occur through infection
with the actual live organism (resulting in natural immunity) or introduction of a dead or
weakened form of the disease organism through vaccination (vaccine-induced immunity). Either
way, if an immune person comes into contact with a disease, his or her immune system will
recognize it and immediately produce the antibodies needed to fight it. Active immunity is long-
lasting, sometimes lifelong.
Practice Point
It may be important for nurses working with clients older than 60 or in communities where
chronic illnesses abound to consider the use of the vaccine against shingles. Shingles is a
painful localized skin rash, often accompanied by blisters, caused by the varicella zoster
virus (VZV), the same virus that causes chickenpox. Any person who has had chickenpox
can develop shingles because VZV remains in the nerve cells of the body after the
chickenpox infection clears and can reappear many years later. Shingles most commonly
occurs in people 50 years of age or older, in those who have medical conditions that keep
the immune system from working properly, or in those who receive immunosuppressive
drugs. The vaccine against shingles is recommended by the Advisory Committee on
Immunization Practices (ACIP) to reduce the risk of this condition and its associated pain in
people 60 years of age or older. See http://www.cdc.gov/vaccines/vpd-
vac/shingles/default.htm for further information.
Passive immunity results when a person is given antibodies to a disease rather than
producing them through his or her own immune system. A newborn infant acquires passive
immunity from its mother through the placenta. This type of immunity can also occur with the
use of antibody-containing blood products such as immune globulin, which may be given when
immediate protection from a specific disease is needed. This is the major advantage to passive
immunity; protection is immediate, whereas active immunity takes time (usually several weeks)
to develop. However, passive immunity lasts only for a few weeks or months. Only active
immunity is long lasting. Herd immunity is a type of passive immunity; the presence of a large
proportion of immune individuals in a community decreases the chances of contact between any
infected people and susceptible individuals. An entire population need not be immune to prevent
an epidemic of a disease. Herd immunity is often attributed to either antibody formation, which
occurs when populations acquire an illness in a non–life-threatening form as a result of medical
care interventions or reduced virulence, or to vaccination programs.
Secondary Prevention
Secondary prevention is a planned effort to minimize the impact of a disease or injury once it
is in effect. Secondary prevention is used at an early stage of pathogenesis or physical or
emotional challenges. It includes, through the science of screening, initial recognition of the
stage of an illness or physical challenge, which can progress to greater or lesser severity over
time. The types of screening procedures and examples are found in Box 5.5.
Women diagnosed with HIV/AIDS and children who are identified as having scoliosis are
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examples of the need for secondary prevention. To screen effectively for the presence of these
conditions, a test should be (1) cost-effective, meaning that the cost of producing and
distributing the screening tool is justified by the positive effect on protecting the public; (2) easy
to use; (3) available to large sectors of the population at risk; (4) sensitive and specific enough to
identify true positives and true negatives; (5) backed by a healthcare infrastructure that can
implement programs of care for people who have a verified risk of disease or physical challenge;
and (6) acceptable to clients. Sensitivity and specificity are criteria used to measure how valid
and reliable a screening test can be. Sensitivity measures the strength of a screening test’s ability
to correctly identify people who have a disease or physical challenge. Specificity measures the
strength of a screening test’s ability to correctly identify people who do not have a disease or
physical challenge. In an ideal world, all screen tests should have both high sensitivity (100%)
and high specificity (100%). The 100% level is approached but not met. Thus, confirmatory
studies need to be undertaken to verify the presence of the disease. In the case of diseases that
could be fatal, sensitivity is crucial (Box 5.6). For nurses participating in screening and
delivering results of screening, it is most important to be aware of the test’s limitations of
validity and reliability and to remember that serious economic costs to communities and health
systems can be incurred when testing is not accurate. Nurses should also be aware of the
psychological costs when a false-positive result occurs, which can create debilitating fear and
anxiety. Calculation of sensitivity and specificity is discussed in Chapter 7.
5.5 Types and Examples of Screening Procedures
Mass screening: applied to entire populations
Blood lead level screening
Papanicolaou (Pap) smears
Phenylketonuria of newborns
Selective screening: performed for specific high-risk populations
Mammographies for young women at high risk for cancer
Tuberculin tests for hospital employees
Occupational diseases
Exposure to radiation
Multiphasic screening: a variety of screening tests applied to the same population on the same
occasion. Data can be used for establishing baseline data in a healthcare facility and for risk factor
appraisal
Series of tests performed on a single blood sample
Periodic surveillance of drug therapy
Monitoring the stage of an illness
Case finding: clinician’s search for illness as a part of a client’s periodic health examination
Monitoring the health of individuals in a case load
Source: U.S. Preventive Services Task Force. (2002). Guide to clinical preventive services (3rd ed.). McLean, VA: International Medical Publishing.
5.6 Sensitivity and Specificity
Sensitivity = testing correctly to identify persons who have the disease/physical challenge
High sensitivity: True positive (people who have the disease and test positive)
Low sensitivity: False negative (people who have the disease but test negative [normal])
Specificity = testing to identify persons who do not have the disease
High specificity: True negative (people who do not have the disease and test negative)
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Low specificity: False positive (people who do not have the disease but test positive [abnormal])
Student Reflection
I recently participated in an immersion trip to Central America as a nursing student. I kept
asking questions to our guides about disease screening and secondary prevention related
to breast cancer, HIV, human papillomavirus, cholesterol, and high blood pressure. In
several instances, it was clear that no screening was being performed in some of the areas.
I was upset that screening, which has been established as reputable and accurate, was not
occurring—especially in population groups that suffered from poverty and suboptimal living
situations (lack of running water, outdoor ditches for latrines, garbage dumps as housing,
unavailable barrier protection with sexual intimacy). After discussions with local health
officials, it was clear that the lack of health personnel to offer the screening, the cost of the
necessary materials, and the severe lack of infrastructure to follow up if people tested
“positive” meant that there could be no screening at all. This stunned me and allowed me to
understand the economic and ethical considerations related to screening and secondary
prevention.
For example, when a client is tested initially for HIV with the OraQuick HIV test for oral
fluid, a test supported by the CDC based on many years of serum testing (CDC, 2017d), the
healthcare team has a responsibility to verify these findings despite the high sensitivity and
specificity of this test (99.3% and 99.8%, respectively). If a person tests positive for HIV, the
initial result is confirmed by using an HIV antibody test known as the enzyme-linked
immunosorbent assay (ELISA), which was developed in the 1980s (Homsy, Thomson-
Honnebier, Cheng-Mayer, & Levy, 1988). After all confirmatory HIV testing has been
completed and infectious disease experts, including physicians and nurses specializing in
infectious disease, have reviewed the findings, these professionals may consider the client to be
at the stage of illness early in the trajectory of pathogenesis. For example, the client may have a
low viral load or absent viral load with a CD4 count greater than 200 cells/µL. This would mean
that the client has the ability to fight infection and that replication of the virus is not high.
Involving this client in medical care, with the support of infectious disease services such as
housing, nutrition services, counseling, addiction recovery, financial support, and primary care
services, offers him or her the potential to maintain health and wellness.
Some may question the use of the word “prevention” here, when indeed the person already
has a confirmed diagnosis of HIV. In this context, secondary prevention means that efforts are
being made to minimize (1) any further extension of the HIV illness to “full-blown” AIDS (CD4
count less than 200 cells/µL, with detectable viral loads); (2) the need to use antiretroviral
medications, which have severe and debilitating side effects; (3) any exacerbation of other
comorbidities that could affect HIV status, such as intravenous drug use; and (4) any possibility
of communicating the virus to others. People living with HIV/AIDS need to have support to
counter perceptions of stigma and discrimination that can lead to depression. Depression can be
linked with decreased healthcare adherence, which can cause HIV to worsen and AIDS to
develop. If these clients are sexually active and not using safe sex practices, which include not
maintaining recovery from substance abuse and not using barrier protection, the virus will be
spread to others and they, in turn, may become infected with another strain of the virus.
Is it possible to screen for the problems identified in the three case studies (depression,
nutrition, and physical activity)? How would this screening occur? What resources would be
used?
In a school screening program for idiopathic scoliosis, a school nurse may find that a child
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has an anatomical abnormality. Depending on the stage of the abnormality, the school nurse
makes appropriate referrals on the basis of orthopedic and neurologic screening standards
(Scoliosis Screening, 2017). Generally, scoliosis screening is conducted because of evidence-
based predictions of development at a cross-section of time when identification of the problem is
critical to timely interventions.
Sometimes, when screening is completed, the client’s level of disease or injury is found to be
at a more advanced stage and is not considered to have been “caught early.” This is true for
many women of color who are tested for HIV. History of intimate partner violence may inhibit
personal motivation to receive care or may create situations in which the client may not be free
to get care. Lack of healthcare insurance, mental health challenges, and active substance
addictions can also cause women to delay testing for HIV. Subsequently, when they are
diagnosed, they may be very ill, experiencing the life-threatening chronic and/or end stage of the
illness called AIDS (Earnshaw, Smith, Chaudoir, Lee, & Copenhaver, 2012).
The U.S. government requires screenings for some conditions and not others. Some
screenings are mandatory because of the physical and economic costs that may result if they are
not performed (e.g., newborn screenings). On the other hand, some people see screenings as
stigmatizing and may experience feeling of vulnerability or discrimination in a variety of ways
(interpersonally, with regard to health insurance, and at work).
Tertiary Prevention
Tertiary prevention is the long-term management and treatment of clients with chronic
conditions, such as HIV/AIDS and cancer, so that quality of life is maintained, despite the fact
that the condition will not improve and will most likely worsen. Tertiary prevention includes
rehabilitation and palliative care. AIDS-related cancers such as lymphoma are not uncommon.
In general, cancer is a life-threatening illness that may occur along with other conditions.
Cardiovascular disease, diabetes, and pulmonary disease may be present as well and require
clinicians such as nurses to plan clients’ cancer treatment, continue to assess HIV/AIDS disease
progression, watch for opportunistic infections, and control pain or other side effects of the
treatment. Care also includes supporting life choices that bring emotional comfort to clients such
as family involvement, decreased isolation, supportive spiritual development, and organized
help from communities.
Practice Point
Public health nurses should become familiar with those resources available to communities
that can help address prevention at all levels. Local and state health departments have
directories of both publicly and privately funded prevention support programs and services,
and many hospital systems provide directories for clients to consider in their time of need.
Finally, internet-based directories are being created to help citizens find a network of services
in their community or region.
For example, nurses involved in cardiac care might do the following: Rather than
envisioning end-stage cardiac rehabilitation as the focus of prevention after a cardiovascular
event, or when cardiovascular disease is prominent in a community, they could think about
approaches to prevention that are inclusive of all stages of health promotion and prevention.
Many cardiovascular centers provide unique, prevention-as-treatment approaches for
communities with high incidence and prevalence rates for heart disease or an unusual number of
people who are at risk for developing heart disease. Interdisciplinary teams of clinicians,
including nurses, offer clients and communities the strategies and tools necessary to reduce their
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risks. For example:
FIGURE 5.2 Natural history of disease, levels of wellness/illness, and levels of prevention
continuum.
Primary prevention programs: Clients and families who are at risk for heart disease because of
family history are treated. This level of prevention focuses on evaluation of personal risks in
light of family history to help clients reach their heart health goals.
Rehabilitation: Cardiac rehabilitation programs assist clients and families in recovery from
heart attacks, angioplasty, and cardiac surgery and provide them with important information to
make lifestyle changes to prevent recurrence.
Associated comorbidities programs: Clients and families at risk for, or who already have,
diabetes are assisted in weight loss and in managing other cardiac risk factors such as
hypertension and high cholesterol. In addition, they are assisted in managing the combination
of effects the illnesses have on daily life.
Therapies can include monitored exercise, stress management, yoga and meditation,
nutrition counseling, smoking cessation, weight management, and stress testing.
In summary, prevention efforts are intended to decrease the physical, psychological, and
economic costs of chronic, serious illness as well as physical and emotional challenges. Efforts
to address these potential costs use an epidemiologic model of levels of prevention throughout
the natural history of disease (prepathogenesis, early pathogenesis, and pathogenesis across
time). These efforts include the use of immunizations, screening, and rehabilitation (see Figs.
5.1 and 5.2). Health promotion using this model is based on public health science and
surveillance of trends related to diagnoses that are identified through sensitive and specific
screening tests and the natural history of particular diseases. Nurses in public and community
health practice, being advocates of decreasing risk in populations, use this model to care for
individuals, groups, and communities through instrumental care or through health policy.
BEHAVIOR MODELS
The focus of prevention efforts is the development of culturally relevant and gender-sensitive
interventions that demonstrate positive outcomes in health and well-being. To promote health
and well-being, one of the key approaches of primary, secondary, and tertiary prevention is a
focused effort to change behaviors that have a negative impact on the natural history of disease
and to promote behaviors that have a positive impact on the natural history of disease.
Approaching individuals and groups about behavior change must incorporate knowledge of
diverse client perspectives and include the use of counseling skills and motivational
interviewing.
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Motivational interviewing, which was developed by Rollnick and Miller (1995), is defined
as a “directive, client-centered communication style for eliciting behavior change by helping
clients/[groups] to explore and resolve ambivalence” (Motivational Interviewing, 2017). It is a
focused, goal-directed approach (Box 5.7). It originated with problem drinkers who presented
themselves to clinicians; the drinkers needed help to change a behavior, although they wanted to
continue it (ambivalence). To address behavior change using this method, the motivation comes
from the client and is not imposed by a clinician. The client needs to resolve ambivalence to
change a behavior with autonomy. Persuasion on the part of the clinician only intensifies
resistance. The communication style is therefore one of directing the client to examine and
resolve ambivalence. This method does not (1) argue with a group or community by insisting it
has a problem that needs to change, (2) offer advice without actively encouraging group-
identified choices, (3) give advice while the group is put in a passive role, (4) impose diagnostic
labels, or (5) use coercive tactics. Motivational interviewing teaches all clinicians that making
efforts to change behavior is based on a clinician–client exchange. Whether individuals or
groups represent specific interests in communities, participation in decision making, informed
consent, advocacy, and health literacy must be considered in using models of behavior change.
5.7 Actions Involved in Motivational Interviewing Behaviors for Clinicians
Seek to understand the person’s frame of reference through reflective listening.
Express acceptance and affirmation.
Elicit and select reinforcing motivational statements of problem recognition, concern, desire, intention,
and ability to change.
Monitor the degree of readiness to change and ensure that resistance is not generated by clinician control.
Affirm freedom of choice and direction.
Source: www.motivationalinterview.org/clinical/whatismi.html.
The quality of health at the individual, family, and community level is influenced by many
factors. As discussed earlier, decreasing health disparities was an objective of HP 2010 and was
identified as a key component in addressing barriers for some community dwellers who may
desire to keep healthy and are ready to do so. So, despite the desire to change a behavior, there
may be social, economic, or biologic nonmodifiable influences that prevent change. Behavior
health models describe, explain, or predict prevention health behaviors. The models discussed
here are available to help nurses consider creative methods of implementing the preventive
measures identified earlier in this chapter. Although they appear to stand alone as unique and
unrelated frameworks of behavior change, consideration of multiple influences cannot help but
foster health, as in a “perfect world” (i.e., one in which nurses understand this concept and use
all these methods together). The following section describes the theoretical frameworks of
behavior change and many of the behavior change models that have been used to address
health promotion and risk reduction (Glanz et al., 2015). This section ends by describing the
ecologic model. The ecologic model is a model that considers multiple influences as a way to
address complex behaviors to promote health at the individual, environmental, and policy level.
Learning Theories
According to Skinner (1953), health behaviors are seen as incremental steps toward a final goal.
In the so-called learning model, a goal is established and reinforced by the nurse, with rewards
given for partial accomplishment, if necessary. Incremental increases are then made as the
pattern of behavior is shaped toward a specific goal. Reinforcement is used as motivation to
either continue or discontinue a behavior. This model uses extrinsic, or external, factors for
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reinforcement. Although extrinsic factors are successful in the adoption of initial behavior,
intrinsic, or internal, factors are more effective in long-term adherence. Praise, encouragement,
or prizes are examples of extrinsic rewards for the initial adoption of healthy behaviors. Feelings
of accomplishment and changes in personal health habits are examples of intrinsic rewards that
are often used in the long-term adoption of healthy behaviors.
A good example of the use of a classic learning model is the syndicated weight reduction
program called Weight Watchers. Through the use of group encouragement, incremental weight
loss is rewarded with public recognition and even a presented “ribbon” or “star” to indicate
success. Intrinsic rewards, including the ability to show successful weight loss, as well as
leadership opportunities within the program, can be helpful to people just beginning Weight
Watchers, and have been documented within the past 10 years (Mitchell, Ellison, Hill, & Tsai,
2013).
Nurses in home care situations who work with clients with chronic illnesses, such as
diabetes, congestive heart failure, and hypertension, have used the learning approach
successfully while being actively involved in teaching and surveillance of client care. The
difficulty with this approach is that there is a high level of expectation that intrinsic rewards will
last over time, despite the influence of social norms and economic conditions. For example, in
inner city and rural area communities, it is not uncommon to find a dearth of grocery stores,
fresh fruit and vegetable stands, and farmer’s markets as options for purchasing low-calorie,
low-fat, and low-cost healthy foods. Instead, small stores sell high-calorie, high-fat processed
foods (Liu, Stephenson, Houlihan, & Gustafson, 2017). Thus, clients with diabetes may have
received intrinsic and extrinsic rewards for glycemic control but have little opportunity for
continuity given the economic and social choices available in their communities.
Anything that changes your values changes your behavior. George A. Sheehan
Evidence for Practice
Barch and colleagues (2017) explored how an important aspect of motivation in behavior is
reinforcement learning that is implicit (outside of conscious awareness) or explicit (direct
examples of rewards), as well as direct positive reinforcement or punishment. Motivational
impairments are core features of a variety of types of psychopathology. Positive
reinforcement is an important aspect of motivational function (learning about actions that
lead to reward) and punishment (learning to avoid actions that lead to loss). In examining
performance on tasks among individuals with schizophrenia, schizoaffective disorder, and
bipolar disorder with psychosis, individuals with schizophrenia and schizoaffective disorder
performed significantly worse than controls, but the individuals with bipolar disorder did not.
Worse performance on an explicit reinforcement learning task, but not the implicit
reinforcement learning task, was related to worse motivation and pleasure symptoms
across all diagnostic categories. Performance on explicit reinforcement learning, but not
implicit reinforcement learning, was related to working memory, which accounted for some
of the diagnostic group differences.
Positive reinforcement has been used successfully in research studies to increase social
behavior, improve cognitive and language skills, increase functional skills, and improve play
skills. The questions that should be asked in reference to practices related to clients,
groups, and communities are as follows:
How do I deal with challenging behaviors during an interaction?
How do I structure care to facilitate appropriate behaviors?
What strategies do I use to teach new behaviors?
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How am I currently using positive reinforcement in my practice?
How can I use positive reinforcement more effectively in my practice?
Health Belief Model
The health belief model, developed by Hochbaum (1956) and Rosenstock (1974), specifies that
individual, family, or community health–related behavior depends on (1) the severity of the
potential illness or physical challenge, (2) the level of conceivable susceptibility, (3) the benefits
of taking preventive action, and (4) what stands in the way of taking action toward the goal of
health promotion. This model uses cues as an important way to remind people of healthy
behaviors and to promote these actions. Examples of this model include posting a note stating,
“Don’t overdo it at dinner” (individual) or “Let’s try to do one thing tonight that is not related to
a television set” (family), and placing a “Got Milk?” billboard in the neighborhood
(community/population). Critical to this approach is the belief that the cue messages can be
accomplished. If a community group does not believe that they can sustain a “walking” club in a
safe section of a neighborhood, cues will not successfully encourage community members to
follow a walking program. At the individual level, age-specific considerations are important. If
people think they are healthy, they will not adhere to a preventive health program. Older people,
who more readily see chronic illness and death as imminent, may become frightened with the
prospect of susceptibility, while younger people often believe that they are invincible and
impervious to illness and physical challenges.
Evidence for Practice
VanDyke and Shell (2017) explored the role of the health belief model in predicting breast
cancer screening among women in rural Appalachia. Health beliefs (perceived susceptibility
to breast cancer, severity of breast cancer, and benefits and barriers to screening) were
used to predict health behavior through frequency of mammograms in a total of 170 women
aged 18 to 78. Demographic characteristics, mammogram frequency, and perceived
susceptibility, severity, and benefits and barriers to mammography were assessed. Findings
included that women with objectively elevated risks for breast cancer (history of abnormal
mammograms or family history of breast cancer) perceived themselves to be at higher risk
for breast cancer, and those with a history of abnormal mammograms were more likely to
receive mammograms regularly. Consistent with the health belief model, fewer perceived
barriers to mammography predicted greater mammogram frequency. However, the model
was not fully supported because perceived susceptibility, severity, and benefits to
mammography did not predict mammogram frequency.
Student Reflection
My instructor in community health asked us to use the health belief model in caring for
clients who were receiving care in a sexually transmitted infection (STI) clinic. He suggested
that I show the clients some of the consequences of syphilis in particular (graphic pictures),
because there had been a large increase in the incidence of the disease in the section of
town where the clinic was situated. After I interviewed 10 different clients and really tried to
increase their fear about the consequences of their actions, more than 50% stated that they
never thought they would get an STI despite not using any precautions to reduce the
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chances of becoming infected. In fact, 30% of the clients revealed during assessment that
this was their second or third diagnosis of syphilis. So, despite the severity of the results of
the disease, other factors affected choices of risk about acquiring an STI. Some of those
factors were alcohol abuse; inability to practice safe sex effectively; and trading unprotected
sex for money, housing, and food.
Transtheoretical Model
The transtheoretical model, developed by Prochaska and DiClemente (1983), is a sequential
approach to behavior change that involves timely readiness of the learner. This model promotes
change using a five-stage process; the stages are (1) precontemplation, (2) contemplation, (3)
preparation, (4) action, and (5) maintenance. Experts believe that individuals, families, and
communities progress through these stages in a back-and-forth manner, not in a linear fashion.
For nurses, the key to this approach is developing interventions tailored to clients’ levels of
readiness. For example, using this model to establish a twice-yearly blood pressure screening
program in a community setting would require the following stages:
1. Precontemplation (no screening programs scheduled and no intention to schedule screening)
2. Contemplation (no screening programs scheduled but intent to start a program soon)
3. Preparation (no definite screening program but have taken steps to develop a program)
4. Action (a developed screening program and intent to sustain the program)
5. Maintenance (have had the program for some time and intend to continue)
6. Relapse (had a program, does not have a program currently but intends to be active with a
program soon)
Evidence for Practice
Owusu, Quinn, Wang, Aibangbee, and Mamudu (2017) analyzed data from 43,540
participants of the Global Adult Tobacco Survey in low- and middle-income countries
because over 80% of active smokers live in these countries. Intentions to quit smoking were
categorized into precontemplation (referent category), contemplation, and preparation
stages based on the transtheoretical model. Approximately 82%, 14%, and 4% of the
smokers were in precontemplation, contemplation, and preparation stages, respectively.
Rural residents had increased odds of being in contemplation stage (OR = 1.41, 95% CI =
1.09–1.83) compared with urban residents. Compared to homes where smoking was
allowed, smoke-free homes were associated with increased odds of contemplation (OR =
1.77, 95% CI = 1.41–2.23) and preparation (OR = 2.18, 95% CI = 1.78–2.66). Exposure to
anti-smoking messages in more than one media channel was associated with increased
odds of contemplation (OR = 1.60, 95% CI = 1.33–1.92) and preparation (OR = 1.73, 95%
CI = 1.28–2.33) compared with no exposure to anti-smoking messages. The results suggest
that anti-smoking media campaigns and smoke-free policies may promote intention to quit
smoking. While these suggest the need for implementation of comprehensive anti-smoking
campaigns and smoke-free policies, longitudinal studies are required to confirm these
findings and to evaluate how intention to quit translates into quit attempts.
Theory of Reasoned Action
The theory of reasoned action states that a person’s given behavior is primarily determined by
his or her intention to perform that behavior (Fishbein & Ajzen, 1975). This intention is
determined by the person’s attitude toward the behavior (beliefs about the outcomes of the
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behavior and value of these outcomes), and the influence of the person’s societal environment or
subjective norm (beliefs about what others think the person should do). The ability to perform
the behavior (a belief that it can be done) is the critical aspect of the change process. Social or
subjective norms are significant, and the importance of abiding by these norms is reflected in
what people expect of individuals, families, and communities. For example, healthcare
practitioners may use this model in smoking cessation. If a client believes that he or she cannot
give up the addiction, no social norm will influence the behavior change. Smokers may isolate
themselves from others or from circumstances which might influence their belief in their ability
to change. Thus, the notion of addictive behaviors being hidden to decrease social pressure is a
formidable challenge when trying to encourage healthy behaviors. The theory of planned
behavior (a theory that links attitudes with behavior) is aligned with the theory of reasoned
action, which states that perceived control over skills is needed to perform a behavior. This is
similar to Bandura’s concept of self-efficacy (the belief that one is capable of achieving a certain
goal which may be a behavior).
Evidence for Practice
Kim, Darwish, Lee, and DeMarco (2017) used self-efficacy theory to create a community-
engaged research protocol to help women living with HIV infection to quit smoking. Video
conferencing to strengthen the belief that one can quit smoking was delivered on smart
phones and was compared with telephone counseling. The counseling (video or phone)
with actual treatment to quit (nicotine patches) were intended to be intervention components
to help the women quit and sustain smoking cessation over time. Preliminary findings
indicate that age predicts preference for phone call delivery of the intervention, thought to
be chosen because of stigma related to smoking behavior.
Social Learning (Social Cognitive) Theory
Social learning, or social cognitive, theory is a behavior change approach in which
environmental influences, personal factors, and attributes of the behavior itself have an effect.
Most importantly, a person must believe in his or her capability to perform the behavior (self-
efficacy) as well as perceive an incentive to do so (positive expectations outweigh negative).
The immediate or long-term benefits must be valued. Providing skill development by modeling
desired behavior can increase self-efficacy (Bandura, 1986).
Evidence for Practice
Wieland and team (2016) studied U.S. immigrants with increasing cardiovascular risk
because of barriers to physical activity and health diets. They developed a physical activity
and nutrition intervention through a community-based participatory research approach
where they developed and used a modular content manual based on social learning theory.
Family health promoters from the participating communities (Hispanic, Somali, Sudanese)
were trained to deliver the intervention using the modules through 12 home visits during the
first six months and up to 12 phone calls during the second six months. Key measurements
included accelerometer-based assessment of physical activity and 24-hour dietary recall.
Secondary measures included biometrics and social learning theory–based instruments. Of
150 individuals that included adolescents and adults, moderate levels of self-efficacy and
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social support were reported for physical activity and nutrition. What is particularly relevant
in this study is how the processes and products from this program may be relevant to other
social learning communities aiming to reduce cardiovascular risk and negative health
behaviors among immigrants and refugees.
Theories of Social Support
Family members, friends, neighbors, and adjacent communities can influence change by
offering social support—instrumental assistance, informational support, emotional support,
and/or appraising support. An example of instrumental assistance is providing transportation to
buy groceries or building a safe place to walk in a community. An example of informational
support would be providing a community board with information on how to obtain assistance to
clean a polluted pond. An example of emotional support is calling an isolated family that has
lost a child to assist them in their bereavement. An example of appraising support is giving
positive feedback about a new health skill (Berkman & Krishna, 2014). Although the literature
suggests that social support is not equivalent to professional support, professionals can assist
interested community members in organizing and developing social support opportunities that
promote health in the community.
Evidence for Practice
Rackow, Sholz, and Hornung (2015) studied the concept of “enabling” in exercise where it
was hypothesized that social support has an indirect association on exercise through self-
regulation and self-efficacy. These researchers examined the effects of different kinds of
social support (emotion and instrumental) on exercise not only through self-efficacy but also
through self-monitoring and action planning. Using an eight-week online program, study
participants were randomly assigned to an intervention or a control group. The intervention
included exercising regularly with a new exercise companion (social support). The
researchers found that received emotional social support predicted self-efficacy, self-
monitoring, and action planning in the intervention group. No direct or indirect effect of
received instrumental social support on exercise emerged. In the control group, neither
emotional nor instrumental social support was associated with any of the selfevidence for
the enabling hypothesis of received social support via self-efficacy on physical exercise in
an intervention study. This study demonstrated the contribution of received emotional and
instrumental social support in the context of the “enabling” hypothesis.
The Relapse Prevention Model
The relapse prevention model has been used specifically with issues that relate to adherence.
Relapse often occurs because of (1) negative emotional states; (2) lack of or limited coping
skills; (3) decreased motivation; (4) stress; and (5) high-risk experiences. Taylor (2013) supports
the idea that there are differences between a relapse and short lapse from healthy behavior and
suggests that planning a strategy related to high-risk situations is critical for success, especially
in the realm of harm reduction efforts. For example, communities interested in crime prevention
and harm reduction may be aware that in certain months of the year, there is an increase in
violent crime. They would then create a community campaign to promote nonviolence by
increasing law enforcement presence and improving faith-based, school system, elder health,
and neighborhood watch supports.
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Evidence for Practice
Luciano and colleagues (2014) studied strategies of people with co-occurring disorders
such as severe mental and substance use disorders. Strategies for relapse prevention
described by men with co-occurring disorders with one or more years of sobriety were
identified by analyzing semi-structured interviews from a sample of 12 men with
demographic and diagnostic clinical data. The men were receiving treatment in residential
or outpatient care and were primarily Caucasian (91.7%) and unmarried (100%) with ages
ranging from 23 to 42. The two most common psychiatric disorders were schizoaffective
disorder (n = 4, 33.3%) and bipolar disorder (n = 4, 33.3%), while the two most commonly
misused substances were alcohol and cannabis. Qualitative analyses showed that
participants maintained sobriety for at least one year by building a supportive community,
engaging in productive activities, and carefully monitoring their own attitudes toward
substances, mental health, and responsibility. Alcoholics Anonymous might act as a catalyst
for building skills. The researchers concluded that a variety of self-management strategies
are used to prevent relapse—seeking support, activities, and a healthy lifestyle. The
researchers identified a relapse prevention model from this work, in which social networks,
role functioning, and self-monitoring and conceptualizing self-care are critical to extending
periods of health and wellness.
The Ecologic Model
The ecologic model stems from the original work of Bronfenbrenner (1979, 2004). This model
is based on the belief that all processes occurring within individuals and their environment
should be viewed as interdependent. It suggests that behavior change in individuals needs to be
considered in a broader social context, including developmental history, psychological
characteristics, interpersonal relationships, physical environment, and culture.
According to this model, behavior is a result of the knowledge, values, and beliefs of people,
as well as numerous social influences. These social influences include relationships, social
support networks, and community structure. According to the ecologic model, there are four
levels of reciprocal influence, and it is necessary to consider all of these levels in order to
change behavior. The four levels of influence, which may either promote risk or support
protective factors, are (1) ontogenetic, (2) microsystem, (3) exosystem, and (4) macrocultural
(Fig. 5.3) (El-Bassel et al., 2003). The influences represent biologic, environmental, and social
influences as a dynamic and collective group of variables that need to be considered as a whole.
This model has been successfully used in health promotion and prevention research as a way
to decrease barriers to mammography screening and safer sex practices (Eddy, Donahue,
Webster, & Bjournstad, 2002; McLeroy, Bibeau, Steckler, & Glanz, 1988; Richards, Viadro, &
Earp, 1998; Schaalma, Abraham, Gillmore, & Kok, 2004). Burke (2003) used the ecologic
model to provide a better understanding of intrapersonal, interpersonal, and environmental
factors associated with intimate partner violence in low-income communities. Others have used
this model to identify individual and community resources, such as trust and partnership, to
develop effective interventions for health access (Bhattacharya, 2003). El-Bassel and team
(2003) used the ecologic model to study communication strategies for preventing HIV infection
in African American and Latino heterosexual couples (n = 217).
USE OF THE ECOLOGIC MODEL: EVIDENCE FOR
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HEALTH PROMOTION INTERVENTION
The ecologic model is an appropriate framework to help identify and measure complex
processes at a variety of levels for women living with HIV/AIDS. It allows public health
interdisciplinary teams to (1) emphasize the unique developmental nature of variables that
influence behaviors; (2) use a multilayered understanding of influence on behaviors; and (3) test
variables from each of the identified systems in the model to guide the assessment, development,
implementation, and evaluation of targeted interventions. The following is an example of how
public healthcare providers implement each of the systems in the model in order to develop
appropriate health promotion interventions. The ecologic model is more inclusive than many of
the theories of behavior change previously discussed. The references used include publications
that are more than five years old, which indicates the historical development of evidence since
the 1980s, when HIV was first identified in gay men in San Francisco, California.
FIGURE 5.3 Ecologic model.
Ontogenic System: Personal Factors
Characteristics such as race, marital status, and level of education are predictors of effective
HIV prevention strategies (Hodder et al., 2013). Three trends emerging from these studies are as
follows: (1) black women with lower levels of education are less likely to use HIV prevention
measures than other groups surveyed; (2) older women and women of color are less likely to use
condoms; and (3) strong correlations exist between education level and AIDS-related
knowledge. In research which explores sexual risk factors, intimate partner violence, and
selected psychosocial illnesses (injection drug use, alcohol abuse, anxiety, depression,
psychosis, and dementia), HIV-positive menopausal women without childbearing issues have
been overlooked (Stockman et al., 2013). Regardless of gender, identity, race, or ethnicity,
traumatic events, mental illness, distrust, and stigma have all been linked to poor adherence to
health promotion and prevention efforts, and behaviors associated with increased HIV risk
(Kalichman, Katner, Banas, & Kalichman, 2017). These factors are barriers to HIV prevention
for black women, and the lack of economic opportunity means they must focus on immediate
survival, restricting their choices. In spite of the help of public funding and support services,
lack of adequate and sustaining income is formidable (Chandler, Ansley, Ross, & Morrison-
Beedy, 2016).
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The relationship between trauma and HIV in African American–seropositive women and the
contexts in which these risks occur are critical areas in need of understanding and successful
intervention. Trauma, such as child sexual abuse, intimate partner violence, adult sexual abuse,
and victimization from exposure to violent environments, contributes to behaviors associated
with increased HIV risk and disease sequelae (Kalichman et al., 2017; Glover et al., 2010).
“Research has shown that histories of physical and sexual trauma can affect the decisions
women make with regard to risks for STIs and HIV, including the choice of partners and the
ability to negotiate the use of barrier methods of protection” (Myers, Wyatt, Loeb, & Carmona,
2006, p. 401). In African American women, being a victim of violence increases depressive
symptoms, decreases safe sex behaviors, increases the chance of becoming HIV-seropositive,
and increases the chances of acquiring and being treated for an STI (Kalichman et al., 2017).
Severe child sexual abuse is also associated with substance use and lower self-esteem (Willie,
Overstreet, Sullivan, Sikkema, & Hansen, 2016).
In the health histories of aging African American women with no history of HIV, comorbid
chronic conditions challenge self-care, especially when there is little or no social support (Willie
et al., 2016). Risk-taking behaviors, such as having multiple sexual partners, unprotected sex,
and drug and alcohol abuse greatly complicate HIV risk, HIV infection, and STIs when these
behaviors are superimposed on chronic conditions such as hypertension, obesity, lupus, diabetes,
and congestive heart failure. These behaviors continue to be major issues in prevention efforts
(Buzi, Smith, Weinman, & Novello, 2013). Prevalence of hepatitis C virus is as high as 30%
among those living with HIV and 90% if HIV was contracted through intravenous drug use.
End-stage liver disease from hepatitis C virus is a major cause of death in people coinfected with
HIV (HRSA, 2017). According to the CDC (2017c), the retrovirus responsible for HIV/AIDS
targets the CD4+ T lymphocyte as a primary target, thus crippling a number of important
immunologic functions. Progressive impairment of the immune response leads to susceptibility
in a variety of opportunistic infections and chronic life-threatening conditions. Measurements of
CD4+ T lymphocytes and the amount of HIV virus in the system (viral load in copies/mL),
along with clinical manifestations of disease or infection, are used to guide clinical and
therapeutic management of HIV-infected persons in the United States. Results of viral load
assessments are used to make decisions regarding initiation of antiretroviral therapy and to
determine whether current antiretroviral therapy is effective. These measures are critical in
decreasing mortality and morbidity rates.
Microsystem: Relationship between Women and the
Environment
Disclosing one’s HIV status has been reported to increase feelings of shame and stigma, partner
violence, rejection, depression, and high-risk sexual behavior (Herek, Gillis, & Cogan, 2009).
Stigma is highly correlated with low self-image, depression, lack of social support, a lack of
subjective social integration, and social conflict (Kalichman et al., 2017). Withdrawal from
personal interaction as a way to reduce tension is part of stigmatization, and for persons living
with HIV/AIDS who have strong histories of substance abuse, the temptation to fall out of
recovery is profound (Logie & Gadalla, 2009). Poor self-image is linked to increased risk
behaviors for HIV infection (Mahajan et al., 2008) and decreased disease adjustment, health
promotion, self-advocacy, and self-efficacy for negotiating safe sex and safe sex practices
(Herek et al., 2009). When women are empowered by HIV prevention efforts, they experience
increased self-image, control over healthcare treatment decisions, self-efficacy, increased
knowledge, and a positive sense of self as individuals and in relationships (Norris & DeMarco,
2005).
In non-HIV studies, such as breast cancer survivorship, self-image is related to relationship
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satisfaction and a positive feminine identity (Zimmermann, Scott, & Heinrichs, 2010). Self-
image is a factor which affects risk behavior and perceptions of risk for unplanned pregnancies
and is a predictor of the ability to negotiate safe sex behaviors (Zimmermann et al., 2010). In
women, there is a relationship between poor self-image, depression, and lack of self-advocacy in
sexual relationships (DeMarco, Johnsen, Fukuda, & Deffenbaugh, 2001). From a treatment
perspective, depressive symptoms are underdiagnosed and are associated with lower medication
adherence, risky behaviors, and poor health outcomes (Lennon, Huedo-Medina, Gerwien, &
Johnson, 2012). Lack of adherence to antiretroviral medication schedules has an effect on CD4
and viral load counts (i.e., adherence slows the progression of HIV, thereby maintaining health
and survivorship). Substance abuse (drugs and alcohol) in HIV-infected persons decreases the
use of appropriate and needed healthcare interventions, and in addition, it decreases HIV
prevention by increasing the likelihood of risky sexual behavior (Liebschutz, Geier, Horton,
Chuang, & Samet, 2005).
Exosystem: Formal and Informal Social Structures
Simoni, Walters, and Nero (2000) found that in women of African descent (black Hispanics,
non-Hispanic blacks) living in New York City, disclosure of their HIV status to adult family
members, friends, and coworkers was related to greater frequency of HIV-related social support
but was not directly related to a decrease in depression or mood disturbance. During and after
disclosure, social support was found to help with coping and improve psychological distress.
Isolation, stigma, managing their medical care, and being a mother caused women to be
unwilling to talk about their illness with their children, family, friends, and partners (DeMarco et
al., 2001).
There is a strong connection between highly active antiretroviral therapy (HAART) and
health. For poor women of color, adherence to medical protocols, which include HAART, and
medical follow-up, as well as less high-risk behavior, is compromised by (1) believing that other
people in their lives, specifically family and friends (children and sexual partners), come first;
(2) subsisting on a low income, which affects resource allocation; (3) experiencing race
discrimination, which magnifies the seropositive stigma; and (4) choosing to enter high-risk
situations to obtain money (sex work) to change their circumstances. Many strategies are used to
improve medication adherence, including counseling, support groups, educational information,
telephone/computer-based feedback, improving motivation and self-efficacy, and directly
observed therapy. Adherence may be improved with these strategies, but much needs to be
understood within a particular group to determine their best use in a cost-effective manner
(Haynes, Ackloo, & Sahota, 2008; Wolitski, Janssen, Onorato, Purcell, & Crepaz, 2005).
However, despite the use of these methods, a proven method for implementing long-term
behavior change remains unknown.
Social support includes relationships with family, friends, and community members. This is
usually thought of as perceived social support; it represents the degree to which needs for
relevant (or important) support are fulfilled by a person’s social network. High levels of
depressive symptoms are related to lack of HIV social support from friends, relatives, partners,
groups, and organizations. In contrast, increased social support improves self-esteem and
mastery. Thus, interventions that include group support can benefit psychological health
(Simoni, Huang, Goodry, & Montoya, 2005).
Psychosocial factors contribute to disease progression, which can be measured by CD4 and
viral load levels. These levels are indirect measures of adherence to HIV medications (Ironson et
al., 2005). Factors that support adherence to HIV treatment protocols include supportive family
members and other emotional support, whereas barriers to adherence include stigma, feeling
unloved, and relationship turbulence (Edwards, 2006).
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Macroculture: Values and Beliefs of Culture
To reduce the spread of HIV/AIDS, women who are seropositive must reduce the number of
instances when reinfection by other HIV strains may occur, and protect partners from the virus
by increasing safe sex behaviors. Safer sex strategies, from adolescence and onward in sexual
development, include assertiveness, self-advocacy to negotiate protection during intercourse,
verbal strategies, avoidance of drugs and/or alcohol consumption before or during sex, and
avoidance of contact with potentially infected body fluids (Buzi et al., 2013). Negotiated safer
sex in adults has almost exclusively been associated with condom use (Widman, Carol, & Noar,
2013). Because of the belief that partners are not sexually active with others, heterosexual adults
use condoms less often with primary or regular partners than with casual sexual partners
(Widman et al., 2013). In addition, as mentioned earlier, many social and situational factors
contribute to decreases in behavior that may prevent HIV in women, such as feeling intense
stigma, victimization, substance abuse, mental health problems, and contracting other STIs
(Crepaz et al., 2007; Mize, Robinson, Bockting, & Scheltema, 2002).
Gender roles in women and, in particular, the need to maintain connection in relationships at
the cost of one’s own health are major issues for all women living with chronic diseases, but
particularly for those who are HIV-positive (DeMarco & Johnsen, 2002, 2003; DeMarco,
Lynch, & Board, 2002; DeMarco, Miller, Patsdaughter, Grindel, & Chisholm, 1998). Jack
(1991, 1999) discussed the concept of silencing in the context of women’s experiences with
relationships. Jack’s work is relevant today, since the experiences women have in relationships
continue to be oriented toward understanding and defining themselves in the context of others.
Jack supports the position that women’s relationships are influenced not only by biologic factors
but also by psychosocial factors (Bancroft, 2002) and asserts “women’s orientation to
relationships is the central component of female identity and emotional activity” (Jack, 1991, p.
3). This researcher’s extensive exploratory and longitudinal studies with diverse groups of
women resulted in the development of the concept of “silencing the self” and the Silencing the
Self Scale. This concept of “silencing the self” has been used to explain how gender roles
negatively influence self-advocacy behaviors in women. Women tend to silence their voice in
relationships in order to maintain connections with others, even if that means they will
subsequently suffer physically, psychologically, or socially. According to Jack (1991), women
are reinforced culturally to (1) care for others’ needs before their own, (2) abide by designated
societal rules of behavior, (3) refrain from directly expressing their feelings and needs, and (4)
outwardly maintain compliance, while feeling hostility inwardly because of their silencing
behaviors. Silencing the self is relevant to the proposed study because it is a concept that is
identified and understood in the context of relationships with others (i.e., a relational concept).
The nature of intimate heterosexual relationships where seropositive safe sex occurs is an
example of this relational context. Women living with HIV continue to be sexually active with
men. Being quiet during times of sexual intimacy, rather than making direct requests and taking
care of themselves, will not protect them against further strains of HIV and other STIs, and will
infect others (DeMarco et al., 1998, 2001, 2002; DeMarco & Johnsen, 2002, 2003; DeMarco &
Norris, 2004a, 2004b; Norris & DeMarco, 2004, 2005; Lanier & DeMarco, 2015).
HEALTH PROMOTION AND SECONDARY/TERTIARY
PREVENTION FOR WOMEN LIVING WITH HIV/AIDS
Using the ecologic model, the aim of any intervention to promote health and minimize the
spread of HIV/AIDS requires the creative inclusion of a prevention initiative that is community-
based, peer-led, and interdisciplinary. Advancing the scientific understanding of secondary HIV
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prevention (what is called positive prevention) and exploring ways to reduce behavioral risk in
African American women may prevent further transmission of HIV and the serious negative
psychological consequences of living with HIV disease. African American women experience
disproportionate levels of (1) interpersonal mistrust and fear of disclosure because of the fear of
stigma, (2) poor adherence to treatment and other health promotion and disease prevention
efforts, (3) delay in seeking care related to mental health comorbidities and addiction recovery
issues, and (4) compromised self-advocacy in sexual relationships. An innovative, culturally
relevant, and gender-sensitive intervention that would address these barriers for women who are
already disproportionately saddled with HIV/AIDS, racism, ageism, and poverty would be
beneficial not only to them but also to their families and the communities in which they live.
Ultimately, public health nurses would be trying to improve health outcomes for this
underserved population of women.
Within the context of HIV physical care and efforts to decrease communicability using the
ecologic model, consideration should be given to mental health symptoms, severity/frequency of
the effects from significant trauma (PTSD), substance use, abuse, and addiction. In Table 5.1,
the sectors of the model and areas that need to be considered to address prevention are shown as
a process of collaboration between interdisciplinary teams, evidence, and real, population-based
needs.
The previous sections of this chapter provided a theoretical grounding in varied frameworks,
which can guide the planning, implementation, and evaluation of health promotion and disease
prevention interventions and programs. In addition, empirical evidence of the use and
effectiveness of the frameworks was discussed. The following sections explore the centrality of
health literacy in its relationship with health education and health promotion.
TABLE 5.1 Ecologic Model with Health Promotion and Disease Prevention
Considerations for African American Women Living with HIV
Ontogenetic System:
Personal Factors
Microsystem:
Relationship between
the Individual and the
Environment
Exosystem: Formal
and Informal Social
Structures
Macroculture: Values
and Beliefs of Culture
Health history
Physiologic indicators
Comorbidities
Mental health
Age, education, marital
status, income,
pregnancies, health
history, sexual history,
mental health symptoms
Effect of trauma
CD4 count/viral load
Sexually transmitted
infections
Relationships and
influences in interactions
in relationships
Stigma related to
disclosure
Substance abuse/recovery
Healthcare adherence
Self-advocacy in sexual
relationships
Stressors or buffers that
influence risky behaviors
Relationships with family,
friends, community
members
Healthcare adherence,
substance use, self-
advocacy in sexual
relationships
Stigma
Culture of women
Culture of African
American women
Self-advocacy in sexual
relationships
Stigma
Health literacy, health education, and health promotion are interrelated concepts, which
individually and collectively have substantial effects on the health and well-being of individuals,
families, and communities. Health literacy, health education, and health promotion seek to
change knowledge, skills, attitudes, behavior, and social determinants to improve the health
outcomes of individuals, families, and communities. Community and public health nurses are
well-positioned to partner with individuals, families, and communities and to work
collaboratively to initiate and maintain needed change. To be effective, nurses and their clients
must understand health literacy and how the level impacts both access to healthcare and health
outcomes. In addition, nurses must have skill in adapting health communication, health
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education, and health promotion strategies so that they can be clearly understood and acted upon
by individuals, families, and communities at varied levels of health literacy.
The promise of health literacy is the promise of improved health. Pleasant et al., 2016
HEALTH LITERACY
Origins of Health Literacy
The concept of health literacy has evolved over the past two decades. Initial interest in health
literacy stemmed from population studies of adult literacy. The 1992 National Adult Literacy
Survey (NALS) conducted by the U.S. Department of Education revealed a surprisingly high
prevalence of low literacy among the U.S. adult population (Weiss et al., 2005; Zarcadoolas,
Pleasant, & Greer, 2009). This survey defined literacy as “the ability to use printed and written
information to function in society, to achieve one’s goals, and to develop one’s knowledge and
potential” (National Center for Education Statistics, 1993, p. 6). The survey categorized literacy
into three general kinds of tasks: (1) prose tasks, which measure reading comprehension and
ability to extract themes; (2) document tasks, which assess the ability of readers to interpret
documents (consent forms, insurance forms); and (3) quantitative tasks, which assess the ability
to work with numerical information embedded in written material (figure taxes, calculate
calories on a nutrition checklist) (National Center for Education Statistics, 1993). As low
literacy can negatively impact everyday functioning, questions were raised as to how low
literacy might affect health and healthcare. Therefore, the concept of health literacy began
getting attention in the 1990s.
The initial focus was on the content of health-related written materials, and the readability of
that content. It was assumed at the time that most health consumers had the literacy skills to be
able to read and understand materials disseminated by healthcare providers. However, multiple
studies that examined the reading level and suitability of health materials across an array of
health topics found repeatedly that the written materials exceeded the average reading ability of
the public. For example, one out of five American adults read at the fifth grade level or below,
and the average American adult reads at the eighth or ninth grade level, yet most healthcare
materials are written at the 10th grade level (NPSF, 2018). This serious mismatch was found to
contribute to inaccessibility of understandable health education and communication and to
adverse events, compromising healthcare safety and quality.
In 2003 and most recently in 2016, the U.S. Department of Education, National Center for
Education Statistics conducted the National Assessment of Adult Literacy (NAAL) and the
Program for the International Assessment of Adult Competencies (PIAAC, 2016), which
assessed the status of English adult literacy in the United States. For the first time, health
literacy was included as a component of the larger assessment, providing the first nationally
representative sample measuring the ability of the American public to read, understand, and
apply health-related information (White, 2008). The results of this study provided insight into
the levels of health literacy in the U.S. population. As community health nurses provide both
individual and group health education and health promotion interventions, understanding the
definitions and levels of health literacy is critical.
Definitions and Basic Level of Health Literacy
The definition of health literacy has and continues to evolve (Cutilli & Bennett, 2009; Nuttbeam,
2000). Initially health literacy was viewed primarily as an individual’s ability to read health
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information. As the routes (verbal, written, media, internet) of health communication were
viewed more broadly, the healthcare system became more complex, and the expectations for
shared decision making (health consumer and health provider) and self-care increased, the
definition of health literacy expanded (Cutilli & Bennett, 2009). Rather than just focusing on an
individual’s ability to read health information, the Institute of Medicine (now the National
Academies of Science) (2004) expanded the definition of health literacy to include, “The degree
to which individuals have the capacity to obtain, process, and understand basic health
information and services needed to make appropriate decisions” (p. 32). This is one of the most
widely used definitions and, like others, considers the individual’s capacities, such as conceptual
knowledge, and listening, speaking, numeracy, reading, and writing skills, along with abilities to
access information and services, and uses all this information to make effective health-related
decisions (Healthy People 2020, 2017a; IOM, 2004; Speros, 2006). Attention, although
broadened beyond the written word, still was directed toward the abilities of the individual
health consumer, and there was a widely held assumption that general literacy assured health
literacy, and that most of the American public could understand basic health information as it
was presented in health-related materials. This level of health literacy is referred to as functional
health literacy, as it involves the basic level of reading and writing skills to obtain, understand,
and apply information related to health risks, medication prescriptions, or access to health
services (Nutbeam, 2000). The results of the NAAL were eye-opening, as it had a subsection
specifically on health literacy, in demonstrating that health literacy was different than general
literacy, and that proficiency in health literacy was very low in the U.S. population.
The 2003 NAAL study remains the only population-level study of health literacy and
continues to be cited in the literature (National Center for Education Statistics, 2006). The health
literacy tasks focused on the skills needed to address typical health-related materials, including
insurance forms, medication labels, and pamphlets about specific diseases. The health-related
tasks were divided among three principal healthcare domains: (a) clinical, (b) preventative, and
(c) navigation of the healthcare system. The results showed that many U.S. adults struggle to
understand healthcare information, with over one third (77 million people) at a basic or below
basic health literacy level, who could therefore be confused about basic healthcare tasks such as
how to take their medications by reading the label, how to follow a childhood immunization
schedule by reading a standard chart, or how to understand critically important warnings on the
label of an over-the-counter medication. Just over half demonstrated intermediate health literacy,
whereby an individual could determine cause and effect, make simple inferences, and read
instructions on a prescription label and determine what time to take the medication. Only 12% of
Americans were proficient in health literacy, meaning that they could handle more complex
health-related tasks, for example, using a table to calculate an employee’s share of health
insurance costs for the year, or understanding a risk–benefit ratio. The results of the study also
provided insights about risk factors for low health literacy and preferences for sources of health
information. Other studies have identified an array of knowledge and skills that are related to
health literacy (Speros, 2011).
Increasing Interest in Health Literacy
Beyond the shocking prevalence of limited health literacy, three other factors fueled increasing
interest in and study about health literacy: the risk factors contributing to low health literacy, the
wide range of knowledge and skill required for proficient health literacy, and the relationship
between health literacy and health outcomes. The increasing and ongoing study of health
literacy revealed that limited health literacy can affect anyone and crosses gender, age, race,
ethnicity, and socioeconomic status (IOM, 2004; Speros, 2011). However, beginning with the
NAAL study and supported by subsequent studies, factors such as age, income, education, race,
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and linguistic ability were found to influence health literacy and contribute to health disparities
(Rikard, Thompson, McKinney, & Beauchamp, 2016). Box 5.8 identifies the populations that
have been found to be at the highest risk for limited health literacy.
Health literacy has been described as a state, not a trait, as it can be variable within the same
individual, based on context (Berkman, Davis, & McCormack, 2010). The complexity of the
task and the condition of the individual influence health literacy. Even adults with strong literacy
skills can face health literacy challenges and feel overwhelmed, typically in situations when they
(a) are not familiar with medical terms or how their body works, (b) have to interpret numbers or
risks to make a healthcare decision, (c) are diagnosed with a serious illness and are scared or
confused, or (d) have complex conditions that require complicated self-care. Therefore, health
literacy is not a fixed characteristic but able to change during an individual’s lifespan, influenced
by education, aging, culture, social interaction, life experiences, and specific context (IOM,
2004; Nutbeam, 2008).
Knowledge and Skills Related to Health Literacy
Adults at the below basic level for health literacy were the least likely to use any written
material to obtain information on health topics with 43% indicating that they used written
information infrequently, far less than those at the intermediate or proficient level. Nonprint
sources, including broadcast media, such as radio or television, were rated higher than any type
of print source. The lower the health literacy level, the less apt the individual would be to use the
internet as a source of health information. Only 15% of adults with below basic health literacy
used the internet “some” or “ a lot” compared to 31% of adults with basic health literacy, 49% of
adults with intermediate health literacy, and 62% of adults with proficient health literacy. This is
an issue, as being computer-literate (able to operate and navigate a computer, portals with health
information, and web-based health information) has been identified as one of the competencies
for health literacy. Figure 5.4 illustrates the role of the community health nurse in educating an
older adult in the use of computer technology to gain access to trustworthy health information.
All adults, regardless of their health literacy skills, reported that they were more likely to get
health information from nonprint sources, such as radio/television, friends/family, and most
often health professionals (National Center for Education Statistics, 2006).
5.8 Populations at Risk for Low Health Literacy
Adults over 65
Individuals with limited education or low income
Non-native speakers of English
Racial and ethnic minorities
Recent refugees and immigrants
Adults with any type of disability, difficulty, or illness
Source: National Center for Education Statistics. (2006). The health literacy of America’s adults: Results from the 2003 national assessment of adult literacy.
Washington, DC: U.S. Department of Education.
Further exploration of what constitutes health literacy has revealed that it requires broad
knowledge and skills applied to a wide range of health topics, tasks, and situations. Beyond
reading, health literacy involves a complex group of listening, computational, navigational,
analytical, and decision-making skills, and the ability to apply these skills to varied health
situations. Healthcare consumers need to be able to obtain, evaluate, and apply health-related
information, which can require the use of technology. They need computational skills to
calculate insurance premiums, deductibles, and copays, and analytical skills to make
comparisons. For safe and accurate medication administration, the healthcare consumer must be
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able to read and interpret the prescription label or over-the-counter medication instructions and
warnings, calculate or measure doses, understand the desired effect and potential side effects,
obtain refills, and determine insurance medication benefit. Table 5.2 identifies the varied health
literacy skills and tasks required for self-health management.
FIGURE 5.4 A community health nurse teaching an older adult how to navigate the web and find
credible health information.
TABLE 5.2 Skills and Tasks Required for Health Literacy
Aspects of Health Literacy Examples of Skills and Tasks
Information-literate Reading ability
Comprehend complex health information
Identify key information from dense text
Understand directions for medication
Understand nutrition labels
Understand and follow directions for varied health-related procedures
and treatments
Understand information to give informed consent
Read and follow appointment slips
Apply written information to make effective health-related decisions
Find credible health-related information independently
Visually literate Understand and apply information from graphs, charts, diagrams,
pictures, graphic instructions
Communication-literate Provide a health history
Describe symptoms
Ask and respond to health-related questions
Listen and understand verbal instructions and teaching
Computationally literate Calculate doses
Calculate calories within specialized diets
Measure liquid medications
Calculate deductibles, co-payments, and premium costs
Analytically literate Compare and analyze insurance costs and covered benefits
Understand risk–benefit ratio of treatment options and health
promotion activities
Interpret test results (blood glucose, peak flow results, etc.)
Computer-literate Operate a computer
Navigate the internet
Obtain, evaluate, and apply web-based health-related information
Access and use personal information from a health portal
Source: Agency for Healthcare Research and Quality. (2010). Health literacy universal precautions tool-kit. AHRQ publication no. 10-0046-EF. Rockville, MD:
AHRQ. Retrieved from http://www.ahrq.gov/qual/literacy/index.html; Institute of Medicine. (2004). Health literacy: A prescription to end confusion.
Washington, DC: The National Academies Press; and Speros, C. (2011). Promoting health literacy: A nursing imperative. Nursing Clinics of North America, 46,
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321–333.
Health Outcomes Linked to Health Literacy
Studies have shown that limited health literacy is associated with multiple suboptimal health
outcomes. Adults with low health literacy have a higher risk and rate of hospitalization, and
higher use of emergency room service (Baker et al., 2002; Schillinger, 2002). However, they are
less likely to access preventative care, and had lower use of mammography and receipt of flu
shots (IOM, 2004; White, Chen, & Atchison, 2008). Other problematic areas revealed that adults
with low health literacy had less ability to interpret labels and health messages, and
demonstrated poor ability in accurate self-administration of medications (Bennett et al., 2009).
Among older adults, those with low health literacy presented lower overall health status and
higher mortality (Baker et al., 2007). Patients with low health literacy and chronic diseases such
as diabetes, asthma, or hypertension have less knowledge of their disease and its treatment and
fewer correct self-management skills than literate patients (AHRQ, 2010a). Among primary care
patients with type 2 diabetes, inadequate health literacy is independently associated with worse
glycemic control and higher rates of retinopathy. Inadequate health literacy may contribute to
the disproportionate burden of diabetes-related problems among disadvantaged populations
(Schillinger, 2002).
In addition to the effects of low health literacy on the individual, there are economic
consequences of low health literacy to society. Low health literacy is an enormous cost burden
on the U.S. healthcare system. According to the report Low Health Literacy: Implications for
National Health Policy, “low health literacy is a major source of economic inefficiency in the
U.S. healthcare system” (Vernon, Trujillo, Rosenbaum, & DeBuono, 2007). Annual costs for
individuals with low health literacy are four times higher than those with higher literacy skills.
The annual cost of low health literacy to the U.S. economy was $106 billion to $238 billion
(Vernon et al., 2007). This represents between 7% and 17% of all personal healthcare
expenditures. Medical errors and behaviors labeled as noncompliant may be based on poor
understanding of the healthcare information. Inpatient spending increases by approximately
$993 for patients with limited health literacy (Howard, Gazmararian, & Parker, 2005).
Improving health communication reduces healthcare costs and increases the quality of
healthcare.
Expanding Responsibility for Health Literacy
Low health literacy was initially viewed as an individual client’s deficit, that is, a client’s lack of
knowledge and skills regarding health issues. The alarming prevalence of low health literacy and
the concerning, varied, and serious negative health outcomes linked to limited health literacy
drew increasing attention. It was evident that issues of health literacy went beyond reading
written materials and individuals’ abilities. Health literacy began to be viewed as a systems
problem within healthcare, reflecting the complexity of both the presentation of health
information and navigation of the healthcare system (Parker & Ratzan, 2010; Rudd, 2010). It
was becoming apparent that the healthcare consumer, healthcare provider, healthcare system,
and government all have a role to play in addressing limited health literacy.
The Joint Commission (TJC), the major accrediting organization for healthcare organizations
in the United States, recognizes the importance of health literacy and health communication as a
critical component of patient safety and quality healthcare. TJC acknowledged the relationship
among health literacy, health communication, and patient safety, stating in a 2007 report,
“Health literacy issues and ineffective communications place patients at greater risk of
preventable adverse events. If a patient does not understand the implications of her or his
diagnosis and the importance of prevention and treatment plans, or cannot access healthcare
services because of communications problems, an untoward event may occur” (TJC, 2007, p. 7).
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In addition, TJC’s accreditation standards “underscore the fundamental right and need for
patients to receive information—both orally and written—about their care in a way in which
they can understand this information” (TJC, 2007, p. 7). TJC called for more attention to the
structure and function of the healthcare system and the manner in which it can be changed to
“permit patients to receive more time, attention, education and understanding of their conditions
and their care” (TJC, 2007, p. 49).
Three federal policy initiatives also addressed health literacy. The Affordable Care Act of
2010 addressed efforts to improve health literacy in two areas: (a) incorporating health literacy
into professional training; and (b) requiring that the health plans and insurers provide consumers
with clear, consistent, and comparable health information in a standardized summary of benefits
and coverage template. The National Action Plan to Improve Health Literacy provided seven
coordinated health literacy goals (Box 5.9) for the United States, based on the following two
principles: (a) all people have the right to health information that helps them make informed
decisions, and (b) health services should be delivered in ways that are understandable and lead
to health longevity, and good quality of life (USDHHS, 2010). The Plain Writing Act of 2010
requires all new publications, forms, and publicly distributed documents from the federal
government to be written in a clear, concise, and well-organized manner so that the public can
understand and use them.
These notable reports and regulations have moved health literacy from a limited focus on an
individual’s capacity to read and comprehend health information to a healthcare system’s issue
related to the responsibilities of provider communication, and the challenges of navigating the
complex system, and further to an issue of health policy and reform.
Practice Point
Health literacy influences the ability to understand, interpret, and act on health information.
5.9 The National Action Plan to Improve Health Literacy’s Seven Health
Literacy Goals
1. Develop and disseminate health and safety information that is accurate, accessible, and actionable.
2. Promote changes in the healthcare system that improve health information, communication,
informed decision making, and access to health services.
3. Incorporate accurate, standards-based, and developmentally appropriate health and science
information and curricula in childcare and education through the university level.
4. Support and expand local efforts to provide adult education, English language instruction, and
culturally and linguistically appropriate health information services in the community.
5. Build partnerships, develop guidance, and change policies.
6. Increase basic research and development, implementation, and evaluation practices and
interventions to improve health literacy.
7. Increase the dissemination and use of evidence-based health literacy practices and interventions.
Source: U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2010). National action plan to improve health
literacy. Washington, DC: Author. Retrieved from https://health.gov/communication/hlactionplan/pdf/Health_Literacy_Action_Plan .
HEALTH LITERACY AND HEALTH EDUCATION
As further understanding of the impact of low health literacy emerged, efforts were directed at
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communication between healthcare providers and their clients, and clients’ ability to navigate
the healthcare delivery system and more actively participate in self-care. Expectations in
healthcare are changing and moving away from the healthcare provider as the expert and in
charge of care. Health promotion and disease management are becoming more of a shared
responsibility of the individual and the healthcare provider. In actuality, more and more is being
expected of individuals and their informal family caregivers. If individuals are unable to
understand what is taught or prescribed, then follow-through will be poor in relation to health
behavior changes and the many tasks needed to manage chronic disease and to promote health.
Consequently, another level of healthcare literacy, beyond functional health literacy, was
proposed. Interactive health literacy refers to more advanced cognitive and social skills that
empower an individual’s active participation in healthcare, promotes more shared decision
making between the healthcare provider and their clients, and increased responsibility for self-
care management of both disease and health promotion (Fernandez-Gutierrez, Bas-Sarmiento,
Albar-Marin, Paloma-Castro, & Romero-Sanches, 2017; Nutbeam, 2000). Community health
nurses provide health education and care coordination, and promote the client’s self-
management of chronic conditions and health maintenance in many settings, including homes,
schools, and ambulatory clinics. Therefore, nurses must have the knowledge and skill to assess
and understand the health literacy levels of their clients in order to improve the safety and
quality of the care they provide.
Health Literacy Competencies and Practices Useful in Health
Education
Health communication and health education seek to change knowledge, skill, and behavior, and
ultimately to improve health and well-being. For change to occur, nurses and other healthcare
providers must ensure that their oral and written health communication is presented in a manner
that clients can comprehend and utilize. Addressing health literacy requires the use of clear and
effective communication practices. Coleman, Hudson, and Pederson (2017) had 25 health
literacy experts examine 32 previously identified health literacy and clear communication
practices and competencies (knowledge, skills, and attitudes) (Coleman, Hudson, & Maine,
2013; Toronto, 2016; Toronto & Weatherford, 2015), and rank them in order from high to low
importance. Consensus among the experts revealed a cluster of eight top-rated practices. Box
5.10 describes these practices, which provide guidance for healthcare providers in improving
their health communication and health education strategies and outcomes. Toronto’s (2016)
study of health literacy competencies for nurses examined knowledge, skills, and attitudes. The
highest-rated knowledge competency focused on the importance of knowing that all individuals,
regardless of their literacy level, prefer and benefit from clear, plain language communication.
The most frequently identified skill related to the nurse’s ability to speak slowly and clearly.
Regarding attitude, the findings emphasized the nurse’s understanding that you cannot tell who
is at risk for low literacy by looking or even interacting with them. Therefore, nurses need to
approach all health communication and education using health literacy universal precautions.
5.10 Eight Top-Rated Health Literacy Practices (Consensus From Experts)
1. In written and oral communication avoids using medical terminology, and when avoidable, clearly
defines using lay terms
2. To assess understanding (knowledge) and ability (skill) and correct any misunderstandings of
material taught/shared, uses a “teach-back” or “show-me” method
3. Invites questions from patients using a patient-centered approach (e.g., “what questions do you have”
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rather than “do you have any questions”)
4. Uses health literacy universal precautions method in written and oral communication with all patients
5. Uses a professional medical interpreter when communicating with a patient whose preferred language
is other than English
6. Partners with the patient from the outset of the encounter negotiating a mutual agenda
7. Prioritizes health messages/teaching with emphasis on one to three “need to know” or “need to do”
concepts during a clinical encounter
8. At the beginning of the clinical encounter asks the patient to share all of his or her concerns
Source: Coleman, C. A., Hudson, S., & Maine, L. L. (2013). Health literacy practices and educational competencies for health professionals: a consensus study.
Journal of Health Communication, 18(Suppl 1), 82–102.
Health Literacy Universal Precautions
As limited health literacy is so prevalent in the United States, is difficult to determine, and can
vary based on the client’s current condition and the complexity of the health-related information
or task, experts recommend that healthcare providers adopt the use of health literacy universal
precautions, meaning that “healthcare providers make all health information easier to
understand, confirm everyone’s comprehension, and reduce the difficulty of health-related
tasks” (Liang & Brach, 2017, p. e216). Through the use of health literacy universal precautions,
community health nurses can structure health communication and education to improve client
understanding, informed decision-making, and ability to follow-through on a mutually
established plan of care. Health literacy universal precautions promote specific strategies and
practices that should be used with all clients to reduce the common mismatch that occurs
between a clinician’s level of communication and a client’s level of comprehension. In fact,
evidence shows that clients often misinterpret or do not understand much of the health
information given to them by healthcare providers. This lack of understanding can lead to
medication errors, poor self-management of chronic conditions, limited participation in health
promotion activities, and adverse health outcomes (AHRQ, 2010a; Bennett et al., 2009).
ESTABLISHING A SUPPORTIVE LEARNING ENVIRONMENT
No matter what the setting in which the community health nurse is providing health teaching, a
supportive, shame-free learning environment in which clear communication is intentionally used
must be established. The learning environment should foster clients as active partners in their
healthcare, specifically by encouraging clients to ask questions. Clients may be embarrassed to
ask questions, or not know how to express their question, particularly when the nurse appears
pressed for time or unsupportive. Asking “What questions do you have?” communicates to the
client an expectation that they should have questions and will more likely encourage questions,
rather than saying “Do you have any questions?” which typically leads to a “no” answer by
clients even if they do have questions. In addition, the nurse can support client questioning by
(a) making it clear that the nurse has time and wants to address questions; (b) sitting at the same
level as the client (not standing); (c) looking at the client, listening attentively, and not
interrupting; (d) helping the client to prioritize his or her questions; and (e) encouraging the
client to write down questions before interactions with any healthcare provider (primary care
provider, specialist, pharmacist) (AHRQ, 2010b).
EFFECTIVE QUESTIONING
An effective tool for community health nurses to teach clients is the Ask Me 3 Good Questions
for Good Health developed by the National Patient Safety Foundation (now available through
the Institute for Healthcare Improvement). Community health nurses should teach these three
questions to their clients, and encourage them to ask these questions every time they meet with a
healthcare provider. The questions are:
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What is my main problem?
What do I need to do?
Why is it important for me to do this?
Ask Me 3 can provide a useful guide for clients, encouraging them to speak up and ask
questions. These three questions are useful in focusing important conversations; making all
clinical encounters and health education sessions interactive can increase understanding for both
the provider and the client. Clients are more apt to follow a plan of care if they understand what
the problem is, specifically what they need to do, and the rationale for the actions advised.
However, community health nurses can also use it to structure how they share information with
clients to ensure that the answers to the three questions are provided in the course of the
conversation.
EVIDENCE-BASED HEALTH LITERACY UNIVERSAL PRECAUTIONS
The Agency for Healthcare Research and Quality has developed a Health Literacy Universal
Precautions Toolkit (https://www.ahrq.gov/professionals/quality-patient-safety/quality-
resources/tools/literacy-toolkit/index.html) that provides evidence-based guidance to improve
health communication between healthcare providers and clients at all levels of health literacy.
The toolkit includes 21 tools and 30 resources addressing four domains that are essential for the
promotion of health literacy: (a) spoken communication, (b) written communication, (c) self-
management and empowerment, and (d) supportive services.
Research has demonstrated that for spoken language, the healthcare provider should avoid
medical jargon; use simple, clear, lay terms; speak clearly and slowly; and listen attentively. The
amount of information should be limited with no more than four main messages all focusing on
the desired behaviors and actions, which are repeated and reinforced during the session. Most
people prefer clear communication using simple words and short sentences, covering the
essential, need-to-know information. Using pictures or other visuals and everyday examples to
supplement the teaching is effective (Speros, 2011).
Written health education materials should also use simple terms, active voice, and short
sentences. They should be easy to read, using bulleted lists, beginning with the most important
information first and limiting the amount of information. Headings and subheadings are useful
in separating and introducing new information. Pictures and graphic illustrations are helpful in
improving understanding and retaining information (Speros, 2011).
The focus of health communication and education should be on moving the client to well-
informed, self-care management of all aspects of their health, including management of illnesses
and preventative and health promoting activities. Promoting clients as active partners in their
healthcare decisions and management supports client empowerment.
Table 5.3 summarizes health literacy universal precautions evidence-based practices.
Studies have shown that 40% to 80% of the medical information patients receive is forgotten
immediately and nearly half of the information retained is incorrect (Kessels, 2003). It cannot be
assumed that what the nurse has taught has been understood by the client and that the client can
act on it. Therefore, another important health literacy–health education related tool is using the
teach-back method every time the nurse shares health-related information with a client. The
purpose of this teach-back technique is to ensure that the nurse has explained the information
clearly and that the client has accurately understood the information. The nurse asks clients to
explain in their own words what they have been taught, what they need to know, and what they
need to do. If a client is unable to teach back the information, the nurse would explain the
information again, reassess, and repeat the process until the client can demonstrate
understanding. A variation of the teach-back method is the show-me method, wherein the nurse
has the client demonstrate a skill, such as blood glucose monitoring or medication
administration, so that the nurse and client are confident in the client’s ability to perform the
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skill at home. Effectiveness of the teach-back technique has been shown to improve client–
provider communication, client follow-through on plans of care, and client health outcomes
(Sudore & Schillinger, 2009). Clients who understand their personal health information make
fewer mistakes and demonstrate greater follow-through with instructions. Health literacy can be
improved through intentional provision of information, effective communication, and structured
education.
TABLE 5.3 Health Literacy Universal Precautions Practices in Health
Communication and Education
Health Literacy Domain Practices
Written communication Use plain, simple words
Avoid medical jargon
Write at the fifth grade level
Use short sentences
Use bulleted lists
Use active voice
Focus on no more than four key points
Begin with most important point
Use headings and subheadings to separate information
Chunk similar information
Use white space and reasonable font size
Add pictures graphic illustrations to illustrate information
Summarize key points at the beginning and the end
Spoken communication Establish a shame-free learning environment
Show respect and a helpful, caring attitude
Face the client
Speak slowly, clearly
Use simple, everyday language, avoiding medical jargon
Encourage questions
Teach clients to use Ask Me 3
Repeat and review key points
Use written information, pictures, videos, and other visual aids to
reinforce spoken communication
Use teach-back and show-me methods to verify comprehension
Summarize at the end
Source: Agency for Healthcare Research and Quality (AHRQ). (2010). Health literacy universal precautions tool-kit. AHRQ publication no. 10-0046-EF.
Rockville, MD: AHRQ. Retrieved from http://www.ahrq.gov/qual/literacy/index.html; Speros, C. (2011). Promoting health literacy: A nursing imperative.
Nursing Clinics of North America, 46, 321–333.
Evidence for Practice
Bailey and team (2016) completed a mixed-methods study to determine if a health literacy
universal precautions approach resulted in similar or different satisfaction levels among low
and high health literacy participants. This study was part of a larger research project that
tested the effectiveness of SIPsmartER, a six-month behavioral intervention designed using
a health literacy universal precaution approach. The intervention was directed at reducing
the sugar-sweetened beverage (SSB) intake in a population of rural-dwelling, low
socioeconomic adults. The intervention was comprised of several health education
components including 3 small group classes, one live teach-back call, 11 interactive voice
response (IVR) calls, personal action planning, and self-monitoring (SSB) logs. The
researchers analyzed the program’s interview-administered summative evaluation, which
was completed by 105 participants (68 identified as high and 37 low health-literate).
Overall results demonstrated no significant differences in the satisfaction of each of the
interventions components and that participants with low and high health literacy benefitted
from and were satisfied with an intervention designed using health literacy universal
precautions. Quantitative data revealed that each component was positively evaluated. The
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small group classes received the highest rating and were chosen as the most motivating by
both groups. A higher number of low health literacy participants liked the content and length
of the IVR system as compared to the high health literacy participants. The IVR calls
reviewed and reinforced information from the small group sessions and may have been
more beneficial to the low health literacy participants; however, the completion rate of the
IVR calls was the same for both groups. Qualitative findings indicated more likes than
dislikes in both groups.
HEALTHY PEOPLE 2020 AND HEALTH LITERACY
Healthy People 2020 acknowledges the relationship among health literacy, health
communication, and health outcomes. Health communication objectives were identified to
improve population health outcomes and healthcare quality and to achieve health equity. The
objectives proposed that improvements in health communication will provide accurate,
understandable, actionable, tailored health information that will contribute to improved health
literacy, which should support better health outcomes.
Two overarching health communication objectives identified in HP 2020 are:
a. Improve the health literacy of the population
b. Increased proportion of persons who report that their healthcare providers have satisfactory
communication skills
5.11 Healthy People 2020: Health Communication Objectives
Increase the proportion of persons who report that their healthcare providers always explained things so they could
understand them.
Increase the proportion of persons who report that their healthcare provideres always gave them easy-to-understand
instructions about what to do to take care of their illness or health conditions.
Increase the proportion of persons who report that their healthcare provider always asked them to describe how
they will follow the instructions.
Increase the proportion of persons who report that their healthcare providers always involved them in decisions
about their healthcare as much as they wanted.
Source: Healthy People 2020. (2017a). 2020 Topics and objectives. Retrieved from https://www.healthypeople.gov/2020/topics-objectives.
Improved health literacy can empower individuals to assume more responsibility for their
health and actively participate in better informed, shared decision making with their healthcare
providers. The health communication sub-objectives measure an increase in the evidence-based
practices outlined in health literacy universal precautions (Box 5.11).
Evidence for Practice
Improving health literacy is a goal included in the U.S. Department Health and Human
Services’ national health promotion and disease prevention initiative, Healthy People 2020
(USDHHS, 2010). To track progress in the adoption of health literacy universal precautions,
Healthy People 2020 selected measures of three health literacy strategies: (1) providing
easy-to-understand instructions about what to do for self-management of an illness or
health condition; (2) asking patients to describe in their own words, how they will follow the
instructions (teach-back method); and (3) offering assistance in completing a form. Liang
and Brach (2017) used data from the Agency for Healthcare Research and Quality’s
Medical Expenditure Panel Survey (MEPS)— Household Component, which tracks
progress in Healthy People 2020 healthy literacy measures to examine the extent of health
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providers’ use of recommended health literacy universal precautions. The findings, which
analyzed changes from 2011 to 2014, did reveal an improvement in each measure. Seventy
percent of adults reported always receiving easy-to-understand instructions (increased from
64% in 2011), 29% (up from 24% in 2011) reported that their providers always asked them
to explain how they will follow the instructions, and 17% (up from 14% in 2011) were offered
assistance in completing a form.
Practice Point
Improved health literacy should be a goal of health education and health promotion.
Health communication, health literacy, and health education can be more than the sum of
their parts. By working together we can progress farther to improve individual and
community health. Allen et al., 2017
HEALTH LITERACY AND HEALTH PROMOTION
Both in practice and research, the focus of health literacy has been on individual abilities in
basic functional literacy and interactive literacy, and health communication between clients and
healthcare providers. Attention has been on the effect of low health literacy and the
implementation of practices to alleviate the potential negative outcomes. Health literacy
researchers and experts have suggested an additional perspective that views health literacy as an
asset, which can increase through health education and health promotion (Pleasant et al., 2015).
Low health literacy is linked to poor health outcomes and health disparities, while strong health
literacy is connected to improved health outcomes. It has been suggested that improving health
literacy could contribute to decreasing health disparities. To improve health literacy, health
providers and consumers need to look beyond individual health literacy capacities and health
providers’ health literacy competencies, to necessary system’s level changes in the social,
economic, and environmental context (Allen, Auld, Logan, Henry Montes, & Rosen, 2017;
Chinn, 2011; Rudd, 2015). In its landmark report, Health Literacy: A Prescription to End
Confusion (IOM, 2004), the Institute of Medicine noted “improving individual health literacy
requires great effort from the public health and healthcare systems, the education system, and
society overall” (IOM, 2004, p. xiv). To realize the broader goal of improving health literacy
across populations requires a larger effort, one that addresses health literacy at the community
and population levels. This requires broadening definitions and another level of health literacy
that are closely related to health promotion and public health, which address the social
determinants of health and health disparities.
The following three expanded definitions of health literacy recognize the relationships
among health literacy, health promotion, and public health. According to the World Health
Organization’s (WHO) definition, health literacy “represents the cognitive and social skills
which determine the motivation and ability of individuals to gain access to, understand and use
information in ways which promote and maintain good health. By improving people’s access to
health information and their capacity to use it effectively, health literacy is critical to
empowerment” (WHO, 2018b). Sørensen and colleagues (2012) also included health promotion
in their enhanced definition, “Health literacy is linked to literacy and entails people’s
knowledge, motivation, and competences to access, understand, appraise, and apply health
information in order to make judgments and take decisions in everyday life concerning
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healthcare, disease prevention and health promotion to maintain or improve quality of life
during the life course” (p. 3). In these expanded definitions, health literacy is viewed as an asset,
an outcome of health promotion efforts, and as having both personal and social benefits.
Advanced cognitive skills include critical thinking, analysis, decision making, and problem
solving in a health-related context. These cognitive skills are combined with social skills of
communication and questioning to empower individuals to improve their personal health status
and the health of the communities in which they live (Crondahl & Karlsson, 2016).
Freedman and colleagues (2009) broadened the definition of health literacy to include a
focus on public health and the community, “The degree to which individuals and groups can
obtain, process, understand, evaluate and act upon information needed to make public health
decisions that benefit the community” (p. 448). The authors propose that in addition to
individual-level health literacy efforts, equal attention should be given to literacy about public
health with more emphasis on primary prevention and population health. Health literacy is not
just a personal resource; higher levels of health literacy within populations, such as public health
literacy, yield social benefits, for example, by mobilizing communities to address the social,
economic, and environmental determinants of health, which can be the root causes of health
illiteracy. An emphasis on community recognizes that individuals and families are embedded in
environmental and sociocultural contexts. This understanding supports the perspective that
health literacy is a collaborative responsibility among individuals, communities, the healthcare
system, the government, and other related societal institutions, to promote health and reduce
health disparities among individuals, families, communities, and societies (Rudd, 2015).
Critical Health Literacy
Critical health literacy reflects elements of the above definitions. This level of health literacy
requires more advanced cognitive skills, coupled with social skills that can “be applied to
critically analyse (sic) information, and to use information to exert greater control over life
events and situations” (Nutbeam, 2000, p. 264). Chinn’s (2011) concept analysis of critical
health literacy revealed three domains, including (a) critical appraisal of information, (b)
understanding the social determinants of health, and (c) collective action. Similarly, Nutbeam
(2000, 2008) asserts that critical literacy requires individual and collective action to understand
and address the social, economic, and environmental determinants of health. People with critical
health literacy can change general and organizational practices related to health, and
communicate with leaders and politicians to realize changes they consider important. The author
suggests a strong relationship between health promotion and health literacy. Nutbeam (2000)
references the WHO’s (1986) Ottawa Charter for Health Promotion’s influence on defining
health promotion, “as public health action directed toward improving people’s control over all
modifiable determinants of health” (p. 261). Concern is not only for personal behaviors and
lifestyle, but also for living and working conditions and public policy, all of which influence
public health.
International Health Promotion Efforts Supporting Critical
Health Literacy
The United Nations ECOSOC Ministerial Declaration of 2009 provided a clear mandate for
action: “We stress that health literacy is an important factor in ensuring significant health
outcomes and in this regard, call for the development of appropriate action plans to promote
health literacy. Indeed, knowledge and understanding remain powerful tools in health
promotion” (WHO, 2016). Improving health literacy in populations provides the foundation for
self and community empowerment, whereby individuals are enabled to assume an active role in
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improving their own health, and coalitions form to promote community action for health, and to
move local, state, and national governments to meet their obligations in addressing public health
issues.
Health Promotion and the Social Determinants of Health
The Ottawa Charter for Health Promotion is an international agreement signed at the First
International Conference on Health Promotion, organized by the WHO and held in Ottawa,
Canada, in November 1986. The charter defines health promotion as “the process of enabling
people to increase control over, and to improve, their health. It moves beyond a focus on
individual behaviour (sic) and toward a wide range of social and environmental interventions”
(WHO/Ottawa Charter for Health Promotion, 1986; WHO/Health Promotion, 2018). Health
promotion seeks to both support individuals to assume responsibility for their own health and to
work to create an environment in which they can be successful. It involves motivation and self-
efficacy, community empowerment, and health-promoting political and social activism. Good
health is a major resource for personal, family, community, social, and economic development
and has an essential impact on the quality of life. Political, economic, social, cultural,
environmental, behavioral, and biologic factors can either foster or limit health. Most
communication and health education interventions remain focused on personal health and
lifestyles. There is a real need to develop, implement, and evaluate interventions to improve
knowledge, understanding and capacity to act on social, economic, and environmental
determinants of health, thus developing individual and community empowerment. Public health
literacy is as much citizen-based as it is expert-driven, and it can take multiple forms from
voting to organizing grassroots initiatives to establishing healthy policies and structures.
The Ottawa charter identified five action areas for health promotion, which remain relevant
today:
Build healthy public policies: Health promotion goes beyond healthcare. Health and health consequences
should be considered in all public policies, including non-health sectors.
Create supportive environments: Health is strongly affected by environmental factors. The environments
in which people live, work, learn, and play must be structured to promote health and well-being.
Strengthen community action: Community empowerment in health promotion activities must be
emphasized. Community stakeholders need to be involved in all areas of community action including
setting priorities, making decisions, and planning, implementing, and evaluation strategies to improve
health.
Develop personal skills: Health education is a component of health promotion that supports the
acquisition of knowledge and skills required for self-management of health, informed decision-making,
and participation in community action.
Reorient health services: Responsibility for health is shared among individuals, community groups,
health professionals and service institutions, and governments. Healthcare needs to move beyond its
focus on illness and clinical interventions and services, toward a health promotion direction that
embraces broader social, economic, cultural, political, and physical environmental factors that exert a
strong influence on health.
As community health nurses focus on the multiple determinants of health, stressing the
crucial social factors, and emphasize health promotion and disease prevention, they are well
positioned to support the development of critical health literacy and community empowerment.
The five action areas emphasized by the Ottawa Charter provide guidance for community health
nurses as they develop individual and community-based health promotion activities, form
community health action coalitions, and support efforts to address health in all public policies
and create environments where healthy choices are accessible by all.
Health literacy at the community level has many implications regarding daily decisions
201
about health promotion and disease prevention, not only for individuals, but decisions for and by
the family and community units. Community-based health literacy interventions have been
defined as “Any purposeful, organized activity to help a group of people find, understand, use,
or communicate about health information, services, or issues for themselves or their
communities” (National Academies of Sciences, Engineering and Medicine, 2018, p. 8). Health
literacy in the community setting has profound influence on an individual’s and community’s
ability to engage in negotiations, decision making, activism, and community level empowerment
and development focused on health (Batterham, Hawkins, Collins, Buchbinder, & Osborne,
2016).
Practice Point
Health literacy, including all three levels (functional, interactive, and critical), is an asset that
improves individual, family, and community health, and has the potential to reduce health
inequities.
Evidence for Practice
Low health literacy among Korean American women has been identified as a significant
barrier to their participation in breast and cervical cancer screening. Han and colleagues
(2017) tested a community health worker (CHW)–led health literacy intervention on
mammogram and Papanicolaou test screening among Korean American women. The
authors used a cluster randomized control design to compare a CHW-led health literacy
intervention with an educational control group. Participants had to be Korean American
women aged 21 to 65, who were able to read and write in either English or Korean, and had
not had a mammogram or Pap test in the past 24 months. Trained CHWs from 23 ethnic
churches recruited the study sample of 560 women (intervention n = 278 and control n =
282). The control group received publicly available educational breast and cervical cancer
brochures. The intervention group received an educational brochure tailored specifically to
their risk factors. After receiving this, they received a two-hour health literacy training
facilitated by the trained CHW, within a small group community-based setting. The training
introduced key medical terms, and allowed practice of phrases in English and role play of a
typical screening process. In addition, participants received practice reading and
interpreting appointment slips and instructions, and guidance on how to effectively navigate
the healthcare system screening process.
At the end of the small group meeting, participants received a DVD and guidebook that
reinforced all aspects of the class. For six months, the CHWs initiated monthly calls to
reinforce the knowledge and skill gained in the health literacy session, and assist with any
navigational barriers. The researchers assessed self-report of mammogram and Pap test
utilization at baseline, and medical record review at three- and six-month intervals. At six
months, 56.1% and 54.5%, respectively, of those in the intervention group had received a
mammogram and Pap test compared with 10.0% and 9.2%, respectively, of women in the
control group. Having read all of the intervention materials was an important factor, as
completing a screening test doubled for both cancers when a participant had read all
materials compared to a participant who read only some or none. The CHW-led health
literacy intervention was successful in promoting mammogram and Pap test screening
among Korean American women, which could contribute to decreasing existing cancer
health disparities among this population. In addition, the findings support the importance of
transforming the design of health literacy training from a knowledge-based to a skills-
building and empowerment focus.
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ROLE OF NURSES
This chapter addresses real examples of how nurses, as part of an interdisciplinary team, can be
involved in fundamental prevention and health promotion efforts. After using public health
science and evidence to identify risk, the focus of prevention and health promotion can proceed
using culturally relevant, sensitive, ethical, and creative ways to motivate others to consider
health and wellness as individuals, groups, and communities. Historical behavior change
theories are examples of how health science has developed in using psychology, sociology,
anthropology, and ethical perspectives to advance efforts at the national level and beyond.
Although primary prevention in particular is often overlooked as a critical component to health
and wellness when it comes to resource allocation in the U.S. health system, in truth it is one of
the most influential areas where nurses as teachers can make a difference in people’s lives.
In addition, the chapter explores the relationship among health literacy, health education, and
health promotion, areas of healthcare in which community health nurses have a central role and
responsibility. Understanding the complexities of health literacy is a core responsibility.
Community health nurses need to integrate health literacy universal precautions best practices
into their health education and health promotion interventions to improve health outcomes.
Knowledge of the three levels of health literacy—functional, interactive, and critical—allows
the community health nurse to intervene at the individual, provider, and community level.
KEY CONCEPTS
National goals and directives to maintain the health of individuals, families, and communities are important
road maps for healthcare professionals.
Three levels of prevention assist health professionals to advance quality of life and health through the
natural history of disease and disability.
Identifying modifiable risk and using health promotion models to address change in behaviors, beliefs,
attitudes, and intentions can significantly increase the health of individuals, families, and communities.
Health literacy involves three levels: functional, interactive, and critical, all of which must be addressed to
improve individual and public health.
Health literacy, health education, and health promotion are interrelated and collectively work to support
health self-management, effective provider–client communication and collaboration, and community
engagement and activism to address the social determinants of health.
CRITICAL THINKING QUESTIONS
1. What does it mean to be healthy and well when diagnosed with multiple sclerosis?
2. Name community indicators that would demonstrate health and wellness for a particular geographic area.
3. What are the responsibilities of community and public health nurses in promoting health and decreasing
illness and injury in populations, families, and individuals?
4. Identify five key influences on health and wellness in the United States.
5. If national health policies are identified but cannot be funded because of national fiscal deficits, how would
community/public health nurses initiate support for these policies?
6. Choose a data-based publication that represents each level of prevention and take a position about which
level is the most complex to put into action for advancing health and wellness.
7. Critique behavior change from the perspective of measuring the change after a health promotion
intervention has been implemented (e.g., teaching communities to decrease saturated fat in their diet and
to exercise more).
8. Evaluate the written teaching materials used at your clinical placement. Do they reflect the use of health
203
literacy universal precautions? If not, take one and revise it using the universal precautions practices.
9. Reflect on your spoken communication with clients. Do you consider health literacy issues? List five ways
that you can use health literacy universal precautions in your spoken communication and then practice
them at clinical and evaluate your competence.
COMMUNITY RESOURCES
State and local departments of health (divisions of maternal and child health, communicable disease,
occupational health, addictions, gerontology)
YMCA/YWCA programs
Gyms/athletic complexes
State and local police departments
Parks and recreation departments
Places where blood pressure equipment is sold or screenings are available (local retail stores)
School systems (school nurse associations)
Local restaurants
Air and water control areas
Primary care physician and advanced nurse practices
Dentists
Elder services
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Chapter 6
Epidemiology: The
Science of Prevention
Patrice Nicholas and Patricia Lussier-Duynstee
For additional ancillary materials related to this chapter. please visit thePoint
There are in fact two things, science and opinion, the former begets knowledge, the latter
ignorance.
Hippocrates
Science is organized common sense, where many a beautiful theory was killed by an ugly fact.
Thomas Huxley
Get your facts first, then you can distort them as you please.
Mark Twain
CHAPTER HIGHLIGHTS
Defining epidemiology
Development of epidemiology as a science
Epidemiologic conceptual frameworks
Applying epidemiologic principles in practice
Assessment of health needs and assets
Using assessment data for planning and implementing interventions
Promoting healthy lifestyles
Preventing and controlling outbreaks
Contributing to a safe and healthy environment
Evaluating the effectiveness of health services
OBJECTIVES
Trace the origins of epidemiology.
Comprehend the basic principles and scope of epidemiology.
Contrast three epidemiologic conceptual models.
Apply principles of epidemiology to Healthy People 2020.
Relate the problem-solving process to both the epidemiologic process and the nursing process.
Apply epidemiologic principles to the practice of public health nursing.
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KEY TERMS
Epidemic: An outbreak that occurs when there is an increased incidence of a disease beyond
that which is normally found in the population.
Epidemiologic triad: Model based on the belief that health status is determined by the
interaction of the characteristics of the host, agent, and environment.
Epidemiology: Study of the distribution and determinants of states of health and illness in
human populations; used both as a research methodology to study states of health and
illness, and as a body of knowledge that results from the study of a specific state of health or
illness.
Natural history: Course of a disease or condition from the onset to resolution.
Outbreak: Epidemic usually limited to a localized increase in the incidence of the illness.
Rate: Primary measurement used to describe either the occurrence or the existence of a specific
state of health or illness.
Risk: Probability or likelihood that a disease or illness will occur in a group of people who
presently do not have the problem.
Risk factor: Characteristics or events that have been shown to increase the probability that a
specific disease or illness will develop.
Web of causation: Epidemiologic model that strongly emphasizes the concept of multiple
causation while de-emphasizing the role of agents in explaining illness.
Wheel of causation: Epidemiologic model that de-emphasizes the agent as the sole cause of
disease while emphasizing the interplay of physical, biologic, and social environments.
CASE STUDY
References to the case study are found throughout this chapter (look for the case study icon).
Readers should keep the case study in mind as they read the chapter.
In 2011, there were an estimated 782,500 gang members in the United States. In 2012, an
increase brought the known total to 850,000, with an estimated 30,700 gangs, up from 29,900 in
2011. Gang members often come from socially and economically disadvantaged communities. In
2012, cities with populations of 50,000 or more had a prevalence of 85.6 as compared to suburban
counties at 49.5, smaller cities at 25.4, and rural counties at 16.0. Gang members commit a
disproportionate amount of violence and crime compared with youths not involved in gangs. Gang
members are also more likely to use drugs and alcohol, as well as engage in unsafe sex. As a
result, youths who belong to gangs can be considered a vulnerable population at increased risk for
negative health outcomes. Public health nurses in large cities have developed programs that target
youths in gangs. These nurses represent local healthcare facilities, community service agencies,
churches, schools, businesses, and other neighborhood groups focusing on increasing access to
expanded community health services, promoting healthy living behaviors and fostering a positive
community environment. Healthy People 2020 (Centers for Disease Control and Prevention [CDC],
2010a) objectives include decreasing the proportion of secondary school students who report the
presence of youth gangs at school during the school year with a baseline of 12.4% and a target of
10.4%.
(2012 National Youth Gang Survey; Healthy People 2020)
Katie, a public health nurse in Los Angeles, has developed a partnership with a local police
department juvenile diversion program that offers a delinquency prevention program to young
people from 13 to 18 years of age. These young people have been arrested for nonviolent
offenses, such as possession of drugs, burglary, theft, joy riding, and vandalism. Some of these
young people are gang members, and others are at risk for joining gangs because they come from
neighborhoods with long histories of gang activity. Katie’s responsibilities are to lead interactive
three-hour sessions that primarily focus on health-related issues for the youths. She identifies three
topics for discussion: (1) major causes of morbidity and mortality in youth, (2) major health issues
common in a particular age group, and (3) risk prevention and health promotion (adapted from
Sanders, Schneiderman, Loken, Lankenau, & Bloom, 2009).
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L ike other types of modern science, epidemiology arose from building blocks constructedby ancient civilizations. Humans have experienced disease for as long as they haveexisted, and in the early days, attempts that people made to understand the onset of
disease and to prevent its occurrence were crude. People perceived health as something holy,
and healers looked to the spiritual world to protect health and prolong life. People often
considered disease and disability as a great curse and a divine punishment, and they believed
that amulets, totems, charms, and rituals prevented all sorts of evils. However, early cave
dwellers experimented with medicinal plants and became adept at treating some illnesses. These
discoveries were primarily a direct result of trial-and-error observations, enhanced by doses of
curiosity, common sense, and chance.
For thousands of years, the practice of healing slowly developed as humans observed that
more and more herbal remedies and therapeutic treatments had beneficial results. Some cultures,
such as in Egypt, had an extensive repertoire of treatments. More than 700 remedies existed for
ailments resulting from crocodile bites to infections following childbirth. Practitioners at that
time reduced dislocations, aligned and immobilized fractures, and applied hot and cold
treatments to reduce inflammation. People recognized and understood differences in individual
constitutions and observed that many diseases were contagious in nature. Interestingly, they
conceptualized the influence of the environment on the occurrence of disease. However, priests
and religious healers kept most of this knowledge secret.
Hippocrates of Cos (460 to 370 bc), considered the father of modern medicine, was the first
person to record these secrets in writing. In a textbook of medicine that was used for centuries,
he recorded the belief that external factors in the environment were a cause of illness in humans.
He wrote of the effects of seasons, winds, and water, as well as the characteristics of the ground.
He encouraged healers to observe what are known today as lifestyle patterns: “what are their
pursuits, whether they are fond of drinking and eating to excess, and given to indolence, or are
fond of exercise and labor” (Hippocrates, 1938). Hippocrates also wrote On Air, Waters and
Places, a book that provided details on the relationship between humans and the environment.
Experts now consider this book as a milestone in the development of the science of
epidemiology, illustrating the connection between human life and the environment. However,
people overlooked this concept for centuries, and it was not seriously considered again until
investigators in the late 19th century developed the science of bacteriology.
Men and women today still search for reasons for their illnesses, and many still perceive
illness as a punishment for sins. However, the wealth of scientific knowledge developed within
the last 160 years has permitted the understanding of the complexities of the human body and
the effects of internal and external stressors. This knowledge has provided the means for
preventing and modifying illness and repairing disabilities. Much of this knowledge has been
gained through the extension of the observations of the past to the rigorous study of specific
illnesses or disabilities in large groups of people.
DEFINING EPIDEMIOLOGY
Early attempts to understand illness and disease focused on studying the experiences of
individual people. Today, clinicians consider these case reports or case studies. Studying
individual experiences is invaluable for forming ideas, or hypotheses, about possible causes of
specific diseases. However, studying individual people may not provide accurate information
about the characteristics of the disease being investigated, because individual experiences with a
disease may vary. Also, examining the experiences of individual persons does not provide
213
evidence of causality (see Chapter 8). To gather more accurate information about disease,
studying groups of people is essential.
An example is the relationship between smoking and lung cancer that experts statistically
determined in the 20th century. Without studying the experiences of groups of people, they may
never have identified this relationship. Some smokers never develop lung cancer, and some
nonsmokers do develop lung cancer. However, epidemiologists Doll and Hill, in the 1950s,
demonstrated the relationship between lung cancer and smoking by comparing a group of people
with lung cancer to a group of people without lung cancer. They discovered that the people with
lung cancer had smoked significantly more cigarettes than those without lung cancer (Doll &
Hill, 1950). Further epidemiologic research studies provided more evidence of a causal link
between smoking cigarettes and lung cancer.
Unfortunately, after 50 years, smoking is still a cause of significant illness and death
throughout the world. In the United States alone, in 2015, 15.1% of all adults were identified as
smokers, as defined by smoking every day. The percentage is even greater in American
Indians/Alaska Natives, multiple race individuals, and non-Hispanic Blacks (CDC, 2016).
Epidemiology as the science of prevention emerged from the rigorous study of disease and
illness in groups of people. Epidemiology is defined as the study of the distribution and
determinants of states of health and illness in human populations. States of health and illness
include health, disease, morbidity, injuries, disability, and mortality. The goals of epidemiology
are to prevent or limit the consequences of illness and disability in humans, as well as to
maximize their state of health (Harkness, 1995). The word epidemiology is derived from the
word epidemic in the Greek language: epi—upon, demo—people, and logos—thought. In
epidemiology, the community replaces the individual client as the primary focus of concern
(Mausner & Kramer, 1985).
The science of epidemiology has been traditionally associated with infectious disease. Many
of the techniques used in epidemiologic investigations were developed when cholera was killing
much of the population of Europe. Therefore, early epidemiologic attempts to control and
prevent infectious disease involved altering the characteristics of the agent, the host, and the
environment (see Chapter 14).
The scope of epidemiology has expanded and shifted substantially. Primarily as a result of
improved public health practices in the early 20th century, life expectancy in the United States,
the United Kingdom, and European countries, as well as in other developed countries, rose.
With it, a change in the patterns of disease occurred. No longer are infectious diseases the
leading causes of death; the morbidity and mortality from noninfectious diseases and chronic
degenerative conditions have increased (Table 6.1). Advancing technology in the 20th century
made everyday life increasingly complex. There were unparalleled changes in diagnostic
practices and therapeutic methods, resulting in expanded strategies for the prevention and
control of disease. A focus on maintenance of wellness evolved.
All truths are easy to understand once they are discovered—the point is to discover them.
Galileo Galilei
Investigators now use epidemiologic techniques to study all aspects of health, including
factors that keep people well. Chronic disease, psychosocial problems, occupational injuries,
environmental effects, and the planning and evaluation of health services are but a few of the
disciplines that have been enhanced by using principles of epidemiology. Today, epidemiology
is both a research methodology used to study states of health and illness and a body of
knowledge that results from the study of a specific state of health or illness. When using
epidemiology as a research methodology, the calculation of rates is the primary measurement
used to describe either the occurrence or the existence of a specific state of health or illness (see
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Chapter 7).
How can Katie use these principles of epidemiology, both as a research method and as a
body of knowledge, in her preparation for the three-hour sessions? How does her
knowledge interface with Healthy People 2020 (CDC, 2010a) data?
TABLE 6.1 Comparison of the Leading Causes of Death in the United States,
1900 and 2010
1900a 2010b
1. Major cardiovascular–renal disease
2. Influenza and pneumonia
3. Tuberculosis
4. Gastritis, duodenitis, enteritis, and colitis
5. Accidents
6. Malignant neoplasms
7. Diphtheria
8. Typhoid and paratyphoid fever
9. Measles
10. Cirrhosis of the liver
1. Heart disease
2. Malignant neoplasms (cancer)
3. Chronic lower respiratory diseases
4. Cerebrovascular diseases (stroke)
5. Unintentional injuries
6. Alzheimer disease
7. Diabetes mellitus
8. Nephritis, nephritic syndrome, and nephrosis
9. Influenza and pneumonia
10. Suicide
aUnited States Census Bureau. (1975). Historical statistics of the United States, colonial times to 1970, bicentennial edition, Part 2. Washington, DC.
bCenters for Disease Control and Prevention. Health, United States, 2013. Retrieved from http://www.cdc.gov/nchs/hus.htm.
DEVELOPMENT OF EPIDEMIOLOGY AS A SCIENCE
John Graunt and the Bills of Mortality
The study of illness in groups of people developed gradually. One of the first people to study
patterns of disease in populations was a London haberdasher, John Graunt. In 1662, he analyzed
the weekly reports of births and deaths in London; his analyses were the precursor of modern
vital statistics. Graunt found that more male infants were born than female infants and that more
men died than women. He also observed that infant mortality was high, and he noted that
seasonal variations occurred in deaths.
Through his analysis of the Bills of Mortality, Graunt developed a better understanding of
diseases and conditions that led to death. He published his observations and findings in Natural
and Political Observations Made Upon the Bills of Mortality. Graunt added an essential step in
the development of epidemiology as a science. He developed a new logic of statistical inference,
demonstrating that examining routinely collected data from groups of people would yield clues
to human illness. His publication can be found online.
Two centuries passed before William Farr expanded Graunt’s work. In the meantime, James
Lind instituted the precursor of the clinical trial when he compared responses to dietary
treatments for scurvy, and Percivall Pott observed cancer of the scrotum in English chimney
sweeps, hypothesizing that soot was the cause. Edward Jenner performed the first successful
vaccination against smallpox with the liquid from a cowpox pustule, resulting in the vaccination
of more than 100,000 people in England within three years. These accomplishments in the 18th
century linked specific diseases with the characteristics of groups of people and documented the
effects of various treatments. Table 6.2 summarizes the milestones in the evolution of
epidemiology from 460 bc through the 20th century.
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http://www.cdc.gov/nchs/hus.htm
William Farr, Registrar General
In 1839, William Farr was appointed to the new Office of the Registrar General for England and
Wales. Farr set up a system for the consistent collection of the numbers and causes of deaths.
With these data, he was able to compare the death rates of workers in various occupations, the
differences in mortality according to gender, and the effect of imprisonment on mortality. He
also discovered an inverse relationship: deaths from cholera decreased with an increase in
elevation above sea level (Farr, 1852).
Farr and his predecessors contributed significantly to the understanding of the distribution of
illness and death. As one of the first epidemiologists, he recognized (1) the value of a precise
definition of both the illness and the population at risk for the illness, (2) the importance of using
appropriate comparison groups, and (3) that factors such as age, health status, and environmental
exposure can confound statistical results.
TABLE 6.2 Selected Milestones in the Evolution of Epidemiology
Time Person Accomplishment or Event
460–377 BC Hippocrates of Cos First to record the relationship of the external environment to the
health of individuals. Considered the first epidemiologist.
ca. 81 AD Aretaeus, the
Cappadocian
Described pulmonary tuberculosis in detail.
129 Claudius Galen Described the four humors and introduced many drugs derived from
plants. First to describe smallpox.
500 Susruta Brahmin physician who associated malaria with the mosquito.
850 Rhazes Arab physician who wrote al-Hawi, papers that incorporated all
known medical, anatomical, and pharmacologic knowledge of the
time. Differentiated smallpox from measles.
1347 Italian 40-day ban on travel and trade was established to control
bubonic plague. Quarantine comes from the Italian word
quarentina, meaning 40 days.
1589 Thomas Moffet First description of living organisms causing disease: lice, fleas, and
scabies mites.
1662 John Graunt London haberdasher who analyzed weekly reports of births and
deaths. Found infant mortality was high and deaths varied
according to seasons.
1683 Anton van
Leeuwenhoek
Used a microscope to observe and describe “animalcules” from
pond water and human saliva.
1701 Nicolas Andry French surgeon who proposed that infection by germs was a cause
of disease.
1747 James Lind Observed and compared responses to dietary treatments for scurvy
—the first evidence of a clinical trial. Recommended preventive
techniques for typhus.
1760 Daniel Bernoulli Demonstrated that smallpox conferred lifelong immunity through the
use of the first life table techniques.
1775 Percivall Pott Observed that many English chimney sweeps developed cancer of
the scrotum; hypothesized that exposure to soot was the cause.
1779 Johann Peter Frank German who wrote A System of a Complete Medical Policy, the first
book about public health.
1798 Edward Jenner Discovered the first vaccination against smallpox with cowpox
pustule liquid. Within three years, 100,000 people in England
were vaccinated.
1800 William Cruikshank Scottish surgeon who used chlorine to purify water.
1836 Pierre-Charles-
Alexandre Louis
Conducted observational studies demonstrating the ineffectiveness
of bloodletting. Emphasized statistics.
1840–1860s William Farr First Registrar General in England. Considered father of modern
statistics. Developed mortality surveillance systems and
addressed basic epidemiologic concepts. Pioneered public health
reforms.
1846 Peter Ludvig Panum Danish physician who described the epidemiology of measles and
the mechanism for spread of disease.
216
1847 Ignaz Semmelweis Hungarian obstetrician who demonstrated that mortality from
puerperal fever could be dramatically reduced if doctors washed
their hands.
ca. 1850 Jean Baptiste Emile
Vidal
French dermatologist responsible for the introduction of an efficient
sewage system in Paris.
ca. 1854 John Snow Performed epidemiologic research on transmission of cholera using
natural experiments, mapping, and rates. Removed London’s
Broad Street drinking water pump handle to stop the spread of
cholera.
1854 Florence Nightingale Initiated sanitary reforms in the Crimean War and demonstrated that
preventable or contagious diseases were the primary cause of
mortality. Later used statistics to improve public health in
England. Considered the founder of the nursing profession.
ca. 1860 John Parkin English surgeon who used charcoal filters to purify water in an
attempt to prevent the spread of cholera.
1860–1880s Louis Pasteur Developed pasteurization. Suggested that living organisms called
“germs” caused infectious diseases.
1864 Contagious Diseases Act passed in England to combat the spread
of venereal disease.
1865–1880s Robert Koch German who discovered the causal agents for anthrax, cholera, and
tuberculosis. Developed criteria for identifying cause. Won Nobel
Prize for bacteriology in 1905.
1866 Joseph Lister Developed a carbolic acid spray for surgical disinfections.
1921 Johns Hopkins University established the first academic program in
epidemiology.
1927 Wade Hampton Frost Developed cohort analysis of mortality data and developed life
tables. Credited for moving epidemiology from a descriptive to an
analytical discipline.
1930 National Institutes of Health established in the United States.
1946 U.S. Communicable Disease Center was established. Now Centers
for Disease Control and Prevention (CDC).
1948 Framingham cohort study of cardiovascular disease initiated.
1950s Richard Doll and A.
Bradford Hill
English researchers who conducted the landmark studies on the
relationship between smoking and lung cancer.
Second half of the
20th century
Chronic degenerative diseases replaced infectious diseases as
leading causes of death worldwide.
Sources: Lee, H. S. J. (2002). Dates in infectious diseases: A chronological record of progress in infectious diseases over the last millennium. New York:
Parthenon Publishing Group.; Timmreck, T. C. (2002). An introduction to epidemiology. Boston, MA: Jones and Bartlett; and Lilienfeld, D. E., & Stolley, P. D.
(1994). Foundations of epidemiology. New York: Oxford University Press.
John Snow and the Broad Street Pump
Perhaps the best known epidemiologist of the 19th century was John Snow, a contemporary of
William Farr. He was a British physician who used population data and his own observations to
investigate the epidemic of cholera that occurred from 1848 through 1854. He observed that
deaths from cholera were particularly high in the parts of London supplied by two water
companies the Lambeth Company and the Southward and Vauxhall Company.
Sewage heavily polluted a section of the Thames River, and interwoven water mains piped
untreated water into the homes of two thirds of London’s residents. Houses on the same street
received water from different companies. Sometime between 1849 and 1854, the Lambeth
Company changed its water source to a less contaminated location upstream. During a
particularly bad cholera outbreak from 1853 to 1854, Snow demonstrated through calculation of
death rates from cholera that the disease decreased in those areas supplied by the Lambeth
Company but remained the same in those areas supplied by the Southward and Vauxhall
Company (Table 6.3).
TABLE 6.3 Death Rates From Cholera by Water Company, London, 1853–
1854
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Water Company Population, 1851 Cholera Deaths Deaths/100,000
Southwark and Vauxhall 167,654 192 114
Both companies 301,149 182 60
Lambeth 14,632 0 0
Source: Snow, J. (1855). On the mode of communication of cholera. London: John Churchill. Retrieved from http://www.ph.ucla.edu/epi/snow/snowbook.html.
The most severe outbreak during this time was in the area of Broad Street, Golden Square,
where people obtained their water from a local pump. More than 500 people died from cholera
within 10 days. Believing that the water delivered by the pump was responsible for the cases of
cholera, Snow removed the handle, and the number of cases immediately declined. However,
there also were a number of other factors that contributed to this event, for example, an exodus
of the population to other locations. Nonetheless, he is credited for “staying the epidemic,” and a
pump now has been erected in his honor on the corner of Broad Street in Soho.
Snow, during his investigations, mapped the areas where cholera occurred, developed rates
as an objective measure to compare populations, made use of the natural experiment provided by
the unusual pattern of water mains, and found evidence for the cause of cholera. These were
outstanding accomplishments in an era that preceded bacteriology. He published his findings in
On the Mode of Communication of Cholera (Snow, 1855). The entire document is available
online.
Florence Nightingale, Nurse and Epidemiologist
Florence Nightingale, the daughter of a wealthy Englishman, was also a contemporary of
William Farr and John Snow. She devoted her life to the prevention of needless illness and
death. She used compelling statistics to bring about healthcare reforms, both during the Crimean
War and later in her English homeland. Also, she is credited with founding the profession of
nursing.
Prior to leading a group of nurses to aid the British soldiers in the Crimean War, Nightingale
was superintendent of a London hospital. There she supervised nurses, the operation of the
physical plant, and the purity of the medicines. In 1854, she and a group of carefully chosen
nurses and servants joined the troops in Scutari, in the Crimea. She was appalled by the
conditions of the hospital barracks. Rats and fleas infested buildings, facilities were
overcrowded, linen was filthy, essential supplies were missing, and an open sewer ran
underneath the barracks. The soldiers suffered not only from wounds, but also from dysentery,
malnutrition, frostbite, cholera, typhus, and scurvy. The mortality rate for the soldiers was
42.7% (Cohen, 1984).
Using carefully gathered data that were unique at the time, Nightingale documented the
results of her sanitary reforms. The polar area diagram she designed (Fig. 6.1) illustrates the
needless deaths in the military hospitals during the Crimean War. Deaths peaked in January
1855. During that month, 83 soldiers died from wounds, but 2,700 died from infectious diseases.
If the dead soldiers had not been replaced, infectious diseases would have wiped out the entire
army. By the end of the war, the death rate in British soldiers in the Crimea was less than that of
the troops at home (Cohen, 1984).
With the help of William Farr, Nightingale continued documenting events after the war that
were associated with poor sanitary conditions. She compared mortality in civilians with that in
soldiers and found that in peacetime, the soldiers in England had a mortality rate nearly twice
that of civilian males. Nightingale asked for and received a formal investigation of military
healthcare, and eventually, the government implemented her sanitary reforms. She studied the
health of soldiers in India, the mortality in British hospitals, and the mortality following surgery.
Throughout her career, she experimented with graphs and diagrams that everyone could
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http://www.ph.ucla.edu/epi/snow/snowbook.html
understand and tried to introduce statistics into higher education. As a pioneering
epidemiologist, she effectively demonstrated that statistics provide an organized way of learning
from experience.
FIGURE 6.1 Florence Nightingale’s polar area diagram illustrating the extent of needless deaths in
British military hospitals during the Crimean War, April 1854 to March 1855. The blue wedges
measured from the center of the circle represent area for area the deaths from preventable
zymotic diseases, the red wedges measured from the center the deaths from wounds, and the
black wedges measured from the center the deaths from all other causes. The black lines across
the red triangles in September and November 1854 mark the boundaries of the deaths from all
other causes during those months. In October 1854, the black area coincides with the red. The
entire areas may be compared by following the blue, the red, and the black lines enclosing them.
(From Aiken, L. [1988]. Assuring the delivery of quality patient care. State of the Science
Invitational Conference, Nursing resources and the delivery of patient care [NIH Publication No.
89–3008, pp. 3–10]. Washington, DC: U.S. Department of Health and Human Services, Public
Health Service; Cohen, I. B. [1984]. Florence Nightingale. Scientific American, 250[3], 129.)
EPIDEMIOLOGIC MODELS
Epidemiologic Triad
The epidemiologic triad is the classic model based on the belief that health status is determined
by the interaction of the characteristics of the host, agent, and environment, not by any single
factor. The host is the client whose health status is the concern, whether it is a person, a family, a
group of high-risk people, or the community as a whole. Agents are an element or force that
under proper conditions can initiate or perpetuate a health problem. Environment refers to the
context within which the agent and host interact (Fig. 6.2).
Host factors, sometimes called intrinsic factors, include both variable (modifiable) and
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absolute (nonmodifiable) factors. Age, race, and genetic makeup are examples of absolute, or
nonmodifiable, factors. Lifestyle, exercise level, nutrition, health knowledge, and motivation for
achieving optimal wellness are examples of host factors that are variable, or modifiable.
Agents can be classified into five groups. These agents may be physical, such as heat and
trauma; chemical, such as pollutants, medications, and drugs; nutritional, such as the absence or
excess of water, vitamins, fats, proteins, and carbohydrates; psychosocial, such as stress, social
isolation, and social support; and biologic, such as bacteria, viruses, arthropods, toxins, and
conditions that interfere with the normal function of the body.
Environmental factors are frequently divided into three categories: biologic, physical, and
social. The biologic environment is composed of plants, animals, and the toxins they produce;
this includes pathogenic microorganisms, vectors that carry the infectious agents, and the
reservoirs where infectious agents are normally found. The physical environment includes light,
heat, air, atmospheric pressure, radiation, geologic factors, and the structures in the environment.
The social environment includes culture, technology, educational opportunities, political
systems, demographic characteristics, sociologic factors, and economic and legal systems.
The Wheel of Causation
Many diseases, illnesses, and conditions have multiple or no discernible agents, or the agent may
be a part of the environment. An alternate model is conceptualized as a wheel, with a circle as
the genetic core of the host, surrounded by a larger, segmented wheel representing the biologic,
physical, and social environments (Fig. 6.3). The wheel of causation de-emphasizes the agent as
the sole cause of disease, whereas it emphasizes the interplay of physical, biologic, and social
environments. Interaction between the host and environment, with or without an identifiable
agent, remains the major determinant of health status in all epidemiologic models.
FIGURE 6.2 The epidemiologic triad.
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FIGURE 6.3 The wheel of causation.
The Web of Causation
The web of causation is an epidemiologic model that strongly emphasizes the concept of
multiple causation while de-emphasizing the role of agents in explaining illness. At the time of
development, there was a need to create a model that would help describe the multiple factors
underlying chronic illnesses. These causal webs are more focused and realistic, and they may be
as intricate and complex as needed. In this model, it is necessary to identify all possible
antecedent factors that could influence the development or prevention of a particular health
condition. Each factor is perceived as a link in multiple interrelated chains. By making the
pathways explicit in a web of causation, a diagram deepens understanding and provides a
framework for statistical analysis. It also serves as a valuable practical guide. Direct and indirect
factors can be identified that can be changed or modified to improve health. Not only does it
provide multiple entry points for intervention, but it also has the capacity to demonstrate the
interrelationship of different factors. These can include both unpredicted and possibly
undesirable side effects. Public health professionals use web of causation models such as this to
design methods that interrupt the chain of events that lead to adverse states of health. Figure 6.4
exemplifies a classic web of causation that identifies multiple ways to reduce health problems, in
this case drug use and abuse in adolescents.
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FIGURE 6.4 The web of causation for drug use. (Used with permission from Duncan, D. F., &
Petrosa, R. [1999]. Social and community factors associated with drug use and abuse among
adolescents. In T. P. Gullotta, G. R. Adams, & R. Montemayor (Eds.). Substance misuse in
adolescence (pp. 56–91). Thousand Oaks, CA: Sage Publications.)
Natural History of Disease
In 1958, Leavell and Clark developed a conceptual model for the natural history of any disease
affecting humans (Leavell & Clark, 1965). This groundbreaking model integrated the
pathogenesis of an illness with primary, secondary, and tertiary prevention measures (Fig. 6.5).
The initial interactions between the agent, host, and environment occur during the
prepathogenesis period. Primary prevention measures specific to the disease can be implemented
at this stage to prevent its onset in a population of well people. The period of pathogenesis
begins when there are biologic, psychological, or other responses within the host. Secondary
prevention measures focus on early diagnosis and prompt treatment. This can limit resulting
disabilities when implemented during the early stages of the disease. Tertiary prevention follows
with rehabilitation measures that enable the individual to function at his or her maximum
capability. This model, used widely in practice, is discussed in more detail in Chapter 5 (see Fig.
5.2).
Every human being is the author of his own health or disease. Buddha
APPLYING EPIDEMIOLOGIC PRINCIPLES IN
PRACTICE
The epidemiologic process and the nursing process are both derived from the problem-solving
process that provides a framework for gathering data about health problems, analyzing the
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information, generating diagnoses or hypotheses, planning for resolution, implementing plans of
action, and evaluating results (Table 6.4). The focus of the nursing process is on caring for the
client within his or her family, whereas the focus of the epidemiologic process is on caring for
the population of the community as a whole. Whether caring for the individual or the members
of a community, nurses need access to data, abstract critical thinking skills, and complex
reasoning abilities.
Assessment of Health Needs and Assets
Community and public health nurses assess both health needs and health assets for individual
people within their environment and for the population within the community as a whole. Both
the individual and the community are considered clients.
FIGURE 6.5 Leavell and Clark’s natural history of any disease affecting humans. (From Leavell,
H. R. & Clark, E. G. (1979). Preventive medicine for the doctor in his community: An
epidemiological approach. Malabar, FL: Krieger Publishing Company.)
Individual Assessment
Providing personal healthcare services to individual persons is a cornerstone of nursing practice.
Community health and public health nurses often provide direct health services, including
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preventive services, to high-risk, displaced, and vulnerable populations. The nurse is usually the
first person to systematically observe the individual person, either in the home, clinic, parish, or
healthcare facility. The public health nurse takes a nursing history, performs a physical
assessment, and makes both objective and subjective observations about the condition of the
person. He or she establishes where the person is in relation to the full spectrum of health and
identifies the person’s assets as well as needs. Assets include strengths and resources of the
client such as general state of health, prior use of healthcare services, health behaviors, lifestyle,
motivation, and other factors. This information establishes the database about the client. The
planning process and the interventions that are subsequently implemented are based on this
assessment. Also, the database becomes a baseline for measuring the outcomes of care.
TABLE 6.4 Similarities Between the Nursing Process and the Epidemiologic
Process
Nursing Process, Client Based Epidemiologic Process, Population Based
Assessment
An individual client database is established
Data are interpreted
Data are gathered from reliable sources
Nature, extent, and scope of problem are defined
Problem described by person, place, and time
Diagnosis
Healthcare needs and assets are identified
Goals and objectives for care are established
Tentative hypothesis is formulated
Data analyzed to test the hypothesis
Planning
Processes for achieving goals are selected Plans are made for control and prevention of the
condition or event
Implementation
Actions initiated to achieve goals Actions are initiated to implement the plan
Evaluation
Extent of goal achievement is determined Actions are evaluated and report is prepared
Further research is conducted if necessary
Considering the goals of the delinquency prevention program, what information does
Katie need to gather from her group of young people? How could she access this
information?
Practice Point
You have to ask the right questions to gather the information (data) you need.
Nurses use the information that epidemiologic research has established when performing
most client assessments, although they may not be aware that they are doing so. For example, a
common process is to assess individuals for risk factors that have been associated with a disease
or illness through epidemiologic research. Risk refers to the probability or likelihood that a
disease or illness will occur in a group of people who presently do not have the problem. Risk
factors are those characteristics or events that have been shown to increase the probability that a
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specific disease or illness will develop. Some risk factors are modifiable, and others such as age
are not. For example, epidemiologic research has established that certain risk factors, such as a
sedentary lifestyle, obesity, increased cholesterol, hypertension, and smoking, are associated
with cardiovascular disease. These risk factors are now a part of the epidemiologic body of
knowledge, or the epidemiology, of heart disease. As a result, several health appraisal
approaches are now commonly used to profile client risk.
What factors increase the risk of negative health outcomes for youths in gangs?
Epidemiologic research has also established the natural history of most illnesses. This refers
to the course of a disease or condition from onset to resolution. It includes (1) pathologic onset
stage, (2) the presymptomatic stage, and (3) the manifestation of clinical disease (Leavell &
Clark, 1965). Through the individual assessment process, the nurse can begin to determine the
stage of the illness in question. Cues identified at the initial assessment may indicate whether
primary, secondary, or tertiary prevention interventions would be most appropriate.
Evidence for Practice
Decline in the physical functioning of the elderly is of concern worldwide. Chen, Chang, and
Lan (2015) conducted a study that evaluated the association between changes in physical
functioning and a variety of other factors in an older population in Taiwan. The data of 907
participants were derived from the Functioning and Aging Study conducted in Taipei
between 2005 and 2009.
Functional status was assessed using activities of daily living, instrumental activities of
daily living and mobility tasks, and classification as being normal, with mild disability,
moderate disability, and severe disability.
The proportion of elderly participants with normal function decreased with time
throughout the study period. Risk factors, both modifiable and nonmodifiable, that were
associated with changes in physical functioning included the following:
Age
Living arrangements, social support
Self-rated health
Stroke
Diabetes
Parkinson disease
Osteoporosis
Depression
Cognition
Vision
History of fracture and falls
Incontinence of urine and feces
Physical activity
Body mass index (BMI), short physical performance
Researchers conclude that older persons with stroke, Parkinson disease, diabetes,
osteoporosis, geriatric conditions, and poor short physical performance would benefit the
most from prevention measures for functional decline. Older people not living with spouses,
with poor self-rated health, with low social support, who are malnourished and live a
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sedentary lifestyle might also benefit from interventions protecting against functional
decline. All public health nurses can assess their elderly clients and plan interventions that
will protect them from excessive decline in the ability to function well in their daily lives.
Community Assessment
Conceptualizing the community as a client is difficult for the individual-oriented nurse.
Assessing the health needs and assets of a community involves creating a comprehensive
community profile or database. The individual nurse may be solely responsible for the
assessment, but usually he or she contributes to the assessment as a member of a team.
Epidemiologic statistical methods, such as calculation of rates, are used in this process (see
Chapter 7). A detailed discussion of community assessment is found in Chapter 11.
Epidemiologists gather available demographic data that provide information about the age
and sex distribution, socioeconomic characteristics, and cultural and ethnic distributions. They
access vital statistics, including applicable epidemiologic morbidity and mortality rates.
Additional data can be obtained from community members or community groups. Information
about the accessibility and availability of healthcare services, such as health manpower, may or
may not be community assets. To obtain information about health beliefs, norms, values, goals,
perceived needs, and health practices, healthcare workers may use focus groups, interviews or
observation, or surveys. Nurses may participate in field-testing new tools for data collection.
After epidemiologists collect the data, they synthesize and analyze the information and
generate a list of community health needs and assets. Identifying patterns of disease, illness, and
injuries detects trends that form the rationale for program development. Critical thinking skills
are essential for the appropriate analysis of this information. Finally, it is necessary to set goals
and objectives to address high-priority problems.
Practice Point
A thorough and accurate client database, whether that of individuals, groups, or the
community, provides the evidence and rationale for your interventions.
To understand the scope of the health problems facing the young people who were
enrolled in the delinquency prevention program, a community assessment should be
considered. What information does Katie need to gather, and where would she find that
information?
Student Reflection
Although my nursing program focused a lot on research findings, particularly in writing
assignments, I did not fully understand the impact that statistics can make in nursing until I
had my community practicum in a local women’s health center. When I arrived there, the
staff was talking about a violent episode that had occurred the previous week. Everyone
seemed to think that there was more violence in the community than there should be, and
that we needed to know more about it.
My preceptor was a program developer, and the women at the center asked her if they
needed a violence prevention program. One of my first assignments was to find out just how
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much and what types of violence had occurred in the last year. The first thing my preceptor
suggested was to go online and look at websites for various states and towns. I was
amazed at how much information was available. For example, I found out that the rates of
homicide, assaults, and rapes in our town were greater than the average for both the state
and the nation. Also, I found out that 45% of the poor, young males from minority groups
were in jail for crimes of violence! I learned that most violence occurs between people who
know each other, and that violence is related to substance abuse. I presented my
information to the staff, and they all decided to have my preceptor contact other community
agencies and the local college to form a coalition to address violence. I attended the first
meeting, and people tossed around lots of ideas. They decided to look into a 24/7 free
telephone line to give people support in a crisis, increase housing for women suffering from
domestic violence, and consider a number of initiatives for youth in the town.
This experience taught me several things.
Lots of information is available about health problems in a community.
New ideas require presentation of supportive data.
Involving other interested communities can enhance whatever is planned to reduce health
problems.
One person’s efforts can really make a difference.
Using Assessment Data for Planning and Implementing
Interventions
The individual or community client database, much of which has been gathered using
epidemiologic methods, provides the rationale for planning and implementing interventions. It is
possible to use the epidemiologic body of knowledge that describes the natural progression of
specific diseases or illnesses to target ways to break the problem cycle once it has been
identified. An intervention plan outlines the goals, objectives, and strategies for achieving the
interventions and provides completion dates for their accomplishment. The type of health
problem, the readiness of the individual or community to address the problem, the availability of
health services, the nurse’s role, the characteristics of social change, and other related factors
influence successful implementation.
Three goals for the delinquency prevention program are presented at the beginning of this
chapter.
Write an objective for each goal.
Promoting Healthy Lifestyles
Every phase of public health nursing involves the provision of health education whenever the
opportunity arises. Lifestyle patterns are modifiable, and nurses can help make the public aware
of the benefits of preventive health through use of the media and meeting with individuals and
community groups.
Following the landmark epidemiologic studies of smoking and lung cancer in the 1950s, the
general public gradually recognized that personal behaviors such as smoking were risk factors
for the leading conditions causing morbidity and mortality in the United States and other
countries. In 1984, the CDC and the U.S. state health departments collaboratively established the
Behavioral Risk Factor Surveillance System (BRFSS). The goal of this surveillance system is to
collect, analyze, and interpret specific behavioral risk factor data that can be used to plan,
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implement, and monitor health promotion and disease prevention programs.
The BRFSS gathers information about health behaviors, such as lack of physical activity,
obesity, and safety belt use, primarily by telephone calls. It also gathers data about preventive
health services, such as screening for breast and cervical cancer and elevated blood cholesterol.
The BRFSS used these epidemiologic statistics when national objectives were established for
Healthy People 2000, Healthy People 2010, and Healthy People 2020. Healthy People 2020,
developed by the U.S. Department of Health and Human Services, sets behavioral objectives to
be achieved over the second decade of the 21st century. Experts developed these objectives
through a broad consultation process, built on the best scientific knowledge and designed to
measure programs over time. Along with the BRFSS data, Healthy People 2020 serves as the
basis for the development of state and community plans to improve the health of their
populations. Each state collects statistics for the BRFSS, and thus these data are available for
nurses to access when planning educational programs for primary prevention.
Dietary factors are associated with 4 out of the 10 leading causes of death: heart disease,
some types of cancer, stroke, and type 2 diabetes. Obesity rates have doubled in adults and
tripled in children and adolescents over the last two decades. The data are alarming (CDC,
2015).
The prevalence in the United States between 2011 and 2014 is as follows:
36.5% of adults aged 20 years and older were obese
20.5% of adolescents aged 12 to 19 years were obese
17.5% of children aged 6 to 11 years were obese
8.9% of children aged 2 to 5 years were obese
These are significant increases in obesity as compared to the period of 1999–2000.
The estimated cost of these diet-related conditions is more than $123 billion annually in
medical expenses. Including lost productivity in these statistics adds billions more (CDC,
2010b). The BRFSS data dramatically demonstrate the significant increase in the prevalence of
overweight people in the United States (Fig. 6.6). Using these data, Healthy People 2020
identified overweight and obesity as a major health issue in the United States. Sex and ethnicity
are also important factors in the development of obesity (Fig. 6.7). Overweight is most prevalent
in African American and Hispanic females. If nurses find that such statistics apply to the
members of their own community, they can initiate programs to address the problem.
The burden of food-related ill health measured in terms of mortality and morbidity is similar
to that attributable to smoking. The cost is twice the amount attributable to car, train, and other
accidents, and more than twice that attributable to smoking. The vast majority of the burden is
attributable to unhealthy diets rather than to food-borne diseases (Rayner & Scarborough, 2005).
Practice Point
Use statistics to demonstrate the need for program development and community
interventions.
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FIGURE 6.6 Changes in prevalence of obesity among U.S. adults. Note that the data are for ages
18 years and over, based on self-reported weight and height via telephone interview. Obesity is
defined as body mass index ≥30. (From National Health and Nutrition Examination Survey, NCHS,
CDC; BRFSS, 2012.)
FIGURE 6.7 Age-adjusted prevalence of obesity among adults aged 20 and over, by
race/ethnicity: United States, January to June 2013. Note that data are age adjusted to the 2000
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standard population. Obesity is defined as body mass index ≥30. (Retrieved from
www.cdc.gov/nchs/data/nhis/earlyrelease/earlyrelease201312_06 .)
Evidence for Practice
Healthier food access in schools is a major objective of Healthy People 2020. To
accomplish this goal, the United States has invested heavily in actions to prevent youth
obesity by promoting healthy eating and physical activity. With support from the CDC, the
Communities Putting Prevention to Work (CPPW) obesity prevention program was initiated
in King County, Washington, during 2010 and 2012 (CDC, 2014). Components of the robust
obesity prevention program included the following:
Implementation of nutrition standards for school meals
Student-led healthy eating and active living promotional campaigns
Farm to school initiatives
High-quality physical education
Nutrition and culinary training for school cafeteria staff
Participation in community health coalitions
The CPPW focused on low-income school districts and communities, since community
health assessment data indicated that the prevalence of obesity, poor nutrition, and physical
inactivity was disproportionately high relative to higher-income communities. Data were
obtained from a school-based survey analogous to the national Youth Risk Behavior
Survey. The Washington State Department of Health used self-reported height and weight
from the survey to calculate BMI. The survey response rates ranged from 63% to 71%,
resulting in approximately 34,000 respondents per survey year, for the project group, and
61% to 67% for the rest of the population of Kings County and the state of Washington
resulting in approximately 18,500 respondents per survey year.
Results indicated a statistically significant 17% decline in youth obesity after
implementation of CPPW school districts, but not in non-CPPW districts. Also, there was a
statistically significant reduction in youth obesity in Kings County when compared with the
rest of the state of Washington.
These findings suggest that focused, multifaceted, and comprehensive policy, systems,
and environmental change interventions located in each community can reduce obesity in
youth. Continued community level interventions such as these have the potential to meet
the CDC’s obesity prevention priority as one of its 10 “winnable battles.”
Preventing and Controlling Outbreaks
The investigation of an epidemic or outbreak is an example of the epidemiologic process in
action. Epidemics occur when there is an increased incidence of a disease or event beyond that
which is normally found in the population. Although the term outbreak is often used
synonymously with epidemic, outbreaks are usually limited to a localized increase in the
incidence of the illness. The steps of investigating an outbreak are presented in Box 6.1. A
detailed description of outbreak investigations is found in Chapter 14.
6.1 How to Investigate an Outbreak
Establish the existence of the outbreak.
Describe the outbreak according to person, place, and time.
Formulate and test hypotheses as to the most probable causative factors.
Implement a plan for control of the outbreak and prevention of further outbreaks.
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Evaluate results, prepare reports, and conduct further research if necessary.
Public health nurses may be involved in any of the steps of the outbreak investigation. The
nurse’s role varies with the workplace. Generally, nurses are involved in education of the public,
mobilization of community resources, and implementing regulatory and control measures.
Practice Point
When you are investigating unusual events, determine whether the incidence is greater than
what normally would occur at that time and place.
What types of outbreaks may occur during the delinquency prevention program?
Contributing to a Safe and Healthy Environment
Individual and community risk assessments should include detection of real or potential threats
from the environment. Environment includes physical, biologic, social, cultural, or any other
external factors that can influence the health status of individuals or populations. The principles
of epidemiology, normally used in investigating disease and illness, can be applied to the human
effects of natural disasters such as hurricanes and earthquakes, as well as to industrial disasters
such as injuries, air pollution, nuclear accidents, and release of toxic chemicals.
Practice Point
Evaluate your community, and subsets of the community, for potential environmental
hazards.
When healthcare professionals gather demographic data, vital statistics, and epidemiologic
morbidity and mortality statistics, they should also consult environmental health sources. Using
detailed individual or community client databases, nurses then have the potential to link
environmental exposure to illness and disease. Nurses often provide case management for both
communicable and chronic illnesses that result from environmental exposure. Nurses also may
be risk consultants, communicators, and educators, working with community groups, agencies,
and industry to protect the health of their workers.
What are the environmental risks for the group of delinquent youth? How would Katie
address these in her sessions with the youth?
The World Health Organization (WHO), the National Institute for Occupational Safety and
Health (NIOSH) in the United States, and other international and national agencies review
existing knowledge about chemicals, radiation, and other environmental hazards that have
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immediate and long-term effects on health, and issue reports concerning environmental health
criteria. See Chapter 19 for detailed information regarding environmental assessment.
Evaluating the Effectiveness of Health Services
Public health professionals who collect epidemiologic data during assessments and use them for
establishing the need for health programs can also use them to evaluate those services.
Evaluation requires a systematic and objective process that determines the relevance,
effectiveness, and impact of the health service. Creating objectives that are measurable assists in
this process. Nurses should continuously monitor the health status indicators in the community,
especially for vulnerable populations. Age-specific mortality rates, low birth rates, infant
mortality rates, health services utilization, and other indexes specific to the characteristics of the
community are examples (see Chapter 7). This information assists in identifying gaps and
detecting emerging problems early so that appropriate responses can be facilitated. In addition,
nurses and other healthcare professionals can also use epidemiologic principles to develop
surveys to gather specific information from targeted populations such as child care centers or the
population of census tracts that may be at high risk.
The primary way to demonstrate prevention or control of a health problem is to compare
epidemiologic statistics before and after the implementation of the health service. Planning and
evaluation are continuous processes. As new data become available, modification in health
services may be necessary, and those modifications require evaluation.
Practice Point
Use your program objectives to evaluate your interventions.
Outline an evaluation program for the delinquent youth prevention program discussed in
the case at the beginning of this chapter.
KEY CONCEPTS
Early attempts at understanding the reasons for disease were primarily a direct result of trial-and-error
observations of individual people.
Study of illness and causes of death in groups of people began in the 17th century. Founders of
epidemiology as the science of preventive medicine included John Graunt, William Farr, John Snow, and
Florence Nightingale.
Epidemiology is defined as the study of the distribution and determinants of the states of health and illness
in human populations, with the goal of preventing or limiting consequences and maximizing states of
health.
Individual and community assessments, using epidemiologic principles, form the database that provides the
evidence and rationale for interventions.
Promoting healthy lifestyles uses epidemiologic data such as that found in the BRFSS. The U.S. publication
Healthy People 2020 defines measurable objectives to be achieved over the second decade of the 21st
century.
Nurses, in their care of individual and community clients, have the potential to link environmental exposure
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to illness and disease.
Epidemiologic data, collected during assessments that establish the need for health programs, are also
used to evaluate those services.
CRITICAL THINKING QUESTIONS
1. Jeff is 11 years old and slightly overweight. His father is a truck driver who was recently diagnosed with
type 2 diabetes. His mother is a licensed practical nurse at the local hospital. At a recent health science
fair at his school, a student-led screening clinic documented Jeff’s blood pressure at 140/92 mm Hg.
a. Is Jeff at risk? If so, for what?
b. Utilizing the Guidelines for High Blood Pressure in Adults (American College of Cardiology, 2017), what
is Jeff’s future risk from adolescence through adulthood?
c. What other data do you need?
d. How does epidemiologic data define hypertension in a child of Jeff’s age?
e. What recommendations would you make?
f. Are there health promotion activities that you would recommend?
2. Look through several major newspapers for articles containing health statistics.
a. What are the implications of these statistics for your community?
b. What further data would you obtain to document the problem in your community?
3. Go to the CDC website www.cdc.gov. Pick a topic to explore. Show how epidemiologic information has
been used to describe the topic.
4. Explore the website “Violence Prevention”
(http://www.cdc.gov/ViolencePrevention/pub/PreventingYV.html). Identify at least one activity that Katie
could use to meet each of the goals of her program.
REFERENCES
American College of Cardiology. (2017). 2017 Guideline for high blood pressure in adults. Retrieved from
http://www.acc.org/latest-in-cardiology/ten-points-to-remember/2017/11/09/11/41/2017-guideline-for-
high-blood-pressure-in-adults
Centers for Disease Control and Prevention. (2010a). Healthy people 2020. Retrieved from
https://www.healthypeople.gov/2020/About-Healthy-People
Centers for Disease Control and Prevention. (2010b). National health priorities, reducing obesity, heart
disease, cancer, diabetes and other diet and inactivity related diseases, costs, and disabilities. Retrieved
from http://www.cdc.gov/nccdphp/dnpao/index.html
Centers for Disease Control and Prevention. (2014). Declines in student obesity prevalence associated with
a prevention initiative—King County, Washington, 2012. Morbidity and Mortality Weekly Reports,
63(07), 155–157.
Centers for Disease Control and Prevention. (2015). Prevalence of obesity among adults and youth: United
States, 2011–2014. Retrieved from https://www.cdc.gov/nchs/data/databriefs/db219
Centers for Disease Control and Prevention. (2016). Current cigarette smoking among adults—United
States, 2005–2015. Morbidity and Mortality Weekly Report, 65(44), 1205–1211. Retrieved from
https://www.cdc.gov/mmwr/volumes/65/wr/mm6544a2.htm
Chen, C. M., Chang, W. C., & Lan, T. Y. (2015). Identifying factors associated with changes in physical
functioning in an older population. Geriatrics and Gerontology International, 15(2), 156–164.
Cohen, I. B. (1984). Florence Nightingale. Scientific American, 250(3), 128–137.
Doll, R., & Hill, A. B. (1950). Smoking and carcinoma of the lung; preliminary report. British Medical
Journal, 2(4682), 739–748.
Farr, W. (1852). Influence of elevation on the fatality of cholera. Journal of the Statistical Society of
London, 1(2), 155–183.
Harkness, G. A. (1995). Epidemiology in nursing practice. St. Louis, MO: Mosby.
Hippocrates. (1938). On airs, waters, and places [400 BC]: Translated and republished. Medical Classics,
3, 19–42.
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http://www.cdc.gov
http://www.cdc.gov/ViolencePrevention/pub/PreventingYV.html
http://www.acc.org/latest-in-cardiology/ten-points-to-remember/2017/11/09/11/41/2017-guideline-for-high-blood-pressure-in-adults
https://www.healthypeople.gov/2020/About-Healthy-People
http://www.cdc.gov/nccdphp/dnpao/index.html
https://www.cdc.gov/nchs/data/databriefs/db219
https://www.cdc.gov/mmwr/volumes/65/wr/mm6544a2.htm
Leavell, H. R., & Clark, E. G. (1965). Preventive medicine for the doctor in his community: An
epidemiologic approach (p. 21). New York: McGraw-Hill.
Mausner, J. S., & Kramer, S. (1985). Epidemiology—An introductory text (2nd ed.). Philadelphia, PA: W.
B. Saunders.
Rayner, M., & Scarborough, P. (2005). The burden of food related ill health in the UK. Journal of
Epidemiology and Community Health, 59(12), 1054–1057.
Sanders, B., Schneiderman, J. U., Loken, A., Lankenau, S. E., & Bloom, J. J. (2009). Gang youth as a
vulnerable population for nursing intervention. Public Health Nursing, 26(4), 346–352.
Snow, J. (1855). On the mode of communication of cholera. London: John Churchill. Retrieved from
http://www.ph.ucla.edu/epi/snow/snowbook.html
WEB RESOURCES
Please visit thePoint for up-to-date web resources on this topic.
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http://www.ph.ucla.edu/epi/snow/snowbook.html
http://thepoint.lww.com/vitalsource/ebook/9781975111694
Chapter 7
Describing Health
Conditions: Understanding
and Using Rates
Patrice Nicholas and Patricia Lussier-Duynstee
For additional ancillary materials related to this chapter. please visit thePoint
Perplexity is the beginning of knowledge.
Khalil Gibran
There are three kinds of epidemiologists: those who can count and those who can’t.
Anonymous
Prejudice is a great time saver. You can form opinions without having to get the facts.
E.B. White, author
CHAPTER HIGHLIGHTS
Concept and calculation of rates
Crude, specific, and adjusted rates
Incidence and prevalence rates
Sensitivity and specificity calculations
OBJECTIVES
Describe the primary method used to measure the existence of states of health or illness in a population
during a given time period.
Explain the formula and rules for calculation of a rate.
Differentiate between crude and adjusted rates.
Contrast incidence rates and prevalence rates.
Discuss the use of specific rates when describing characteristics of person, place, and time.
Differentiate between incidence density, incidence rates, and relative risk ratio.
Discuss differences between the sensitivity and specificity of tests.
Using examples, interpret the relevance of the use of rates in nursing practice.
KEY TERMS
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Adjusted rate: Statistical procedure that removes the effects of differences in the composition of
a population, such as age, when comparing one to another.
Attack rate: An incidence or occurrence rate.
Attributable risk: The difference between the incidence rates in an exposed and an unexposed
group of people.
Case fatality rate: Calculated by dividing the number of deaths from a specific disease by the
number of people living with that disease during the year, and multiplying by 100.
Cause-specific mortality rate: The probability of death from a specific cause.
Crude rate: Measurement of the occurrence of the health problem or condition being
investigated in the entire population.
Demographic data: The study of the size, distribution, and characteristics of human populations.
Epidemic curve: A graph that plots the distribution of cases by the time of onset of the disease.
Epidemiologic descriptive studies: Research studies designed to acquire more information
about the occurrence and distribution of states of health, such as characteristics of person,
place, and time.
Incidence density: Use of a person-time denominator in the calculation of rates; a person-day
reflects one person at risk for 1 day, and a person-year represents one person at risk for 1
year.
Incidence rate: Measure of the probability that people without a certain condition will develop
that condition over a period of time.
Long-term change: Fluctuations in time surrounding health problems that extend over decades,
reflecting gradual changes.
Morbidity: A departure from a state of physiologic or psychological well-being.
Mortality rate: The probability of death from any cause among the entire population within a
given time frame.
Period prevalence: A prevalence rate that indicates the existence of a condition during an
interval of time, often a year.
Periodic change: Seasonal or cyclic fluctuations in time surrounding health problems.
Point prevalence: A prevalence rate that indicates the existence of a condition at a specific point
in time.
Populations at risk: Groups of people who have specific characteristics, or risk factors, that
increase the probability of developing health problems.
Prevalence rate: Measures the number of people in a given population who have an existing
condition at a given point in time.
Proportion: A type of ratio that includes the quantity in the numerator as a part of the
denominator.
Proportional mortality ratio: A ratio that compares deaths from a specific illness with deaths
from all other causes.
Rate: The primary measurement used to describe the occurrence (quantity) of a state of health in
a specific group of people in a given time period.
Ratio: A fraction that represents the relationship between two numbers.
Relative risk ratio: The ratio of the incidence rate in the exposed group and the incidence rate in
the nonexposed group.
Sensitivity: Ability of a test to correctly identify people who have a health problem; the probability
of testing positive if the health problem is truly present.
Short-term change: Variations measured in hours, days, weeks, or months; commonly found in
outbreaks of infectious disease.
Specific rates: Detailed rates that are calculated using the number of people in the smaller
subgroups of the population in the denominator. Often, people are divided into subgroups by
age and sex, although any characteristic can be used.
Specificity: Ability of a test to correctly identify people who do not have a health problem; the
probability of testing negative if the health problem is truly absent.
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T
CASE STUDY
References to the case study are found throughout this chapter (look for the case study icon).
Readers should keep the case study in mind as they read the chapter.
The Visiting Nurse Association serving two rural counties in Florida has received a grant from the
United States Office of Minority Health for a human immunodeficiency virus/acquired
immunodeficiency syndrome (HIV/AIDS) prevention outreach program targeted toward the two
counties’ large African American population. The counties are adjacent to each other and have a
combined population of 312,838 people. The number of African American people in the two
counties is 57,875, or 18.5% of the population.
Lindsay is on the team that developed the program grant, and she is now the program director.
She and the team members develop a HIV/AIDS outreach survey, a yes-or-no checklist that serves
as a data collection form. Demographic information will be collected at the end of the interview.
Outreach workers from the African American community are hired to interview people on the street
and in their homes following a week-long training session on HIV/AIDS and methods of establishing
rapport (adapted and updated from [Brown & Brown, 2003])
Data from a recent survey in seven African countries found that in 2016, an estimated 1.5
million females aged 15 to 24 years were living with HIV infection in Eastern and Southern Africa,
where the prevalence of HIV infection among adolescent girls and young women (3.4%) is more
than double that for males in the same age range (1.6%) (Brown et al., 2018). Consider the
questions on the HIV/AIDS Outreach Survey below for both of these HIV surveys.
HIV/AIDS OUTREACH SURVEY FORM
1. Do you know about HIV/AIDS?
2. Are you doing anything to protect yourself from HIV?
3. Have you used drugs?
4. Have you been tested for HIV?
5. Modes of HIV transmission reviewed?
6. Risk factors reviewed?
7. Discussed HIV risk reduction?
a. Correct condom use
b. Monogamous partners
c. Reduce number of partners
d. Cleanliness of equipment
8. Literature given?
9. Condoms given?
10. Is subject male or female?
Comments: _____________________
o understand the extent of a state of health, whether it is a disease, disability, or factors
that keep people well, it is necessary to describe the magnitude or frequency of the
condition. Since people differ in terms of health, it is important to know how they differ.
By looking at the frequency of the condition in groups of people who either have or do not have
the problem under investigation, it can be determined who is at risk or not at risk for that
condition. Using this technique, descriptive epidemiology can demonstrate the seriousness of the
problem, determine the characteristics of the people it affects, and identify where and when it
occurs. It can also provide data, or clues, that suggest how the condition evolves and why the
condition exists. This information can indicate which people are likely to develop certain health
problems; what diseases, disabilities, or needs they have; how these health problems are
distributed within the community; and what kind of health services are needed. The use of
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existing resources in a community can then be determined and programs planned to address the
needs.
Using the information about the frequency and distribution of a condition, nurses and other
healthcare professionals can examine the characteristics of groups of people in the community,
or within institutions, who are most likely to develop health problems. These groups are
considered to be populations at risk. Knowledge about the population at risk and risk factors
can be also used to set priorities for the development of strategies to meet emerging health needs
and for expansion or change in programs or services that are directed toward secondary or
tertiary prevention.
The process of using epidemiologic techniques to generate a knowledge base about a
specific health problem and plan for its control and prevention is best illustrated by
cardiovascular disease. The knowledge gained from the study of populations at risk and
identification of predisposing risk factors has been the foundation for the primary, secondary,
and tertiary prevention strategies used widely today. Since the initial development of objectives
in the earlier reports on Healthy People 2000 and 2010, Healthy People 2020 (CDC, 2010a) has
strengthened the focus on health promotion activities in the United States. With a vision based
on developing a society in which all people live long, healthy lives, its mission is to identify
nationwide health improvement priorities; increase public awareness and understanding of the
determinants of health, disease, and disability and the opportunities for progress; provide
measurable objectives and goals that are applicable at the national, state, and local levels;
engage multiple sectors to take actions to strengthen policies and improve practices that are
driven by the best available evidence and knowledge; and identify critical research, evaluation,
and data collection needs.
The overarching goals of Healthy People 2020 (CDC, 2010a) are:
Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death
Achieve health equity, eliminate disparities, and improve the health of all groups
Create social and physical environments that promote good health for all
Promote quality of life, healthy development, and healthy behaviors across all life stages
Although most epidemiologic studies have focused on disease and disability, it should be
emphasized that this process can also be used to study states of wellness. For example, studies of
the factors that are associated with healthy, community-dwelling elderly people can lead to the
implementation of strategies to enhance wellness in the elderly population.
To demonstrate that African American people are a population at risk, Lindsay examines
Florida statistics. She finds that since the epidemic began, a cumulative total of 107,980
cases of HIV/AIDS have been diagnosed in Florida. Nearly half (48.7%) of these cases
have occurred in African American people.
Make a list of other information that Lindsay needs to understand the scope of the
HIV/AIDS problem in the two counties.
UNDERSTANDING AND USING RATES
Although the most basic measure of frequency involves counting the number of affected people,
this may result in misleading impressions and usually is of limited use. A higher number of
cases in one group of people versus another may mean that the number of susceptible people in
that group is greater or that the counting took place over a longer period of time. To provide
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more valid descriptions of the frequency of various states of health, it is necessary to use ratios,
proportions, and rates.
However, there are some statistics that are impressive even if they involve counting (or
estimating) just the number of affected people. For example, Figure 7.1 illustrates the 10 leading
causes of death in the world in 2015. The figure shows that ischemic heart disease and stroke
caused 15 million deaths. Chronic obstructive pulmonary disease caused 3.2 million deaths, lung
cancer 1.7 million deaths, and diabetes 1.6 million, an increase from 1 million in 2000 (World
Health Organization [WHO], 2015).
A ratio is a fraction that represents the relationship between two numbers. It is the value
obtained by dividing one quantity by another quantity. People (or things) counted in the
numerator are not counted in the denominator. For example, the number of boys (160) in an
elementary school could be contrasted with the number of girls (80) in that school using a ratio
(160/80 = 2/1 = twice as many boys as girls).
A proportion is a type of ratio that includes the quantity in the numerator as a part of the
denominator; it is the relationship of a part to the whole. Dividing the number of boys by the
total number of children in the school results in a proportion (160 divided by 240 = 0.67; 67% of
the students are boys).
The rate is the primary measurement used to describe the occurrence (frequency or quantity)
of a state of health in a specific group of people in a given time period. It is a proportion that
includes the factor of time. Therefore, rates are the best indicators of the risk (probability) that a
specific disease, condition, or event will occur. The rules for calculation of rates are outlined in
Box 7.1. Rates are used to quantify either the occurrence (incidence) or the existence
(prevalence) of states of health or illness. Using rates rather than counting cases takes both the
size of the population at risk and the time frame into account.
Not everything that counts can be counted, and not everything that can be counted
counts. Albert Einstein
For example, suppose it is necessary to compare 2,250 cases of H1N1 influenza diagnosed in
February in Lake County having a population of 104,000 with 10,500 cases of H1N1 influenza
diagnosed in February in Barnes County having a population of 950,000. If only the frequency
count is examined, Barnes County has the greatest number of people with the flu, and therefore,
it could be concluded that Barnes County has the greater community problem. However, it is not
appropriate to compare the raw numbers alone; more cases would be expected in a county with
more residents. Indeed, the calculation of rates in Table 7.1 indicates that Lake County had the
most severe outbreak of the illness in February.
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FIGURE 7.1 The 10 leading causes of death in the world (WHO, 2015). (Available from
http://www.who.int/mediacentre/factsheets/fs310/en.)
7.1 How to Calculate Rates
1. All of the events being measured should be included in the numerator.
2. Everyone included in the denominator should be at risk for the event in the numerator. For example,
it would be inappropriate to include males in the denominator when calculating a rate for ovarian
cancer because no males are at risk for the illness.
3. A specific period of time for the observations must be clearly indicated. This can range from a single
point in time to several years, depending on the type of rate that is being calculated.
4. A rate is a fraction or a proportion; therefore, it is necessary to multiply by a base, usually a multiple
of 10, to make the rates understandable. This removes the decimal points and makes the comparison
of rates easier to interpret. Any base multiple of 10 may be chosen that results in a rate above the
value of 1. For large populations, 100,000 is often used. For smaller populations, 100 is often used,
and the rate can then be expressed as a percentage.
5. Formula for calculation:
Practice Point
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When assessing the extent of a health problem in a community at a given time, the number
of cases should be counted, the number of people in the population should be obtained, and
a rate should be calculated.
Crude Rates
Crude rates are general or summary rates that measure the occurrence of the condition being
investigated in the entire population. Calculation of these rates usually involves averaging the
population numbers at the beginning and end of the year, and that number is used in the
denominator. However, smaller groups within the entire population (subgroups) may differ
significantly with regard to their risk of developing the condition, and thus, calculating only
crude rates may obscure important information. For example, the formula for a crude birth rate
has the entire population in its denominator. Births can occur only to females who are of
childbearing age; therefore, the total population may not be an ideal denominator.
There are 2,150 people living with HIV/AIDS this year in two Florida counties. What is the
crude rate of the HIV/AIDS burden in these two counties?
Adjusted Rates
There is often a need to remove the effects of differences in the composition of a population
when comparing one with another. For example, an investigator may want to compare two or
more groups knowing that they differ in terms of a characteristic, such as age, that may
influence the results. The process of adjusting rates controls for these differences. Although age
adjustment and other types of adjusted rates are artificial, they provide a valid way to compare
two populations without the confounding variable (such as age) affecting the results.
As an example, Figure 7.2 illustrates age-adjusted death rates by race, Hispanic origin, state,
and territory: United States and U.S.-dependent areas, average annual 1979 to 1981, 1989 to
1991, and 2013 to 2015 (Centers for Disease Control and Prevention [CDC], 2016).
Age-adjusted rates are meaningful only as a comparison and should not be used if an
accurate description of a population is desired and not a comparison of populations. It is also
possible to adjust rates to remove other variables, such as race or occupation, that are
confounding an investigation.
Incidence Rates
An incidence rate (also an occurrence or attack rate) is a measure of the probability that
people without a certain condition will develop the condition over a period of time, often a year.
It measures the pace at which new illnesses, such as H1N1 influenza, occur in a previously
disease-free group of people. The general rules that apply to rates also apply to calculation of
incidence rates (see Box 7.1). However, only the new cases that have occurred in the designated
time period are counted and placed in the numerator. Common incidence rates and ratios that
provide indexes of the health of a community are presented in Table 7.2.
TABLE 7.1 Calculation of Rates of H1N1 Influenza in Lake and Barnes
Counties
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FIGURE 7.2 Age-adjusted death rates, by race, Hispanic origin, state, and territory: United States
and U.S. dependent areas, average annual 1979–1981, 1989–1991, and 2013–2015 (CDC,
2016). (Available from https://www.cdc.gov/nchs/data/hus/2016/016 .)
Determination of the date of onset is required for studies of incidence. For acute conditions,
this can be quickly established. H1N1 influenza is an acute, time-limited condition; thus, the
data in Table 7.1 result in incidence or occurrence rates. For other conditions such as cancer or
depression, it may be difficult to determine the time of onset. In this case, an event that can be
verified, such as the date of diagnosis, is considered as the time of onset.
Lindsay finds that 384 new cases of HIV infection were diagnosed in the two counties
within the past year. What is the incidence rate? Contrast this incidence rate with: (1) the
crude rate of the HIV/AIDS burden calculated above; and (2) the incidence rate in the
United States of 83.7 new HIV infections per 100,000 in 1 year. Interpret the results.
Prevalence Rates
Both incidence rates and prevalence rates can be measures of morbidity—a departure from a
state of physiologic or psychological well-being. Prevalence rates measure the number of people
in a given population who have a specific existing condition at a given point in time. The
general rules that apply to rates also apply to calculation of prevalence rates (see Box 7.1).
However, both new cases and existing cases (old and new cases) are counted in the designated
time period and placed in the numerator.
There are two types of prevalence rates. Period prevalence indicates the existence of a
condition during a period or an interval of time. Point prevalence refers to the existence of a
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condition at a specific point in time and provides a picture of an existing situation for a group of
people. If the time frame is not given, point prevalence is inferred. Point prevalence does not
have to be expressed in calendar time; it can refer to an event that happens to different people at
different times. For example, it could refer to the day of discharge from an institution for a group
of people or a specific day of attendance at a screening clinic.
Prevalence is influenced by two factors: the number of people who have developed the
condition in the past and the duration of their illness. The longer the duration of a condition, the
higher the prevalence rate. This is best illustrated with chronic diseases. Even if the incidence
rate is low, the prevalence rate may be high. For instance, there are many more existing cases of
cancer in a community than are indicated by examining the number of new cases of cancer.
Prevalence statistics are very important in identifying public health problems that exist in a
community. They are particularly useful to health planning professionals because they measure
the burden of a condition or illness in a community. This information documents the need for
developing programs such as the initiation of primary, secondary, or tertiary prevention
strategies for people at risk. Also, these data provide the rationale for modification of facilities
and hiring staff to meet the requirements of the community.
TABLE 7.2 Incidence Rates and Ratios That Provide Indexes of the Health of
a Community
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Evidence for Practice
Researchers at the Centers for Disease Control and Prevention (CDC, 2010b) used the
results of the Oregon Healthy Teens Survey, which had questioned eighth-grade students
to determine the demographic characteristics and risk factors for participation in the
“choking game.” This is an activity where youths become “high” by cutting off blood and
oxygen to the brain with a belt, towel, rope, or other item. Evaluation of earlier studies had
indicated that youths experiencing peer rejection or other disruptive factors are more likely
to participate in strangulation activities.
This investigation (CDC, 2010b) reported prevalence rates as percentages because the
base multiplier for calculation of the rates was 100. A total of 36.2% of the youths had heard
of the choking game, 30.4% had heard of someone participating, and 5.7% had taken part
themselves. Risk factors included substance use and mental health factors, such as
depression. Youths with these factors had the highest participation rate (15.8%) and were
approximately nine times more likely to participate. Of those who reported only substance
use and no mental health factors, the participation rate was 7.9%, and of those who
reported only mental health factors and no substance use, the participation rate was 4%. In
students with no reported risk factors, the participation rate was 1.7%.
Public health surveillance of these strangulation activities in youths should be expanded
to understand the frequency of the risk and the motives and circumstances surrounding
participation. Along with parents and educators, nurses, counselors, and others who work
with youths should be aware of strangulation activities and their serious health effects. They
should watch for signs of participation in strangulation activities, especially in youths with
suspected substance use or mental health risk factors. Three quarters of parents
responding reported being familiar with the choking game, but considerably fewer (20%)
reported having talked to their children about this activity. Ninety-six percent of parents
reported knowing that unintentional death was a potential risk and 90% believe information
about this activity should be included in school health curricula (Bernacki & Davies, 2012).
In addition, this report indicated the importance parents’ perspectives on the topic of the
prevention of the choking. The association between participation in strangulation activities
and other sensation-seeking behaviors or mental health risk factors suggests that effective
methods for substance use prevention might serve as models for effective prevention
strategies. However, prevention methods for this activity should be tested before being
incorporated into general use. For example, an unintended consequence of prevention
methods may be increased youth participation in the choking game. Effective prevention
methods could be incorporated into existing substance use and mental health screening
instruments, curricula, or related public health tools (CDC, 2010b).
SPECIFIC RATES: DESCRIBING BY PERSON, PLACE,
AND TIME
Specific rates are more detailed rates and are calculated using the number of people in the
smaller subgroups of the population in the denominator. Often, people are divided into
subgroups by age and sex, although any characteristic can be used. The frequency and severity
of most illnesses vary according to age more than any other personal characteristic.
When investigating the distribution and the determinants of a health condition, one of the
first steps is to use statistics to find out who is experiencing the condition (person), where it is
occurring (place), and when it appears (time). This information about the distribution of the
condition is an essential step in the identification of high-risk groups and in the search for
possible solutions.
There are three ways of examining descriptive information that can be helpful in developing
244
plausible explanations (hypotheses) for the occurrence of the condition under study. First, look
for differences in frequency of characteristics between groups; second, look for areas of
agreement where factors are identified that are occurring frequently; and third, look for
variations in the data that may present clues for control and prevention of the condition. Rates
are usually used in this process, and it is often helpful to use graphs or charts to depict the
results.
If you can’t explain it simply, you don’t understand it well enough. Albert Einstein
Person: Who
Within any general population, whether it consists of members of a neighborhood, the clients in
a community clinic, or the residents in an assisted living facility, there are differences among the
individual people. These differences are genetic, biologic, behavioral, and socioeconomic.
Because of these variations, specific incidence and prevalence rates should be calculated
according to these specific characteristics. Statistics of this type that are gathered to describe
populations are referred to as demographic data, or the study of the size, distribution, and
characteristics of human populations.
Two characteristics are considered routine descriptors of a person: age and sex. Most health
problems vary in both frequency and severity by age, and many are sex-specific. Therefore,
morbidity and mortality rates for almost all health conditions vary by age or sex. Because of
this, age- and sex-specific incidence and prevalence rates should be calculated whenever
describing a problem.
Practice Point
Age is the most important characteristic to address when describing the state of people’s
health; it is directly associated with risk for illness or disability.
The CDC has used specific incidence rates in its surveillance of injuries in the United States
(CDC 2014a). Figure 7.3 shows the percentage distribution of injury episodes by place of
occurrence in 2010. As can be expected, 47% of the nonfatal, medically attended injury episodes
took place in or around the home. Nearly 40% of these injuries occurred while a person was
engaged in leisure activities, including sports (CDC, 2012). Figure 7.3 shows percentages;
however, these are also rates with a multiplier of 100. Knowing what an injured person was
doing and where his or her injury occurred is very important for designing prevention programs.
Figure 7.4 presents an example of specific prevalence rates for adults aged more than 45
years who need help with routine activities, by age group and selected race or ethnicity. Again,
this example shows rates expressed as percentages; examining this figure shows that needing
help with routine activities increased steadily with age for all racial/ethnic groups. Non-Hispanic
blacks were more likely to need help with routine activities compared with Hispanics and non-
Hispanic whites for those aged 45 to 74 years. Among adults aged 45 to 54, Hispanics were least
likely to need help with routine activities. However, the pattern changes among adults aged 75
years and over. Hispanics and non-Hispanic blacks were both more likely to need help with
routine activities than non-Hispanic whites. Studying figures such as this one can give public
health practitioners data that is needed to institute primary, secondary, and tertiary interventions
to enhance the health of these groups (CDC, 2013).
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FIGURE 7.3 Percentage distribution of injury episodes, by place of occurrence: United States,
2010. (Source: National Health Interview Survey, 2010. Available from
http://www.cdc.gov/nchs/data/factsheets/factsheet_injury.htm.)
FIGURE 7.4 Percentage of adults aged greater than or equal to 45 years who need help with
routine activities by age group and selected race/ethnicity—National Health Interview Survey,
United States, 2011. (Available from https://www.cdc.gov/nchs/data/series/sr_10/sr10_255 .)
Facts are stubborn, but statistics are more pliable. Mark Twain
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https://www.cdc.gov/nchs/data/series/sr_10/sr10_255
Place: Where
Examining the differences in the rates of illness or disability and determining where they are
highest or lowest assists in determining health needs, planning prevention and control measures,
and allocating resources. Natural boundaries, political boundaries, and environmental
characteristics are taken into consideration in this process.
Variations in incidence and prevalence rates can be examined by continent, nation, states,
city, census tract, city block, or other geographic area. Differences between urban and rural
areas or among smaller localities may be helpful in investigating specific health needs for
communities. Place of occurrence is almost always examined when investigating outbreaks, both
in the community and within institutions. Rates can be compared among institutions, among
units in a single institution, or among different groups within any healthcare facility. This
information indicates where prevention and control measures and health resources should be
concentrated to decrease incidence and prevalence of a particular problem.
FIGURE 7.5 Number of laboratory-confirmed cases (n = 135) of Salmonella typhimurium infection
with the outbreak strain, involving pet turtles in the United States, March 13 through November 17,
2008. (Data from Centers for Disease Control and Prevention. [2010]. Multistate outbreak of
human Salmonella typhimurium infections associated with pet turtle exposure—United States,
2008. Morbidity and Mortality Weekly Report, 59[07], 191–196. Retrieved from
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5907a2.htm.)
Evidence for Practice
The CDC monitored the 2015–2017 outbreak of salmonella related to exposure to pet
guinea pigs, the fourth such outbreak since 2006 (CDC, 2018). A total of nine cases have
occurred in eight states and the District of Columbia, but many more unreported illnesses
likely occurred. This is similar to the 2008 outbreak, demonstrated in Figure 7.5, which
caused a multistate outbreak of salmonella related to exposure to pet turtles (CDC, 2010c).
In this third outbreak in 2015–2017, a total of 135 cases occurred in 25 states and the
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District of Columbia. Figure 7.5 shows the distribution of the confirmed cases by state. The
first known (index) case was a 2-year-old girl who was brought to a physician’s office in
Philadelphia after 3 days of diarrhea and fever. Salmonella typhimurium was isolated from
her stool specimen. Three weeks earlier, the family had purchased two pet turtles with shell
lengths less than 4 in from a street vendor. Within weeks, more clients in Pennsylvania
were diagnosed with the same strain of the organism, and matching isolates had been
found in cases from 10 states. Most ill people reported exposure to turtles with shell lengths
less than 4 in that had been acquired from flea markets, street vendors, and souvenir
shops. It is important to note that small turtles pose a greater risk to young children because
they are perceived as safe pets, but are small enough to be placed in the mouth or handled
inappropriately.
Investigation of the salmonella outbreak documented that young children without direct
turtle exposure are at risk for turtle-associated salmonellosis through person-to-person
transmission in child care settings. This investigation reinforced the need for continuing the
existing prevention and control measures. Increasing enforcement of the existing local,
state, and federal regulations against the sale of small turtles, increasing penalties for illegal
sales, and enacting more state and local laws regulating the sale of small turtles could
enhance federal prevention efforts and facilitate a more rapid public health response (CDC,
2010d).
Time: When
Variations in time can be short-term, periodic, or long-term. Short-term changes are measured
in hours, days, weeks, or months. They are commonly found in outbreaks of infectious disease.
Figure 7.6 illustrates an epidemic curve created from study of an outbreak of mumps that
occurred from June 2009 to January 2010 in New York and New Jersey. Cases of reported
confirmed or probably mumps (n = 1,494) are shown by week of illness onset and age group
during the outbreak. At the time of the report, local transmission continued to occur (CDC,
2010e).
More recently, reports on an increase in newborn microcephaly in northeast Brazil
demonstrated an emerging epidemic of the Zika virus. Infants born with a small head, measured
by circumference, and those whose head circumference fails to increase in infancy have a
condition called microcephaly (WHO, 2016). This is a rarity and usually occurs in one case
among several thousand births. The outcome of microcephaly is severe, with physical and
learning disabilities occurring.
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FIGURE 7.6 Number (n = 1,494) of reported confirmed or probable mumps cases, by week of
illness onset and age group in New York and New Jersey, June 2009 through January 2010.
(Data from Centers for Disease Control and Prevention. [2010]. Update: Mumps outbreak—New
York and New Jersey, June 2009–January 2010. Morbidity and Mortality Weekly Report, 59[05],
125–129. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5905a1.htm.)
TABLE 7.3 Zika Information From Brazil: Date, Total Cases, Locations, and
Deaths
Date Total #
Cases
Locations Reported
Deaths
As of October 2015 Increase #
cases
Northeastern Brazil 0
As of 17 November
2015
399 Northeastern Brazil
Seven states
0
As of 21 November
2015
739 Northeastern Brazil
Nine states
1
As of 05 December
2015
1761 Nationally across 42 municipalities across 14 federal units
The Northeastern region continued to report the highest
number
19
As of 02 January 2016 3,174 Nationally across 684 municipalities of 21 federal units.
The Northeastern region continued to report the highest
number of suspected cases
38
Source: World Health Organization. (2017). Microcephaly Brazil. Retrieved from http://www.who.int/csr/don/8-january-2016-brazil-microcephaly/en.
In 2016, the Ministry of Health of Brazil reported to the World Health Organization (WHO,
2017) the data shown in Table 7.3.
In response to this emerging data, the World Health Organization and Brazilian public health
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agencies responded with an increase in vector prevention and control (WHO, 2017).
Periodic changes may be seasonal or cyclic. For example, respiratory diseases are more
common in winter and spring, and infectious hepatitis increases in incidence every 7 to 9 years.
Figure 7.7 shows the percentage of all deaths attributed to pneumonia and influenza for 122
cities in the United States between 2009 and 2013. The seasonal variation in death rates reflects
the seasonal variation in respiratory infections. When studying these mortality statistics, it is
possible to compare the percentage of all deaths attributable to pneumonia and influenza with a
seasonal baseline and epidemic threshold value calculated for each week. An increase of 1.645
standard deviations above the seasonal baseline deaths is the “epidemic threshold.” This is the
point at which the observed proportion of deaths attributed to pneumonia or influenza is
significantly higher than would be expected at that time of the year. Long-term changes extend
over decades and reflect gradual changes. An interesting example follows the tracking of West
Nile virus infection, a disease that is transmitted by a mosquito vector. Figure 7.8 follows the
progression of the illness from one state to another after it was first reported in New York in
1999. This figure combines variation in both place and time over a period of 15 years (CDC,
2014b).
FIGURE 7.7 Pneumonia and influenza mortality for 122 U.S. cities: Week ending March 8, 2014.
(Available at http://www.cdc.gov/flu/weekly.)
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FIGURE 7.8 Average annual incidence of West Nile virus neuroinvasive disease reported to CDC
by state, 1999 to 2012. (Source: ArboNET, Arboviral Diseases Branch, Centers for Disease
Control and Prevention. Retrieved from
http://www.cdc.gov/westnile/statsMaps/cumMapsData.html.)
Figure 7.9 shows that variations in trends of the mortality of various cancers can be seen
when examined over many years. Overall, the age-adjusted cancer rates between 1930 and 2010
have fluctuated but are decreasing slowly. Cancer of the lung and bronchus leads all cancers as
the cause of mortality in both men and women. It is interesting to note that the mortality rate for
cancer of the stomach has decreased steadily since 1930, that cancer of the lung rose steadily
until the 1990s, and that cancer of the colon and rectum continues to decrease (American Cancer
Society, 2018). This is likely a result of primary prevention measures such as education and
increased awareness as well as secondary prevention measures such as colonoscopy screening.
TYPES OF INCIDENCE RATES
Mortality Rates
Mortality rates or death rates are common incidence rates that are calculated for public health
purposes. Crude mortality rates indicate the probability of death from any cause among the
entire population in a designated geographic area. Cause-specific (disease-specific) mortality
rates indicate the probability of death from a specific cause; the number of deaths from a
specific disease is divided by the number of people in the population at midyear and multiplied
by 100,000. In calculating the case fatality rate, the number of people with a specific disease
such as lung cancer becomes the subgroup being studied out of the entire population in a
designated geographic area. For example, the case fatality rate is calculated by dividing the
number of deaths from lung cancer by the number of people living with lung cancer during the
year, and multiplying by 100. Further breakdown into specific subgroups might involve age, sex,
occupation, tobacco use, or other characteristics for calculation of mortality rates.
It is possible to confuse the proportional mortality ratio (PMR) with the cause-specific
mortality rate. The PMR compares deaths from a specific illness to deaths from all other causes;
it reflects the proportion of deaths due to a specific cause. The PMR is not a rate. The
denominator includes all deaths within a given time period rather than the entire population
under study. In contrast, the cause-specific mortality rates indicate the risk of death from a
specific disease for a given living population. Both the PMR and cause-specific mortality rates
should be calculated when death statistics are being examined for public health purposes.
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Incidence Density
When there are unequal periods of observation for study subjects, it may be necessary to use a
person-time denominator in the calculation of incidence rates. This technique provides a
measure of incidence density. In healthcare, people often enter a study period at different times
and therefore contribute unequal periods of time to the study. To identify the precise period of
observation for each person and weigh that period of observation properly in calculating rates, a
person-time unit, such as person-day or person-year, can be constructed. A person-day
represents one person at risk for 1 day, and a person-year represents one person at risk for 1
year. Incidence density can be calculated as:
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FIGURE 7.9 A: Age-adjusted cancer death rates, males by site, United States, 1930 to 2010. B:
Age-adjusted cancer death rates, females by site, United States, 1930 to 2010. Rates are per
100,000 age-adjusted to the 2000 U.S. standard population. (Data from American Cancer Society.
[2018]. Cancer Facts & Figures 2018. Atlanta: American Cancer Society. Retrieved from
https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-
cancer-facts-and-figures/2018/incidence-and-mortality-rates-for-selected-cancers-by-race-and-
ethnicity-us-2010-2015 .)
TABLE 7.4 Incidence Rates of Institution-Associated Pneumonia in an Acute
and Long-Term Care Setting
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Table 7.4 demonstrates the difference between the calculation of crude incidence rates and
incidence density in a study that examined the development of hospital- and institution-
associated pneumonia in both an acute care facility and a long-term care facility. These
incidence data illustrate the need to calculate and compare both crude incidence and incidence
density rates when comparing different settings with varying lengths of stay. In this example, the
incidence rate in long-term care was almost five times that of the acute care setting. However,
when the researchers included client days in the denominator, the acute care setting reflected
twice the incidence density of the long-term care setting. More clients contributed shorter
periods of time in the acute care setting, whereas there was relatively little turnover in residents
in the long-term care setting.
Measures of incidence density can account for those persons who die, those who are lost to
follow-up, or those who have acquired the illness and are therefore not at risk for the entire
study period. Normally, it is assumed that the risk of acquiring the illness is constant throughout
the entire period of the study.
Attributable Risk
Attributable risk is the difference between the incidence rates in an exposed group of people
and an unexposed group of people. It measures the risk of a condition occurring in an exposed
group that is attributable to a specific exposure but not to other factors. In almost any health-
related event, some risk occurs normally in a population without a specific exposure. In
calculating attributable risk, the risk of the event that would have occurred under normal
circumstances is subtracted from the risk of the event in the exposed group:
Relative Risk Ratio
Incidence rates indicate the occurrence of a health-related event in a population in a given period
of time. It is an indicator of the probability that people without a specific condition will develop
the condition within a designated period of time. Therefore, it is a measure of the risk of
developing the condition. Often, incidence rates for groups exposed to a certain risk factor are
compared with the incidence rates for people who are not exposed. This procedure results in a
relative risk ratio. It is a ratio of the incidence rate in the exposed group and the incidence rate
in the nonexposed group.
A relative risk of 1.0 indicates that the risk is equal for both groups, and conversely, a relative
risk greater than 1.0 indicates that the risk is greater in the exposed group. For example, a
relative risk of 6.0 can be interpreted to mean that people who are exposed to a disease are six
times more likely to develop it. The CDC used this technique to develop an educational chart for
use in HIV prevention programs (Fig. 7.10). This chart shows how the relative risk for
transmission from a person living with HIV to a person without the infection varies according to
254
sexual activity and condom use. For example, it is possible to contrast insertive oral sex while
using a condom, which has a low risk for HIV transmission, with receptive anal sex without a
condom, which is 2,000 times more risky. This kind of information regarding HIV transmission
can influence decisions about sexual activity and condom use (CDC, 2007).
A relative risk less than 1.0 indicates that the risk is less in the exposed group; the factor in
question may possibly protect against the condition under study. Although this finding is not
very common, it may signify that further study is warranted. Statistical tests, such as the
calculation of the chi-square statistic, are used to determine whether the relative risk ratios are
different from those that would be expected by chance. In this way, the statistical significance of
the findings can be established.
SENSITIVITY AND SPECIFICITY
Sensitivity and specificity are statistical measures that evaluate the validity and reliability of a
test. Sensitivity is the ability of the test to identify correctly people who have the health problem
under study. It is the probability of testing positive if the health problem is truly present.
Specificity is the ability of the test to correctly identify people who do not have the health
problem. It is the probability of testing negative if the health problem is truly absent. Increasing
the sensitivity of a test causes a decrease in specificity, and conversely, increasing the specificity
of a test decreases sensitivity. The formulas for calculation of sensitivity and specificity are
found in Box 7.2. To obtain sensitivity and specificity values, it is necessary to perform research
studies that obtain the values of screening tests and then determine whether the health problem
truly exists in each subject.
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FIGURE 7.10 Relative risk for transmission from a person living with HIV. (Data from CDC.
Relative risk for transmission from a person living with HIV. Retrieved from
http://www.cdc.gov/hiv/topics/treatment/PIC/pdf/chart .)
In an ideal situation, a screening test is able to identify the presence or absence of a health
problem correctly in every person screened with a sensitivity and specificity of 100%. However,
this is almost impossible to achieve in actual practice. One way to address this problem is to use
several screening tests to make health decisions.
7.2 How to Calculate Sensitivity and Specificity
Before screening projects are undertaken, it is important to determine carefully the screening
levels or test values. Much depends on the consequences of leaving some cases undetected (false
negatives) or classifying healthy people as having a health problem (false positives). When the
disease being studied is rare, the specificity of a test is rarely high enough to give an adequate
positive predictive value. Only the sensitivity of a test is useful in the case of a rare disease. The
choice of screening levels is subjective and based on the severity of the disease, cost, time
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factors, advantages of early treatment, and other screening criteria.
The outreach program promotes HIV testing in the African American population. Lindsay
examines the types of tests available and finds that rapid, same-day testing has a high
sensitivity and specificity. She reviews the below example to understand what this means.
This is perhaps best illustrated by example. Imagine a population of 100,000 people,
of whom 10,000 are actually HIV-infected and 90,000 HIV-uninfected. The goal of a
screening procedure would be to correctly identify all 10,000—and only those 10,000—
HIV-positive individuals. A test with 99% sensitivity would correctly identify 9,900 of the
10,000 infected individuals (99%). One hundred infected people would test falsely
negative (a false-negative rate of 1%).
If the same test procedure had a specificity of 90% (an unrealistically low value used
to simplify this example), it would correctly identify 90% (81,000) of the HIV-uninfected
individuals as HIV-negative. However, 9,000 HIV-uninfected persons would test falsely
positive (a false-positive, http://www.aidsmap.com/Sensitivity-and-
specificity/page/1322984/ rate of 9,000/90,000=10%). Box 7.2 for the equations used to
calculate sensitivity and specificity.
USE OF RATES IN DESCRIPTIVE RESEARCH
STUDIES
Epidemiologic descriptive studies include the descriptions of health conditions, case reports,
and correlational studies. Descriptive studies are very useful in describing the characteristics of
disease occurrence and in generating hypotheses for further study. They are the first studies to
be performed in investigating the determinants of a health problem and are essential in
determining the rationale for an experimental or intervention study.
Researchers design descriptive studies to acquire more information about the occurrence of
health problems or, alternatively, the factors that keep people well. The specific rates calculated
in these studies describe people who have or do not have the health problem in terms of person,
place, and time. These studies provide a picture of the events as they naturally occur. Therefore,
this type of data is very helpful for nurses involved in health planning or administration in both
community and institutional settings. Knowledge of people who are the most or least susceptible
to a health problem can help when deciding to implement programs for prevention or control of
health problems and to allocate resources.
Lindsay develops a plan to evaluate the effectiveness of the outreach program. Using the
HIV/AIDS Outreach Survey, decide what statistics should be calculated for each of the 10
questions. Include the calculation of both general (crude) rates and specific rates where
appropriate.
KEY CONCEPTS
Measuring the magnitude or frequency of a state of health determines the characteristics of those who are
at high risk.
Epidemiologic descriptive studies have determined measurable risk factors for major illnesses.
Calculation of rates provides the best indicators of the probability that a specific state of health will occur.
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Indexes of the health of a community, region, or country include comparisons of general mortality rates and
maternal infant rates.
A variety of rates can be calculated according to need, including incidence, prevalence, adjusted, and
specific rates.
Specific rates calculated by person, place, and time provide the best description of a health condition.
Prevalence is influenced by the number of people who have developed the condition in the past and the
duration of their illness. Prevalence rates provide essential data for implementing prevention measures.
Before screening projects are undertaken, the sensitivity and specificity of screening levels or test values
should be carefully reviewed.
CRITICAL THINKING QUESTIONS
1. Between January 1 and December 31, 35 new cases of tuberculosis were diagnosed in a city. There were
a total of 300 active cases among the population of 400,000 on December 31 of that year. Twenty deaths
from tuberculosis were recorded during the 1-year period.
a. What was the incidence rate per 100,000 people for tuberculosis during the year?
b. What was the prevalence rate of tuberculosis per 100,000 on December 31?
c. What is the cause-specific death rate per 100,000 for tuberculosis during the year?
2. A recent report from a state health department included a map indicating the distribution and number of
rabid animals for each of the 167 towns in the state between January 1 and October 31. What type of
information about the occurrence of rabies does this report include? Why were rates not calculated? How
might this information be used to control rabies?
3. A community nurse uncovers the following statistics regarding HIV infection in African Americans in two
rural counties in the United States:
a. What is the incidence rate in black males and black females per 10,000 people in the 1-year period?
b. What is the prevalence rate in black males and black females per 10,000 people in the 1-year period?
c. Interpret the incidence and prevalence rates. Which statistics provide the best information to use for
program planning?
d. What population group should be targeted for the HIV/AIDS outreach program? Why?
New HIV Infection Living With HIV Population Total
Males 150 838 29,560
Females 234 1,312 28,315
African American population 384 2,150 57,875
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Retrieved from https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-
statistics/annual-cancer-facts-and-figures/2018/incidence-and-mortality-rates-for-selected-cancers-by-
race-and-ethnicity-us-2010-2015 .
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Injury and Violence Research, 4(2), 73.
Brown, E. J., & Brown, J. S. (2003). HIV prevention outreach in black communities of three rural North
Florida counties. Public Health Nursing, 20(3), 204–210.
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HIV epidemic control among adolescent girls and young women aged 15–24 years—Seven African
countries (2015-2017). Morbidity and Mortality Weekly, 67(1), 29–32.
Centers for Disease Control and Prevention. (2007). Relative risk for transmission from a person living
with HIV. Retrieved from http://www.cdc.gov/hiv/topics/treatment/PIC/pdf/chart .
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8th graders—Oregon, 2008. Morbidity and Mortality Weekly Report, 59(1), 1–5.
Centers for Disease Control and Prevention. (2010c). Multistate outbreak of human Salmonella
typhimurium infections associated with pet turtle exposure—United States, 2008. Morbidity and
Mortality Weekly Report, 59(7), 191–196.
Centers for Disease Control and Prevention. (2010d). Multistate outbreak of human Salmonella
typhimurium infections associated with pet turtle exposure—United States, 2008. Morbidity and
Mortality Weekly Report, MMWR News Synopsis. Retrieved from
https://www.cdc.gov/media/mmwrnews/2010/n100225.htm.
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Jersey, June 2009–January 2010. Morbidity and Mortality Weekly Report, 59(5), 125–129. Retrieved
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from http://www.cdc.gov/nchs/data/factsheets/factsheet_injury.htm.
Centers for Disease Control and Prevention. (2013). QuickStats: Percentage of adults aged ≥45 years who
need help with routine activities by age group and selected race/ethnicity—National Health Interview
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january-2016-brazil-microcephaly/en/.
WEB RESOURCES
Please visit thePoint for up-to-date web resources on this topic.
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https://www.cdc.gov/media/mmwrnews/2010/n100225.htm
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5905a1.htm
http://www.cdc.gov/nchs/data/factsheets/factsheet_injury.htm
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6233a7.htm?s
http://www.cdc.gov/nchs/data/factsheets/factsheet_injury.htm
http://www.cdc.gov/westnile/statsMaps/cumMapsData.html
https://www.cdc.gov/nchs/data/hus/2016/016
https://www.cdc.gov/salmonella/guinea-pigs-03-18/index.html
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http://thepoint.lww.com/vitalsource/ebook/9781975111694
Chapter 8
Gathering Evidence for
Public Health Practice
Barbara A. Goldrick
For additional ancillary materials related to this chapter. please visit thePoint
Of course we don’t know what we’re doing, that’s why it’s called research.
Albert Einstein
1. Statistical significance is not the same thing as practical importance.
2. The more complex the test required to show statistical significance, the less
important to an individual the association is likely to be.
3. The word “significant” without the prefix “statistical” is usually a coward’s way of
implying “important” without mathematical evidence.
Cowden’s Three Rules of Statistics; John M. Cowden, English epidemiologist
People commonly use statistics like a drunk uses a lamppost: for support rather than for
illumination.
Mark Twain
CHAPTER HIGHLIGHTS
Epidemiologic/public health research defined
Observational studies: Descriptive versus analytical research
Strengths and limitations of epidemiologic research methodology
Applying epidemiologic research to public health nursing practice
OBJECTIVES
Describe the difference between descriptive and analytical research.
Discuss the strengths and weaknesses of retrospective, prospective, case–control, and experimental
designs.
Generate research questions related to problems identified in community and public health nursing
practice.
KEY TERMS
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Analytical study: Investigation that uses comparisons between groups to determine the role of
various risk factors in causing the problem.
Association: Statistical relationship between two or more events, characteristics, or other
variables.
Case–control study: Observational analytic study that enrolls one group of persons with a
certain health problem (case patients) and a group of persons without the health problem
(control subjects). It compares differences in exposures, behaviors, and other characteristics
to identify and quantify associations, test hypotheses, and identify causes.
Case study: Research method that involves an in-depth analysis of an individual, group, or
institution.
Causality: Relationship between two variables in which the presence or absence of one variable
(the “cause”) determines the presence or absence of the other (the “effect”).
Clinical trial: Experimental study in which the investigator specifies the type of exposure for each
study participant and then follows each person’s health status to determine the effects of the
exposure.
Cohort study: Observational analytic study in which enrollment is based on status of exposure to
a certain factor or membership in a certain group.
Controls: Subjects in an experiment who do not receive the “treatment” and provide baseline
data against which the effects of the treatment can be measured.
Cross-sectional study: Study in which a sample of persons from a population is enrolled and
their exposures and health outcomes are measured simultaneously.
Demographic variables: Characteristics or attributes that are collected to describe the sample.
Dependent variable: The response, behavior, or outcome presumed to be affected by the
independent variable(s).
Descriptive study: Study in which information is collected to characterize and summarize a
health event or problem.
Epidemiologic research: The study of the distribution and determinants of health conditions or
events among populations. The studies may be descriptive or analytic.
Extraneous variables: Variables outside of the study that can affect (confound) the
measurement and relationship among study variables. These can be intrinsic to the subjects
(e.g., stress) and/or external factors (e.g., environment). Randomization is the most effective
method to control for extraneous variables in study subjects. Control over variables external to
the study generally take place in an artificial environment such as a laboratory setting.
Hypothesis: Statement of the expected outcome between two or more variables in a specific
population.
Independent variable: The treatment or experimental activity that is manipulated by the
researcher to test its effect on the dependent variable.
Intervention study: Investigation designed to test a hypothesized relationship by modifying an
identified factor in a population. Studies may be therapeutic (clinical) or preventive.
Null hypothesis: Statement that there is no difference between/among the variables under
study.
Observational study: Study in which the investigator observes rather than influences exposure
and disease among participants.
Odds ratio (OR): Measure of association used in comparative studies, particularly case–control
studies, which quantifies the association between an exposure and a health outcome.
p value: In statistical testing, the probability that the obtained results are not due to chance
alone. Generally, the significance level set by the researcher is less than or equal to 0.05.
Preventive trial: Study in which the investigator provides a specific preventive measure to the
group under study and follows the group to determine the effects of the intervention.
Prospective study: Analytic study in which participants are enrolled before the health outcome
of interest has occurred.
Quasi-experimental study: Study with limited control where the subjects cannot be randomly
assigned to an intervention. However, the researcher can still manipulate the dependent
variable.
Relationship: See association; the two terms are often used interchangeably.
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Relative risk (RR): Ratio of the risk of disease or death among those exposed to the risk among
the unexposed; synonymous with risk ratio.
Retrospective study: Analytic study in which participants are enrolled after the health outcome
of interest has occurred.
Sample: Selected subset of a population; a sample can be random or nonrandom and
representative or nonrepresentative.
Survey research: Systematic canvassing of persons to collect information, often from a
representative sample of the population. Studies may use questionnaires and/or interviews to
collect data.
Therapeutic trial: Clinical trial in which the investigator provides a specific intervention/treatment
(therapy) to the group under study and follows the group to determine the effects of the
treatment.
Type I error: An error created by rejecting the null hypothesis when it is true; that is, a difference
is seen to exist when in fact it does not.
Type II error: An error created by accepting the null hypothesis when it is false; that is, it is
concluded that no difference exists when in fact it does.
Variables: Qualities or characteristics of persons, things, or situations that change and can be
manipulated or measured in research. Extraneous variables can affect the measurement and
relationship among study variables.
CASE STUDIES
References to the case studies are found throughout this chapter (look for the case study icon).
Readers should keep the case studies in mind as they read the chapter.
CASE 1
A Healthy People 2020 goal is to increase the proportion of adults aged 65 years and older who are
vaccinated against pneumococcal disease, which is caused by Streptococcus pneumoniae, to at
least 90% (USDHHS, 2010). However, data from the Centers for Disease Control and Prevention
(CDC)/National Center for Health Statistics (NCHS) found that only 61% of persons 65 years of age
or older had ever received pneumococcal polysaccharide vaccine in 2014 (CDC, NCHS, 2014b).
A group of community health nurses learn that their state is not on target to meet the Healthy
People 2020 objective to increase the proportion of persons aged 65 years or older vaccinated
against pneumococcal disease to 90% (USDHHS, 2010). In addition, the state health department
has reported the occurrence of four cases of multidrug-resistant S. pneumoniae in the state within
the past several months.
CASE 2
In 2014 the World Health Organization (WHO) updated its 2011 report and confirmed that
noncommunicable diseases (NCDs) are still the leading cause of mortality worldwide.
Cardiovascular diseases account for most NCD deaths, at 17.7 million people annually, followed by
cancers (8.8 million), respiratory diseases (3.9 million), and diabetes (1.6 million). These four
groups of diseases account for 81% of all NCD deaths and share four common risk factors:
Physical inactivity
Tobacco use
Poor diets
Harmful use of alcohol
Seventeen million people die from a NCD before the age of 70, with 87% of these “premature”
deaths occurring in low- and middle-income countries (WHO, 2014).
n Chapter 6, epidemiology was defined as the study of the distribution and determinants of states
of health and illness in human populations. This information provides the data necessary to
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I
justify the establishment of health services designed to maintain and improve health.
Epidemiologic surveillance is then conducted to monitor and evaluate these health services.
The purposes of epidemiologic research, on the other hand, are to: (1) identify
community/public health problems; and (2) describe natural history and etiology of diseases.
Community/public health nurses use a variety of epidemiologic research methods to generate
new knowledge and provide evidence for best practice. As can be seen in Figure 8.1, the
epidemiologic research cycle includes both experimental or intervention studies and
observational studies.
OBSERVATIONAL STUDIES
Observational studies may be either descriptive or analytical. In descriptive studies, the
researcher collects information to characterize and summarize the health event or problem when
little is known about the phenomenon. Descriptive studies provide the foundation for the
development and testing of hypotheses.
As can be seen in see Figure 8.1, observational studies can be hypothesis-generating and
hypothesis-testing studies. Hypothesis-generating research includes case studies and cross-
sectional studies. Hypothesis-testing studies, on the other hand, include analytical studies that
test the relationship between two or more variables in a specified population (see further
discussion below).
FIGURE 8.1 Epidemiologic study cycle.
In analytical studies, the researcher relies on comparisons between groups to determine the
role of various risk factors in causing the problem.
Descriptive Studies
Descriptive studies are fundamental to public health research and practice (CDC, 2012a).
Descriptive research identifies the characteristics of individuals, situations, or groups and the
frequency with which certain phenomena (risks) occur (Gray, Grove, & Sutherland, 2017). The
concept of risk was defined in Chapter 6 as it relates to person, place, and time. Therefore,
descriptive studies, which are frequently used in public health, are designed to acquire more
information about characteristics of health (or disease) as they pertain to person, place, and time.
People in the study population will all have some characteristic in common; therefore, some
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restrictions to this broad definition must be made. For example, research is limited to
considering people of the same age range, sex, or geographic location.
Many descriptive studies are observational; that is, no intervention or treatment is included.
However, descriptive studies provide the foundation for the development and testing of
hypotheses.
If it looks like a duck, and quacks like a duck, we have at least to consider the possibility
that we have a small aquatic bird of the family Anatidae on our hands. Douglas Adams,
science fiction writer
Case Studies
Case studies involve an in-depth analysis of an individual, group, or social institution (Gray,
Grove, & Sutherland, 2017). In epidemiologic and public health research, the case study often is
the first clue that a problem may exist. A case series is a group of people with the same, or
similar, illness or injury and with the same, or similar, factors that may be importantly related to
the disease or injury. A historic example of a case series was the first cases of young men who
presented with Kaposi sarcoma and Pneumocystis carinii pneumonia in California and New
York in the early 1980s. What these young men had in common was having sex with other men.
In June 1981, the CDC published the first report about AIDS in the United States, which alerted
the medical and public health communities 4 months before the first peer-reviewed article on the
subject of AIDS was published. For more information on the history of HIV/AIDS, see the CDC
website at http://www.cdc.gov/hiv/topics/basic/#origin and AVERT website at
http://www.avert.org/history-aids-1986.htm.
Survey Research
Another method used in public health to collect data is survey research. Survey research
focuses on the collection of information regarding the status quo of some situations by
questionnaire or by interviews with a sample of respondents (Gray, Grove, & Sutherland, 2017).
The main principle of survey research is that the sample of respondents must represent the
population from which it was drawn.
An example of survey research was conducted by nurse researchers using existing data from
a larger study. The purpose of the study was to determine the predictors of smokers’
participation in a smoking cessation program among patients with head and neck cancer from
three Veterans Affairs medical centers. All participants who agreed to participate (N = 136) had
smoked within the past 6 months and were classified as currently smoking, having quit in the
past month, or having quit in the past 6 months. The dependent variable for the analysis was
the smoker’s participation (yes/no) in the smoking cessation program (intervention). The major
independent variables of interest included perceived difficulty in quitting, health behaviors
(smoking and problem drinking), clinical characteristics (depression and cancer site and stage),
and demographic variables.
More than half of the participants believed it would be very to extremely difficult to quit
smoking. More than 60% were currently smoking and were smoking a pack a day or less. The
remaining 40% of participants had quit smoking within the past 1 to 6 months. Significant
associations were found between participation in the smoking-cessation program and high
perception that it would be difficult to quit, miles traveled to the clinic, and hospital site (p <
0.05). No significant associations were found between participation status and alcohol use
problems, greater symptoms of depression, time since diagnosis, age, or educational level.
The authors cited several limitations to the study. Although depressive symptoms and
alcohol use were measured by a validated screener, they were not confirmed by a medical
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http://www.avert.org/history-aids-1986.htm
evaluation, which may have resulted in an overestimation of drinking problems and depressive
symptoms. Despite the researchers’ efforts to recruit from three Veterans Affairs medical centers
with a large number of minorities, the sample was predominantly white. The original sample
included 286 patients with approximately equal numbers of participants and nonparticipants;
however, only 136 (48%) agreed to participate. Therefore, some of the studied variables may
have reached significance had the sample size been larger (Duffy et al., 2010).
Another example of survey research is the National High Blood Pressure Education
Program, coordinated by the National Heart, Lung and Blood Institute (NHLBI) of the National
Institutes of Health. Established in 1972, the program has succeeded in increasing awareness,
prevention, treatment, and control of hypertension. Considerable success has been achieved in
the National High Blood Pressure Education Program. The last hypertension guidelines
published by NHLBI Joint National Committee (JNC) on Blood Pressure in Adults was in 2014
(James et al., 2014). However, in 2017, the American College of Cardiology/American Heart
Association Task Force on Clinical Practice Guidelines developed new high blood pressure
clinical practice guidelines, which update prior JNC reports (Whelton, P. K., et al., 2017). The
2017 hypertension guidelines, presented in Table 8.1, used an evidence-based approach to the
management of hypertension in adults. Table 8.2 outlines the 2013 American Heart
Association/American College of Cardiologists recommendations for lifestyle management to
lower blood pressure and cardiovascular risk (Eckel et al., 2014).
TABLE 8.1 2017 Guideline for the Prevention, Detection, Evaluation, and
Management of High Blood Pressure in Adultsa
BP Category SBP DBP
Normal <120 mm Hg and <80 mm Hg
Elevated 120–129 mm Hg and <80 mm Hg
Hypertension
Stage 1 130–139 mm Hg or 80–89 mm Hg
Stage 2 ≥140 mm Hg or ≥90 mm Hg
aIndividuals with SBP and DBP in 2 categories should be designated to the higher BP category.
BP indicates blood pressure (based on an average of ≥2 careful readings obtained on ≥2 occasions); DBP, diastolic blood pressure; SBP, systolic blood pressure;
mm Hg, millimeters of mercury.
Source: Whelton, P. K., et al. (2017). ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection,
Evaluation, and Management of High Blood Pressure in Adults. Hypertension, 70(5), 1–283. Retrieved November 30, 2017 from
http://hyper.ahajournals.org/content/guidelines2017.
Evidence for Practice
Hepatitis C virus (HCV) infection is the most common bloodborne infection in the United
States. According to a 2015 study, it is estimated that 3 to 4 million people are currently
infected with hepatitis C in the United States. Based on the CDC data, an additional
800,000 individuals are estimated to be infected each year (CDC, 2018).
More than 75% of adults infected with HCV are baby boomers (those born from 1945 to
1965). It is believed that most boomers became infected in the 1970s and 1980s when rates
of hepatitis C were the highest. People with hepatitis C can live for decades without
symptoms, and approximately half are unaware that they were infected with HCV many
years ago (CDC, 2018).
The following persons are known to be at increased risk for HCV infection and should be
tested:
Current or former injection drug users, including those who injected only once many years
ago
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Recipients of clotting factor concentrates made before 1987, when more advanced methods
for manufacturing those products were developed
Recipients of blood transfusions or solid organ transplants before July 1992, when better
testing of blood donors became available
Chronic hemodialysis patients
Persons with known exposures to HCV, such as healthcare workers after needlesticks
involving HCV-positive blood, recipients of blood or organs from a donor who tested HCV-
positive
Persons with HIV infection
Have persistently abnormal alanine aminotransferase levels (ALT)
Children born to HCV-positive mothers (CDC, 2018)
Who should be tested for HCV?
One-time HCV testing is recommended for adults born from 1945 through 1965 (without
prior ascertainment of HCV risk factors and regardless of country of birth).
There is no vaccine against HCV infection, but research into the development of a
vaccine is under way.
The Food and Drug Administration (FDA) has approved several antiviral drugs to treat
chronic HCV infection. These medications have proven efficacy when used as a component
of a combination antiviral regimen to treat HCV-infected adults with compensated liver
disease, cirrhosis, HIV co-infection, and hepatocellular carcinoma awaiting liver transplant
(CDC, 2018).
Guidance for hepatitis C treatment in adults is changing constantly with the advent of
new therapies and other developments. The Infectious Diseases Society of America (IDSA)
and American Association for the Study of Liver Diseases (AASLD), in collaboration with the
International Antiviral Society–USA (IAS–USA), developed a web-based process for the
rapid formulation and dissemination of evidence-based, expert-developed
recommendations (CDC, 2018). For the latest published recommendations for testing,
managing, and treating hepatitis C, see their website at http://www.hcvguidelines.org.
TABLE 8.2 Recommendations for Lifestyle Management to Lower Blood
Pressure
Recommendations NHLB Strength of
Evidence
Diet
1. Consume a dietary pattern that emphasizes intake of
vegetables, fruits, and whole grains
Strong
2. Include low-fat dairy products, poultry, fish, legumes,
nontropical vegetable oils and nuts
Strong
3. Limit intake of sweets, sugar-sweetened beverages and
red meats
Strong
4. Achieve this by following the USDA food pattern, or the
ADA diet
Strong
5. Lower sodium intake to 1,500 mg/day
Moderate
6. Combine the DASH dietary pattern with lower sodium
intake
Strong
Physical
Activity
Engage in aerobic physical activity three to four times a week, lasting on
average 40 minutes, and involves moderate-to-vigorous physical
activity
Moderate
Adapted from Eckel, R. H., Jakicic, J. M., Ard, J. D., de Jesus, J. M., Houston Miller, N., Hubbard, V. S.,…Tomaselli, G. F. (2014). 2013 AHA/ACC guideline
on lifestyle management to reduce cardiovascular risk: A report of the American College of Cardiology/American Heart Association task force on practice
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http://www.hcvguidelines.org
guidelines. Circulation, 129(25 suppl 2), S76–S99. Retrieved July 10, 2017, from http://circ.ahajournals.org/content/129/25_suppl_2/S76.
Cross-Sectional Studies
Cross-sectional studies (prevalence studies) are another example of public health survey
research. In this type of study, the population to be studied is defined, and data are collected
from members of the group about their disease and exposure status. The data represent a point in
time; therefore, they provide a “snapshot” of the population. Cross-sectional studies are good for
examining the relationship between a variable and a disease/condition but not for determining
cause and effect, which requires the collection of data over time. Cross-sectional studies may be
designed to gather data from two or more groups with different characteristics or with different
exposure risk.
An example of cross-sectional studies is the Behavioral Risk Factor Surveillance System
(BRFSS) established by the CDC in the early 1980s when scientific research clearly indicated
that personal health behaviors played a major role in premature morbidity and mortality. The
BRFSS is an efficient method that takes a cross-section of the population at a single point in
time and monitors the prevalence of the major behavioral risks in adults associated with
premature morbidity and mortality at the state level. These data are useful for planning,
initiating, supporting, and evaluating health promotion and disease prevention programs. Several
states use these data to determine progress toward achievement of Healthy People 2020
objectives (USDHHS, 2010). For more information on the BRFSS, see the CDC’s BRFSS
website at http://www.cdc.gov/brfss/.
TABLE 8.3 Assessment of Selected Healthy People 2020 Objectives, 2014
Objective Year 2014 (%) Target 2020 (%)
Reduce the proportion of adults (aged ≥18 years) who are obese 28.9 30
Increase the proportion of adults (aged ≥18 years) who engage in
leisure-time physical activity
47.5 47.9
Reduce cigarette smoking by adults (aged ≥18 years) 17.0 12
Increase the proportion of adults (aged ≥65 years) who are
vaccinated annually against influenza
70.1 90
Increase the proportion of adults (aged ≥65 years) who are
vaccinated against pneumococcal disease
61.3 90
Sources: Centers for Disease Control and Prevention, National Center for Health Statistics. (2014). Health, United States, 2014. Retrieved July 14, 2017, from
https://www.cdc.gov/nchs/data/hus/hus14_inbrief .; U.S. Department of Health and Human Services. Healthy People 2020. Retrieved July 14, 2014, from
http://www.healthypeople.gov/2020/topicsobjectives2020/default.aspx.
Table 8.3 outlines an assessment of how progress was being made on selective objectives of
Healthy People 2020 in 2014. These data are based on the CDC National Center for Health
Statistics (NCHS) 2014 (CDC, NCHS, 2014b). As can be seen in see Table 8.3, the prevalence
of obesity among U.S. adults aged 18 and over was lower than the 2020 objective for obesity in
this age group. Also, the percentage of adults (18 years and older) who had participated in
federal guidelines for physical activity in 2014 was closer to the 2020 target of 47.9%. However,
the percentage of adults who were current smokers in 2014 was more than the targeted 12% by
2020 (USDHHS, 2010).
Healthy People 2020 targets to increase influenza and pneumococcal vaccination in adults,
which had been retained from Healthy People 2010, still had not been met as of 2014 (CDC,
NCHS, 2014b). The percentage of adults aged 65 and older who had received influenza and
pneumococcal vaccinations in 2014 remained well below the targets of 90%, respectively. It will
be interesting to see how many of the objectives proposed for Healthy People 2020 are met by
the target date (USDHHS, 2010).
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http://www.cdc.gov/brfss/
https://www.cdc.gov/nchs/data/hus/hus14_inbrief .
http://www.healthypeople.gov/2020/topicsobjectives2020/default.aspx
Case 1: In an attempt to increase the number of people aged 65 years or older who are
vaccinated against pneumococcal disease, the community health nurses in Case 1
decide to conduct the following:
An assessment of baseline knowledge, attitudes, and practices among healthcare
providers in the community regarding pneumococcal vaccination to identify barriers to
providing pneumococcal vaccination
An assessment of baseline knowledge, attitudes, and beliefs among community
residents aged 65 years or older to determine barriers to receiving pneumococcal
vaccination
1. What research method could the nurses use to perform these assessments?
2. How would you go about gathering the data for these assessments?
Analytical Studies
As can be seen in Figure 8.2, research study designs are on a continuum, ranging from strongest
to weakest designs.
There are two general types of nonexperimental designs used in epidemiologic studies:
cohort (prospective) studies and case–control (retrospective) studies. These nonexperimental
studies may be “weaker” on the continuum; however, they can lead to hypothesis testing based
on established associations (correlations).
The research design continuum in Figure 8.2 is designed to be used as a tool to help
researchers, practitioners, and policymakers better understand best available research evidence.
On a practical level, the continuum can be used to help practitioners and policymakers make
decisions about which prevention strategies to adopt in their communities. It also can be used by
researchers and practitioners to identify which aspects of a prevention program, practice, or
policy can be improved to better demonstrate the evidence of its effectiveness.
Cohort Studies
Cohort studies, sometimes referred to as longitudinal studies, are prospective studies that
monitor subjects over time to find associations between risk factors and health outcomes (Porta,
2014). Although they are stronger in design methodology than are case–control studies when
well executed (see later discussion), cohort studies also are more expensive. In their simplest
form, a sample (cohort) of subjects who are exposed to the risk factor(s) is matched with a
sample of subjects not exposed to the risk factor(s). Some prospective studies, such as the
Framingham Heart Study, which were designed to estimate the lifetime risk of coronary heart
disease, lasted for decades. Many recommended public health guidelines for BP, total
cholesterol, and low-density lipoprotein cholesterol resulted from the Framingham Heart Study
(Shortreed, Peeters, & Forbes, 2013).
Practice Point
A biased sample will result in a biased study with biased results. Randomization is crucial to
obtaining a representative sample. The larger the sample, the greater the chances of a true
representation of the population.
The advantages of cohort studies are that they minimize selection bias, a threat to internal
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validity, and provide preliminary evidence of the incidence of a risk factor with which the
relative risk (RR) can be established. Internal validity is the degree to which the effects
detected in a study are real rather than from confounding or extraneous variables (Gray, Grove,
& Sutherland, 2017). See Box 8.1 for threats to internal validity.
Relative risk is defined as the ratio of disease incidence (or death) in an exposed population
to that in an unexposed population. The assumption is that the underlying risk without the
exposure is the same in both groups:
Relative risk is a ratio ranging from zero to infinity that indicates the strength of the
association between the risk factor and the outcome. It is calculated by dividing the risk in the
group exposed to a risk factor by the risk in the unexposed group.
An RR significantly greater than 1 (statistically) indicates that the exposure is associated
with increased risk of disease. An RR significantly less than 1 (statistically) indicates that the
exposure is associated with decreased risk of disease; that is, the exposure is protective. An RR
not significantly different from 1 (statistically) indicates that there is no association between the
exposure and the risk of disease (Washington State University, n.d.).
FIGURE 8.2 Research design continuum.
8.1 Threats to Internal Validity
History: Refers to events that are occurring during the study, which could influence participants’
responses to the intervention.
Maturation: Refers to unplanned and unrecognized changes in the participants that could affect the
findings of the study, such as fatigue, hunger, or increased knowledge.
Testing: Refers to the effect of multiple measurements of participants’ responses that could influence the
participants’ responses thereby altering the outcome of the study.
Selection: Refers to the process by which participants are selected and grouped for a study. This threat is
more likely to occur when randomization is not possible.
Instrumentation: Refers to changes in the measurement instrument used in the study, which result in
inconsistent data collection.
Mortality: Refers to loss of subjects from the study. When those who drop out of the study differ
significantly from those who remain in the study, and if there is a difference in those who remain in
experimental and control groups, the outcome of the study would be affected.
Source: Gray, J. R., Grove, S. K., & Sutherland, S. (2017). Burns and Grove’s the practice of nursing research: Appraisal, synthesis, and generation of evidence
(8th ed.). St. Louis, MO: Elsevier.
Epidemiologic cohort studies are developed to examine causality among variables in
illnesses. Causal associations found in this manner are known as inferred causality. Repeated,
multiple studies strengthen the causal link. This strategy may not be as powerful as experimental
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designs; however, in many epidemiologic studies, a true experimental study would not be
ethical. For example, a researcher would not deliberately expose one group to an infectious
microorganism to study its effect. An important finding of inferred causality came from the
well-known cohort study, the Harvard Nurses’ Health Study, which has followed female
registered nurses from 14 states since 1976. A 1994 landmark study established an association
between breast cancer and long-time use of hormone replacement therapy (Colditz et al., 1995).
The Nurses’ Health Study, considered the “grandmother” of women’s health studies, is the
world’s largest, longest-running study of women’s health. The study, which is now in its third
phase (Nurses’ Health Study 3, n.d.), has also provided other valuable information on women’s
health (e.g., increased dietary calcium intake does not protect against fractures of the hip and
wrist among postmenopausal women; birth control pills do not increase the risk of heart disease
among nonsmoking women). More information on the Harvard Nurses’ Health Study can be
found at http://www.channing.harvard.edu/nhs/.
Cohort studies attempt to find cause-and-effect relationships; however, to find statistically
meaningful data (i.e., causality), a large number of cases are needed. There may also be threats
to internal validity due to loss of subjects from the study (mortality). Nonetheless, data from
cohort studies may be used as the basis for hypotheses generation for stronger experimental
studies, such as randomized controlled trials (CDC, 2012a). The five criteria listed in Box 8.2,
which are based on the historical Bradford Hill criteria (1965) have been used in assessing the
quality of research evidence and include considerations arising to establish a cause-and-effect
relationship.
8.2 Criteria for Causality
The relationship must be clear (strength of association).
Observation of the association must be repeatable in different populations at different times
(consistency).
The cause must precede the effect (temporality).
The explanation must make sense biologically (plausibility).
There must be a dose–response relationship (biological gradient).
Source: Adapted from Hill, A. B. (1965). The environment and disease: Association or causation. Proceedings of the Royal Society of Medicine, 58(5), 295–300.
To every complex question there is a simple answer…and it is wrong. H. L. Mencken,
writer and wit
Case–Control Studies
Case–control studies, also known as retrospective studies, work backward from the effect to
the suspected cause (Porta, 2014). Subjects are selected on the basis of the presence or absence
of the disease or outcome in question: one group of people (case subjects) with the health
problem and another group without the health problem (controls). The two groups are then
compared to determine the presence of specific exposures or risk factors.
For example, diethylstilbestrol (DES) was thought to be a safe and effective way to prevent
miscarriages or premature deliveries. It has been estimated that between 5 and 10 million people
were exposed to DES in the United States between 1938 and 1971. However, landmark case-
controlled epidemiologic studies have found health risks associated with DES in women for
whom it was prescribed during pregnancy and the offspring born of those pregnancies (DES
sons and daughters). DES daughters and sons are defined as women or men who were exposed
to DES in utero. Research has confirmed that daughters of mothers who took DES are at risk for
clear cell adenocarcinoma, a rare kind of vaginal and cervical cancer that may affect females
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from their early teens to their 40s. Studies have also demonstrated that sons of mothers who took
DES are at risk for epididymal cysts and other genital abnormalities, including testicular
hypoplasia, cryptorchidism, and microphallus (CDC, 2012b).
In addition, research is underway to determine whether the offspring of sons and daughters
of mothers who took DES might have health effects related to DES exposure. These
grandchildren of women prescribed DES during pregnancy are sometimes called the “third
generation” (CDC, 2012b). More detailed information about DES can be found at the CDC
website DES Update Home at http://www.cdc.gov/des/hcp/nurses/index.html.
The relationship between exposure and outcome in a case–control study is quantified by
calculating the odds ratio (OR). The OR is an estimate of RR that is interpreted in the same
manner as RR. When a disease is relatively rare (e.g., a cumulative annual incidence of less than
5% in the unexposed population), the OR is similar to the RR. Otherwise, the OR overestimates
RR. An OR significantly greater than 1 (statistically) indicates that the exposure is associated
with increased risk of disease, and an OR not significantly different from 1 statistically indicates
there is no association between the exposure and the risk of disease (CDC, 2012a).
Case–control studies have several advantages: they (1) allow for the examination of multiple
exposures for a single outcome; (2) are suitable for studying rare diseases and those with long
latency periods; (3) require fewer case subjects; and (4) generally are quicker and less expensive
to conduct than cohort studies, making them well suited for an outbreak investigation (see
Chapter 14). They have several disadvantages: (1) they are not appropriate for studying rare
exposures, (2) they are subject to bias because of the method used to select controls, and (3) they
do not allow the direct measure of the incidence of disease. Also, because they look backward,
case–control studies may create uncertainty about the temporal relationship between exposure
and disease (CDC, 2012a).
INTERVENTION (EXPERIMENTAL) STUDIES
True experiments that control all factors other than the one under investigation are rare when
studying human populations. Many studies, although experimental in design, are not able to
either randomize selection of subjects or exert the same degree of control of the study variables
that would be found in true experimental studies. Manipulation of the independent variable
occurs, but it may not be possible to control influencing or confounding factors.
Case 2: Data from the 2016 National Health and Nutrition Examination Survey indicate
that adults aged 20 years and older in the United States had at least one of the following
preventable cardiovascular disease risk factors: obesity, diabetes, or smoking. For 2016,
30.6% of U.S. adults aged 20 and over were obese. Also, in 2016, 9.4% of adults aged 18
and over have been diagnosed with diabetes. The prevalence of current cigarette
smoking among U.S. adults declined from 24.7% in 1997 to 15.8% in 2016. However, the
percentage of adults aged 18 and over who were current cigarette smokers was still
higher than the 12% target for 2020 (CDC, 2016). The incidence of heart disease is
increased in persons who are overweight or obese (BMI >25), while high blood pressure
is twice as common in adults who are obese than in those who are a healthy weight. And
obesity is associated with elevated triglycerides, diabetes, and decreased HDL
cholesterol (USDHHS, 2013).
The Framingham Heart Study estimated the lifetime risks for cardiovascular disease,
which account for most noncommunicable diseases worldwide, at 17.7 million (WHO,
2014).
1. What type of epidemiologic study was conducted in the Framingham Heart Study?
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2. What does a “more-than-twofold increase in RR for cardiovascular disease” mean?
Student Reflection
Public health practitioners strive for comprehensiveness in characterizing an epidemiologic
event, whether it be a pandemic of influenza or mammograms to detect early breast cancer.
Descriptive epidemiology covers time, place, and person.
The 5Ws in descriptive epidemiologic research include:
What: health issue of concern
Who: person
Where: place
When: time
Why/how: causes, risk factors, modes of transmission
In epidemiologic research public health professionals tend to use synonyms for the 5Ws:
diagnosis or health event (what); person (who); place (where); time (when); and causes, risk
factors, and modes of transmission (why/how). Community and public health nurses
reviewing and/or conducting research should keep these five essential components of a
study in mind.
Adapted from CDC. (2012a). Principles of epidemiology in public health practice. 3rd ed. Retrieved July 6, 2017 from,
https://www.cdc.gov/ophss/csels/dsepd/ss1978/index.html.
Practice Point
When gathering evidence for practice, nurses should consider the strength of the evidence
as follows:
High: There are consistent results from good-quality studies. Further research is very unlikely
to change the conclusions.
Moderate: Findings supported, but further research could change the conclusions.
Low: There are very few studies, or the existing studies are flawed.
Insufficient: Research is either unavailable or does not permit estimation of a treatment
effect.
Source: Agency for Healthcare Research and Quality. (2012). Treatment to prevent osteoporotic fractures: An update. Retrieved July 14, 2017, from
http://www.effectivehealthcare.ahrq.gov/ehc/products/160/1048/lbd_clin_fin_to_post .
Intervention studies in public health are categorized as preventive trials and therapeutic
trials, and both can be either quasi-experimental studies or true experimental studies. Quasi-
experimental study designs are weaker because assignment of subjects into groups is not
randomized, the researcher is unable to manipulate the variable under study (see Fig. 8.2), or
because of situations where it may be unethical or impractical to randomize subjects. The quasi-
experimental design is used in preventive trials that focus on primary prevention (i.e., during the
prepathogenesis stage to reduce the incidence of disease).
Preventive Trials
An example of a preventive trial using a quasi-experimental design is a study of a school
district participating in a smoking prevention program. The sample is divided into two groups:
some schools receive a health education program on smoking (“treatment”), and the others
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receive nothing (“control”). The two groups are then assessed for the incidence of smoking at 3
months, 6 months, and 1 year following the program. In this case, assignment to the treatment
and comparison groups was not randomized; therefore, it is considered a quasi-experimental
study. The greatest strengths of quasi-experimental studies are their practicality, feasibility, and,
to some extent, their generalizability (external validity) to similar groups. External validity is the
degree to which the results of a study can be generalized to other settings or samples other than
the ones studied (Gray, Grove, & Sutherland, 2017). Box 8.3 for threats to external validity.
When a quasi-experimental design is used, control over other factors (confounding
variables) may result in statistical differences due to competing hypotheses (type I error) or
result in no statistical difference when it does exist (type II error). Also, if a quasi-experimental
design is used, it cannot be assumed that the treatment and control groups were equal. However,
the design can be made stronger by pretesting both groups before the intervention. If both
groups respond similarly on the pretest, then information obtained after the intervention can be
assumed to be the result of the intervention (Gray, Grove, & Sutherland, 2017).
8.3 Common Threats to External Validity
Reactivity: Also known as the “Hawthorne effect;” this threat occurs when participants behave in a
certain way because they know they are being studied, affecting the generalizability of the findings.
Novelty: Occurs when a new intervention affects the outcome of the study because of either enthusiasm
or skepticism by the researchers or the participants.
Experimenter/participant effect: Occurs when the researcher or subject has preconceived expectations
of the intervention, resulting in bias and affecting generalizability of the findings.
Interaction of selection and intervention: Occurs when subjects willing to participate in the study are
not representative of the target population, thus limiting the generalizability of the results.
Interaction of setting and intervention: Occurs when the characteristics of the study setting influence
the outcome of the study, limiting the generalizability of the findings to other settings.
Interaction of history and intervention: Occurs when the circumstances (history) of the study influence
the results of the study, and decrease the generalizability of the findings.
Source: Gray J. R., Grove, S. K., & Sutherland, S. (2017). Burns and Grove’s the practice of nursing research: Appraisal, synthesis, and generation of evidence
(8th ed.). St. Louis, MO: Elsevier.
Practice Point
Although statistical analysis is beyond the scope of this text, it is important to know that the
sample size in intervention trials should be large enough for adequate statistical power to
prevent a type II error. In addition, the researcher should set the expected statistical p value,
generally at 0.05, to ensure that the study results are not due to chance alone and to avoid
committing a type I error.
A type I error occurs when the null hypothesis (Ho, a theory that has been put forward,
either because it is believed to be true or because it is to be used as a basis for argument) is
rejected when it is true. A type II error occurs when one accepts the null hypothesis when it
is false (i.e., the alternative hypothesis [Ha] is true). For example, in a clinical trial of a new
drug, the null hypothesis might be that the new drug is no better than the current drug. The
null hypothesis and alternative hypothesis, respectively, would be:
Ho: there is no difference between the two drugs.
Ha: there is a difference between the two drugs.
From error to error, one discovers the entire truth. Sigmund Freud
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Evidence for Practice
Falling is a significant problem among community-living older adults in the United States.
Liu and Frank (2010) examined 19 published longitudinal studies that studied the effects of
the Chinese art of Tai Chi on reducing the risk of falling among the elderly through regular
exercise. They found that Tai Chi exercise duration of 12 weeks or longer, with frequencies
of twice a week or more, and session lengths of at least 45 minutes had the following
outcomes: reduced fear of falling, increased single-leg stance, decreased rate of falling,
increased flexibility, and improved walking. The authors concluded that Tai Chi could be an
economic and effective exercise program for improving balance and balance confidence in
older adults.
Properly executed experimental studies provide the strongest empirical evidence. The
hallmark of the experimental study is random assignment of subjects to treatment (intervention)
and control groups, which controls for potential unknown extraneous (confounding) variables.
Randomization also provides a better foundation for statistical procedures to prevent type I and
type II errors than do observational and quasi-experimental studies. The research continuum in
Figure 8.2 indicates that experimental study designs are the strongest because they control for all
factors except that which is under investigation. The “gold standard” for experimental studies is
the prospective, double-blind, placebo control group design, also referred to as clinical trials or
therapeutic trials. In double-blind experimental studies, neither the researchers nor the subjects
are aware to which group they are randomly assigned.
Therapeutic Trials
Therapeutic trials are based on secondary prevention, which focuses on limiting the spread of
disease (see Chapter 14), and where the treatment (independent variable) is manipulated by the
researcher. For example, the 1994 landmark study conducted between 1991 and 1993 enrolled
477 HIV-infected pregnant women between 14 and 34 weeks of gestation. In this double-blind,
placebo-controlled, randomized therapeutic trial, the women were stratified according to
gestational age (14 to 26 weeks or greater than 26 weeks) and were randomly assigned to
receive either zidovudine (AZT) or placebo. There were no significant differences between the
characteristics of the AZT group and the placebo (control) group (Connor et al., 1994).
The AZT regimen consisted of antepartum AZT (100 mg orally five times daily) plus
intrapartum AZT (administered intravenously every hour until delivery), as well as AZT for the
newborn beginning 8 to 12 hours after birth (2 mg/kg orally every 6 hours for 6 weeks). During
the study period, 409 women gave birth to a total of 415 live infants. The infants were evaluated
by cultures and HIV serologic tests both at birth and at several weekly intervals until 78 weeks
of age. At the 18-month analysis for AZT efficacy, there was a two-thirds reduction (67%) in the
risk of HIV transmission from mother to infant in the AZT group. Because of these rather
dramatic findings, the study was halted, and all mothers were given AZT (Connor et al., 1994).
Recent studies of antiretroviral prophylaxis in the prevention of mother-to-child HIV
transmission have found similar results (Sturt, Dokubo, & Sint, 2010; Tudor-Car et al., 2013).
The U.S. Public Health Service Task Force recommends the use of antiretroviral therapy to
reduce perinatal HIV transmission, universal prenatal HIV counseling, and HIV testing with
consent for all pregnant women in the United States. As a result, the number of HIV-infected
infants born each year in the United States has decreased from approximately 1,750 (in the mid-
1990s) to approximately 143 in 2010 (CDC, 2013). For more information regarding the
prevention of maternal–child transmission of HIV, see CDC, Eliminating Perinatal HIV
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Transmission at http://www.cdc.gov/primarycare/materials/hivtransmission/.
In both preventive trials and therapeutic trials, planning includes sample selection, protocol
methodology, data collection, and data analysis. Sample selection is taken from the target
population, the population to which the results of the intervention are applicable. In the Connor
and colleagues (1994) AZT trial described above, the target population was HIV-infected
pregnant women. The sample consisted of HIV-infected pregnant women who were randomly
assigned to the treatment (AZT) group or the placebo (control) group. The study was a double-
blind study, in which neither the researchers nor the participants knew who was receiving AZT
treatment until the study was ended. A double-blind study is one method to prevent observation
bias. In a single-blind study, only the investigator knows which participants are receiving the
treatment and which are not. In unblinded studies, both the investigator and the participants
know who is in the treatment group and the control group. Nonetheless, measures should be
taken to prevent observation bias in both single-blind and unblinded studies.
Chance favors the prepared mind. Harlan Ellison, American author
Practice Point
Do not evaluate all research studies at the p value of 0.05. No researcher has a fixed level of
significance that accepts or rejects hypotheses from year to year, and in all circumstances.
Rather, consider each finding according to its usefulness in clinical situations. Studies may
have clinical significance and not be statistically significant.
KEY CONCEPTS
Epidemiologic research identifies community/public health problems and describes the natural history and
etiology of diseases.
Epidemiologic/public health research can be descriptive or analytical. Study designs are based on the
problem under study and range in strength on a continuum, with the weakest design being the retrospective
design and the strongest being the experimental design.
Descriptive studies are most frequently used in public health research. They may be observational or
analytical.
Findings from descriptive epidemiologic studies lead to hypotheses for future research.
The case study provides an in-depth examination of a single unit, such as a person, family, community, or
institution.
Case–control studies retrospectively compare subjects (cases) with a condition (disease) and matched
subjects/control without the condition/disease (e.g., those with a foodborne infection compared with those
without an infection).
Cohort studies, also called longitudinal studies, examine phenomena prospectively to observe presumed
effects over time (e.g., effects of diet and exercise on heart disease).
Cross-sectional studies examine the relationship of health-related characteristics and other variables of
interest (e.g., age, gender) in a defined population at a particular point in time.
Quasi-experimental and experimental designs are used to examine causality.
The “gold standard” for research design is the randomized, control group design.
Preventive trials focus on primary prevention to reduce the incidence of disease.
Therapeutic trials are based on secondary prevention, which focuses on limiting the spread of disease.
Community health nurses are the consumers of health-related research, which is the foundation of
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evidence-based nursing practice and also is used to inform and educate the public.
Healthy People 2020 has identified several objectives that have not met their targets. These provide
opportunities for community health programs to meet these objectives.
CRITICAL THINKING QUESTIONS
1. Read the following report: Qaseem, A., Forciea, M. A., McLean, R. M., Denberg, T. D. Treatment of low
bone density or osteoporosis to prevent fractures in men and women: A clinical practice guideline update
from the American College of Physicians. Annals of Internal Medicine, 2017, 166(11), 818-839. Retrieved
July 14, 2017 from http://annals.org/aim/article/2625385/treatment-low-bone-density-osteoporosis-
prevent-fractures-men-women-clinical.
a. Is the report evidence-based?
b. Identify the strengths and weaknesses of evidence in the report.
c. What prevention strategies would you recommend for patients at risk for osteoporotic fractures?
2. There is a high increase in teenage smoking in your community, and community leaders are developing a
plan to decrease the incidence of smoking to reach the Healthy People 2020 target of 12%.
a. Develop a research question to address the problem.
b. Design a study to decrease the incidence of smoking in teenagers.
c. Would the study be descriptive or analytical?
d. Where on the research design continuum (see Fig. 8.2) would the study fall?
3. In 2014, the CDC found that the percentage of adults (18 years and older) who had participated in federal
guidelines for physical activity was closer to the Healthy People 2020 target of 47.9%. However, the
percentage of obesity among adults in your community has not reached more than 40%. A cross-sectional
study of this population would include:
a. A representative sample
b. A survey questionnaire
c. Demographics
d. All of the above
4. Read three studies of your interest using the following link:
http://journals.lww.com/nursingresearchonline/Pages/issuelist.aspx.
a. What type of studies were conducted? Descriptive? Analytical?
b. What additional research questions would you develop based on the studies?
c. Did they provide evidence for best practice?
d. Were nurse researchers identified in the studies?
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http://www.who.int/nmh/publications/ncd-status-report-2014/en/
Part 3
Implementing Nursing
Practice in Community
Settings
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Chapter 9
Planning for Community
Change
Stephanie M. Chalupka and Cheryl L. Hersperger
For additional ancillary materials related to this chapter. please visit thePoint
Change will not come if we wait for some other person or some other time. We are the ones
we’ve been waiting for. We are the change that we seek.
Barack Obama
Never believe that a few caring people can’t change the world. For indeed, that’s all who ever
have.
Margaret Mead
For time and the world do not stand still. Change is the law of life. For those who only look to
the past or the present are certain to miss the future.
John Fitzgerald Kennedy
CHAPTER HIGHLIGHTS
Health planning at the state, national, and global level
Social and environmental determinants of health
Social ecologic model and multilevel interventions
Community coalitions
Community empowerment
Health impact pyramid
Health equity and social justice
Lewin’s change theory, force field analysis, and levers of change
Logic models
Role of the community health worker
Funding community health interventions
Evaluating community health interventions
Nurse-managed health centers
OBJECTIVES
Explain social determinants of health and how they contribute to the health status of a community.
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Describe social justice and health equity.
Apply force field analysis as a technique for managing change at the community level.
Explain the importance of changing the social and environmental context to improve health promotion
and interventions through community empowerment.
Use a logic model as a planning and communication tool for community programs.
Develop community program objectives that are specific, measurable, achievable, relevant, and time-
bound (SMART).
Describe the role of the community health worker in providing services for poor, underserved, and
diverse populations.
Explain why multilevel interventions are needed to achieve change in complex community health
conditions that have multiple determinants.
Identify sources of funding for community health intervention programs.
Describe the contributions made by nurse-managed health centers.
KEY TERMS
Coalition: Group of consumers, health professionals, policy-makers, and others working together
to improve community health status or to solve a specific community health problem.
Community empowerment: Community ownership and action for social and political change. A
process of gaining more community control to address social, cultural, political and social
determinants of health.
Key informant: Person knowledgeable about specific aspects of a problem and the community’s
current and past attempts to address it.
Logic model: Visual representation of how a program is organized, including activities,
resources, short-term and intermediate outcomes, and program goals.
Population aggregate: A defined subset of the population such as people with or at risk for a
specific health problem or having specific social or demographic characteristics.
Stakeholder: An individual, organization, or group that has an interest (stake) in a specific
community health issue or the outcome of a community-level intervention.
Sustainability: Establishing the conditions for the health improvements achieved by an
intervention to continue beyond the period of a formal community health program or for a
program to continue after grant funding ends.
CASE STUDIES
References to case studies are found throughout this chapter (look for the case study icon).
Readers should keep the case studies in mind as they read the chapter.
Helen, a public health nurse, is the coordinator of Health Promotion for Children for the prevention
of asthma in the city of Rockville. A federally funded health study of the school-aged children in
Rockville revealed a very high rate of childhood asthma. The rate was especially high in the more
economically challenged neighborhoods in the city. A program for assessment and interventions for
the prevention and the reduction of morbidity and mortality in childhood asthma was established
between the department of public health and the local children’s hospital. Helen’s role is to
supervise her lay workers who assist with the home exposure risk evaluations and coordinate
prevention education throughout the school district. The goal of the program is to reduce
hospitalizations for severe asthma in children by 10% in 3 years through a grant from the U.S.
Department of Housing and Urban Development.
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HEALTH PLANNING
Health planning is an organized and systematic process in which problems are identified,
priorities selected, and objectives set for the development of community health programs on the
basis of the findings of community health assessments (CHAs) and health surveillance data.
Health planning occurs at the global, national, regional, state, county, and local levels. Ideally,
health planning is coordinated and consistent among each of these levels.
Health Planning at the Global Level
WHO Description of Community Empowerment
The World Health Organization (WHO) defines community empowerment as “the process of
enabling communities to increase control over their lives” (1998a). The model identifies forces
from the individual and the community as influencing the options available to them when
planning a program of intervention for a community. The goal in using the model is to develop
plans of care interventions for communities with lay workers toward more effective health for
the individuals and the community (WHO, 1998).
OTTAWA CHARTER
In 1986, the Ottawa Charter was developed during the first international conference on health
promotion held in Canada (WHO, 1986). The strategies to promote action for better health in
communities include the following: building healthy public policy, strengthening community
action, developing personal skills, and reorienting health services (WHO, 1986). The model
directs communities to increase awareness and ownership for their health decisions and
consequences by increasing responsibility in which a community is more empowered to effect
change. The charter assumes that people and the community are willing to learn and develop
strategies for the betterment of their health. Another assumption of the charter is the existence of
a collaborative approach within and throughout health promotion systems and the healthcare
system toward similar goals. An effective approach for the application of health promotion is
demonstrated with the ecologic approach to health promotion assessment, planning, and
interventions (see Chapter 5). The charter speaks to community empowerment through skill
development, enabling community change, mediating for solutions, and advocating for
vulnerable populations.
SUSTAINABILITY DEVELOPMENT GOALS
The Sustainability Development Goals (SDGs) are an evolution of the original Millennium
Developmental Goals (MDGs) ratified by the United Nations in 2000. The MDGs sought to
reduce morbidity and mortality while promoting health in areas including child and maternal
mortality; to halt the epidemics of HIV, malaria, and tuberculosis; to increase sustainable access
to safe drinking water and sanitation; to reduce violence and injuries; and to decrease tobacco
use and chronic disease, including cardiovascular disease (UN, 2012). Data from the
participating countries for the SDGs demonstrated much progress but many areas lacking. For
instance, target goals were met by many countries in the areas of poverty, gender parity, and
improvement in water sources. However, several target goals were seriously unmet for many
countries in the areas of maternal morbidity and mortality, sanitation, and infant mortality and
malnourishment (UN, 2015a).
To address the ongoing health and well-being goals the MDGs are transitioning to the SDGs.
The SDGs include 193 countries working with the United Nations toward sustainable actions for
health and well-being by the year 2030.
Principles underlying the SDGs include investing in universal health and health coverage,
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sustainability, participation by all to recognize determinants of health, and increase the equality
of health and well-being throughout the world (UN, 2015).
SHANGHAI DECLARATION
In 2016, the ninth global conference on health promotion was held in Shanghai China. A
declaration was promulgated in support of the SDGs of the United Nations SDGs. The
declaration committed to support cities to promote policies for health using the most up to date
innovations and technologies. The declaration includes a focus on fairness in access and
inclusion in the healthcare system and community services through vigorous community
engagement with key stakeholders. The declaration recognizes that health literacy is a key
component in the determination of health investments and program development. Community
empowerment through local control and citizen involvement in their own health in an
environment that provides and promotes healthy choices is a key to sustainability (Shanghai
Declaration, 2016).
In 2008, the WHO Commission on Social Determinants of Health (CSDH) issued their
report Closing the Gap in a Generation, calling on all nations to address such social issues as
poverty, lack of access to education and job opportunities, poor infrastructure, and
environmental pollution, which all have a significant impact on health. The three overall
recommendations of the CSDH are to (1) improve the conditions under which all people are
born, grow, live, work, and age to minimum standards; (2) ensure more equitable distribution of
power, money, and resources; and (3) expand knowledge of the social determinants of health
and establish a system to measure and monitor health inequity. These national and international
health planning documents recognize the need to promote health and prevent disease by
addressing their underlying political, economic, and social causes and to ensure health equity.
Health Planning at the National and State Levels
Ongoing health planning occurs within state health departments, the Centers for Disease Control
and Prevention (CDC), and the U.S. Department of Health and Human Services (HHS) through
initiatives such as Healthy People 2020 and the National Prevention Strategy (NPS). This
ongoing planning is driven by trends in health outcomes and health behavior identified from
disease surveillance by the states and the CDC; data produced by the National Center on Health
Statistics (NCHS) from the Behavioral Risk Factor Surveillance System (BRFSS), National
Health Interview Survey (NHIS), and other sources; claims data from the Centers for Medicare
and Medicaid Services (CMS); and data from the U.S. Census Bureau from the ongoing
American Community Survey. Such data are used for the periodic evaluation of progress toward
meeting the objectives of Healthy People 2020 and for identifying trends in the incidence or
prevalence of health problems such as diabetes, asthma, or Alzheimer disease; of health
behaviors such as binge drinking or smoking; or of communicable diseases such as influenza or
chlamydia. Trends identified in these data may lead the CDC, HHS, and other federal agencies
or state health departments to develop new initiatives or to change health polices or programs.
Healthy People 2020
Healthy People 2020 are national objectives for improved health outcomes that guide the health
promotion and disease prevention efforts in the United States. Healthy People 2020 objectives
are 10-year targets for health improvement that build on four decades of health improvement
efforts that began with the publication of Healthy People: The Surgeon General’s Report on
Health Promotion and Disease Prevention in 1979. The overall goals of Healthy People 2020
are to:
Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death
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Achieve health equity, eliminate health disparities, and improve health of all groups
Create social and physical environments that promote good health for all
Promote quality of life, healthy development, and healthy behaviors across all life stages (HHS, 2012,
para. 5)
There are 26 leading health indicators (LHIs) that represent strategic opportunities to address
high-priority health issues that contribute to preventable death and health disparities across the
lifespan (HHS, 2010). The Healthy People 2020 objectives are organized into 42 topic areas,
including many new topics such as genomics, LGBT health, and healthcare-associated
infections. Healthy People 2020 objectives and resources are available on an interactive website
that includes links to data sources, evidence-based practice guidelines, and state-level plans. The
Healthy People 2020 website also includes historical data on progress toward meeting prior
Healthy People objectives. Healthy People 2020 objectives provide a framework for assessing
the health status of a community and can serve as the benchmark against which to compare the
health status of a population aggregate when conducting a CHA. The Healthy People 2020
objectives can also serve as the long-term goals of a community health intervention.
The goals for Healthy People 2030 are under evaluation and public feedback at the time of
the writing of this chapter.
Practice Point
When conducting a CHA, think of the target level within the Healthy People 2020 objective as
the ideal goal for health improvement. For example, the Healthy People target for the
reduction of adult obesity is 10% by 2020. Using state or local data for the total population of
adults aged 18 to 79 in your community or population aggregate, compare the percentage
with type 2 diabetes in the city and to the Healthy People target goal in the reduction of type
2 diabetes to set your goal. The aggregate data total provides a context for interpreting the
percentage rate reduction in obesity for your population and for setting health improvement
goals.
National Prevention Strategy
The Patient Protection and Affordable Care Act (ACA) of 2010 (see Chapter 4) created the
National Prevention Council which was charged with developing the NPS, published by the
Office of the Surgeon General in 2011. The goal of the NPS and several other initiatives
embedded in the ACA is to focus the nation’s healthcare system on population health through
initiatives and funding to prevent disease and to support health promotion and wellness across
the lifespan (HHS, 2016a; Koh & Sebelius, 2010).
The overall goal of the NPS is to increase the number of Americans who are healthy at every
stage of life. The NPS has four strategic directions for national prevention efforts that form the
foundation for the plan and its recommendations. These are (1) creating healthy and safe
community environments, (2) integrating clinical and community preventive services, (3)
empowering people in making healthy choices, and (4) eliminating health disparities. The NPS
also makes evidence-based recommendations for actions in seven priorities which have the
greatest potential to improve the health of the U.S. population and to reduce the burden of
preventable chronic disease, disability, and death. The seven original priorities are as follows:
Tobacco-free living
Preventing drug abuse and excessive alcohol use
Healthy eating
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Active living
Injury- and violence-free living
Reproductive and sexual health
Mental and emotional well-being
Detailed recommendations for policies, programs, and system changes at the local, state, and
national levels are included for each of the priorities (National Prevention Council, 2011).
Recently, the advisory board for the National Prevention and Health Promotion Council has
issued an overview of the strategies of the council and recommendations moving forward. The
council identified the need to add a focus to health equity throughout the NPS. They also note
that not all populations are insured with health coverage despite the intention of the ACA. They
have noted the value of other healthcare workforces that should be included to create a more
holistic approach to care recognizing traditional, and nontraditional healthcare providers who are
licensed or nationally recognized through certification. They reiterate that the lead-tainted water
in Flint, MI, was a herald call to investigate and mitigate health disparities.
Through community engagement, the advisory board is focused on the following strategies:
(1) the opioid crisis; (2) core surveillance and response for older long-standing issues like
tuberculosis and emerging infectious diseases like Ebola and Zika; (3) climate change and its
effect on health through water, agriculture, food production, and air quality; (4) and bridging the
political and social divisions regarding violence in the use of guns (HHS, 2016a). An example
provided by the advisory board is the city of Minneapolis’s “Blueprint for Action to Prevent
Youth Violence” (HHS, 2016a, p. 8).
State Departments of Public Health
In the United States, state departments of public health have a central role in health planning.
These departments coordinate planning at many levels—with federal agencies, including the
CDC, with other agencies of state government, with local or county health departments, and
with health providers. Most states have adopted state health plans that build on the national
objectives in Healthy People 2020. HHS and state departments of public health use state-level
data from the BRFSS, Youth Risk Behavior Survey (YRBS), NHIS, and the National Health and
Nutrition Examination Survey (NHANES), as well as vital statistics and disease surveillance
information, to monitor progress toward meeting the Healthy People 2020 objectives and other
health improvement goals.
Practice Point
Each state and territory has a Healthy People coordinator who is responsible for coordinating
with the HHS Office of Disease Prevention and Health Promotion to ensure that the state’s
health plan is in line with Healthy People 2020. To find the Healthy People coordinator for
your state, go to www.healthypeople.gov and search for state-specific plans.
Community Health Improvement Planning Process
Community health improvement planning is a systematic process that involves all sectors of a
community to conduct a comprehensive CHA, identify priorities for action, develop and
implement a CHIP, and guide future community decisions and resource allocations. Although
similar to several other public health and community organizing models (Box 9.1), the CHIP
emphasizes accountability and includes specific performance measures for improvement.
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http://www.healthypeople.gov
Hospitals, community health centers, schools, employers, public officials, housing authorities,
faith communities, and many other sectors of a community are included in the planning and
implementation process. Nurses working in the community in public health, community health
centers, clinics, home care, schools, and occupational settings are often actively involved.
Planning health promotion or prevention interventions at the community level can be a
complex process. Several models and frameworks help organize some or all of the steps in the
planning process (see Box 9.1). One model developed specifically for public health nursing is
the intervention wheel that describes 17 public health nursing interventions at the individual,
community, and systems levels (see Chapter 1).
COMMUNITY ASSESSMENT
Community health assessment is a systematic process that may use several approaches,
including key informant interviews, analysis of data on health status and health behavior
indicators, observation, and community surveys. The goal of a CHA is to identify the
community health problems that are the priorities for intervention, as well as community
resources available to address each health problem or need. Assessment of a community
includes identification of community assets and strengths, as well as specific health problems or
health needs. Assessment of community readiness and community capacity to address the
identified health problems is also an important part of the process. The process of community
assessment is discussed in Chapter 11.
9.1 Models and Tools for Community Health Planning
MAP-IT is a framework developed by HHS to help communities to implement Healthy People 2020.
http://www.healthypeople.gov/2020/implement/MapIt.aspx
Mobilizing for Action through Planning and Partnerships (MAPP) is a framework for community
health assessment and strategic planning developed by the National Association of County and City
Health Officials (NACCHO). MAPP focuses on community engagement to help communities
identify and address public health priorities (Lenihan, 2005).
http://www.naccho.org/topics/infrastructure/MAPP/index.cfm
Community Toolbox is an online set of tools and practical suggestions for community health
assessment, coalition-building, logic models, and the community health improvement process (CHIP)
from the University of Kansas. http://ctb.ku.edu/en/default.aspx
Guideline and Template for Community Health Improvement Planning was developed by the
Connecticut Department of Public Health to develop comprehensive prevention and control plans for
specific diseases or conditions such as HIV, smoking, or lead poisoning.
http://www.naccho.org/topics/infrastructure/accreditation/upload/CHIP-Guide
Lifestyle Medicine Institute explains, reviews, and educates on the history of the CHIP model for health
improvement. https://www.chiphealth.com/About-CHIP/ProgramOutline/
Precede–Proceed Model was developed for planning health promotion programs to address health
behaviors. A toolkit to help use this model in practice is included in the community toolkit.
http://ctb.ku.edu/en/tablecontents/sub_section_main_1008.aspx
Community Health Assessment and Group Evaluation (CHANGE) is a tool developed by the CDC
to help communities focus on changes in policies, systems, and environments to improve population
health. Includes a CHANGE tool to track progress.
http://www.cdc.gov/healthycommunitiesprogram/tools/change.htm
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http://www.healthypeople.gov/2020/implement/MapIt.aspx
http://www.naccho.org/topics/infrastructure/MAPP/index.cfm
http://ctb.ku.edu/en/default.aspx
http://www.naccho.org/topics/infrastructure/accreditation/upload/CHIP-Guide
https://www.chiphealth.com/About-CHIP/ProgramOutline/
http://ctb.ku.edu/en/tablecontents/sub_section_main_1008.aspx
http://www.cdc.gov/healthycommunitiesprogram/tools/change.htm
Data from the Rockville City Department of Public Health indicate that the schools
reported a total of 18.4% of absences of 1 to 5 days for asthma attacks. The reported
prevalence rate for Hispanic children is 14.9%, black non-Hispanics 24.1%, and white
non-Hispanics lower at 7.6%. What social determinants of health may contribute to the
significant variation in the prevalence of childhood asthma? How can the community
engage and empower the population toward health promotion and prevention strategies?
Helen has used health status data to identify higher asthma rates among school-aged
Hispanics and blacks as the community health problem her program will address. What
community assets and strengths might be available to address this priority health problem
and how might Helen identify them? How can she apply the framework of Persily and
Hildebrand to address the CHA needs of the children of Rockville?
SYSTEMS THEORY
A community is a complex system of human activity conducted within the context of the social
and ecologic environment. Every family, neighborhood, workplace, school, and recreational
facility is itself a system with its own boundaries, rules, and purpose. These systems overlap to
the extent that individual people in each family system participate in the activities or are affected
by the decisions made within other systems. Social systems engage in reciprocal exchange or
flows of information, energy, resources, and goods or services. Systems within the community
are interdependent and interconnected. Change in one system leads to reciprocal changes in
interconnected systems (McLeroy, Norton, Kegler, Burdine, & Sumaya, 2003). This
interconnectedness means that bringing about change in the community often requires
influencing systems at multiple levels because the conditions within one system, such as the
family or workplace, are influenced by and reflect the broader social, economic, environmental,
or political systems. It also means that changes made within one system, such as the school or
workplace, may have an impact on other areas with reciprocal exchange of information or
resources such as the family or the broader community.
WORKING WITH THE COMMUNITY
Just as the nurse would engage an individual patient or family in their plan of care, the
community health nurse seeks the participation of community members and institutions as
partners in planning and implementing programs, or changing policies, to achieve desired health
outcomes at the community level. One strategy to enlist the community as a partner in the
change process is the formation of a coalition, task force, committee, consortium, or community
advisory board. (Although each has a distinct meaning, the term coalition is used in this chapter
to mean any of these types of community partnership.)
Coalitions bring together consumers, health professionals, policymakers, and other
constituencies to work together to improve community health status. The strategy of using
coalitions to bring about change recognizes that (1) population health results from the interaction
of social, cultural, economic, and political determinants in the overall community and (2) both
the problems and the solutions are embedded in the community system. Systems change and an
increase in community capacity are often necessary to improve the health status of the
community (Emshoff et al., 2007; McLeroy et al., 2003).
Research to increase the social accountability in engaging and empowering communities
through coalitions and partnerships recommend that the information shared in the community is
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actionable, that there is a concerted effort to identify the community partners, an assessment is
conducted that specifically indicates how the environment can be improved, and how
accountability and sustainability goals will be met (Fox, 2015).
Great things are done by a series of small things brought together. Vincent Van Gogh
Evidence for Practice
The Allies Against Asthma initiative used community coalitions to improve the quality of care
and health outcomes of low-income children in seven communities with high prevalences of
asthma. These coalitions included diverse groups of stakeholders and focused on systems-
level changes in homes and schools to help families manage asthma better and to improve
the indoor and outdoor air quality. The odds of hospitalizations and emergent treatment for
asthma among children under age 18 on Medicaid for the seven communities where these
coalitions intervened, was significantly lower than in a matched group of control
communities. The evaluation of this program indicated that “…ongoing consumer voices in
coalition processes and decisions likely increased the quality of policy and systems
changes…[because] they reflected the actual needs of families attempting to manage
asthma” (Clark et al., 2013, p. e4).
Defining the Population of Interest
To develop a plan for a community program or initiative, first identify the population of interest
that will be affected by, benefit from, or participate in the planned change. The population of
interest may be an entire nation, state, county, or city on the basis of geographical or political
boundaries. This may be the case, for example, when planning responses to pandemic influenza
or programs to reduce carbon emissions at all levels, even global, where the objective is to
protect the health of all people. The population of interest may also be a population aggregate
such as adults aged 50 and older for an initiative to increase the rate of screening for colon
cancer. It is important for the community health nurse who is planning a program to know, for
example, whether the population of interest is the population of adults aged 55 to 74 living in
Wisconsin; the panel of patients served by a large group medical practice; families of migrant
farm workers in Broward County, FL; or the students in kindergarten through sixth grade in the
Chicago public schools.
Coalitions
When forming a coalition, it is important to be clear about the nature and scope of responsibility
of the group. A common mistake is to ask people to serve on a coalition to satisfy the
requirements of a grant or government agency without providing the coalition with a “real job”
(Box 9.2). The reasons for a coalition’s failure may include lack of a clear mission, goals,
objectives, and expectations; lack of leadership; and lack of accountability for meeting
expectations. Poor management of meetings and lack of consideration for the time and expertise
of members can also lead to the failure of a coalition (Zakocs & Edwards, 2006). Organizers
should do the following (see Box 9.2):
Make use of the expertise of individual members by asking for their help and input on matters directly
related to their field.
Seek out people with a range of opinions and roles in the community. Find out who has been a valuable
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member of previous community coalitions or teams.
Consider how each member of a coalition and the organization or group they represent will benefit from
the work of the coalition.
Understand group dynamics and remember that people agree to serve on coalitions in exchange for more
than feeling good about helping address a community issue.
Try to have a heterogeneous group but one in which members are able to show mutual respect and listen
to each other’s ideas without criticism of the person.
When we turn to one another for counsel we reduce the number of our enemies. Khalil
Gibran
9.2 How to Be a Valuable Member of a Coalition or Program Team
Only say “yes” to invitations to serve when you are really interested and have time to do the work. Do
not agree and fail to participate.
Come to meetings on time, and stay for the entire meeting.
If you are leading a meeting, start and end on time.
Come to meetings prepared. Read any material sent to you in advance.
Come to meetings undistracted—no texting or multitasking.
Practice active listening and ask questions.
Show respect for differing opinions and suggestions—listen without interrupting, and look for ways to
build on the strengths of all ideas.
Observe group dynamics to learn how group leaders achieve consensus, maintain momentum, and make
progress toward goal achievement.
Keep your commitments. Complete your assignments.
Exchange business cards and network with colleagues.
Practice Point
To run meetings efficiently, it helps to:
Know the purpose of the meeting (to make a decision, generate ideas, communicate something, or to
plan).
Show respect for the time and expertise of coalition members.
Begin and end on time.
Send an agenda and background materials in advance.
Get the right people to attend. Know who your resources are and the role that they play.
Invite only key stakeholders.
Stay on topic.
Communicate results.
Learn how to resolve conflicts and reach consensus.
Stakeholders and Opinion Leaders
The people and organizations that are stakeholders (Box 9.3) are commonly included in
coalitions. Factors to consider in forming a coalition include the history of the stakeholders
working together (successfully or unsuccessfully); success or failure of prior attempts to resolve
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the community health problem being addressed, including the reasons for these results; and the
degree to which prior improvements were sustained. As part of the community assessment, it is
helpful to discuss factors that contribute to the problem, and other issues that may need to be
addressed, with community leaders. These community leaders may include formal and informal
leaders from faith organizations, schools, and employers. It is important to consider whose
opinion counts most with the population group(s) expected to participate in the program. Such
“opinion leaders” often make good members of coalitions or may recommend others to
participate.
9.3 Questions to Help Identify Community Stakeholders
Who is most affected by this community health problem or issue? Who is most concerned?
Who are the “opinion leaders” in the community who would be interested in this health issue? Who may
have different views?
Who stands to “gain” or “lose” if this community health problem is addressed? How can they be engaged
in finding solutions?
Whose help will be needed to address this community health problem?
Who needs to be “on board” or “invested” for this intervention to be successful and for the changes to be
sustained after the intervention?
Who are the stakeholders in the Rockville City initiative? Who would you suggest Helen
ask to serve on a community coalition to achieve the goals of this program? Why?
SOCIAL ECOLOGIC MODEL
The social ecologic model is based on general systems theory and health promotion theory.
Multiple determinants of health interact at different levels to affect the health status of individual
people, population aggregates, or communities (Bopp, Kaczynski, & Campbell, 2013; McLeroy
et al., 2003; Smedley & Syme, 2002). Planning for change at the community level is often based
on a social ecologic approach with interventions at multiple levels. The social ecologic model
includes consideration for how social, cultural, economic, political, environmental,
organizational, and neighborhood factors influence health behaviors and health status within a
community (refer to the discussion of the ecologic model in Chapter 5). Although people may
change their health behavior or receive services as part of a community-level program, the
concern of public health professionals is primarily the health status of the community as a whole
or of a population aggregate. “[T]he goal of community-based interventions is not only to
change individual perceptions and behavior but also to embed public health values in our social
ecology…” (McLeroy et al., 2003, p. 532).
Even small changes in health behavior at the community or population level have the
potential to significantly affect health status. The overall impact of interventions implemented at
the community level is greater than the sum of the changes made by individuals or families as a
result of community-level programs (Smedley & Syme, 2002). Change in health behavior or
health status at one level produces changes at other levels of the community system (McLeroy et
al., 2003). For example, a community-level intervention that results in 200 people quitting
smoking may also lead to changes in community or family norms that affect future levels of
smoking initiation or reduce the number of cigarettes smoked each day because of new
restrictions at work and public places. A person or family who brings unwanted pharmaceuticals
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to a community take-back program instead of flushing them down the toilet contributes to
environmental health by preventing contamination of drinking water supplies. A city or town
that contracts for curbside pickup of recycled materials and charges residents a fee for each bag
of trash collected may achieve a greater impact.
Interventions at institutional or societal levels may achieve significant changes in public
health without the need for behavior change on the part of individual people. Examples abound.
Fluoridation of water and advances in preventive dentistry improved dental health and
dramatically reduced the incidence of dental caries in children. Laws banning trans fats in foods
served to the public in New York City led to reformulation of foods throughout the fast food and
snack food industry. Folic acid supplementation of cereals reduced the incidence of neural tube
birth defects.
Practice Point
Sometimes, the most important action that the community health nurse may take is to
advocate for a change in public policy or to collaborate with officials with responsibility for
environmental health or elder services. It is important to consider the range of social, cultural,
economic, or policy forces that influence the health behavior or health condition of concern
and then to work at multiple levels to bring about change.
HEALTH IMPACT PYRAMID
Figure 9.1 presents the health impact pyramid. Developed by Frieden (2010), this is a
framework that describes the public health impact of interventions at different levels in the
social ecologic model.
At the base of the pyramid are interventions to address socioeconomic conditions such as
poverty, lack of education, and lack of access to clean water or sanitation. At the next level are
interventions that change the environment or options available so that making the choice for a
healthy behavior is the “default” or easy choice while choosing a less healthy option would
require a person to spend more time, effort, or money. Examples include food and drug safety,
iodization of salt, elimination of trans fats in food, and restrictions on smoking in public places
and work sites. Changing food manufacturing to eliminate trans fats, for example, will have a
positive impact on the health of the entire population without people having to change their
buying or eating habits and would be sustained over time. “Changing the environmental context
so that individuals can easily take heart-healthy actions in the normal course of their lives can
have a greater population impact than clinical interventions that treat individuals” (Frieden,
2010, p. 592). Interventions to improve socioeconomic conditions and to make the healthy
choice the default choice may yield large returns in population health without requiring
individuals to change health behaviors, but some may be politically difficult to achieve or
require significant investment of time, money, or political capital.
At the middle of the pyramid are community health interventions such as immunizations that
have a long-term protective effect as well as periodic screenings such as colonoscopy. At the
next highest level are clinical interventions such as treatment of hypertension, hyperlipidemia,
and diabetes. While clinical interventions can have an important impact on the prevention or
control of disease at the individual level, the benefits may be limited because not everyone has
access to primary care, people often do not adhere to treatment regimens over the long term, and
treatments are not always effective. At the top of the pyramid are counseling and health
education. These interventions require the largest effort by individuals, and achieving sustained
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health behavior change is the exception rather than the rule. In addition, counseling and health
education reaches a limited number of people and may have little effect if used as the sole
intervention. Health counseling may be helpful in individual and family interventions, but must
be repeated with each new client and may have little effect at the population level.
“Nevertheless, educational interventions are often the only ones available, and when applied
consistently and repeatedly may have considerable impact” (Frieden, 2010, p. 592).
FIGURE 9.1 Health impact pyramid. (From Frieden, T. R. [2010]. A framework for public health
action: The health impact pyramid. American Journal of Public Health, 100[4], 590–595. Used with
permission.)
The health impact pyramid is a useful framework for community health nurses when
planning health promotion interventions at multiple levels. While we often think about health
education and screening interventions, these require the greatest effort on the part of individuals
and have the least population impact. In addition to these interventions, we should think about
what changes could be made in the environment, in policy, and in programs to make it easier for
people to make healthy choices.
MULTILEVEL INTERVENTIONS
Because of the complexity of the problems that most community-level interventions are
designed to address and the multiple determinants or causes of such problems, the most
successful interventions are those that combine interventions at more than one system level.
Even when changes in individual health behaviors such as smoking, exercise, or healthful eating
are the desired outcomes of an intervention, it is important to focus efforts on higher levels to
change the social and cultural norms or context within which the behavior occurs (Frieden,
2010; McLeroy et al., 2003; Smedley & Syme, 2002). Interventions directed at different system
levels can be described as follows:
Upstream: at the societal, environmental, or policy level
Mainstream: at the population or community level
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Downstream: at the individual level
Downstream one-on-one interventions do little to address the social or environmental
determinants of population health and require continued and repeated efforts as new people
continue to experience the relevant health problem. Prevention of disease by intervening
upstream at the social or environmental levels or mainstream at the community level amplifies
the impact of such interventions on population health (Bekemeier, 2008; Eisen, 2012). “The
ways that behavior is institutionalized (organizational-level change), normalized (community-
level change), and legally bound (policy-level change) are essential “social facts,” without
which individual behavioral change is not easily sustained” (McLeroy Norton, Kegler, Burdine
& Sumaya, 2003, p. 533).
Bekemeier (2008) points out that practitioners of public health nursing in the early 20th
century, including Lillian Wald and visiting nurses, recognized that their most important work
was to reform “…the conditions that create and exacerbate disease” (p. 50) and call on nurses to
focus their practice and research on primary prevention and the root causes of ill health.
“Focusing…on the underlying causes of poor health and health disparities requires an upstream
perspective that brings nursing (back) into the realm of policy analysis, social reform,
environmental health, sociology, and international health” (p. 50).
Practice Point
Remember to always “look upstream” when thinking about where to target interventions. Dr.
Richard Jackson at the UCLA School of Public Health explains that “public health needs to
look at the cause of the cause.” He gives the example of a person struck by a car and killed.
That death is recorded as the result of an accident. Dr. Jackson suggests looking upstream:
Why was the person hit by the car? Was there a way to walk along the road safely? Was
there a sidewalk? Dr. Jackson asks if the cause of death was actually the poor design of the
community or the lack of a place to walk in an area without the risk of being hit by a car
(Brown, 2012).
How can we apply this same thinking of upstream causes to the primary prevention of
chronic disease? What are the “causes of the cause” of diabetes, cancer, or heart disease?
How can we better address these upstream determinants of health?
SOCIAL DETERMINANTS OF HEALTH
The circumstances in which people are born, grow up, live, work, and age, and the systems put
in place to deal with illness are termed the social determinants of health. These circumstances
are in turn shaped by the wider context, including economics, social policies, and politics
(WHO, 2017).
The social ecologic model recognizes that the determinants of health are complex and
multidimensional. The health status of a community, a population aggregate, a group, or an
individual person results from a complex interaction of social, economic, environmental, and
behavioral factors. Chronic diseases, including cardiovascular disease, diabetes, cancer, and
chronic respiratory disease, are among the leading causes of morbidity and mortality in
developed nations. These diseases have multiple interactive causes that accrue over the course of
the lifespan, including diet, physical activity levels, smoking, alcohol intake, exposure to toxic
environments, genetic and familial factors, socioeconomic status, and demographics (Gostin &
Powers, 2006; Smedley & Syme, 2002; Stokols, 1992). Community health nurses may construct
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a web of causation (see Chapter 5) to help identify the multiple factors that contribute to the
chronic disease or community problem of interest as part of the planning process.
Obesogenic and Salutogenic Environments
Understanding the impact of the social, economic, and political systems on the factors that
contribute to childhood obesity, for example, reframes the problem. Obesity is not just an issue
of personal or family responsibility but one created by an obesogenic environment—defined as
an environment promoting or contributing to obesity (Schwartz & Brownell, 2007; Smedley &
Syme, 2002). Rather than directing interventions toward individual behavior change by families
whose children are overweight or obese, the goal of community-level interventions is to change
the environment to one that creates the conditions where healthy choices are the default or norm.
Making school a salutogenic environment, where only healthy food choices are available and
physical activity is incorporated into school curricula, benefits all children (Schwartz &
Brownell, 2007). Salutogenic environments are ones “…that reduce vulnerability to illness and
promote enhanced levels of well-being” (Stokols, 1992, p. 12).
Healthy people require healthy environments to live in, work, and play. The built
environment is broadly defined as human-made surroundings that include buildings, public
resources, land use patterns, the transportation system, and design features. Research is
increasingly demonstrating links between the built environment and eating and physical activity
behaviors, which in turn affect health outcomes (Prevention Institute, 2008). Environments
should be designed in ways that help people access healthy foods and easily incorporate physical
activity into their daily routines. The creation of healthy environments is not accomplished by
any single group or entity. It requires coordinated and comprehensive efforts by stakeholders,
community leaders, multiple sectors, professional organizations, and leaders. Healthy
community design integrates evidence-based health strategies into community planning,
transportation, and land-use decisions. Toolkits for healthy community design can guide the
planning for improving people’s health by increasing physical activity, reducing injury;
increasing access to healthy food; improving air and water quality; minimizing the effects of
climate change; decreasing mental health stresses; strengthening the social fabric of a
community; and providing fair access to livelihood, education, and resources (CDC, 2013).
Student Reflection
We attended one of the public hearings for the city’s community health improvement plan.
One of the people that provided testimony was Gina, a public health nurse for the city. She
was advocating for the adoption of a “complete streets” policy. She explained that complete
streets are focused on safe access without exceptions across population groups and their
needs (Smart Growth America, 2018). Pedestrians, bicyclists, motorists, and public
transportation users of all ages and abilities are able to safely move along and across a
complete street. Complete streets make it easy to cross the street, walk to shops, and
bicycle to work. It was interesting to see evidence-based practice in action because Gina
provided data from research that demonstrated that residents who live in communities with
pedestrian- and bicycle-friendly infrastructure are more physically active. She also provided
evidence that residents in a highly walkable neighborhood have been shown to engage in
about 70 more minutes per week of moderate and vigorous physical activity than residents
in a low-walkability neighborhood.
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Health Impact Assessment
A health impact assessment (HIA) helps communities make informed choices about improving
public health through community design. HIA is a process that helps evaluate the potential
health effects of a plan, project, or policy before it is built or implemented. A HIA can provide
recommendations to increase positive health outcomes and minimize adverse health outcomes.
HIA brings potential public health impacts and considerations to the decision-making process
for plans, projects, and policies that fall outside the traditional public health arenas, such as
transportation and land use (CDC, 2012).
HIA is usually voluntary, although several local and state laws support the examination of
health impacts in decision-making and a few explicitly require the use of the HIA. Outside the
United States, HIA is more widely used. Some countries have mandated HIA as part of a
regulatory process. In the United States, HIA is a rapidly emerging practice among local, state,
and federal jurisdictions, mostly on a voluntary basis.
HIA holds promise for incorporating aspects of health into decision-making because of its
applicability to a broad array of policies, programs, plans, and projects; consideration of adverse
and beneficial health effects; ability to consider and incorporate various types of evidence; and
engagement of communities and stakeholders in a deliberative process (CDC, 2012).
Health Disparities, Health Equity, and Social Justice
The WHO CSDH wrote that the “unequal distribution of health-damaging experiences is not in
any sense a “natural” phenomenon but is the result of a toxic combination of poor social policies
and programs, unfair economic arrangements, and bad politics” (WHO, 2008, p. 1). Differences
in health status exist at the population level between nations or within nations; the basis of these
differences is age, race or ethnicity, gender, socioeconomic status, or other characteristics.
“Health disparities become health inequities when they are unnecessary, unfair, and preventable
resulting from social injustices that become engrained in the fabric of society through its social,
economic, and political structures, laws, policies, and culture so as to become largely invisible”
(Falk-Rafael & Betker, 2012, p. 98).
Achieving health equity is the overarching goal established in Healthy People 2020, WHO
Millennium Declaration and the WHO 2030 Agenda for Sustainable Development. The
Sustainable Development Goals (SDGs) build on the Millennium Development Goals (MDGs)
universally apply to all; countries will mobilize efforts to end all forms of poverty, fight
inequalities, and tackle climate change to ensure that no one is left behind. The SDGs are unique
in that they call for action by all countries, poor, rich, and middle-income to promote prosperity
while protecting the planet. They recognize that ending poverty must go hand-in-hand with
strategies that build economic growth and address a range of social determinants of health
including education, health, social protection, and employment opportunities while tackling
climate change and environmental protection (United Nations, 2015).
Health inequities are avoidable inequalities in health between groups of people within
countries and between countries. These inequities arise from inequalities within and between
societies. Social and economic conditions and their effects on people’s lives determine people’s
risk of illness and the actions taken to prevent them becoming ill or to treat illness when it
occurs (WHO, 2013). There are numerous examples of health inequality within the United
States. The United States has the world’s highest per capita spending on healthcare, but it ranks
50th in global life expectancy with a very significant gap in life expectancy between the rich and
poor. The gap is as large as 20 years between rich whites living in Maryland and poor African
Americans living only 20 miles away in Washington, D.C. (Eisen, 2012). Health equity requires
the elimination not only of health disparities, but also of health inequalities resulting from
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disparities in the living and working conditions that are the social determinants of health. Health
equity is based on the principles of fairness and social justice, as well as the belief that all people
have an equal value.
Villeneuve (2008) of the Canadian Nurses Association issued a call to action to the world’s
nurses to rally around a vision of eliminating health disparities and to understand the importance
of population health. Nurses need to be informed about the dynamics of economics, global
demographics, and access to healthcare and begin to learn to frame health status indicators and
health disparities “as examples of system-level vital signs” (italics in the original; p. 335).
Villeneuve suggests that nurses need to “find policy levers with which to weave these dynamics
into their work in order to influence the development of healthy public policy based on broad
determinants of health” (2008, p. 339).
Social justice is a value central to the practice of nursing and public health. Social justice
refers to an equitable sharing of both the common burdens and the common benefits or
advantages in society. The basis of social justice is a value system in which healthcare is a right
and achieving health equity and population health are goals. Social justice holds that all
individuals are entitled to equal protection from health hazards in the environment produced by
the powerful (Beauchamp, 1976). In contrast, in the value system of “market justice,” which
characterizes modern American society, health is one of personal individual responsibility, and
healthcare and other social goods are treated as commodities or economic goods (Beauchamp,
1976; Budetti, 2008; Gostin & Powers, 2006). Achieving social justice requires addressing the
root causes of ill health, including “poverty, substandard housing, poor education, unhygienic
and polluted environments, and social disintegration…[that] lead to systemic disadvantage not
only in health, but also in nearly every aspect of social, economic, and political life” (Gostin &
Powers, 2006, p. 1054).
The gross inequalities in health that we see within and between countries present a
challenge to the world. That there should be a spread of life expectancy of 48 years
among countries and 20 years or more within countries is not inevitable. A burgeoning
volume of research identifies social factors at the root of much of these inequalities in
health…[The Millennium Declaration] goals challenge the world community to tackle
poverty in the world’s poorest countries. Included in these goals is reduction of child
mortality, the health outcome most sensitive to the effects of absolute material deprivation.
Marmot, 2005, p. 1099
Practice Point
Nurses are in a unique position in society to act as role models, advocates, and champions
of community health change. They should identify an issue about which they are passionate
and let others know of their interest. They should seek out a mentor and look for
opportunities to help bring about changes they want to see in the community. Read the
inspirational stories of nurses working in their communities to improve human health and
make a difference at the Luminary Project at http://www.theluminaryproject.org.
Philosophical, Theoretical, and Ethical Basis for Practice for Nurses in
Public Health
Cynthia Persily and Eugenie Hildebrandt developed a middle range theory to describe
community empowerment in 2003. The purpose of the theory was to answer questions in
research and clinical practice for ways to offer effective interventions to communities (Persily &
Hildebrandt, 2008). Early in her career, Persily conducted research using other disciplines to
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http://www.theluminaryproject.org
help provide needed services for high-risk pregnant woman living with diabetes (Persily, 1995).
She noticed in her study that inventions of care could be provided by not only the nurse but
effectively by others as well. This conclusion led to a study providing services to pregnant
women in a rural setting with lay persons. The conclusion of a need for community involvement
became evident with the research of the pregnant women in a rural community. She began a
literature search to see if a model of community involvement existed. In her search she came
across the work of Hildebrandt who worked with a cohort of 100,000 people in a South Africa
city to test her model of community-based participatory research (CBPR) (Hildebrandt, 1996).
The two then worked on the original model developing the middle range theory of community
empowerment (Persily & Hildebrandt, 2008).
The theoretical model includes three critical concepts: (1) lay workers, (2) involvement, and
(3) reciprocal health. By definition, community empowerment is defined as “the involvement or
participation of community-based lay workers in the promotion of reciprocal health” (Persily &
Hildebrandt, 2008, p. 132). The lay worker is viewed in relationship between the community,
the involvement, and actions within the community while focusing on their role and the
relationship of health in the community which is termed “reciprocal health” (Persily &
Hildebrandt, 2008).
Community Empowerment Model: Empowering
Neighborhoods and Communities
A neighborhood engagement study in Philadelphia by Alicea-Alvarez and colleagues (2016)
utilized the local medical community in an intervention to engage low-income, minority
neighborhoods with local healthcare education within their own neighborhoods. The study
indicated improving education to the population with a focus on health literacy has the potential
to impact the health of urban community dwellers. The study notes a lack of a framework for
eliminating health disparities exists. Future plans to provide specific local financial resources in
realignment of how resources are currently allocated for community education for health
promotion and preventions are in step with the goals of the ACA (Alicea-Alvarez et al., 2016).
In 2015, a qualitative study in Africa of the children of Uganda regarding childhood
mortality before the age of 5 was conducted using the concept of community empowerment.
Deaths are due primarily related to infectious diseases, pneumonia, diarrhea, and malaria. A
project with UNICEF called the Community and District Empowerment for Scale-Up (CODES)
project assessed the priorities and barriers or bottlenecks to bringing services together and
engaging the community to discuss and find solutions for their local health challenges. The
CODES project used a combination of a four-tool analysis approach to identify needed
interventions. Prioritizing interventions is a determined key component to engage and empower
the community. With the primary intention to improve childhood mortality, the health team (1)
identified bottlenecks, (2) analyzed root causes, (3) identified solutions and strategies, and (4)
consulted stakeholders (Katahoire et al., 2015). Continuing community communication with the
local population, stakeholders, and government proved critical. A focus on health literacy using
images and peer-to-peer learning helped to create a dialogue to identify the barriers, challenges,
and successes within the communities in the study. Prioritizing interventions within each
community rather than a blanket approach improves the use of resources and creates an
environment for better outcome measures (Katahoire et al., 2015).
CHANGE THEORY
Bringing about change in the health status of a community and its members may come through
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change in health behaviors, as well as through change in the environment, public policy, social
or cultural norms, or healthcare delivery. Theories of health behavior change at the individual,
family, and community levels have been discussed in Chapter 5. Such theories of health
behavior change are embedded in many interventions to bring about change at the community
level. In addition to changing health behavior, interventions at the community level use theories
and techniques designed to bring about change in complex systems, including theories of
organizational change.
Lewin’s Model of Change
The field theory developed by Karl Lewin, an organizational and social psychologist in the
1950s, is one useful change theory. In recent years, the discussion of change has been largely
dominated by the issue of power and politics. This has resulted in diminished interest in Lewin’s
planned approach to change, with its ethical basis and stress on democratic participation. The
emergent approach, which is consistent with the free market approach and focuses on use of
power and politics to bring about change, has been in ascendency. However, we are in an era
where ethical and socially responsible behavior is becoming more important than profit
maximization and self-interest; therefore, Lewin’s work is even more relevant (Burnes, 2009).
Lewin envisioned planned organizational change as a three-step process of unfreezing,
changing, and refreezing (Shirey, 2013). Understanding the three steps of Lewin’s theory, the
technique of force field analysis, and the levers of change are useful in visualizing and creating
change at the community level.
Unfreezing
Unfreezing the status quo is a necessary precursor to change. This may occur either gradually,
through generational changes in beliefs, language, and group norms, or rapidly through a
paradigm shift (e.g., the terrorist attacks of September 11, 2001). Gradual, incremental change in
attitudes and behaviors related to drinking and driving have led to new community norms such
as “designated drivers” and the hiring of limousines for prom nights. Rapid unfreezing of a
community’s indifference about bicycle helmets may occur when a local child riding without a
helmet dies or is seriously injured in an accident when a helmet could have prevented injury.
Unfreezing moves a community from the stage of denial or lack of awareness of the need to
change a condition or to address an issue, to a stage of preplanning or preparation for change.
Education about the extent of the problem or condition and its consequences may begin the
process of unfreezing a community’s state of denial of a health problem or acceptance of current
unhealthy behaviors or norms. Nurses can play a role as change agents during this stage to help
mobilize the community by helping to highlight discrepancies between current and desired
community health status, or creating a sense of urgency about a health issue (Shirey, 2013).
Public policies requiring restaurants and fast food outlets to display the calories and fat grams of
menu items or requiring public schools to send parents a periodic “health report card,” including
a body mass index (BMI) calculation, are examples of interventions intended to begin the
process of unfreezing the status quo. Creating dissatisfaction with the current state and raising
awareness of a need for change are catalysts for unfreezing (Shirey, 2013).
A round man cannot be expected to fit in a square hole right away. He must have time to
modify his shape. Mark Twain
Changing
Once a community has become sufficiently aware of the need for change, or sufficiently
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dissatisfied with the current conditions through increasing awareness of an issue or as the result
of a crisis, the process of changing or transition may begin. Change is a dynamic process that
may be more successful when it is actively managed rather than allowed to happen haphazardly.
It is seldom a neat, linear process. Change is more often achieved incrementally through
repeated cycles or steps than it is by large paradigm shifts. Changing requires an understanding
of what needs to be changed, how the change will take place, and an idea of what the change
will “look like” when the desired state has been achieved (Shirey, 2013).
Refreezing
Refreezing is the process of stabilizing once a change has occurred with the goal of sustaining
the change in the community’s systems, policies, and customs. Making the new behaviors the
community norms helps ensure that the change toward more positive health status will remain in
place once the intervention or program is completed. Refreezing establishes a new status quo
from which further change may be possible in the future (Shirey, 2013).
Sustainability must always be a concern when planning changes in health beliefs,
knowledge, behavior, or social conditions. New behaviors are difficult to maintain until they
become habitual. Part of the process of planning community health change is to anticipate the
support system that must be in place when a program ends so that the positive changes in health
are maintained. Involvement of the community as a partner in the change process is a key to
such sustainability. Community members and stakeholders must be involved in all stages of the
planning process so that they have “ownership” of the process or program and feel engaged and
empowered by the changes that are accomplished (Cyril, Smith, Possamai-Inesedy, & Renzaho,
2015; MacDuffie & DePoy, 2004). If change is imposed from outside the community or
embraced only by the health professional, lasting change is unlikely.
Force Field Analysis
Force field analysis is a change management technique developed by Lewin. Force field analysis
involves identifying factors within a community or organization that are driving or reinforcing
change in the desired direction, as well as those that are restraining or resisting change. When
the driving forces and restraining forces are relatively equal, a state of equilibrium exists.
Knowing the direction and strength of each force helps identify which can be increased or
decreased to allow the process of unfreezing to occur. It is also important to identify which
forces are not possible to change due to political, structural, cultural, organizational, financial, or
other constraints so that the plan for change is realistic and achievable. It is not necessary or
possible to change every force that is driving or restraining change. Ideally, force field analysis
is a participatory process involving the major stakeholders in the community (MacDuffie &
DePoy, 2004).
The key is to identify those forces that will require the investment of a reasonable amount of
time or resources yet yield the greatest opportunity to effect change in the situation. The primary
value of a force field analysis is to help one select the most appropriate targets for
intervention(s). Reducing restraining forces and/or strengthening driving forces may create the
unfreezing, disequilibrium, and dissatisfaction with the status quo necessary to bring about
change in community beliefs, behaviors, social and environmental conditions, and health status.
An example of a force field analysis applied to the case study is shown in Figure 9.2. If
you were Helen, which of the restraining forces would you try to decrease and which of
the driving forces would you try to increase? Why? What strategies might Helen use to
unfreeze the status quo to create an environment conducive to change?
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Levers of Change
The purpose of using levers of change is to increase driving forces and/or to decrease restraining
forces—leverage points identified in the force field analysis. Just as physical levers amplify the
force applied to move a physical object and allow a person to move a larger object with a
smaller expenditure of energy or effort, levers of change are tools or techniques that achieve the
largest changes with the least investment of resources. Policymakers can strategically use these
levers in public policy or social marketing to bring about desired change in the health status of
the community (Berenson, Li, Lynch, & Pagán, 2017).
Examples of public policy levers used to reduce the rates of smoking were laws requiring
workplaces, restaurants, and other public places to be smoke-free; ordinances against the sale of
cigarettes to minors; and significant taxes on tobacco products. Levers to change social norms
about smoking have included social marketing concerning the detrimental effect of secondhand
smoke on children and the value of smoke-free homes. These “levers” have helped amplify the
impact of health education and smoking cessation programs designed to change individual
health behaviors on smoking rates in the United States (Smedley & Syme, 2002).
Community Readiness for Change
Planning programs or interventions to change community health status includes an assessment
of the community’s readiness to undertake the change process related to a specific health issue.
Communities may be at different states of readiness, ranging from not being aware of a problem
or denying that a problem exists to having already initiated or undergone changes (Åhström,
Larsson, & Lindberg, 2016).
A community’s readiness for change is issue-specific (Åhström, Larsson, & Lindberg,
2016). The community readiness model (CRM) is a tool used to measure a community’s
readiness to change in six dimensions through key informant interviews. Developed by the Tri-
Ethnic Center for Prevention Research at Colorado State University for drug and alcohol use
prevention programs, researchers have shown that the CRM is a useful framework in planning
prevention programs addressing such issues as intimate partner violence, HIV/AIDS, breast
cancer education, needle exchange programs (York & Hahn, 2007), and childhood obesity
(Findholt, 2007). York and Hahn extended the evaluation of the CRM beyond community-based
prevention programs to study its usefulness in developing and implementing public policies to
limit exposure to smoking. (York, Hahn, Rayens, & Talbert, 2008). A handbook for using the
CRM, including a set of questions for key informant interviews, is available at the CRM website
and is included in the Community Toolbox at the University of Kansas (see Box 9.1).
Evidence for Practice
Findholt (2007) evaluated the readiness of a county in Oregon to address the problem of
childhood obesity and found the community had no awareness of the problem. Rather than
implementing a program, Findholt worked with community leaders to establish a childhood
obesity prevention coalition and to implement activities to increase community awareness
and level of readiness to address the problem. The process of conducting key informant
interviews as part of applying the CRM “…stimulated community interest in the problem of
childhood obesity and generated support for a community-wide prevention effort, even
before strategies were implemented to increase readiness” (p. 570). Findholt’s evaluation of
community readiness resulted in “unfreezing” and the first steps toward change in this
community health problem.
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FIGURE 9.2 Force field analysis: Length of arrow indicates strength of driving or restraining force.
PLANNING COMMUNITY-LEVEL INTERVENTIONS
The success of community health programs depends on well-conceived interventions and
implementation plans. Selecting the most appropriate intervention(s) requires consideration of
the resources available, including people, money, facilities, and time. The types of interventions
available to address childhood obesity will be different for the staff of an individual school
working within their current budget for one school year than for a community-wide coalition
with a large foundation grant for a 3-year demonstration project. Trying to do too much with
limited resources may result in failure to achieve stated objectives when a more realistic plan
with achievable objectives and the same results would be judged a success.
Guide to Community Preventive Services
The Task Force on Community Preventive Services (TFCPS) conducts systematic reviews of
research for evidence of the effectiveness of community-based prevention and health promotion
programs and practices. The goal of the TFCPS is to make recommendations for translation of
research into practice. The work of this task force parallels that of the U.S. Preventive Services
Task Force, which conducts similar work related to clinical prevention services in primary care.
The work of the TFCPS is published online as the Guide to Community Preventive Services,
also known simply as the Community Guide. New systematic reviews are published periodically
in the American Journal of Preventive Medicine and Morbidity and Mortality Weekly Report
(MMWR) and summarized on the task force website.
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9.4 Sources of Evidence for Community Health Interventions
Healthy People 2020—Each section of the Healthy People 2020 Topics & Objectives has a tab for
“interventions and resources” with links to the major evidence that supports the objectives.
www.healthypeople.gov
National Prevention Council with information on the evidence supporting the recommendations in the
National Prevention Strategy.
https://www.surgeongeneral.gov/priorities/prevention/strategy/index.html
National Council on Aging Center for Healthy Aging—evidence-based health promotion programs for
chronic disease management, fall prevention, and other programs for older adults.
http://www.ncoa.org/improve-health/center-for-healthy-aging/
The Guide to Community Preventive Services, known as the “Community Guide.”
http://www.thecommunityguide.org/index.html
U.S. Preventive Services Task Force (USPSTF) recommendations.
https://www.uspreventiveservicestaskforce.org/Page/Name/recommendations
AHRQ Guide to Clinical Preventive Services. http://www.ahrq.gov/professionals/clinicians-
providers/guidelines-recommendations/guide/index.html
National Guideline Clearinghouse. http://www.guideline.gov/
The Cochrane Library of systematic reviews. http://www.cochrane.org/
Research and systematic reviews published in Public Health Nursing, American Journal of Public
Health, Preventing Chronic Disease, and other nursing, public health, and health promotion journals.
The Community Guide is organized by topics such as injury prevention, obesity, and
diabetes. Interventions within each topic are listed either as recommended or as not yet having
sufficient evidence from research to support a recommendation. Other sources of evidence for
community-based interventions are identified in Box 9.4.
Helen consults the local CHIP and the state data on asthma in school-aged children for
recommendations on asthma prevention and respiratory health promotion. She finds that
multiple interventions implemented in combination with community healthcare workers
and engaging a wide variety of organizations that touch the school-aged child such as
school, the health clinic, the emergency room, and local social areas where community
leaders may be identified. Interventions conducted in a silo without community
engagement had limited impact for outcome changes and sustainability. What does this
tell Helen about how she should plan her intervention?
Logic Model
A logic model—also known as a program model, theory of change, or theory of action—is a
graphic illustration of how a program or intervention is expected to produce desired outcomes. It
shows the relationships among the inputs and resources available to create and deliver an
intervention, the activities the intervention offers, and the expected results (Petersen, Taylor, &
Peikes, 2013). A logic model for a community health program illustrates who will receive
services (target population), what will be done (activities), when it will happen (timeline),
where, and why (program theory) (Taylor-Powell & Henert, 2008).
The model is usually a formal process map or flow diagram (Fig. 9.3) but can be more
informal using graphics or pictures. The logic model is a tool for both planning and
communication. It helps the community health nurse identify available and needed resources,
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http://www.healthypeople.gov
https://www.surgeongeneral.gov/priorities/prevention/strategy/index.html
http://www.ncoa.org/improve-health/center-for-healthy-aging/
http://www.thecommunityguide.org/index.html
https://www.uspreventiveservicestaskforce.org/Page/Name/recommendations
http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/guide/index.html
http://www.guideline.gov/
http://www.cochrane.org/
plan the sequence and timeframe for program implementation, develop a budget, and identify
how results will be measured. The logic model also informs community leaders, program staff,
stakeholders, and decision-makers on the operation of the program and how it will achieve the
desired results (Petersen, Taylor, & Peikes, 2013).
Logic will get you from A to B. Imagination will take you everywhere. Albert Einstein
A program’s theory or logic is evidence-based and derived from epidemiologic and program
research using sources of evidence such as those listed in Box 9.5 and a critical review of
relevant literature. The program theory may also be one of those described in Chapter 5, such as
the health belief model or the ecologic model. It may be important to adapt or modify the
program theory or assumptions to the specific community by using information from the
community assessment, such as a community’s capacity, resources, results of previous efforts to
address the problem, and community readiness to change. Step-by-step guides to developing and
using logic models are provided in the community toolkit (see Box 9.1) and the resources for
program evaluation listed in Box 9.6.
Practice Point
Logic models are great tools for communicating with decision-makers and grant sources.
Proposals that include a well-constructed logic model are more likely to be approved and
funded.
FIGURE 9.3 Logic model for healthy food program. (Adapted from Taylor-Powell, E., & Henert, E.
[2008]. Developing a logic model: Teaching and training guide. Retrieved from
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http://www.uwex.edu/ces/pdande/evaluation/pdf/lmguidecomplete . Used with permission.)
9.5 Writing SMART Program Objectives
Specific: What behaviors, knowledge, skill, change in health status indicators or outcome will result
from the program?
Measurable: How will the outcome be measured and how will one know if the objective is achieved?
Are the data available?
Achievable: Is it realistic to reach the desired outcome with the resources and time available to the
program?
Relevant: Is the objective related to the program’s goals and activities?
Time-bound: When will the objective be achieved?
Not SMART: The program will reduce teen pregnancy.
SMART: The number of births to girls aged 19 and younger in Springfield will be reduced by 20% from
40 births in 2010 to 32 or fewer in 2015.
Not SMART: Fewer teens will start smoking.
SMART: The proportion of high school sophomores in the state of Georgia who report having ever
smoked a cigarette on the Youth Behavioral Risk Factor Survey in 2020 will be no more than 7%.
Not SMART: The number of older minority residents of River City receiving a flu shot will double.
SMART: The number of people aged 50 and older who receive a flu shot at a clinic sponsored by RC3-I
and who identify themselves as Hispanic or Latino will increase 50% in the fiscal year (FY) 2015
over the baseline number in FY 2012.
9.6 Resources for Program Evaluation
CDC Framework for Program Evaluation including steps and standards.
http://www.cdc.gov/eval/framework/index.htm
CDC Introduction to Program Evaluation for Public Health Programs: A Self-Study Guide.
http://www.cdc.gov/eval/guide/index.htm
CDC Division for Heart Disease and Stroke Prevention Evaluation Guides include step-by-step
instructions and examples for writing SMART objectives, developing and using a logic model,
writing an evaluation plan, and other skills.
https://www.cdc.gov/dhdsp/evaluation_resources/index.htm
University of Wisconsin Extension. Program development and evaluation website including tools and
resources for developing program evaluations and logic models.
http://www.uwex.edu/ces/pdande/evaluation/index.html
Helen reviews the theory and assumptions underpinning the statewide asthma initiative
based on the goals of Healthy People 2020. She learns that the goals for decreasing
emergency room visits for acute asthma exacerbations and more effective asthma
management in school-aged children are based on the research data found in the state
data registry for hospital data and collected state data for attendance and absences from
school.
The reported prevalence rate of asthma for the city of Rockville’s Hispanic children is
(14.9%), black non-Hispanics (24.1%), and white non-Hispanics lower at (7.6%). The
identified need for asthma attack management and prevention dovetails with top indicator
goals for promoting respiratory health in the Healthy People 2020 data
(HealthyPeople.gov). Community empowerment theory informs Helen that she will need
community leaders, community health workers who are bilingual, the support of nurses in
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http://www.uwex.edu/ces/pdande/evaluation/pdf/lmguidecomplete
http://www.cdc.gov/eval/framework/index.htm
http://www.cdc.gov/eval/guide/index.htm
https://www.cdc.gov/dhdsp/evaluation_resources/index.htm
http://www.uwex.edu/ces/pdande/evaluation/index.html
http://HealthyPeople.gov
other disciplines, and the healthcare providers in local clinics and the hospital. Reciprocal
health potential for the community involves actualizing accountability and action to
increase health. Indeed, it is a delicate balance to build an environment that supports
coalitions, promotes trust, and maximizes rapport to increase and improve communication
for better outcomes.
Using the logic model in Figure 9.3 and information provided in the case, write three
objectives for the asthma program in the SMART format.
Smart Objectives
SMART is an acronym for program objectives that are specific, measurable, achievable,
relevant, and time-bound. Program objectives written in the SMART format help in planning
interventions and establishing measurement systems to evaluate programs and outcomes (see
Box 9.5).
COLLABORATION AND TEAMWORK
Rarely does the community health nurse work alone. The practice of public health and
community health nursing requires a willingness and readiness to work on a collegial basis with
community members from all walks of life and with other professionals from a wide range of
fields. Other members of a team may include social workers, policy-makers, elected officials,
public health professionals, school officials, senior center directors, educators, community
health workers (CHWs), and researchers.
Respect for the abilities and appreciation for the contributions of community members and
other health and social service professionals are essential to the success of team building and
collaboration. Depending on the specific needs and composition of the group, the community
health nurse may play many different roles—team leader, team member, consultant, educator, or
facilitator. Active listening is just as important a nursing skill when working with community
members as it is when caring for an individual person. CHWs and community members have
much to teach health professionals about how to provide services that are concordant with the
unique social, cultural, and linguistic needs of the community.
One of the tests of leadership is the ability to recognize a problem before it becomes an
emergency. Arnold Glasgow
Practice Point
Nurses should seek input and feedback from community members using focus groups and
key informant interviews to tailor an intervention to the unique needs, culture, and priorities of
the community of interest.
Community Health Workers
Community health workers (CHWs), also called lay health advisors, outreach workers,
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promotores(as) de salud (promoters of health), peer educators, patient navigators, and
community health advocates, are essential to effective and comprehensive health systems
globally (Fig. 9.4). Over the past five decades, CHWs have been a growing force for extending
healthcare and improving the health of populations. CHWs frequently work in communities
outside of health facilities and have some type of formal, but limited, training for the tasks they
are expected to perform (Perry, Zulliger, & Rogers, 2014). CHWs are recognized in the Patient
Protection and ACA as important members of the healthcare workforce. CHWs have unique
access and local knowledge. They are therefore able to provide a cultural and language bridge to
the members of the target population (Islam, Nadkarni, Zahn, Skillman, Kwon, & Trinh-
Shevrin, 2015; Pérez & Martinez, 2008). CHWs work with community health nurses and other
members of the program team in both urban and rural areas to provide health education,
outreach and assistance in accessing services, translation, and specific interventions. Generally
recruited from the community of interest and trained by program staff, CHWs make an
important contribution to providing patient-centered care and decreasing health inequalities. The
evidence shows that they can help improve healthcare access and outcomes; strengthen
healthcare teams; and enhance quality of life for people in poor, underserved, and diverse
populations and communities (Rosenthal et al., 2010). In addition to connecting patients to
existing services and improving outreach, communications, and adherence, CHWs can also have
an important impact on healthcare costs and on the prevention and control of both chronic and
infectious disease. The successes of the CHW model have resulted in broader use of CHWs into
the health delivery system (Sabo et al., 2013).
FIGURE 9.4 Promotora de salud providing diabetic instruction. (Photo courtesy of the Migrant
Clinician’s Network.)
Evidence for Practice
In October 2010, New York-Presbyterian Hospital in association with the Columbia
University Medical Center launched an integrated network of patient-centered medical
homes that were linked to other providers and community-based resources and formed a
“medical village” to address the health needs of the Washington Heights-Inwood section of
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Manhattan. Washington Heights-Inwood is a Hispanic and low-income community with
disproportionately high rates of chronic disease, including diabetes, asthma, and congestive
heart failure.
Three years later, among 5,852 patients some combination of diabetes, asthma, and
congestive heart failure, researchers found a 29.7% reduction in that emergency
department visits and a 28.5% reduction in hospitalizations, compared to the year before
implementation of the network. In addition, researchers noted a 36.7% decrease in 30-day
readmissions and a 4.9% decrease average length-of-stay. Patient satisfaction scores
improved across all measures.
New York-Presbyterian also had fiscal gains through a short-term return on investment
of 11%. A portion of this gain was the result of increased reimbursements from New York
State. However, these findings demonstrate that academic medical centers can improve
outcomes for low-income communities by building regional care models centering on
medical homes that incorporate patient-centered processes and are linked through
information systems and service collaborations to hospitals, specialty practices, and
community-based providers and organizations (Carillo, Carillo, Guimento, Mucaria, &
Leiman, 2014).
Although CHWs have much to teach healthcare professionals about their communities, the
CHWs need a structure within which to work and training to develop skills and to understand
the activities and strategies of the specific community health program. Building relationships,
mutual respect, and trust between the CHWs, community or public health nurses, and other
members of the program team is critical to success. Written job descriptions, step-by-step
intervention guidelines, scripts for health education, and ongoing training and supervision for
CHWs are required to ensure the fidelity and consistency of interventions as well as to support
CHW job satisfaction and job performance (HRSA, 2007; Pérez & Martinez, 2008).
What skills and knowledge might CHWs recruited to work on the Rockville asthma
prevention program bring to the program that Helen may not have? How can Helen work
with the CHWs to make the best use of their talents?
EVALUATING COMMUNITY-LEVEL INTERVENTIONS
Evaluation begins as a program is being planned. The activities and intermediate outcomes
identified in the logic model and the SMART program objectives are the start of an evaluation
plan. It is critical to make plans for evaluating a program at the time of initial program planning
to ensure the development of the necessary tools and methods for collection of data to measure
the impact of the program in advance of the intervention. Planning for the evaluation of a
program also includes, when possible, measuring preintervention levels of health status or
behavior using the same evaluation criteria to establish a baseline for comparison with program
results.
The evaluation plan often includes both process and outcome evaluations. Process
evaluations focus on how well the program was implemented and looks at processes, activities,
and capacity building. Outcome evaluation focuses on the extent to which the intervention
achieved its objectives for changes in knowledge, skills, or health behavior and for improvement
in community health status. Measures used for evaluation include both quantitative and
qualitative data (CDC, n.d.).
Steps in developing the evaluation plan include the following:
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1. Develop evaluation questions “focused on what happened, how well it happened, why it
happened the way it did, and what the results were” (CDC, n.d., p. 5).
2. Determine indicators or measures you will use to answer your evaluation questions.
3. Identify where you will find the data you need to measure your indicators and answer your
questions.
4. Decide what method you will use to collect data.
5. Specify the time frame for when you will collect data.
6. Plan how you will analyze your data based on the type of data you are using.
7. Decide how you will communicate your results (CDC, n.d.).
In addition to evaluation done by the program staff or consultants, foundations or
government agencies funding the program may hire outside evaluators to conduct process and
outcome evaluations. This often happens with large multisite demonstration projects in which
the results of evaluation research are important outcomes used to determine the efficacy and
impact of new intervention strategies.
The RE-AIM framework was developed to evaluate health behavior research and has helped
to establish the evidence base of many health promotion programs. The RE-AIM framework
includes five dimensions that together represent the elements that a health promotion program
needs to have an overall impact on population health. The dimensions are reach, effectiveness,
adoption, implementation, and maintenance and are measured at both the participant and
organizational levels.
Reach is based on how well the intervention reaches its target audience. This includes the number and
percent of people in the target population who are served.
Effectiveness is the impact of the intervention on health behaviors, health status, quality of life, and other
outcome measures. This includes a consideration of any negative effects or consequences of the
intervention.
Adoption looks at the extent to which the community-based organizations or providers who were
expected to participate actually implemented the program.
Implementation evaluates intervention fidelity or the extent to which the program was carried out as it
was intended and how consistently service delivery was given between providers.
Maintenance evaluates how well the behavior change or health improvements are maintained by the
participants as well as the extent to which the program is continued by the participating providers (Belza,
Toobert, & Glasgow, n.d.; Gaglio, Shroup, & Glasgow, 2013).
“The overall goal of the RE-AIM framework is to encourage program planners, evaluators,
readers of journal articles, funders, and policy-makers to pay more attention to essential program
elements that can improve the sustainable adoption and implementation of effective evidence-
based health promotion programs” (Belza et al., n.d., p. 2). More information and resources on
using the RE-AIM framework are available at www.re-aim.org.
Practice Point
It is important to include short-term and intermediate objectives and evaluation measures in
the logic model and evaluation plan. Most community-level interventions require many years
before there are measurable changes in community health status or health outcomes.
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http://www.re-aim.org
The public health nurse has a directive to provide specific measures for part of the
outcome analysis according to the federal grant. An evaluation subcommittee has
developed process and outcome measures that each entity within the community coalition
of school, hospital and community health clinics has agreed to use to facilitate cross-city
comparative analysis. In addition, each person attending an education session for asthma
prevention and respiratory health promotion will be asked to complete a card that asks
their reason for attending the program if they ever had education about asthma before,
how they heard about the public health clinic, and if they required language assistance.
Why did the evaluation committee include these questions?
FUNDING COMMUNITY-LEVEL INTERVENTION
PROGRAMS
Planning and implementing community health programs includes finding and securing funding.
Funding for a new program may come from the internal budgets of the sponsoring organization
and its collaborative partners or may require outside funding from a foundation or government
grant. To address a community health problem, some initiatives may not need additional funds
but simply the reconfiguration of current programs or creation of a coalition to use existing
resources. Additional funding may come from other sources such as community benefit
programs of local health providers or insurance companies, in-kind contributions from business
enterprises, and sponsorship of specific aspects of a program by a local bank or business.
Accountability
Whether a program is funded by one’s own agency or an outside grant, the community health
nurse will have to be accountable for how the program was implemented. Accountability
includes regular communication about how funds were used, details of program activities, and
progress toward achieving program goals. Large foundations and government agencies often
expect logic models and formal evaluation plans as part of grant proposals. Performance in
meeting the expectations for regular and meaningful progress, outcome, and financial reports is
an important factor in decisions about renewal of grant funding.
Sustainability
Sustainability is an important consideration in program planning and a key factor in grant
making. Most funding agencies expect programs to give a clear and convincing plan outlining
how efforts started with grant funding will be continued after the grant ends. For example, is
there a written commitment from the participating agencies that they will maintain changes in
the delivery of services brought about by the program if those changes prove effective and
produce the desired results? Developing a strategy for how a program will continue after initial
funding ends should begin early in the planning process.
Helen is planning to decrease the number of emergency room visits for acute asthma
attacks, and increase prevention strategies in the homes of the vulnerable populations
targeted by the program through community engagement. The sustainability of the
program relies on effective education measures that become part of common knowledge
among the populations of the neighborhoods most at risk. How does Helen engage the
leaders of the communities to promote health and prevention strategies in order that
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emergency room acute attack care measures are not the treatment plan of choice for the
parents who have children with asthma? How does the socioeconomic status effect the
outcome of sustainability?
Program Replication
What may have succeeded in one location may reflect how ready the community was to change,
not how well a program was designed and/or how well it was implemented. The ability to
replicate or reproduce a successful program within a different community or with a new
population aggregate is a test of the strength of the design of an intervention. When an
intervention has yielded positive results in one community, the next step in establishing
evidence for practice is to test the intervention by replication.
Student Reflection
The elementary school where I am doing my community health nursing practicum has just
begun an “Andrews Elementary Walking School Bus” program. The program began in the
fall, during International Walk to School Month. There is a structured walking route with
meeting points, a timetable, and a schedule of trained volunteers. It sounds simple, and it is.
It can be as informal as two families taking turns walking their children to school or
something larger and more structured such as a route with meeting points, a timetable, and
a regularly rotated schedule of trained volunteers. Many other communities have used the
“walking school bus” program, and the school was able to take advantage of information
available from the CDC and other schools to help the program get off to a good start.
Project Funding
Government Agencies
Funding of community health programs by state or federal government agencies usually
involves a formal competitive request for proposal (RFP) process. Most often grants from the
NIH, CDC, or HRSA are categorical (e.g., targeted to a specific disease or health behavior such
as childhood obesity or smoking initiation by teens), with a limited set of target populations and
program models. Grants from federal agencies are usually made to a state’s department of health
or human services, universities, or large regional service providers with an established track
record. Grants from state and local government agencies are often made using a combination of
federal funds granted to the state and funds allocated from the state or local government budget.
The ACA has created new opportunities for federal and state funding of health promotion
and prevention programs. These opportunities include community transformation grants that will
fund programs to improve nutrition, physical activity, and wellness with priority given to
strategies to reduce healthcare disparities. Grants will be available to small business to provide
comprehensive workplace wellness programs. New funding will be available to expand the
services of community health centers and to expand Medicaid. The ACA established the
Prevention and Public Health Fund with the purpose of targeting health outcomes and quality of
care values by the public. This particular fund targets the use of evidence in public health
practice and includes programs, research, data analyses, and tracking as well as sustainability
through capacity building in the workforce. Some states have also established similar prevention
funds. The planned use of Prevention and Public Health Fund resources, including funding to be
targeted at $931,000,000 in fiscal year 2017 and beyond to invest in new prevention and
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wellness initiatives, brings many new opportunities for funding community health nursing
programs and interventions (U.S. DHHS, 2016b).
Private Foundations
Private foundations of all sizes provide grants for community health services. Most foundations
publish guidelines that identify their program interests, proposal guidelines, range of grant
amounts, and eligible grantees. It is important to learn as much as possible about a foundation
before submitting a proposal, to select a foundation or foundations whose interests align closely
with the proposed program, and to follow guidelines carefully. If an applicant is submitting
proposals to more than one foundation for the same program, it is important to indicate this fact
in the cover letter and proposal budget.
Local Resources
Local banks and other businesses, faith communities, civic groups such as Rotary International
or the Junior League, and other local resources may provide seed money, matching funds, or in-
kind support for community health programs. In-kind support such as donating items for a silent
auction, volunteering hours at a food bank, or printing program materials are valuable
contributions that local businesses can make in addition to, or instead of, cash. Even if the
amount of funds from local groups is not large, it is important to seek local support. Not only
does the support of the program by local groups demonstrate community engagement to larger
funding sources, the interest and involvement of local leaders helps ensure program success and
increases the likelihood of sustainability.
Community Benefit Programs
Community benefit programs of local or regional hospitals and health maintenance
organizations (HMOs) may be valuable partners to the public health department or community
health nurse in planning, implementing, and funding programs to improve population health.
Each nonprofit hospital is required to provide and document community benefits as the basis for
their tax exemption. Community benefits are programs and services designed to improve health
in communities and increase access to healthcare (Barnett, 2009). Hospital community benefit
programs can provide both leverage and resources to increase the effect of regional health
initiatives. While community benefit programs are most commonly focused on services related
to direct patient care (e.g., free care or unreimbursed services), redirecting only a portion of the
community benefit contributions toward high-leverage community health improvement
initiatives could have a significant impact on the health of vulnerable populations and build
community capacity to access other potential funding sources (Corrigan, Fisher, & Helser,
2015). More information and tools for community benefit programs are available on the website
of the Association for Community Health Improvement (ACHI).
Practice Point
Develop long-term relationships with funders by thanking them, providing regular progress
reports on the program they have funded, and acknowledging their support in each press
release about the program. Foundations and businesses are more likely to fund proposals
from organizations that have communicated well and have been accountable for funds
previously provided than from organizations that only contact them when funding is needed
(Box 9.7).
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9.7 Community Benefit Programs in Action
The Care-A-Van
The Bon Secours Care-A-Van is a free medical service that provides primary care to uninsured adults
and children of the Greater Richmond community. Often, an uninsured individual may wait to access
care until their health gets to an emergency level. Care-A-Van services are designed to provide medical
care in a timely manner to those who need it. Bon Secours Care-A-Van has been operating in Richmond
since 1994. The program currently serves 21 different locations.
The Care-A-Van team is bilingual (Spanish/English) and composed of physicians, nurse
practitioners, registered nurses, patient care technicians, licensed practical nurses, drivers, registrars,
trained medical interpreters, registered dieticians, licensed clinical social workers, and outreach workers.
Healthy Dollar
St. John Providence Health System/Ascension Health Alliance, Detroit, MI, Enterprising Health
Ascension Health Holdings, a subsidiary of Ascension Health Alliance, is a sponsor of Enterprising
Health (EH), a program to help new or potential entrepreneurs build the skills necessary to develop and
operate sustainable businesses, which must be focused on improving the health of Detroit and the
surrounding communities. One of the selected projects is a project called “Healthy Dollar,” a
strategically located storefront and meeting space that creates a hub for health in the city of Flint by
providing access to low-cost fresh fruits and vegetables, and a setting for health education and
community health events. Other supported projects include a web-based grocery store that makes home
deliveries of fresh food to make healthy eating more convenient for families, professionals, students. It
is an innovative approach to improving the health literacy of Detroit- area mothers with the goal of
reducing infant mortality.
Helen planned a launch event for the asthma initiative with the nurse program
coordinators from the hospital, the schools, and the community health workers along with
two identified community leaders in the targeted neighborhoods. A local news crew and
local community papers in both English and Spanish were invited to attend. After the start
of the program Helen recorded outcomes data and reported this to the Chief of the Public
Health department, the medical director of the hospital, the chief of the emergency room,
the Superintendent of the targeted school, the selected community leaders, the health
clinic director, and the manager of the community health workers. Why is outcomes data
collection important? What is the value of communicating the success and challenges of a
program?
SOCIAL MARKETING
Social marketing (Box 9.8) is the use of marketing principles and practices to change health
behaviors or beliefs, social or cultural norms, or community standards to improve health or
benefit society (CDC, 2011b). Social marketing is used primarily to design, develop, use, and
evaluate initiatives specifically in the area of communicable diseases such as sexually
transmitted infections (CDC, 2011). It has also been effective in meeting noncommunicable
disease challenges such as smoking and other social challenges such as safety and environmental
issues. Social marketing approaches add value to public health programs by providing
systematic ways of active engagement with individuals and communities end-users (European
Centre for Disease Prevention and Control, 2014). Examples include the use of social marketing
to promote health behavior change related to eating fruits and vegetables (five a day), breast-
feeding, active play by children, and following guidelines for cancer screenings. It has also been
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used to change social and cultural norms related to smoking, texting while driving, condom use,
and consumption of transfats. Social marketing is an increasingly important tool in bringing
about change in individual and population health (Crawshaw, 2013; Hoek, 2011). Several
resources are available to help the community health nurse learn to use social marketing through
the CDCynergy Lite: Social Marketing Made Simple website
(https://www.cdc.gov/healthcommunication/pdf/CDCynergyLite ).
Social marketing is more than just media communication or health education. The goal is to
change behavior. All people are exposed to commercial and social marketing each day.
Marketing may look easy and seem intuitive but it is really very challenging to do well. Most
public health programs lack the resources to develop social marketing campaigns; fortunately, it
is not necessary to “recreate the wheel.” Many social marketing programs and materials that can
be adapted for local use are available through the CDC, HHS, and national associations such as
the American Heart Association and the National Dairy Council. These programs are available
free or for a nominal fee (CDC, 2011).
9.8 Social Marketing
Take a look at these sentences. What do the bold words have in common?
Fasten your seat belt.
Eat more fruit.
Pull over to use your cell phone.
Don’t litter.
Get a mammogram.
Talk to your doctor
These words describe problems to be addressed by changing behavior. Research may help to
describe what your audience is currently doing or thinking, which can help shape realistic goals for
behavior change. Social marketing is about identifying the specific target audience segment(s),
describing the benefits you will offer, and the creating interventions that will influence or support the
desired behavior change.
Social marketing planning requires us to understand and incorporate the “The Four Ps of
Marketing,” into our program planning. Social marketing is critical because it looks at the “Four Ps” and
the provision of health services from the viewpoint of the consumer. The “Four Ps of Marketing” are:
1. PRODUCT represents the desired behavior you are asking your audience to do, and the associated
benefits, tangible objects, and/or services that support behavior change.
2. PRICE is the cost (financial, emotional, psychological, or time-related) of overcoming the barriers
the audience faces in making the desired behavior change.
3. PLACE is where the audience will perform the desired behavior, where they will access the program
products and services, or where they are thinking about your issue.
4. PROMOTION stands for communication messages, materials, channels, and activities that will
effectively reach your audience.
Sometimes there is a fifth P — policy. POLICIES are the laws and regulations that influence the
desired behavior, such as requiring sidewalks to make communities more walkable or prohibiting
smoking in shared public spaces.
Adapted from Gateway to Health Communication and Social Marketing Practice (2011).
Student Reflection
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https://www.cdc.gov/healthcommunication/pdf/CDCynergyLite
When I was in high school, the school nurse showed us an empty soft drink bottle half filled
with sugar. She said there are 10 tsp of sugar in a 12-oz (350-mL) bottle. Can you imagine
eating that much sugar with a spoon? The nurse said that diet drinks are no better because
they change your metabolism and make you crave sweets. I stopped drinking soft drinks
that day and started drinking water and diluted fruit juice and lost 10 lb in 6 months without
trying. The visual aid that nurse used did more to convince me than anything I had read.
NURSE-MANAGED HEALTH CENTERS
Nurse-managed health centers (NMHCs) are a unique model of community health services led
by advanced-practice nurses and providing a wide range of services and programs to vulnerable
and underserved populations. The communities served by NMHCs are usually geographically
defined and are most often vulnerable and underserved population aggregates such as the rural
poor, migrant farm workers, low-income mothers and children, inner-city neighborhoods, and
immigrant communities. The NMHC may offer services in subsidized housing projects,
homeless shelters, correctional institutions, schools, faith communities, storefronts, and other
locations easily accessible to the population aggregate being served. The NMHCs emphasize
health promotion, disease prevention, and health education. Many provide specialized programs
to meet the needs of specific population aggregates such as pregnant and parenting women,
teens, or homeless people. Primary prevention is a core component of the care provided, and the
range of services varies from health promotion programs to a full range of primary care and
chronic disease management programs (Esperat, Hanson-Turton, Richardson, Debisette, &
Rupinta, 2012).
Many NMHCs are academic nursing centers established by colleges of nursing to provide
service to the community as well as clinical practice and research opportunities for students and
faculty, and to prepare students with skills to work in medically underserved areas. Other
NMHCs are federally qualified health centers of federally qualified look-alikes or are clinics
within the structure of a hospital or health system. HRSA has funded some NMHCs, particularly
those at schools of nursing, and NMHCs are included in provisions for expanded funding of
safety-net providers and community health centers under the ACA. NMHCs belong to the
National Nursing Centers Consortium, where you can find more information about these
community health nursing programs that build on the legacy of Lillian Wald in meeting the
needs of vulnerable and underserved communities (Esperat et al., 2012).
9.9 Healthy People 2020—Indicator Nutrition, Physical Activity, and Obesity
Nutrition, physical activity, and obesity are a top goal for Healthy People 2020. The obesity rate of
adults remains high at 36.2% and 16.1% in children and youths aged 2 to 19 years. Physical activity
guidelines recommend aerobic and muscle-strengthening exercises totaling 150 minutes for a lighter
work out or 75 minutes for very intense activity per week. Targets for increased physical activity are met
with a 10% improvement over the baseline. Several determinants of health may influence the outcome
of success in this indicator based on an assessment of environmental, social, and nutritional barriers to
healthy weight and activity.
1. How would you calculate the percentage of improvement expected in the adult group? In the children
and youth group?
2. Go to the website below and click the top tab named “Life Stages and Determinants.” How does the
built environment inform the populations ability for increasing health for this Healthy People,
indicator?
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https://www.healthypeople.gov/2020/leading-health-indicators/2020-lhi-topics/Nutrition-Physical-Activity-and-Obesity/data.
KEY CONCEPTS
Common themes of current national and international health plans include providing health promotion and
disease prevention at the population level, addressing social determinants of health, and achieving health
equity.
Social justice and health equity are key values in community health and public health nursing.
Changing the social and environmental context to make healthy choices the default is an effective strategy
for improving the health of a community.
Even small changes at the community or population level have the potential to create significant change in
the health status of a community.
Logic models provide a visual representation of how a program is organized: what it will do (activities), what
resources are needed (inputs), how short-term and intermediate outcomes will be measured, and how the
program goals will be achieved.
The change process can be visualized as three steps of unfreezing the status quo, changing or moving to a
new state, and refreezing to sustain the change or changes made.
Force field analysis is a tool used to identify the forces driving or restraining change.
The health status of a community and its members is the result of a complex interplay of social, economic,
environmental, behavioral, political, and cultural forces.
Health behavior change, whether at the individual or community level, requires sustained effort, and results
may not be evident in the short term.
Community participation through engagement and empowerment in all steps of the change process helps
to increase the potential for program success and sustained change in community health status.
Community readiness to change needs to be considered in selecting the most appropriate types and levels
of interventions.
Multilevel interventions are needed to achieve change in complex community health conditions that have
multiple determinants.
Public policies such as tax increases on tobacco, alcohol, or soft drinks can serve as policy levers to bring
about change in community health status.
Nurses can play an important role in their professional and personal lives as advocates and champions for
health improvement, social justice, and health equity at the local, regional, national, and global levels.
Community health workers can help bridge the gap between the community health nurse and the
community, especially when there are cultural and language differences.
Nurse-managed health centers provide health promotion and primary care services to vulnerable and
underserved population aggregates.
CRITICAL THINKING QUESTIONS
1. Think about the factors (social, developmental, environmental, and policy) that contribute to the problem of
binge drinking on college campuses. Use a force field analysis to think about how the change process
could be applied to reduce binge drinking on your campus.
a. Which driving force(s) would you want to strengthen? What approach would you use to accomplish
this? Why?
b. Which restraining force(s) would you want to decrease? What approach would you use to accomplish
this? Why?
2. Can you think of recent changes in public policy, the environment or social context that have made it
easier to make healthy choices in your own health behaviors? How might you apply the concept of making
healthy choices the default choice to your nursing practice to support healthier behaviors among your
clients?
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3. How can community empowerment and engagement effect health behavior changes?
4. Based on community-level data, you have identified the need to increase immunization rates in the
refugee and immigrant population in your community. Who might you enlist as partners in planning and
implementing programs to achieve desired health outcomes at the community level? Why did you select
these partners?
5. Bekemeier, Villeneuve, and Falk-Rafael all suggest that nurses need to actively work to bring about
change upstream in the social and environmental determinants of health. How might this vision for the role
of nurses in population health manifest itself in your practice?
6. How does the Persily and Hildebrand model offer a framework for community engagement in the following
case?
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WEB RESOURCES
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Chapter 10
Cultural Competence:
Awareness, Sensitivity,
and Respect
Teresa Eliot Roberts
For additional ancillary materials related to this chapter. please visit thePoint
I don’t think things are moving toward an omega point; I think they’re moving toward more
diversity.
Clifford Geertz
Preservation of one’s own culture does not require contempt or disrespect for other cultures.
Cesar Chavez
I do not want my house to be walled in on all sides and my windows to be stuffed. I want the
cultures of all the lands to be blown about my house as freely as possible. But I refuse to be
blown off my feet by any.
Mohandas Gandhi
CHAPTER HIGHLIGHTS
Culture in community settings
Cross-cultural nursing
Cultural competence and related concepts
How culture affects health
Cultural health assessment
OBJECTIVES
Define culture and describe ways in which it is propagated.
Define cross-cultural nursing practice.
Explain how culture can affect health.
Explain ways in which a nurse can be culturally competent.
Define subculture and explain how it may come into play in a clinical encounter.
Describe the limitations and possible pitfalls of cultural competence.
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T
KEY TERMS
Culture: Knowledge, values, practices, customs, and beliefs of a group.
Cross-cultural or transcultural nursing: Any nursing encounter in which the client and nurse
are from different cultures.
Cultural competence: Openness to and respect for others’ ideas and ways of life; curiosity,
patience, and self-awareness of one’s own culture and culturally mediated ideas.
Cultural safety: Culturally appropriate health services to disadvantaged groups while stressing
dignity and avoiding institutional racism, assimilation (forcing people to adopt a dominant
culture), and repressive practices.
Ethnocentrism: The assumption that others believe and behave as one’s own culture does, or
the belief that one’s own culture is superior to others.
Subculture: A group sharing some practices, language, or other characteristics in common,
within a larger society that does not share those characteristics.
CASE STUDY
References to the case study are found throughout this chapter (look for the case study icon).
Readers should keep the case study in mind as they read the chapter.
Susan, who works in a community health clinic, is explaining to her client, Nilda, why she needs a
colposcopy. She tells her that her Papanicolaou (Pap) smear shows cell changes that could, if left
untreated, develop into cervical cancer. A colposcopy and biopsies are necessary to determine a
more exact diagnosis and guide treatment. To Susan’s surprise, Nilda looks stricken and begins to
cry quietly.
After further conversation, Susan realizes that Nilda, who is from Brazil, believes that she has
cancer. Nilda understands English very well; therefore, Susan has not used an interpreter.
However, even if she had, her remarks may still have been confusing, because language is not the
only difference between people from different countries. Their cultural assumptions may not be the
same.
What Susan does not know is that in Brazil serious diagnoses such as cancer are generally not
given directly and bluntly; the clinician brings the conversation slowly around to the illness and hints
at the serious diagnosis (Graça & Barry, 2016). In Anglo-American culture, clinicians tend to be
both direct and blunt. Values such as time efficiency during an appointment and the patient’s right
to know all the possible differential diagnoses make Anglo-American culture feel impersonal and
confusing to many people from other cultures. When Susan explains that cancer is a possibility,
Nilda assumes that this is a gentle way of saying she probably has cancer. So, it is a cultural
misunderstanding that makes Susan’s first nursing intervention fail.
his chapter introduces the reader to culture as a health mediator, especially as it relates to
community health. Aspects of culture that directly affect health and health decision-
making are discussed, as well as specific challenges that face nurses and patients when
they come from different cultures. Nurses and nursing students face challenges when they
consider their cultural origins and assumptions; they need to remain respectful, open, and
curious when interacting with patients from cultures different from their own. First, though, an
analysis of what culture is will help focus the discussion.
CULTURE AND NURSING
What Is Culture?
Culture has been defined in many different ways, yet it remains hard to describe. A basic
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definition of culture could be the music, language, economy, fashion, religion, and art of a
community. A more thorough analysis reveals, however, that although culture encompasses
those phenomena, it also includes intangibles that are even more subtle and sometimes abstract.
Culture is “a set of practices and behaviours defined by customs, habits, language, and
geography that groups of individuals share” (Napier et al., 2014, p. 1609). Culture has been
described as that which occupies the space between people in the world. Anthropologist Renato
Rosaldo explains that “[c]ulture lends significance to human experience by selecting from and
organizing it. It refers broadly to the forms through which people make sense of their lives,
rather than more narrowly to the opera or art museums…. All human conduct is culturally
mediated. Culture encompasses the every day and the esoteric, the mundane and the elevated,
the ridiculous and the sublime. Neither high nor low, culture is all-pervasive” (1993, p. 26).
Culture includes language, religion, occupation, economics, art, politics, and philosophy. It
affects practices of individuals, families, and institutions. Culture is how people approach the
world. One difficulty in discussing culture, though, is that because of its nature, people often fail
to recognize its influence on themselves. Generally, only when we are outside our own culture
do we even recognize that it exists, when “the fish becomes aware of the water in which it
swims” (Rahmawati & Taylor, 2017).
Nurses and other human service professionals have come to realize what anthropologists
have long known, that culture affects how people view health, illness, treatment, regaining and
maintaining health, as well as death and dying. For these reasons, culture has become a major
nursing concern. It is a fundamental and important issue in evidenced-based practice in
community settings.
Properties of Culture
Dynamic, Not Static
Culture is an ever-changing phenomenon. Culture changes over time. For example, the culture
of 19th-century Egypt is related to that of present-day Egypt, but it is not the same. The
language has lost a few words and gained new ones. Social media, climate change, and other
21st-century concerns have affected Egyptian work, communication, agriculture, and education.
Egyptian religion, language, values, and family dynamics are closely linked to what they used to
be but have evolved over time.
Culture also adapts to new circumstances. For example, in and around Houston, the culture
changed dramatically after Hurricane Harvey in 2017. Evacuations, damage to infrastructure,
housing, and flooding radically changed how residents lived and thought about their
communities. The cultures of individual people and families also evolve with changes in home
life, illness, or migration to a new country, although these changes are usually less dramatic.
Shared, Not Private
The definition of culture can vary among anthropologists, but all agree that one characteristic of
culture is that it is something that is shared among people. Families and peers are the source of
the first cultural sharing for most children. When a parent explicitly explains a value system to
his or her children or cooks food for them or even teaches them their primary language, that
parent is sharing cultural knowledge. A similar process happens in schools and neighborhoods,
through online social media, or in any place where people interact. Individual people may have
cultural values, beliefs, and practices, but the sharing of these among people is the process of
culture.
I have always felt that the action most worth watching is not at the center of things but
where edges meet. Anne Fadiman
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Learned, Not Inherited
A person is not born with culture the way he or she is born with genes. Thus, if a Honduran
newborn is adopted by an English couple and raised in London, that child will be culturally
British. Usually, culture is first “learned” from parents and siblings and then from peers,
teachers, neighbors, books, television, and other media. A Hungarian parent may teach a child
that rich food is fundamental to a healthy diet and that Christianity is the best religion, for
example, whereas a Japanese parent may teach that fish and rice are a healthy diet and that
studiousness and selflessness are virtues. These lessons may be explicit, as in when a parent
explains his or her own values, or parents or peers may teach cultural norms implicitly, as when
they model or reward certain behaviors.
Cross-Cultural Nursing
Cross-cultural nursing is any nursing work in which the nurse and patient have different
cultures. Transcultural nursing is sometimes used as a synonym but can also refer specifically
to the work and model of Leininger (2002), a nurse-anthropologist who sought to focus nursing
attention on culture.
In the case of Nilda and Susan, their different cultural assumptions contributed to a
misunderstanding. However, the experiences of cross-cultural clinical encounters are also
potentially enriching, showing each participant new ways of looking at the world and
providing opportunities for introspection.
How can nurses working in communities develop a non–self-blaming and
nondefensive posture when they make mistakes based on cultural assumptions and
misunderstandings? How can mistakes like this be used and turned into learning
experiences?
It is critical that nurses understand that culture is neither static nor deterministic (Usher,
Mills, West, & Power, 2017). For example, just because a client is Indonesian, Mayan, Angolan,
or French, that person does not necessarily act or believe like most people from the same
culture. Moreover, an individual’s culture does not necessarily have the same importance to that
person at all times or in every situation. Rather than assuming anything, “communicate a
recognition that people live their ethnicity differently, that the experience of ethnicity is
complicated but important, and that it bears significance in the healthcare setting” (Kleinman &
Benson, 2006).
Student Reflection
During my first clinical rotation in home care, I was visiting a 50-year-old Vietnamese lady
recovering from pneumonia. While I was assessing her respiratory status, I noticed several
round brown bruises down her back, bilaterally. I was a little shocked, not knowing what it
was. I could not think of anything about her infection that would cause that. But she told me
that when she came from the hospital, her sister-in-law had given her a “fire cupping”
treatment. I went home and did some research. It turns out that people in many countries
treat some respiratory conditions by trapping hot air in little cups on the skin of the back,
which can cause bruising. I wrote a paper about it and did a presentation to my community
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health class. My instructor said that even she had not really known much about cupping
until she read my paper!
Cultural Competence
Nurses in an ethnically diverse society, then, should strive to serve their clients in a culturally
sensitive, respectful, and effective manner. In other words, they should demonstrate cultural
competence. In nursing, cultural competence means considering cultural aspects of health,
illness, and treatment for each client or community, as well as doing so at each stage of the
nursing process. Giger describes cultural competence as “A dynamic, fluid, continuous process
whereby an individual, system, or healthcare agency finds meaningful and useful care delivery
strategies based on knowledge of the cultural heritage, beliefs, attitudes and behaviors of those
to whom they render care” (2017, p. 7).
Institutional Cultural Competence
Nurses and other health professionals should take culture into account in providing client-
centered care, but to promote community health and well-being, healthcare organizations must
also strive for cultural competence and be aware of and seek to minimize structural hindrances
to cultural openness and respect. For community and public health agencies to be culturally
competent, they must “provide effective, equitable, understandable and respectful quality care
and services that are responsive to diverse cultural health beliefs and practices, preferred
languages, health literacy and other communication needs,” through governance, leadership,
workforce, communication, engagement, continuous improvement, and accountability (Office of
Minority Health, 2016).
Proponents of cultural competence also conceptualize it as a process, which is to say that as
people, groups, and cultures change, nurses will never arrive at one point of mastery but should
continue striving for culturally sensitive care (Jeffreys, 2015; Smith, 2017).
In Susan’s case, especially if she has many Brazilians in her community service area, it
would be good nursing practice to find out more about Brazilian culture. The facility in
which Susan works should consider hiring Brazilian staff and/or consultants, find out
whether there are health concerns specific to this population (a form of community health
assessment; see Chapter 11), have a strong and professional interpretation department,
and continuously ask in what ways the facility can improve services to this population,
including ongoing self-assessment to consider how the nurses’ cultures affect care.
How could nurses organize a descriptive research study that could answer some of
these questions? How could Susan investigate how nurses feel about hiring practices?
How could she design a study to answer if interpreter services are adequate?
It is crucial that nurses expand their views beyond the individual practitioner and client.
Nurses must be culturally knowledgeable and sensitive, but they should also be critical of the
systems and policies in society that perpetuate health disparities among groups. Healthcare
professionals who have tolerant nondiscriminatory attitudes will not necessarily be culturally
competent if they are not also trained to recognize when behavior unintentionally supports the
status quo or a business-as-usual mentality and favors some over others (Rajaram & Bockrath,
2014). Indeed nurses must be actively critical to best promote the wellness of their clients.
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Evidence for Practice
Silvestri-Elmore and colleagues (2017) surveyed new nurses across the United States and
several factors to see which, if any, perceived level of cultural competence. Among this
group of 126, being at least 10 months postgraduation statistically predicted increased
cultural competence, as did Hispanic ethnicity and participation in a cultural immersion
experience.
Practice Point
Memorizing a list of cultural traits of clients is simplistic; it may facilitate stereotyping and
obscure the fact that each client is a multifaceted human for whom culture can play unique
roles. It is incumbent that nurses approach their clients as individuals who may be more or
less acculturated and should not be prejudged.
Some cross-cultural nursing texts list traits of various cultures, implying that memorizing
these will make a person sensitive cross-culturally. However, human beings are complex,
and culture is just one of the many factors that influences how they view health and illness.
Indeed, using lists of common cultural themes can be seen as reductionist, demeaning, and
too simplistic, given that all cultures are ever-changing, and that every individual has his or
her own life experiences, feelings, and viewpoints.
Principles of Cultural Competence
There are thousands of cultures in the world, countless because they are always changing. A
nurse cannot have encyclopedic knowledge about every culture a client might come from. But as
a nurse is focusing on a certain community, it is advisable to learn what major cultural groups
comprise that community and what facets of the community give it its own unique subculture as
well. Indeed, nurses should do this while they are doing the general community health
assessment (see Chapters 9 and 11). Although the nurses will not be fluent in all cultures at all
times, certain principles will make nurses more culturally competent: openness to others’ ideas
and ways of life; respect, curiosity, patience, and self-awareness of one’s own culture and
culturally mediated ideas; and the humility to know that one can always learn more about a
certain client’s culture and that person as an individual. Individual nurses must work toward
cultural awareness and competence to help erase health disparities and power imbalances among
groups.
In such diffused changes of culture two factors are necessary: contact and understanding.
Hu Shih, Chinese philosopher
Cultural Safety
Historically, many practices of healthcare institutions and clinicians have been discriminatory
and hurtful to minority groups. Cultural safety refers to providing culturally appropriate health
services to disadvantaged groups while stressing dignity and avoiding institutional racism,
assimilation, and repressive practices. “Fundamental to cultural safety theory are issues of social
justice and the significance of nurses’ power, prejudice and attitudes. This requires the
recognition of power disparities within the nurse/patient relationship as well as at the level of
social structures, policies and processes” (Richardson, Yardwood, & Richardson, 2017).
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For the community health nurse, this means ongoing learning about the health beliefs and
practices of their clients and never dismissing or disrespecting folk traditions. For instance,
communities in the United States that use healing practices of Vodou (or Voodoo), a Haitian
religion, often feel that they have to hide their practices because the dominant society considers
the religion unacceptable or even evil. A nurse who is not familiar with these practices might at
first be shocked or scared by Vodou, but providing culturally safe care means that he or she
would need to analyze those feelings and instead approach Vodou with respect and openness,
encouraging clients to use Vodou if they see it as beneficial.
Evidence for Practice
A survey of 358 Ethiopian immigrants in the United States showed that more than 57% had
recently used herbs and supplements, mostly for respiratory illnesses. They also used
acupuncture, chiropractic, holy water, incense, prayer, and wegesha (traditional
physiotherapy and bone-setting). Though the majority of this group did have health
insurance, most did not discuss their alternative therapies with their primary care
practitioners (Hailemeskel, Habte, Fullas, & Al-Matari, 2017).
Cultural Humility
Because “competency” implies mastering a finite task, “cultural humility” has been proposed as
another, perhaps more appropriate, goal (Fisher-Borne, Cain, & Martin, 2015). If nurses treat
patients’ cultures as atypical behavior that needs to be learned and mastered, “this approach can
further reinforce existing stereotypes and cultural essentialism” (Rajaram & Bosckrath, 2014).
Cultural humility requires nurses to continually self-evaluate and critique their own cultural
assumptions and to advocate for their clients in a nonpaternalistic way. To do the latter, they
should:
Ask open-ended questions about beliefs and practices of the client and family and
Ask about traditions. What does the client think may have caused an illness, and how has the client
already tried to address it?
Rather than trying only to learn tricks or nuggets of cultural knowledge, it is better to have
an ongoing, humble attitude and commitment to self-awareness and client-centered care.
For example, a school nurse interacting with students from many cultural groups finds it
impossible to be an expert on the health beliefs and practices of all the cultures. However, he or
she understands the common health practices of some of the cultures. A teacher complains that a
boy is wearing small magnets on his ears, which is against the dress code. After interviewing the
child, the school nurse learns that he has been experiencing headaches in class. It turns out that
the magnets have been placed on his ears by a traditional Chinese medicine practitioner as
treatment for his headaches. The school nurse should explain to the teacher that this is a valid
therapeutic technique and that Chinese medicine is a legitimate healthcare system 10 times older
than Western allopathic medicine. Also, the therapy is likely to make the child more comfortable
in class and better able to learn.
Ethnocentrism
Ethnocentrism refers to two related phenomena. First, ethnocentrism means the tendency of
people to assume that everyone else thinks the same way they do, and has the same worldview,
logic, and culture. For instance:
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A family that eats a big Christmas dinner of ham and sweet potatoes in the afternoon of Christmas day
might assume that everyone celebrates the Christmas holiday that way—even that everyone celebrates the
holiday. Christmas as a holiday at all, as well as specific Christmas rituals, differ significantly across
cultural groups, even for those living near each other.
Nurses often assume that they can reach clients by phone or e-mail, but if their clients are indigent, they
may have neither phones nor internet access.
A woman drives to work and has an office job, and she forgets that many other people commute on foot,
or have an occupation that requires them to be physically active.
A student nurse asks a client, “What do you usually eat for dinner?” The client answers, “Oh, regular
food.” The client is assuming that most people eat the same things he or she does and does not even know
how to describe it, perceiving his or her own diet as the norm.
Ethnocentrism can also refer to the tendency of people to view their way of doing things and
their culture as superior to the cultures and ways of others. For instance, someone may feel that a
“real” marriage requires a wedding in a certain religious denomination. This may reflect
ignorance about or even disdain for hundreds of other ways of creating marriages that occur
across the world. If people think that their own regions’ fashions or medicines or languages are
better than those of another region (as opposed to just personally preferring them), they are
thinking ethnocentrically.
Perhaps Nilda would like to consult an herbalist about ways to treat her cervical cellular
changes. Susan can ethnocentrically reject the idea, telling Nilda that herbalism is
primitive and dangerous, or she can find out more about it, offering to work together with
Nilda’s chosen herbalist to develop a complementary treatment plan.
What would be some concrete first steps in finding an herbalist? How could a nurse
build community-collaborative relationships from small-scale relationships with patients in
communities?
Subculture
Just as any group of people from a certain place may share a culture, any group of people who
share a certain characteristic can share a smaller culture, or subculture. For instance, within the
United States, Methodists share a subculture of their religion and religious practices. Just as with
larger cultures, there is plenty of heterogeneity within Methodism, and not all Methodists are the
same or have exactly the same religious beliefs. We can say, however, that it is likely that they
share certain beliefs, practices, experiences, and/or religious discourse.
Subcultures might be groups of an occupation, age cohort, sexual orientation, avocation,
socioeconomic status, region, or some other characteristic that the individuals share. It is
reasonable to assume that construction workers from Tampa to Seattle share some experiences,
language, and practices. Similarly, motorcycle enthusiasts have interests and knowledge in
common that make them a subcultural group, as are nurses, skiers, lesbians, cancer survivors,
and café owners. A subculture may be large or small, clustered together or scattered, but its
members share some cultural facets such as experience, belief, language (or “lingo”), practices,
and values.
It is time for parents to teach young people early on that in diversity there is beauty and
there is strength. Maya Angelou
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Nilda’s original culture was Brazilian, but the fact that she has had a new experience of
migrating to the United States means that she also belongs to a smaller subculture of
Brazilians living in the United States. These people have shared certain experiences. She
also probably belongs to other subcultures, such as her church, neighborhood, and
occupational group. Nilda and Susan also share subcultures; for example, they are both
women, they live in the same city, and may be of the same age or love the same
television program.
Race
Race can also be thought of as a subculture because people of the same race often share
experiences, such as how they are treated by and reflected in a larger society. What is important
to understand is that race is a social construct, not a biologic entity. Because there is more
genetic variation within a “race” (e.g., black, white, Hispanic) than there is between races and
because its use can actually contribute to discrimination, some scientists have decried using the
concept of race in biologic sciences at all (Perez-Rodriguez & de la Fuente, 2017; Yudell,
Roberts, DeSalle, & Tishkoff, 2016). Racism is certainly a reality and can have devastating
effects on health (Brondolo, Libretti, Rivera, & Walsemann, 2012), but race itself is based on
social ideas and not on biologic determinants. Indeed, there are significant health disparities
among races in the United States (United States Department of Health and Human Services,
2016). It is important to know that although a nurse may use a client’s appearance to consider
what diseases he or she may be susceptible to, appearance may not be a good indicator of
genetic propensity, and there are many more factors that are probably more predictive of risk
than what apparent race a client might belong to. Similarly, a person’s eye shape, skin tone, or
hair texture does not tell very much about that person’s cultural practices or lifestyle, and not
even a great deal about his or her genes.
WESTERN BIOMEDICINE AS “CULTURED”
For many years, anthropologists (scientists who study culture) approached culture in a one-sided
way. That is, they studied their subjects, the Maori in New Zealand or the Maasai in Kenya, and
did not realize that they themselves were viewing the world from a certain cultural lens. The
truth is that no one is “normal” or views the world from a blank slate of neutrality. Every person
comes from a certain cultural background. However, people from some cultures, having enjoyed
more dominance in the world, may feel more “normal” because their culture is well reflected in
world and local media.
Similarly, and importantly, nurses also belong to a cultural subset. The common educational
experience, working conditions, such as shift work, and views of health and illness, based on a
belief in microbial theory, all contribute to a shared cultural perspective among nurses. In
addition, nurses who are from or were educated in the United States share much in common with
American national culture and are infused with “Western” values in addition to the values and
outlooks shared with medicine and allied health professions. All nurses should recognize and
acknowledge this special cultural perspective and the ways in which it influences nursing care of
clients.
The first imperative of cultural competence is to be competent in one’s own cultural
heritage. The nurse should ask himself or herself, “Where are my ancestors and current family
from? What traditions and health beliefs did I explicitly inherit and what subtler assumptions
were implicitly handed down to me? With what major cultural groups do I identify and which
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other ones have also affected my worldview?” Answering these questions can be extremely
difficult because the nature of culture is that we grow up with it without identifying it. It is, by
its nature, assumed. “Indeed, the hardest thing to know in a relative and comparative sense
might be one’s own culture: what anthropologists call the anthropological paradox…to critique
objectively the subjective nature of our own practices” (Napier et al., 2014, p. 1610).
After personal understanding come respect and appreciation for the values and behaviors of
others. Knowledge of cultural differences is essential if sensitivity and competence are to occur.
Only when self-awareness combines with insight about others can nurses and other healthcare
professionals demonstrate true sensitivity (Napier et al., 2014). This concept is important to keep
in mind as nurses approach their clients, especially those who come from cultures different from
their own. Culture is not a curiosity or a phenomenon that “exotic” clients have, unrelated to the
nurses themselves. Indeed, clients from different cultures can just as easily view their clinicians
as exotic. In reality, every clinical encounter is a cultural exchange.
ASPECTS OF CULTURE DIRECTLY AFFECTING
HEALTH AND HEALTHCARE
Attribution of Illness
Different cultural world views tend to reflect different ideas about what causes disease. Anglo-
American culture, for instance, emphasizes infection, genetics, and personal responsibility as
factors in disease and health. Illness is seen as something inside or inherent to an individual
(Brown & Closser, 2016). Other cultures may be “macroreligious,” meaning there is more
emphasis on divine influence on health and illness. Likewise, luck, fatalism, curses or piety may
be seen as mediating disease.
Evidence for Practice
A multinational group of scientists conducted an ethnography about birthing practices and
beliefs in Akwa Ibom, Nigeria (Mboho, Furber, & Waterman, 2013). They found that
traditional birth attendants were considered to have supernatural powers. Women often
preferred to labor in the homes of traditional birth attendants or even churches, rather than
in hospitals, because they felt that there they would be protected from malevolent witchcraft.
Additionally, if labor was particularly difficult, it was believed to be an indication of past sin,
and a confession of infidelity would be required before traditional birth attendants would
intervene.
Diet
What and how people eat vary tremendously among cultures, the understanding of which is
crucial to good nursing care. Perhaps a nurse needs to teach a client who is newly diagnosed
with diabetes or hyperlipidemia about dietary restrictions. The nurse will be much more
effective if he or she chooses examples that resonate with that particular client. For instance, a
new immigrant from India is more likely to eat rice and legumes than is a fourth-generation
Midwesterner whose staples are red meat and bread. A nurse teaching an anemic client about
iron-rich foods would want to use food examples that might appear in the client’s own diet.
Buddhism, Judaism, Hinduism, Islam, and other religions have dietary restrictions about various
meats, for instance, and nursing interventions are more successful if the nurse is sensitive to a
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client’s predilections. Often, various cultures and religions incorporate certain herbs, teas, and
honeys into their diets, and the potential medicinal effects should be noted (Fig. 10.1).
Evidence for Practice
Researchers were interested in finding out more about how Korean immigrants to the
United States viewed diabetes, in order to formulate effective strategies to prevent and treat
the disease in this group. They held focus groups in a Korean community center, asking
adult Korean Americans with type 2 diabetes about the disease. They found that diabetes
held a significant social stigma and that, before their own diagnoses, many participants had
believed that diabetes happened to “lazy” people and those who “cannot control”
themselves (Nam, Song, Park, & Song, 2013).
Communication
Verbal Communication
Culture also has a significant impact on communication, in terms of verbal as well as nonverbal
language, and style of communication. “Health communication has to be sensitive to the cultural
background of the message receiver to maximize its effectiveness…a ‘one-size-fits-all’
approach will not be sufficient” (Betsch & Böhm, 2016, p. 795). Clinical encounters should
always be held in a language in which the client is fluent, and if interpretation is necessary, a
professional interpreter should be used. Interpretation should never be conducted by family or
friends of a client, except in emergencies. Use of family or friends as interpreters subverts
privacy and confidentiality. Further, professional interpreters are not only fluent in both
languages and technical healthcare terms, they are also trained in issues of ethics and cultural
brokerage. “Cultural brokerage” means mediating an interaction between people of different
cultures. A broker may point out and/or explain cultural differences to the participants, in order
for the parties to understand each other better. A professional interpreter knows how and when
to carefully add context, as opposed to invisibly translating word for word.
FIGURE 10.1 A: Examples of herbs used for medicinal purposes, from Dominican botánica.
Clockwise, from bottom left: mastuerzo (vining nasturtium, spitfire, Tropaeolum majus)—used as
an antimicrobial, source of vitamin C, and to fight coughs and colds; ajenjo (wormwood)—used
against intestinal worms and for gallbladder maladies; tilo (linden)—used for anxiety, colds,
hypertension, and fevers; guatapanal (divi-divi)—used against infections, especially of the tonsils,
for hemorrhoids, and to dress sores. B: Medicinal teas for sale in a Brazilian store (Somerville,
MA). Boldo (Peumus boldus)—for stomach and digestive ailments; Laxante—laxative; Hepatico—
liver maladies. C: Honeys with medicinal supplements, Brazilian store (Somerville, MA).
Practice Point
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Lack of fluency in English implies nothing about a client’s level of education. Bilingual nurses
or those with professional interpreters can aim their teaching at the appropriate educational
level for each client, regardless of the client’s English language skills.
Nonverbal Communication
Nonverbal language also varies significantly with culture, and misinterpretation of body
language can lead to clinical misunderstandings. Some examples are as follows:
Eye contact: In many cultures (e.g., Native American, Chinese, Haitian), a younger client meeting the
gaze of a clinician is a sign of disrespect. However, in other cultures (e.g., white American or German),
eye contact is a necessary sign of respect. A clinician from those cultures might misinterpret lack of eye
contact as signifying inattention, depression, or noncompliance.
Personal space: Clients from cultures in which people normally stand close together (e.g., Italian, many
Latin American cultures) may feel that a nurse who sits or stands further away is cold and unfriendly.
However, people from a Nordic-influenced culture may be more comfortable with larger spaces between
people.
For clinical encounters with refugees and survivors of war or torture, the nurse should
conduct interviews gently and pleasantly so that it does not seem like an interrogation. The
client should feel in control, and the nurse should explain all procedures. Sometimes, medical
devices or procedures reminiscent of healthcare practices are used in torture (shock, acid,
excisions, sharps). Gynecologic procedures may invoke memories of rape or sexual assault,
especially if the refugee has not had similar gynecologic care in the past. Also, it may be
necessary to have interpretation needs more closely regulated by the client if he or she is a
refugee of violence or war. The Yugoslav and the Rwandan conflicts of the 1990s, for instance,
pitted people who spoke the same languages against each other, and a client may not feel safe
with certain groups of people who speak their own language.
Style of Communication
Cultures are often described as communicating either linearly or nonlinearly. People from
Western European and U.S. cultures generally favor direct narrations with a beginning, middle,
and end (in that order). American medical and nursing cultures may be among the most linear
and direct of all, with our emphasis on time efficiency and concise documentation. Many other
cultures use nonlinear narratives, communicating ideas in more subtle and, arguably, more
sophisticated ways. Interactions between clients from those cultures and U.S. acculturated care
providers can sometimes be jarring for the client and frustrating for the clinician.
Nilda might start explaining her symptoms with a story about her job back in Brazil, only
coming slowly around to how this relates to her current condition. Although this could feel
frustrating and ambiguous to Susan, Nilda is contextualizing her symptoms, albeit slowly,
while also providing quite a bit more detailed information about herself and her illness. If
Susan realizes that this style of communication is culturally valid and listens attentively,
she may get much more helpful information about her client.
If time constraints on the part of the nurse interfere with giving individuals the culturally
relevant time they need to explain their symptoms, what may be some creative options to
support this style and use the time of the nurse wisely?
Time Orientation
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Cross-cultural studies refer to “past-,” “present-,” and “future-oriented” cultures. Although this
may be somewhat simplistic, it is true that different cultures do view time differently. For
instance, people from highly industrialized and western cultures tend to plan ahead, be stricter in
their concept of time, plan, and behave in the present with an eye toward the future (Fulmer,
Crosby, & Gelfand, 2014). Some cultures, for instance some East Asian ones, focus more on the
past, consulting history to help make decisions now (Gao, 2016). Other cultures, such as
agricultural-based or less industrialized ones, focus more on the present, meaning that people
focus on the activity more than the clock (Fulmer et al., 2014).
Differences in how people view time can create a clash of expectations in clinical
encounters. For Anglo-American culture, for instance, time is thought of as linear and
perishable. This is especially true in the healthcare world, in which time is considered a scarce
commodity. In contrast, a Hispanic immigrant may view 10:00 am as a suggested time for a
clinic appointment and will arrive when other responsibilities are accomplished. If this patient
reports to the appointment at 11:00 am, an Anglo-American provider is likely to view this
negatively. It is also necessary to consider a client’s orientation to time when teaching about
medication dosing.
When Susan tells Nilda to “take your medication at the same time every day” she may
mean to take it when the clock says 8:00 AM every day, whereas Nilda may infer that
anytime between 5:00 and 11:00 AM is OK, because morning is the “same time every
day.”
Can you think of some creative ways to make Susan’s message clear to Nilda?
Evidence for Practice
Researchers in the Midwest United States examined homelessness using transcultural
nursing theory and found several ideas and strategies for nurses caring for homeless
patients (Woith, Kerber, Astroth, & Jenkins, 2017). They found strong themes of wanting to
be “listened to,” “taken seriously,” and treated with compassion, empathy, respect, and
fairness. Participants very often felt judged by care providers, and, interestingly, felt strongly
that they wanted nurses to show that they enjoyed their work.
Roles
Cultures around the world have different expectations of the roles of children, young adults, and
elderly adults; of men versus women; and of the role of a sick person. For instance, some
children speak for themselves; others are taught to remain silent. In some cultures, such as
American and British ones, a sick person makes decisions for him or herself; in others, such as
many Asian and Latin American ones, the family makes treatment decisions as a group. Some
cultures expect difficult prognoses and test results to be discussed with the family first and the
patient later, if at all, which explicitly conflicts with the U.S. values of confidentiality and
autonomy.
Practice Point
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No matter what culture your clients are from, you want to know what roles they fulfill at home
or in their families, because that will affect the significance of their illness and treatment in
their lives. For instance, many clients are the primary caregivers in their families, and an
illness may have ramifications in their families or communities, or in the patient’s own sense
of self, that might not be immediately apparent to you as the nurse or nursing student.
Religion
One central facet of culture is religion, and this also directly affects health, illness, and treatment
(Fig. 10.2). Some religions attribute disease to divine forces, for instance. Some cultures are
relatively fatalistic, affecting health behaviors (Brittain, Christy, & Rawl, 2016; Hayward,
Krause, Ironson, & Pargament, 2016). Insha’Allah (“if God wills”) is a common refrain for
many Muslims, although they may mean it more or less literally. Some congregations practice
faith healing and may reject secular treatment plans. Prayer and other religious practices can also
amicably complement nursing interventions. Prayers, especially for a client who believes in a
supportive god, may be advantageous to health (Simão, Caldeira, & de Carvalho, 2016). Indian
yoga and Chinese Tai Chi are popular health promotion practices that grew out of ancient
religious traditions.
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FIGURE 10.2 Religion and spirituality bear directly on health, illness, and treatment. A: Buddha
statuette, from Puerto Rican botánica (Boston, MA). B: Saints, Italian storefront (Somerville, MA).
C: Candelas from a Boston supermarket. Left to right: Siete Potencias Africanas—seven African
powers; black candle—against negative spirits; Yamaya Olocun—the ocean goddess Yamaya. D:
Spiritual remedial oils from a Caribbean botánica (Boston, MA). Left to right: Healing Curativo—
healing curative; La Milagrosa—the miracle; Oil San Lazaro—Saint Lazarus oil; Jinx Killer Contra
El Mal—jinx killer against evil.
All religions have traditions and rituals around death and dying, and although an individual
client and family may or may not desire traditional practices, culture has a tremendous impact
on end-of-life issues (Irish, Lundquist, & Nelsen, 2014). The nursing process has a history of
acknowledging and incorporating some spiritual interventions, although most nurses could learn
more about specific religious beliefs. In a nursing home that serves mostly Jewish clients, for
instance, the nurses learn the Jewish death ritual of washing the body after death so that they are
ready to do so if the family requests it. Buddhist monks, who come to chant for dying people,
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may join hospice nurses who serve Burmese clients, or a Hindu family may request that a
deceased patient be constantly attended until and after the body leaves the hospital.
If Nilda belongs to a Christian denomination that believes that God regulates health and
illness, she may be less likely to make changes in her own health behaviors, such as
getting a colposcopy and subsequent Pap smears.
Evidence for Practice
To investigate the beliefs about and uses of salt of Mexican and Central American farm
workers in California, researchers conducted individual interviews as well as focus groups.
They found that salt was ingested not only for gustatory purposes, but also because it is
believed to restore balance, prevent disequilibrium, and reduce vulnerability to disease.
Participants described beliefs illustrating hot/cold humoral balance dichotomy, a worldview
long identified in Latin America. Though the farm workers did view excess salt as
dangerous for the cardiovascular system, it was also thought to be beneficial for certain
symptoms, like dizziness, stomach ache, fever blisters, and insect bites (Barker, Guerra,
Gonzalez-Vargas, & Hoeft, 2017).
Folk Medicine
Herbs and other home remedies are used in every culture around the world (Fig. 10.3). However,
some folk healing traditions are currently more robust, whereas others were marginalized in the
20th century with the dominance of professional biomedicine. Clients may be self-prescribing or
going to folk practitioners such as Curandero(as), Santero(as), Shamans, or Ayurvedic
practitioners. There are myriads of folk remedies a client might be using, some of which can
have very powerful effects (Box 10.1). Just as nurses ask about over-the-counter medication use,
they should also inquire, respectfully, about what other preparations or nonpharmacologic
strategies their clients may be using to maintain or regain health.
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FIGURE 10.3 A: Supplements for sale in a Brazilian store (Somerville, MA). Óleo de Copa’ba—
antiinflammatory and antimicrobial; Castanha da India—astringent, analgesic, vasoconstrictor, and
antiinflammatory; Alcachofra com Beringela—for problems of the liver and gallbladder as well as
diabetes and high cholesterol; Cáscara Sagrada—laxative; Ginkgo Ginseng—(thought to have)
numerous beneficial effects; Ginkgo biloba—circulation and memory aid. B: Tiger balm from
Vietnamese store (Boston, MA). Tiger balm, applied topically, is used for muscle strains and
soreness as well as for respiratory congestion.
10.1 Examples of Folk Remedies and Healing Practices
Foods Herbs Methods
Chicken soup Comfrey Coining
Garlic Ginger Cupping
Ginger tea Ginseng Exorcism
Honey Lavender Holy candle burning
Lemon Rosemary Massage
Pepper St. John’s wort Protective jewelry
Evidence for Practice
Health researchers conducted a systematic review of the literature to investigate the
prevalence of medicinal herbs (or “botanicals”) by racial and/or ethnic minorities in the
United States (Gardiner et al., 2013). They reviewed 108 studies and found that African
Americans used herbs for health reasons at a rate of 17%, 30% of Hispanics and 30% of
Asians used botanicals, although regional and smaller studies tended to find higher rates of
use than did national or larger studies. Patients were using herbs for cancer, menopause,
diabetes, arthritis, and HIV-related diseases, and many groups rarely disclosed their herb
use to their healthcare providers.
CULTURAL HEALTH ASSESSMENT
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Individual Clinicians
There are several ways to approach cultural health assessment. Kleinman and Benson (2006)
recommend using Kleinman’s explanatory models. These researchers prefer using this
individualist method (a “mini ethnography”), tailored to each client, as opposed to the concept
of generalized cultural competence. Kleinman’s explanatory models are a set of questions that
explore the clients’ view of illness and treatment, including what they think caused it, how
serious they think it is, and what they fear about it. These questions can often uncover cultural
ideas that the provider would not otherwise have known. They may also show, of course, that
the client views his or her illness and treatment much the same way as the provider does. Others
suggest using a cultural genogram to explore and illustrate how a client’s heritage affects his or
her health perspectives. Whatever method is chosen, it is important to create an atmosphere that
encourages the client to tell his or her own story, with all its cultural nuances.
Healthcare Organizations
As mentioned above, it is also imperative that healthcare organizations such as hospitals and
visiting nurses agencies conduct ongoing cultural assessments of their service areas. Douglas
and team (2014, p. 113) contend that “healthcare organizations should provide the structure and
resources necessary to evaluate and meet the cultural and language needs of their diverse
clients.” The Office of Minority Health (2016) recommends that healthcare organizations
“[c]onduct regular assessments of community health assets and needs and use the results to plan
and implement services that respond to the cultural and linguistic diversity of populations in the
service area.”
Cultural competence requires ongoing self-assessment by both individual nurses and by
healthcare organizations (Jeffreys, 2015). “Understanding one’s own cultural values and beliefs
as well as the culture of others is essential if nursing care is to be not only appropriate but
deemed effective by the patient, family, and community. Self-awareness, as the initial step, is
the…process of identifying one’s own values and beliefs” (Douglas et al., 2014, p. 112).
KEY CONCEPTS
Culture is dynamic, shared, and learned.
“Cultural competence” is an attitude of openness to, respect for, and curiosity about different cultural values
and traditions, and ideally includes a broader critical analysis of power relations affecting health disparities.
For community health nurses, it necessitates familiarizing oneself with (and continuing to learn about in an
ongoing way) cultures that are represented in the communities they serve. In this way, “culture” could mean
a national culture (e.g., Vietnamese or Honduran culture), a religious culture (e.g., Jewish culture), the
culture of homelessness, a school’s culture, or that of any other subculture. Further, “inherent in culturally
competent nursing is the moral obligation to advocate for and protect the rights of the most vulnerable
through social justice” (Douglas et al., 2014).
Advocates for groups that have been sociopolitically marginalized promote “cultural safety,” the ideal of
considering cultural aspects of groups while working against assimilation and repression.
“Cultural humility” is an acknowledgment that everyone’s views are culturally influenced, that our own are
not inherently better than those of our clients, and that our clients can teach us.
Ethnocentrism can be defined as an assumption that everyone shares your cultural values, or an opinion
that your culture is superior to others.
Subcultures, or smaller subgroups of a larger society, have characteristics in common that may impact
health beliefs or practices.
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CRITICAL THINKING QUESTIONS
1. Do you think that the notion of cultural competence risks stereotyping? If so, how, and if not, why not?
2. How can nurses strive for cultural competence without pigeonholing or prejudging clients?
3. What are some of the main cultural groups in the region or city in which you live? What are some of the
smaller cultural groups in your city or region?
4. Think for a while about cultural practices and how they affect health or illness in your own family. They
may be difficult to identify as such at first, but they do exist. What ideas about illness prevention does your
family adhere to? What do you do when someone gets sick? What rituals does your family practice when
someone dies?
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WEB RESOURCES
Please visit thePoint for up-to-date web resources on this topic.
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http://dx.doi.org/10.12968/ajmw.2013.7.1.26
https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=2&lvlid=53
https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=2&lvlid=53
http://thepoint.lww.com/vitalsource/ebook/9781975111694
Chapter 11
Community Assessment
Rosanna F. DeMarco
For additional ancillary materials related to this chapter. please visit thePoint
Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed,
it is the only thing that ever has.
Margaret Mead
One of the signs of passing youth is the birth of a sense of fellowship with other human beings
as we take our place among them.
Virginia Woolf
I don’t even know what street Canada is on.
Al Capone
CHAPTER HIGHLIGHTS
Components of a community assessment
Defining a community
Frameworks of community assessment
Different approaches to community assessment
OBJECTIVES
Define and describe types of communities.
Describe the process of a community assessment.
Identify biologic, psychological, and sociocultural indicators of community health.
Conduct a systematic community assessment using a specific framework or a combination of
frameworks.
Explain how community health nurses can affect change within a community based on conclusions
drawn from assessment.
KEY TERMS
Asset-based assessment: Attention is directed to community strengths and resources as a
primary approach to community assessment.
Collaborative models: An approach to assessment that begins with planning that includes
representative parties of a population, including service organizations, corporations, and
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government officials.
Community: A group of people sharing common interests, needs, resources, and environment;
an interrelating and interacting group of people with shared needs and interests.
Community as partner: Within the process of community assessment, considering the expertise
of community dwellers as central to the task of understanding the health and well-being of the
community.
Developmental model: A retrospective, historical analysis of system parameters such as the
physical environment, education, safety and transportation, politics and government, health
and social services, communication, economics, and recreation in a community.
Epidemiologic model: A process used to assess a community using data collected from
descriptions and statistical relationships to evaluate the level of health and well-being within a
community to address identified healthcare needs.
Framework: A model or a road map that assists the direction toward a goal.
Functional health pattern: A systematic and deliberate approach to community assessment,
evaluating patterns of behaviors of community dwellers that occur sequentially across time.
Geopolitical community: Group of people who live within identified boundaries and governing
systems.
Phenomenologic community: Group of people who have interpersonal and intrapersonal
connections.
Windshield survey: Observation of a community while driving a car or riding public
transportation to collect data for a community assessment.
CASE STUDY
References to the case study are found throughout this chapter (look for the case study icon).
Readers should keep the case study in mind as they read the chapter.
In many circumstances, communities undertake in-depth assessments to understand what the
needs of the community may be and how members of the community who have ways of assisting
(health, business, religious, mental health, policing agencies, for example) can be part of a solution
for the needs that are uncovered. Some recent examples of this approach include (1) using a
participation of community dwellers to understand the health needs of the community (DeMarco &
Lanier, 2014); (2) healthcare providers evaluating barriers to colorectal cancer screening in high-
risk populations (Patel et al., 2012); and (3) community leaders against violence evaluating threat
assessment related to mental health indicators of potential violence in communities
(Interdisciplinary Group on Preventing School and Community Violence, 2013).
Similarly, a classic and seminal example of a detailed, step-by-step assessment undertaken
more than 10 years ago used a report card approach to assessment. The population of San Diego
County is the second largest in California and the fourth largest in the United States. The 2.7 million
residents represent diverse racial and ethnic backgrounds, and present many challenges to those
providing public health and social services. Many recent social changes, such as welfare reform,
managed care, and restructuring of healthcare services, have affected healthcare delivery in the
region. The San Diego County Board of Supervisors, along with members of the community,
wanted to know what impact these changes might have on the health and well-being of children
and families. To address this issue, the board ordered that a monitoring system be developed, and
the San Diego County Child and Family Health and Well-Being Report Card was created to monitor
community-level outcomes.
The San Diego Health and Human Services Agency (HHSA), which was in the process of
creating performance measures for its operations, partnered with Children’s Hospital and Health
Center in San Diego to develop the components of the community “report card.” There were five
key stages of development:
An evaluation of other community report cards
A literature review
An extensive community information–gathering process
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Reviews by technical and community advisory groups and a national consultant
Final approval from the board
The resulting report card reflected a broad definition of health and well-being. Data sources
ranged from local health, education, and law enforcement entities to state and federal agencies.
Included were 3 to 5 years of historical data, state and national comparative data, and, where
available, race/ethnicity data. Compilation of these comprehensive statistics created a population-
based, data-driven monitoring system (Simmes, Blaszcak, Kurtin, Bowen, & Ross, 2000).
In examining the San Diego case study, we can see that many people representing many
groups needed to be identified, be organized with a particular mission, and then be encouraged to
work together to establish key indicators that eventually became a report card for health in their
community. The information obtained can then be used to design health programs to address the
needs that were identified from the assessment data. Thus, the effort has a very practical and
important end.
INTRODUCTION
Understanding the interactions between people, health, and environment is a primary concern of
nursing practice. Community assessment has been called a critical process for the future which
can be used as a means for understanding these interactions, as well as for finding a way to
improve both the health status of at-risk populations, and outreach activities. Most recently, we
have seen the value of community assessment as a key contributor to advancing humanitarian
aid to communities in times of emergency need (Kirsch et al., 2012). In addition to providing
information that is essential to understanding the community, community assessment allows for
critical thinking about its strengths, weaknesses, assets, and deficits. Whenever nurses conduct
an assessment of a community, they examine biologic, psychological, and sociocultural
influences of the environment of a group of people who share specific characteristics. Initially,
the idea of conducting a community assessment might seem overwhelming. However,
knowledge gained from this endeavor provides valuable insight into the ways that people’s
health behaviors directly and indirectly influence the overall health and well-being in their
community.
A man of a right spirit is not a man of narrow and private views, but is greatly interested
and concerned for the good of the community to which he belongs, and particularly of the
city or village in which he resides, and for the true welfare of the society of which he is a
member. Edgar Allan Poe
The principles of epidemiology that are described in Chapter 6 provide a valuable
framework to begin community assessment. In addition, information about communities can be
expanded beyond the context of community health nursing and applied to other areas of nursing
practice. This chapter defines communities and identifies a variety of methods and tools that can
be used to assess communities. Community assessment is a comprehensive evaluation of the
status of a community. It identifies vulnerable populations, determines unmet needs, and
documents community resources. The information is then used to set goals, plan programs for
intervention, and evaluate outcomes. The approach that is used for community assessment
depends on the type and characteristics of community. Most frameworks described will be
feasible for the assessment of geopolitical communities, yet using some frameworks with
phenomenologic communities or specific aggregates can present challenges. When data are
collected, combinations of frameworks can be integrated if it makes sense. The methods of
community assessment that will be described are all useful but are not equally appropriate in all
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settings.
Community assessment is an integral function that supports all aspects of nursing practice.
The approaches to assessment that will be described provide a foundation to develop and
implement interventions that build and maintain healthy communities. Although community
assessment presents some challenges, the information yielded from the assessment is invaluable
in accomplishing health-related goals. Within the context of a greater healthcare team, and with
the community members as partners, a community assessment assists community health nurses
to maintain wellness and prevent illness in a population. An overview of the community
assessment process is found in Box 11.1.
DEFINING THE COMMUNITY AND ITS BOUNDARIES
Geopolitical Communities
The word community has several meanings that are relevant to the process of assessment.
Community can be a group of people who live in the same area, or can be the area in which they
live. Types of communities that commonly come to mind are municipalities or townships with
identifiable geographic or other designated boundaries. These communities may be cities, towns,
neighborhoods, or locales. A community that is described as a specific area, possessing
geographic boundaries and sharing the same governing structure, is often called a geopolitical
community.
11.1 How to Complete a Community Assessment
1. Establish a working group, including community members.
2. Define the composition of the community.
3. Identify the information that needs to be collected.
4. Identify an organizing framework for collecting data.
5. Use existing data to describe the community’s strengths and weakness, assets, and liabilities.
Collect demographic data from national, state, county, and city or town from the internet.
Collect local data from libraries, service organizations, municipal records, newspapers, phonebooks, and other
local sources.
6. Gather new data as necessary.
Community forums
Focus groups
Key informants
Participant observation
Surveys
7. Analyze the data, looking for similarities, differences, and inconsistencies.
8. Develop a profile of the community.
9. Identify vulnerable populations, unmet needs, resources, and unique characteristics.
10. Outline a plan for intervention based on findings.
11. Prepare a report and disseminate it to others.
12. Design, implement, and evaluate a project based on findings.
The group of people, or an aggregate as it is often called in the literature, consists of those
who live within the boundary of the geopolitical community. However, these borders are really
ambiguous. The aggregate could also include people who work within the community but who
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do not necessarily live there and could include those living close to community boundaries who
visit the communities to purchase goods or use facilities for nonwork activities.
Practice Point
Seek data about people who funnel in and out of the community. These are often overlooked
by students who are trying to understand who constitutes the community. Local town or city
employment data may direct you to companies that employ large numbers of people. For
example, most of the population from a metropolitan area may work for three or four large
corporations. By approaching these corporations, you can find data about employee
residence. Interviewing some employees may tell you where they are receiving healthcare. In
addition, you may identify these peoples’ concerns related to their health and well-being
while working for this particular corporation.
Evidence for Practice
A community health education center, which was affiliated with an academic institution,
recognized that a way to invest in the professional development of students was to develop
a project called “Creating Community Connections.” This project was designed to
characterize the evolving community landscape following Hurricane Katrina while providing
opportunities for students to engage in experiential learning. Students in the project gained
skills in program planning and community assessment, as well as in leadership and
communications. Twenty-three students worked on the project during its 2 years,
developing data collection tools, organizing and conducting key informant interviews,
facilitating focus groups and community forums, managing data, and summarizing project
findings for community presentations. Participation in this project allowed the students to
grow as public health leaders and researchers while gaining a greater appreciation for
community collaboration (Martin, Cunningham, & Magnus 2011).
Phenomenologic Communities
Another way to understand or describe a community is to think of it as a group of persons who
share common interests or beliefs. For example, neighbors interested in enhancing their property
to maintain the unique qualities of a neighborhood have a common interest but not necessarily a
formal organizational structure, whereas members of a church congregation do have a formal
structure and interests that bind them together. The term phenomenologic community (Maurer
& Smith, 2013) refers to members of a community with common interests who have
interpersonal and intrapersonal connections. Community members share common interests,
beliefs, or goals, and together they identify what activities, structures, and outcomes are
meaningful specifically to them. Phenomenologic communities frequently exist within a
geopolitical community, although their borders are often less well defined. Examples of
phenomenologic communities include groups such as the homeless or persons with disabilities.
Phenomenologic communities also include groups that are referred to as “communities of
solution” (Maurer & Smith, 2013). A community of solution is formed by an aggregate
specifically to address health concerns within a particular area. Communities of solution are not
only composed of persons from the area of need, but also include members of neighboring
communities who have a vested interest in a challenge the community faces. These communities
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can form in response to a health threat, such as contaminated water or industrial air pollution.
Other examples include certain political action groups or the formation of ad hoc task force
groups.
Underserved populations can also be regarded as a phenomenologic community. Social
connections between members are likely to be loose and not integrated, and without an
organized structure. Often, members of these aggregates are disenfranchised in many ways.
Also, members of these communities might be included within other larger groups. Examples
are undocumented immigrants, women living with HIV/AIDS, or teens at risk for being
involved in violent crimes.
I would never belong to a group that would accept someone like me as a member.
Groucho Marx
Student Reflection
One of the most rewarding things I have realized is that my dormitory floor could be a
community of solution. I was very concerned for a long time about the drinking behavior of
some of the students who lived around me. Three students got drunk beyond belief after a
hockey game one week and pulled a fire alarm in the dorms to be funny. All of them were
suspended. I talked with some of the students on the floor about this, and we began to plan
how we could try to address this situation. The first step involved obtaining accurate
information about the rate and severity of the drinking behavior on the floor, what was
causing the behavior, and how the behavior compared to that on other floors and to the
campus as a whole. It was really interesting to see how many of us banded together out of
concern and shared the same valued concerns about the well-being of our colleagues and
ourselves while attending school.
Evidence for Practice
The topic of this research report was the role of promotoras (health promoters in Spanish
language) briefly trained in depression care at community health centers. Community
assessment revealed the need to understand and develop interventions within the world of
those living in the community. The intervention focused on four contextual sources of
depression in underserved, low-income communities: underemployment, inadequate
housing, food insecurity, and violence. A multimethod design included quantitative and
ethnographic techniques to study predictors of depression. A community assessment was
completed to evaluate the intervention’s impact. On the basis of an intake interview, 120
patients with depression were randomly assigned to enhanced care plus the promotora
contextual intervention, or to enhanced care alone. All four contextual problems emerged as
strong predictors of depression (χ2, p < 0.05). Logistic regression revealed housing and
food insecurity as the most important predictors (odds ratios [ORs] both 2.40, p < 0.05).
Research that assessed both ethnic and geographic factors demonstrated a predominantly
positive response to the intervention among stakeholders, which included patients,
promotoras, primary care practitioners (PCPs), nonprofessional staff workers,
administrators, and community advisory board members (Waitzkin et al., 2011).
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Evidence for Practice
To understand differences and similarities in demographics, health, and healthcare access
in Chinese and Vietnamese adults, this study used a cross-sectional participatory
community health assessment in an urban city in Massachusetts. The researchers collected
qualitative data from community stakeholders to create a community health assessment tool
that addressed information on healthcare access, health status, behavioral health, and
chronic disease history and treatment. Areas of concern were issues of healthcare access
and poor health status, particularly among Chinese participants, and mental health
symptomology in both groups. These findings revealed important health concerns in two
Asian ethnic groups. Studies like this one are needed to better understand these concerns
and inform programs and policies to improve health outcomes in these Asian ethnic groups
and other groups (Tendulkar et al., 2012).
Societal, National, or International Communities
In its broadest context, community is used to describe society in general, or a nation. For
example, U.S. citizens have a common federal government and share ideals, whereas individual
communities within the country have different state and local governments and priorities in
relation to individual needs and interests. Recently, however, references have been made to the
international community or global community, which encompasses nations outside the United
States. Although the overall composition of these communities may differ, some have strikingly
similar characteristics, with shared interests and goals, including members’ health and safety. To
continue to advance the goals of health and safety, there must be a thorough way of
understanding each of the communities described, especially if nurses are to accurately target
ways to address goals for change. The first step in any plan to help a community is to assess the
community’s needs. These needs should be assessed in multiple ways.
Practice Point
Different navigational techniques have evolved over the ages in different cultures, but all
involve locating one’s position compared to known locations. Patterns are derived from
multiple perspectives. Triangulation, which comes from navigation methodology, is defined
as the process of planning, recording, and controlling the movement of a craft or vehicle from
one place to another. Specifically, triangulation involves finding coordinates and distance to a
point by calculating the length of one side of a triangle, using measurements of angles and
sides of the triangle formed by that point, and two other known reference points. In summary,
triangulation is the use of multiple methods or perspectives to collect and interpret data about
some phenomenon, and is used to come together for an accurate representation of reality
(Grove, Burns, & Gray, 2013). In other words, whenever you are trying to find an accurate
answer to a question you may have about a community, consider looking at the question in
different ways or finding more than one way to address it.
The amorphous nature of the community can create some challenges to the identification of
its members and to the assessment of their immediate needs. In thinking about the nursing
process, the initial phase of gathering data to develop a diagnosis, problem statement, or
challenge needs to be addressed. Establishing goals, objectives, and key interventions seems
formidable if nurses do not consider how they are defining the community that is to be assessed.
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What type of community was described in the case study about San Diego? Was more
than one type of community represented? If so, what kinds?
How did the working group define who was and who was not a member of the
community?
Student Reflection
I was scared to death when trying to figure out how to complete my community assessment
assignment. However, after a while I realized how exciting it was to feel like a private
investigator on a quest of trying to solve a problem (i.e., figuring out the truth about the
health of the community in which I was serving: elders in their homes). After I was able to
understand where to look for health information data on the internet and in city records,
what I really liked was interviewing members of the community about what they thought
about living in this city, what was good about it, and what was not so good. After a while, I
was able to take all sorts of information I had found and merge it together—like finding
hidden pieces of a jigsaw puzzle. What really helped me was organizing a plan of how to do
this, and what areas I wanted to investigate, into a priority list. It was a really cool
assignment.
How community health nurses conduct a community assessment varies depending on the
overall purpose of the assessment. Each setting, and those who are part of the setting, defines the
context within which a plan can be developed. The plan should include appropriate ways to
access and assess data, validate the findings develop a plan to address challenges, and include a
plan to evaluate interventions that are instituted.
Often, community assessments are related to a specific practice setting. Some examples of
an assessment in a school setting might include the following:
Learning about the outbreak of a specific communicable infectious disease (lice)
Learning about healthcare practices associated with a specific chronic disease (asthma)
Learning how best to protect children and adolescents, as well as their families, from the spread of
infectious disease in a school setting
Therefore, school health nurses must be familiar with information about the disease, such as
the organism that causes it, incubation periods, mode of transmission, symptoms, protective
measures, and necessary treatment.
Knowing these parameters helps these nurses devise a plan to assess the numbers of students
and family members who may have symptoms of a disease, and to identify those who are at risk
for acquiring the infection. The school nurse can then assist them in understanding how they can
care for themselves or access resources. The evidence that follows is an example of the
principles and processes of gathering health-related information related to obesity, and an
intervention to address this issue in children.
Evidence for Practice
This study evaluated a school nurse–delivered intervention in improving diet and activity,
and in reducing body mass index (BMI) among overweight and obese adolescents. Six high
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schools were randomly assigned to either a six-session, school nurse–delivered counseling
intervention that utilized cognitive–behavioral techniques or contact with a nurse who
provided information. Eighty-four overweight or obese adolescents in grades 9 through 11
completed behavioral and physiologic assessments at baseline and at 2- and 6-month
follow-ups. At 2 months, participants who received the counseling intervention ate breakfast
on more days per week (difference = 1.01 days; 95% CI: 0.11, 1.92) and had a lower intake
of total sugar (difference = −45.79 g; 95% CI: −88.34, −3.24) and added sugar (difference =
−51.35 g; 95% CI: −92.45, −10.26), compared to control participants. At 6 months, they
were more likely to drink soda once a day or less frequently (OR: 4.10; 95% CI: 1.19, 16.93)
and eat at fast food restaurants once a week or less frequently (OR: 4.62; 95% CI: 1.10,
23.76) compared to control participants. There were no significant differences in BMI,
activity, or caloric intake (Pbert et al., 2013).
Evidence for Practice
One program (Allegheny County Immunization Coalition, 2017) is a great example of school
nurses developing a coalition between clinician pharmacists, physicians, and students to
design a true collaborative solution to increasing uptake of immunizations in school-aged
children. School nurses caring for children learned five key lessons that are examples of
what these nurses need to assess when considering how to plan for the needs of these
children in their school community:
Establish strong links with clinicians. Immunization as primary prevention helps decrease
morbidity, but without ongoing follow-up and communication and coordination with clinicians
in the community, primary care becomes inconsistent.
Target students and parents who are most affected by decreased access to prevention
care. School nurses should assess their school community for those children who may be
at risk for not having immunizations addressed in a timely manner or who may have parents
who are unable or unwilling to address immunization needs.
Identify an appropriate mix of resources (videos, immunization schedules, web links, and
vaccine manufacturers’ information) which should include an immunization champion at the
school, appropriate school nurse staffing, and the involvement of parents.
Use a collaborative approach, which is critical. Collaboration in this sense means identifying
at risk children.
Support evaluating this combination of efforts by measuring outcomes.
This approach allows for adjustment and readjustment of interventions to make the
outcomes more successful over time.
Assessments made by community health nurses are often informal. They use the windshield
survey to learn about the neighborhoods in which their clients live. Many community health
providers use this method, but it has its limitations. It is a subjective process which nurses may
use to understand the community by viewing surroundings. It is a descriptive way of
understanding what appears to be the physical expression of the community as it is viewed on
foot or through the windshield of a car. Anderson and McFarlane (2015) suggest that a
community assessment can be accomplished this way by observing the level of economic
development through physical environment, educational systems, safety and transportation,
health and social services, communication, and recreation. Anderson and McFarlane refer to this
approach as “learning about the community on foot.”
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Practice Point
A windshield survey is a great way to get a subjective idea of what a community is like. When
you decide to either walk or ride through a community (keeping safety precautions in mind at
all times and being alert to the level of crime or danger), try to plan the experience by first
consulting a map. Get a sense of the physical boundaries that define the community, and
explore not only residential spaces, but also recreational open space and businesses. Look
at all the details and observe closely. Look at the quality of streets, bridges, types of house
materials (e.g., wood, brick), people, light, air quality, and stores, especially grocery stores.
Make the survey an adventure.
FRAMEWORKS FOR COMMUNITY ASSESSMENT
Community assessment is not unique to community or public health nursing practice.
Epidemiologists, genetic counselors, and social workers also conduct assessments to understand
which people are at risk of acquiring a specific illness, or to identify those who may need social
support as they experience a traumatic event. Understanding and appreciation for community
strengths, deficits, resources, and needs through community assessment is the objective that
community health nursing shares with other disciplines (Jackson et al., 2014; Piper, 2011;
Wessells, 2016).
There is recent criticism that community assessments have often emphasized what was
missing in communities to address health and safety, rather than looking at the strengths and
resources the community may have to address these issues (Piper, 2011).
In the examples presented, nurses followed identical underlying principles and processes to
gather health-related data about communities. The nurses developed a planned community
assessment to determine how people who share social or spatial relationships respond to internal
and/or external influences on health. Identifying patterns of response to these influences can
help planning interventions to preserve or improve the health of the community. However, it is
always difficult to know how to start and the best way to approach this process. Previously
defined frameworks are examples of successful ways to assess communities. They provide
direction for the assessment. The following frameworks serve as methods that can be used to
develop assessments. The approach to the assessment will require considerable organization and
a sequential plan.
Most nursing perspectives on community assessment incorporate concepts used in
epidemiologic models to identify areas that affect the health of communities. The scope of
nursing assessment also includes identification of communities’ assets and capacity to create and
implement changes from within the aggregate. There are two main reasons to conduct a
community assessment: (1) to gain information and clarify the need for change and (2) to
empower those responsible for implementing that change (Piper, 2011). The following section
includes several frameworks for community assessment that can be used individually or in
combination to identify key strengths and weakness in a community’s health and well-being.
Epidemiologic Approach to Community Assessment
Healthy People 2020, the broad-based collaborative effort among federal, state, territorial, and
private and nonprofit organizations, has established the leading health indicators and priorities
for action in the United States (Box 11.2). These 10 public health indicators are tracked,
measured, and reported regularly using epidemiologic methods and a wide variety of data-
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collection techniques. Although these objectives can be applied to the nation as a whole, or to
populations of a state, county, region, city, or town, it is the practical impact at the individual
and family level that is most important. For many reasons, communities vary in their ability to
reach targeted objectives. Therefore, investigating the community’s status in reaching these
objectives is a part of any community assessment.
Community report cards provide a snapshot of the overall health and well-being of a
community through the use of indicators or measurements of local social and health trends. Such
reports are used increasingly across the United States to communicate critical information
concerning local issues to community members, service groups, and policymakers. Developing a
community report card helps articulate the community’s desired goals—to establish means of
measuring the condition of the community in relation to what is desired, and to collect data to
measure progress toward goals. Members of the community and professional groups then decide
how to create programs to address needs, change the circumstances that exist, or maintain those
activities that have created a healthy community.
11.2 Leading Health Indicators: 10 High-Priority Public Health Issues in the
United States
Physical activity
Overweight and obesity
Tobacco use
Substance abuse
Responsible sexual behavior
Mental health
Injury and violence
Environmental quality
Immunization
Access to healthcare
Source: Healthy People 2020. From https://www.healthypeople.gov/2020/leading-health-indicators.
In developing the San Diego County community report card, indicators were developed to
assess the community. Technical, community, and scientific advisory groups were
established to firmly ground the development process in local technical and political
realities. More than 20 local data experts reviewed and helped refine a list of indicators
from secondary sources that would require no primary data collection. In addition, a
scientific advisory committee of eight local leaders from the fields of public health, social
work, pediatrics, and medicine provided scientific oversight throughout the development
process. These two committees reviewed the preliminary list of indicators and made
recommendations for refinement of five domains: economics, health, safety, education,
and access to services. Twenty-nine scientifically based or consensus-driven indicators
are listed according to their domain (Table 11.1).
What are the epidemiologic methods that have been used to develop the community
report card? Explain how these indicators relate to (1) describing the who, what, where,
and when and (2) the descriptions of person, place, and time that are necessary
components of a community report card (see Chapter 6).
TABLE 11.1 Community Report Card Indicators: San Diego County,
California
Economics
Average percentage unemployed
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https://www.healthypeople.gov/2020/leading-health-indicators
Percentage of children living in poverty
Rate of public assistance to children
Percentage of parents receiving public assistance who are working or involved in work-related activities
Rate at which children receive food stamps
Rate at which children are identified as homeless
Health
Infant mortality rate
Percentage of infants born with low birth weight
Rate of births to teenagers
Rate of youth suicides
Rate of hospitalization of children and youth for mental illness
Percentages of adolescent health risk behaviors: cigarette use, binge drinking, marijuana use
Access to Services
Number of subsidized child care spaces
Average wait time for publicly funded outpatient alcohol and drug treatment services for adolescents
Average wait time for publicly funded nonemergency outpatient mental health services for children and youth
Percentage of children who are adequately immunized
Percentage of children with health insurance
Safety
Rate of delinquency petitions filed in juvenile court
Rate of child and youth homicides
Rate of children living in out-of-home placement owing to abuse/neglect
Number of domestic violence reports
Rate of unintentional injuries and unintentional injury–related deaths
Rate at which children and youths are killed or injured in alcohol/drug-related motor vehicle crashes
Education
Annual percentage of students who drop out of high school
Percentage of students who attend school daily
School suspension rate
School expulsion rate
Principles of epidemiology are used throughout the development, planning, implementation,
and evaluation phases of the community assessment process. Epidemiologic methods can help
identify patterns of health and social inequity and can be used to determine trends in three ways:
(1) by describing the disease or disability, (2) by determining relationships that can predict
health or health disparities, and (3) by developing and testing interventions.
Describing the Disease or Disability
Before engaging in any data collection, the members of the community must be defined. It
should be very clear who is a member of the community and who is not. The organizing
framework and resulting plan of action should articulate what information needs to be collected
and how it will be obtained. Then, the working group can begin the assessment (see Box 11.1).
Existing (secondary) data can often be used to identify the community’s strengths and
weakness, to determine assets and liabilities, and to describe, along with available community
resources, the amount of disease/disability or health in a population. (Box 11.3 provides
resources for this data.) Finding data that identify the “who, what, where, and when” related to
disease, disability, and exemplars of health must then be systematically organized and analyzed.
Plans for collecting new (primary) data may include community forums, focus groups, key
informants, participant observation, and surveys. (For more information on developing and
using these methods, please refer to a nursing research textbook.)
By exploring data available on the internet, community health nurses can not only describe
trends but can also identify resources that address the trends and determine where gaps may
exist. The aggregate data from these resources include local demographics, such as death rates,
causes of death, marital status, gender, age, ethnicity, and density of the population. Depending
on the purpose of the community assessment, records in health facilities may be examined. This
information can provide a sense of what the people living or working in the community face in
terms of health problems, and can assess what happens to them over time in terms of follow-up
and wellness. The local chamber of commerce can help identify and describe the physical
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environment, health and social services, economy, transportation/safety, politics and
government, communication, education, and recreation facilities available to the population. In
addition, census tract data and the perceptions of informants (people who live in the community)
about how they experience the physical environment, health and social services, economy
transportation/safety, politics and government, communication, education, and recreation can all
be considered descriptive data relative to the community and the way it is experienced by those
who live in it. Census tract maps are often electronically produced and accessible by state, city,
county, and town. These maps include an option to click and zoom in on a specific area of
interest. Embedded in the maps is the capacity to access specific data related to the earlier
mentioned areas of interest.
11.3 Resources for Community Assessment
Administration for Children and Families
Agency for Healthcare Research and Quality
Alcoholics Anonymous
Alzheimer’s Association
American Association of Retired Persons
American Cancer Society
American Dental Association
American Diabetes Association
American Heart Association
American Public Health Association
American Red Cross
American School Health Association
Association for Children and Adults with Learning Disabilities
Asthma and Allergy Foundation
Centers for Disease Control and Prevention
Healthy People 2010
Indian Health Services
March of Dimes
National Alliance for the Mentally Ill
National Association for HealthCare
National Association of Rural Health Clinics
National Center for Farmworker Health
National Council of the Aging
National Hospice and Palliative Care Organization
National Kidney Foundation
National Wellness Institute
Occupational Safety and Health Administration
Planned Parenthood
Real Solutions to Gun Violence
Substance Abuse and Mental Health Administration
World Health Organization
Women’s Health (Health and Human Services)
Youth Risk Survey
For example, a Massachusetts census tract and statistical site (Massachusetts Public Health
Statistics, 2017) provides the opportunity to access specific city data, including health data: birth
rate, birth weight rate, teen birth rate, birth rate changes by year, lead poisoning rate, cancer
incidence, and presence of hospitals. As shown in Figure 11.1, the city of Brockton,
Massachusetts, a suburb of the major metropolitan city of Boston, demonstrates higher-than-
normal premature mortality. The color legend for Brockton indicates a higher-than-normal
premature mortality rate (>400 per 100,000 people), whereas the town of Avon, which borders
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Brockton, has a less-than-normal rate (<200 per 100,000 people). Similarly, in a more rural
setting in the United States, epidemiologic data may reveal high levels of farm machine
fatalities, but may also reveal equally high levels of family instability related to intrafamilial
conflict and mental health.
FIGURE 11.1 Premature mortality rate in Brockton, Massachusetts, and surrounding communities.
(Data from MassStats, 2013. Premature mortality rate: Brockton, Massachusetts. Retrieved from
http://www.caliper.com/Maptitude/MassStats/Map.aspx.)
Determining Relationships That Can Predict Health Status
Data can be analyzed in such a way that relationships that predict health status (i.e., illness) can
be defined. This information can be very helpful to community health nurses in planning
programs and/or interventions. In Chapter 7, measures of association are described as statistical
measures which are used to investigate the degree of relationship between events and/or
circumstance of illness/disability in cases and cohorts of the population. The idea of association
means that events or illness/disability may have a strong tendency to occur together rather than
just by chance. In more recent years, statistical information has been transferred graphically so
that assessment can be seen as concentrations on maps of cities, towns, counties, and states. The
relationships that occur can be vividly portrayed as an association.
CHOLESTEROL AND CARDIOVASCULAR DISEASE
It is known that there is a strong relationship between high levels of cholesterol and
cardiovascular disease. The Centers for Disease Control and Prevention (CDC) provide state-by-
state information about the rate of screening for cholesterol by providing the percentage of
individual responses (Table 11.2). These data, which can be gathered at the state, county, or city
level, help to assess the use of prevention in health behaviors of citizens. This helps target
education and support programs that can help members of populations obtain the information
they need to make decisions that promote health. In addition, it assists healthcare providers in
making sure that citizens have access to resources where reasonably inexpensive screening and
follow-up are available.
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http://www.caliper.com/Maptitude/MassStats/Map.aspx
Practice Point
Scrutinize your data carefully for similarities and differences. For example, using see Table
11.2, determine which state has the lowest percentage of cholesterol screening within the
past 5 years. If you were going to target an age group for a screening program in this state,
what age group would you choose? If you had to choose a state that did the best job of
cholesterol screening of its residents within the past 5 years, which state would you choose?
Using the list of San Diego community health indicators, suggest some relationships that
could be examined to develop further information about the population.
TABLE 11.2 Cholesterol Screening Among Adults by Selected State, 1997–
2005
Geographic Information Systems
Geographic information systems (GISs) are another example of drawing relationships and
associations that are important in community assessments. An example of a United States
Geological Survey (USGS, 2017) GIS map outlining water deficiencies (hydrologic drought) in
the United States is found in Figure 11.2, with noted visual comparisons of drought in Tucson,
Arizona, from 1942 to 1989. The GIS system takes the physical knowledge of drought change to
another level of comparison in a map system. GIS is a system of hardware and software used for
storage, retrieval, mapping, and analysis of geographic data. Spatial features are stored in a
coordinate system that refers to a particular place on the earth. Spatial data and associated
attributes can be layered together for mapping and analysis. GIS can be used for scientific
investigations, resource management, and development planning.
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FIGURE 11.2 United States Geological Survey (USGS, 2017) GIS map outlining water
deficiencies (hydrologic drought), with noted visual comparisons of drought in Tucson, Arizona,
from 1942 to 1989.
The use of GIS in health sciences is relatively new, but it appears to be expanding faster than
any other area of GIS application. Health scientists have long used geographic information
conceptually, but the availability of user-friendly GIS tools for community health research is
recent. The GIS tools assist in determining locations of disease incidence, characteristics of
surrounding environments, location of healthcare facilities, identification of the geographic
boundaries of the communities, and other essential community infrastructures (CDC, 2017)
Developing and Testing Interventions
Using both descriptive data and relational data, nurses can develop interventions that can
empower communities and effect change. These are then evaluated according to the results or
outcomes of the interventions. As in the case study, the report card’s indicators are now being
used as outcome measures for county health and human services programs.
Evidence for Practice
Children with attention-deficity/hyperactivity disorder (ADHD) often exhibit psychiatric
comorbidities, which may impact interventions because of how psychiatric comorbidities can
affect illness presentation, diagnosis, and treatment outcomes. Guidelines exist for dealing
with these complex cases but little is known about how comorbidities are being handled in
community pediatric settings. This study explored 319 medical charts of children presenting
at primary care community clinics for ADHD-related issues. Assessment and treatment
behaviors were identified and parents rated ADHD symptoms at the time of diagnosis and
at 3, 6, and 12 months. Fifty percent of the sample met screening criteria for a comorbid
mental health condition. It was concluded that children with ADHD and mental health
comorbidities, particularly internalizing disorders, exhibit less robust response to ADHD
medication and may require additional testing before starting medication and/or alternative
treatment approaches in community primary care (Al Ghriwati et al., 2017).
Community as Partner Framework
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Anderson and McFarlane (2015) use a wheel to represent a core surrounded by eight subsystems
(Fig. 11.3). The core represents people as central members of the community. The eight parts of
the community that interact with the various members of the community are physical
environment, health and social service, economy, transportation and safety, politics and
government, communication, education, and recreation. Anderson and McFarlane (2015) have
proposed that it is necessary to consider the history, demographics, ethnicity, and values and
beliefs of the entire community. “Flexible lines of defense” (buffer zones), “normal lines of
defense” (health), and “lines of resistance” (strengths) are identified and surround the wheel, as
well as separate each subsystem. These lines of defense represent a dynamic level of health after
stressors have impinged on the system and can be used as a systems approach by teams to
effectively assess a community. The word “partner” and particularly “community as partner”
is key, because it demonstrates the equity of the nurse’s relationship with the community.
The development of the San Diego Community Report Card used a partnership
approach. Members of the Child Well-Being Subcommittee, composed of 13 people from
diverse professional backgrounds, served as community ambassadors and provided
broad policy guidance. To gain the trust and support of the large, diverse San Diego
community, the project team solicited extensive feedback from more than 40 community
groups. They distributed an information packet and survey in Spanish, English, and
Vietnamese. After evaluating the input from the community, the list of indicators was
modified to reflect comments made during this process.
Functional Health Status Approach
Functional health patterns (FHPs) assessment (Gordon, 1994) is designed to be used for
individual, family, or community assessment. FHP assessment involves a systematic and
deliberate format. Gordon defines assessment as a form of evaluation. Pattern, according to
Gordon, represents “a configuration of behaviors that occur sequentially across time” (p. 70).
Understanding community patterns provides insight into how groups respond to problems and
take action.
Gordon includes questions that are applicable to community assessment for 11 FHPs (Box
11.4). Because the FHPs were designed for use with nursing diagnoses, clinicians are expected
to identify defining characteristics from each pattern and assign relevant diagnoses. Although
the FHPs are arranged in numerical order, the assessment format is intended to be used as a
guide. Questions for community assessment are open-ended, specifically to elicit responses that
provide depth and breadth to inquiries. Gordon acknowledged that because the community
encompasses a number of systems, completion of the assessment requires time.
Community and public health nurses will appreciate the format, which is adaptable for use in
most communities (Gordon, 1994). Assessment questions are not limited to informants’
responses but also include clinicians’ descriptions of the community. Novice nurses, especially
if they have some familiarity with FHP, might find the model easy to follow as they learn about
community assessment. The questions are clear and direct. The FHP community assessment also
calls on students to use a variety of means to collect data.
Using Box 11.4, identify five FHP assessments that would be helpful in developing the
San Diego Community Report Card.
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Developmental Models and Approaches
An effective way to assess a community can be a retrospective, historical approach; this is a
developmental model. Using system parameters, a community health nurse could travel back in
history through historical documents, data, figures, and images, and piece together the stages a
population or community has experienced. These system parameters can include the physical
environment, education, safety and transportation, politics and government, health and social
services, communication, economics, and recreation as segments of community life that are
shared between those that live and work in a community (see Fig. 11.3). This approach could
include gathering historical reports from interviews with community members who could
describe their experiences in their own words. Both historical informants and mined data (i.e.,
data that are examined through extensive and rigorous searches) can help describe the cultural
changes within a community or aggregate over time, and help to plan for the future. In this way,
developmental data are obtained, and then compared, to determine what variables may have
enhanced or detracted from development, and what resources were available at the time.
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359
FIGURE 11.3 Communities as interdependent systems.
11.4 Functional Health Patterns
I. Health Perception/Health Management Pattern:
1. History (community representatives)
a. In general, what is the health/wellness level of the population on a scale of 1 to 5, with 5 being
the highest level of health/wellness? Any major health problems?
b. Any strong cultural patterns influencing health practices?
c. People feel that they have access to health services?
d. Demand for any particular health services or prevention programs?
e. People feel that fire, police, safety programs are sufficient?
2. Examination (community records)
a. Morbidity, mortality, disability rates (by age group, if appropriate)
b. Accident rates (by district, if appropriate)
c. Current operating health facilities (types)
d. Ongoing health promotion/prevention programs; utilization rates
e. Ratio of health professionals to population
f. Laws regarding drinking age
g. Arrest statistics for drugs, drunk driving by age groups
II. Nutritional/Metabolic Pattern:
1. History (community representatives)
a. In general, do most people seem well nourished? Children? Elderly?
b. Food supplement programs? Food stamps: rate of use?
c. Foods at a reasonable cost in this area relative to income?
d. Stores accessible for most? “Meals on Wheels” available?
2. Examination
a. General appearance (nutritional appearance; teeth; clothing appropriate to climate)? Children?
Adults? Elderly?
b. Food purchases (observations of food store checkout counters)
c. “Junk” food machines in schools?
d. Specific nutritional risk factors: socioeconomic status (SES), culture, gender, and age
III. Elimination Pattern:
1. History (community representatives)
a. Major kinds of wastes (industrial, sewage, etc.)? Disposal systems? Recycling programs? Any
problems perceived by community?
b. Pest control (type, method, frequency)? Food service inspection (restaurants, street vendors)?
c. Water supply source and quality; testing services; water usage costs; drought restrictions?
d. Concern that community growth will exceed good water supply?
e. Heating/cooling costs manageable for most? Help programs?
f. Air pollution sources and control?
2. Examination
a. Communicable disease statistics
b. Air pollution statistics
IV. Activity—Exercise Pattern:
1. History (community representatives)
a. How do people find the transportation here? To work? To recreation? To healthcare?
b. People have/use community centers (seniors, others)? Recreation facilities for children? Adults?
Seniors?
c. Is housing adequate (availability, cost)? Public housing?
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2. Examination
a. Recreation/cultural programs
b. Aids for the disabled
c. Residential centers, nursing homes, and rehabilitation facilities relative to population needs
d. External maintenance of homes, yards, and apartment houses
e. General activity level
V. Sleep—Rest Pattern:
1. History (community representatives)
a. Generally quiet at night in most neighborhoods?
b. Usual business hours? Industries round the clock?
2. Examination
a. Activity-noise levels in business district? In residential districts?
VI. Cognitive—Perceptual Pattern:
1. History (community representatives)
a. Most groups speak English? Bilingual?
b. Educational level of population?
c. Schools seen as good/need improving? Adult education desired/available?
d. Types of problems that require community decisions? Decision-making process? What is the best
way to get things done/changed here?
2. Examination
a. School facilities (type and condition); dropout rate
VII. Self-Perception/Self-Concept Pattern:
1. History (community representatives)
a. Good community to live in? Going up in status, down, about the same?
b. Old community? Fairly new?
c. Any age group predominates?
d. Peoples’ moods in general: enjoying life, stressed, feeling “down?”
e. People generally have the kind of abilities needed in this community?
f. Community/neighborhood functions?
2. Examination
a. Racial, ethnic mix (if appropriate)
b. Socioeconomic level
c. General observations of mood
VIII. Role—Relationship Pattern:
1. History (community representatives)
a. People seem to get along well together here? Places where people tend to go to socialize?
b. Type of government? Do people feel they are heard by government? High/low participation in
meetings?
c. Enough work/jobs for everyone? Wages good/fair? Do people seem to like the kind of work
available (happy in their jobs/job stress)?
d. Any problems with riots, violence in the neighborhoods? Family violence? Problems with
child/spouse/elder abuse?
e. Get along with adjacent communities? Collaborate on any community projects?
f. Do neighbors seem to support each other?
2. Examination
a. Observation of interactions (generally or at specific meetings)
b. Statistics on employment, income/poverty
c. Divorce rate
IX. Sexuality—Reproductive Pattern:
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1. History (community representatives)
a. Average family size?
b. Do people feel there are any problems with pornography, prostitution? Other?
c. Do people want/support sex education in schools/community?
2. Examination
a. Family size and types of households
b. Male-to-female ratio
c. Average maternal age, maternal mortality rate, infant mortality rate
d. Teen pregnancy rate
e. Abortion rate
f. Sexual violence statistics
g. Laws/regulations regarding information on birth control
X. Coping—Stress Pattern:
1. History (community representative)
a. Any groups that seem to be under stress?
b. Need/availability of phone helplines? Support groups (health related, other)?
2. Examination
a. Delinquency, drug abuse, interpersonal violence, alcoholism, suicide, psychiatric illness statistics
b. Unemployment rate by race/ethnicity/sex
XI. Value—Belief Pattern:
1. History (community representative)
a. Community values: What seem to be the top four things that people living here see as important
in their lives (note health-related values, priorities)?
b. Do people tend to get involved in causes/local fund-raising campaigns?
c. Religious groups in community? Churches available?
d. Do people tend to tolerate/not tolerate differences/socially deviant behavior?
2. Examination
a. Zoning laws
b. Scan of community health department reports (goals, priorities)
c. Health budget relative to total budget
Source: Used with permission from Gordon, M. (1994). Nursing diagnosis: Process and application (3rd ed.). St. Louis, MO: Mosby.
One generation plants the trees; another gets the shade. Chinese proverb
In the San Diego County case, 3 to 5 years’ worth of historical data, as well as
comparisons with other areas that were geographically comparable, were used in the
development of the report card.
What data do you think would be particularly helpful in understanding the historical
movement of a community in this particular case, and what do you think would be the
strategies to obtain this information?
COMMUNITY ASSESSMENT ASSETS-BASED APPROACH
More than a decade ago, Ammerman and Parks (1998) observed that those who assess
communities often approach community assessment with a distinct bias toward traditional
deficit-based models. Despite good intentions, the focus of assessment even today is often on
numerous problems, grim health statistics, and widening gaps in services. In an effort to build
collaboration between a particular university and community, although it could be another
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institution in another area, an assets model can change the perspective on how one conducts an
assessment within a community. When attention is directed to community strengths and
resources, better relationships can be developed between all those working on the assessment,
especially when the community is part of the process. Working relationships are enhanced when
community members realize that the assessment process has the potential to be an empowering
experience; the strengths and positive aspects of the community are measured in conjunction
with what is needed or not actualized.
Use of the asset-based assessment model led to development of the community-based
public health initiative (CBPHI) for research, practice, and teaching (Ammerman & Parks,
1998). A key factor of the CBPHI is building coalitions and active partnerships with the
community during the assessment phase. Collaboration with community members shifts the
focus from dependency on experts to empowerment of all, working together toward a goal.
Using an assets model requires taking a different philosophic approach to the assessment
process. Interaction with the community is the primary approach.
Using the San Diego Community Report Card indicators as a guideline, create a list of
indicators for assessing the strengths and resources of the community.
Evidence for Practice
Historically, Gerberich, Stearns, and Dowd (1995) supported the idea that overemphasis on
statistics and other data resources could divert assessment attention away from
opportunities to know a community’s “personality.” To support a level of understanding, the
Community Assessment Instrument for Baccalaureate Learners (CAIBL) was developed,
which continues to be used today. Based on Benner’s model of skill acquisition, the CAIBL
was designed for the novice nurse. The overall purpose of the CAIBL is to allow students to
develop observation skills and learn to apply abstract concepts and principles of community
health nursing practice. The authors outlined the four-part instrument in detail. Part I of the
tool was used to identify and describe the community for assessment. Part II consisted of a
windshield assessment. Here, 14 categories for data collection were detailed: housing;
zoning; space use; boundaries; common areas; transportation; service centers; stores;
street scene; community growth; race, ethnicity and religion; politics; media; and
“community personality.” The students’ task in part III was to review documents and begin
to summarize data. Students gathered data by visiting agencies and interviewing key
informants. Students were encouraged to share data with other students during
postconference. Part IV is divided into three phases. First, students reviewed the 14
systems to decide whether each was an “important asset,” “problem or deficit,” or “no effect”
in relation to the community (p. 242). Next, to improve community health, students identified
goals at a health status, health structure and function, or process level. The final step in this
phase included students recommending nursing interventions for each goal on the basis of
community assets and resources.
Collaborative Model
A collaborative model of assessment is an integral function of community health nursing
practice. To develop the skill of collaboration, public health experts can work in partnership in a
community assessment model that emphasizes the interdisciplinary nature of the task (Campbell,
Whitcomb, Culver, & McClanahan, 2015). Assessment includes nurses as well as social workers
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in collaboration with community residents. Beyond interdisciplinary expert collaboration,
another approach used in community assessment is collaboration between experts and those with
health concerns. It is important to ensure that members of a population have an active voice in
identifying issues and in making decisions about what is needed. Engaging participants with a
“we can do it together” approach is more effective than using a “we/they” approach.
This process, however, has distinct drawbacks. This form of assessment is time-consuming,
and logistical, systematic approaches must be pre-established to maintain clarity in the process
for all those involved.
Evidence for Practice
Focus groups provide an effective means of incorporating the perspectives of “hidden”
populations in assessments of community health needs and assets. In the study reported by
Yoshida, Craypo, and Samuels (2011), researchers conducted a series of focus groups with
youth in specifically targeted segments of a community to develop a comprehensive picture
of community health. Despite differences in age, length of residence, and ethnicity, the
focus groups were remarkably similar regarding the issues raised. Leadership capacity was
facilitated through teamwork, community assessments, and policy work. Conclusions
included that youth gained leadership confidence while successfully advocating for
community-level change. Focus group findings have been used to initiate activities which
address identified community problems. Focus group participation has the added benefit of
increasing community members’ participation in other community endeavors.
KEY CONCEPTS
Community assessment includes examination of biologic, psychological, and sociocultural influences of the
environment that surrounds a specific group of people.
Community can be defined as follows:
Geopolitical, sharing geographic boundaries and governing structures
Phenomenologic, sharing common interests or beliefs
Communities of solution, formed by a group of people to address common interests, beliefs, or needs
A society, nation, or international or global communities
The epidemiologic approach to community assessment includes the following:
Describing the health of a population
Determining relationships that can predict health and illness
Developing and testing interventions to empower communities and affect change
The community as partner framework uses a systems approach with a focus on partnerships to affect
change.
The functional health status approach evaluates health patterns in the community.
The developmental approaches use a retrospective historical approach to understand cultural changes
over time to provide information for future initiatives.
The assets-based approach identifies community resources and strengths along with community needs.
The collaborative model involves assessment by an interdisciplinary term and members of the community.
The approach used depends on the type of community that is to be assessed. Combinations of frameworks
can often be used.
CRITICAL THINKING QUESTIONS
Use the following scenario when answering the six questions given below. Use a group format so that sharing
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can occur across and between students and faculty.
In conducting a community assessment targeting information about women of color at risk for or living with
HIV/AIDS, you gather key collaborative stakeholders together. You want to begin the process by engaging
everybody’s goodwill for the project. You start the process by having a 2-day retreat where you discuss and
educate everybody as to the parameters of this process. You need to consider many things before the retreat.
Please answer them as a way of preparing for the retreat by using a critical thinking approach that raises vital
questions, offers relevant information, develops well-reasoned conclusions, and fosters open-minded
communication by recognizing assumptions. Feel free to use information from websites, such as the Centers
of Disease Control and Prevention, which discusses GIS and mapping; the United States Census, which
includes expansive census tract data; and local city halls or areas where data are collected statewide
describing the community activities and statistics, as resources for answering these questions.
1. What does this assessment involve?
2. How do those in a partnership conduct a community assessment?
3. How can a community assessment engage families and community members?
4. What factors are involved in understanding community assets?
5. How should assessment information be used and by whom?
6. How can a partnership use assessment results to move from planning to action?
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Ammerman, A., & Parks, C. (1998). Preparing students for more effective community intervention: Assets
assessment. Family and Community Health, 21(1), 32–45.
Anderson, E. T., & McFarlane, J. (2015). Community a partner: Theory and practice in nursing (7th ed.).
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https://water.usgs.gov/ogw/drought/
Chapter 12
Care Management, Case
Management, and Home
Healthcare
Rosanna F. DeMarco
For additional ancillary materials related to this chapter. please visit thePoint
Without a sense of caring, there can be no sense of community.
Anthony J. D’Angelo
Care is the state in which something does matter; it is the source of human tenderness.
Rollo May
We can all make a difference in the lives of others in need, because it is the most simple of
gestures that make the most significant of differences.
Miya Yamanouchi
CHAPTER HIGHLIGHTS
Defining care management and case management
Situating case management as a key component to home visiting
Historical overview and definition of home care practice
Description of the home care provision of services
Examining types of home care agencies, services, and reimbursement
Exploring role and scope of home care nursing practice during a home visit
Identifying interprofessional roles in models of care delivery and use of telehealth
Describing types of chronic care conditions found in home care patients
Review of current healthcare reform and home healthcare delivery
OBJECTIVES
Identify the relationship between care and case management as a philosophical underpinning to the care
given by community health nurses in the home.
Define home care nursing practice.
Identify the role of the home care nurse as part of an interdisciplinary team.
Describe the key components of a home visit.
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http://thepoint.lww.com/vitalsource/ebook/9781975111694
Identify common care situations and interventions in home care.
KEY TERMS
Assisted living: A model of care for the elderly or disabled that includes services such as home
care to maintain the independence of patients.
Balanced Budget Act: The historical federal act of 1997 that made significant cuts in home care
budgets on the basis of the enactment of prospective reimbursement.
Care management: Coordination of a plan or process to bring health services together as a
common whole in a cost-effective way.
Case management: Development and coordination of care for a selected patient and family.
Family caregiver: A member of the patient’s family, as defined by the patient, who has voluntary
responsibility to assist with the care of a patient.
Homebound: A condition in whicha patient cannot leave his or her home without significant
effort.
Home healthcare: A provision of healthcare that occurs in the setting patients consider their
home.
Hospital-based agency: A home health agency that is not freestanding in the community, one of
many specialty services offered at a hospital setting.
Interprofessional collaboration: Sharing of evidence-based practice and skills by several
disciplines as an integration strategy with patients and families in homes and other healthcare
settings.
Intermittent care: Care that is not required continuously.
Managed care: A framework of fiscal management that emphasizes cost containment.
Medical home: A model of organization of primary care that includes care and case
management and home care.
Medical necessity: Home care service given by a home care agency is reasonable on the basis
of the status of the patient.
Official agency: A home health agency that exists at the bequest of local, state, or federal
legislation.
Parish nursing: A model of care for members of a faith community that can include wellness
care through home visiting.
Patient outcomes: Measurable objectives related to specific patient care interventions.
Plan of care: An agency-generated written document that is guided by a lengthy assessment of
patient and family needs.
Population health management: The aggregation of patient data across multiple health
information technology resources.
Proprietary agency: A home health agency that is motivated by a for-profit philosophy.
Reimbursement: The form of financial payment offered to home health agencies, among others,
for services rendered to patients and families.
Skilled care: The requirement for reimbursement of services in home care (specifically,
Medicare, but also Medicaid).
Skilled needs: Refer to the needs of the patient that are accomplished through the professional
abilities of a registered nurse or his or her supervised designee (e.g., a home health aide).
Telehealth: A form of electronic communication used to deliver healthcare information.
Voluntary agency: A home health agency that is motivated by a not-for-profit philosophy.
CASE STUDY
References to the case study are found throughout this chapter (look for the case study icon).
Readers should keep the case study in mind as they read the chapter.
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I
Eleanor is an 85-year-old woman who lost her husband a year ago. She never learned to drive, and
she was dependent on her husband. Now she must rely on her family, both functionally and
financially. Eleanor owns a single-family home, and with the support of local family members, she
has chosen to live alone there. She has savings of $20,000.
Eleanor is receiving Medicare benefits, including Medicare supplements for prescription drugs
at extra cost. On the advice of an internal medicine physician whom she trusts, she takes several
prescription drugs and sees a podiatrist. Her blood glucose level has been so high that she
requires insulin therapy. She has been unable to leave her home without much effort. A home care
nurse who came for two months helped find a homemaker and home health aide to provide
assistance with bathing, meals, and light housekeeping. (This is a state-funded project for the
elderly.)
Even with the help of her family and services, it is becoming less and less safe for Eleanor to
live at home alone, and she needs to have more home health aide care for her safety. She has
been told that to qualify for more services she would need to become eligible for Medicaid by
“spending down” the $20,000 to $2,000. However, before Eleanor could become eligible for
Medicaid services, she falls and is admitted to the local hospital with a hairline fracture in her upper
humerus.
ncreased longevity and improvements in the ability to care for people with chronic illness
have led to an enormous increase in healthcare needs for people older than 65 years, as well
as for younger people with chronic or life-threatening conditions. Even though 47 million
Americans have no health insurance, the United States spends more on healthcare than other
industrialized nations where all citizens are insured (California Health Care Foundation, 2018).
Despite the increasing quality of life seen in older people and others who are disabled in some
way, experts agree that excessive administrative costs, inflated prices, and inappropriate care are
some of the many complicated reasons healthcare costs so much in the United States (Elder Care
in the United States, 2014). These are the key demographic factors behind the need to address a
multigenerational complex of healthcare management, both globally and locally. Preventing
illness and promoting health has often been given a lower priority financially in the United
States, as described in Chapter 2. However, on an optimistic note, recent data do suggest that
there is (1) a decrease in the prevalence of chronic disability, (2) an earlier diagnosis and
treatment of disease, and (3) improved treatment of health problems (National Coalition on
Health Care [NCHC], 2013).
Health-related quality of life and well-being is a key objective of Healthy People 2020 (HP
2020, 2018). As such, this chapter emphasizes the need to create, develop, and continue to invest
in the evolution of an infrastructure that allows diverse populations to create the best place and
circumstances for them to stay well in terms of how they define relevant and sensitive “quality.”
The following unravels key components of the efforts being made across all three levels of
prevention to allow quality of life and well-being to be defined and addressed.
CARE MANAGEMENT
Care management is a term coined to define the evaluation of healthcare interventions,
including need and appropriateness of care, and the actions taken to attain effective and efficient
outcomes. The Utilization Review Accreditation Commission (URAC, 2018), an independent,
not-for-profit organization committed to promoting healthcare quality, identifies health
utilization management as a key component in the care of patients because of continued rising
medical costs. Care management and utilization management are often used as synonyms. In
many cases, advances in technology, including the use of predictive modeling and other methods
of data analysis, are creating opportunities for utilization management to be targeted to specific
disease management areas more precisely.
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In the case of Eleanor, care management or utilization management is the process by
which her physician’s office designates a nurse utilization manager to review patient
records along with her physician. Eleanor has Medicare coverage and has chosen to be
part of a health provider system that offers inpatient and outpatient care directly or by
referral. Her care is centralized by electronic record, so the utilization manager or care
manager can easily track use of services within the approved system. The tracking is
completed not just to keep statistical trends, but to understand the trends and costs
associated with them. Once the trends and costs are understood, ways to give quality
care at the best cost are offered to Eleanor. Care management and utilization
management will inevitably benefit her by helping caregivers anticipate her needs, like
home care, as more disability evolves from her advancing chronic comorbid conditions.
CASE MANAGEMENT
The Case Management Society of America (2018) defines case management as “an integrated
collaborative process of assessment, planning, facilitation and advocacy for options and services
to meet an individual’s health needs through communication and available resources to promote
quality cost-effective outcomes.” Advocacy in case management is significant, as is the case
with all levels of patient care across the lifespan, because it requires health professionals and
others to bring private needs to the level of public awareness. Advocacy is always moving the
needs of patients, families, and communities to a point of awareness that will advance change
and increase quality of a life and experience.
According to the URAC (2018), case management was first practiced by public health
service providers early in the last century. The concept has been integrated into other systems
over time and has become associated with the care of low-income patients and families who are
considered at risk. The chief motivation in this integration is the need for a healthcare
professional who advocates for the resources needed by patients. Care management is related to
case management; without case management, care management could not be successful. Thus,
case management can be considered a building block of care management.
Case management involves an intensive process called disease management. Disease
management is a system of coordinated healthcare interventions and communications for groups
of people with conditions in which patient self-care efforts are significant. Disease management
emphasizes prevention at the secondary and tertiary level using evidence-based practice
guidelines. Collaborative practice models are a key to the success of disease management
programs. These programs include physicians, nurses, and support-service providers, patient and
family, self-management education, process, and outcomes measurement, evaluation, and
management; there is a routine reporting/feedback loop (Disease Management Association of
America-The Care Continuum Alliance, 2018). Disease management often focuses on the care
of populations in the context of a continuum of care such as chronic illnesses like heart disease,
heart failure, diabetes, pulmonary disease, urinary incontinence, and asthma.
In disease or care continuum management programs, in addition to medications, there is
strong emphasis on the use of telephone coaching, internet resources, and intensive patient and
family teaching to advance self-care and adherence to wellness care. Recently, to help patients
and families manage their health problems in an effective and efficient manner, there has been
an effort to bundle disease states together in light of many comorbidity patterns.
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Eleanor’s care and case management takes the form of a home care nurse, who uses a
disease management approach to Eleanor’s diabetes, congestive heart failure (CHF), and
hypertension. This disease management approach involves these three conditions
because they are all interrelated.
Other examples of management approaches may not be disease oriented at all. For example,
case management programs may evolve uniquely for pregnancy or postpartum care (County
Health Rankings and Roadmaps, 2018).
Evidence for Practice
According to the County Health Rankings and Roadmaps (2018), case management for
pregnant or parenting teens provides a range of services that is “needs”-based.
Caseworkers provide support and counseling, assist in creating plans with specific goals
such as finishing high school, work to create support networks among a teen’s family,
friends, and partner, or connect teen parents to healthcare or social services. Case
management typically takes place in schools or other community locations, and may be
utilized into dropout prevention programs for teen mothers. Expected outcomes that have
been evaluated based on this type of intervention management include (1) reduced teen
pregnancy, (2) reduced rapid repeat pregnancies, (3) increased use of contraception, (4)
improved social networks, (5) increased academic achievement, and (6) increased
graduation rates. In particular, there is some evidence that intensive case management
(increased frequency of interventions over a shorter period of time) reduces repeat
pregnancies among black and Hispanic adolescent mothers while they participate in the
intervention (Tolma, 2014). A South Carolina-based study indicated that case management
programs may also strengthen support networks, improve academic outcomes, and
increase graduation rates among black teen mothers in rural areas. Research suggests that
programs to reduce repeat pregnancy among pregnant and parenting teens are more likely
to be effective when easy access to services, contraceptive education, home visiting, and
tailored messages are included and when programs are presented in individual rather than
group formats (Kan et al., 2012). For case management programs that include home visits,
more frequent visits appear to reduce repeat pregnancy more effectively than usual care
(Kan et al., 2012); frequent visits can also increase use of long-acting reversible
contraception (LARCs) (Kan et al., 2012).
To be a case or disease manager, one need not be a nurse. Although the American Nurses
Credentialing Center (2018) does certify nurses in this specialty, social workers and public
health experts may also serve in this role. The role is complex, and the many responsibilities
include addressing the direct and immediate needs of patients and families and achieving quality
improvement in the future (Box 12.1).
12.1 Case Managers’ Role
A case manager’s responsibilities include the following functions:
Advocacy and education—ensuring that the client has a representative who can speak up and represent their needs
for needed services and education
Clinical care coordination/facilitation—coordinating multiple aspects of care to ensure that the client progresses
Continuity/transition management—transitioning of the client to the appropriate level of care needed
Utilization/financial management—managing resource utilization and reimbursement for services
Performance and outcomes management—monitoring and, if needed, intervening to achieve desired goals and
outcomes for both the client and the hospital
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Psychosocial management—assessing and addressing psychosocial needs, including individual, familial, and
environmental
Research and practice development—identifying practice improvements and using evidence-based data to
influence needed practice changes
Source: Data from Kongstvedt, P. R. (2001). The managed healthcare handbook (4th ed.). New York: Aspen.
Care management and case management can be used across the continuum of health from
acute care to care within communities. One important area where practices of care management
and case management occur is in the home. The rest of this chapter is devoted to discussing
home healthcare.
HOME HEALTHCARE
People spend most of their time in their neighborhoods and communities to which they belong.
When they are ill and need care, they continue to spend most of their time in those same
neighborhoods and communities. Home care nurses are challenged in many ways in caring for
patients in their own homes. Home care nurses continue a historical legacy of autonomy,
creativity, connection, and talent in advancing nursing practice using research and professional
experience as their guides. If there is one thought that comes to mind when one says, “home
care,” it is the place where the fainthearted need not apply. Home care is a place where nurses
practice in the extremes of complexity. It takes a competent and knowledgeable professional to
make home care their professional “home.”
People facing an acute or chronic illness or a new health-related situation may be candidates
for home healthcare. This service involves caring for patients and their families wherever they
may call “home,” regardless of economic and class divisions. Home healthcare is part of a
continuum of care to which nurses contribute. It has evolved over time on the basis of three
distinct needs: (1) quality healthcare in places and spaces where people live most of their lives
(homes and communities), (2) continued development of ways to inform healthcare providers
what realities affect health promotion and prevention in the diverse, complex lives of people and
families, and (3) cost containment in the healthcare industry. The development of health
insurance, rising costs in healthcare in general, and medical and nursing specialization all have
played a part in the development of home healthcare as it is today.
History of Home Healthcare
In the United States, home healthcare began in the early 1800s. Key historical points are listed in
Box 12.2. The last historical event in this list, the establishment of Medicare, has set a pattern
for payment for home services for the next 40 years. The federal government and its fiscal
intermediaries at the state level established Medicare’s initial payment protocol. This protocol
involved fee-for-service (i.e., a set fee for a particular service) charges. Home health agencies
such as visiting nurse associations (VNAs) and other agencies established the cost for a
particular service and then billed Medicare for that service. Unfortunately, this payment
approach left Medicare and patients vulnerable to a blossoming industry where some home care
services fraudulently inflated costs and service billing frequency to increase profit margins
(National Center for Policy Analysis, 2013).
In the past 20 years, Medicare regulations have served as the basis for Medicaid programs,
as well as for other health insurance protocols for payment or reimbursement. In this context,
payment for healthcare costs was scrutinized because of its inflationary nature. As patients aged
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and became more seriously ill with chronic illnesses, the system of managed care was
introduced to encourage healthcare providers to hold costs down through the streamlining of
services (Kongstvedt, 2001). Managed care efforts included the idea of prospective
reimbursement. Prospective reimbursement is a system in which reimbursement rates are set for
a given period of time prior to the circumstances giving rise to actual reimbursement claims
(Prospective Reimbursement, 2008). In response to this payment approach, hospitals began to
reduce the stays of patients and more patients went home earlier and sicker than before. In a
continued effort to decrease costs in home health industry, in 1997, Congress passed the
Balanced Budget Act (DeMarco & O’Brien, 1999). Congress cut $16 billion in payments to the
home health industry over five years; that is, it slashed reimbursement rates. As a result, home
health agencies closed or began to merge because they could not keep up with the costs. In 1997,
there were 10,000 home care agencies. After the Balanced Budget Act of 1997, there were 7,000
such agencies (Magee, 2007). Agencies were forced to develop so-called care mixes, where the
incentive based on reimbursement encouraged them not to take care of the sickest or the most
costly “cases”—patients.
12.2 History of Home Healthcare
1800s—Large wave of immigration to the United States with poverty and poor health facing families and
professional caregivers
1859—William Rathbone, a wealthy Quaker philanthropist business man, with the help of Florence Nightingale,
sent trained nurses into the homes of the sick poor in Liverpool, England
1885—First Visiting Nurse Associations established in Buffalo (NY), Boston (MA), and Philadelphia (PA)
1893—Henry Street Settlement established by nurse Lillian Wald in New York City
1894—VNAs are established and grow rapidly
1909—Metropolitan Life Insurance Company offers homecare services as a benefit
1910—Columbia University offers the first university course in public health nursing
1929—Crash of the stock market occurs, and federal government allocates funds to help those in need of home
care
1940s—Hospitals interested in home care because of chronic illness rates
1966—Medicare established
Source: Data from Buler-Wilkerson, K. (2001). No place like home. Baltimore, MD: The Johns Hopkins University Press.
As the previous discussion indicates, many home care agencies depend on reimbursement
trends, and trends in payment for home care are beginning to change again. In 2003, the
Medicare Modernization and Improvement Act included a provision to eliminate what would
have been an inflation increase in home health rates (Centers for Medicare & Medicaid Services
[CMS], 2018). Medicare is exploring reimbursement based on performance (i.e., successful
outcomes) (Rosenthal & Frank, 2006). However, home care agencies continue to be needed for
the aging population of the United States because most people continue to want to be cared for
in their own homes, whether they are facing acute or chronic illness or death. The saying “there
is no place like home” is truly a reality.
Types of Agencies
Because of the variety of reimbursement mechanisms that have evolved over time in home
healthcare, many different forms of services have evolved based on levels of philanthropy;
profit-making needs; and federal, state, and city funding. There are four distinct types of home
healthcare agencies: private/voluntary (not-for-profit), hospital-based, proprietary (for-profit),
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and public (Medline Plus, 2013).
Private/Voluntary Agencies
Voluntary agencies are generally established as not-for-profit entities, although they operate
with the same fiscal objectives as “for-profit agencies.” The difference is that they are often
governed by a voluntary board of directors and community-based advisory boards that are
interested in fiscally sound, high-quality care for patients they decide will be their service
population. Any profit margin that is acquired is reinvested in the operations of the home
healthcare service. The advisory and legislative members of the boards direct the chief executive
and fiscal officers in how home healthcare should be offered to the service population. A good
example is a VNA.
Hospital-Based Agencies
Hospital-based agencies have developed within the past 25 years to save money and maintain
control of patient care costs. In addition, a key objective is to maintain levels of quality and
increase collaboration by establishing home healthcare services as part of a continuum of care
offered by the hospital. As a healthcare system, hospitals embraced an approach to care that
included prevention and health promotion through divisions that offer primary care, emergency
care, acute care, and chronic care in various onsite or offsite facilities. The home is one such
site. The principal idea was to establish plans of care that were congruent with a hospital system
philosophy. Hospital-based home healthcare agencies are governed by not only the same board
that governs the hospital but also an advisory board similar to that of a VNA; this helps match
their care initiatives to the realities of the population they serve. Depending on the hospital,
hospital-based agencies can be “for-profit” or “not-for-profit.”
An example of a home healthcare agency associated with a hospital is the Home Health Care
Department of Boston General Hospital. All Boston General Hospital patients who need skilled
nursing care at home are referred to the home healthcare department of the hospital and followed
over time. People that have been readmitted and others may also be referred to this group.
Eleanor receives all of her home care services, including skilled nursing, physical therapy,
and occupational therapy, through a hospital-based hospice program that is part of a
hospital system made up of five hospitals. The hospitals are owned by the Catholic
diocese of the city in which Eleanor lives.
Proprietary Agencies
Proprietary agencies are private agencies that plan to and want to make a profit. They can be
part of a local, national, or international chain of home healthcare agencies directed toward any
group of patients with particular healthcare problems or challenges. For example, an agency that
has as its goal the provision of home health aides and homemaking services to people in need of
personal care and housekeeping services will provide for profit trained home health aides and
homemakers to assist people and families with these needs. Their services are often paid for
privately by families, and any profit margin is used to benefit the owner of the agency or chain
of agencies.
Official Agencies
Official agencies are supported by public monies that often come from taxes. The public monies
can come from local, state, or federal governments. Essentially, citizens and legislators identify
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a need for home health services that are often part of a larger public health approach to certain
populations. For example, a county health department may be established with several goals and
objectives to promote the health of people in the area for which they are responsible. This may
include lead paint screening for children, tuberculosis treatment and follow-up, well-child
clinics, water-testing facilities, and a public home care agency. Generally, there is a mandate to
serve all people without exception. Thus, public home health programs often care for many
patients that may not be admitted to private, voluntary, or proprietary home health programs.
However, with the constant rise in public health problems such as obesity, diabetes, human
immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), low–birth-weight
births, and infant mortality, many public home health agencies are supported financially for the
care they give to citizens who may have little access to any other care.
Financing and Regulation of Home Care
Home healthcare services are reimbursed by local, state, and federal funds; private insurance;
and private individuals. Government funding for home healthcare includes Medicare (federal)
and Medicaid (state) (CMS, 2018) as well as monies from TRICARE (federal funds for military
personnel and their dependents) and the Veterans Administration (federal funds for those who
are currently serving or have served in the armed services of the United States [TRICARE,
2014]). Insurance companies that pay for home healthcare can be independent (e.g., State Farm
Insurance) or can be part of a health maintenance organization (HMO) or a case management
organization. Medicare, Medicaid, TRICARE, and Veterans Administration coverage is
generated from monies that citizens contribute to the state or federal government through taxes.
Insurance companies, HMOs, and case management organizations give coverage based on
monies that are paid directly to them in monthly or annual increments for the purpose of giving
home healthcare when and if they are needed. What is common in the latter type of insurance is
these organizations coordinate with home healthcare agencies from which the patients are able
to obtain care.
Home healthcare is regulated by the state and federal government. Insurance companies
generally align themselves with the regulations stipulated by these governments but may have
their own rules and regulations. Home health agencies are certified through a process in which
stipulated conditions must be present for the agency to give services to the public and receive
payment for those services. For example, Medicare has the following criteria for eligibility:
homebound, a plan of care, skilled needs, intermittent care needs, and necessity.
Homebound refers to a condition based upon how difficult it is for a patient to leave the
home. To leave home must require a taxing effort and must be related to maintaining health and
personal care. This may include attending a medical day care program where the patient would
receive medications and therapy while family members may be at work. It may also include only
leaving home when going to an appointment with a healthcare provider. There may be variations
in why a patient must leave home (church, a family birthday event, to buy a pair of shoes), but
the key stipulation is the taxing effort required to do this and the infrequency of the event.
Determining a patient’s homebound status is primarily a way reimbursement systems qualify the
severity level of an illness for which they will pay for services.
Eleanor manages to move from a chair in the kitchen to a chair in the living room and to
the bathroom with a walker. She requires great effort in ambulating with a walker. In the
past, if she had to leave the house, she used to need two people to descend eight steps.
Eventually, her family installed an exterior elevator lift to help her access a car to go to
physician appointments or family gatherings. By definition, she is homebound because of
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the taxing effort required to leave her home.
A plan of care is an agency-generated written document that is guided by a lengthy
assessment. The assessment that is currently used across the United States is called the Outcome
and Assessment Information Set (OASIS, 2018). This assessment tool represents items that help
home care professionals assess adult home care patients. The items in OASIS assessment
include sociodemographic, environmental, health, functional health, personal support data, and
the status of adult patients who are in a pre- or postnatal state. The OASIS data are reported to
the state where the home health agency exists to create a larger database that can be used for
state comparisons across the United States. The accuracy needed to complete this assessment is
critical because each assessment item becomes the standard from which patient outcomes are
measured. In addition, the OASIS data are used by Medicare to help determine how home
healthcare agencies are paid for their services (CMS, 2014).
Evidence for Practice
O’Connor and Davitt (2012) recognized that the OASIS is the patient-specific, standardized
assessment used in Medicare home healthcare to plan care, determine reimbursement, and
measure quality in home care settings. The authors studied the debate over the reliability
and validity of the OASIS as a research tool and outcome measure. They undertook a
systematic literature review of English-language articles and identified 12 studies published
in the last 10 years examining the validity and reliability of the OASIS. Empirical findings
indicated the validity and reliability of the OASIS range from low to moderate but vary
depending on the item studied. Limitations in the existing research include
nonrepresentative samples; inconsistencies in methods used, items tested, measurement,
and statistical procedures; and the changes to the OASIS itself over time. The
inconsistencies suggest that additional research is needed to confirm the value of the
OASIS for measuring patient outcomes, research, and quality improvement.
The home health nurse completes the assessment and establishes the functional needs of the
patient and the services required. What is important to understand is that, like many areas of
healthcare, home healthcare is progressing toward a system of reimbursement that will be based
not just on prospective reimbursement (diagnosis and presumed trajectory of care) but on
outcomes of care. Therefore, a plan of care based on an accurate assessment with identified
activities leading to outcomes will be critical to sustaining all types of home healthcare agencies
in the future.
Another very well-known system that assists healthcare providers in organizing clinical data
in the context of assessment is called the Omaha System (Omaha System, 2013). This model of
organizing data includes three relational components: a problem classification scheme (patient
assessment), an intervention scheme (care plans and services), and a problem rating scale of
outcomes (patient change/evaluation). The work on creating this model began in the 1970s by
the Visiting Nurse Association of Omaha, Nebraska, while adopting a problem-oriented
approach as a guide to practice and documentation and management (Omaha System, 2013).
The idea was conceived and developed so that an information system could be used that was
standardized (written or now computerized) based on an integrated, valid, reliable clinical
approach which was organized for patients who received services, and their specific needs. Over
10 years of nationally funded research yielded consensus on standardized language used in
patient assessment, care plans, and outcomes. This system currently meets Medicare/Medicaid,
Joint Commission, and Children’s Health Care Assistance Plan (CHAP) guidelines and
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regulations. It has been recognized by the American Nurses Association (ANA) since 1992 and
passed the Healthcare Information Technology Standards Panel (HITSP) Tier 2 selection criteria
for Use Cases in 2007. It is integrated into the National Library of Medicine’s Metathesaurus;
CINAHL; ABC Codes; NIDSEC; Logical Observation Identifiers, Names, and Codes (LOINC);
and SNOMED CT. It is registered (recognized) by Health Level Seven (HL7), and is congruent
with the reference terminology model for the International Organization for Standardization
(ISO). It is being mapped to the International Classification of Nursing Practice (ICNP) (Omaha
System, 2013). Current users are mostly in the United States and include home care, public
health, and school health practice settings, nurse-managed center staff, hospital-based and
managed care case managers, educators and students, occupational health nurses, faith
community staff, acute care and rehabilitation hospital/long-term care staff, researchers,
members of various disciplines, and computer software vendors (Omaha System, 2013). In each
instance, the focus of care is skilled needs provided by these professionals and directed to
patients, families, and communities. See Box 12.3 for domains, intervention schemes, and
outcome rating scales of the Omaha System.
12.3 Omaha System (Domains, Intervention Schemes, and Outcome Rating
Scale) (Omaha System, 2013)
Domains and Problems of the Problem Classification Scheme
Environmental domain: Material resources and physical surroundings both inside and outside the living
area, neighborhood, and broader community
Income
Sanitation
Residence
Neighborhood/workplace safety
Psychosocial domain: Patterns of behavior, emotion, communication, relationships, and development
Communication with community resources
Social contact
Role change
Interpersonal relationship
Spirituality
Grief
Mental health
Sexuality
Caretaking/parenting
Neglect
Abuse
Growth and development
Physiological domain: Functions and processes that maintain life
Hearing
Vision
Speech and language
Oral health
Cognition
Pain
Consciousness
Skin
Neuromusculoskeletal function
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Respiration
Circulation
Digestion–hydration
Bowel function
Urinary function
Reproductive function
Pregnancy
Postpartum
Communicable/infectious condition
Health-related behaviors domain: Patterns of activity that maintain or promote wellness, promote
recovery, and decrease the risk of disease
Nutrition
Sleep and rest patterns
Physical activity
Personal care
Substance use
Family planning
Healthcare supervision
Medication regimen
Intervention Categories
Teaching, guidance, and counseling: Activities designed to provide information and materials,
encourage action and responsibility for self-care and coping, and assist the
individual/family/community to make decisions and solve problems
Treatments and procedures: Technical activities such as wound care, specimen collection, resistive
exercises, and medication prescriptions that are designed to prevent, decrease, or alleviate signs and
symptoms of the individual/family/community
Case management: Activities such as coordination, advocacy, and referral that facilitate service
delivery, improve communication among health and human service providers, promote assertiveness,
and guide the individual/family/community toward use of appropriate resources
Surveillance: Activities such as detection, measurement, critical analysis, and monitoring intended to
identify the individual/family/community’s status in relation to a given condition or phenomenon
Targets
Anatomy/physiology
Anger management
Behavior modification
Bladder care
Bonding/attachment
Bowel care
Cardiac care
Caretaking/parenting skills
Cast care
Communication
Community outreach worker services
Continuity of care
Coping skills
Day care/respite
Dietary management
Discipline
Dressing change/wound care
Durable medical equipment use
Education
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Employment
End-of-life care
Environment
Exercises
Family planning care
Feeding procedures
Finances
Gait training
Genetics
Growth/development care
Home
Homemaking/housekeeping
Infection precautions
Interaction
Interpreter/translator services
Laboratory findings
Legal system
Medical/dental care
Medication action/side effects
Medication administration
Medication coordination/ordering
Medication prescription
Medication setup
Mobility/transfers
Nursing care
Nutritionist care
Occupational therapy care
Ostomy care
Other community resources
Paraprofessional/aide care
Personal hygiene
Physical therapy care
Positioning
Recreational therapy care
Relaxation/breathing techniques
Respiratory care
Respiratory therapy care
Rest/sleep
Safety
Screening procedures
Sickness/injury care
Signs/symptoms—mental/emotional
Signs/symptoms—physical
Skin care
Social work/counseling care
Specimen collection
Speech and language pathology care
Spiritual care
Stimulation/nurturance
Stress management
Substance use cessation
Supplies
Support group
Support system
Transportation
Wellness
Other
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Concepts and Ratings of the Problem Rating Scale for Outcomes
Skilled needs refer to the needs of the patient that are accomplished through the professional
abilities of registered nurses or their supervised designees (e.g., home health aides). This
includes skilled observation, assessment, teaching, management, and evaluation of a variety of
conditions and situations. Examples of skilled nursing needs versus nonskilled nursing needs are
presented in Table 12.1.
Eleanor has had several admissions for home care. Each admission stopped after a 60-
day period (required by Medicare guidelines), when her skilled care condition stabilized.
For example, one admission occurred after a hospitalization for CHF. When her weight,
breathing patterns, medication adherence, and blood pressure stabilized, she was
discharged to the care of her daughters, and the local elder services provided her with
home health aides to help with meals, bathing, and housekeeping needs.
Intermittent care refers to a situation in which skilled care is usually provided over several
hours during the day several days during the week for a specified time period. Medicare requires
the specified time period to be 60 days with appropriate renewals if skilled needs continue to
exist.
TABLE 12.1 Comparison of Skilled and Nonskilled Nursing Care
Skilled Nonskilled
Assessment of lungs and weight of a client diagnosed
with congestive heart failure
Changing a dry dressing
Teaching a newly diagnosed diabetic client how to fill
insulin syringes or use an insulin pen
Teaching the client’s significant other/spouse how to pay
healthcare bills
Management of care given to a client
postcerebrovascular accident by speech therapy,
physical therapy, and home health aide services
Managing care of a home health aide after all healthcare
skilled needs have been stabilized
Changing a complicated wet-to-dry dressing on a client’s
abdomen
Pouring medications in plastic labeled container
Monitoring the fluctuating blood pressure of an elderly
man who has just started taking antihypertensive
medication
Visiting the client to decrease loneliness
Medical necessity means that the service given by a home care agency is reasonable based
on the status of the patient. For example, it would be unreasonable to schedule daily visits to the
home of patients who have learned to use a glucometer to test their blood glucose levels
effectively. It would be reasonable to visit twice a week for two weeks to see if the patient is
conducting the blood glucose test correctly and accurately.
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Role and Scope of Home Health Practice
The ANA has provided nurses in home health practice with an official document called the
Scope and Standards of Home Health Nursing Practice (American Nurses Association, 2014). It
provides guidelines for nurses involved in home healthcare practice, including standards of care
and standards of professional practice. The standards of care include the key elements of the
nursing process:
1. Assessment by collecting data about home care patients
2. Diagnosis through the analysis of data
3. Outcome identification that helps home care nurses identify nurse-sensitive measures
4. Planning in the form of nurse-sensitive interventions directed to the identified outcomes
5. Implementation-identified, nurse-centered actions in collaboration with patients and families
6. Evaluation outcome accomplishment through nurse-sensitive interventions
Although this may sound familiar in view of the standards of care in many areas of the
continuum of nursing practice, Medicare, Medicaid, and private insurance agencies are moving
in the direction of using these standards of practice as reimbursement strategies for agencies
based on successful outcome management. Thus, fiscal rewards in the future may be related to
identifying nurse-sensitive outcomes as described in this process.
Standards of professional performance described in the ANA document are areas that home
care nurses must address in the context of their practice. They include the following:
Evaluating quality of care
Evaluating their performance in the agency or home care work in which they are involved, maintaining
current competency
Helping develop nursing students and other colleagues who aspire to become home care nurses, as well
as collaborating with others in the care of home care patients
Being ethical in their practice, as well as using evidence-based practice in their encounters with patients
and families
One of the most powerful professional performance standards, unique to home care because
of patient and family engagement in patients’ own world (their home), is the emphasis on
helping patients and families be consumers of healthcare. This may take the form of helping
patients and families receive information about their health conditions, health promotion, and
disease prevention, as well as the risks and benefits of receiving healthcare in the home.
Student Reflection
I absolutely loved my clinical rotation in home care. One of my patients was an older man. I
really liked traveling to his home and meeting him in his own living space. I could really
teach and apply principles of medical-surgical care by adapting them to his world. For
example, I needed to figure out where the cleanest and most optimal place for him to sit and
bend over to change a small dressing on his leg would be, and I managed to do this
successfully by observing the cleanest and safest place during the home visit. We together
decided that the first floor bathroom would work because he could sit on the elevated toilet,
reach the sink to wash his hands, and bend effectively without becoming hypotensive.
I have to admit that despite having a cell phone and easy access for help and advice,
when I was allowed to visit my patient without my instructor for the first time, I was nervous.
There is a lot of autonomy in this role, and many people say that before you take a job in
home care, you should have two years of hospital experience. If I really wanted to
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concentrate in home care, I would need to figure out how to be mentored as a new graduate
so my confidence would be supported by a system that would help me learn to think
critically while being a solitary practitioner of nursing care in the community.
Interprofessional Care
Home care, like many areas of healthcare, is made up of workgroups where interprofessional
collaboration occurs. Various members of the healthcare team, not just nurses, contribute their
expertise to patient management in the home. Generally, the following groups receive care from
home health agencies: adults with acute or chronic illnesses, older adults, mothers and
newborns, and children and their parents. Nurses are often the clinical leaders who manage the
necessary care. Often, this care is highly specialized and requires the expertise of other members
of the healthcare team. Often, physical therapists, occupational therapists, speech therapists,
recreational therapists, social workers, nutritionists, and home health aides assist the nurse in
meeting patient-centered outcomes. Home health aide assistants and home care nurses follow
through with delegated tasks that are legally appropriate in terms of the standards of practice
designated by the ANA and the local board of registration of nursing. Other members of the
home health team are members of different disciplines—professionals who have a special and
unique knowledge about an area of clinical science, such as physicians or nurse practitioners in
specific fields. It is not uncommon for clinicians on these teams to work together on particular
outcomes that benefit the patient and family as a whole (Lehning & Austin, 2011).
The challenge of interprofessional work and teams is to be able to work together in a
complementary way to help patients and families on the basis of their assessed needs. This is not
always easy because many members of various healthcare disciplines see only the unique
contribution they make as an isolated involvement with patients and families (Chatfield,
Christos, & McGregor, 2012). In reality, all healthcare professionals, regardless of discipline,
must work together and find common outcomes so that patients and families can achieve
wellness. For example, a woman diagnosed with a cerebrovascular accident may be a patient of
a home health agency. In this case, she may have speech difficulties and restricted use of her
upper and lower extremities. Together with coping with the loss of control, she also needs to
make healthier food choices directly related to the pre-existing condition that is thought to have
caused the “stroke” (hypertension). The nurse who makes the home visit would immediately
consult with a speech and language expert, physical therapist, occupational therapist, and a
nutritionist in conjunction with a physician as a team. The home care nurse, acting as a clinical
leader, would talk together formally at case conferences, or informally with a group of experts,
about the need to change or to maintain the plan of care to meet identified outcomes.
An example and extension of interprofessional collaboration with shared outcomes that
includes the use of home care services is the “medical home” model. This model of care
delivery has five components: (1) comprehensive care, (2) patient-centered care, (3)
coordination of care, (4) accessible services, and (5) quality and safety. According to Agency for
Healthcare Research and Quality (AHRQ) of the U.S. Department of Health and Human
Services (AHRQ, 2018 https://pcmh.ahrq.gov/page/defining-pcmh), comprehensive care refers
to the accountability of meeting each patient’s physical and mental health needs including
prevention and wellness, acute care, and chronic care. An interprofessional team of providers
that includes physicians, advanced practice nurses, physician assistants, home care nurses,
pharmacists, nutritionists, social workers, educators, and care coordinators work together to
build teams to link themselves and patients to providers and services in communities. Patient-
centered care means that the care is relationship-based. Partnership with patients and families to
learn to manage their care with consideration of their values and culture is central to the care
given. Coordinated care is an effort to organize care across services that can include home care,
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https://pcmh.ahrq.gov/page/defining-pcmh
hospitals, and other community services. The key skill for successful coordination is clear and
open communication. Accessible services refers to every effort to be responsive in terms of
timing (shorter waiting periods to see a care provider on the team), availability (24/7), and
responsive to the particular preference patients and families request. Quality and safety is a
comprehensive commitment to the use of evidence-based clinical care and decision-making with
attention to outcomes and the practice of population health management.
Population health management as defined as a component of a medical home is a system
within any model of delivery of care that creates a way to manage care comprehensively.
Population health management is focused on the analysis of data from patients that are
organized in a record where providers and researchers can make efforts to understand and
improve health and financial outcomes. Telehealth is an operational component of a population
health management approach that gathers data to contribute to the larger system or aggregate of
data to help nurses and other health professionals understand effectiveness and efficiencies of
care for the better. The following discusses at length telehealth and how it is used to advance
quality and safety.
Telehealth
Telehealth is a form of electronic communication used to deliver (1) acute care and specialty
consultations, (2) home telenursing, and (3) electronic referrals to specialists in expert health
facilities. According to Sewell (2016), telehealth as a form of informatics involves the use of
electronic or digital communications for transmitting healthcare information such as health
promotion, disease prevention, professional or lay education, diagnosis, or actual treatment to
people located at a different geographical areas. Telehealth relates to two kinds of approaches
that are applicable in home care. The first involves electronically stored information that can be
shared with others using technology, and the second involves a real interaction between a patient
and a healthcare provider. The latter telehealth approach is called real-time technology (Sewell,
2016), which can include the use of diagnostic instruments that can transmit images or sounds to
professionals in other areas. For example, an otoscope can be used in a patient’s home to send
images electronically to an otolaryngology expert for evaluation. In another instance, monitoring
devices can be installed in homes to record the blood pressure, pulse, and weight of a patient
who has been diagnosed with CHF. Telecommunication and informatics sent to home health
agencies allows interprofessional teams to enhance their responsiveness related to subtle
changes in patient’s conditions (Omboni, Gazzola, Carabelli, & Parati, 2013). The goal is for the
patients to be stable and well at home and for the home health system to have electronically
stored and shared information that be useful to others in the larger scope of healthcare practice
have information at their fingertips to help individuals, families, and communities.
Evidence for Practice
Antonicelli, Mazzanti, Abbatecola, and Parati (2010) undertook a research study addressing
the needs of the elderly diagnosed with CHF. Despite evidence showing that administration
of β-blockers (β-adrenoceptor antagonists) can improve the clinical status of CHF patients,
use of these agents in adequate dosages is not routine at home because of the possible
risk of bradyarrhythmia. Telecardiology has recently been investigated as a means of
constantly monitoring the heart rate of CHF patients in their homes, and may be a solution
to increase use of β-blockers (β-adrenoceptor antagonists) while decreasing the risk of
bradyarrhythmia. Antonicelli and colleagues assessed the impact of telemonitoring on
patients’ adherence to prescribed therapeutic regimens, particularly β-blockers, and
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whether use of home telemonitoring reduced mortality and rate of readmission to hospital in
elderly CHF patients compared with normal specialized CHF team care. A total of 57
patients with CHF (31 New York Heart Association [NYHA] class II, 23 NYHA class III, and
3 NYHA class IV), with a mean ± SD age of 78.2 ± 7.3 years, were randomized to a control
group who received standard care, or to a home telemonitoring (TM) group. Patients were
followed up over 12 months. Compared with the control group, the TM group had a
significant increase in the use of β-blockers, HMG-CoA reductase inhibitors (statins) and
aldosterone-receptor antagonists. A reduction in nitrate administration compared with
baseline was also seen in the TM group. The 12-month occurrence of the primary combined
endpoint of mortality and hospital readmission for CHF was significantly lower in the TM
group than in the control group (p < 0.01). This study showed that a home care model,
including telemonitoring of relevant clinical parameters, may provide useful support in the
management of patients with CHF.
Telehealth can also be used in other ways. Information that is stored electronically and
shared with others using electronic devices is another way home care providers can keep records
of patient and family progress, but it can also be a way to share patient education information
(Sewell, 2016). For example, slide presentations can be transferred to help patients and families
learn about an intervention that may help with their care or help them learn more about a chronic
illness and the usual care practices offered to help their situation. Other examples are programs
that allow downloadable information with dynamic pictures and multimedia effects to help
patients understand their illness, or transition to a new role (new mothers), or adjust to changes
in mobility (Sewell, 2016).
Home Care Models
Assisted Living
Long-term supportive services have evolved and currently include assisted living and continuing
care communities, as well as nursing homes.
Assisted living is a type of community-based long-term care that combines quasi-
independent living with the availability of nursing care onsite and through home care visits
(CDC Long Term Care Services, 2018). It generally is a level of care for people who cannot live
on their own, but are not yet ready for a nursing home. This type of living arrangement is
different from living independently in one’s own apartment, such as living in a senior living
facility, in that many activities are provided communally (e.g., eating, recreation). There is an
organized effort to create a “caring community” where residents are supervised and help is
available for day-to-day living tasks. Many older community dwellers find assisted living or
continuing care communities to be places where gradual changes in physical, cognitive, and
emotional abilities can be addressed with centralized services. In many cases, this choice is
made on the basis of financial ability to support such an option. Many people may want to stay
in their own homes as a way to protect long-term investments financially and emotionally.
Eleanor does not want to leave her home. She is willing to “spend down” her $20,000 in
the bank to become eligible for Medicaid so that she can receive more services in her
home and not have to move to an assisted living or retirement community. But this
decision to live alone, despite having family nearby, puts her in jeopardy for falls and
other possible emergencies. The decision is an autonomous one because she has no
cognitive deficits. Once she was “admitted” to home care for a skilled need, a social
worker came to visit her and tried to convince her to think about a safer way to live, but
she adamantly refused.
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Home health nurses see many patients in assisted living communities. The care they give is
congruent with the standards of care described previously, but often the other members of the
assisted living community become the patient’s “family”—and rightfully so. Retirement
community dwellers consistently live an ethic of caring for each other and are involved with
each other’s care. Interdisciplinary teams from home care agencies have developed, with great
success, extensive resources to support community elders in assisted living units (Flatt, Agimi,
& Albert, 2012). There is a growing belief that not only do patients (particularly elders
experience chronic care issues), families, and communities benefit from the contributions of the
many healthcare professionals (physicians, nurses, midwives, dietitians, pharmacists, podiatrists,
mental health and addiction professionals, physiotherapists occupational therapists, and
chiropractors among others), but these professions themselves benefit in the context of case and
care management. Interdisciplinary collaboration improves patient care and outcomes, access to
care, recruitment and retention of health providers, and improved satisfaction among patients
and health providers. Family health teams are evolving in effectively providing comprehensive
primary healthcare as well as long-term care for elders for improved health-related quality of life
(Zubritsky et al., 2012). The opportunity to be part of an interdisciplinary team can expand the
scope of services by allowing teams to evolve with unique cultures and skill sets.
The patient-centered medical home (PCMH) is an evolving model that improves access to
care by increasing coordination between patients, families, and their interdisciplinary team.
Emerging data show that an integrated approach from a professional team to care of the whole
person improves management of chronic illnesses wherever the patient lives (National
Committee for Quality Assurance, 2018).
Evidence for Practice
Ivery and Akstein-Kahan (2010) used a collaborative health model to hypothesize that
health management in conjunction with environmental determinants have a different impact
on people at different ages. These researchers refer to retirement or assisted living
communities as naturally occurring retirement communities (NORCs). Health benefits to
living within NORCs have been observed and likely vary depending on where the specific
NORC exists on the healthy NORC spectrum. Some NORC environments are healthier than
others for seniors. Health benefits within healthy NORCs are higher where physical and
social environments facilitate greater activity and promote feelings of well-being. Compared
with the provision of additional medical or social services, healthy NORCs are a low-cost,
community-level approach to facilitating healthy aging. Municipal governments should
pursue policies that stimulate and support the development of healthy NORCs.
Home Visits to the Homeless
The thought of making a home visit to a person who may not have a home seems
counterintuitive, but home care nurses do visit many homeless people (Pijl-Zieber & Kalischuk,
2011). There are unique challenges related to timing, location, and clean conditions in making a
visit and providing care to someone who is homeless, but it is possible and quite rewarding.
Many facilities provide shelter to homeless patients, including shelters devoted to post-
hospitalization care, until the patients are strong enough to return to their usual way of surviving
in the community. These shelters may be where the home visit occurs. “Home” care for stasis
ulcer care or follow-up related to tuberculosis or HIV is not unusual. There are also groups of
interprofessional caregivers who make visits to patients throughout the streets of the community,
especially at times when many homeless people are at great risk for injury and may need care.
This includes during very cold or hot weather, natural disasters, and during unstable conditions
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related to violence in communities. The comorbidities that are often present pose challenges
(National Health Care for the Homeless Council, 2012). Many homeless people have two or
more medical and/or surgical conditions, along with mental health problems or addiction
histories, including smoking (Okuyemi et al., 2013). For example, people may have mental
health problems as well as alcoholism and other addictions. Special skills are required to
understand how to assist these people while trying to obtain affordable and safe housing for
them.
Other underserved adults and older adults, including uninsured, underinsured, and racially
and ethnically diverse populations, are being treated in hospitals, or are receiving extended care
in long-term care facilities because they face serious, chronic illness that require palliative care.
Many clinical management issues are pertinent to caring for seriously ill patients and their
families, including the need to integrate Healthy People 2020 objectives, such as those that
specifically address the epidemic of HIV, cancer, kidney disease, diabetes, chronic and disabling
health conditions, respiratory illness, heart disease and stroke, dementia, drug safety, mental
health, nutrition, and preventive services. Home care nurses who specialize in the area of
palliative care may visit these areas specifically because they offer the patient and staff expertise
in comfort care as a patient’s condition deteriorates. Hospice home care is one example of a
“home visit” made to facilities that care for the serious and chronically ill who are choosing to
stop all curative interventions. Hospice home care is discussed in more detail in Chapter 23.
Parish/Faith Community Nursing
According to Carson and Koenig (2011), parish nursing is an approach to holistic care for
patients and families in the community. The seminal work of Westberg (1999) identified seven
key roles of the parish or faith community nurse: (1) health educator, (2) personal health
counselor, (3) referral agent, (4) coordinator of volunteers, (5) developer of supportive groups,
(6) integrator of faith and health, and (7) health advocate. Faith community nursing can be
delivered in several ways in communities. One aspect of faith community nursing is that of
home visiting. The home visits are focused on care given in the context of the seven roles
identified by Westberg (1999) and are often negotiated with a faith leader in a community
parish, congregation, or synagogue. In many cases, these roles are not reimbursed by insurance,
but serve as ways to coordinate care to families as needed.
Tis not enough to help the feeble up, but to support them after. William Shakespeare
The Home Visit
There are five phases to a home visit: (1) initiating the visit, (2) preparation, (3) the actual visit,
(4) termination of the visit, and (5) post-visit planning. In the context of each of these phases,
attention must be paid to safety for the nurse as well as for the patient.
Initiating the Visit
Community health nurses initiate home visits for a variety of reasons. Many home care agencies
receive referrals from physicians or their designees (discharge planners from other healthcare
institutions). Referrals can be sent to home health agencies at any time (24/7). Generally, home
care agencies make sure that an initial visit is made within 24 hours after receiving a referral.
The patient’s situation must satisfy the reimbursement criteria mentioned earlier if Medicare
funding is to be used. Often, these conditions are validated during the first home visit, and plans
or alternatives are discussed if these are not met. When receiving a referral, it is particularly
important to make sure that the orders and directions for care are clear and accurate. If
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necessary, a clarifying phone call should be made prior to the visit to the person who has
referred the patient to the agency.
Preparation
Documentation is critical. All appropriate paperwork required for the assessment of the patient
and family must be available in electronic format if the nurse plans to use a laptop computer for
charting, or as hard copy.
EQUIPMENT
The home care nurse must bring supplies and equipment that may be needed for the visit,
depending on the patient’s diagnosis and specific skilled need. Examples include sterile or clean
dressings, urinary catheters, a walker, sterile saline solution, and distilled water, as well as
antimicrobial agents and paper towels that can be used for handwashing. A home care nurse
does not use patient sink areas to wash his or her hands in order to decrease the chance of cross-
contamination. Many nurses use alcohol-based cleansers as a reasonable and aseptic way to
cleanse their hands in home situations. In addition, the nurse must keep equipment that is often
used and may be needed unexpectedly (e.g., dressings, sterile solutions if weather permitting,
catheters) in his or her vehicle. These articles should be secured in the trunk or hatch of the car
so that they are not visible; this decreases the potential for theft and damage to the vehicle used
for the home visit.
DIRECTIONS AND VISIT VERIFICATION SYSTEMS
Getting directions for the home visit is very important. Portable or vehicle-installed global
positioning systems (GPSs) are available, which work via a satellite, or generic maps or hard
copy maps in areas where there is little or poor connectivity can help home care nurses locate
patients. However, becoming familiar with the directions of routes (north, south, east, west),
using landmarks, and making sure that unusual locations are explained before one leaves for a
visit are important. More sophisticated systems are evolving currently in the form of apps. These
include electronic visit verification tracking the type of service once it occurs. The term
“Electronic Visit Verification” with respect to personal care services or home healthcare services
is a system under which visits conducted as part of such services are electronically verified with
respect to type of service, patient receiving the service, as well as date, time, delivery and
provider giving the service (my Geo Tracking, 2018). Geofences also known as geozones can
predefine areas on a map and assist with finding patients’ homes in communities and verifying a
visit that has been made to decrease fraudulence (my Geo Tracking, 2018).
PERSONAL SAFETY
Safety prevention for home care nurses is part of preparing for a home visit. Many issues need to
be considered. Some key advice is given in Box 12.4. Home care nurses must think about
questions such as, “When and where will I go to the bathroom? When and where will I eat?
What will I do if I get lost? What will I do if I am involved in an automobile accident?”
Generally, home care nurses locate public restrooms in the community where they can stop for a
bathroom break safely. Stopping in the community for eating breaks is also a decision that
requires familiarity and safety as part of a process during the average work day, although many
nurses bring their own break food from home. In both cases, this not only allows the nurse
privacy but also does not expose them to conditions where they could contaminate patients and
their families and vice versa. Carrying a functioning cell phone and having a list of emergency
numbers to call is critical. A cell phone can also help if directions are lost or if an accident
occurs.
12.4 Safety Tips for Home Care Nurses
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Be alert and aware of your surroundings.
Act like you know where you are going.
Do not let your guard down.
Trust your gut; if you feel unsafe, leave the area.
Go to high-risk areas early in the day.
Carry a whistle.
Keep car doors locked at all times.
Vary your parking spot or route.
Keep your keys in your hand en route to and from your car.
Dress comfortably and conservatively, and wear comfortable and sturdy shoes.
Make connections in the community.
Do not carry large amounts of cash or valuables.
The In-Home Visit
The actual home visit includes introducing home care services to the patient and family, as well
as the process of obtaining help from the home care agency when a planned home visit is not
occurring. Details are given orally and in writing about when, whom, and how to call in an
emergency or nonemergency. It also includes the application of the standards of care for home
care practice, which includes the use of the nursing process with defined initial outcomes. The
key component of the first in-home visit is assessment. The home care nurse is a guest in the
patient’s home, and must obtain the patient’s permission and ask for the patient’s guidance about
how to carry out the initial assessment in the context of the home. It is necessary to carry out an
overall assessment of the patient’s and family’s strengths, weaknesses, and challenges. In
addition, it is also essential to assess home safety risks—medication errors, falls, and abuse and
neglect.
ASSESSING FOR RISK OF MEDICATION ERRORS
The risk of errors associated with medications is inherently high. Medications may be taken
incorrectly (wrong medication, wrong route, wrong dose) and may have adverse effects or
interactions. These negative side effects include hypotension/bradycardia/syncope, dizziness,
ataxia, adverse bleeding, confusion/sedation, and urinary urgency (Romagnoli, Handler, Ligons,
& Hochheiser, 2013). Taking the wrong medication/wrong dose/wrong route can occur because
of errors in prescribing, errors in transcribing during the referral phase of the home care visit
process, and errors in hearing the medication order; patient and family confusion; pharmacy
errors; and cultural beliefs. Although all of the various kinds of medication errors can occur in
hospitals as well as homes, there are some unique circumstances that make home care
medication safety particularly challenging. Sometimes, in the freedom of their own home,
patients refuse to take medications, forget to take medications, do not fill prescriptions because
of cost, lack of knowledge about how to renew a prescription, or lack of access to a pharmacy.
Sometimes, medication errors occur because of multiple physician involvement in care,
transitions from hospital to home, patient or family error, or the use of over-the-counter (OTC)
drugs in addition to prescribed medication that may cause adverse reactions.
On average, community-dwelling elders use 4.5 prescription medications at any giving time
in addition to OTC drugs. Corbett, Setter, Daratha, Neumiller, and Wood (2010) found a mean
of 10.4 medications prescribed to patients at time of hospital discharge, supporting the frequency
with which polypharmacy is occurring at time of hospital discharge (Box 12.5). Adverse
reactions included death, falls/confusion/sedation, adverse bleeding, inappropriate/ineffective
treatment, disease exacerbation, emergency department visits and/or rehospitalizations, and
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ineffective pain control (Romagnoli et al., 2013). At the initial home visit, it is important for the
home care nurse to develop a medication profile that is accurate and will be reviewed at each
visit. It is critical to talk about the use of prescribed medications with OTCs and herbal
supplements, and develop a plan that includes the patient and family being vigilant about
medication safety (Box 12.6).
ASSESSING FOR RISK OF FALLS
Falls are a major health problem in home care. One-third of older adults fall every year with
serious consequences that include death, fractures, and head injuries. For the elderly, there are
even more consequences when a fall is sustained. These include an ongoing fear of falling, loss
of function and mobility, disability, restriction of activity, decreased independence, increased
social isolation, depression, and nursing home placement (Leveille et al., 2009)).
Fifty-five percent of fall-related injuries occur inside the home (Greene, Sample, & Fruhauf,
2009). The most common rooms where people fall include the living room (31%), bedroom
(30%), kitchen (19%), bathroom (13%), and hallway (10%). Fall rates for the elderly are related
to intrinsic and extrinsic factors (Table 12.2). In the context of the first home visit, many of
these factors are modifiable. For example, the home care nurse can make plans with the family
or home care agency to make environmental modifications that can decrease the chance of a fall.
For example, this may involve having handrails installed in the bathroom and removing scatter
rugs or putting nonskid pads under them. The initiation of an exercise program, medication
adjustments, and the management of pain, orthostatic hypotension, and corrected vision all can
begin at this first visit (multimodal exercise programs for older adults [Baker, Atlantis, &
Fiatarone-Singh, 2007]).
12.5 Interventions Related to Medication Safety at Home
Teach clients and/or families to always check prescription labels when filling or refilling prescriptions.
Use medication prefill systems.
Have the client and/or family repeat back medication instructions given over the phone.
Focus on tricyclic antidepressants, benzodiazepines, and antipsychotic medications, since they are prone to
medication errors.
12.6 Herbal Medications and Adverse Interactions
Ginkgo biloba
Used as an antioxidant and natural blood thinner
Adverse interactions with anticoagulants, OTC pain relievers (causes adverse bleeding), anticonvulsants,
and antidepressants
Ginseng
Decreases stress and effects of aging
Adverse interactions with digoxin, anticoagulants, antidepressants, and analgesics
St. John’s Wort
Used as antidepressant
Adverse interactions with chemotherapy, indinavir, cyclosporine, digoxin, and theophylline
Source: Data from Salmond, S. (2002). Polypharmacy and phytotherapy: Issues of herb/drug interactions in the elderly. Australian Journal of Medical
Herbalism, 14(1), 12–14.
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Eleanor and her family obtain a “fall alert” bracelet from their local hospital. This
encourages them. The technology works very much like other wireless systems, alerting
emergency services and the police if needed. This alert system is connected
electronically to Eleanor’s home phone with a special piece of equipment that always
allows a person to converse with her if she pushes the alert bracelet and needs help.
During two occasions in the early evening, Eleanor uses the alert bracelet when she slips
off the side of her bed and cannot get up. This effectively allows her to stay at home and
have the psychological feeling of being connected to someone who could help her in an
emergency when her children are not available.
ASSESSING FOR RISK OF ABUSE AND NEGLECT
Unfortunately, in community settings, there can be instances when patients and family members
can be victims of abuse and neglect. This is often hidden until home care nurses or other home
care personnel enter the home and observe the potential, or actual, abuse, or neglect. In thinking
about the difference between abuse and neglect, there are not only subtle differences between
the two conditions but also differences in motivating factors behind the situations. Some authors
define abuse as blatant disregard for the safety and welfare of a patient versus neglect as a
chronic, eroding lack of physical, psychosocial, and spiritual support of another (Stark, 2011).
Abuse can be physical, emotional (often in the form of verbal abuse), and, especially with the
elderly, financial. This is often true when caregivers are responsible for the financial
management of the household. Neglect is not always the responsibility of others. Some patients,
for a variety of reasons that include diagnosed and undiagnosed depression, can be victims of
self-neglect (Underwood et al., 2013). Self-neglect can take the form of not taking care of
personal hygiene, refusing to take medications that may improve their physical or mental
condition(s), and refusing to eat.
TABLE 12.2 Intrinsic and Extrinsic Factors Related to Falls in the Home
Intrinsic Extrinsic
Age Poor or inadequate lighting
Previous history of falls Changes in floor surface or slippery surface
Cognitive impairment High-gloss floors
Muscle weakness, decreased lower extremity strength Lack of handrails on stairs
Female Inappropriate chair height
Taking four or more medications a day Clutter, throw rugs, electrical cords, loose carpeting
Taking psychotropic medications Poor sidewalk and pavement conditions, snow and ice
Vision impairment Pets
Peripheral neuropathy
Parkinson disease
History of a stroke (cerebrovascular accident)
Arthritis
Abuse and neglect are sometimes motivated intentionally, but more often they can be
unintentionally present as issues for patients. This is the case particularly with neglect and self-
neglect. Extenuating circumstances may involve a lack of knowledge (not being aware of the
resources in the community that are available to help with a situation) (Johannesen &
LoGiudice, 2013).
One important cautionary note is that home care nurses need to be careful about making
judgments related to identifying abuse and neglect involving patients and families.
Consideration must be given to cultural beliefs, lack of caregiver knowledge and/or skill,
caregiver burden or lack of support, well-intended but misguided care, and patient autonomy and
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the right to self-determination (Johannesen & LoGiudice, 2013).
Termination
In terminating the initial visit, it is critical to make sure that patients and families know how to
reach the home care nurse at any time of the day, and that an emergency plan is understood by
the patient and the family. This understanding may involve the neighbors. It is equally important
to establish an initial plan of care, and to make a plan for the next scheduled visit. If there are
any circumstances that would impede future visits, it is important to address these at this time.
For example, if the patient or family members smoke, and the home care nurse is allergic to
smoke or cannot tolerate smoking, the home care nurse should make a contract related to a “no
smoking” visit policy. If there are pets that disrupt the visit, the home care nurse needs to make a
contract that the pet will be put in another area during future home visits.
Student Reflection
I have to admit, with the short length of stay in hospital settings, caring for patients in the
community over many months, depending on their skilled needs, and recertification of care
by members of a physician team, makes it difficult to discharge the patient. It is not just the
patient but the family that is missed because they are often caregivers that make the care a
possibility. So the goodbye is doubly hard sometimes. As a student, I became much more
aware of the realities facing patients when they left the hospital and now often wonder why
there is such a separation in practice from the hospital to the home. Wouldn’t it be great if
nurses in the hospital could visit or check in on patients at home after they left?
Post-Visit Planning
After the initial visit, the home care nurse establishes, through the nursing process and the use of
the initial assessment protocol, a specific plan of care that may include other healthcare
disciplines and home health aide services. Outcome goals are established, and a schedule of
planned visits is organized. The most crucial post-visit activity is the establishment of outcome
measures, so that the home health team can plan an intervention approach that allows reasonable
time and effort for healthcare providers and the patient and family to achieve these measures.
This is accomplished through the expert judgment of the home care nurse, who manages the
home care effort, and consideration of the constraints of Medicare, Medicaid, and other health
insurance policies.
Nurse–Family Interactions in Home Care
Professional boundaries in the home care setting are an important consideration because home
care nurses are guests in a patient’s home (Rowem & Kellam, 2011). Home care nurses are very
aware that dealing with the three Cs—culture, contracts, and confidentiality—is important and
that they have unique applications in nonhospital settings.
Culture
In Chapter 10, culture and cultural competency are addressed extensively. However, it is
important to reiterate that in home visiting, it is important to converse with patients and families
about cultural patterns with which the home care nurse may not be familiar. This includes
assessing the degree of acculturation, religious or spiritual needs, the patient and family
understanding of the health problem that brought the home care nurse to the home, etiquette, and
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social customs and rituals and practices.
Contracting
In many home care patient and family situations, one of the roles of the home care nurse is to
develop a plan of care that is mutually accepted so that health outcomes can be met, and at a
variety of levels of prevention (primary, secondary, and tertiary; see Chapter 5). In many
instances, a patient- or family-centered approach leads to differences in levels of motivation to
meet outcomes. For example, the home care nurse established positive glycemic control as an
outcome for a patient who is living with type 2 diabetes at the age of 85. There are instances
when the patient and family find it difficult to accomplish this mutually agreed-upon activity,
related to exercise, food portion control, types of food selections, and medication scheduling. On
the surface, it may seem as though a patient or family is “fighting against” needed lifestyle
changes that are highly connected with health outcomes. On the other hand, a patient may say
that he wants to get well and be healthy, which results in two conflicting and ambivalent
positions. Thus, finding a way to make a contract that is mutually binding between the patient,
family, and nurse is crucial.
Motivation to change behaviors may be related to ambivalence. Motivational interviewing is
a patient-centered, directive method for enhancing intrinsic motivation to change by exploring
and resolving ambivalence (Wilcox, Kersh, & Jenkins 2017). There are four principal
approaches used in motivational interviewing: express empathy, support self-efficacy, roll with
resistance, and find a discrepancy (Motivational Interviewing, 2013).
An empathetic approach involves identifying with the emotional aspects of the patient’s
experiences, attempting to understand those experiences from the patient’s perspective. When
patients perceive empathy on a counselor’s part, they become more open to gentle challenges
about lifestyle issues and beliefs about substance use. Patients become more comfortable fully
examining their ambivalence about change and less likely to defend unhelpful attitudes, such as
the denial of problems (Wilcox, Kersh, & Jenkins 2017).
Self-efficacy is the belief on the part of the patient that change is possible. Self-efficacy by
definition is a critical motivator to operational change in health behaviors. A person who has a
high sense of self-efficacy regarding a particular behavior is more likely to engage in that
behavior. For example, people with stronger perceived self-efficacy for carrying out safer
healthcare behaviors will be more likely to persist with these behaviors in the face of
interpersonal pressure to behave otherwise (Bandura, 1997). Home care nurses can help patients
believe that they can make a change by asking about other changes they have made in their lives
in the past and how they were particularly successful. This approach emphasizes the ability of
the patient to accomplish a goal successfully.
In motivational interviewing, the home care nurse does not fight patient resistance but “rolls
with it.” Statements demonstrating resistance are not challenged. Instead the home care nurse
lets the patient take the lead. Using this approach, resistance tends to be decreased rather than
increased. Patient’s argumentative resistance to suggestions is not reinforced and the “devil’s
advocate” role is minimized.
Home care nurses also work to develop opportunities for patients to discover discrepancies
between their current behavior and what they want to accomplish through changed behaviors.
When patients perceive that their current behaviors are not leading toward some important future
goal, they become more motivated to make important life changes. This approach is
accomplished gently and gradually to help patients see that the way they approach health issues
may be leading them away from accomplishing their stated goals.
Privacy, Confidentiality, and Security
In 1997, the Health Insurance Portability and Accountability Act (HIPAA) was passed in the
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United States (United States Department of Labor, 2018). The law assures that personal
healthcare information will be kept private and secure. Home care as an industry has strived to
maintain privacy of patients and families since its inception. However, new challenges arise
related to longitudinal medical records and the numerous healthcare professionals who will have
access to healthcare information over a continuum of care. In recent years, the increased use of
portable internet systems to document patient and family information brings new challenges to
the rights of patients and confidentiality (Sewell, 2016). Protecting patient and family privacy is
a nursing responsibility. Home care nurses must be careful to do the following:
1. Conduct assessment interviews in environments that protect privacy (i.e., a place where
conversation may not be overheard, if applicable).
2. When using a computer to access or document data, be mindful that no one else can view the
screen.
In addition, home care computerized records must be maintained with an organizational
commitment to allow only those with an appropriate identification and password to “log in.”
This approach is associated with ethical responsibility. Confidentiality also is an issue when
healthcare data are transmitted. Much data is transferred electronically through facsimiles
(faxes) or computer transfers. Encryption is often used as a way of protecting information so that
only persons with special “keys” can decrypt messages that are sent (Sewell, 2016). The best
way to enhance a commitment to confidentiality in a home care agency is to maintain written
policies about the use of patient and family data. This includes an orientation and annual updates
with staff to ensure that the policies are understood.
Finally, it is the responsibility of all home health agencies to keep all the data they collect
secure. Data must be checked for accuracy. Decisions must be made at the organizational level
as to (1) who are the personnel that absolutely need access to the information, (2) what type of
firewalls will be established on computerized documents to protect patient data from outside
intruders, and (3) when and how data will be backed up to prevent loss of information.
Key Chronic Conditions and Quality Improvement in Home
Care
In many healthcare situations, there are several chronic diseases and conditions that are often
managed in the home by nurses in collaboration with other healthcare providers. Because of the
management of this care by nurses, they often are involved with quality improvement related to
these key conditions. Quality improvement simply means that nurses are interested in
developing and managing healthcare interventions of a home health team that can improve or
stabilize chronic conditions in the home. Common diseases and conditions include diabetes
(Hartman, Litchman, Reed, & Burr, 2009), incontinence (Flanagan et al., 2012), pain (Duke,
Botti, & Hunter, 2012), hypertension, and CHF (Taylor & Campbell, 2007). It is important to
understand that, although these conditions are studied by nursing students in adult healthcare or
medical–surgical nursing class and clinical settings, they take on a new complexity when
patients leave a controlled environment such as an acute care hospital or rehabilitation facility.
During in-home care, complexity of care may include such issues as (1) family, (2)
environment, and (3) even the home care nurse’s capacity to attend consistently to assessment
and intervention criteria. Complexity of care also arises from the fact that many patients cared
for in homes live with multiple healthcare problems and conditions (comorbidities). For
example, a patient living with diabetes at home who has a problem with chronic incontinence
needs a family caregiver to be informed of nutritional needs. If a family caregiver does not
collaborate or participate, the interactive effects of glycemic and incontinence control through
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diet will be defeated. Although incontinence may have many complex etiologies in and of itself,
often the bundling of interventions can help patients have positive outcomes in several areas of
concern as long as a principal caregiver participates in the plan of care.
In the same way, if the household environment is not safe, the patient with diabetes or
dyspnea from CHF may suffer falls and unexpected injuries that could lead to nonhealing
wounds, further dyspnea, and unnecessary pain. Careful analysis of safety within the home, and
interventions directed toward making the home environment safer through physical adjustments
or through the assistance of ambulation strengthening, are key in keeping patients healthy at
home.
Finally, home care nurses must be exacting and consistent in their assessment and follow-up
with patients and their family caregivers. Because patients are in their own homes, many times
home care nurses are faced with trying to balance the need to expeditiously care for patients
when they are often fully dressed. This is different than in the hospital setting where patients are
often in hospital gowns. In caring for patients living with diabetes, it is critical for home care
nurses to ask patients to take off their socks and shoes so that full neurovascular assessments can
be completed consistently over time. Symptoms such as subtle changes in sensation may be
ignored or overlooked in the context of a chronic health condition, although these same
symptoms would warrant immediate care in a more acute illness (Centers for Disease Control
and Prevention [CDC], 2012; Hartman et al., 2009).
CASE MANAGEMENT, HOME HEALTHCARE, AND
CURRENT HEALTHCARE REFORM
According to the Medicare Payment Advisory Committee (MedPAC, Home Health Care
Services, 2016), in 2014 about 3.4 million Medicare beneficiaries received home care, and the
Medicare program spent about $18.4 billion on home health services (MedPAC, Home Health
Care Services, 2016). The number of agencies participating in Medicare reached 12,199 in 2011
where indicators of payment adequacy for home healthcare were seen as generally positive
(MedPAC, Home Health Care Services 2016). However, almost one in five Medicare patients
will be readmitted to the hospital within 30 days of discharge, at a cost of $15 billion and which
does not include the heavy emotional and health toll on the patients and their families
(MedPAC, Home Health Care Services, 2016). Avoidable hospital readmissions are typically
caused by insufficient posthospitalization care, failure to adhere to recommended medication or
therapy regimens, and lack of physical support for the discharged patient.
The federal government’s Medicare program has created initiatives and incentive programs
in a broad effort to lower the costs of avoidable utilization and to improve the quality of care
that is delivered and received at healthcare institutions nationwide (MedPAC, Home Health Care
Services, 2016). The healthcare home model is an evolving, comprehensive, and cost-saving
model that includes home care and case management. This model was introduced originally in
the late 1960s as a model of healthcare delivery for children with special needs and was a way to
coordinate multiple services to children with complex developmental and physical challenges.
Outcomes of the model, beyond family-centered comprehensive care, included a way to
coordinate care effectively while being culturally relevant and sensitive. This model is currently
referred to as the PCMH and includes a chronic care model congruent with home care services
described in this chapter. The distribution of services was originally introduced as a way to
address those populations who were underserved and at high risk who needed coordinated care
when they could not access primary care easily. The current terminology referring to this model
is “healthcare home” versus “medical home” so that the true nature of the coordination is
interprofessional with nursing as a central role (American Nursing Association, 2014). The
394
healthcare home model intends to reduce barriers to access by providing services such as
enrollment into healthcare services, transportation, and coordination with service providers that
include home care services.
Currently pilot projects and efficacy and efficiency studies are underway that use this
approach to develop a reimbursement structure. Projects are particularly looking at care
coordination for patients with chronic conditions where decreased emergency room and hospital
use, in terms of rehospitalization, brought notable savings per year (National Partnership for
Women and Families, Side-by-Side Summary of State Medical Home Programs, 2013).
Challenges related to adopting and implementing healthcare home approaches continue to be
formidable because current reimbursement rates do not cover the larger scope of services that
are meant to be provided. The accountable care organization (ACO) model now utilized by
hospital systems was created to coordinate care with an emphasis on prevention, and provide
incentive structures in the context of the provisions of the Affordable Care Act (ACA) in which
the healthcare home model would be seen as a key component in partnership with those hospital
systems utilizing the ACO approaches (McClellan, McKethan, Lewis, Roski, & Fisher, 2010).
For many, the need to reform the current primary care model in partnership with case
management and home care is critical so that collaborations between ACOs and healthcare home
models can truly coordinate care for individuals, families, and communities (Child and
Adolescent Health Initiative, 2013).
Evidence for Practice
The National Partnership for Women and Families (2013) last updated a list of all those
states that have used medical home programs. Factors include organizational leadership,
populations served, provider requirements, payment policies, and outcome measures of
success. Please refer to http://www.nationalpartnership.org/research-
library/general/standing-up-for-women-families-in-2013
Look up your state or regional location for ongoing information/evidence of success.
In the final analysis, it is the home care nurse who has a significant role in reducing acute
care emergency department and hospital use. As healthcare reform continues, the home care
nurse will play a significant role in reducing emergency department and hospital use by
improving outcomes in chronic care. In a recent study of all home healthcare agencies,
Medicare-certified agencies offered training in outcome-based quality improvement to their
professional staff, particularly nursing, as a way to ensure outcomes that did not involve
expensive and unnecessary interventions (Pace & Johnson, 2006). Those that addressed (1) pain
interfering with activity, (2) improvement in transferring, (3) improvement in managing oral
medications, and (4) improvement in ambulation and locomotion demonstrated improved
outcomes in comparison with national rates. Improvement continues to be needed in (1)
emergent care needs, (2) dyspnea, (3) acute care hospitalization, (4) care of surgical wounds, (5)
bathing, and (6) incontinence as home care progresses in its scope and standards of care to the
public.
Healing is a matter of time, but it is sometimes also a matter of opportunity. Hippocrates
KEY CONCEPTS
Home care is part of a continuum of care on which patients have the opportunity to live and move through
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http://www.nationalpartnership.org/research-library/general/standing-up-for-women-families-in-2013
the experiences of subacute, chronic, and end-of-life care.
The care given in home care settings is often managed and directed by a registered nurse.
Many aspects of the care in both generic and hospice home care are part of a larger care management
plan that is individualized using a case management approach.
The care given in home care settings is interdisciplinary in nature.
Caregivers are often family members and friends. They must be considered members of the home care
team and offered appropriate support if their commitment to care for a loved one at home is to be
successful.
CRITICAL THINKING QUESTIONS
1. You are caring for a home care patient with a large venous stasis wound on her left calf. She is obese and
also suffers from CHF and osteoarthritis. She has trouble transferring out of her recliner chair due to pain
and shortness of breath. Her physician has recommended daily cleansing of her venous ulcer in the
shower. Her bathroom is fully handicapped-accessible with grab bars, a handheld shower head, and a
transfer bench, but her pain and shortness of breath prevent her from using the shower. What would you
do first?
a. Explain to the physician that given the patient’s limitations, showering is not a possibility.
b. Order a Hoyer lift for the patient to assist with transfers.
c. Consult with a physical therapist about getting the patient an electric scooter to facilitate transfers.
d. Consult with the physician about a better regimen to manage the patient’s arthritis pain and add a
home health aide to her home care services.
2. Look through several major newspapers for articles that discuss care of the elderly in the community or
care of those at the end stage of a life-threatening illness.
a. What is the role of a community health nurse in assisting families in the care of these citizens in their
homes?
b. What are some of the barriers related to the initiation of home care services in communities?
c. How does living in an urban area versus a rural area affect home care services?
3. There is an increased use of drugs with elderly populations raising concerns related to adverse outcomes,
falls, and hospitalizations. The following list of references represent published manuscripts that may be of
interest to nurses interested in addressing this serious and complex situation facing healthcare practice in
the home and other locations of care. Choose three articles of interest from the list, and share your
insights with your class.
4. Go to the National Association for Home Care and Hospice website (http://www.nahc.org/) and choose a
legislative issue that affects home care. What are the key issues related to the political efforts made by
promoters of home care? What are the political barriers that affect home care?
5. In thinking of five social determinants of health as identified in Healthy People 2020, identify the social
determinants specifically that may be barriers to home care and case or care management services, and
explain why.
COMMUNITY RESOURCES
Local hospitals that have hospital-based generic or hospice home care programs
Visiting nurse associations
Elder affairs organizations
Local and state health departments
State offices of Medicare and Medicaid
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http://www.nahc.org/
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Chapter 13
Family Assessment
Judith Healey-Walsh
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The family is one of nature’s masterpieces.
George Santayana
Feelings of worth can flourish only in an atmosphere where individual differences are
appreciated, mistakes are tolerated, communication is open, and rules are flexible—the kind of
atmosphere that is found in a nurturing family.
Virginia Satir
If we are peaceful, if we are happy, we can smile, and everyone in our family, our entire
society, will benefit from our peace.
Thich Nhat Hanh
CHAPTER HIGHLIGHTS
Family nursing practice
Definitions of family
Theoretical perspectives of family
Descriptions of current family configurations
Family Systems Nursing: Calgary Family Assessment and Intervention Models
Family-focused home visiting
Family caregivers
OBJECTIVES
Define family nursing practice competencies.
Compare three theoretical perspectives of family nursing.
Analyze contemporary family issues
Apply the Calgary Family Assessment and Calgary Intervention Clinical Practice Models
Examine evidence-based maternal-child health home visiting programs
Analyze components of family caregiving.
KEY TERMS
Calgary Family Assessment Model (CFAM): A clinical practice model linked to Family Systems
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Nursing developed to assist nurses in performing a family assessment in an organized,
systematic manner. The CFAM is a multidimensional model comprised of three basic
assessment categories: structural, functional, and developmental.
Calgary Family Intervention Model (CFIM): A clinical practice model linked to Family Systems
Nursing developed to assist nurses in family-focused interventions. The model address three
domains: cognitive, affective, and behavioral and focuses on enhancing, improving, and
sustaining family functioning through the establishment of a collaborative partnership between
the nurse and the family, the use of therapeutic conversations, and a focus on family
strengths and resiliency.
Caregiver burden: Fatigue or frustration expressed by persons who care for convalescing or
chronically ill persons on a daily basis.
Ecomap: A diagram used to identify the direction and intensity of family relationships between
members and/or community institutions of importance to the family (e.g., schools, workplaces,
places of worship).
Family: Two or more persons who share emotional closeness and identify themselves as
members of a family.
Family Systems Nursing: A conceptual framework developed to promote family nursing
practice. It emphasizes the reciprocal relationship between individual members and the family
as a whole. Nurses provide care for the family as a unit.
Genogram: A diagram of family relationships between blood relatives that can span two or more
generations. Life events such as marriages, divorces, births, and deaths are included in the
diagram. The genogram is used to identify relationships as well as possible patterns of
disease.
Intrafamily strain: The effect of stressors on families that can interfere with effective family
communication, interaction, and functioning, and negatively impact family well-being.
System: A group that works on the principle that each part contributes to the way the whole
functions.
Theory: A system of interrelated statements that is used to explain, predict, control, or
understand a phenomenon.
CASE STUDIES
References to case studies are found throughout this chapter (look for the case study icon).
Readers should keep the case studies in mind as they read the chapter.
CASE 1
Lucy, a public health nurse in a mid-sized city, has been following the Barnes family for two years.
Eight-year-old Tanya and her 6-year-old brother Luke have asthma, and Lucy has been helping the
family control asthma triggers at home. Tanya and Luke’s 51-year-old grandmother, Elsa Morris, is
their guardian. The children’s mother is in the military and is now overseas. She sends e-mails with
photos to the children almost daily. The children’s father, who never married their mother, has had
no contact with the children for more than four years.
At Lucy’s most recent home visit, Elsa tells Lucy that Tanya has been unable to sleep through
the night. Lucy also learns that the children have “too many treats” between meals and after dinner.
Mrs. Morris tries to get the children to go to bed around 8 p.m., but they like to watch television.
Elsa says that she knows she needs to be stricter, but the children miss their mother and she wants
to avoid upsetting them.
Elsa’s husband has been unemployed for several months. Although he received a generous
severance payment from his company, he has had to apply for unemployment. He is generous and
caring to the children and to their mother. Elsa works part-time and only makes enough money to
cover expenses. She tells Lucy that the cost of the children’s medications is “adding up.” She also
wants to enroll the children in extracurricular activities, but they are “too expensive.”
What three priorities for this family can you identify?
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What additional information would you want from Mrs. Morris?
What types of community resources to support this family would you recommend?
CASE 2
Agnes and Mark Thomas are 83 and 84 years of age, respectively. They have four adult children
and eight grandchildren; all live within 25 miles of the couple. Mrs. Thomas likes the family to have
dinner together at least twice a month at her home. Over the past six months, her children have
noticed that their mother often forgets her grandchildren’s names. Mr. Thomas, a retired firefighter
and once avid swimmer, has arthritis in his spine, which has decreased his mobility.
The Thomases’ elder daughter, 58-year-old Arlene, is developmentally delayed and has lived in
various state-run residential facilities since she was 5 years old. Arlene’s siblings had little contact
with her when she was growing up except on birthdays and holidays. Recently, the director of the
facility sent the Thomases a letter to inform them that the state is closing the facility and that they
need to find housing for Arlene.
Laura, a nurse from the residential facility where Arlene lives, phones Agnes to arrange a home
visit. Agnes tells Laura that Arlene cannot live with her and Mark, and she asks Laura to talk to her
youngest son Jim, 47 years old. Although Jim has had minimal contact with his sister, he agrees to
meet with Laura. He tells her that his parents’ health is declining, especially his mother’s, and
proposes that Arlene might be able to move into the in-law apartment in his home. Jim and Laura
arrange another meeting that includes Arlene, as well as Jim’s wife and their adolescent twin
daughters.
What potential conflicts can arise in this family?
What information about the family’s resources could help to offset their anxiety about Arlene’s
change in housing?
Who else should be included in any plans?
INTRODUCTION
Nursing is defined as the “protection, promotion, and optimization of health and abilities,
prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of
human response, and advocacy in the care of individuals, families, communities, and
populations” (ANA, 2010, p. 10). Therefore, working with families is an inevitable and integral
aspect of nursing practice. However, much emphasis in clinical practice is on individual
problems and needs. Family care is frequently the focus of concern in particular clinical
situations, such as nursing sick children, family-centered maternity care, and home health and
hospice nursing care. Learning about the complex nature of family can provide insight into the
ways that family life, interactions, and practices influence individual health, and how individual
health and illness impact the family. In many cases, family connections play a vital role in
providing support to members. Yet, at other times, family influences can be perceived less
positively, and can cause challenges to both family members and the healthcare providers who
care for them. This chapter explores family-focused care and family nursing practice. It includes
a discussion of the expanded definition of family, and the comparison of three theoretical
perspectives of family nursing. The current diversity of family forms is explored. The Calgary
Family Assessment Model (CFAM) and Calgary Family Intervention Model (CFIM) are
described as evidence-based clinical practice models that guide family nursing practice.
Maternal-child health home visiting programs and the role of family caregivers are presented to
exemplify how community health nurses apply family-focused nursing practice. The case
studies at the beginning of the chapter illustrate how complex issues can affect families and their
health management, and how a family-focused approach is necessary for both assessment and
intervention.
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FAMILY NURSING PRACTICE
Family nursing practice asserts that there is a reciprocal relationship between a family and its
individual members, and between the family and illness. The health and illness of individual
members impacts the family, and the family affects the health and illness of individual members
(Bell & Wright, 2015; IFNA, 2013; Kaakinen, Hanson, & Denham, 2010). Wright and Leahey
(2013) explain that health and “illness are a family affair” (p. ix). The International Family
Nursing Association’s position statement (2013) explains that “A family’s life world is therefore
an integrative experience of individual and collective health and illness. In response nurses must
accommodate both an individual and collective focus to meet health and illness needs” (p. 2).
The holistic nature of nursing supports the inclusion of the family when providing nursing care
to individuals of all ages and in varied settings (Abraham & Moretz, 2012). Although family
nursing is frequently associated with maternity and pediatric practice, IFNA emphasizes that
family nursing is appropriate and effective within many nursing specialties including home
health and palliative care (Ferrell & Whittenberg, 2017; Harding, 2014; Imanigoghary, Peyrovi,
Nouhi, & Kazemi, 2017; Norinder, Goliath, & Alvariza, 2017). IFNA proposes that family-
focused nursing care should be the standard of practice across the lifespan. In 2015, to support
this goal, the IFNA published a Position Statement on Generalist Competencies for Family
Nursing Practice. The identified competencies are listed in Box 13.1. To be competent in the
provision of quality family nursing, community health nurses need to have a theoretical
understanding of family.
13.1 Family Nursing Competencies: Generalist
1. Enhance and promote family health.
2. Focus nursing practice on families’ strengths; the support of family and individual growth; the
improvement of family self-management abilities; the facilitation of successful life transitions; the
improvement and management of health; and the mobilization of family resources.
3. Demonstrate leadership and systems thinking skills to ensure the quality of nursing care with families
in everyday practice and across every context.
4. Commit to self-reflective practice based on examination of nurse actions with families and family
responses.
5. Practice using an evidence-based approach.
Source: IFNA. (2015). Position statement on generalist competencies for family nursing practice. Retrieved from
https://internationalfamilynursing.org/wordpress/wp-content/uploads/2015/07/GC-Print-friendly-PDF-document-in-black-white-no-photos-English-
language1 .
Practice Point
Family nursing practice requires that the nurse understands the reciprocal relationship
among individuals and their family and addresses both the health of individual members and
the functioning and health of the family. Family-focused care should be practiced across the
lifespan.
UNDERSTANDING FAMILY
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Family is a complex phenomenon. The concept of family is dynamic, as it is impacted by
sociocultural and economic factors. Therefore, varied definitions and theoretical perspectives
exist, which can assist the community health nurse in acquiring a broad and deep understanding
of the universal characteristics and changing nature of family. Looking at different definitions of
and theories relevant to family is a good place to begin exploring this concept.
Definitions of Family
For demographic use and purposes, the U.S. Census Bureau narrowly defines family as “people
living together and are related by birth, adoption, or marriage” (Vespa, Lewis, & Keide, 2013).
The concept of family is not static and evolves over time influenced by cultural and societal
changes. Historically, the nuclear family was defined as comprised of a mother, father, and
children. Families today assume a variety of forms. Factors such as delayed marriage and child-
bearing, increased divorce rates, remarriage rates, increased co-habitation, smaller family size,
grandparenting, and the same-sex marriage ruling have all influenced family structures, A
nurse’s own family of origin is usually a frame of reference for what comprises family and how
its members relate to one another.
One broad definition of family is “two or more persons who are joined together by bonds of
sharing and emotional closeness…who identify themselves as being part of the family”
(Friedman, Bowden, & Jones, 2003, p. 10). This definition characterizes the range of families in
21st-century America and covers a wide range of relationships, including those outside the
genetic and legal definitions of family. Another definition is that families decide who they are,
and family boundaries are not limited to traditional definitions (Wright & Leahey, 1999, 2009).
Although this definition might seem simplistic, it draws attention to individual group needs to
affirm identity as family and establish connection to others within that group.
Overall, both definitions of family have characteristics of living in a diverse society that
includes groups of different ethnic, religious, or political backgrounds. Both definitions clearly
indicate that individual people determine their status as family. An advantage to these
definitions is that the ideal of what constitutes family includes groups that 50 years ago would
not be recognized as such (e.g., gay and lesbian families, cohabiting partners, and single-parent
families). However, sociologic trends make describing families based solely on their attributes
difficult (Wright & Leahey, 1999, 2009).
Theoretical Perspective of Family
Generally speaking, a theory presents a systematic view of related statements to describe,
explain, predict, or prescribe a phenomenon of interest (Walker & Avant, 2010). A range of
theoretical frameworks has been used to analyze and describe family composition, roles,
interactions, and behaviors. Given the complexity of the concept of family, no one theory is
broad enough to explain all the aspects of family. Therefore, several theoretical perspectives
must be considered. Family theories use a specific perspective to provide a guide to analyze and
understand the concept of family. Family systems theory, family structural-functional theory,
and family developmental theory are frequently used to provide an understanding of typical
characteristics of family.
Family Systems Theory
Family theorists have applied general systems theory principles to explain how families interact
with their members and with society. From a systems perspective, the family social system is
comprised of interacting subsystems (individual members) and is also a part of and in constant
interaction with suprasystems in the external environment (neighborhood, community, and
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societal institutions). The family is defined as a system characterized by continual interaction
between its members and with the environment. A central tenet of systems theory is that the
system, as a whole, is greater than its parts. The interrelationships and interactions in the family
system, are such that a change in one member affects a change in all other members. In nursing
practice, the word system is often used to describe families. A system works on the principle
that each part contributes to the functioning of the whole. Its structure, personal history, and
patterns of communication affect how well the system operates. Family systems are groups of
individual people whose functioning depends on one another (Wright & Leahey, 1999, 2009,
2013). Therefore, to understand the family, interrelationships of the members with each other
and with the larger society must be analyzed.
Family Structural-Functional Theory
Structural-functional theory views the family as a social system, but emphasizes the organization
or structure of the family and how this structure facilitates its functioning. Family structure
refers to the ordered set of relationships among the parts and between the family and other social
systems. The structure serves to facilitate the achievement of the functions. The functions serve
both the individual family members, the community, and society. Societal and cultural norms
also affect changes in family structure.
Traditionally, family structure was distinguished between what constituted the nuclear
family and the extended family. Nuclear families consist of first-degree relatives—that is, two
generations who live together. Commonly, the two generations include parents and children.
Extended families include both first- and second-degree relatives and can include grandparents,
aunts, uncles, and cousins. Traditional definitions of extended family indicate that the family
shares a dwelling, but members can live in the same neighborhood or in relatively close
proximity to one another. The time that an extended family spends together depends not only on
geographic closeness to one another but also on family customs. Extended family can also
include persons who are not blood relatives, but who share a common locale of origin or culture.
This situation is common in immigrants or in persons whose own families live elsewhere. To
determine family structure, the community health nurse must identify the individuals that make
up the family, their relationships to each other, and the relationships between the family and
other social systems. Family structure is evaluated based on how effectively it accomplishes the
functions that are essential to its members and society.
From a sociological perspective the family serves as the basic sociocultural and economic
unit in society. The family provides the initial context in which children learn, grow, and
develop. Therefore, families provide essential functions including all basic needs such as food,
shelter, and clothing. In addition, five critical functions of the family have been identified that
are important for community health nurses to understand (Friedman, 1998):
Reproductive: addition of new members through procreation or adoption
Affective: provision of nurturance, love, and sense of belonging
Socialization and social placement: transmission of culture, values, rules, social norms, and social
identity
Economic: production, consumption, and distribution of goods and services
Healthcare: promotion and protection of health and well-being, coordination of care and health services
Family Developmental Theory
The developmental or life-cycle theory proposes that families progress through typical stages.
Stages begin with marriage followed by childbirth and child-rearing. Duvall (1977) and Duvall
and Miller (1985) were major contributors toward the advancement of family developmental
theory. The stages from their work are based on the traditional, nuclear, heterosexual middle
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class family experience, which was the predominant and widely accepted family structure at the
time. The theorists identified eight stages within the family life cycle. The first stage viewed the
young adult, typically in their early 20s leaving their family of origin to get married and start a
career (primarily to support their family). The following four stages focused on childbearing and
child-rearing in a heterosexual two-parent family. The sixth stage involved the parents launching
their adult children to begin their married life and career. And the final two stages involved
middle-aged and aging families with a focus on the empty nest, establishing new
intergenerational relationships, retirement, coping with the loss of a spouse and living alone. The
stages assume homogeneity (two parents, husband and wife), presenting a middle class bias.
Given the sociocultural and economic factors, which have prompted variations in family
structure and the timing of family developmental tasks over the past 30 years, these life-cycle
stages have limitations. The timing of leaving home, getting married, and having children has
changed. The stages are not as predictable and do not fit as well with the changing structure of
contemporary families. A familiarity with family theories provides nurses with a foundational
understanding of the concept of family. However, community health nurses must be attentive to
the changing definition, structure, and life cycle of families, so that the diversity of family forms
is respected and that family health and well-being is promoted for all families (McGoldrick,
Garcia-Preto, & Carter, 2016). To accomplish this, community health nurses need to understand
the contemporary family configurations and the sociocultural and economic factors that have
shaped these changes.
Practice Point
An understanding of theoretical perspectives of the concept of family can guide community
health nurses in promoting family nursing practice and addressing family health and well-
being.
Family isn’t something that’s supposed to be static, or set. People marry in, divorce out.
They’re born, they die. It’s always evolving, turning into something else. Sarah Dessen
Contemporary Family Issues
A range of sociocultural and economic factors has prompted family configurations that vary
from the traditional family and historically were not accepted by major social institutions.
Community health nurses are in a position in which they can advocate for wider acceptance of
and policies that support diversity of family forms.
Changes in Family Life Cycle
Timing of developmental tasks in the traditional family life cycle has changed significantly,
impacting contemporary families. In the past, young adults were expected to have completed
school, started a career, and moved out usually with a spouse, in their 20s, with the arrival of
their first child to soon follow. Unlike their parents, young adults are leaving home at an older
age, and many return home after living independently. In addition, young adults are delaying
marriage and childbearing, or having children outside of marriage (Vespa, 2017). Schondelmyer
(2017) reported that that there were fewer married households (down to 44%) and more
individuals living alone (20%), or with a partner (8%), which represents the biggest change in
households in the last five decades. The United States has seen a rise in both males and females
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delaying marriage. Since 1967, the median age for first marriage for women has increased from
20.6 to 27.4 years of age and from 23.1 to 29.6 years of age for men (Schondelmyer, 2017).
Delaying marriage can delay childbirth. In 1967, 53.3% of 18- to 24-year-olds had children
living with them, and by 2016, only 31.2% of the same age group had children living with them.
An even greater change was reported among 25- to 34-year-olds. In 1967, only 23.9% in that
age group did not have their own children living with them, whereas by 2016, the number more
than doubled with 61.5% not having their own children living with them.
In 1960, 88% of children were living in two-parent families (America Counts, 2017). By
2016, this percentage had dropped to 69%, with 65% of children living with two married parents
and 4% with two unmarried, cohabitating parents (America’s Children, 2017). The birth rate
among unmarried women ages 15 to 44 peaked at 52 births per 1,000 in 2007 and decreased to
43 births per 1,000 in 2015. The largest decline occurred to adolescents aged 15 to 17, with the
birth rate for this age group declining from 33 live births per 1,000 females in 1980 to a record
low of 10 per 1,000 in 2015.
Divorce, which has increased in prevalence, is a major variation in the family life cycle that
can compound the complexity of developmental tasks (Friedman et al., 2003). It affects families
at every stage of development (U.S. Census Bureau, 2005). Most importantly, divorce has far-
reaching effects for family members at every generational level in both the nuclear and extended
families. The sequelae of divorce depend on the family. For example, divorce in a family
without children is substantially different from one with children. A child’s age and stage of
development determines his or her perception of the change in marital relationship, and the
resolution of any conflicts. For the married couple, the stage of their relationships helps
determine the level of loss and bereavement. For example, divorce that occurs after 25 years of
marriage can be devastating and cause “couple identity” crisis as shared financial investments
and possessions are dissolved (Friedman et al., 2003). In the same way, divorce that occurs in
marriages of shorter duration can be equally upsetting; marital identity is in process and may
leave members of the family unit with a sense of unfinished process or a sense of abject failure
that may impact other relationships in the future.
McGoldrick and colleagues (2016), have identified specific family life-cycle phases for
divorcing and remarrying families, which include the divorce, the post-divorce family, and the
remarriage. During the divorce phase, families are working through the actual decision, planning
for the separation and changes in the family system. During this time, family members, both
nuclear and extended, are dealing with many emotions including anger, sadness, guilt, and fear,
along with practical issues such as living arrangements, finances, custody issues, and
restructuring relationships. All of these stressors impact family health and well-being. In the
post-divorce family with children, adjusting to a single-parent structure and some form of shared
custody or visitation schedule are focal issues. Developing respectful co-parenting relationships
and processes is important in assisting children’s adjustment to new living arrangements and
family dynamics. Remarriage leads to complexity and the formation of multiple new
relationships and structural changes within the family system. Adjustment to these changes
requires time and patience, as family membership, roles, functions, and boundaries evolve.
The bond that links your true family is not one of blood, but of respect and joy in each
other’s life. Richard Bach
Changes in Family Structure
In 2016, the majority (69%) of American children under the age of 18 still lived in two-parent
families, yet this reflected a significant decrease from 88% in 1960 (America Counts, 2017). The
concept of family has broadened and become more inclusive, and extends beyond the two-parent
traditional nuclear family. Families share some common traits, but structural configurations have
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become more varied. Single-parent, blended, cohabitating, gay and lesbian, and homeless
families are all more prevalent contemporary family configurations. The assessment and clinical
approach to families and family health, now and in the future, require expanding the traditional
notions of family.
SINGLE-PARENT FAMILIES
Single-parent families can form due to divorce or widowhood (death of a spouse). However, as
more women have become pregnant outside of a marital relationship, this family form has
become more prevalent and accepted. Between 1980 and 2015, the percentage of all births to
unmarried women increased by 22% points, from 18% to 40%. In 2015, the birth rate among
unmarried women ages 15 to 44 was 43 births for every 1,000 women, down from 52 per 1,000
in 2007, when rates had reached their peak. In 2017, 27% of children under the age of 18 lived
with one parent, 23% with their mothers, and 4% with their fathers. Of the almost 20 million
children under 18 who lived with one parent in 2017, 83.9% lived with their mothers (down
from 87.5% in 2007) and 16.1% lived with their fathers (up from 12.5% in 2007) (U.S. Census,
2017). Forty-nine percent of single mothers have never been married, whereas the most common
marital status of single-parent fathers is divorced. Between 1960 and 2015, the birth rate among
adolescents aged 15 to 17 declined from 33 live births per 1,000 females to 10 live births per
1,000, a record low for the United States (Forum on Child and Family Statistics, 2017).
BLENDED FAMILIES
Blended families form when two single-parents either marry or cohabitate and raise their
children from previous relationships together. This type of family has become widespread as
more divorced or widowed people remarry. The Pew Research Center (2011) found that four in
10 Americans currently have at least one step-relative, and three in 10 have a step or half sibling.
Thirteen percent of adults have at least one stepchild. Survey respondents showed higher levels
of commitment and obligation to biological parents, grown children, and siblings over those
with stepparents, stepchildren, or step/half siblings (85% vs. 56%; 78% vs. 62%; and 64% vs.
42%, respectively).
COHABITING COUPLES AND FAMILIES
Marriage is a valued institution in most cultures. In American culture, the decision to marry or
not is regarded as individual and personal. Couples might choose to cohabit either before they
marry, or instead of marrying. According to U.S. Census Bureau (2017) figures, 7.8 million
unmarried opposite-sex couples comprise households. Of the unmarried opposite-sex couples
living together, 37% live with children under the age of 18. Families often form when couples in
a group of people cohabit. They consider themselves to be a family, as they have formed
committed emotional bonds and share possessions and possibly home ownership.
GAY AND LESBIAN FAMILIES
As the prevalence of marriage in the general population continues to decline, marriage between
same-sex couples has substantially increased in the past decade as same-sex marriage was
initially recognized in some states and then established in all 50 states (June, 2015) as a result of
the Supreme Court ruling. There are now more than 547,000 married same-sex couples in the
United States (Romero, 2017). In addition, there are about 400,000 unmarried same-sex partners
living together. Approximately 220,000 children in the United States are being raised by same-
sex couples. While same-sex couples have the right to marry in all states, anti-LGBTQ
discrimination and social stigma remains. Despite substantial evidence of successful parenting
by same-sex couples and increasing societal acceptance of sexual minorities (Gates, 2013;
Miller, 2017; Richards, Rothblum, Beauchaine, & Balsam, 2017), some negative attitudes
toward same-sex parenting continue to exist with opponents contending that the parents’ sexual
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orientation is detrimental to their children. Same-sex couples may be raising their families in a
heteronormative community where their family status is devalued and possibly discriminated
against (Ollen & Goldberg, 2016).
HOMELESS FAMILIES
Family homelessness has become a major national problem. Families with children comprise
35% of the homeless population in the United States. The 2017 federal point-in-time-count
reported that on any given night, almost 60,000 families with children are homeless. Almost
16,000 people in families were living on the streets or in a car. During 2016, about half a million
people in families stayed at a homeless shelter or in a transitional housing program, including
292,166 children, of whom about 145,000 were younger than 6 years of age (National Alliance
to End Homelessness, 2017). Poverty contributes to homelessness as families struggle with
incomes that are too low to pay for housing and other basic financial needs. Precipitating factors
to homelessness can include lost jobs or work hours, eviction, overcrowding, a catastrophic
illness, unanticipated major bills, interpersonal violence or natural disaster (Brush, Gultekin,
Dowdel, Saint Arnault, & Satterfield, 2017; Grant, Gracy, Goldsmith, Shapiro, & Redlener,
2013; Sandel, Sheward, & Sturtevant, 2015).
Young single mothers (with young children) with limited education head a majority of
homeless families (Bassuk & Beardslee, 2014). Homeless families are at greater risk for illness
and disability, substance use disorder, violence-related injuries, and mental health problems.
Living in shelters or temporary facilities is associated with depression, anxiety, and sadness
(Gultekin, Brush, Bairidi, Kirk, & VanMaldehem, 2014). Homelessness impacts children’s
physical and mental health, education, sense of safety, and overall development (Bassuk &
Beardslee, 2014).
Evidence for Practice
As the majority of homeless families with young children are headed by single mothers, it is
important for community health nurses to understand what the experience of homelessness
is like, how it impacts family health, and what services are needed to support these families.
Gultekin, Brush, Baiardi, Kirk, and VanMaldenhem (2014) conducted a qualitative
descriptive study using focus groups at a Michigan service agency, which provided case
management services to homeless families. The study aims were to (a) explore individual
pathways into homelessness, (b) understand the day-to-day experience of living in an
emergency shelter and the process of re-housing, (c) identify real and perceived barriers for
families attempting to reestablish stable housing, and (d) understand the impact of
homelessness on families’ overall health and well-being. The researchers’ intent was to use
the focus groups “to capture the how and why of individuals’ lives as either homeless
mothers or caseworkers” (Gultenkin et al., 2014, p. 394). The sample included five
caseworkers and 13 homeless mothers (who met the inclusion criteria of female, 18 or over,
caring for at least one dependent child). Semi-structured interview questions guided the four
focus groups (one with caseworkers and three with homeless mothers). The questions for
the mothers centered on (a) causes for homelessness, (b) experiences in the shelter and
with re-housing, (c) health impacts on the family’s health, and (d) hopes for the future.
Whereas, questions for the caseworkers concentrated on (a) their roles in case
management, (b) their perceptions of barriers to assisting families, and (b) their impressions
of the health risks for the homeless families. The mothers were single, separated, or
divorced with children ranging in age from 4 months to 16 years; two were pregnant.
Transcribed digital recordings and field notes of nonverbal communication and
interactions were analyzed for themes. Four main themes, each with subthemes were
identified. Perceptions of the mothers and caseworkers included both similarities and
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differences. Under the theme of “pathways to and meaning of homelessness,” mothers
expressed pride in their roles as mothers but also identified pride as blocking them for
reaching out when they needed help. They acknowledged that they were on their own,
lacking a safety net as family relationships were broken, and they expressed family legacies
of poverty, violence, and substance use disorders. In the second them, “daily shelter life
and the rehousing process,” participants expressed that they felt labeled and misunderstood
about the complicated choices that they faced. They wanted to be viewed as more than
homeless and acknowledged for their commitment to their children and the value they put
on education and job training. They expressed frustration with many rules of the shelter that
did not account for individual needs or circumstances and frequently felt disrespected.
“What women need and want” formed the third theme, and the women reported that being
homeless made them think about the future, and begin to focus on goals that would support
their education, employment, and healthier lives for themselves and their children. The final
theme addressed “impact on health and well-being,” with the women admitting to physical
and emotional exhaustion from dealing with their difficult circumstances. They described
their struggles dealing with stress, anxiety, and depression, and frustration with the lack of
accessible mental health services. Despite the difficulties that they faced, they expressed a
sense of hope and optimism in trying to plan for a better future for their family. Their
spirituality was identified as a strength that helped them with their daily struggles.
The caseworkers’ responses mirrored the mothers’ in many areas but diverted around
the mothers’ motivation and actions toward change. They did not view the mothers as
making reasonable plans for education or job training. They worried that their interventions
did not push the mothers to achieve independence and may have been disempowering,
rendering the mothers unable to self-identify actions that could improve their lives and those
of their children. The caseworkers realized that all shelter workers need to be trained in
acknowledging the trauma these families experienced and that trauma-sensitive care
needed to be integrated into the program.
Practice Point
Families form when a group of persons has strong emotional bonds, and they may simply
proclaim themselves to be families. Sociocultural and economic factors have influenced
changes in family structure and life cycle.
Happiness is having a large, loving, caring, close-knit family in another city. George
Burns
FAMILY NURSING THEORY
Family Systems Nursing (FSN) is a conceptual framework developed by Wright and Leahey
(1990) to promote family nursing practice. At its core, FSN emphasizes “a focus on the
interaction, reciprocity, and relationships among several systems levels, that is, individual,
family, and larger systems” (Bell & Wright, 2015, p. 180). The intent of FSN is to focus on the
family as the unit of care. Wright and Leahey (2009, 2013) emphasize the importance of
concentrating on both the individual and the whole family simultaneously. FSN is theoretically
rooted in systems theory, communication theory, and change theory (Bell & Wright, 2015). In
FSN practice, the nurse must assess the interaction between and impact of health, illness
suffering, and family functioning. A central belief in the FSN framework is that there are
relationships and an interconnectedness among systems and subsystems (individual, family, and
community), which have a strong reciprocal effect on health and illness. Community health
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nurses provide care to individuals, families, and the community, and therefore need to employ a
conceptual framework, such as FSN, to understand the relationships, interactions, and
reciprocity at multiple systems levels. A central tenet of the framework is the primacy of the
relationship between the individual/family and a nonjudgmental nurse. The relationship between
the nurse and the family must be nonhierarchical, meaning that the nurse does not approach the
family as the expert, but forms an authentic, respectful collaborative partnership with the family.
FSN accepts that family members can have multiple perspectives of the family’s health and
illness, which needs to be explored through a nurse-guided therapeutic conversation with the
family. Although problems, needs, and concerns are addressed, family strengths are openly
acknowledged and resiliency is emphasized. FSN recognizes that the family “suffers” when they
are dealing with an illness, injury, or disability of a family member and the suffering needs to be
examined, and forms of relief, such as maximizing family strengths and connecting with needed
resources, can be identified (Ostlund and Persson, 2014). The overall goal is to restore, enhance,
and sustain family health and well-being (Bell, 2009).
To operationalize this broad conceptual framework in nursing practice, Wright and Leahey
(2009, 2013) developed two clinical practice models: the Calgary Family Assessment Model
(CFAM) and the Calgary Family Intervention Model (CFIM) to link FSN to nursing practice, in
a practical and understandable manner. The models were initially conceptualized from their
extensive experience in family nursing practice, and have continued to evolve, reflective of
changes in family structure, functioning, and development, and in response to widespread use,
evaluation, and research findings. Having a clinical practice model to guide family assessment is
essential for the community health nurse to provide high quality, individualized care to families
who vary in structure, function, and developmental stage, access to resources, and health and
illness experiences. For example, the community health nurse may be providing care to a family
whose teenage daughter is pregnant, or a young family that is adjusting to the realities of the
father’s (primary breadwinner) slow recovery from a major stroke, or an extended family trying
to arrange care of an older adult declining quickly from Alzheimer disease. Using the CFAM,
which is described in detail in the next section, can help the nurse obtain a thorough and focused
assessment of both individuals, the family as a whole, and the family’s relationship with
community-based resources. The assessment findings will then provide insight to and guidance
in the selection of the necessary, individualized family interventions.
Family Assessment: Calgary Family Assessment Model
Families are complex social systems and there are multiple factors that influence their health and
illness experiences. To understand and intervene with families to promote their health and soften
their illness experiences, a detailed assessment needs to be completed. The CFAM was
developed to assist nurses in performing a family assessment in an organized, systematic
manner. The CFAM is a multidimensional model comprised of three basic assessment
categories: structural, functional, and developmental, and the multiple subcategories of each that
combine the elements needed to gain a multilayered understanding of family components. The
model is comprehensive and can initially seem impractical and somewhat overwhelming given
time constraints, however the nurse is responsible for selecting and prioritizing which
subcategories are most relevant to the family. Not all subcategories will need to be addressed
with every family; it is up to the nurse’s clinical judgment. For example, a community nurse
whose practice involves home visits and an ongoing relationship may complete a comprehensive
assessment, while a community nurse working in a clinic setting and seeing the family in a more
episodic manner may have to prioritize and focus the assessment more specifically.
Structural Assessment
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Three aspects of family structure can be assessed using identified subcategories: (a) internal
structure (family composition, gender and sexual orientation of the members, birth order of
children, subsystems including couple, parent–
child, and sibling, and boundaries; (b) external structure (extended family, larger systems which
include social and community connections such as schools, work, religious and healthcare
organizations) and (c) context (culture, race, social class, spirituality and/or religion,
environment) (Wright & Leahey, 2013). Identifying family relationships can be complicated.
Diagrams are a useful visual aid to identify these relationships. Community health nurses
encounter family health concerns in a wide range of circumstances. Attention to the dimensions
and influence of family helps identify ways to support everyone involved. Identifying key
relationships, both within and outside the family, is a good starting point. Two structural
assessment tools, the genogram and the ecomap, are frequently used to provide a graphic
portrayal of the internal and external structure of a family. Although they are similar, each
highlights different aspects of family connections and relationships.
The genogram provides a diagram of the family constellation, and can provide substantial
information about family structure in a clear and simple format. It should include the
information that is most important in assessing the particular family unit. Typically it will
include at least two generations, highlighting family members’ age, gender, relationship, birth
order, marital status, and mortality (Tavernier, 2009) (Fig. 13.1). However, it can be expanded to
include other areas, such as health status, education, and occupation. Genograms show how
interdependent family members are related to each other. Nurses can use genograms to help
families identify common traits as well as unique attributes of various members. Ecomaps
outline the influence that other systems or groups have on families (Fig. 13.2). They illustrate
family relationships and show vital connections, which can include religious, work, educational,
cultural, healthcare and social organizations and groups. Solid or hatched lines plot the strength
of connections. Community health nurses often find that ecomaps are especially helpful to
identify social supports and to show families whether resources are available to assist them
(Rempel, Neufeld, & Kushner, 2007).
Sister is probably the most competitive relationship within the family, but once the sisters
are grown, it becomes the strongest relationship. Margaret Mead
Practice Point
Genograms and ecomaps are graphic representations of family relationships. Nurses can
use genograms to identify key events and relationships within families, and ecomaps can be
used to identify interactions between families and the communities in which they live.
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FIGURE 13.1 Example of the Thomas family’s genogram. SIDS, sudden infant death syndrome.
FIGURE 13.2 Ecomap. The circles represent both persons and institutions or organizations to
which a person or family is connected. The number of lines indicates the strength of the
relationship, the jagged line indicates a negative relationship, and arrows indicate the direction or
reciprocity of the relationship.
Functional Assessment
The functional assessment emphasizes the interaction among family members, assessing how
members actually behave with each other. It focuses on the present, how the family is
functioning now, although past history can be considered. The model includes two basic aspects
of family functioning: instrumental and expressive. The instrumental aspect includes both
activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The nurse
assesses the routines, patterns, behaviors, and interactions related to typical daily activities, such
as hygiene, grooming, meal prep, laundry, sleeping, shopping, housework, medication
administration, and how the family’s current state of health and illness(es) are impacting
instrumental family functioning. During the assessment, the nurse is identifying who is
responsible for certain tasks, how well the tasks are being performed, if all family members
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ADLs and IADLs are being met, and if the division of labor is fair and reasonable.
The CFAM identifies several key subcategories of expressive function. A focal area is on
family communication, which is influenced by culture, socioeconomic status, and family history.
The community health nurse should use observations and effective questioning to assess the
communication patterns of the family, including verbal and nonverbal behaviors. The nurse
should be sensitive to how emotions are expressed among the family members, observing during
interactions if a healthy range of emotions are accepted and supported or if emotional expression
limited and suppressed. Additionally, the nurse should assess the meanings and messages in
verbal communication: are they clear and direct, or are there concealed meanings, vague
responses, and frequent misunderstandings? Nonverbal communication, such as facial
expressions, body posture, and gestures can be detrimental to or supportive of family
interactions and functioning. Table 13.1 describes each of the subcategories of expressive
function and includes sample questions that could be used during the family assessment.
Developmental Assessment
The developmental assessment explores the evolving path the family goes through and the tasks
that need to be addressed at key periods. Wright and Leahey (2013) distinguish between family
development which “emphasizes the unique path constructed by a family” and “is shaped by
predictable and unpredictable events” (p. 91) and family life cycle, which “refers to the typical
path most families go through” (p. 91). Typical life-cycle events include birth, child-rearing,
departure of children, retirement, and death. Historically, the sequence of stages had been fairly
predictable, even with individual, cultural, and ethnic variations. However, more recently,
sociocultural, economic, and other societal factors have increased the variety of family
constellations and influenced family development and life cycle. Given that families present in
various forms, community nurses should avoid a focus on universality and an expectation of
smooth progression through stages. Family life is dynamic, filled with expansion and
contraction (as members join or leave), joys and satisfactions, as well as stresses and conflicts.
During these critical transitions, roles change resulting in a distinct change in the family life
patterns. The nurse should individualize the assessment of the family’s current stage and its
ability to accomplish the tasks that will allow the family to continue on its unique developmental
path.
Family Interventions: Calgary Family Intervention Model
The CFAM and the CFIM are closely integrated with areas of assessment and intervention
overlapping. The therapeutic relationship established between the nurse and the family is central
to both models. The CFIM focuses on enhancing, improving, and sustaining family functioning
through the establishment of a collaborative partnership between the nurse and the family, the
use of therapeutic conversations, and the focus on family strengths and resiliency (Bell, 2013,
2016; Ostlund & Persson, 2014; Persson & Benzein, 2014; Wright, 2015; Wright & Leahey,
2013). Interventions are not standardized or pre-planned; they are specific to each family context
and are directed by the family’s beliefs, preferences, behaviors, and experiences, as shared
during nurse–family interactions and conversations. The nurse–family relationship, which is
based on respect and trust, is integral to the interventions. The focus of interventions is on
needed changes within three domains of family functioning, which would support the lessening
of family suffering (difficulty) and the promotion of family healing and well-being related to the
family experience of illness, injury, or disability. The three domains include cognitive, affective,
and behavioral.
Cognitive domain is related to thinking and the need to gain new information and knowledge
about a health problem affecting the family. The desired outcome of the cognitive domain is to
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change the way a family perceives its health problem so that members can discover new
solutions. Studies found that family nursing interventions improved family members’
understanding and increased their confidence and capability to live with illness. Families gained
new and multiple perspectives and an enhanced adjustment (Bell, 2013, 2016; Ostlund &
Persson, 2014; Persson & Benzein, 2014)
Affective domain is related to feelings and the need to reduce emotions that may be
interfering with a family’s ability to problem solve, cope, and heal, or the need to increase
emotions that support family functioning within the illness experience. Studies found that family
systems interventions softened suffering and increased a sense of individual and family well-
being. The therapeutic conversation enhanced families’ emotional engagement in problem
solving as well as feelings of closeness and affirmation within family relationships (Bell, 2016;
Bell & Wright, 2015; Ostlund, Backstrom, Lindh, Sundin, & Saveman, 2014; Perrson &
Benzein, 2014).
Behavioral domain is related to action and doing and involves helping families change
behaviors that may be detrimental to family functioning and promote behaviors that support
healthy coping, adjustment, and family functioning. Interventions are directed to help family
members interact with and behave differently when relating to each other. Studies have found
outcomes of family members acting in a more caring manner and being more supportive of each
other, improving family communication, and identifying improved methods in coordinating care
and completing family activities (Bell, 2016; Bell & Wright, 2015; Ostlund et al., 2014).
TABLE 13.1 Calgary Family Assessment Model: Assessing Key Areas of
Expressive Functions
Expressive
Functions
Explanation Questions to Ask
Emotional
Communication
Range of emotions that family expresses,
wide or narrow
How does your mother react when your
father is angry? How do you know when
your brother who has diabetes is happy?
How is your family coping with the loss of
your grandmother? Are you and your
family members comfortable crying when
you are sad?
Verbal
Communication
The clarity and directness or masked
meaning in a verbal interaction
When discussing family rules, who is the
clearest and most direct? How do you
respond when your father accuses you of
being late?
Nonverbal
Communication
Influenced by culture: eye contact, body
posture, personal space, gestures, facial
expressions, linked to emotional
communication
How do you feel when your stepsister rolls
her eyes when you are telling your mom
that your migraine headaches have gotten
worse?
Problem Solving Involves behaviors, patterns, and resources
the family uses to respond to and solve its
own problems
What do you do when your baby won’t fall
asleep each night? How are you dealing
with your mother’s safety as her Alzheimer
disease progresses? How did you respond
when your brother told you he was being
bullied at school?
Roles Behaviors and responsibilities that serve to
fulfill family functions
Who is most responsible for managing the
house (shopping, cooking, cleaning)?
When things go wrong, who usually gets
blamed? You described your foster
daughter as a perfect child; can you tell
me what you mean? Who takes care of
you when you are sick?
Influence and Power Refers to the ability of one family member to
persuade, pressure, negotiate, or control
responses and behaviors of another
member; relationship can be hierarchical
or collaborative
Who is responsible for financial decisions?
Who makes the decisions about mealtime,
bedtime, use of electronic devices? Who
decides on discipline for any family
infractions? How are decisions made on
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things that affect most family members?
Beliefs Refers to the values, attitudes, assumptions,
and premises that guide individuals’ and
family’s thoughts and behaviors; culture,
socioeconomic status, and life experience
influence beliefs
What is important to do to maintain your
health? What do you think is the cause of
your son’s illness? How does your chronic
pain affect the family? What do you think
will improve your partner’s asthma
control?
Source: Wright, L. M., & Leahey, M. (2013). Nurses and families: A guide to family assessment and intervention (6th ed.). Philadelphia, PA: F.A. Davis.
The therapeutic conversation provides family members the opportunity to hear each other’s
concerns, challenges, and strengths. The purpose of the conversation is to “create a context for
change and to support the creation of new beliefs, new meanings, and opportunities in relation to
problems described by the family, that is things hampering the family’s health” (Ostlund et al.,
2014, p. 582). The nurse’s openness and interest encourages family members to ask questions
and to share their experience. Each family member present is given time to describe his or her
experience and perspective of the illness experience within the family context. The nurse’s role
is to listen and observe to gain a broad and deep understanding of the concerns, questions,
emotions, behaviors, and interactions among family members. The family members and the
nurse work collaboratively, identifying family strengths, resiliency, and resources. The nurse
provides information, education, training and referral to community resources as indicated and
found acceptable by the family.
Table 13.2 provides examples of interventions for each of the three domains of family
functioning: cognitive, affective, and behavioral.
TABLE 13.2 Calgary Family Intervention Model
Domain of Family
Functioning
Interventions Advice for Interventions Outcomes
Cognitive Domain (a) Commend family and
individual strengths by
observing positive patterns of
behavior
(b) Offer information and
opinions, including new ideas,
and education on a specific
health problem or risk
(a) Observe family for strengths
in coping with health
problems
Communicate sincerity
Begin and end family
conversation with
commendations
(b) Use clear, relevant,
understandable language
Provide easily readable,
written information
Provide information on
community services and
resources
Encourage family to respond
to the information and
opinions shared
(a) Focus on
strengths and
resiliency to
promote families’
positive self-view
and self-efficacy
Foster nurse–
family relationship
(b) Provide new
ideas,
information, and
education to
change the way
the family thinks
about the health
problem and finds
new and effective
solutions
Affective Domain (a) Acknowledge, validate, and
normalize emotional
(b) Encourage family members
to share their unique
experience with the illness or
health condition
(c) Establish emotional support
to respond to family
members’ concerns and
feelings
(a & b) Establish a safe
environment and facilitate a
family conversation in which
all members can express
their feelings, find support,
and understand any negative
impact
(b) During the family
conversation, ask each
member to tell their specific
experience in dealing with an
illness in the family
(c) Listen intently to family
members’ feelings and
concerns, and observe for
(a) Reduce intense
emotions that
may be interfering
with the family’s
ability to
communicate and
problem-solve
(b) Gain a broad
understanding of
the illness
experience for the
family beyond the
specific diagnosis
and treatment
(c) Identify emotional
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emotional support that family
members are able to offer
each other
strengths that can
support healthy
coping and
adjustment
Behavioral Domain (a) Identify family caregivers and
provide caregiver education
and support
(b) Encourage self-care and
respite for the family
caregiver
(c) Assist the family in
developing helpful daily
rituals and routines
(a) Provide education on the
illness Provide training on all
caregiving tasks
Observe the interactions
between the care recipient
and caregivers
(b) Inform family of available
community services (support
groups, home health aids,
daycare, respite facilities)
Teach components of self-
care
(c) Assess typical pre-illness
routines and rituals
Work with family members to
identify adjustments and new
routines needed to deal with
the illness or problem
(a) Improve
understanding of
the caregiver role,
performance of
caregiver tasks,
and care for the
recipient
(b) Decrease
caregiver burden
and support
caregiver health
and well-being
(c) Routines and
rituals provide
structure and
organization and
decrease stress
Source: Wright, L. M. & Leahey, M. (2013). Nurses and families: A guide to family assessment and intervention (6th ed.). Philadelphia, PA: F.A. Davis.
Practice Point
Establishing a nonhierarchical, nonjudgmental nurse–family relationship is foundational to the
Calgary Family Assessment and Intervention Models and essential to family nursing practice.
Family Interview
As in other areas of clinical practice, community health nurses frequently have limited time for
family assessments because of demanding caseloads or staffing shortages. It may not be
reasonable or necessary to complete a comprehensive assessment following the CFAM.
Additionally, focused family interviews of 15 minutes or less can yield a wealth of information
(Box 13.2). The 15-Minute Family Interview, which is based on the CFAM and CFIM, offers a
pragmatic framework for nurses to engage families in a purposeful, therapeutic interaction.
Wright and Leahey (1999, 2005, 2009, 2013); (Duhamel, Dupuis, & Wright, 2009) suggest the
following five leading principles, which maximize information gleaned in a 15-minute family
interview:
Manners: Common courtesies, such as the nurse introducing himself or herself to the family, indicate a
desire to connect with the family and to instill trust in family members.
Use of therapeutic conversation: When time is limited, purposeful and focused conversation helps build a
relationship. Nurses validate family concerns with their active listening.
Ecomaps and genograms: These tools are invaluable, especially when family members are likely to be
involved with the care of another member.
Use of therapeutic questions: Asking family members therapeutic questions helps them not only identify
their expectations about nursing care but also assign priorities to their most urgent needs.
Commendations acknowledging family strengths: Informing families about the assets and resources they
already possess leads them to view their situation differently and makes them more likely to move toward
more effective problem-solving.
Studies have supported the components of the 15-Minute Family Interview as a purposeful,
effective, and efficient means of providing support to families (Bell, 2016; Holtslander, 2005;
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Holtslander, Solar, & Smith, 2013; Moules, & Johnstone, 2010; Ostlund et al., 2014; Ostlund,
Backstrom, Saveman, Lindh, & Sundin, 2016; Persson & Benzein, 2014; Sveinbjarnardottir,
Svaavarsdottir, & Wright, 2013; Yarwood, Richardson, & Watson, 2016). The guidelines for the
15-minute assessment (Wright & Leahey, 2005, 2009) are useful to help keep the interview
focused and family-centered.
13.2 Key Points for a 15-Minute Family Assessment
Show interest throughout.
Keep body language relaxed.
Face the family member when asking a question.
Try to minimize writing while listening.
Acknowledge the family’s strengths.
Share any genograms and ecomaps that illustrate relationships with family members.
Ask family members for their interpretations/impressions (shared between the family and clinician).
Avoid offering advice prematurely.
Allow everyone present to voice observations, insights, or concerns before offering how they could change the
situation.
Ask the family if they see an area that could be changed.
Plan goals and outcomes with the family.
Forge a partnership with the family’s full participation.
Collaborate with the family to set priorities, plan care, and evaluate goals.
Source: Adapted from Wright, L., & Leahey, M. (2005). The three most common errors in family nursing: How to avoid or sidestep. Journal of Family Nursing,
11(2), 90–101.
Evidence for Practice
Holtslander and team (2013) wanted to find an effective educational strategy to integrate
classroom learning in a family nursing course to a clinical practicum and to provide an
authentic opportunity for student nurses to engage with families. To promote students’
ability to develop interpersonal relationships and therapeutic communication, they
implemented the use of the 15-Minute Family Interview in a clinical practicum. Students
used all five components of the interview, and were surprised that families were willing and
enthusiastic about participating in the interview. Students evaluated the use of this
educational strategy through reflective papers and a course survey. By intentionally
focusing on using manners, students realized that their respectful, thoughtful, and courteous
approach developed a trusting relationship with the family that remained throughout the
day. Students reported being more conscientious about not interrupting the family members
as they spoke and interacted. They were surprised that simple gestures, such as calling
each member by name, were so appreciated. While establishing a brief therapeutic
conversation, students realized the value of listening actively, giving undivided attention,
showing genuine concern, and making an effort to connect with the family and understand
the suffering that the illness has caused throughout the family. Completing the genogram
and ecomap at the beginning of the interview engaged all members of the family and
provided foundational information that guided the remainder of the interview.
One family was hesitant to complete the tools, and the student learned that they were
afraid as they felt that their family structure varied from the norm and that they might be
judged harshly. One mother who was quite fearful and stressed about her daughter’s illness
felt reassured after completing the genogram and ecomap that she had many family and
community supports that could assist her with her daughter’s care. Students are frequently
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concerned about asking the right questions, and faculty reminded them that a primary goal
of the therapeutic questions were to “meet the family’s needs for information, referrals,
acknowledgement, and involvement as caregivers” (Holtslander et al., 2013, p. 240). Using
a variety of questions (direct, open-ended and circular), students gained confidence in
facilitating the interview, making it individualized to the family’s context and needs.
Students also realized that the interview provided a valuable opportunity to observe
family communication and differences in their personality and perspectives. Family
members can be quite fatigued, distressed, and demoralized as they struggle to deal with
the multiple stressors that accompany a family member’s illness or injury. Acknowledging
the challenges the family faces while also recognizing the strengths and resources that the
family possesses provided family members with a sense that they had the ability to cope,
change, and find solutions to the current problems they were facing. In their reflection
papers, students reported that following the interview components provided a deeper
understanding of the family’s needs and priorities, which then guided their ability to provide
therapeutic family-focused intervention and care. Clinical faculty found that use of the
interview helped move students from only focusing on and providing care to the individual
patient to addressing the needs and concerns of the whole family.
Review the components of the 15-Minute Family Interview, is this something that you
could use in your community health clinical setting to provide more family-focused care?
FSN and the CFAM and CFIM emphasize the centrality of the nurse–family relationship and
how the relationship can be used therapeutically to improve and sustain family development and
functioning, and ultimately family health and well-being. The typical settings in which
community health nurses practice (home, schools, public health departments, and community-
based clinics and organizations), support a family focus and allow more continuing care and the
structure to establish a committed and longer-term relationship.
HOW COMMUNITY HEALTH NURSES SUPPORT
FAMILIES
Focusing on individual illness or health needs often obscures or omits the influence of the
family. Community health nurses encounter family health concerns in a wide range of
circumstances. Therefore, community health nurses provide family-focused care to family units,
for example, who are dealing with pregnancy and childrearing, an acute illness or injury of a
family member, a chronic illness of a family member, or end-of-life care to a family member.
Community health nurses have an advantage in providing family-focused care as many
community health nurses make home visits. Home visiting allows the nurse to observe and
assess the family in their natural setting. Several generations may live in a single household. For
example, a teen mom might share a home with her parent(s), or a grandparent with early signs of
dementia might live with his or her children and their families. Observation of interpersonal
dynamics in these intergenerational households during family assessment can provide much
insight into patterns of coping and communication within the family.
Diversity embraces every aspect of family life and finds expression in family history,
heritage, and language, as well as in the ways that families manifest and maintain health.
Understanding diversity in individual families emphasizes the need for community health nurses
to pay close attention to various dimensions of family life. Patterns of everyday family life are
likely to change if a family member has to assume full-time or part-time responsibility for the
care of another family member. Cultural considerations related to ethnicity, religion, and
language figure prominently; however, generational difference and lifestyle choices also
contribute significantly to diversity among and within families.
Home visiting programs by community and public health nurses have proven beneficial for
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family nursing provided to vulnerable populations, such as pregnant women and their young
children (Davis, & Gufstafson, 2014; Dmytryshyn et al., 2015; Garcia, McNaughton,
Radosevich, Brandt, Monsen, 2013; Jack et al., 2015; Jean-Baptiste et al., 2017; Olds, 2006,
2012). Community and public health nurses are strong advocates for maternal-child and family
health.
Your children are not your children. They are the sons and daughters of Life’s longing for
itself. They came through you but not from you and though they are with you yet they
belong not to you. Khalil Gibran
Family-Focused Home Visiting in Community-Based Maternal-
Child Health
Pregnancy is a developmental event in families. Whether a pregnant woman is an adolescent or
an adult, accessible high-quality prenatal and postpartum care is essential to prevent a host of
negative short- and long-term outcomes. Infant mortality rates in the United States are
considered high for an industrialized country, and low birth weight continues to be directly
related to poverty more than any other variable (Meade & Ickovics, 2005). Prevention initiatives
are essential to respond to situations that are threatening to the mother, child, father, and
extended family engaged in the prospective birth and in learning nurturing parenting skills.
Efforts to prevent substance use, including alcohol, during pregnancy are vitally important
(Koniak-Griffin, Anderson, Verzemnieks, & Brecht, 2000). Finally, pregnant adolescents need
support from their families and schools because teen pregnancy is a distinct predictor of poverty,
intrafamily conflict, substance use disorder, and violence (Pickett, Mookherjee, & Wilkinson,
2005). Early intervention programs in which nurses establish a trusting relationship and provide
prenatal care, emotional support and counseling, and parenting skill education have promoted
individual and family health and positive development.
Nurse–Family Partnership is an evidence-based, community health program focused on
promoting maternal and child health for vulnerable low-income expectant first-time mothers
(including adolescent mothers) and their newborns. Each expectant mother is paired early in her
pregnancy with a community health nurse, who provides ongoing home visits until the child’s
second birthday. The program design and implementation is based on over 30 years of research,
including several randomized controlled trials, which have examined both short- and long-term
outcomes in mother, child, and family health and well-being. Based on the evidence of success,
the program has been replicated throughout the United States (Olds, 2006, 2012; Olds et al.,
2013) and also internationally in Canada (Dmytryshyn et al., 2015; Jack et al., 2015), the United
Kingdom (Rowe, 2013; Smyth & Anderson, 2014), Australia, and New Zealand (Fowler et al.,
2012).
The following are the three major goals for the Nurse–Family Partnership Program:
To improve pregnancy outcomes by helping women engage in good preventive health practices
To improve child health and development by helping parents provide responsible and competent care
To improve the economic self-sufficiency of families by helping parents develop a vision for their own
future, plan future pregnancies, continue their education, and find work
The program is funded by a range of private and public sources (services are free), and it is
offered in 42 states in the United States. It has served 280,487 families since its inception in
1996 and currently has 33,804 families enrolled with 1,888 nurses providing the home visits
(Nurse-Family Partnership [NFP], 2018). Throughout the home visits, the nurses focus on three
major interventions: (a) promoting behaviors (new mother and other family members) which
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positively affect pregnancy outcomes, the child’s health and development, and the parents’ life
course (future pregnancy decisions, education, and work); (b) guiding the women in establishing
supportive relationships with family members and friends; and (c) connecting the women and
their family members with needed health, educational, work-related, and social services. The
program is family-centered and strength-based such that the nurses approach the interventions in
ways that are consistent with the parents’ values, beliefs, and aspirations and build on the
parents’ and family’s assets. The nurse facilitates the parents’ belief in their ability to change
while focusing on understanding the family circumstances and views.
Multiple studies have revealed positive multigenerational outcomes that benefit individuals,
families, and communities, and reduce the costs of long-term social service programs. Positive
outcomes reported when compared to a control group include decreased pre-term and low-
weight births, increased breastfeeding, improvements in up-to-date immunizations by 6 months
of age (NFP, 2018); improved prenatal nutrition and decrease in smoking, increased informal
support and improved use of formal community services (Olds, 2006); sensitive, competent care
of the child with a decrease in injuries, emergency room visits, and child maltreatment (Olds,
2006), and regarding the parental life course, fewer subsequent pregnancies with longer intervals
between the first and second children, greater participation in the workforce, and less
dependence on entitlement programs (welfare, food stamps).
What is home? My favorite definition is “a safe place,” a place where one is free from
attack, a place where one experiences secure relationships and affirmation. It’s a place
where people share and understand each other. Its relationships are nurturing. The people
in it do not need to be perfect; instead, they need to be honest, loving, supportive,
recognizing a common humanity that makes all of us vulnerable. Gladys M. Hunt
Evidence for Practice
The family–nurse relationship, which is developed through respect and trust and focused on
strengths and collaboration, is foundational to family nursing practice. The relationship is
critical to guiding the family through the necessary changes to promote positive family
functioning and health. Aston and colleagues (2015) explored how public health nurses
(PHNs) supported mothers and families during postpartum home visits. The researchers
recruited 16 nurses who worked in the postpartum home visiting program (range 2.5 to 12
years working in the program) and 16 mothers who received the home visits. The mothers
ranged in age from 18 to 38 years of age, were first-time mothers, and most lived in urban
areas. Individual semi-structured interviews were conducted in a private office at work for
the PHNs and in their home for the mothers. Open-ended questions were used to
encourage participants to share their perspective on the home visiting experience. A core
finding was the importance of establishing a positive relationship beginning with the initial
phone call and continuing throughout all the home visits. The nonhierarchical, therapeutic
relationship fostered the formation of trust and allowed significant learning, acquisition of
parenting skills, and necessary changes to occur within a supportive environment. The
mothers admitted that they were initially fearful of being judged by an authority figure as
inadequate as a new mother.
The findings provided insight into the “how to” of relationship development. It was
important that the PHNs present as friendly and approachable, not as distant and
controlling. Being aware of the power dynamic was critical so that the PHNs did not use a
directive, invasive approach as the expert but genuinely were open to and fostered an
authentic, collaborative relationship. The nurses encouraged the mother to lead the visits so
that the focus was on her needs at the time, and that she was viewed as the expert of her
baby. Although the program had specific topics that had to be addressed during the visits,
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the nurses did not present them in a prescriptive manner but remained flexible and let the
mothers’ and the families’ needs dictate what was addressed at each visit. The PHNs
reported using a strength-based interactional process, as opposed to a deficit model, and
the mothers verified the significance of this. They never felt criticized or demeaned. The
PHNs intentionally chose the words they used, the timing of interventions, and teaching
strategies employed so that they built confidence, competence, and self-esteem and
promoted positive family functioning and development. The study’s findings supported the
major premises of family systems nursing practice and the Calgary Family Models.
I sustain myself with the love of family. Maya Angelou
Family Caregivers: In Need of Education and Support
When illness or disability becomes part of a family experience, community health nurses
distinguish themselves as facilitators by helping both the family unit and individual family
members to find balance. Whether caring for an older adult who has functionally declined due to
chronic comorbidities such as diabetes and heart failure or a neurodegenerative condition, such
as Alzheimer’s disease, caregiver burden has been well documented in the literature as a
significant stressor on the family member who assumes primary responsibility for care (Easom,
Cotter, & Ramos, 2018; Spurlock, 2005). In most cultures, women (mothers, wives, sisters,
daughters, or female in-laws) have assumed this role, usually by default. Caregiver burden is a
significant issue for families because it can cause the development of physical or emotional
illness in the caregiver over time (Blair & Perry, 2017; Caceres & Perez, 2018; Friedemann, &
Buckwalter, 2014). Caregivers might express feeling trapped, isolated, and overwhelmed with
no possible help with care. In addition, caring for a family member can lead to financial and
work strain in some circumstances. An important consideration is that, although caregiver
burden does exist, caregivers articulate their desire to provide caregiving in grateful appreciation
for what the recipient has done for them in the past. Expression of positive feelings and the
privilege connected with caring for another is plentiful in the literature (Baker, 2018; Lund,
2005). Yet, caregiver burden inevitably affects the dynamic of the entire family unit and is
considered intrafamily strain (Baker, 2018; Friedemann, & Buckwalter, 2014).
Family Caregiver Characteristics and Needs
More attention is being directed at the role and challenges related to informal family caregiving,
as the older adult population, many of whom suffer from debilitating chronic conditions,
continues to increase. Family members are expected to assume more responsibility in their care.
To help understand the complexity of caregiving in the U.S. population, the American
Association of Retired Persons completed an extensive study, which provided valuable findings
for healthcare providers and public policy makers (AARP, 2015). An estimated 43.5 million
adults in the United States provide unpaid care to an adult or a child. The estimated prevalence
of caring for an adult is 16.6%, or 39.8 million Americans, of whom approximately 34.2 million
provide unpaid care to an adult aged 50 or older. The majority of caregivers are female (60%),
but male family caregivers are increasing and now account for 40%. Almost half (48%) of
family caregivers are providing care to a parent or parent-in-law. On average, caregivers spend
24 hours a week providing care to the family member, however, spouse/partner caregivers,
considered higher-hour caregivers, typically provide 45 hours a week (AARP, 2015). Higher-
hour caregivers are a vulnerable population as they characteristically experience higher levels of
emotional stress, physical impact, and financial strain, which collectively affect their health and
well-being (Cohen, Cook, Sando, Brown, & Longo, 2017). Family caregivers perform a wide
range of care tasks, including personal hygiene and grooming, meal preparation, housework,
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errands, transportation, coordination of healthcare, and complex nursing tasks. Many care
providers are also trying to balance other aspects of their life, such as work, child care, and their
own home maintenance. In addition, care providers report feeling ill-prepared to assume all the
responsibilities, particularly coordinating healthcare and assuming responsibility to perform
nursing tasks. They report that information and teaching from healthcare providers were lacking
or inadequate.
Reinhard, Levine, and Samis (2012) published results from their survey of 1,677 family
caregivers that exposed the challenges they faced in providing more complex care to family
members suffering from serious chronic conditions. The findings of this report prompted public
policy and legislative action in the form of the Caregiver Advise, Record, and Enable (CARE)
Act. Within three years of the publication of this report, 39 states had enacted this legislation
that involves the family caregiver from the point of hospital admission, through adequate notice
of and preparation for discharge home (Gould, 2018). This act stipulates that hospitals
participate in very specific exchanges with family caregivers on the patient’s behalf in order to
collect information and provide education. Under this law, hospitals must do the following:
1. Record the name of the family caregivers in the patient’s medical record at the point of
admission.
2. Inform the identified family caregivers when the patient is to be discharged, providing
adequate notice.
3. Provide the family caregivers with education and live instruction to prepare them for
undertaking medical/nursing tasks on behalf of the discharged patient. (Gould, 2018)
This may seem like a simple or even obvious addition to standard healthcare practices, but it
represents an acknowledgement that caregivers are significant and relevant to a person’s
transition home and overall health management. Family caregivers need detailed discharge
teaching related to coordination of care and the specific tasks that they will be providing.
Home Health Nurses and Family Caregivers
The American Journal of Nursing has assumed a leadership role in efforts toward educating
nurses to provide improved support to family caregivers through the development and
dissemination of Supporting Family Caregivers: No Longer Home Alone, a series of articles
with the purpose of helping nurses provide caregivers with the tools they need to manage their
family member’s healthcare at home. The series includes topics such as discharge planning and
teaching, medication administration and management, home safety and fall prevention, ostomy,
skin, and wound care, and was produced in cooperation with the AARP Public Policy Institute.
Each article includes an informational handout and links to instructional videos. The series was
published between 2017 and 2018, and is available at
https://journals.lww.com/ajnonline/pages/collectiondetails.aspx?TopicalCollectionId=38.
Family caregivers are critical to the ability of family members to remain at home and to have
their ADLs and specific healthcare needs met. However, assuming this role can put a strain on
individual family members and overall family communication and functioning. Home health
nurses can serve an essential role in providing education, training, and support to family
caregivers. In addition to teaching family members how to provide the needed care, home health
nurses can assist families dealing with challenging caregiving issues to avoid or resolve family
conflict, stress, burden, and burnout. Caregivers are diverse, varying in age, gender, race,
ethnicity, and socioeconomic status (Cohen et al., 2017). Although they may share some
commonalities in the challenges they face and the positive aspects they experience, caregivers
may encounter different burdens based on their circumstances. Based on the care recipient’s
condition and needs and the caregiver’s own problems and resources, different education,
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https://journals.lww.com/ajnonline/pages/collectiondetails.aspx?TopicalCollectionId=38
services, and support may be required. A recent study demonstrated that family caregivers
beyond expending substantial time and effort in providing care, also spend significant amount of
their own money, adding financial stress (Rainville, Skufca, & Mehegan, 2016). The authors
found that in 2016, family caregivers spent approximately $7,000 on caregiving expenses,
accounting on average to 20% of their total income. In addition, caregivers experience work
strain and personal strain related to their finances. More than half of the caregivers in the study
reported at least one work-related strain, such as reducing or changing their hours and taking
paid or unpaid time off. To meet these additional financial obligations, caregivers were
decreasing their own personal spending, using savings, and reducing retirement contributions
(Rainville et al., 2016).
Certain groups of caregivers face a disproportionate burden in caregiving. Community health
nurses need to be aware of these higher-risk caregivers. For example, there has been increased
interest in and concern for Latino family caregivers. Latino older adults experience health
disparities, suffering from a disproportionate burden of chronic illnesses, such as diabetes,
cardiovascular diseases, and an increasing prevalence of Alzheimer disease and other dementias.
Latino older adults are also economically disadvantaged; 70% of Latino adults who are 65 and
older have incomes less than two times the supplemental poverty threshold (Gould & Cooper,
2013). Many Latino older adults live with their children or extended family. Twenty-one percent
of the estimated 40 million family caregivers are Latino (AARP, 2017). Given cultural values
and expectations, Latino older adults are typically cared for by Latina female family members
and are much less apt to be aware of or to seek assistance outside of the family (Caceres &
Perez, 2018; Cruz-Oliver, Parikh, Wallace, Malmstrom, Sanchez-Reilly, 2018). These family
caregivers spend 44% of their annual income on caregiving related expenses (more than double
the average) and provide 52% more time on weekly caregiving when compared to the caregiver
population (Rainville et al., 2016). The National Hispanic Council on Aging (2017) completed a
survey on caregiving in the Latino population and asked about the challenges the caregivers
face. The top three challenges included (a) balancing family caregiving and personal
responsibilities (64%), (b) problems understanding governmental insurance and assistance
programs (56%), and (c) locating information and resources that would assist with their
caregiving (47%). Half of the respondents reported that they lacked training and would benefit
from formal information and training on caregiving, and stress management. The nurse needs to
be aware that the needs of family caregivers can vary based on race, ethnicity, gender, and
socioeconomic status, with some groups at risk for higher burden and burnout.
Through family assessment, home health nurses can identify areas of teaching, training and
referral, which will benefit both the care recipient and the caregiver and overall family
functioning. Using the 15-Minute Family Interview could help the nurse establish trust and
rapport; encourage family members (care recipient and care provider) to openly share their
needs, concerns, and frustrations; prioritize needs (information and training); and acknowledge
their strengths and efforts. Using the genogram, the nurse and family could recognize other
family members who may be able to assist and how roles and responsibilities could be better
distributed. Using the ecomap would reveal any external resource connections that the family
may have and then assist the nurse in making recommendations and referrals for other services
that could assist the family. Improving a family’s understanding of available services and
community resources and how to apply for them is an important aspect of the home health
nurse’s role. Box 13.3 lists several of the important services and resources of which the home
health nurse should be knowledgeable and able to discuss with family members.
13.3 Resources for Family Caregivers and Care Recipients
Caregiver support groups
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Stress management programs
Individual and family counseling
Home delivered meals
Adult daycare programs
Homemakers
Home health aides
Companions
Assisted living
Nursing homes
Transportation services
Information on Medicare and Medicaid
Information on fuel assistance and SNAP benefits (food stamps)
Grocery delivery services
Mail order pharmacy services
The nurse could facilitate periodic family meetings and conversations that allow family
members to express their feelings about the caregiving, assess the effectiveness of their
communication related to caregiving needs, prioritize the multiple demands, organize the
required tasks, develop a caregiving schedule (that avoids duplication and gaps), and identify
helpful community resources.
During home visits, the nurse could provide teaching on the family member’s condition so
that the caregiver is aware of signs and symptoms of decline, how to follow the plan of care, and
who to contact when a symptom occurs. In addition, the nurse is able to provide training on
home safety, medication administration, personal care, specialized feedings, wound and ostomy
care, and any other typical nursing tasks that the caregiver is now providing. Providing feedback
on the caregiver’s performance of the skills and expressing confidence in his or her ability to
learn and safely perform the needed nursing tasks will promote the caregiver’s sense of self-
efficacy.
Helping family caregivers understand that self-care is essential for them to maintain their
physical and emotional well-being, to balance all of their responsibilities, and to sustain their
role and functioning as a care provider. The family caregiver needs to understand the importance
of period of respite, when he or she can have a break from responsibilities, either through in-
home services (homemaker, home health aid) or out-of-home services (adult daycare, overnight
residential facilities). The home health nurse can encourage both the caregiver and the care
recipient of the need for respite services, and facilitate the referral for the appropriate ones.
The home health nurse is well positioned to address the needs of family caregivers through
the provision of emotional support, care coordination, didactic teaching, task training, and
resource referral.
Evidence for Practice
All caregivers, and in particular caregivers for family members who have dementia, need
respite from their caregiving functions. Caregiving for a family member with dementia has a
lengthy trajectory (five years or more) and involves continual functional decline, with
increasing occurrence of difficult behaviors. Understanding the need for and seeking respite
is essential for continued caregiving survival.
Easom and team (2018) studied self-efficacy, defined as “the degree to which one is
motivated to take action” (p. 16) in relation to seeking respite care among a sample of family
caregivers of family members with Alzheimer’s disease. The researchers wanted to
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examine if an intervention led to any differences in self-efficacy between African American
and Caucasian caregivers. The study was based on the Resources for Enhancing
Alzheimer Caregiver Health (REACH II), a randomized controlled trial that evaluated a
multicomponent, evidence-based intervention for caregivers of individuals with dementia.
The intervention involved individualized education, support and stress management skills
through home visits, and telephone contact over a six-month period.
The current study is a translation of the clinical trial in a community setting, which
followed all the previous study’s protocols and measurements but did not include a control
group. The researchers used a pre- and post-test design with self-efficacy measured using
the Revised Scale for Caregiving Self-Efficacy, at the first home visit (baseline) and at the
last home visit (program’s end). The scale has a 15-item checklist used to measure
caregiver confidence in caregiving skills. The higher the score, the higher self-efficacy. The
subscale for self-efficacy included obtaining respite. The intervention was completed by 123
caregivers, including 66 African American and 49 Caucasian participants. Both groups
showed significant improvements in self-efficacy related to obtaining respite. Of note,
although the percentage of change in self-efficacy score was the same in both groups, the
African American caregivers both began the study and ended it with higher levels of self-
efficacy. The study demonstrates that self-efficacy in obtaining respite, an important skill
relative to maintaining the caregiver’s well-being and ability to sustain caregiving can be
enhanced for different racial groups through a tailored intervention. The authors recommend
further research to study individual components of the intervention to determine if
improvement is related to specific components.
CASE STUDY 1
Both Tanya and Luke Barnes have been sleeping poorly at night. They have not received
any e-mails or phone calls from their mother for 10 days. Lately, they show little interest in
school or other activities they usually enjoy. They constantly ask Elsa and her husband
when they will hear from their mother. One afternoon before the children returned from
school, an army chaplain visits the home to inform the family that Elaine has been
severely wounded in a mortar attack. Elsa phones Lucy immediately and asks, “What do I
do now?”
Thinking about the Calgary Family Assessment Model, which areas would be most
important for the nurse to assess?
Using the Calgary Family Intervention Model” Affective Domain, what therapeutic
questions and interventions could the nurse use to help Tanya and Luke express and
cope with their emotions, after hearing about their mother’s injury?
Use an ecomap to identify the family’s probable connections with the community (school,
medical care, church, etc.). Which connections should be aware of the children’s
situation? What community resources could the nurse identify to assist the family?
CASE STUDY 2
Laura arranged a meeting at Jim’s home with his family, Arlene, and Nancy, the social
worker assigned to the case. Jim took everyone to see the new facility. Arlene would eat
breakfast and lunch at a day program from 7:30 to 4:00 on weekdays and have dinner
with the family. Arlene was unhappy with the plan because she does not want to leave
her “home.” Jim’s daughters were also upset about their aunt moving into their home and
said their life will not be “normal” anymore.
Later that week, Laura phoned Jim and Liz to tell them that several vacancies have
opened in a residential community. Several of Arlene’s friends are moving there. Although
Arlene would receive a small subsidy to move into the facility, the family would have to
pay approximately $2,000 a month for expenses.
Jim wants to talk to his sisters, especially because their parents’ health is declining.
The elder Thomases receive homemaker services through their town’s council on aging.
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Mrs. Thomas’s dementia is advancing, and she might need placement in an Alzheimer
care facility. Mr. Thomas receives a monthly pension, and his savings are limited.
The three Thomas siblings have had difficulty trying to agree on care arrangements for
both their parents and older sister. The elder of the two, Marilyn, 55 years old, strongly
opposes placement. Their sister Alice, 50 years old, is relatively indifferent. Use the
Calgary Family Assessment and Intervention Models and 15-Minute Family Interview as
guides when thinking about your responses to the following questions:
Describe strategies for an open conversation at a family meeting. How would the nurse
intervene in the cognitive, affective, and behavioral domains (to provide information,
address feelings and emotions, and identify needed actions).
What are the family caregiver issues related to Arlene and Mrs. Thomas? How can the
nurse assist the family with distributing the tasks, and assuring quality care?
Identify the factors that will affect the Thomas siblings’ decisions about placement for
their mother and sister.
What approaches could help the Thomas family learn about possible placement options?
Identify social factors that might influence the Thomas family’s decision-making.
What type of community resources could help the Thomas family cope with care and
financial issues?
How would you support Arlene during the decision-making process?
As illustrated in the two case studies, illness, disability, and death can affect family structure
(the head of the household), function (decision-making), and outcomes (economic stability) both
positively and negatively, in a variety of ways, (Mactavish & Schleien, 2004; Maes, Broekman,
Dosen, & Nauts, 2003; McIntyre, Blacher, & Baker, 2002; Williams et al., 2002).
Happy families are all alike; every unhappy family is unhappy in its own way. Leo Tolstoy
Practice Point
Education, training, and support by nurses are essential to effective family caregiving. Family
caregivers need encouragement to use community and respite services to reduce their
burden and allow for self-care so that they can continue their caregiving responsibilities.
Student Reflection
Throughout my nursing program, I have struggled to find a balance between being a student
and a nurse. After my community health clinical practice, I am struck by the difficulty families
have in making decisions for one another, even if it’s in their best interest. Today, I worked
with an 84-year-old woman who was discharged from the hospital after treatment for a fall at
home. She cannot remember what happened right before she fell, but her doctors
suspected that she had a mild seizure or stroke. The nurse at the center let me come along
on a visit to the woman’s home last week to assess home safety. The woman’s children are
concerned about her living alone, and until now, they have been reluctant to talk about
alternative living arrangements.
At the family meeting, the woman’s doctor said that it was in the family’s best interest to
consider assisted living arrangements because of Mrs. J.’s impaired mobility and decreased
cognitive status. Both her social worker and community health nurse expressed that the
family needed more time to make a decision. Her adult children said that they could see the
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advantages of assisted living. They worry about their mother’s safety living alone and want
to make sure that she is safe and has some independence, and they would like to visit a
local facility. As a student nurse, I thought this situation was difficult. Clearly, the decision to
move a parent into an assisted living facility is complicated, but I observed that the goal of
the meeting was to help them make an informed decision and support them through the
process. I realized how difficult it was for adult children to make decisions on their parents’
behalf. I can’t imagine having to do that for my mom or dad. Every family has a different way
of dealing with difficult situations. As I develop as a nurse, I have to remember that
everyone I care for has someone to call family, and learn how to meet individual and family
needs. Experience will help me master this skill.
COMMUNITY HEALTH NURSES’ RESPONSIBILITY TO
FAMILIES
Family configurations and life cycles have changed due to the influence of sociocultural and
economic factors. Community health nurses need to gain a theoretical understanding of family
and of the contemporary changes in family structure, function, and development. In fulfilling
their responsibility to provide family-focused care, community health nurses must develop
family nursing competencies, provide care to the family as a unit, and understand the critical
importance of the nurse–family relationship in family nursing practice.
Working with families frequently requires community health nurses to be creative when
planning interventions. Family assessment, using a structured guide, such as the 15-Minute
Family Interview, provides a good starting point, which enables nurses to explore a family’s
practices and priorities related to health and wellness. The ultimate goal should be to enable the
family to identify its health needs and to help them choose the best way they can meet the needs
and any required change. In this instance, a community health nurse’s responsibility is to listen
and facilitate building consensus within the family. The Calgary Family Assessment and
Intervention Models provide evidence-based guidance on completing a family assessment and
offering family interventions.
Community health nurses are known for being resourceful. Sharing information about
available agencies and relevant resources will help families meet their health goals. Actions
could be as simple as providing internet websites or as complex as finding all the resources
needed by family caregivers.
Most importantly, community health nurses have a responsibility to advocate for families. A
primary challenge is to promote health and wellness within the family. The two overarching
goals of Healthy People 2020 (CDC, 2011) are to improve the quality and years of healthy life
and to eliminate health disparities. Community health nurses often intervene on a family’s
behalf to make sure that families receive access to optimal healthcare. Families often need
assistance to navigate the healthcare system, especially when the family is unfamiliar with the
setting or trying to cope with illness or crisis that disrupts everyday life.
Practice Point
The responsibilities of community health nurses to families are to provide theory-guided and
evidence-based family assessment and intervention to promote family health and well-being.
KEY CONCEPTS
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Family nursing practice acknowledges the interrelatedness of the health of the family and its individual
members. In providing care for both the family and its individual members, a therapeutic nurse–family
relationship is essential.
Community health nurses need to be knowledgeable about changes in family structure and lifestyle based
on sociocultural and economic factors.
The Calgary Family Assessment and Intervention Clinical Models and 15-Minute Family Interview provide
theoretical and practical guidance for providing family nursing care.
Home visiting programs by nurses support nurse–family relationships, and promote maternal-child family
health.
Family caregiver burden and stress is a major problem for families. Home health nurses can provide the
education, training, referral and support necessary to improve care for the recipient, sustain family
caregiving, and promote self-care for the caregiver.
CRITICAL THINKING QUESTIONS
1. Consider a family from your clinical practice that is different in some way from your own. Discuss the
challenges of working with the family and describe how you were able to support them. Write a short
paragraph about something you learned from that experience. Include an action that you might approach
differently if you were in a similar situation again.
2. Draw an ecomap for a family that you recently encountered. Identify what could be an obstacle to that
family’s health. Discuss how limitations in a family could be made more positive, and how using the
ecomap would be helpful.
3. Family assessment can be challenging, often because of time constraints. Describe how you could gather
valuable information about a family in the following situations, use the 15-Minute Family Interview to guide
you:
a. A student’s aunt who comes to the school health office to take her nephew home because of head lice
b. A single father who brings his toddler to the clinic because of an earache
c. Two married adult daughters of an elderly woman with dementia during a home visit
d. An elderly man who never married visits the local senior center for a blood pressure check
4. Describe a situation from clinical experience in which a family’s culture influenced how they approached
healthcare. Include factors that affected interaction, for example, language barriers.
5. Discuss how unexpected life crises, catastrophic illness, and chronic illness affect families. Use examples
from your clinical experience to illustrate the ways that the nurse–family relationship can support family
coping and functioning with these events.
6. Use pertinent components of the Calgary Family Assessment and Intervention Models to assess and
intervene with a family from your clinical practice.
REFERENCES
American Association of Retired Persons (AARP). (2015). Caregiving in the U.S. Retrieved from
https://www.aarp.org/content/dam/aarp/ppi/2015/caregiving-in-the-united-states-2015-report-revised
American Association of Retired Persons (AARP). (2017). AARP launches major effort to raise awareness
on the impact of family caregiving on U.S. Latinos. Retrieved from https://states.aarp.org/aarp-to-raise-
awareness-about-latino-family-caregiving/
Abraham, M., & Moretz, J. G. (2012). Implementing patient-and family-centered care: Part I-understanding
the challenges. Pediatric Nursing, 38(1), 44.
America’s Children. (2017). Key national indicators of well-being. Federal Interagency Forum on Child
and Family Statistics. Retrieved from https://www.childstats.gov/pdf/ac2017/ac_17
America Counts Staff. (2017). Living with mothers only is second-most common. US Census. Retrieved
from https://www.census.gov/library/stories/2017/08/majority-of-children-live-with-two-parents.html
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https://www.aarp.org/content/dam/aarp/ppi/2015/caregiving-in-the-united-states-2015-report-revised
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WEB RESOURCES
Please visit thePoint for up-to-date web resources on this topic.
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http://thepoint.lww.com/vitalsource/ebook/9781975111694
Part 4
Challenges in Community
and Public Health Nursing
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Chapter 14
Risk of Infectious and
Communicable Diseases
Barbara A. Goldrick
For additional ancillary materials related to this chapter. please visit thePoint
WE ARE LEGEND
We are HIV. Our family is ancient.
Out of Africa,
Monkey to man,
From the trees and forests,
To the towns and cities.
We are here.
For we are HIV, we are legion.
Our children are billions,
Our home, in your defenses,
In your blood, your brain,
Your saliva, your semen.
We are everywhere.
For we are HIV, we are immortal.
We are part of you,
And you of us,
We live with you, but
May not die with you.
We go on.
For we are HIV, we are travelers.
From lover to lover,
Mother to baby,
Donor to blood bank,
Blood bank to patient,
We follow you.
For we are HIV, we evolve.
NRTIs, NNRTIs, PIs, INIs,
New designs, new drugs,
Bring it on, bring it on,
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http://thepoint.lww.com/vitalsource/ebook/9781975111694
Q151M, K103 N, L90M.
We adapt, we survive.
We are HIV. We consume.
Your resources, your time,
Your hope, your lives,
Your new drugs are easy.
Where are your vaccines?
Can you stop us? We will see.
—Julian W. Tang
CHAPTER HIGHLIGHTS
Infectious versus communicable disease
Outbreak investigation: person, place, time
Healthcare-associated infections
Public health surveillance
Foodborne and waterborne illnesses
Sexually transmitted diseases
OBJECTIVES
Explain the difference between infectious and communicable diseases.
Examine the agent, host, and environmental characteristics of healthcare-associated infections and
common community-acquired infections.
Describe the major means of transmission of communicable diseases.
Define an outbreak investigation by person, place, and time.
Describe public health surveillance.
Differentiate between foodborne and waterborne illnesses.
Outline prevention and control measures for sexually transmitted diseases.
KEY TERMS
Agent: Infectious agents are biological in nature and are capable of producing an infection or
infectious disease and include bacteria, viruses, rickettsiae, fungi, protozoa, and helminths.
Carrier: A person or animal that harbors an infectious organism and transmits the organism to
others, although having no symptoms of the disease.
Colonization: The presence and multiplication of infectious organisms without invading or
causing damage to tissue.
Common source outbreak: An outbreak characterized by exposure to a common, harmful
substance.
Contagious: Communicable by direct or indirect contact.
Endemic: The constant or usual prevalence of a specific disease or infectious agent within a
population or geographic area.
Epidemic: Significant increase in the number of new cases of a disease than past experience
would have predicted for that place, time, or population; an increase in incidence beyond that
which is expected.
Healthcare-associated infection: Originating in a healthcare facility; formerly called nosocomial
infection.
Incubation period: Time period between initial contact with the infectious agent and the
appearance of the first signs or symptoms of the disease.
Infectious disease: Presence and replication of an infectious agent in the tissues of a host, with
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manifestation of signs and symptoms. An infectious disease need not be contagious or
communicable.
Pathogenicity: Ability of the agent to produce an infectious disease in a susceptible host.
Propagated outbreak: Outbreak resulting from direct or indirect transmission of an infectious
agent from an infected person to a susceptible host; secondary infections can occur.
Reservoir: Location where an infectious agent is normally found, where it lives and reproduces
under normal circumstances.
Secondary infection: Infections that occur within the accepted incubation period following
exposure to a primary case.
Surveillance: A continual dynamic method for gathering data about the health of the general
public for the purpose of primary prevention of illness.
Transmission: The transfer of an infectious agent from one person or place to another.
CASE STUDIES
References to case studies are found throughout this chapter (look for the case study icon).
Readers should keep the case studies in mind as they read the chapter.
CASE 1
In 2008–2009, contamination of the municipal drinking water supply occurred in Alamosa, CO. At
that time, the city’s drinking water was not chlorinated for disinfection due to a waiver from the
statewide requirement for disinfection granted to the city in 1974. In 2007, the city was in
compliance with all health-based drinking water standards, with the exception of the arsenic
standard (Adapted from Falco & Williams, 2009).
CASE 2
Megan is a high school senior who moved into the community several months ago with her parents
and younger brother. She has been sexually active for 2 years. She has had unprotected
intercourse with three classmates since her arrival in town. For the past 2 weeks, she has had an
urge to urinate frequently. Her vaginal secretions have increased, and the mucus has an unusual
odor. She has made an appointment with the school nurse to discuss her symptoms.
INTRODUCTION
Infectious disease is universal, and any attempt to imagine how it arose…will inevitably
take us back to the very earliest phases of life. Frank MacFarlane Burnet and D. O.
White
According to the World Health Organization (WHO), more than half (54%) of the 56.4 million
deaths worldwide in 2015 were due to the following top 10 causes: ischemic heart disease,
stroke, lower respiratory infections, chronic obstructive pulmonary disease, lung cancer (along
with trachea and bronchus cancers), diabetes, dementias/Alzheimer disease, diarrheal diseases,
tuberculosis (TB), and road injuries. Lower respiratory infections remained the most deadly
communicable disease, causing 3.2 million deaths worldwide in 2015. The death rate from
diarrheal diseases almost halved between 2000 and 2015, but still caused 1.4 million deaths in
2015. Similarly, TB killed fewer people during the same period, but was still among the top 10
causes of disease, with a death toll of 1.4 million (WHO, 2015). As populations age in middle-
and low-income countries over the next 20 years, the proportion of deaths due to
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noncommunicable diseases will rise significantly. Globally, noncommunicable disease deaths
from cancer will increase to 12.6 million by 2030, and deaths from cardiovascular diseases will
rise to 22.2 million during the same period (WHO, 2013).
Although HIV/AIDS is no longer among the world’s top 10 causes of death, it killed 1.1
million people in 2015 (compared with 1.5 million in 2000), but it is projected to fall to less than
400,000 by 2030 (WHO, 2013).
Almost half of the world population was still at risk for malaria in 2015, with 214 million
cases and 438,000 deaths; two-thirds of these deaths occurred in children under 5 years of age.
The global target is to reduce this number by 90% by 2030 (WHO, 2013). In addition, new
pathogenic microorganisms have emerged, new strains of known organisms have developed that
are more virulent, microorganisms have become resistant to many antibiotics, and infectious
diseases have now become a means of terrorism. The characteristics of infectious diseases have
changed, but they still are a significant health burden in most of the world.
This is true despite the great advances during the 20th century in the prevention and control
of infectious diseases. These advances primarily occurred in developed countries and included
purified drinking water, waste control, plentiful foods, immunizations, and drug therapy. This
was preceded, however, by the need to prevent and control epidemics of infectious diseases,
such as cholera, typhus, and influenza, which killed many people in Europe, America, and much
of the rest of the world in the later part of the 19th century. By 1900, infectious diseases were
the leading cause of death in the United States. Today, changes in health patterns in the world’s
more developed countries reflect an increased lifespan, with associated chronic diseases such as
heart disease, cancer, and cardiovascular accidents.
Nonetheless, influenza and pneumonia remained in the top 10 causes of death in the United
States in 2015 (National Center for Health Statistics, 2016). The Healthy People 2020 (U.S.
Department of Health and Human Services [USDHHS], 2010) initiative in the United States
provides science-based, 10-year national objectives for improving the health of all Americans.
For three decades, Healthy People has established benchmarks and monitored progress over
time regarding established goals and objectives. Specific goals and objectives for prevention and
control of infectious diseases are designed to reduce morbidity, mortality, and costs associated
with infectious diseases. Selected objectives from Healthy People 2020 for immunization and
infectious diseases are found in Box 14.1.
Several new and reemerging infectious diseases have been identified in the past 40 years.
Some examples are briefly described below.
1. In the 1970s, toxic shock syndrome (TSS) killed several women before it was linked to the
use of high-absorbency tampons that provided a moist, warm home where the bacteria could
thrive. It was also found to be associated with the contraceptive sponge and diaphragm birth
control methods. TSS is caused by a well-known organism, Staphylococcus aureus.
Streptococcal TSS, a related infection, is caused by Streptococcus bacteria.
2. Legionnaires disease, which is caused by the Legionella pneumophila bacterium, was first
recognized among hotel guests during an outbreak in Philadelphia, PA in 1976. Between
8,000 and 18,000 people are hospitalized with Legionnaires disease in the United States each
year.
3. Another infectious disease that occurred in the last century is acquired immunodeficiency
syndrome (AIDS), which was first observed in a few young men in 1981. Infection with HIV,
largely transmitted through sexual contact, is now a major cause of morbidity and mortality
throughout the world. Today, 35 years after the first cases were reported, HIV is still a leading
cause of death and a health threat to millions worldwide. Each year, HIV claims more than a
million lives, and about 2 million people become newly infected with the disease. The U.S.
Centers for Disease Control and Prevention (CDC) provides support to over 75 countries to
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strengthen their national HIV/AIDS programs and build sustainable public health systems
through the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). PEPFAR is
supporting life-saving antiretroviral treatment (ART) for nearly 11.5 million people,
exceeding its 2016 target of 11.4 million, and up from the 50,000 individuals who were
receiving ART in sub-Saharan Africa prior to when PEPFAR began.
4. Lyme disease began in 1975 when a cluster of children and adults residing in the Lyme, CT
area experienced uncommon arthritic symptoms. By 1977, the first 51 cases of Lyme arthritis
were described, and the Ixodes scapularis (black-legged) tick was linked to the transmission
of the disease. In 1982, Borrelia burgdorferi, the tick-borne spirochete that causes Lyme
disease, was discovered. Lyme disease is focally endemic in North America, Europe, and Asia
and is probably the most common tick-borne bacterial disease in the world. Lyme disease is
the most commonly reported vector-borne illness in the United States; in 2015, it was the
sixth most common nationally notifiable disease. However, this disease is concentrated
heavily in the northeast and upper Midwest, and so far, it has not occurred nationwide (CDC,
Lyme disease). See Chapter 15, Emerging Infections, for more on Lyme disease.
5. A new respiratory disease appeared in May 1993, when several healthy young members of the
Navajo Nation in New Mexico died within a short period of time from an unexplained
respiratory condition. This cluster of strange, unexplained deaths caught the attention of the
world, resulting in rapid diagnosis of what was later called hantavirus pulmonary syndrome
(HPS). As of November 1, 2012, the National Park Service had announced a total of 10
confirmed cases of hantavirus infection in people who recently visited Yosemite National
Park (CDC, Outbreak of hantavirus infection in Yosemite National Park).
6. About this same time, a toxic strain of Escherichia coli (O157:H7), an organism that normally
inhabits the intestines of animals, caused illness and death in children in many parts of the
United States. When there are news reports about foodborne outbreaks of “E. coli” infections,
they are usually talking about E. coli O157.
7. Also, a virulent strain of Streptococcus pyogenes (Group A strep), known for its ability to
evade the normal walling-off process by human immune systems, was named a “flesh-eating
bacteria” (necrotizing fasciitis) because of the serious consequences of the infection.
8. In 1996, the possible transmission of mad cow disease (bovine spongiform encephalopathy, or
BSE) to humans resulted in the slaughter of thousands of cattle in England. This is a
particularly interesting disease, because the infectious agent is a protein (prion) rather than a
microorganism.
9. Ebola hemorrhagic fever was initially recognized in 1976, with two simultaneous outbreaks in
Nzara, Sudan, and in the Democratic Republic of Congo in Africa. The latter outbreak
occurred in a village near the Ebola River, from which the disease takes its name. Ebola
hemorrhagic fever outbreaks, with a case-fatality rate of 50% or more, have appeared
sporadically since its initial recognition. The most recent Ebola outbreaks occurred in 2018,
where by mid-December 2108, 529 cases of Ebola virus disease (EVD) were reported to the
WHO. In total, at that time, there were 311 reported deaths due to EVD, for a case-fatality
rate of 58.8% (ISID, 2018).
10. Researchers believe that the virus is zoonotic (animal-borne) and is normally maintained in an
animal host that is native to the African continent. The Ebola virus is transmitted through
close contact with the blood, other body fluids, or organs of infected animals. It also is
transmitted by contact with blood or other body fluids (including semen) from persons
infected with EVD. See Chapter 15, Emerging Infections, for more on Ebola.
11. In 2003, newspapers, television, and the internet were full of frightening articles and images
about an outbreak of severe acute respiratory syndrome (SARS), a viral illness, in Asia. At
that time, the possibility of a SARS pandemic was worldwide news.
12. Shortly thereafter, also in 2003, fear of a bird flu (avian influenza virus H5N1) outbreak
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captured the attention of the world. Avian viruses do not usually infect humans, which means
that the risk for avian influenza is generally low for most people. However, since 2003, the
WHO has reported a total of 859 laboratory-confirmed cases of human infection with avian
influenza A(H5N1) virus, including 453 deaths, from 16 countries (WHO, 2017). Most cases
of H5N1 avian influenza infection in humans have resulted from contact with infected
poultry. See Chapter 15, Emerging Infections, for more on H5N1 avian influenza.
13. In 2009, H1N1, a new influenza virus, was identified that caused illness in people. This new
virus, which was first detected in Mexico and the United States in April 2009, caused the first
flu pandemic in more than 40 years. The virus spread from person to person worldwide, in
much the same way that regular seasonal influenza viruses spread. In mid-2009, the WHO
had declared a pandemic of 2009 H1N1 influenza. By August 2010, worldwide more than 214
countries and territories had reported laboratory-confirmed cases of pandemic influenza
H1N1 2009, including over 18,449 deaths. The CDC estimated that the total number of 2009
H1N1 cases in the United States between April 2009 and April 2010 ranged between 43 and
89 million, with an estimated 12,469 related deaths (Shrestha et al., 2011; WHO, Pandemic
(H1N1) 2009). For more information on the 2009 H1N1 virus, see Chapter 15, Emerging
Infections, for more on H1N1.
14. Avian influenza A(H7N9) had not previously been seen in either animals or people until it
was found in March 2013 in China. As of September 2018, a total of 1,567 laboratory-
confirmed human cases, including at least 615 deaths, had been reported to the WHO. The
2018 wave of A(H7N9) was the sixth wave of the outbreak. However, only three new human
cases had been detected as of September 2018. Also, there had been fewer A(H7N9) virus
detections in poultry and environmental samples. See Chapter 15 for more on Avian influenza
A(H7N9).
15. In late 2012, the WHO received reports of two clusters of human infection with a novel
coronavirus (CoV) in the Middle East. Although this new coronavirus is distantly related to
SARS-CoV, it is different, and this particular strain of CoV had not been previously identified
in humans. However, the WHO and the CDC recognized that the emergence of a new
coronavirus was capable of causing severe disease and raised concerns due to the recent
experience with SARS. Because of the location of the discovery of the new coronavirus, it
was named Middle East respiratory syndrome coronavirus (MERS-CoV). As of September
2018, 27 countries had reported a total of 2,229 laboratory-confirmed cases of MERS-CoV to
WHO, including at least 798 deaths (case-fatality rate, 35.8%). The majority of cases had
occurred in Saudi Arabia, as well as in multiple other countries of the Arabian Peninsula. See
Chapter 15 for more on Middle East respiratory syndrome coronavirus.
16. The Zika virus, a mosquito-borne virus, was first discovered in 1947 in the Zika Forest in
Uganda. The first human cases of Zika virus infection were detected in 1952. Since 2015,
outbreaks of Zika virus infection have reported evidence of mosquito-borne Zika virus
transmission to the WHO from 73 countries and territories, including the United States.
Twelve countries, including the United States also have reported evidence of person-to-person
transmission of the Zika virus. Pregnant women are at increased risk for congenital infection,
and 23 countries and territories reported microcephaly, or suggestive congenital infection, and
other CNS malformations potentially associated with Zika virus infection. See Chapter 15 for
more on Zika virus.
14.1 Healthy People 2020 Objectives for Immunization and Infectious Diseases
Reduce, eliminate, or maintain elimination of cases
of vaccine-preventable diseases.
Reduce early-onset group B streptococcal disease.
Reduce meningococcal disease.
Reduce invasive pneumococcal infections.
Increase the percentage of children under 6 years of
age whose immunization records are in a fully
operational, population-based immunization
information system (IIS).
Increase the number of states collecting
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Achieve and maintain effective vaccination coverage
levels for universally recommended vaccines
among young children.
Increase the percentage of children aged 19 to 35
months who receive the recommended doses of
DTaP, polio, MMR, Hib, hepatitis B, varicella and
pneumococcal conjugate vaccine (PCV).
Decrease the percentage of children in the United
States who receive 0 doses of recommended
vaccines by age 19 to 35 months.
Maintain vaccination coverage levels for children in
kindergarten.
Increase routine vaccination coverage levels for
adolescents.
Increase the percentage of children and adults who
are vaccinated annually against seasonal
influenza.
Increase the percentage of adults who are
vaccinated against pneumococcal disease.
Increase the percentage of adults who are
vaccinated against zoster (shingles).
(Developmental) Increase hepatitis B vaccine
coverage among high-risk populations.
(Developmental) Increase the scientific knowledge
on vaccine safety and adverse events.
Increase the percentage of providers who have had
vaccination coverage levels among children in
their practice population measured within the
past year.
kindergarten vaccination coverage data
according to CDC minimum standards.
Increase the number of states that have 80% of
adolescents with two or more age-appropriate
immunizations recorded in an IIS among
adolescents aged 11 to 18 years.
Increase the number of states that use electronic
data from rabies animal surveillance to inform
public health prevention programs.
Increase the number of public health laboratories
monitoring influenza virus resistance to antiviral
agents.
Reduce hepatitis A.
Reduce chronic hepatitis B virus infections in infants
and young children (perinatal infections).
Reduce hepatitis B.
Reduce new hepatitis C infections.
Increase the proportion of persons aware they have
a hepatitis C infection.
(Developmental) Increase the proportion of persons
who have been tested for hepatitis B virus within
minority communities experiencing health
disparities.
Reduce tuberculosis (TB).
Increase treatment completion rate of all
tuberculosis patients who are eligible to complete
therapy.
Increase the percentage of contact to sputum
smear–positive cases who complete treatment
after being diagnosed with latent tuberculosis
infection.
Reduce the average time for laboratories to confirm
and report tuberculosis cases.
Source: U.S. Department of Health and Human Services. Healthy People 2020: Immunization and infectious diseases objectives. Retrieved April 29, 2013, from
http://healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=23.
With the global mobility of humans, animals, food, and feed products greater than ever
before, the spread of dangerous pathogens has and will continue to increase. Infectious diseases
are a growing threat to all nations, although the burden is greatest in the developing world. To
address these issues, the CDC and a network of international public health partnerships have
been formed. These partnerships, which include WHO, the United Nations, the World Bank, and
the Bill & Melinda Gates Foundation, are contributing to the increased availability of drugs and
vaccines, and providing better public health education programs worldwide (CDC, CDC’s
Global health partnerships).
Student Reflection
When I was a teenager, I went to summer camp for 2 weeks. We cooked our own meals
over a campfire. It was great. However, by the second week, several of us went to the camp
nurse for help with diarrhea and/or vomiting. After several days, 23 of us were ill with these
symptoms. As a result, the local health department was notified, the camp was closed, and
environmental disinfection was undertaken. Hand hygiene was emphasized. Stool samples
were obtained from symptomatic campers and tested for bacterial and viral pathogens.
Fifteen out of the 23 (65%) stool samples were positive for norovirus. All the campers
recovered from their gastroenteritis. Although the cause of this outbreak was never
identified, the encounter stayed with me and made me aware of how important sanitation
and hand hygiene is to public health.
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http://healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=23
FIGURE 14.1 Chain of infection.
EPIDEMIOLOGY OF THE INFECTIOUS PROCESS: THE
CHAIN OF INFECTION
According to the germ theory of disease, specific microorganisms cause specific diseases.
As described in Chapter 6, the epidemiologic triangle is a model that scientists have developed
for studying health problems. It helps us understand infectious diseases and how they spread.
The agent, or the microbe that causes the disease, is the “what” of the triangle. The host, or the
human, animal, or insect that is harboring the infectious agent, is the “who” of the triangle. The
environment, which includes those external factors that cause or allow disease transmission, is
the “where” of the triangle.
An infectious disease in a human (or animal) host is one caused by the growth of pathogenic
microorganisms in the body. Other necessary elements that add to the epidemiologic triangle are
in the so-called chain of infection, which include a portal of exit from the host, environmental
reservoirs, transmission, and a portal of entry to a new host (McKenzie, Pringer, & Kotecki,
2014) (Fig. 14.1). For a disease to be communicable, or contagious, there must be a portal of
exit from the infected person (or animal), a means of transmission, and a portal of entry to a
susceptible host.
Agent
Infectious agents are biologic agents capable of producing an infection or infectious disease and
include bacteria, viruses, rickettsiae, fungi, protozoa, and helminths (Heymann, 2014). An
infectious disease need not be contagious or communicable.
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Case 1: A month-long investigation found that there were 442 reported cases of
Salmonella typhimurium, including 122 laboratory-confirmed cases, 20 hospitalizations,
and one death. An epidemiological investigation estimated that up to 1,300 people may
have become ill from the city’s water supply. Residents were advised to drink bottled
water while the entire water system was flushed and hyperchlorinated. A boil water order
followed the bottled water order, and it remained in place until tests confirmed that the
city’s water was safe to drink again (Adapted from Falco & Williams, 2009).
In this case, what was the “where” of the epidemiologic triangle?
In addition to the interaction between the infectious agent, the host, and the environment, the
progression of an infectious agent depends on its pathogenicity. Pathogenicity is the ability of
an infectious agent to cause disease in a susceptible host (Heymann, 2014). It depends on the
infectivity of the infectious agent, its ability to invade and destroy body cells (invasiveness),
produce toxins (toxicity), and its virulence.
Infectivity varies depending on the route of entry of the infectious agent and the
susceptibility of the host. For example, if Clostridium tetani (tetanus bacilli) gains entry into the
body through a puncture wound, and the person has current tetanus immunization, the person
(host) is not susceptible to infectivity by C. tetani. Various characteristics of an infectious agent
are found in Box 14.2.
14.2 Properties of Infectious Agents Influenced by the Host and the
Environment
Pathogenicity: Ability of the agent to produce an infectious disease in a susceptible host
Infectivity: Ability of the agent to invade the host and replicate
Virulence: Severity of the infectious disease that results from exposure to the agent
Toxicity: Ability of the agent to produce toxins
Immunogenicity: Ability of the agent to produce specific immunity within the host
Invasiveness: Ability of the agent to destroy body cells
Practice Point
An understanding of the pathogenicity of an infectious agent is important in a decision to
initiate prevention and control measures. It is necessary to break the chain of infection. For
example, good hand hygiene breaks this chain by preventing the transmission of infectious
agent from one person to another.
But however secure and well-regulated civilized life may become, bacteria, Protozoa,
viruses, infected fleas, lice, ticks, mosquitoes, and bedbugs will always lurk in the
shadows ready to pounce when neglect, poverty, famine, or war lets down the defenses.
Hans Zinsser
Host
The second component of the epidemiologic triad is the susceptible host. In infectious disease
epidemiology, just the presence of an infectious agent is not sufficient to produce an infectious
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disease. The process requires a susceptible host. There are several host factors that determine
whether a person is at risk for an infection or an infectious disease. These include age, sex, race,
physical and emotional health, and immune status.
Portals of Entry and Exit
Infectious agents both enter and leave the body in multiple ways. Portals include the skin,
respiratory tract, alimentary tract, genital tract, conjunctiva, and vertical transmission from
parent to offspring. An example is the fecal–oral transmission of hepatitis A through indirect
contact with infected fecal material.
Incubation Period
If an infectious agent enters the host and begins to multiply, an infection occurs. The time
between exposure to an infectious agent and the manifestation of symptoms in the host is called
the incubation period. Each infectious disease has its own incubation period, but it can also
vary in different hosts. For example, the incubation period for influenza is 24 to 72 hours after
the virus enters the body, when symptoms start. However, some people can be infected with the
influenza virus but have no symptoms. The period of communicability varies. Adults can begin
spreading the influenza virus one day before they have any symptoms and for 3 to 7 days after
symptoms start. Children can transmit the virus after more than 7 days (Heymann, 2014).
Case 1: Salmonella typhimurium is transmitted via the fecal–oral route and the time when
the strength of the transmission increases is 12 to 72 hours after infection. Over a period
of 4 to 7 days, the majority of people infected feel better even if not treatment but one of
the severe effects of the infection is losing electrolytes through fluid loss in diarrhea and
this symptom and losses can require hospitalization. It typically takes 2 to 4 weeks from
the start of a person’s illness to confirming that they are part of an outbreak.
1. Is Salmonella typhimurium a communicable (contagious) disease?
2. Who were the susceptible hosts?
Some diseases have longer incubation periods. For example, hepatitis B has an average
incubation period of 60 to 90 days, but it can be as short as 2 weeks and as long as 6 to 9
months. A person infected with hepatitis B virus (HBV) may be asymptomatic but still can
transmit the virus to others. Asymptomatic people with chronic hepatitis antigenemia (the
presence of HBV antigen in the blood) are carriers of the HBV and can transmit the virus to
others through percutaneous inoculation, exposure to mucous membranes, and sexual contact
(Heymann, 2014). More information about hepatitis can be found in medical–surgical textbooks.
When an infectious agent is present and there are no clinical signs of disease, colonization
with the infectious agent is said to have occurred, and the infected person is capable of
transmitting the agent. An example is methicillin-resistant S. aureus (MRSA), which has
become increasingly common in many healthcare facilities over the past decade. A person can
carry MRSA in his or her nose and throat and can then shed the bacteria. For example, a
healthcare worker colonized with MRSA can transmit the organism to neonates or to
postoperative patients (surgical wounds), causing severe morbidity and mortality. In recent
years, MRSA has become a community-acquired infection (CA-MRSA), with outbreaks in
athletes, schoolchildren, military recruits, and prison inmates. Factors that have been associated
with the spread of CA-MRSA skin infections include close skin-to-skin contact, openings in the
skin such as cuts or abrasions, contaminated items and surfaces, crowded living conditions, and
poor hygiene. CA-MRSA most often presents as skin or soft tissue infection such as a boil or
444
abscess (CDC, MRSA). Asymptomatic, subclinical, or occult infections are identifiable only by
certain laboratory tests, such as serology or skin tests. An example of a skin test to identify
infection is the purified protein derivative (PPD) skin test used to identify TB infection.
Screening for specific conditions such as TB is also a form of secondary prevention.
Infection with HIV is unapparent in its early stages and may be transmitted from one person
to another when infected blood, semen, or vaginal secretions come in contact with an uninfected
person’s broken skin or mucous membranes. In addition, an infected pregnant woman can
transmit HIV to her infant during pregnancy or delivery, as well as through breastfeeding. At the
end of 2014, the most recent year for which data are available, an estimated 1,107,700 adults
and adolescents were living with HIV. An estimated 166,000 (15%) had not been diagnosed, and
young people were the most likely to be unaware of their infection. Among people aged 13 to
24, an estimated 51% (31,300) of those living with HIV at the end of 2013 didn’t know they
were infected (CDC, 2017).
Environment: Reservoir
The third component in the epidemiologic triad, the environment, provides reservoirs of
infectious agents (microbes); these reservoirs can be humans, animals, plants, insects, water,
and soil. Microbes live everywhere and their habitats expand as humans alter the environment
and extend contact with them. Microbes are adept at adaptation and change under selective
pressures for survival and replication. For example, influenza viruses continually evolve,
resulting in annual epidemics and an ongoing need to develop new influenza vaccines each year.
Another example is antibiotic-resistant strains of microorganisms, such as MRSA.
Infectious disease, then, is not nature’s tantrum against humanity. Often it is an argument
in what becomes a long marriage. Arno Karlen
Infections transmitted from animal reservoirs to humans are known as zoonoses. Examples of
zoonoses are rodent-transmitted plague, hantavirus, and monkeypox. Although rare, zoonotic
infections occur in the United States. Hantavirus pulmonary syndrome (HPS), a severe,
sometimes fatal, respiratory disease in humans, is caused by an infection with a hantavirus.
Anyone who comes into contact with rodents or their droppings that carry hantavirus is at risk
for HPS (CDC, Hantavirus pulmonary syndrome). In November 2012, the National Park Service
announced a total of 10 confirmed cases of hantavirus infection in people who recently visited
Yosemite National Park. Three of the confirmed cases were fatal (CDC, 2012a).
Changes in the environment tend to have the greatest influence on the transmission of
microbial agents that are waterborne, airborne, foodborne, or vector-borne, or those that have an
animal reservoir. Transformation of forest to agricultural land in Venezuela led to emergence of
a new disease in 1989: Venezuelan hemorrhagic fever. Reforestation of abandoned farmlands in
the northeast was a factor in the emergence of Lyme disease in the United States.
In Case 1, at the time of the outbreak, the Alamosa’s community public water system
infrastructure consisted of seven deep artesian wells, from an aquifer considered to be a
protected groundwater source, two elevated storage tanks, and one ground-level storage
reservoir. Over 75% of the water pumped to the city’s water system was from the Weber
well through the Weber reservoir at the time of the outbreak.
Although the Safe Drinking Water Program had increased in recent years, the city of
Alamosa had not addressed integrity issues at the Weber Reservoir, and were not
detected during previous inspections of the water system (Adapted from Falco & Williams,
445
2009).
What environmental factors contributed to this outbreak?
Transmission
Mechanisms of transmission of an infectious agent from a reservoir to another host include
airborne transmission, direct contact, indirect contact, and droplet transmission.
Airborne Transmission
Airborne transmission occurs when microorganisms are carried in the air in small particles,
called droplet nuclei, at distances that exceed a few feet. TB is an example of an airborne
infection transmitted by droplet nuclei. A person with active TB disease of the lungs or throat
releases TB bacteria into the air when he or she coughs, sneezes, speaks, or sings. People nearby
may breathe in these bacteria and become infected. TB bacteria also may spread by droplet
nuclei to persons who are not nearby (e.g., through air-conditioning units).
Bacterial spores (e.g., Aspergillus spores) can spread by airborne transmission through dust
when they are mixed in with dry soil (Heymann, 2014).
Direct Contact
Direct contact occurs through direct body surface-to-body surface contact and physical transfer
of microorganisms between a susceptible host and an infected or colonized person (or animal).
For example, sexually transmitted diseases (STDs) are transmitted by direct contact with an
infected person.
An example of direct contact with an animal reservoir is the transmission of the H5N1 avian
influenza virus, which was transmitted from poultry to humans in the “bird flu” epidemic that
occurred between 2004 and 2008. Recently published papers indicate that we are only three
genetic changes away from a pandemic of H5N1 influenza (Enserink, 2012). See Chapter 15 for
more information on avian influenza viruses.
Indirect Contact
Indirect contact involves contact of a susceptible host with a contaminated intermediate
inanimate object, called a vehicle, such as a contaminated surgical instrument, needle, toy,
soiled clothing, or bed linen. Vehicles also include food, water, and contaminated hands that are
not washed (Heymann, 2014). Indirect contact also includes vector transmission. Vectors are
animal or insect carriers of infectious agents. Mechanical vector-borne transmission occurs
when an insect carries the microorganisms on its feet or proboscis, or through its gastrointestinal
tract. Biologic vector-borne transmission occurs when propagation of the microorganism is
required within the insect before it can be transmitted to another host. Malaria is an example of
biologic vector-borne infectious disease, which is transmitted by mosquitoes (Heymann, 2014).
Evidence for Practice
The CDC has reported an increasing number of outbreaks of enteric disease associated
with animals at fairs and petting zoos. Investigators found the route of transmission was
usually from direct hand-to-mouth contact with animal feces. Guidelines to reduce the risk of
disease are designed to interrupt this route. They include recommendations to wash hands
after touching animals, to keep food and drinks outside of animal areas, and to prevent
children from putting their hands or objects (such as pacifiers or sippy cups) in their mouths
446
while interacting with animals. Most petting zoos provide hand hygiene facilities, but
handwashing compliance varies. The CDC has published measures to prevent infection
associated with animals at fairs and petting zoos. See CDC (2011a)—Compendium of
measures to prevent disease associated with animals in public settings, 2011 at
http://www.cdc.gov/mmwr/pdf/rr/rr6004
Droplet Transmission
Although droplet transmission theoretically is a form of contact transmission, the mechanism of
transfer of the pathogen to the host is quite distinct from either direct or indirect transmission.
Therefore, droplet transmission is considered a separate route of transmission. Droplets are
generated from the source person primarily during coughing, sneezing, and talking, and are
propelled a short distance (less than 3 ft) through the air and deposited on the conjunctivae, nasal
mucosa, or mouth of another person. Measles and influenza are examples of communicable
diseases transmitted by droplet spread (Heymann, 2014).
In Case 1, Salmonella survival studies indicate that a low infective dose of 10 to 100
organisms in drinking water may be sufficient to cause illness. Also, the bacteria can
survive in drinking water or biofilms for at least a week, depending on the level of
contamination. Based on all the information gained during the investigation, the likelihood
that fecal matter from an animal source (e.g., avian source) of Salmonella bacteria
entered the Weber reservoir and then contaminated the remainder of the Alamosa
drinking water system was supported (Adapted from Falco & Williams, 2009).
1. How is Salmonella typhimurium transmitted?
2. What was the portal of entry to the new host(s)?
OUTBREAK INVESTIGATION
An endemic disease, infection, or infectious agent occurs when it becomes prevalent within a
population or geographic area. For example, chloroquine-resistant malaria is endemic in most of
Africa, the Middle East, Asia, and all of the South Pacific islands (CDC, The yellow book 2017).
An epidemic refers to a significant increase in an infection or infectious disease beyond the
expected (endemic) level in a certain population and/or geographic area. Epidemics also occur
when a new infectious agent emerges or reemerges. A pandemic is an epidemic that generally
spreads worldwide. An example of a pandemic is the H1N1 influenza outbreak that occurred in
2009 to 2010. Outbreak carries the same definition of epidemic, but is often used for a more
limited geographic area (Porta, 2014). The steps of an outbreak investigation are outlined in Box
14.3.
14.3 Steps in an Outbreak Investigation
Establish and verify diagnosis of reported cases; identify agent.
Search for additional cases; collect critical data and specimens.
Characterize cases by person, place, and time.
Formulate and test tentative hypotheses regarding possible causative factors.
Implement control measures to control the outbreak.
Evaluate efficacy of control measures.
Communicate findings; prepare written report.
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http://www.cdc.gov/mmwr/pdf/rr/rr6004
Source: Association for Professionals in Infection Control and Epidemiology. (2009). APIC text of infection control and epidemiology (3rd ed.). Washington,
DC: Author.
Establishing the Existence of an Outbreak
To establish that an outbreak exists, a comparison of the current incidence of cases with baseline
or endemic status is essential. If local data are not available, the incidence (described in Chapter
7) of cases should be compared with that in the literature. Observed rates should be greater than
the expected level. In some situations, a single case of a communicable disease long absent from
the population, or the first occurrence of an infection not previously recognized in that
geographic area, requires immediate reporting and epidemiologic investigation; two such cases
associated in time and place may indicate the start of an epidemic (Heymann, 2014). For
example, two cases of smallpox in the United States are above the expected level, because
smallpox was eradicated worldwide in 1977.
The criteria used for defining a case are important aspects of an outbreak investigation;
however, the case definition may change as more data are collected. Once the criteria have been
established, the suspected cases are grouped into definite cases, probable cases, and possible
cases categories.
Describing Cases by Person, Place, and Time
As was discussed in Chapter 6, person, place, and time characterize the description of an
epidemiologic problem. As data are collected on individual cases in an outbreak investigation,
attack rates can be calculated according to demographic variables such as age, sex, and other
factors or attributes like occupation or exposure to the suspected agent. These data are helpful in
comparing the characteristics of those who develop the infection with the characteristics of those
who do not when conducting case-control studies (Chapter 8). This occurs when epidemiologists
test tentative hypotheses to explain the outbreak and identify the population at risk (CDC,
2012b).
When describing an outbreak by place, it may be necessary to use spot maps to identify
concentrations of cases within certain areas, and this may show clustering of cases. The use of
maps also further defines the population at risk. The use of time in describing an outbreak
requires that investigators go back to the first case or indication of outbreak activity. These data
graphically provide a histogram of the epidemic curve, which helps determine whether the
outbreak is from a common source or from a propagated (continuous) source. The epidemic
curve also helps determine the incubation period of the infection and if the problem is ongoing.
As a general rule, a unit of time used in an outbreak investigation is one-fourth (0.25) of the
average incubation period for the illness under investigation (CDC, 2012b).
The data in Figure 14.2 illustrate an epidemic curve from the well-known common source
outbreak of cholera in London in 1854, which was investigated by John Snow, the “father of
epidemiology.” Dr. Snow established that cholera was spread by water from the contaminated
Broad Street well. When the pump handle was removed and people could no longer obtain water
from the well, the epidemic subsided. Note that although the typical incubation period for
cholera is 1 to 3 days, the outbreak lasted more than one month, because of the contaminated
water supply, before the Broad Street pump handle was removed. Figure 14.3 is an example of a
propagated epidemic curve of a measles outbreak. The incubation period for measles is typically
10 days, but may be as short as 7 days and as long as 18 days (CDC, 2012b). The secondary
infections, which are spread from person to person, show intervals in the epidemic curve,
indicating that the outbreak is not from a common source.
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FIGURE 14.2 Common source epidemic curve: Broad Street pump cholera outbreak, London,
1854. (Source: Centers for Disease Control and Prevention.)
FIGURE 14.3 Propagated epidemic curve: Measles outbreak. (Source: Centers for Disease
Control and Prevention. Retrieved from http://www.cdc.gov/epo/dih/Epidemic_Curve/page06.htm.)
A common source outbreak is one that has the same origin (i.e., same person or vehicle as
the reservoir or means of transmission). A propagated (continuous) outbreak is one in which
the infection is transmitted from person to person over a longer period of time than with a
common source outbreak, and it can generate secondary infections with intervals between peaks
that approximate the usual incubation period for the infection. An example of measles cases is
outlined in see Figure 14.3. Secondary infections are those that occur within the accepted
incubation period following exposure to a primary case (Porta, 2014). Characterizing an
outbreak by person, place, and time is called descriptive epidemiology (see Chapter 8), because
it describes the population under study. This step is critical for several reasons. First, by
becoming familiar with the data, it is possible to learn what information is reliable and
informative (e.g., the same unusual exposure reported by many of the people affected) and what
may not be as reliable (e.g., many missing or “don’t know” responses to a particular question).
Second, a comprehensive description of an outbreak is provided by showing its trend over time,
its geographic extent (place), and the populations (people) affected by the disease and the time
period in which it occurs. This description lets an epidemiologist begin to assess the outbreak in
light of what is known about the disease (e.g., the usual source, mode of transmission, risk
factors, and populations affected) and to develop causal hypotheses (CDC, Principles of
Epidemiology, 2012). In turn, these hypotheses can be tested using the techniques of analytic
epidemiology (see Chapter 8).
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HEALTHCARE-ASSOCIATED INFECTIONS
Healthcare-associated infections (HAIs) (previously called nosocomial infections) are a
significant cause of morbidity and mortality in the United States. It is estimated that about one in
every 20 inpatients has an infection related to healthcare. These infections cost the U.S.
healthcare system billions of dollars each year and lead to the loss of tens of thousands of lives.
In addition, HAIs can have devastating emotional, financial, and medical consequences. The
majority of HAIs are urinary tract infections (UTIs), surgical-site infections (SSIs), bloodstream
infections, and pneumonia (CDC, Estimates of Healthcare-Associated Infections). The U.S.
Department of Health and Human Services’ (USDHHS) ultimate goal of eliminating all HAIs
has identified the reduction of central line-associated bloodstream infections (CLABSIs), SSIs,
and catheter-associated urinary tract infections (CAUTIs) as a primary goal in 2013 (USDHHS,
2013).
The CDC’s National Healthcare Safety Network (NHSN) is a public health surveillance
system that maintains and supports the USDHHS national HAI prevention priorities. Since its
inception in 2005, NHSN has collected HAI data from nearly all U.S. hospitals. NHSN data are
reported annually to measure progress toward the HHS goal of HAI prevention. As of 2014, a
50% reduction occurred in CLABSIs, up from the 32% reduction reported in 2010; a 17%
reduction in SSIs since 2008, up from the 7% reduction reported in 2010; and a 5% reduction in
CAUTIs since 2009 (CDC, 2016c).
An estimated 1 to 3 million HAIs occur among residents in long-term care settings each
year. In addition to infections that are largely endemic, such as UTIs and lower respiratory tract
infections, outbreaks of respiratory and gastrointestinal infections are also common. Pneumonia
and other lower respiratory tract infections are the most frequent reasons for transferring
residents of long-term care facilities to the hospital (CDC, Tracking infections in long-term care
facilities). When an outbreak occurs in a healthcare setting, an epidemiologic investigation is
conducted, using the same criteria outlined above. Applying the basic principles of infection
control, which include hand hygiene, aseptic technique, and isolation precautions, can prevent
HAIs. Community/public health nurses also can prevent and control infections in the home by
using appropriate aseptic techniques, attention to good hand hygiene, and educating family
members in the principles of infection control.
Evidence for Practice
In September 2012, an alert clinician notified the Tennessee Department of Health of a
patient who had developed culture-confirmed Aspergillus fumigatus meningitis after he had
received an epidural steroid injection in July at an ambulatory surgical center. The patient
was admitted to the hospital in late August. The Tennessee Department of Health notified
the CDC, and within days, the CDC had identified the source of the largest multistate
healthcare-associated outbreak to be an injectable steroid medication prepared by a New
England Compounding Center (NECC). At that time, the CDC and the Food and Drug
Administration (FDA) recommended that all healthcare professionals discontinue use and
remove from their pharmaceutical inventory any product produced by that compounding
center. A massive effort to contact nearly 19,000 potentially exposed patients and their
physicians was undertaken by the CDC.
By May 2013, there were 753 cases and 64 deaths reported among patients in 20 states
who received injections of the contaminated steroid medication associated with the
outbreak. A probable case was defined as a person who received a methylprednisolone
acetate (MPA) injection, linked to injectable steroids from three recalled lots of preservative-
free MPA distributed by NECC after May 21, 2012, and subsequently developed any of the
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following: meningitis of unknown etiology; posterior circulation stroke without a
cardioembolic source; osteomyelitis, abscess, or other infection of unknown cause at or
near the site of injection; osteomyelitis or worsening inflammatory arthritis of a peripheral
joint (e.g., knee, shoulder, or ankle) of unknown cause. A confirmed case included
identification of a fungal pathogen (by culture, histopathology, or molecular assay)
associated with a clinical syndrome listed above.
In the early stages of the outbreak, the majority of patients were diagnosed with
meningitis. However, the majority of patients developed a localized infection following
exposure to contaminated injections, including epidural abscess, arachnoiditis (a disorder
caused by the inflammation of the arachnoid membrane that surrounds and protects the
nerves of the spinal cord), discitis (an infection in the intervertebral disc space), or vertebral
osteomyelitis.
Most of the cases occurred in Michigan (n = 264), followed by Tennessee (n = 153). The
predominant fungus identified in the outbreak was Exserohilum rostratum. One patient, the
index case from Tennessee, had a laboratory-confirmed A. fumigatus infection. These fungi
are common in the environment, and fungal infections are not transmitted from person to
person. In October 2015, CDC updated its web resources for patients and clinicians.
Patients affected by tainted steroid injections from NECC continue to receive treatment for
their infections and clinicians continue to monitor patient recovery (CDC, Multistate outbreak
of fungal meningitis and other infections).
This is an example of the importance of public health preparedness to identify rare
pathogens and implement measures to control them.
PUBLIC HEALTH SURVEILLANCE
At the federal level, the USDHHS is the U.S. public health infrastructure that develops policies
to protect the nation’s health. The CDC is a major USDHHS agency that protects the nation’s
health by developing guidelines that promote health and quality of life by preventing and
controlling disease, injury, and disability (CDC, About CDC).
Surveillance for infectious and/or communicable diseases in the United States consists of a
variety of efforts at both the state and federal levels. At the state level, healthcare providers and
healthcare facilities are required to report certain infectious diseases to state health departments.
State public health departments that monitor disease incidence and identify possible outbreaks
within their states report these data to the CDC. Certain infectious and/or communicable
diseases must be reported to the CDC. For the current list of notifiable diseases, see the CDC’s
Nationally Notifiable Diseases website at http://wwwn.cdc.gov/nndss/default.aspx
The CDC is also a partner with the WHO through the Global Outbreak Alert and Response
Network and the WHO Surveillance and Response System, which provide international
epidemic alerts and responses (WHO, CSR and global team).
In Case 1, is S. typhimurium a reportable disease?
At the U.S. federal level, the CDC maintains surveillance systems to analyze data for disease
trends and outbreaks. For example, one such surveillance system is FoodNet (Foodborne
Disease Active Surveillance Network), which is a collaborative effort among the FDA, the U.S.
Department of Agriculture, and the CDC. Specific states, which report cases and outbreaks of
foodborne illnesses, are selected to participate in the CDC Emerging Infections Program (CDC,
FoodNet). The Department of Defense (DoD) also has an electronic surveillance system for the
early notification of community-based epidemics (ESSENCE), which has been in operation
since 2001 to detect infectious disease outbreaks (DoD, Global emerging infections system).
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SPECIFIC COMMUNICABLE DISEASES
Foodborne Diseases
Foodborne diseases involve biologic and nonbiologic agents and can be caused by
microorganisms and their toxins, marine organisms and their toxins, fungi and their related
toxins, and chemical contaminants. Raw and undercooked foods of animal origin are the most
likely to be contaminated. The CDC estimates that each year roughly one in six people in the
United States (or 48 million people) get sick, 128,000 are hospitalized, and 3,000 die of
foodborne diseases. The top five pathogens contributing to domestically acquired foodborne
illnesses in 2016 were noroviruses, Salmonella, Clostridium perfringens, Campylobacter, and
Staphylococcus aureus (CDC, Estimates of foodborne illness in the United States).
Recent changes in human demographics and food preferences, changes in food production
and distribution systems, microbial adaptation, and lack of support for public health resources
and infrastructure have led to the emergence of novel as well as traditional foodborne diseases.
With increasing travel and trade opportunities, it is not surprising that the risk of contracting and
spreading a foodborne disease now exists locally, regionally, and even globally.
Foodborne diseases monitored through the CDC FoodNet include infections caused by
bacteria: Campylobacter, Listeria, Salmonella, Shiga toxin–producing Escherichia coli (STEC)
O157 and non-O157, Shigella, Vibrio, Yersinia; and parasites: Cryptosporidium and Cyclospora.
According to the most recent FoodNet surveillance data for 2016, compared to 2013–2015, the
average annual incidence of confirmed Campylobacter infections was lower, incidences of
confirmed STEC, Yersinia, and Cryptosporidium infections were higher, and for incidences of
confirmed or culture-independent diagnostic tests positive, only STEC and Yersinia infections
were higher (Marder et al., 2017). Salmonella infections have not declined for nearly two
decades, and the incidence of 15.40 per 100,000 population in 2016 was nearly higher than the
Healthy People 2020 target of 11.4 cases per 100,000 population (Box 14.4 for Healthy People
2020 objectives for food safety). These findings highlight the need to continue to identify and
address food safety gaps that can be targeted for action by the food industry and regulatory
authorities. Effective measures include preventing contamination of meat during slaughter and
of all foods, including produce, during processing and preparation; cooking meat thoroughly;
vigorously detecting and investigating outbreaks; and recalling contaminated food (CDC, CDC
and food safety). Nurses and other healthcare providers should educate their patients about the
hazards of potentially life-threatening foodborne diseases and the preventive measures to reduce
them.
14.4 Healthy People 2020 Objectives for Food Safety
Reduce infections caused by key pathogens commonly transmitted through food.
Reduce the number of outbreak-associated infections due to Shiga toxin–producing E. coli O157, or
Campylobacter, Listeria, or Salmonella species associated with food commodity groups.
Prevent an increase in the proportion of nontyphoidal Salmonella and Campylobacter jejuni isolates from
humans that are resistant to antimicrobial drugs.
Reduce severe allergic reactions to food among adults with a food allergy diagnosis.
Increase the proportion of consumers who follow key food safety practices.
(Developmental) Improve food safety practices associated with foodborne illness in food-service and
retail establishments.
Source: U.S. Department of Health and Human Services. Healthy People 2020 food safety objectives. Retrieved July 11, 2013, from
http://healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=14.
Noroviruses
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Noroviruses are common foodborne pathogens. Norovirus infections are often called “stomach
flu”; however, this is a misnomer, because the norovirus is not an influenza virus. Noroviruses
are recognized as the most common cause of acute infectious gastroenteritis in people of all
ages, and are the leading cause of disease outbreaks from contaminated food in the United States
(CDC, Vital signs: Preventing norovirus outbreaks). Each year on average in the United States,
norovirus causes 19 to 21 million cases of acute gastroenteritis (inflammation of the stomach or
intestines or both); leads to 1.7 to 1.9 million outpatient visits and 400,000 emergency
department visits, primarily in young children; and contributes to about 56,000 to 71,000
hospitalizations and 570 to 800 deaths, mostly among young children and the elderly (CDC,
Norovirus).
Noroviruses are spread primarily from one infected person to another by the fecal–oral route
through contaminated hands, contaminated food or water, or by contact with contaminated
objects in the environment. In some cases, aerosolized vomitus has been implicated in
transmission of noroviruses. The incubation period for norovirus gastroenteritis is 12 to 48
hours; it causes more vomiting than diarrhea, is self-limited, and usually resolves within 48
hours. However, the elderly, children, and those with severe underlying medical conditions are
at increased risk due to fluid volume depletion and electrolyte imbalance (CDC, Norovirus).
Nearly two-thirds of all norovirus outbreaks reported in the United States occurred in long-
term care facilities. Outbreaks of norovirus illness also have occurred in restaurants, cruise
ships, schools, banquet halls, summer camps, and even at family dinners. These are all places
where people often eat food handled or prepared by others. Outbreaks of noroviruses on cruise
ships and continuation of the outbreaks with the same strains on consecutive cruises in new
passengers suggest that noroviruses have high infectivity (CDC, Norovirus).
Oral hydrating solutions should be given for attacks of norovirus, and in severe cases,
intravenous fluid and electrolyte replacement may be necessary. At the first signs of this acute
gastroenteritis outbreak, good handwashing, thorough and immediate disinfection with
appropriate solutions, and isolation of sick people until 72 hours after they are symptom-free are
critical (CDC, Norovirus).
Campylobacter
Campylobacteriosis is a leading cause of foodborne illness in the United States, and was not
nationally notifiable until 2015. It also is an important cause of diarrheal illness throughout the
world regardless of people’s age. It is often implicated in traveler’s diarrhea. The annual median
number of Campylobacter outbreaks had increased in the United States from 28 in 2004–2006 to
56 in 2010–2012. Antimicrobial susceptibility testing of isolates from 4,793 domestic and 1,070
travel-associated infections revealed that, comparing 2004–2009 to 2010–2012, ciprofloxacin
resistance increased among domestic infections (12.8% vs. 16.1%) (Geissler et al., 2017).
Consumption of contaminated poultry is the most common source of Campylobacter
infection, although undercooked meats, ground beef, pork, cheese, eggs, shellfish, unpasteurized
milk, and direct exposure to pets and farm animals have been implicated. Generally, the
incubation period ranges from 2 to 5 days. The resulting diarrheal illness usually lasts no more
than a week. Typical symptoms include nausea, vomiting, abdominal pain, fever, headache, and
muscle pain. Occasionally, a severe case may last longer, and about 25% of the people affected
may experience a relapse.
Campylobacter infection is usually a self-limited illness, diagnosed by stool culture, and
treated by antidiarrheal medications such as loperamide. In more severe cases, antibiotics are
prescribed. It is essential that affected people drink plenty of fluids, such as oral rehydration
solutions, and wash hands carefully to prevent transmission to others (CDC, Campylobacter).
Listeria Monocytogenes
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Listeria monocytogenes can cause listeriosis, an uncommon but potentially fatal foodborne
bacterial disease. The disease primarily affects older adults, pregnant women, newborns, and
adults with weakened immune systems, and can result in miscarriage, stillbirth, or severe illness
and death in newborn infants. However, rarely, persons without these risk factors can also be
affected. The risk may be reduced by recommendations for safe food preparation, consumption,
and storage (CDC, Listeria).
Practice Point
Nurses and other healthcare providers should suspect listeriosis in high-risk patients (e.g.,
pregnant women) who become ill with diarrhea and/or flu-like symptoms, and have a recent
history of eating delicatessen food, soft cheeses, or smoked seafood.
Nontyphoid Salmonella
Nontyphoid Salmonella is a bacterial disease transmitted by contaminated food and water, or
contact with infected animals and reptiles. Because many milder cases are not diagnosed or
reported, the actual number of infections may be 30 times greater. There are many kinds of
Salmonella bacteria. Salmonella serotypes Typhimurium and Enteritidis are the most common in
the United States. People at risk for severe or complicated illness include infants, the elderly,
people with compromised immune systems, and organ transplant recipients. Salmonellosis is
characterized by diarrhea, fever, and abdominal cramps 12 to 72 hours following exposure, and
generally lasts 4 to 7 days. The majority of those infected recover without treatment.
However, in some cases, the diarrhea may be so severe that the patient needs to be
hospitalized. Each year, 19,000 hospitalizations and 380 deaths from salmonellosis occur in the
United States. A small number of persons with Salmonella develop pain in their joints. This is
called reactive arthritis, and it can last for months or years. It also can lead to chronic arthritis
which is difficult to treat. Treatment of dehydration and electrolyte imbalance is essential.
Antibiotics are not usually necessary unless the infection spreads from the intestines. The CDC
has identified Salmonella bacteria that have become resistant to antibiotics, largely as a result of
the use of antibiotics to promote the growth of food animals (CDC, Salmonella).
Practice Point
An efficient and effective homemade oral rehydration solution is to stir one level teaspoon of
salt and eight level teaspoons of sugar into one quart or liter of clean drinking water or water
that has been boiled and cooled.
Salmonella enteritidis, generally found in shell eggs, has been decreasing as a source of
foodborne illness during the past decade, attributed in part to farm-based egg control
programs, as well as education of farm worker and consumers. Nonetheless, outbreaks
continue to occur. For example, the CDC recently reported a multistate outbreak caused by
Salmonella oranienburg infections linked to an egg company (CDC, Salmonella oranienburg
infections linked to Good Earth Egg Company Shell Eggs: Final update, 2016). Outbreaks of
Salmonella also have been associated with direct or indirect contact with live poultry, frogs,
and turtles (CDC, Salmonella). In 2017, the CDC was conducting an on-going investigation of
a multistate outbreak of human Salmonella infections linked to live poultry in backyard flocks.
There were 790 cases reported in 48 states and the District of Columbia. Illnesses started on
dates ranging from January 4, 2017 to June 20, 2017. Of 580 people with available
information, 174 ill people had been hospitalized. However, no deaths had been reported.
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Figure 14.4 for map of the outbreak (CDC, 2017b).
Escherichia Coli O157:H7
Shiga toxin–producing Escherichia coli O157 is a deadly form of E. coli, which produces
symptoms of severe abdominal cramps, bloody and nonbloody diarrhea, and vomiting that
generally resolve within 7 to 10 days. In the very young and the elderly, infection with STEC
O157:H7 can cause fatal hemolytic–uremic syndrome and renal failure (CDC, E. coli). This
severe complication includes temporary anemia, profuse bleeding, and kidney failure.
Several outbreaks of E. coli O157:H7 have been associated with commercially packaged
foods and fresh produce (CDC, Multistate Foodborne Outbreak Investigations). A recent
multistate outbreak of E. coli O157:H7 involved I. M. Healthy Brand Soy Nut Butter products
(CDC, 2017c). See Chapter 15 for a further discussion of E. coli O157:H7. Foodborne infections
should be considered in people with diarrheal illness who are residents of, or travelers to an area
where foodborne outbreaks have been reported. A careful history also should consist of contact
with animals and reptiles as a source of infection.
Waterborne Diseases
In the United States, Canada, United Kingdom, and much of Europe, the drinking water supply
is normally safe. The United States has one of the safest public water supplies in the world. The
year 2008 marked the 100th anniversary of one of the most significant public health advances in
U.S. history, the disinfection of drinking water. However, millions of people worldwide do not
have access to safe water. In 2015, 71% of the global population (5.2 billion people) used a
safely managed drinking-water service—that is, one located on premises, available when
needed, and free from contamination. However, 884 million people lack even a basic drinking-
water service, including 159 million people who are dependent on surface water. Globally, at
least 2 billion people lack access to adequate sanitation and use a drinking water source
contaminated with feces. Diarrheal diseases such as cholera kill more children than AIDS,
malaria, and measles combined, making it the second leading cause of death among children less
than 5 years of age. The majority of these deaths are attributable to unsafe water, poor sanitation,
and inadequate hygiene (WHO, Drinking-water fact sheet).
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FIGURE 14.4 Multiple outbreaks of human salmonella infections linked to live poultry in backyard
flocks, 2017. (Source: CDC. Retrieved August 2, 2017, from https://www.cdc.gov/salmonella/live-
poultry-06-17/index.html.)
In the United States, state and local governments establish and enforce regulations for
protecting recreational water from naturally occurring and human-made contaminants. No
federal regulatory agency has authority over treated recreational water (e.g., pools and
interactive fountains), and no minimum federal design, construction, operation, disinfection, or
filtration standards exist. The Environmental Protection Agency (EPA) sets water quality
guidelines for natural, untreated recreational water (e.g., lakes, rivers, and oceans). Despite
drinking water treatment advances, it is estimated that millions of annual diarrheal illness
episodes still occur in the United States from exposure to contaminated municipal drinking
water. In addition, we face emerging public health concerns such as chlorine-tolerant pathogens
and the increasing complexity of waterborne diseases.
In surveillance data for 2011–2012, 32 drinking water–associated outbreaks were reported,
accounting for at least 431 cases of illness, 102 hospitalizations, and 14 deaths. Legionella was
responsible for 66% of outbreaks and 26% of illnesses, and viruses and non-Legionella bacteria
together accounted for 16% of outbreaks and 53% of illnesses. The two most commonly
identified deficiencies leading to drinking water–associated outbreaks were Legionella in
building plumbing systems (66%) and untreated groundwater (13%) (CDC, 2015a).
Outbreaks of illness associated with recreational water use result from exposure to chemicals
or infectious pathogens in recreational water venues that are treated (e.g., pools and hot tubs or
spas) or untreated (e.g., lakes and oceans). For 2011–2012, the most recent years for which
finalized data were available, public health officials from 32 states and Puerto Rico reported 90
recreational water–associated outbreaks to the CDC. The 90 outbreaks resulted in at least 1,788
cases, 95 hospitalizations, and one death. Among 69 (77%) outbreaks associated with treated
recreational water, 36 (52%) were caused by Cryptosporidium. Among the 21 (23%) outbreaks
associated with untreated recreational water, seven (33%) were caused by E. coli (E. coli
O157:H7 or E. coli O111). These outbreaks resulted in at least 479 cases and 22
hospitalizations. Twenty (95%) of these outbreaks were associated with fresh water; 18 (86%)
began in June–August; and seven (33%) were caused by E. coli O157:H7 or O11 (CDC, 2015b).
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The CDC has deficiency classifications for drinking water, and water not intended for drinking
used during waterborne outbreak investigations (CDC, 2011b). These are outlined in Table 14.1.
The U.S. EPA and the CDC set national standards to protect drinking water and its sources
against naturally occurring or human-made contaminants. In the United States, all public water
systems must be monitored for total coliform bacteria (fecal contamination), which is 0 (or no)
total coliform per 100 mL of water at a prescribed frequency. State and local governments
establish and enforce regulations to protect recreational water against naturally occurring or
human contaminants. Standards for operating, disinfecting, and filtering public swimming and
wading pools are regulated by state and local health departments and, as a result, vary
throughout the United States. Reports of outbreaks in the states and territories are voluntary.
However, waterborne diseases associated with recreational activities have been added to the
CDC waterborne-disease outbreak surveillance system. Most recreational water outbreaks have
been associated with treated water venues such as swimming pools or spas. Box 14.5 presents
selected Healthy People 2020 objectives for environmental health and water quality.
TABLE 14.1 Estimates of People Affected by Global HIV/AIDS Epidemic,
End of 2010
HIV/AIDS Epidemic 2010 Estimate
People living with HIV/AIDS 34 million
Adults living with HIV/AIDS 30.6 million
Women living with HIV/AIDS 15.3 million
Children living with HIV/AIDS 3.4 million
People newly infected with HIV 2.7 million
Children newly infected with HIV 369,000
AIDS-related deaths in adults and children 1.8 million
More than 30 million people have died of AIDS since 1981.
Africa has more than 15 million AIDS orphans.
At the end of 2010, women accounted for 50% of all adults living with HIV worldwide.
Most countries aspire to expand antiretroviral treatment access to around 80% of those in need. However, this target has not been met, with current global
treatment coverage at 54%.
Source: UNAIDS/WHO. AIDS epidemic statistics 2010. Retrieved April 30, 2013, from http://www.avert.org/worldstats.htm#.http://www.avert.org/
worldstats.htm.
14.5 Healthy People 2020 Environmental Objectives Related to Water Quality
Increase the proportion of persons served by community water systems who receive a supply of drinking
water that meets the regulations of the Safe Drinking Water Act.
Reduce waterborne-disease outbreaks arising from water intended for drinking among persons served by
community water systems.
Reduce per capita domestic water use.
Maintain the percentage of days that beaches are open and safe for swimming.
Reduce the global burden of disease due to poor water quality, sanitation, and insufficient hygiene.
U.S. Department of Health and Human Services. Healthy People 2020 environmental objectives: Water quality. Retrieved April 29, 2013, from
http://healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=12#364.
Two criteria must be met for an event to be defined as a water-associated disease outbreak.
First, two or more people must be linked epidemiologically by time, location of exposure to
water, and illness characteristics. Second, the epidemiologic evidence must implicate
recreational water or volatilization of water-associated compounds into the air surrounding the
water as the probable source of illness. Multiple etiologic agents should be considered when
waterborne disease is suspected and might be related to sewage or septic contamination (CDC,
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2015a). The CDC has distributed guidance for assisting state and local health departments,
aquatic facility inspection programs, building officials, the aquatics industry, and other
interested parties in improving the health and safety at public aquatic facilities (CDC, 2016a).
Case 1: Examine Figure 14.5
1. Did the Alamosa, CO, contaminated water supply meet the definition of an outbreak?
2. If so, what type of outbreak was it?
3. Following the CDC Deficiency Classification for Drinking Water outlined in see Table
14.1, how many deficiencies did the Alamosa water supply have?
As noted above, Legionnaires’ disease was first recognized among hotel guests during an
outbreak in Philadelphia, PA, in 1976. Between 8,000 and 18,000 people are hospitalized with
Legionnaires disease in the United States each year. However, many infections are not
diagnosed or reported, so this number may be higher. More illness is usually found in the
summer and early fall, but it can happen any time of year. Outbreaks of this disease have been
associated with potable water sources, air-conditioning cooling towers, and cruise ships.
Legionella bacteria are not transmitted from person to person (CDC, Legionella).
FIGURE 14.5 Epidemic curve for the waterborne outbreak in Alamosa, CO, 2008. (Falco, R. &
Williams, S. I. [2009]. Waterborne salmonella outbreak in Alamosa, Colorado, March and April
2008. Retrieved August 5, 2017, from https://colorado.gov/pacific/sites/default/files/WQ-DW-
Publications-Alamosa-Outbreak-Investigation-Report .)
Evidence for Practice
The Shelby County Health Department in Tennessee received laboratory confirmation of
nine cases of Legionnaires’ disease among guests at the aquatics facilities and Guest
House at the Graceland Hotel in Memphis, TN. It was estimated that the Legionella
exposure extended from May 15 through June 27, 2017, with the first cases becoming
symptomatic between July 1 and July 6, 2017. The last four cases were reported on July
14, 2017. The aquatic facilities were closed on June 27, 2017. Legionnaires’ disease has an
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incubation period of 2 to 10 days, but can extend for about 2 weeks after exposure.
Therefore, those exposed to the source could become symptomatic up to 2 weeks after
remediation at the aquatic facilities took place. The Guest House at Graceland opened in
October 2016, with 450 rooms and an aquatic area consisting of a hot tub and an outdoor
pool. Unfortunately, no information was provided if the species and genotypes of Legionella
that were isolated from the nine patients matched isolates from environmental sources.
Source: International Society for Infectious Diseases, July 20, 2017. Legionellosis—USA (Tennessee) hotel, hot tub/pool.
Sexually Transmitted Diseases (Sexually Transmitted
Infections)
Sexually transmitted diseases (STDs) or sexually transmitted infections (STIs) affect men and
women of all backgrounds and economic levels. Despite the fact that a great deal of progress has
been made in STD prevention over the past four decades, the CDC estimates that there are about
20 million new STDs in the United States each year, with a cost of nearly $16 billion in direct
medical costs alone. Almost half of the new cases occur in young people aged 15 to 24 years. It
has been estimated that the actual rate of infection may be twice that of the reported rate,
because many cases are undiagnosed and untreated. In addition, the CDC data suggest that there
are more than 110 million total STDs among men and women across the nation. Its analyses
included eight common STDs: chlamydia, gonorrhea, hepatitis B, herpes simplex (caused by
herpes simplex virus type 2 [HSV-2]), HIV infection, human papillomavirus (HPV) infection,
syphilis, and trichomoniasis (CDC, STD fact sheet).
Each of these infections is a potential threat to an individual’s immediate and long-term
health and well-being. In addition to increasing a person’s risk for acquiring and transmitting
HIV infection, STDs can lead to chronic pain and severe reproductive health complications,
such as infertility and ectopic pregnancy. Many cases of chlamydia, gonorrhea, and syphilis
continue to go undiagnosed and unreported, and data on several additional STDs, such as HPV,
herpes simplex virus, and trichomoniasis, are not routinely reported to CDC. As a result, the
annual surveillance reports capture only a fraction of the true burden of STDs in America (CDC,
STD fact sheet).
Although the consequences of untreated STDs often are worse among young women, new
data reveal that the annual number of new infections to be roughly equal among young women
and young men, but young women are heavily affected by STDs since they face the most serious
long-term health consequences. It is estimated that undiagnosed STDs cause infertility in more
than 20,000 women each year.
Chlamydia, gonorrhea, syphilis, and trichomoniasis are easily treated and cured if diagnosed
early. However, too many of these infections go undetected because they often have no
symptoms. But even STDs without symptoms can have serious health consequences.
Undiagnosed and untreated chlamydia or gonorrhea, for example, can put a woman at increased
risk of chronic pelvic pain, life-threatening ectopic pregnancy, and an increase in infertility
(CDC, STD fact sheet).
Any genital symptoms such as discharge or burning during urination or unusual sore or rash
should be a signal for a person to stop having sex and to see a healthcare provider immediately.
Infections caused by bacteria can be treated and usually cured with antibiotics, but those caused
by viruses cannot be cured this way. All partners must be notified so that they can be examined
and treated, if necessary. Other than abstinence, a long-term mutually monogamous relationship
with a partner who has been tested and is known to be uninfected is the best way to avoid STDs.
Sexual partners should talk to each other about their STDs so that preventive action can be
taken. Prevention of STD transmission does not include washing the genitals, urinating, and/or
douching after sex. Latex condoms can reduce the risk of transmission but only when used
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consistently (every time) and correctly. However, genital ulcer diseases, such as syphilis, can
occur anywhere within the male and female genital areas, whether or not they are covered by a
latex condom. Correct and consistent use of latex condoms can reduce the risk of STDS only
when the infected area or site of potential exposure is protected. Condoms lubricated with
spermicides (especially nonoxynol-9 or N-9) are no more effective than other lubricated
condoms in protecting against the transmission of STDs. Based on the findings from several
research studies, N-9 may itself cause genital lesions, providing a point of entry for HIV and
other STDs. Therefore, since 2010, the CDC has recommended that N-9 not be used as a
microbicide or lubricant during vaginal or anal intercourse since 2010), and remains in its
updated 2015 guidelines (CDC, 2015c). The Healthy People 2020 objectives for STDs are
presented in Box 14.6.
Practice Point
Any person is in a high-risk group for STDs if they
Have multiple sexual partners.
Do not use a condom during sex.
Have other STDs.
Have a sexual partner who has had an STD.
Evidence for Practice
The clinical treatment guidelines for STDs typically recommend antibiotic therapy to cover
common infections. However, overtreatment and under treatment of STDs are common
during emergency department (ED) visits. Huppert and colleagues (2013) examined a
quality improvement (QI) project that aimed to improve follow-up care for STDs in the ED.
They compared the point-of-care (POC) treatment patterns for gonorrhea and
trichomoniasis among young women seen in an ED over an 18-month period. Of the 1,877
visits, 8.8% of women had gonorrhea and 16.5% had trichomoniasis. Overtreatment was
higher for women with gonorrhea than with trichomoniasis (54% vs. 23%, p < 0.001).
However, overtreatment for gonorrhea decreased from 58% to 47% (p < 0.01) and
overtreatment for trichomoniasis decreased from 24% to 18% (p < 0.01), which
corresponded to improvements in patient follow-up for the QI project. Undertreatment was
higher for women with gonorrhea than with trichomoniasis (29% vs. 21%, p = 0.03), and did
not change over time. An unanticipated benefit of the QI project to improve patient follow-up
was the decrease in antibiotic usage in the ED. Given the ability of gonorrhea to develop
antibiotic resistance, Hubbert and colleagues recommended that future studies focus on the
development of an accurate POC test for gonorrhea.
14.6 Healthy People 2020 Objectives for Sexually Transmitted Diseases
Reduce the proportion of females aged 15 to 44 years who have ever required treatment of pelvic
inflammatory disease (PID).
Reduce congenital syphilis.
Reduce the proportion of adolescents and young adults with Chlamydia trachomatis infections.
Reduce gonorrhea rates.
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Reduce sustained domestic transmission of primary and secondary syphilis.
Reduce the proportion of adults with genital herpes infection due to herpes simplex type 2.
Reduce the proportion of females with human papillomavirus (HPV) infection.
Increase the proportion of sexually active females aged 24 years and younger enrolled in commercial
health insurance plans who are screened annually for genital Chlamydia infections.
Increase the proportion of sexually active females aged 24 years and younger enrolled in Medicaid who
are screened annually for genital Chlamydia infections.
Increase the proportion of HIV-infected persons who know they are infected.
Source: U.S. Department of Health and Human Services. Healthy People 2020 sexually transmitted diseases objectives. Retrieved April 29, 2013, from
http://healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=37.
In Case 2, Megan discussed her urinary frequency and abnormal vaginal discharge with
the school nurse. What advice might the school nurse have given her?
Chlamydia
Chlamydia, caused by infection with Chlamydia trachomatis, is the most common notifiable
disease in the United States. It is among the most prevalent of all STDs, and since 1994, has
comprised the largest proportion of all STDs reported to the CDC, with 1,526,658 cases reported
in 2015 at a rate of 478.8 per 100,000 population. Studies also demonstrate the high prevalence
of chlamydial infections in the general U.S. population, particularly among young women. The
rate of reported cases of chlamydia is highest among adolescents and young adults aged 15 to 24
years. In 2015, the rate of reported cases of chlamydia among 15- to 19-year-olds was 1,857.8
cases per 100,000 population and the rate among 20- to 24-year-olds was 2,574.9 cases per
100,000 population. From 2011 to 2013, the rate of reported cases decreased to 443.5 cases per
100,000 population. The rate of reported cases then increased in 2014 at 452.2 and up 5.9%
again in 2015 at 478.8 (CDC, Chlamydia).
Substantial racial/ethnic disparities in chlamydial infection exist, with prevalence among
non-Hispanic blacks approximately 5.9 times the prevalence among non-Hispanic whites.
Chlamydia is also common among men who have sex with men (MSM) (CDC, Chlamydia fact
sheet). Chlamydia is a nationally notifiable disease, and CDC 2016 data indicated that the
Healthy People 2020 objective to reduce C. trachomatis infections among females 15 to 24
years of age attending family planning clinics to 6.7% had been met (CDC, 2017). Chlamydial
infection is caused by a bacterium, C. trachomatis, which is transmitted during vaginal, oral, or
anal sexual contact with an infected partner.
Chlamydia is known as a “silent” infection because most infected people are asymptomatic
and lack abnormal physical examination findings. In women, the bacteria initially infect the
cervix, where the infection may cause signs and symptoms of cervicitis (e.g., mucopurulent
endocervical discharge, easily induced endocervical bleeding), and sometimes the urethra, which
may result in signs and symptoms of urethritis (e.g., pyuria, dysuria, urinary frequency).
Infection can spread from the cervix to the upper reproductive tract (i.e., uterus, fallopian tubes),
causing pelvic inflammatory disease (PID), which may be asymptomatic and is a major cause of
infertility among women of childbearing age. A pregnant woman may pass chlamydial infection
to her newborn during delivery, resulting in subsequent neonatal eye infection or pneumonia.
Men who are symptomatic typically have urethritis, with a mucoid or watery urethral discharge
and dysuria. A minority of infected men develop epididymitis (with or without symptomatic
urethritis), presenting with unilateral testicular pain, tenderness, and swelling (CDC, Chlamydia
fact sheet, 2018).
Screening programs have been demonstrated to reduce rates of adverse sequelae in women.
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There are a number of diagnostic tests for chlamydia, including cell culture (the criterion
standard) and nucleic acid amplification tests (NAATs), and others. NAATs are the most
sensitive tests and can be performed on easily obtainable specimens such as vaginal swabs
(either clinician- or patient-collected) or urine (CDC, Chlamydia fact sheet, 2018). Urine is the
specimen of choice for males. Self-collected vaginal swab specimens perform at least as well as
other approved specimens using NAATs. Generally, girls in adolescent phase of development
may collect their own urine or swab their own vagina to screen for Chlamydia especially if they
are not having symptoms. Persons with chlamydia should abstain from sexual activity for 7 days
after single-dose antibiotics or until completion of a 7-day course of antibiotics, to prevent
spreading the infection to partners. Chlamydia can be easily cured with antibiotics. HIV-positive
persons with chlamydia should receive the same treatment as those who are HIV-negative
(CDC, Chlamydia fact sheet). A number of antibiotics such as azithromycin (Zithromax),
doxycycline, or erythromycin may be prescribed for treatment (CDC, Chlamydia curriculum).
Evidence for Practice
The CDC and the U.S. Preventive Services Task Force (USPSTF) recommends yearly
chlamydia screening of all sexually active women aged 25 or younger and older women
with risk factors for chlamydial infections (e.g., women who have a new or more than one
sex partner). Pregnant women should be screened during their first prenatal care visit.
Pregnant women under 25 or at increased risk for chlamydia (e.g., women who have a new
or more than one sex partner) should be screened again in their third trimester. Any woman
who is sexually active should discuss her risk factors with a healthcare provider who can
then determine if more frequent screening is necessary. Routine screening is not
recommended for men. However, the screening of sexually active young men should be
considered in clinical settings with a high prevalence of chlamydia (e.g., adolescent clinics,
correctional facilities, and STD clinics) when resources permit and will decrease screening
programs for women (CDC, Chlamydia fact sheet; Agency for Health Research and Quality
[AHRQ], 2014).
Gonorrhea
Gonorrhea is second only to chlamydia in number of cases reported to the CDC. In 2015,
persons aged 15 to 44 years accounted for 92.7% of reported gonorrhea cases with known age
(CDC, Gonorrhea). Infections with Neisseria gonorrhoeae, like those resulting from C.
trachomatis, cause several clinical syndromes, including urogenital, pharyngeal, and rectal
infections in males and females, and conjunctivitis in adults and neonates. If untreated,
gonorrhea can cause PID, tubal infertility, ectopic pregnancy, and chronic pelvic pain (CDC,
Gonorrhea fact sheet).
Like chlamydia, gonorrhea is substantially underdiagnosed and underreported; the number of
reported cases is suspected to underestimate incidence by approximately 50%. In 2009, the
gonorrhea rate decreased to 98.1 cases per 100,000 population. This was the lowest rate since
recording of gonorrhea rates began in the 1970s. Between 2009 and 2012, the rate increased
slightly each year to 106.7 cases per 100,000 population in 2012. In 2013, the rate decreased
slightly to 105.3 cases per 100,000 population and then during 2013–2015, the rate increased
each year. By 2015, a total of 395,216 cases were reported for a rate of 123.9 cases per 100,000
population. The rate of reported gonorrhea cases among males was higher than the rate among
females. Reported gonorrhea cases continued to be highest among adolescents and young adults,
with persons aged 15 to 44 years accounting for 92.7% of reported gonorrhea cases in 2015
(CDC, Gonorrhea). These data indicate that the rate of gonorrhea still remained higher in 2015
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than the Healthy People 2020 target of 251.9 new cases of gonorrhea among females aged 15 to
44 years per 100,000 population, and 194.8 new cases of gonorrhea among males aged 15 to 44
years per 100,000 population (CDC, 2017a) (see Box 14.6 for Healthy People 2020 STD
objectives).
Patients infected with N. gonorrhoeae frequently are coinfected with C. trachomatis.
Therefore, patients with gonorrhea should be tested for other STDs. Because of findings that
chlamydial and gonorrheal infections often coexist led to the recommendation that patients
treated for gonococcal infection also be treated routinely with a regimen that is effective against
uncomplicated genital C. trachomatis infection. In addition, because most gonococci in the
United States are susceptible to doxycycline and azithromycin, routine co-treatment hinder the
development of antimicrobial-resistant N. gonorrhoeae (CDC, 2015c).
Drug-resistant strains of gonorrhea are increasing in many areas of the world, including the
United States, making successful treatment of gonorrhea more difficult. Antimicrobial
susceptibility patterns of N. gonorrhoeae have been closely monitored since 1986 through the
Gonococcal Isolate Surveillance Project (GISP), and the information has been used to update
treatment recommendations. The increased prevalence of fluoroquinolone resistance in N.
gonorrhoeae became widespread in the United States in the 1990s and 2000s, when the
proportion of N. gonorrhoeae isolates in MSM that were resistant to ciprofloxacin (a
fluoroquinolone antimicrobial) increased significantly. While the first fluoroquinolone-resistant
N. gonorrhoeae cases were detected among heterosexuals, fluoroquinolone resistance became
widespread in the continental United States among MSM with gonorrhea before becoming
widespread among heterosexuals. By 2011, the CDC no longer recommended the use of
fluoroquinolones for the treatment of gonococcal infections and associated conditions such as
PID. Therefore, currently, the CDC recommends dual therapy with ceftriaxone (an injectable
cephalosporin) 250 mg intramuscularly as a single dose plus azithromycin 1 g orally as a single
dose given together for 7 days as the most effective treatment for uncomplicated gonorrhea.
However, in the case of azithromycin allergy, doxycycline (100 mg orally twice a day for 7
days) can be used in place of azithromycin as an alternative second antimicrobial when used in
combination with ceftriaxone (or cefixime) (CDC, 2015c).
People who have had gonorrhea and have been treated can get the disease again if they have
sexual contact with people infected with gonorrhea. Every person who has been diagnosed and
treated for gonorrhea should notify all recent sex partners so that they can see a healthcare
provider and be treated. This will reduce the development of serious complications from
gonorrhea and also reduce the possibility of reinfection. All people involved must avoid sex
until they have completed their treatment of gonorrhea.
In Case 2, following the suggestion of the school nurse, Megan saw a nurse practitioner
at a local women’s health clinic. After taking a history, the nurse suspected an STD. A
pelvic examination revealed mucopurulent cervicitis, and a tissue culture was taken. A
dipstick urine analysis of a urine sample was positive for bacteria. A chlamydial infection
was suspected, and a UTI was diagnosed.
1. What other information should the nurse practitioner consider in this case?
2. What treatment is indicated in this case?
3. What additional recommendations would you make?
Evidence for Practice
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The United States Preventive Services Task Force (USPSTF), an independent panel of
experts supported by the Agency for Healthcare Research and Quality (AHRQ),
recommends that clinicians routinely screen all sexually active women, including pregnant
women, for gonorrhea and chlamydia infections if they have a history of previous STDs,
new or multiple sexual partners, inconsistent condom use, sex work, and drug use.
Currently, the USPSTF concludes that the current evidence is insufficient to assess the
balance of benefits and harms of screening for chlamydia and gonorrhea in men (USPSTF,
2014). Also, the USPSTF recommends prophylactic ocular topical medication for all
newborns for the prevention of gonococcal ophthalmia neonatorum (USPSTF, 2014).
In Case 2, within a few days, Megan’s tissue culture that was collected before treatment
came back positive for N. gonorrhoeae in addition to C. trachomatis.
Does the nurse practitioner need to report these infections to the local health
authorities?
Syphilis
Syphilis has often been called “the great imitator,” because many of the signs and symptoms are
indistinguishable from those of other diseases. This genital ulcerative disease is caused by the
bacterium Treponema pallidum. It is transmitted from person to person through direct contact
with a syphilitic sore. These sores occur mainly on the external genitals, vagina, anus, or in the
rectum, although they can occur on the lips or in the mouth. Transmission occurs during vaginal,
anal, or oral sex, and the organism can pass the placental barrier and infect the fetus.
Syphilis causes significant complications if untreated and facilitates the transmission of HIV
infection. Primary and secondary syphilis rate has increased almost every year since 2000–2001.
In 2015, a total of 23,872 primary and secondary syphilis cases were reported. During 2014–
2015, the national primary and secondary syphilis rate increased 19.0% to 7.5 cases per 100,000
population, the highest rate reported since 1994 (CDC, Syphilis). Primary and secondary syphilis
are the most infectious stages of the disease, and if not adequately treated, can lead to visual
impairment, stroke, and in rare cases, even death. The primary stage of syphilis consists of a
single sore or multiple sores. The sore(s) appears at the location where syphilis entered the body.
The sore is usually firm, round, and painless. Because the sore is painless, it can easily go
unnoticed. The sore lasts 3 to 6 weeks and heals regardless of whether the person is treated.
However, if the infected person does not receive adequate treatment, the infection progresses to
the secondary stage. Skin rashes and/or sores in the mouth, vagina, or anus (also called mucous
membrane lesions) mark the secondary stage of symptoms. This stage usually starts with a rash
on one or more areas of the body. Rashes associated with secondary syphilis can appear from the
time when the primary sore is healing to several weeks after the sore has healed. The rash
usually does not cause itching. This rash may appear as rough, red, or reddish brown spots both
on the palms of the hands and/or the bottoms of the feet. However, this rash may look different
on other parts of the body and can look like rashes caused by other diseases. The latent (hidden)
stage of syphilis begins when primary and secondary symptoms disappear. Without treatment,
the infected person can continue to have syphilis in their body, even though there are no signs or
symptoms. This latent stage can last for years (CDC, Syphilis, Fact sheet). Untreated early
syphilis in pregnant women results in perinatal death in up to 40% of cases and, if acquired
during the 4 years before pregnancy, can lead to infection of the fetus in 80% of cases (CDC,
Syphilis, Fact sheet).
Syphilis cases had been declining significantly in the United States since reporting began in
1941. For example, the overall rate of primary and secondary syphilis in the United States had
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declined 90% between 1990 and 2000. However, the syphilis rate in the United States had
increased each year from 2001 to 2008. But, the overall rate of syphilis infection had been
falling since 2008. In 2010, the overall rate decreased for the first time in 10 years, and the rate
of primary and secondary syphilis in 2011 remained unchanged. Nonetheless, by 2015, there
were 74,702 reported new diagnoses of syphilis (all stages), with 23,872 of the cases being
primary and secondary syphilis. The majority of these cases occurred among gay, bisexual, and
other men who have sex with men (MSM). In 2015, MSM accounted for 81.7% of all primary
and secondary syphilis cases among males in which sex of sex partner was known and 60% of
all primary and secondary syphilis cases overall. However, in recent years, the rate of primary
and secondary syphilis has been increasing among heterosexual men and women as well as
among MSM (CDC, Fact sheet).
Congenital syphilis (syphilis passed from pregnant women to their babies) continues to be a
concern in the United States. After a steady decline from 2008 to 2012, data show a sharp
increase in congenital syphilis rates. In 2015, the number of cases was the highest it’s been since
2001. In 2015, 487 cases of congenital syphilis were reported, with rates 8.0 times and 3.5 times
higher among infants born to black and Hispanic mothers (35.2 and 15.5 cases per 100,000 live
births, respectively) compared to white mothers (4.4 cases per 100,000 live births). The rates of
congenital syphilis remained higher than the Healthy People 2020 objective of 9.6 new cases of
congenital syphilis per 100,000 live births) (CDC, 2017a).
Penicillin G, administered parenterally, is the preferred drug for treatment of all stages of
syphilis. The preparation or preparations used (i.e., benzathine, aqueous procaine, or aqueous
crystalline), the dosage, and the length of treatment depend on the stage and clinical
manifestations of the disease. Treatment for late latent syphilis and tertiary syphilis requires a
longer duration of therapy, because organisms theoretically might be dividing more slowly
although the scientific community has not been able to prove systematically if this is really true.
Treating people diagnosed with latent syphilis for a more extensive time is indicated for
adequate treatment if they were exposed in the previous year. Selection of the appropriate
penicillin preparation is important, because T. pallidum can reside in sequestered sites (e.g., the
CNS and aqueous humor) that are poorly accessed by some forms of penicillin. The
recommended regimen for early latent Syphilis is benzathine penicillin G, 2.4 million units IM
in a single dose. For late latent syphilis, the recommended regimen is benzathine penicillin G, at
weekly doses of 2.4 million units for 3 weeks. The recommended regimen for tertiary syphilis
with a normal CSF examination is benzathine penicillin G 7.2 million units, total, administered
as three doses of 2.4 million units IM each at 1-week intervals. Persons with HIV infection, who
have primary or secondary syphilis should be treated as those without HIV infection. Parenteral
penicillin G is the only therapy with documented efficacy for syphilis during pregnancy.
Pregnant women with syphilis in any stage who report penicillin allergy should be desensitized
and treated with penicillin. As of 2017, Pfizer, the sole manufacturer of penicillin G benzathine
(Bicillin L-A) in the United States, continued to experience a manufacturing delay of this
product. Penicillin G procaine also was unavailable. CDC is working with FDA’s Drug Shortage
Staff and Pfizer to address this situation (CDC, Syphilis).
Because effective treatment is available, it is important that people be screened for syphilis
on an ongoing basis if their sexual behaviors put them at risk for STDs. People who are
diagnosed and treated for syphilis must abstain from sexual contact until the syphilitic sores are
completely healed. All persons who have syphilis should be tested for HIV infection. The
USPSTF recommendations screening of all pregnant women at the first prenatal visit, retest
early in the third trimester and at delivery, if at high risk. In geographic areas in which the
prevalence of HIV is high, sexually active individuals should be screened at first HIV
evaluation, and at least annually thereafter. More frequent screening might be appropriate
depending on individual risk behaviors and the local epidemiology (USPSTF, 2015).
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Evidence for Practice
In addition to all pregnant women, the USPSTF strongly recommends that clinicians screen
people at increased risk for syphilis infection; this includes MSM, commercial sex workers,
people who exchange sex for drugs, and people in correctional facilities (USPSTF, 2015).
Human Papillomavirus
Genital HPV infection is one of the most common causes of STDs in the world. It is estimated
that 100% of sexually active men and women acquire genital HPV infection at some point in
their lives. With an estimated annual incidence of 14.1 million cases, the CDC estimates that
HPV accounts for the majority of newly acquired STDs in the United States. There is an
estimated $1.7 billion annual cost in direct medical costs to treat conditions associated with
genital HPV infection (e.g., warts, cervical dysplasia, cancer). An estimated 79 million women
aged 14 to 59 years are infected with HPV, with the highest prevalence in those between the
ages of 20 and 24 years. While the vast majority (90%) of HPV infections will go away on their
own within 2 years and cause no harm, some of these infections will take hold and potentially
lead to serious disease, including cervical cancer. Although rare, genital HPV infection with
low-risk types can be transmitted from mother to newborn during delivery and can cause
respiratory tract warts in the child, known as juvenile-onset recurrent respiratory papillomatosis
(CDC, CDC curriculum HPV).
More than 100 types of HPV exist, more than 40 of which can infect the genital area. Genital
HPV types are divided into two groups: low-risk types and high-risk types. Low-risk
(nononcogenic) types can cause genital warts and benign or low-grade cellular changes (e.g.,
mild Pap test abnormalities), but are not associated with increased risk of cancer. High-risk
(oncogenic) types can cause cervical dysplasia (both low-grade and high-grade cervical cellular
changes), moderate to severe Pap test abnormalities, and in rare cases, cancers of the cervix. In
addition, these types of HPV infection have been associated with cancers of the vulva, vagina,
anus, penis, and oropharynx. Infection is predominantly associated with sexual activity,
including vaginal and anal intercourse, oral sex, and nonpenetrative sexual activity (genital–
genital contact); therefore, it requires contact with viable HPV and microtrauma to skin or
mucous membranes to establish infection, but transmission can occur from asymptomatic and
subclinically infected persons. The natural history of HPV infection is usually benign. Low-risk
genital HPV types are associated with mild Pap test abnormalities and genital warts. High-risk
types are associated with mild to severe Pap test abnormalities, and rarely, cancers of the cervix,
vulva, vagina, anus, penis, and oropharynx. Most women infected with HPV infection do not
develop cervical cancer. Recurrence of genital warts within the first several months after
treatment is common (CDC, curriculum HPV).
Three HPV vaccines are licensed for use in the United States. Quadrivalent and 9-valent
HPV vaccines (4vHPV and 9vHPV, Gardasil and Gardasil 9, Merck and Co, Inc., Whitehouse
Station, NJ) are licensed for use in females and males aged 9 through 26 years. Bivalent HPV
vaccine (2vHPV, Cervarix, GlaxoSmithKline, Rixensart, Belgium) is licensed for use in females
aged 9 through 25 years. However, as of late 2016, only 9vHPV is being distributed in the
United States. The majority of all HPV-associated cancers are caused by HPV 16 or 18, types
targeted by all three vaccines. In addition, the 4vHPV vaccine targets HPV 6 and 11, types that
cause genital warts. The 9vHPV vaccine protects against these and five additional types: HPV
31, 33, 45, 52, and 58. All three vaccines have been approved for administration in a three-dose
series at intervals of 0, 1, or 2, and 6 months. In October 2016, after considering new clinical
trial results, the Food and Drug Administration (FDA) also approved 9vHPV for use in a two-
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dose series for girls and boys aged 9 through 14 years. In October 2016, the Advisory
Committee on Immunization Practices (ACIP) recommended a two-dose schedule for
adolescents initiating HPV vaccination in this age range (Meites, Kempe, & Markowitz, 2016)
The CDC recommends that all teenage girls and women through age 26 receive HPV vaccines,
as well as all teenage boys and men through age 21 (and through age 26 for gay, bisexual, and
MSM). Also, immunocompromised persons (including those with HIV infection) should be
vaccinated through age 26 years. Neither vaccine is recommended for persons over age 26.
Ideally, the vaccines should be administered before onset of sexual activity (CDC, curriculum
HPV; STD fact sheet). The American Academy of Pediatrics (AAP) has developed a “HPV
Champion Toolkit” to help educate healthcare professionals discuss HPV vaccination with
parents and make changes in practice to improve HPV vaccination rates (AAP, HPV champion
toolkit).
Treatment of warts or cervical cellular abnormalities may reduce, but likely does not
eliminate infectiousness of HPV. Most genital HPV infections, whether caused by low-risk or
high-risk types, are transient, asymptomatic, and have no clinical consequences. CDC-
recommended patient-applied and provider-administered treatment regimens are available.
Choice of treatment should be guided by location of the lesion(s), patient preference, experience
of the healthcare provider, available resources, and pregnancy status. Healthcare providers
should identify warts for patient-applied treatment and teach patients how to apply substances.
Patient-applied treatments consist of podofilox 0.5% solution or gel, imiquimod 5% cream, or
sinecatechins 15% ointment. Podofilox, an antimitotic drug that destroys warts, is relatively
inexpensive, easy to use, and safe. Imiquimod 5% cream is a topically active immune enhancer
that stimulates production of interferon and other cytokines. The safety of podofilox, imiquimod,
and sinecatechins during pregnancy has not been established. Also, the safety of sinecatechins
has not been established in HIV- or HSV-coinfected individuals. CDC-recommended provider-
administered regimens for external genital warts include cryotherapy with liquid nitrogen or
cryoprobe, podophyllin resin 10% to 25% in compound tincture of benzoin, trichloroacetic acid
(TCA) or bichloroacetic acid (BCA) 80% to 90%, or surgical removal (CDC, curriculum HPV).
Practice Point
It is important to incorporate issues of HPV management into well visits for young men and
women of all ages. All boys and girls ages 11 or 12 years should get vaccinated, and they
need to know that the current HPV vaccine can reduce their risk of being infected by four
types of HPV. They also need to know that although condom use does not completely
prevent the transmission of HPV, it can significantly decrease it.
Most HPV infections usually go away by themselves, but having an HPV infection can
cause certain kinds of cancer to develop. These include cervical cancer in women, penile
cancer in men, and anal cancer in both women and men. The virus also can cause cancer in
the back of the throat, including the base of the tongue and tonsils (called oropharyngeal
cancer). All of these cancers are caused by HPV infections that did not go away. Cancer
develops very slowly and may not be diagnosed until years, or even decades, after a person
initially gets infected with HPV. Currently, there is no way to know who will have only a
temporary HPV infection, and who will develop cancer after getting HPV. Screening should
continue, even in vaccinated women, to look for abnormal changes in cells. The vaccine is a
series of injections of a noninfectious virus-like particle. Young men and women need to
know that they cannot develop an HPV infection from the vaccine.
Source: CDC. Human Papillomavirus (HPV). Retrieved August 9, 2017, from https://www.cdc.gov/std/hpv/default.htm.
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Human Immunodeficiency Virus
HIV is a retrovirus that infects cells of the human immune system, impairing and destroying
their function. Symptoms may be absent in the early stages of infection. However, as the
infection progresses, the immune system becomes more compromised, and the person becomes
more susceptible to opportunistic infections. In addition, HIV infection increases the risk of
reactivation of latent TB (CDC, HIV and tuberculosis). The most advanced stage of HIV
infection is AIDS (stage 3). It can take 10 to 15 years for an HIV-infected person to develop
AIDS, but antiretroviral therapy (ART) can slow down the process even further. Before the
highly active ART (HAART) era, the median time from HIV seroconversion to the development
of AIDS was 7.7 to 11.0 years, with a median survival rate from 7.5 to 12 years. These effective
drug therapies keep HIV-infected persons healthy longer and significantly reduced the death rate
in 20 years by 50%. AIDS is now considered a chronic and controlled disease. According to the
United Nations Program on HIV/AIDS (UNAIDS), 19.5 million people globally are now on life-
saving treatment, with AIDS-related deaths halved since 2005. Therefore, the number of people
living with HIV is increasing in countries where HAART treatment is available (AVERT, 2017).
Still, according to the most recent CDC data, 39,513 HIV infections were diagnosed in the
United States in 2015. Gay, bisexual, and other men who have sex with men bear the greatest
burden by risk group, representing an estimated 26,200 of these new HIV infections (CDC,
HIV/AIDS) (Table 14.2).
HIV continues to be a major global public health issue. In 2015, an estimated 36.7 million
people were living with HIV (including 1.8 million children), with a global HIV prevalence of
0.8%. The vast majority of this number live in low- and middle-income countries. An estimated
40% don’t know their infection status. In the same year, 1.1 million people died of AIDS-related
illnesses (AVERT, 2017).
TABLE 14.2 Estimated HIV Incidence and Prevalence in the United States
2010–2015
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Since the start of the epidemic, an estimated 78 million people have become infected with
HIV and 35 million people have died of AIDS-related illnesses. In 2015, there were roughly 2.1
million new HIV infections, 150,000 of which were among children. Most of these children live
in sub-Saharan Africa and were infected via their HIV-positive mothers during pregnancy,
childbirth, or breastfeeding. Progress in decreasing new HIV infections among adults has slowed
in recent years. Since 2010, the annual number of new infections among adults (age 15 years
and over) has remained static at 1.9 million. However, significant progress has been made in the
prevention of mother-to-child transmission of HIV. In 2015, 77% of all pregnant women living
with HIV accessed treatment to prevent HIV transmission to their babies. By the end of 2015,
46% of all adults and 49% of all children living with HIV were accessing ART (AVERT, 2017).
A comparison of country data shows huge discrepancies in efforts to slow the spread of new
HIV infections. Some countries have achieved a decline of 50% or more in new HIV infections
among adults over the last 10 years, while many have made no measurable progress. Yet others
are experiencing worrying increases in new HIV infections (AVERT, 2017). According to
UNAIDS (2016), the number of new HIV infections in 2015 are down an overall 6% from 2010.
The WHO reports that as of 2015, the global number of people living with HIV was 36.7 million
(range: 34.0 to 39.8 million), compared to 31.8 million (range: 29.4 million to 34.5 million) in
2005. This reflects continued transmission of HIV despite reductions in incidence, and the
benefits of signicantly expanded access to antiretroviral, which have helped to reduce the
number of people dying from AIDS-related causes, especially since 2004–2005. These data
reflect not only the number of people newly infected (incidence) with HIV, but the prevalence
(total number of infections, as defined in Chapter 7) of all cases of HIV due in part to the
expanded access to ART, which has helped to reduce the number of people dying from AIDS-
related causes. Sub-Saharan Africa still bears an inordinate share of the global HIV burden.
Although the rate of new HIV infections has decreased, the total number of people living with
HIV continues to rise. In 2015, that number reached 25.5 million, about 70% of the global total
(Fig. 14.6) (WHO, Number of people living with HIV).
FIGURE 14.6 Adults and children estimated to be living with HIV by WHO region, 2015. (Data
from WHO. [2016]. Global summary of the HIV epidemic, 2015. Retrieved August 2, 2017 from
http://gamapserver.who.int/mapLibrary/Files/Maps/HIV_all_2015 .)
HIV targets predominantly young- and middle-aged adults who are the mainstay of the
economy and the principal support of their families. As the loss of productive people in a society
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gradually increases, poverty also increases; there are fewer resources to cope with the situation,
and fewer options for change whether at family, community, or national level. Economic growth
is compromised, and the very fabric of society can be destroyed (CDC, Global HIV/AIDS).
The CDC estimates an estimated 1.1 million people in the United States were living with
HIV at the end of 2014, the most recent year for which this information is available. Of those
people, about 15%, or 1 in 7, did not know they were infected. Gay, bisexual, and other MSM
are most seriously affected by HIV. In 2014, gay and bisexual men accounted for 70% of all
new HIV infections. In the same year, individuals infected through heterosexual sex made up
23% of all new HIV infections. Within the overall estimates, however, some groups are affected
more than others. If we look at HIV diagnoses by race and ethnicity, African Americans are
most affected by HIV. In 2015, African Americans made up only 12% of the U.S. population
but had 45% of all new HIV diagnoses. Additionally, Hispanic/Latinos are also strongly
affected. They made up 18% of the U.S. population but had 24% of all new HIV diagnoses in
2015. Young people aged 13 to 24 are especially affected by HIV. In 2015, they comprised 16%
of the U.S. population but accounted for 22% of all new HIV diagnoses. All young people are
not equally at risk, however. Young gay and bisexual men accounted for 84% of all new HIV
diagnoses in people aged 13 to 24 in 2015, and young African American gay and bisexual men
are even more severely affected (CDC, HIV Basic Statistics).
As for AIDS, it’s a plague. We are human, we get plagues. They come along every so
often, kill off two-thirds of the population; in the next generation it’s a quarter; after that it’s
a childhood disease. Larry Niven
From 2010 to 2014, the annual number and rate of diagnoses of HIV infection in the United
States decreased to 39,513 and 12.3, respectively. However, numbers and rates of diagnoses of
HIV infection increased in some subgroups and decreased in others. From 2010 to 2014, the rate
for persons aged 25 to 29 years increased, with the highest rate among persons aged 25 to 29
years (33.4), followed by persons aged 20 to 24 years (31.2). Nonetheless, the rates for persons
aged 20 to 24 years remained stable. The rates for children (aged less than 13 years) and persons
aged 13 to 19, 30 to 64 years, and 65 years and older decreased. The rates for male and female
adults and adolescents decreased, with males accounting for 81% of all diagnoses of HIV
infection among adults and adolescents. The highest rate was for blacks/African Americans at
44.3, followed by 16.4 for Hispanics/Latinos. Transmission from 2010 through 2014, among
male adults and adolescents, the annual number of diagnosed HIV infections attributed to
injection drug use, to male-to-male sexual contact and injection drug use, or to heterosexual
contact decreased. The number of infections attributed to male-to-male sexual contact remained
stable. Among female adults and adolescents, the number of infections attributed to injection
drug use or to heterosexual contact decreased.
The 2014 revised surveillance case definition for HIV was used to classify cases diagnosed
in 2014 and later. The term diagnosis of HIV infection is defined as a diagnosis of HIV infection
regardless of the stage of disease (stage 0, 1, 2, 3 or unknown) and refers to all persons with a
diagnosis of HIV infection. The term HIV infection, stage 3 (AIDS) and its condensed version,
stage 3 (AIDS), refer specifically to persons with diagnosed HIV whose infection was classified
as stage 3 (AIDS) during a given year (for diagnoses) or whose infection has ever been
classified as stage 3 (AIDS) (for prevalence and deaths). By 2015, the rate of infections
classified as stage 3 (AIDS) was 5.7 (CDC, 2015b).
Healthy People 2020 objectives focused on HIV are outlined in see Box 14.8. A major
objective in this category is to increase the proportion of persons living with HIV who know
their serostatus (Healthy People 2020 HIV objectives). HIV is spread by unprotected sexual
contact with an infected person, by sharing needles and/or syringes with someone who is
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infected, or, very rarely in countries where blood is not screened for HIV antibodies, through
transfusions of infected blood or blood clotting factors. Also, infants born to HIV-infected
women may become infected before or during birth or through breastfeeding after birth (CDC,
HIV/AIDS fact sheets). There are many misconceptions about HIV transmission. Scientists and
medical authorities agree that HIV does not survive well in the environment, making the
possibility of environmental transmission remote. HIV is not transmitted through insects or
insect bites. There is no known risk of HIV transmission to coworkers, clients, or consumers
from incidental contact in industries such as food-service establishments. Although HBV has
been transmitted through tattooing or body piercing, HIV has not been transmitted in this
manner. Casual contact through closed-mouth or “social” kissing is not a risk factor for
transmission of HIV. The CDC recommends against engaging in “French” or open-mouth
kissing with a person known to be infected, although the risk of acquiring HIV in this manner is
believed to be very low. Contact with saliva, tears, or sweat has never been shown to result in
transmission of HIV. Biting is a risk factor only when there is severe trauma with extensive
tissue tearing and damage and presence of blood (CDC, HIV transmission). Box 14.7 presents
guidelines for prevention of exposure to the blood of persons who are HIV infected, at risk for
HIV infection, or whose infection and risk status are unknown.
14.7 Measures for Preventing HIV Exposure and Transmission When Caring for
an Infected Person
Wear gloves during contact with blood or other body fluids such as urine, feces, or vomit.
Cover cuts, sores, or breaks on both the caregiver’s and the patient’s exposed skin with a bandage.
Wash hands and other parts of the body immediately after contact with blood or other body fluids.
Disinfect surfaces soiled with blood with a bleach solution.
Avoid practices that increase the likelihood of blood contact, such as sharing of razors and toothbrushes.
Use and dispose of needles and other sharp instruments appropriately.
Strategies for preventing infection with HIV emphasize testing to identify infected people
and ensuring access to appropriate medical care, treatment, and prevention services. The only
way to know whether someone has HIV infection is to be tested for HIV. More than 1.1 million
people in the United States are living with HIV today, and one in seven of them don’t know it.
To increase awareness of HIV status, the CDC established its Expanded Testing Initiative,
which is aimed at (1) significantly increasing the number of persons tested in jurisdictions with a
high rate of HIV among disproportionately affected populations, and (2) supporting
implementation of the revised recommendations for HIV testing of adults, adolescents, and
pregnant women in healthcare settings (CDC, Expanded Testing Program). The 2006 CDC
Revised Recommendations for HIV Testing advocates routine HIV screening as a normal part of
clinical practice and are targeted to subpopulations of persons at higher risk for HIV, typically
defined on the basis of behavior, clinical, or demographic characteristics. The revised
recommendations include HIV screening for persons aged 13 to 65 years in all healthcare
settings (e.g., hospitals, acute-care clinics, and STD clinics) after the patient is notified that
testing will be performed, unless he/she declines (opt-out screening). In 2013, the USPTF also
recommended HIV screening for persons aged 15 to 65, as well as pregnant women. Younger
and older who are at increased risk should also be screened (USPTF, 2013). HIV screening in
the routine panel of prenatal screening for all pregnant women after the patient is notified that
testing will be performed, unless she declines (opt-out screening) (CDC, HIV among pregnant
women, infants, and children).
HIV infection can be diagnosed by serologic tests that detect antibodies against HIV-1 and
HIV-2 and by virologic tests that can detect HIV antigens. Antibody testing begins with a
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sensitive screening test (e.g., the conventional or rapid enzyme immunoassay [EIA]). Currently
available serologic tests are both highly sensitive and specific and can detect all known subtypes
of HIV-1. Most also can detect HIV-2 and uncommon variants of HIV-1. The advent of HIV
rapid serologic testing has enabled clinicians to make an accurate presumptive diagnosis of HIV
infection within half an hour, which could potentially facilitate the identification of those who
are living with HIV and are unaware of their serostatus. In addition to screening, prevention
counseling should be offered and encouraged in all healthcare facilities that serve patients at
high risk (e.g., STD clinics), because these facilities routinely gather information that places
persons at high risk for HIV. Prevention counseling need not be explicitly linked to HIV testing.
However, some patients might be more likely to think about HIV and consider their risk-related
behavior when undergoing an HIV test. HIV testing presents an excellent opportunity to provide
prevention counseling to assist with behavior changes to reduce the risk for acquiring HIV
infection (CDC, HIV infection: Detection, counseling, and referral). In addition to the strategies
outlined above, barriers to HIV prevention and screening programs can be eliminated by making
these programs culturally sensitive. Box 14.8 presents Healthy People 2020 objectives for HIV
infection.
HIV does not make people dangerous to know, so you can shake their hands and give
them a hug: Heaven knows they need it. Larry Niven
In Case 2, when Megan was seen by the nurse practitioner, a rapid HIV test was
performed. The results were negative. What primary prevention measures would you
recommend?
Caring for the HIV/AIDS patient in the community is a challenge. Because the disease is
chronic and there is no cure, infected people continue to live, work, and socialize as they
normally have in the past. However, appropriately timed interventions in HIV-positive persons
can reduce risks for clinical progression, complications or death from the disease, and HIV
transmission.
Evidence for Practice
The USPSTF 2013 guidelines recommended that clinicians screen for HIV infection in
adolescents and adults aged 15 to 65 years. Younger adolescents and older adults who are
at increased risk should also be screened This includes MSM; men and women having
unprotected sex with multiple partners; past or present injection drug users; men and
women who exchange sex for money or drugs; individuals whose sex partners were HIV
infected, bisexual, or injection drug users; people being treated for STDs; people who have
had a blood transfusion between 1978 and 1985. In addition, the USPSTF recommended
that clinicians screen all pregnant women for HIV.
Source: USPSTF. (2013). Immunodeficiency Virus (HIV) Infection: Screening. Retrieved July 31, 2017, from
https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/human-immunodeficiency-virus-hiv-infection-
screening.
14.8 Healthy People 2020 Objectives for HIV
Diagnosis of HIV Infection and AIDS
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(Developmental) Reduce new HIV diagnoses among adolescents and adults.
(Developmental) Reduce new (incident) HIV infections among adolescents and adults.
Reduce the rate of HIV transmission among adolescents and adults.
Reduce new AIDS cases among adolescents and adults.
Reduce new AIDS cases among adolescent and adult heterosexuals.
Reduce new AIDS cases among adolescent and adult men who have sex with men.
Reduce new AIDS cases among adolescents and adults who inject drugs.
Reduce perinatally acquired HIV and AIDS cases.
Death, Survival, and Medical Healthcare after Diagnosis
(Developmental) Increase the proportion of new HIV infections diagnosed before progression to AIDS.
(Developmental) Increase the proportion of HIV-infected adolescents and adults who receive HIV care
and treatment consistent with current standards.
Increase the proportion of persons surviving more than 3 years after a diagnosis with AIDS.
Reduce deaths from HIV infection.
HIV Testing
Increase the proportion of persons living with HIV who know their serostatus.
Increase the proportion of adolescents and adults who have been tested for HIV in the past 12 months.
Increase the proportion of adults with tuberculosis (TB) who have been tested for HIV.
HIV Prevention
Increase the proportion of substance abuse treatment facilities that offer HIV/AIDS education, counseling,
and support.
Increase the proportion of sexually active persons who use condoms.
(Developmental) Reduce the proportion of men who have sex with men (MSM) who reported unprotected
anal sex in the past 12 months.
Source: U.S. Department of Health and Human Services. Healthy People 2020 HIV objectives. Retrieved 29, 2013, from
http://healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=22.
OTHER SEXUALLY TRANSMITTED DISEASES
Herpes Simplex Virus
There are two types of herpes simplex virus (HSV), both of which can cause genital herpes.
HSV type 1 (HSV-1) most commonly causes sores on the lips (known as fever blisters or cold
sores), but it also can cause genital infections. HSV-2 most often causes genital sores, but it also
can infect the mouth. The CDC estimates that 15.7% of persons aged 14 to 49 years in the
United States have HSV infection, but the overall prevalence is likely higher because an
increasing number of genital herpes infections are caused by HSV-1. HSV-2 infection is more
common among women than men (20.3% vs. 10.6% in 14- to 49-year-olds), and is more
common among non-Hispanic blacks (39.2%) than non-Hispanic whites (12.3%). This disparity
remains even among persons with similar numbers of lifetime sexual partners (e.g., two to four
partners). Annually, 776,000 people in the United States acquire new herpes infections. HSV-2
prevalence has changed very little since 2004, and increases in genital HSV-1 infections have
been found in patient populations worldwide (CDC, Fact sheet: genital herpes).
Most individuals infected with HSV-1 or HSV-2 are asymptomatic, or have very mild
symptoms that are mistaken for another skin condition. As a result, most persons infected with
HSV-2 may be unaware of their infection; in the United States, an estimated 87.4% of 14- to 49-
year-olds infected have never received a clinical diagnosis. Generally, HSV-2 infection is
transmitted during sexual contact with someone who has a genital HSV-2 infection, and most
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commonly occurs from an infected partner who does not have a visible sore and may not know
that he or she is infected. The average incubation period after exposure is 4 days (range, 2 to 12).
The vesicles break and leave painful ulcers that may take 2 to 4 weeks to heal. Experiencing
these symptoms is referred to as having an “outbreak,” or episode. Although the infection can
stay in the body indefinitely, the number of outbreaks tends to decrease over time. Recurrences
are much less frequent for genital HSV-1 infection than for genital HSV-2 infection. Genital
ulcerative disease caused by herpes makes it easier to transmit and acquire HIV infection
sexually. There is an estimated two- to fourfold increased risk of acquiring HIV, if exposed to
virus when genital herpes is present. Type-specific HSV tests may be useful among persons with
HIV infection and MSM at increased risk for HIV acquisition. Healthcare providers should also
screen pregnant women if they have a history of genital herpes, as the virus can be passed from
mother to child, resulting in a potentially fatal infection (neonatal herpes), one of the most
serious complications of genital herpes. However, the CDC does not recommend screening for
HSV-1 or HSV-2 in the general population (CDC, Fact sheet: Genital herpes).
Hepatitis Viruses
The rate of new HBV infections in the United States has declined by approximately 82% since
1991, when a national strategy to eliminate HBV infection was implemented in the United
States. The decline has been greatest among children born since 1991, when routine vaccination
of children was first recommended. In 2014, a total of 2,953 cases of acute hepatitis B were
reported from 48 states to the CDC. The overall incidence rate for 2014 was 0.9 cases per
100,000 population. After adjusting for under-ascertainment and under-reporting, an estimated
19,200 acute hepatitis B cases occurred in 2014. However, because many HBV infections are
either asymptomatic or never reported, the actual number of new infections was estimated to be
approximately 10-fold higher. Rates were highest among adults, particularly males aged 25 to 44
years. An estimated 850,000 to 2.2 million persons in the United States have chronic HBV
infection. Chronic infection is an even greater problem globally, affecting approximately 240
million persons. It also is estimated that 786,000 persons worldwide die from HBV-related liver
disease each year (CDC, Hepatitis B FAQs for health professionals).
Hepatitis B viral infection becomes an STD when it is transmitted through mucosal contact
with infectious blood or body fluids (e.g., semen, saliva) during sex with an infected partner.
Those at increased risk of becoming infected with HBV include sexually active persons who are
not in a long-term, mutually monogamous relationship (e.g., more than one sex partner during
the previous 6 months) and MSM. Although 95% of adults recover completely from HBV
infection and do not become chronically infected, 15% become chronically infected and die
prematurely from cirrhosis or liver cancer; the majority remain asymptomatic until onset of
cirrhosis or end-stage liver disease. In the United States, chronic HBV infection results in an
estimated 1,800 deaths per year. Therefore, the ACIP recommends that hepatitis B vaccination
also include the following:
Susceptible sex partners of hepatitis B surface antigen (HBsAg)–positive persons
Sexually active persons who are not in a long-term, mutually monogamous relationship
Persons seeking evaluation or treatment for an STD
Men who have sex with men (CDC, Hepatitis B FAQs for health professionals).
In addition to hepatitis B, other types of hepatitis viruses, such as hepatitis C and D, can be
transmitted sexually; however, sexual transmission is not the primary means of spread as with
HBV.
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PREVENTION AND CONTROL OF SPECIFIC
INFECTIOUS DISEASES
Nurses can intervene in the infectious process through primary, secondary, and tertiary
prevention strategies that address the specific characteristics and transmission patterns of the
infectious agents. Methods of prevention make it possible to reduce the risk of exposure. The
use of vaccines can reduce the risk of infection before exposure to an infectious agent; this is
termed primary prevention. The CDC recommends vaccinations for children, adolescents, and
adults. The latest recommendations for vaccination can be found at the CDC website:
https://www.cdc.gov/vaccines/index.html. Postexposure prophylaxis can reduce the risk of an
infectious disease after exposure, if the prophylactic treatment is provided shortly after the
exposure; this is called secondary prevention. An example of tertiary prevention is treating
opportunistic infections among HIV-infected adults and adolescents. The CDC periodically
updates its guidelines for treating opportunistic infections. The latest guidelines can be found at
the CDC website. Chapters 5 and 6 discuss the natural history of disease and the levels of
prevention (primary, secondary, and tertiary) that are appropriate to each stage of the illness.
Practice Point
Nurses can reduce the risk of infection through primary and secondary prevention measures
that are specific to the characteristics of the infectious disease. For example, use of insect
repellants and wearing light-colored long pants tucked inside socks is a primary prevention
measure for tick-borne Lyme disease. Examining a “bull’s eye” lesion, prescribing antibiotics,
and performing ELISA testing of serum at a later date are secondary prevention measures.
Case 1. What measures should be taken to protect the citizens of Alamosa, CO, following
the report of fecal contamination of a well that supplied water to the community public
water system infrastructure?
Prevention of Foodborne Diseases
Making food safe is a major undertaking, involving all steps in moving from the farm or fishery
to the table. Many different organizations and regulatory agencies are involved in preventing or
limiting food contamination. Consumers can do their part by purchasing foods that have been
processed for safety, such as juices and ciders that have been pasteurized. Basics for Handling
Food Safely, guidelines for shopping, storage, preparation, thawing, cooking, serving, handling
leftovers, and refreezing food safely can be found at the United States Department of
Agriculture, Food Safety and Inspection Service website. Other precautions include good
handwashing after handling raw eggs, meat and poultry, pets, and farm animals. Also, use soap
and hot water to wash utensils and other surfaces that might have come in contact with raw or
undercooked meat, poultry, or eggs (CDC, CDC and Food safety). Consumers should be advised
to avoid eating fresh produce irrigated with water of unknown quality (CDC, Hepatitis B FAQs
for health professionals). Illnesses that primarily cause diarrhea or vomiting can lead to
dehydration if the person loses more electrolytes than he or she takes in. Replacing lost fluids
and electrolytes and keeping up with fluid intake are important. Medical treatment is necessary
for a diarrheal illness that is accompanied by fever (temperature of more than 101.5°F),
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prolonged vomiting, bloody stools, or dehydration.
Prevention of Waterborne Diseases
It is important to know where drinking water comes from, how it has been treated, and if it is
safe to drink (e.g., a septic tank should not be too close to a private well). Although most
community water systems use groundwater for their water supply, more people actually depend
on community water systems that use surface water. Community water systems supply water to
the same population year-round and are regulated by the EPA. The Safe Drinking Water Act
(SDWA) requires EPA to establish and enforce standards that public drinking water systems
must follow (EPA, Water topics). Transient noncommunity water systems provide water to 25 or
more people for at least 60 days/year, but not to the same people and not on a regular basis (e.g.,
campgrounds).
The EPA has published guidelines for microbiologic water quality for recreational
freshwater (e.g., lakes and rivers) and marine water (EPA, Water topics). States have latitude
regarding their guidelines or regulations and can post warning signs to alert potential bathers
until recreational water quality improves. Unlike treated areas, where disinfection can be used to
address most problems with the microbiologic quality of water, contaminated freshwater can
require weeks or months to improve or return to normal. However, swimming pools might need
to be closed until the water has been adequately treated and filtered or the swimming pool
drained and refilled to remove contamination. Prompt identification of potential sources of
contamination and remedial action are necessary to return bathing water to an appropriate
quality for recreational use.
Swallowing, breathing, or having contact with contaminated water from swimming pools,
spas, lakes, rivers, or oceans spreads recreational water illnesses. Contamination of recreational
water can be avoided when nurses educate the public to remember the following:
Do not swim if you have diarrhea.
Do not swallow the pool water.
Wash hands with soap and water after using the restroom or changing diapers.
Take children to the bathroom often. Change diapers in the bathroom and not at poolside.
Wash children thoroughly with soap and water before swimming (CDC, 12 Steps for prevention of
recreational water illnesses).
Prevention of Sexually Transmitted Infections
At the time of the 1997, Institute of Medicine (IOM) report, The hidden epidemic: Confronting
sexually transmitted diseases (Eng & Butler, 1997), an effective national system for STD
prevention did not exist in the United States. However, the CDC’s efforts to implement the
recommendations of the IOM 1997 report resulted in the development of Comprehensive STD
Prevention Systems and publication of the STD Program Operation Guidelines. The purpose of
the guidelines is to further STD prevention by providing a resource to assist in the design,
implementation, and evaluation of STD prevention and control programs. The target audience
for the guidelines is public health personnel and other persons involved in managing STD
prevention programs (CDC, Program operations guidelines for STD prevention).
STDs are among the leading causes of morbidity and mortality in the United States. They
affect men and women of all backgrounds and economic levels, and account for substantial
healthcare spending. Data suggest the direct cost of treating STDs in the United States is nearly
$16 billion annually (Owusu-Edusei et al., 2013). Nearly 20 million new STDs occur each year
in the United States, with half of them among young people aged 15 to 24. With more than 110
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million total (new and existing) infections occurring across the nation, at any given time, there
are opportunities to focus on prevention and wellness and support the development of national
strategies to improve the nation’s health through evidence-based clinical and community
prevention and wellness activities. The updated CDC Guidelines for the Treatment of Sexually
Transmitted Diseases integrates recommendations on the most effective treatment regimens,
screening procedures, and prevention strategies for STDs. The CDC revised these guidelines in
2015, based on scientific evidence-based review (CDC, 2015c).
KEY CONCEPTS
The epidemiology of the infectious disease process adds other elements to the epidemiologic triad (agent,
host, and environment): a portal of exit for the infectious agent, a means of transmission, and a portal of
entry to a new host.
The environment/reservoirs of infectious agents can be humans, animals (zoonotic), plants, insects, water,
and soil.
Mechanisms of transmission of an infectious agent from one host to another include direct contact, indirect
contact, droplets, and airborne transmission.
An infectious disease may or may not be contagious or communicable.
An epidemic refers to a significant increase in an infection or infectious disease beyond the expected
(endemic) level in a certain population and/or geographic area.
Nurses play an important role in the prevention of healthcare-associated infections and represent the first
line of defense for such adverse outcomes.
The CDC is a major agency that protects the nation’s health by developing guidelines that promote health
and quality of life by preventing and controlling disease, injury, and disability. It also maintains surveillance
systems to analyze data for infectious disease trends and outbreaks.
Healthy People 2020 has outlined objectives for immunizations and infectious diseases.
Foodborne illnesses include biologic and nonbiologic agents and can be caused by microorganisms and
their toxins.
Waterborne illnesses are associated with drinking water and recreational water.
Healthy People 2020 has outlined objectives for food and water safety.
The EPA sets standards for drinking water.
The CDC has deficiency classifications for drinking water, and water not intended for drinking used during
waterborne outbreak investigations.
STDs are among the leading causes of morbidity and mortality in the United States. The CDC reports that
an estimated 1.1 million people in the United States were living with HIV at the end of 2014, the most
recent year for which this information is available. Of those people, about 15%, or 1 in 7, did not know they
were infected. HPV is one of the most common causes of STD in the world. It is estimated that 100% of
sexually active men and women acquire genital HPV infection at some point in their lives, and can lead to
cancer of the cervix in women.
The CDC provides an effective system for STD prevention to assist community/public health professionals
in the design, implementation, and evaluation of STD prevention and control programs.
Healthy People 2020 has outlined objectives for the prevention and control of STDs and HIV/AIDS.
CRITICAL THINKING QUESTIONS
1. In the outbreak outlined earlier, 23 campers became ill with gastroenteritis over a period of 7 days. An
outbreak of norovirus is defined by the CDC as an occurrence of two or more similar illnesses resulting
from an exposure that is either suspected or laboratory-confirmed to be caused by norovirus.
a. Given that the incubation period for norovirus gastroenteritis is 12 to 48 hours, was this a common
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source or a propagated outbreak?
b. What is a major means to prevent the transmission of a communicable disease like norovirus?
2. There is a planned community health project to decrease the incidence of HPV.
a. Who is/are the target population? Why?
b. What are some key factors to consider when planning an HPV prevention program?
3. Check the Healthy People 2020 objectives for HIV website at https://www.healthypeople.gov/2020/topics-
objectives/topic/hiv/objectives
a. How close to the 2020 target is the objective to increase the proportion of persons living with HIV who
know their serostatus?
b. How close to the 2020 target is the objective to reduce newly diagnosed perinatal-acquired HIV cases?
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2017, from http://www.who.int/mediacentre/factsheets/fs310/en/index2.html
WEB RESOURCES
Please visit thePoint for up-to-date web resources on this topic.
(PEPFAR. Fact Sheet, 2016 https://www.pepfar.gov/documents/organization/264882 .)
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https://www.healthypeople.gov/2020/topics-objectives/topic/immunization-and-infectious-diseases
https://www.healthypeople.gov/2020/topics-objectives/topic/sexually-transmitted-diseases
http://www.who.int/hiv/pub/arv/global-AIDS-update-2016_en ?ua=1
https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/human-immunodeficiency-virus-hiv-infection-screening
https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/chlamydia-and-gonorrhea-screening
https://www.cdc.gov/std/tg2015/screening-recommendations.htm
http://www.who.int/gho/hiv/epidemic_status/cases_all/en
http://www.who.int/mediacentre/factsheets/fs391/en/
http://www.who.int/csr/alertresponse/en/
http://www.who.int/mediacentre/factsheets/fs360/en
http://www.who.int/hiv/data/en/
http://www.who.int/influenza/human_animal_interface/Influenza_Summary_IRA_HA_interface_06_15_2017 ?ua=1
http://www.who.int/hiv/en/
http://www.who.int/csr/don/2010_08_06/en/
http://www.who.int/healthinfo/global_burden_disease/projections/en/
http://www.who.int/mediacentre/factsheets/fs310/en/index2.html
http://thepoint.lww.com/vitalsource/ebook/9781975111694
https://www.pepfar.gov/documents/organization/264882
Chapter 15
Emerging Infectious
Diseases
Barbara A. Goldrick
For additional ancillary materials related to this chapter. please visit thePoint
FANTASTIC VOYAGE: INFLUENZA
Time to go! Time to go!
An influenza virus,
Hiding in saliva, buried in a cell,
Antibodies and T cells are coming.
Get out! But how?
Induce a sneeze? Kickstart a cough?
Ah yes, here we go…
Aahhh-choo! Freedom at last!
Where are we?
A quick look around
A hospital? I see children,
Very thin, sick children,
Must be the cancer ward.
No B cells or T cells—a virus paradise!
Let’s travel, find a breeze and float.
Where’s my next victim?
My previous young doctor host
Walking quickly away
Head down, embarrassed
Scolded by a nurse—where was his mask?
Too busy and careless, poor fool
He still serves me well, dragging me into his wake.
Here I go, following and floating
A door nearby opens—negative pressure!
In I go, but on a cancer ward,
This should be positive pressure!
To keep bugs out, not draw them in.
I cannot complain
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All good for me, for now I can see
A young girl with leukemia
Sitting in bed, watching TV
Laughing, inhaling, bringing me close.
But wait, what’s this? Her mother!
Opening the toilet door,
Even greater negative pressure in there.
And worse, wet surfaces glistening inside,
Cleaned by her mother with chlorhexidine.
No! Not yet! Not now! I’m so close!
Being pulled in. No escape. Falling, falling…
The young girl is laughing. Now her mother is too.
—JT Tang, National University Hospital, Singapore
CHAPTER HIGHLIGHTS
Emerging versus reemerging infectious diseases
Factors that influence the emergence/reemergence of infectious diseases
Recent emerging/reemerging infectious diseases
Prevention and control of emerging and reemerging infectious diseases
Reemergence of vaccine-preventable diseases
OBJECTIVES
Identify factors that influence emerging and reemerging infectious diseases.
Describe recent emerging and reemerging infectious diseases from a global perspective.
Relate the methods of transmission of emerging and reemerging infectious diseases to methods of control
and prevention.
Explain prevention and control of reemergence of vaccine-preventable diseases.
Identify antimicrobial-resistant threats in the United States.
KEY TERMS
Antigenic drift: Slow and progressive genetic changes that take place in DNA and RNA as
organisms replicate in multiple hosts.
Antigenic shift: Sudden change in the molecular structure of DNA and RNA in microorganisms,
resulting in a new strain of the microorganism.
Antibiotic stewardship: Refers to a set of coordinated strategies to improve the use of
antimicrobial medications with the goal of enhancing patient health outcomes, reducing
resistance to antibiotics, and decreasing unnecessary costs.
Convergence model: Model illustrating the interaction of 13 factors that contribute to the
emergence and reemergence of infectious diseases.
Directly observed therapy (DOT): Observation of clients to ensure that they ingest each dose of
anti-TB medication to maximize the likelihood of completion of therapy.
Ecosystem: Natural unit consisting of all living things (plants, animals, bacteria, viruses)
interacting with, and dependent on, one another for survival within their nonliving environment.
Emerging infectious disease: Newly identified, clinically distinct (novel) infectious disease.
Herd immunity: Type of immunity in which a large proportion of people in a population are not
susceptible to a communicable disease and the few people who are susceptible will not likely
be exposed and contract the illness.
Microbial adaptation: Process by which organisms adjust and change to their environment.
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I
Pandemic: Epidemic occurring worldwide.
Reemerging infectious disease: The reappearance (reemergence) of a known infectious
disease after its decline, with an incidence that is increasing in a certain geographic area or
among a specific population.
Vaccine-preventable diseases: Dangerous or deadly diseases that are preventable by
vaccination.
CASE STUDIES
References to case studies are found throughout this chapter (look for the case study icon).
Readers should keep the case studies in mind as they read the chapter.
CASE 1
Pandemic influenza is different from other infectious diseases, due to the ability of influenza viruses
to change and spread easily from person to person. Influenza pandemics have led to widespread
morbidity and mortality over the past 100 years. As a result, past pandemic influenza plans have
focused on severe pandemics, like the first pandemic of A (H1N1), known as the “Spanish flu,”
which occurred between 1918 and 1919. It was very deadly, spread across the globe within 6
months, affected young healthy adults, and resulted in 1,400,000 deaths worldwide; 99% of deaths
occurred in persons aged ≤65 years.
In June 2009, the World Health Organization (WHO) declared an A (H1N1) influenza pandemic,
the first global pandemic in 40 years as well as the first in the 21st century. At that point, the
pandemic was in phase 6, the highest WHO alert level, which meant that a global epidemic was
underway. By August 2010, more than 214 countries and overseas territories or communities had
reported laboratory-confirmed cases of pandemic influenza H1N1 2009, including at least 18,449
deaths. However, the A (H1N1) influenza pandemic experienced in 2009 was less severe than
originally thought. Nonetheless, by preparing only for severe pandemics, the former plans did not
include specific guidance for H1N1 2009 pandemic (CDC [2010a]. 2009 H1N1: Overview of a
pandemic).
CASE 2
Despite the overall decline in tuberculosis (TB) incidence in the United States, outbreaks of TB
among homeless persons continue to challenge TB control efforts. In January 2010, public health
officials recognized an outbreak of TB after three overnight guests at a homeless shelter in Illinois
received diagnoses of TB disease caused by Mycobacterium tuberculosis isolates with matching
genotype patterns. In April 2007, a 55-year-old man received a diagnosis of sputum smear–positive
TB disease caused by an M. tuberculosis isolate with a particular genotype pattern not documented
previously in that County. The man had been a frequent overnight guest at a particular county
facility that provided short-term shelter each night for approximately 180 persons whose housing
situation was unstable. Subsequent case finding among other guests and staff members at the
shelter identified no additional cases.
However, in October 2009 and January 2010, two additional cases with the index patient’s TB
genotype pattern were identified among overnight shelter guests, alerting public health officials to a
potential outbreak. By March 2010, three additional cases with the outbreak genotype pattern had
been identified among shelter guests, leading county and state officials to request on-site
epidemiologic assistance from the Centers for Disease Control and Prevention (CDC). Because all
patients had been guests at the shelter, the CDC recommended on-site case finding among guests
and staff members at the shelter.
Source: Adapted from Centers for Disease Control and Prevention (CDC). (2012). Tuberculosis outbreak associated with a
homeless shelter—Kane County, Illinois, 2007–2011. Morbidity and Mortality Weekly Report, 61(11), 186–189.
nfants, children, adolescents, teens, and adults need different vaccinations, depending on
their age, location, job, lifestyle, travel schedule, health conditions, or previous vaccinations.
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INTRODUCTION
Infectious organisms have been with humanity since the dawn of civilization; a basic part of life,
they are universal. Diseases will continue to emerge and reemerge. Emerging infectious
diseases and their basic causes are a global threat that affects the stability of nations and the
entire planet. Developing nations, which have the fewest resources to respond to this emergence
and reemergence, bear the greatest burden of this threat. However, infectious diseases, which
may spread rapidly and indiscriminately, present a significant risk to the health and development
of all nations. No country or population is immune. In its 1992 report, the Institute of Medicine
(IOM, 1992) defined an emerging infectious disease as either (1) a newly identified clinically
distinct infectious disease or (2) the reappearance (or reemergence) of a known infectious
disease after its decline with an incidence that is increasing in a certain geographic area or in a
specific population. An example of a new infectious disease, first recognized by a World Health
Organization (WHO) physician in Hanoi, Vietnam, in 2003, was made very clear when severe
acute respiratory syndrome (SARS) appeared worldwide in 2003.
Practice Point
Astute clinicians can detect a possible emerging infectious disease by taking a careful history
that includes travel history, which may reveal travel to an area where an emerging infection
has been reported.
FACTORS THAT INFLUENCE EMERGING INFECTIOUS
DISEASES
Factors that influence the emergence/reemergence of infectious diseases are complex and
interrelated. In The Coming Plague (1995), Pulitzer Prize–winning author Laurie Garrett pointed
out that by the end of the 20th century, microbes were no longer confined to remote ecosystems
but had transformed the planet into a global village. Although a global village provides social
and economic opportunities, it also gives emerging infectious diseases a chance to spread.
More than 36 new emerging infectious diseases have been identified worldwide in the past
40 years. Figure 15.1 illustrates recent infectious diseases identified by the WHO and the
Centers for Disease Control and Prevention (CDC) (Morens, Folkers, & Fauci, 2008). A 2003
IOM report illustrated that “health protection and disease prevention among the U.S. population
requires global awareness and collaboration with domestic and international partners to prevent
the spread of infectious diseases” (Smolinski, Hamburg, & Lederberg, 2003). In Microbial
Threats to Health: Emergence, Detection, and Response, the IOM identified 13 factors that
affect emerging and reemerging infections. These are listed in Box 15.1. The IOM convergence
model (Fig. 15.2) demonstrates how these 13 factors are grouped and overlap. There are four
types of interrelated and overlapping microbe–human interactions, which can lead to
emerging/reemerging infectious diseases: (1) genetic and biologic; (2)
physical/environmental; (3) ecologic; and (4) social, political, and economic. The ability of
microbes to adapt and the dynamic interaction between microbes and humans are central to the
IOM convergence model. Several of these interactions are discussed below.
Microbial Adaptation and Change
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Microbes live everywhere and are very adept at adaptation. They are constantly interacting with
other living organisms and changing in response to their environment. Their habitats expand as
humans alter the environment, extending their contact with a wider variety of microbes. As
microbes reproduce, genetic changes may result in pathogens that are immunologically distinct
from their parental strains. For example, antigenic drift, the slow and progressive genetic
changes that take place in DNA and RNA as organisms replicate in multiple hosts, causes
changes in influenza viruses each year. Antigenic shift occurs when there is a sudden change in
the DNA and RNA, resulting in a new strain of the microorganism, and people have little or no
acquired immunity.
FIGURE 15.1 Examples of recent emerging and reemerging infectious diseases.
Three stages of microbial adaptation and change occur over varying periods of time.
During stage I, an epidemic occurs. The microbes enter a “virgin” population where hosts have
no prior exposure to the organism and have few defenses. This leads to further spread in the
population. Ultimately, survivors are usually left with improved defenses against reinfection.
During stage II, the infection becomes endemic or continuously present in a geographic area or
population of people. Routine childhood diseases are an example of such infections. During
stage III, symbiosis is possible. Further adaptation occurs, resulting in mutual tolerance and
sometimes mutual benefit for both the microorganism and the host. This is the preferred
outcome.
15.1 Factors That Contribute to the Emergence and Reemergence of Infectious
Diseases
Microbial adaptation and change
Human susceptibility to infection
Climate and weather
Changing ecosystems
Human demographics and behavior
Economic development and land use
International travel and commerce
Technology and industry
Breakdown of public health measures
Poverty and social inequality
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War and famine
Lack of political will
Intent to harm (bioterrorism)
Source: Smolinski, M. S., Hamburg, M. A., & Lederberg, J. (2003). Microbial threats to health: Emergence, detection, and response. Washington, DC: Institute
of Medicine, The National Academies Press.
Our relationship to infectious pathogens is part of an evolutionary drama. Here we are.
Here are the bugs. Joshua Lederberg, molecular biologist
As microbes adapt over the centuries, the illnesses they produce become less acute.
Symptoms become milder, and fewer organs are involved as immunity develops. Syphilis first
appeared in the late 15th century in Europe, causing repulsive pustules over the entire body.
Many internal organs were involved, and death occurred within a few years. Just 50 years later,
symptoms were limited to the genitals, face, and nervous system, and people could live with the
disease for decades, thus having an opportunity to transmit it. Even the mode of transmission
can change over time. For example, the “black plague,” or bubonic plague, that devastated the
European population in the 12th and 13th centuries was transmitted through the bites of fleas
that lived on rats. Centuries later, a new form of the disease emerged. The organism, normally
trapped in the lymph nodes, was released and the lungs became infected. As a result, an even
more deadly form of the disease, the pneumonic plague, emerged. Transmission was now
airborne, and the disease was transmitted from person to person. Pneumonic plague was fatal in
95% of its victims and remains resistant to antibiotic treatment today.
…a flea has smaller fleas that on him prey; And these have smaller still to bite ‘em, And so
proceed ad infinitum. Jonathan Swift, On Poetry: A Rhapsody (1733)
FIGURE 15.2 Institute of Medicine convergence model. (From Smolinski, M. S., Hamburg, M. A.,
488
& Lederberg, J. [2003]. Microbial threats to health: Emergence, detection, and response.
Washington, DC: Institute of Medicine, The National Academies Press.)
Fortunately, a new acute illness is usually the exception rather than the rule. Relatively few
potentially pathologic microbes enter humans, and few survive. Actually, to cause disease,
microbes must beat enormous odds. There is a “parasite’s dilemma.” If the microbe proliferates
rapidly, it may kill the host. If it cannot be transmitted quickly to a new host, the microbe dies.
However, if the microbe proliferates slowly, within a week the host’s immune system will
recognize the microbe as foreign, form antibodies, and destroy the microbe. If microbes survive
and cause disease, the reason is usually due to changes illustrated by the epidemiologic triad: (1)
a change in the behavior of humans—the host, (2) a change in the behavior of the microbes—the
agent, or (3) a change in the environment.
Human Susceptibility to Infection
Many characteristics of the human body and the physical environment determine whether a
microbe will cause a disease. For infections to occur, people must be susceptible to infection. If
the host has not been exposed to the microbe in the past, there is no acquired immunity to the
organism. Immunity can be impaired because of environmental stresses, poor nutrition,
medication, or the presence of other illnesses. Normal defense mechanisms can be bypassed
through injury or deliberate medical or surgical procedures. Diseases persist only if the
population is dense enough to allow continued transmission of germs and large enough to
produce a continual supply of susceptible hosts. If a substantial proportion of people in a
population are not susceptible to a communicable disease, the few people who are susceptible
are not likely to be exposed and contract the illness. This is a process called herd immunity.
Infectious diseases introduced with Europeans, like smallpox and measles, spread from
one Indian tribe to another, far in advance of Europeans themselves, and killed an
estimated 95% of the New World’s Indian population. Jared Diamond, scientist and
author
Climate, Changing Ecosystems, and Human Behavior
Many infectious diseases have characteristic geographic distributions and seasonal variations.
Probably the most common is the influenza virus that peaks each fall and winter. Factors such as
temperature, precipitation, and humidity affect the life cycle of many disease pathogens and
their vectors, and consequently they can affect disease outbreaks. Natural changes in climate,
such as the effects of El Niño ocean current, global warming, and natural disasters, result in a
change in environmental conditions. These changes are not always beneficial to infectious
organisms. However, the relationships between climate and infectious disease are a complicated
web of causation that includes almost all of the factors that underlie the emergence of these
diseases. Dr. Claire Heffernan, a trained veterinarian and a specialist in global health and disease
interaction between animals and humans, is concerned that as the climate warms in Arctic
regions, more and more diseases from around the world are spreading there, threatening both
animal and human populations (International Society for Infectious Diseases [ISID], 2013).
Ecologic changes are one of the most frequently identified factors in the emergence of
infectious diseases. Ecosystems are groups of interacting living things (e.g., plants, animals,
bacteria, and viruses) that depend on each other for survival. Ecosystems become unstable with
climate change, and throughout history, humans have contributed to ecologic flux. Humans are
responsible for land use changes, which are often associated with economic development, with
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the accompanying dislocation of indigenous animals, plants, and microorganisms. For example,
logging and the clearing of timber means that homes and sources of food are lost.
With the death or relocation of indigenous organisms, niches open up for those that thrive
under marginal conditions. Also, practices associated with food production can result in the
creation of ideal homes for the creatures that carry pathogens (vectors). In developing countries,
where ditches may be contaminated by fecal material, irrigation fields can contribute to the
contamination of local water supplies.
Changes in the environment cause new interactions between agents and hosts and can
potentially lead to new infectious disease threats (IOM, 2010). Human population upheavals
caused by war or civil conflicts often result in the forced dislocation of large groups of people,
and migration of such groups of people from rural areas to cities can be accompanied by a
breakdown of public health measures. These have often been the factors in disease emergence
(Fig. 15.3). Although cities have distinct advantages, such as water supplies and transportation,
it was only when towns became big cities that massive die-offs became a regular part of human
life. Urban life, with malnutrition, overcrowding, and poor sanitation, enhances the major
pathways for transmission of infectious disease; plagues and cities have always developed
together. For example, cholera outbreaks occurred four times between 1831 and 1854 in
England because of the large influx of people into cities and the lack of proper sanitary services.
These outbreaks resulted in a total of 10,675 deaths.
FIGURE 15.3 Geographic distribution of recent emerging or reemerging infectious disease
outbreaks and countries affected by conflict, 1990–2006. Countries in yellow were affected by
conflict during this period. Symbols represent outbreaks of emerging or reemerging infectious
diseases. (From Gayer, M., Legros, D., Formenty, P., & Connolly, M. A. [2007]. Conflict and
emerging infectious diseases. [Vol. 13, No. 11]. Geneva, Switzerland: World Health Organization.)
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Evidence for Practice
Polio cases have decreased worldwide by over 99% since 1988, from an estimated 350,000
cases in more than 125 endemic countries to a total number of 22 wild poliovirus (WPV)
cases and 96 vaccine-derived polioviruses (circulating vaccine-derived polio viruses), all
types in 2017. In September 2018, the World Health Organization reported the following
poliovirus update: WPV, 18 (all in endemic countries) and 36 cases of cVDPV, all types.
Eight of the cVDPV cases were from endemic countries and 28 were from nonendemic
countries. In 2018, the WHO reported that only three countries (Afghanistan, Nigeria, and
Pakistan) remained polio-endemic countries. Nigeria had been declared polio-free in 2015;
however, the detection of wild polio in Nigeria in July 2016 after 2 years was a sobering
reminder that polio is a difficult disease to eradicate, especially in areas with ongoing
humanitarian crises and faltering health systems. Afghanistan had the highest number of
WPV cases in September 2018 at 14. The Democratic Republic of the Congo had the
second highest number of cVDPV cases at 15 (WHO, 2018a, Polio today.)
Although the WPV is decreasing in prominence and has disappeared from all but the
three endemic countries, the vaccine virus has increased its presence as a major challenge
in countries that have interrupted the WPV transmission through major campaign activities
but have not been able to keep up the high levels of vaccination coverage following
declaration polio-free status in those countries. Until poliovirus transmission is interrupted in
these countries, all countries remain at risk of importation of polio, especially vulnerable
countries with weak public health and immunization services and travel or trade links to
endemic countries. For an update, the global map of WPV and cVDPV cases can be found
at http://polioeradication.org/polio-today/polio-now/
As a result of the global effort to eradicate the disease, more than 16 million people have
been saved from paralysis. In 2016, 155 countries and territories successfully removed the
polio type-2 strain from the oral polio vaccine (WHO [2016a], Polio global eradication
initiative).
As long as a single child remains infected, children in all countries are at risk of
contracting polio. Failure to eradicate polio from these last remaining strongholds could
result in as many as 200,000 new cases every year, within 10 years, all over the world. The
WHO International Travel and Health recommendation is that all travelers to and from polio
affected areas be fully vaccinated against polio (WHO, Poliomyelitis).
Environmental surveillance is frequently used by countries around the world, to support
the detection of diseases of public health importance. Wild poliovirus type 1 (WPV1) was
detected through routine environmental surveillance in 2013 in southern Israel, a
nonendemic country. Israel has been free of indigenous WPV transmission since 1988. All
viruses were detected in sewage only; no cases of paralytic polio have been reported.
Routine immunization levels in Israel were estimated at 94% (WHO, Poliovirus detected
from environmental samples in Israel – update, 15 July 2013.
Evidence for Practice
The spirochete Borrelia burgdorferi has been identified as being responsible for most
human cases of Lyme disease. In the northeastern and midwestern United States, Borrelia
burgdorferi is transmitted by the vector Ixodes scapularis tick, also known as a deer tick.
Global climate change can affect the distribution of vector-borne diseases. Lyme disease is
one of the most commonly reported vector-borne illnesses in the United States. In 2015,
95% of confirmed Lyme disease cases were reported from 14 states, and it was the sixth
most common nationally notifiable disease. However, this disease does not occur
nationwide and is concentrated heavily in the Northeast and upper Midwest (CDC, Lyme
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http://polioeradication.org/polio-today/polio-now/
disease data and surveillance).
Travel, Technology, and Industry
International air travel now allows people to reach any destination in the world in an average of
10 to 16 hours. Infected travelers can introduce new microbes into new environments, both
while traveling to new places and returning home. An increasing number of travelers increases
the chances of contact with an infectious disease. Also, adventure travelers, who venture into
new environments with exotic wildlife, increase their chances of coming into contact with
microbes that have never before been recognized as human pathogens.
Mass food production that processes or uses biologic products increases the chance of
unknown contamination at every stage. These contaminated food products can be distributed
widely, often to grocery shelves or restaurants within a day, and they may be eaten shortly
thereafter. A single source of contamination has the potential to affect thousands of people in a
large geographic area. A 2012 multistate outbreak of Shiga toxin–producing Escherichia coli
O157:H7 (STEC O157:H7) linked to prepackaged organic spinach and spring mix blend grown
in contaminated fields (CDC, Shiga toxin-producing Escherichia coli O157:H7 infections linked
to organic spinach and spring mix) and the intentional contamination of Chinese milk with
melamine in 2009 (food counterfeiting) are just two examples of the types of problems created
by mass food production.
There have been profound changes in society within the last 100 years, perhaps few greater
than the changes in healthcare technology. Infections acquired in healthcare facilities affect
millions of people annually worldwide. The sickest people are at the highest risk. Microbial
adaptation and change in response to the overuse of antibiotics and consequent accumulation in
the environment have caused the rapid evolution of resistant pathogens. Microorganisms such as
methicillin-resistant Staphylococcus aureus (MRSA) are now found in the community as well as
in healthcare institutions. Antibiotic-resistant pathogens, one of the plagues of the 20th century,
continue to be a problem in the 21st century.
Practice Point
To protect travelers going to countries outside the United States, the CDC publishes its
Health Information for International Travel (commonly called the Yellow Book) every 2 years
as a reference for health professionals providing care to international travelers and is a
resource for anyone interested in staying healthy abroad. It includes important travel
medicine updates, including the latest information about emerging infectious disease threats
such as Zika, Ebola, and Middle East respiratory syndrome (MERS), which are discussed
below. It also provides vaccine recommendations for travel, updated guidance on the use of
antibiotics in the treatment of travelers’ diarrhea, and special considerations for unique types
of travel, such as wilderness expeditions, work-related travel, and study abroad (CDC, Yellow
Book, 2018).
The CDC Yellow Book, 2018, codifies the U.S. government’s most current travel health
guidelines, including pre-travel vaccine recommendations and destination-specific health
advice. For example, destination-specific recommendations for popular itineraries include
new sections for travelers to Cuba. In the summer of 2017, the CDC updated travel
information for malaria in Cape Verde, the Dominican Republic, and Mexico. It also updated
Zika travel warnings in several countries. For more information on travel vaccination
recommendations, see the CDC website at https://wwwnc.cdc.gov/travel.
Source: CDC. Yellow Book, 2018. Retrieved on August 19, 2017, from https://wwwnc.cdc.gov/travel/page/yellowbook-home.
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https://wwwnc.cdc.gov/travel
https://wwwnc.cdc.gov/travel/page/yellowbook-home
Lack of Political Will and Breakdown of Public Health
Infrastructures
Unlike the United States, Canada, the United Kingdom, and European countries, most
developing nations do not have the public health network and technologic advances required to
fight against infectious diseases. Many of these countries have to choose between funding
economic development initiatives and investing in a national public health infrastructure.
The 1991 outbreak of cholera in Peru is a good case study; this outbreak illustrates the
complex web of causation that contributed to the onset and spread of the disease. Historically,
there have been seven acknowledged cholera pandemics. The seventh pandemic of cholera
commenced in 1961 in Indonesia; by 1991, it had reached Peru. Cholera is a disease transmitted
through the fecal–oral route that is associated with poverty. The disease had been absent from
Peru for more than 100 years. It has been suggested that human waste contaminated with Vibrio
cholerae was discharged from a Chinese freighter offshore from infected crew members on
board the ship. The microbes then found their way into plankton, which was in turn ingested by
fish and shellfish. Consumption of raw shellfish is a delicacy in Peru, and one possible source of
the epidemic was contaminated shellfish. Cholera infection in humans occurred because a series
of complex factors existed along Peru’s shores. The rapid population growth in the coastal cities
exceeded the capability of the public health infrastructure to deal with fecal contamination of
water supplies. The cholera outbreak in Peru cost the country U.S. $770 million due to food
trade embargoes and adverse effects on tourism. The disease subsequently quickly spread to
other Latin American countries (Mutreja et al., 2011; WHO, Global epidemics and impact of
cholera).
Practice Point
Infectious disease prevention requires global consciousness. Not all countries have the
public health infrastructure to combat emerging infectious diseases.
RECENT EMERGING AND REEMERGING INFECTIOUS
DISEASES
Severe Acute Respiratory Syndrome, 2002–2003
At least 7 of the 13 factors affecting emerging infections, identified in the 2003 IOM report,
occurred during the 2002–2003 SARS outbreak. The SARS epidemic, which occurred
worldwide between February and July of 2003, began in mainland China in November 2002 but
was not reported to the WHO until February 2003, when the Chinese Ministry of Health
reported that an outbreak of 305 cases of “atypical pneumonia,” including five deaths, had
occurred in Guangdong Province. By then, SARS had spread to several countries, including
Hong Kong, Taiwan, Singapore, Vietnam, and Canada. Secondary cases of SARS were
imported to the respective countries by a “superspreading event” that occurred through exposure
to an index case of SARS from mainland China. Although the causative agent for SARS had not
been identified early in the outbreak, a case definition for SARS was established, and secondary
attack rates of more than 50% were observed in healthcare providers caring for clients with
SARS in both Hong Kong and Vietnam (CDC, Remembering SARS 10 years later).
The causative agent for SARS was identified in April 2003 as a variant coronavirus (CoV),
with an average incubation period of 4 to 6 days (range, 1 to 14 days) and a maximum of 10
493
days. Although SARS-CoV was found to be mostly transmitted by close contact with respiratory
secretions and aerosols, other body fluids, such as saliva, tears, urine, and feces, also
demonstrated presence of the virus. Most cases of SARS among healthcare providers occurred
from contacts with clients and visitors who were not identified as having SARS and before
infection control and quarantine measures were in place or, when infection control precautions
were relaxed (CDC, Remembering SARS 10 years later).
Canada became the first SARS epicenter in the Western Hemisphere, with two clusters of
SARS infection epidemiologically linked to two hospital outbreaks. Globally, the WHO
received reports of SARS from 29 countries and regions; 8,096 persons with probable SARS,
resulting in 774 deaths. In the United States, 8 SARS infections were documented by laboratory
testing and an additional 19 probable SARS infections were reported (CDC, Remembering SARS
10 years later).
Isolation precautions and quarantine measures to prevent the spread of SARS-CoV were
established early in the outbreak, which were effective in containing the epidemic. SARS-CoV
was less transmissible than most respiratory infections; therefore, it was highly susceptible to
appropriate control measures. About 30% of the early SARS cases in China were in healthcare
providers, with the majority of cases occurring before the cause of SARS was identified and
before correct infection control measures were in place. By the end of the epidemic, 21% of
SARS cases had occurred in healthcare providers, ranging from 3% in the United States to 43%
in Canada. Several secondary SARS cases also occurred in household contacts before quarantine
measures were instituted.
In 2012, the National Select Agent Registry Program declared SARS-CoV a select agent. A
select agent is a bacterium, virus, or toxin that has the potential to pose a severe threat to public
health and safety. There have been no known cases of SARS reported anywhere in the world
since 2004, when human cases of SARS-CoV infection were reported in China in an outbreak
resulting from laboratory-acquired infections (CDC, 2017, Remembering SARS 10 years later).
However, in June 2014, Chinese scientists discovered a new type of SARS-like CoV in bats in
the Yunnan Province of China that could be the precursor of the SARS virus or its “relative”
(Hu et al., 2013.) There is no evidence that transmission of this new SARS-like CoV to humans
has occurred. Nonetheless, this discovery represents an important clue in the hunt for the source
of SARS-CoV.
The main lessons learned from SARS, the first new infectious disease to emerge in the 21st
century, were that (1) astute healthcare providers are likely to be the key to early detection and
reporting of initial cases of new CoV infections; (2) containment of disease requires the diligent
application of enhanced infection control measures at the national and local levels; and (3)
control of an emerging infection necessitates swift action by healthcare providers as well as an
adequate public health infrastructure.
Middle East Respiratory Syndrome Coronavirus
As of November 2018, 2,274 global laboratory-confirmed
cases of Middle East respiratory syndrome (MERS) had been reported to WHO, including at
least 806 deaths (case fatality rate, 35.4%). However, the majority of these cases were reported
from Saudi Arabia (1896 cases, including 732 related deaths with a case–fatality rate of 38.6%)
(WHO, Middle East respiratory syndrome [MERS] situation update, November 2018.) In May
2015, the National Health and Family Planning Commission of China notified WHO of one
confirmed case of MERS-CoV. The case was a male traveler from the Republic of Korea.
The Republic of Korea reported its first laboratory-confirmed case of MERS-CoV in May
2015. By July 2015, a total of 186 MERS-CoV cases, including 36 deaths, had been reported.
One of the 186 was the case that was confirmed in China and also notified by the National Focal
494
Point of China. All transmission of these Korean MERS-CoV cases had been linked to
healthcare facilities where MERS patients were treated. Several factors were identified as
contributing to the spread of the infection, including lack of awareness among healthcare
providers and the general public about MERS, patients’ behaviors, and suboptimal infection
prevention and control measures in hospitals (WHO, 2015a, Middle East respiratory syndrome
coronavirus [MERS-CoV]—Republic of Korea.) In September 2018, the Republic of Korea
notified WHO of another laboratory-confirmed case of MERS-CoV. The case was a male
Korean national who visited Kuwait on business from August 16 through September 6, 2018. He
returned to Korea via Dubai (WHO, 2018b, Middle East respiratory syndrome coronavirus
[MERS-CoV] infection—Republic of Korea.)
In August 2018, the International Health Regulations National Focal Point for the United
Kingdom of Great Britain and Northern Ireland notified WHO about a laboratory-confirmed
Middle East respiratory syndrome coronavirus (MERS-CoV) infection. The patient was a
resident of the Kingdom of Saudi Arabia who was visiting the United Kingdom of Great Britain
and Northern Ireland. This is the fifth case of MERS-CoV diagnosed in the United Kingdom of
Great Britain and Northern Ireland, with the four previous cases diagnosed in 2012 and 2013
(WHO, Middle East respiratory syndrome coronavirus [MERS-CoV]—United Kingdom of
Great Britain and Northern Ireland, 31 August 2018.
It should be noted that the recent upsurge of new cases was attributed in part due to breaches
in infection prevention and control measures in healthcare settings. The WHO also has reported
that MERS-CoV has been found in some camels and in some MERS patients who have had
contact with camels. Therefore, in addition to a travel history, patients should be asked if they
have visited farms, markets, barns, or other places where animals are present (WHO, 2014a,
MERS-CoV Summary 11 June, 2014).
The first two imported cases of MERS-CoV infection in the United States (Indiana, Florida)
were reported in May 2014. Both cases involved healthcare workers who lived and worked in
Saudi Arabia and had traveled to the United States. The two cases were not linked (CDC,
2014c). A third asymptomatic Illinois patient, who had contact with the Indiana MERS case, had
previously been identified through contact screening. However, further testing by the CDC
found that the Illinois resident was not previously infected with MERS-CoV (CDC, Press
release, May 28, 2014). All of the cases were transferred from the Middle East to other countries
for care of the disease or returned from the Middle East and subsequently became ill. In
addition, as noted above, some healthcare providers have been diagnosed with MERS-CoV
infection after exposure to infected patients. Although active surveillance has identified an
increase in community-acquired cases, there was no evidence of sustained spreading of MERS-
CoV in community settings (CDC, Press Release [June 17, 2014]). Healthcare facilities that
provide care for patients with suspected MERS-CoV infection should take appropriate measures
to decrease the risk of transmission of the virus to other patients and healthcare providers by
systematic implementation of infection prevention and control measures. A probable case of
MERS-CoV infection is defined as a case where the patient is under investigation (PUI) with
absent or inconclusive laboratory results for MERS-CoV infection who is a close contact of a
laboratory-confirmed MERS-CoV case. A confirmed case is a person with laboratory
confirmation of MERS-CoV infection. Confirmatory laboratory testing requires a positive PCR
on at least two specific genomic targets or a single positive target with sequencing on a second
(CDC, MERS-CoV. Information for healthcare professionals).
Based on information we have to date, the incubation period for MERS (time between when
a person is exposed to MERS-CoV and when they start to have symptoms) is usually about 5 or
6 days, but can range from 2 to 14 days (MERS-CoV. Information for healthcare professionals).
The CDC continues to work in consultation with the WHO and other partners to better
understand the public health risk posed by MERS-CoV. Updated information from the WHO
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indicate that the period for considering evaluation for MERS-CoV infection in persons who
develop severe acute lower respiratory illness days after traveling from the Middle East and
other affected countries should be extended to within 14 days of travel (CDC, MERS-CoV.
Information for healthcare professionals).
Infection Control for the Prevention of MERS-CoV Transmission
In 2015, the WHO updated the interim guidance that was published in 2013 to meet the urgent
need for up-to-date information and evidence-based recommendations for the safe care of
patients with probable or confirmed MERS-CoV infection. Healthcare-associated outbreaks with
transmission to healthcare personnel highlight the importance of infection control procedures. It
is crucial that healthcare personnel are provided with the best locally available protection for
caring for MERS-CoV-infected patients and are followed up with if exposure has occurred. To
prevent the transmission of all acute respiratory infections, respiratory hygiene/cough etiquette
measures should be implemented at the first point of contact with a potentially infected person
and should be incorporated into standard precautions. This includes covering the nose and
mouth when coughing or sneezing, using tissues to contain respiratory secretions and disposing
of them in the nearest waste receptacle after use, and hand hygiene (e.g., handwashing with
nonantimicrobial soap and water, alcohol-based hand rub, or antiseptic hand wash) after having
contact with respiratory secretions and contaminated objects/materials (WHO, Infection
prevention and control during healthcare for probable or confirmed cases of Middle East
respiratory syndrome coronavirus (MERS-CoV) infection Interim guidance. Updated June 4,
2015). The 2015 WHO guidelines for patients with acute respiratory infections, including
suspected or confirmed MERS, called for placing the patient in a single isolation room with
equal or greater than 12 air exchanges per hour (WHO, 2015). The CDC also has developed
updated MERS Interim guidance for healthcare professionals, available at
https://www.cdc.gov/coronavirus/mers/interim-guidance.html
The use of personal protective equipment (PPE) should be guided by a risk assessment
concerning anticipated contact with blood, body fluids, secretions, and nonintact skin for routine
patient care. When procedures include a risk of splash to the face and/or body, PPE should
include the use of facial protection by either a surgical mask, and eye visor or goggles, or a face
shield; and a gown and clean gloves. In addition to standard precautions, all individuals,
including visitors and healthcare providers, in contact with patients with acute respiratory tract
infection should use droplet precautions, which include wearing a surgical mask when in close
contact (i.e., within approximately 3 ft) and upon entering the room of the patient; perform hand
hygiene before and after contact with the patient and their surroundings, and immediately after
removal of a surgical mask (CDC, MERS Interim guidance for healthcare professionals; Ho et
al., 2017).
Additional precautions should be observed and PPE worn when performing aerosol-
generating procedures, which may be associated with an increased risk of infection transmission,
in particular, intubation. These include a particulate respirator (e.g., N95 respirator), eye
protection (i.e., goggles or a face shield), gown, and gloves (some procedures may require sterile
gloves).
These guidelines are interim ones to control transmission of the nCoV (MERS-CoV). In
addition, not all suspected MERS-CoV patients would be admitted to healthcare facilities. They
may prefer to stay in their homes. The CDC and WHO publications are available for MERS-
CoV patient care at home and in the community. The CDC website
(https://www.cdc.gov/coronavirus/mers/index.html) and the WHO website
(http://apps.who.int/iris/bitstream/10665/174652/1/WHO_MERS_IPC_15.1_eng ?ua=1)
should be consulted for periodic updates regarding MERS-CoV recommendations and
guidelines.
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https://www.cdc.gov/coronavirus/mers/index.html
http://apps.who.int/iris/bitstream/10665/174652/1/WHO_MERS_IPC_15.1_eng ?ua=1
Clients in the United States with a history of MERS-CoV who are hospitalized with a severe
febrile respiratory illness, or those who are being evaluated for MERS-CoV, should be managed
using isolation precautions identical to those recommended for clients with known avian
influenza. These precautions are outlined in Appendix A: “Type and duration of precautions
needed for selected infections and conditions” in the CDC 2007 Guideline for isolation
precautions: Preventing transmission of infectious agents in healthcare settings at
https://www.cdc.gov/infectioncontrol/guidelines/isolation/appendix/type-duration-
precautions.html. Clusters of severe acute respiratory illness of unknown etiology in the
community also should be thoroughly investigated, and if no etiology is identified, this should
prompt immediate notification of local public health officials, and testing for MERS-CoV
should be conducted if indicated. In addition, any clusters of severe acute respiratory illness in
healthcare personnel in the United States should be thoroughly investigated (CDC, MERS
interim guidance for healthcare professionals).
Practice Point
Observance of infection control practices can reduce the risk of transmission of an acute
respiratory illness, such as MERS-CoV infection, to healthcare providers. Community and
public health nurses are educators who provide information to prevent the transmission of all
respiratory infections, including MERS-CoV.
Avian Influenza
During the past century, three influenza A pandemics have occurred, and pandemic influenza
will inevitably occur in the future. Although the timing and severity of the next pandemic cannot
be predicted, the probability that a pandemic will occur has increased based on the recent
outbreaks of influenza A (H5N1) in Asia, Europe, and Africa.
Influenza A viruses, which originate in birds, are categorized into subtypes on the basis of
their surface antigens. These viruses have 16 hemagglutinin (H) surface antigen subtypes and
nine neuraminidase (N) surface antigen subtypes. Only viruses of the H5 and H7 subtypes are
known to cause the highly pathogenic form of type A influenza. New influenza virus variants
result from frequent antigenic change (i.e., antigenic drift), which is a consequence of point
mutations that occur during viral replication. These frequent changes that result from antigenic
drift mean that there is a new seasonal influenza vaccine each year (CDC, How the flu virus
changes).
Knowledge of the history of past influenza A pandemics has increased the awareness of the
potential for another pandemic. Three influenza A pandemics have been reported in the past
century. As noted above, the first pandemic, known as the “Spanish flu” (influenza A [H1N1]),
occurred in 1918–1919 and resulted in millions of deaths worldwide, with more than 500,000
deaths in the United States. The “Spanish flu” was unique because the causative agent was very
deadly, and it spread quickly across the globe within 6 months. Almost half of the people who
died were young, healthy adults between 20 and 40 years of age, and many died within the first
few days after infection. Others died of complications soon thereafter. The second pandemic,
known as the “Asian flu” (influenza A [H2N2]), occurred in 1957–1958, and it was first
identified in China in late February 1957. In less than 6 months, it spread to the United States,
where it caused approximately 70,000 deaths. The highest mortality with Asian flu occurred in
the elderly. The H2N2 influenza A virus that caused the pandemic of 1957 disappeared from the
human population 10 years later. The third pandemic, known as “Hong Kong flu” (influenza A
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[H3N2]), occurred in 1968–1969. The first cases were detected in Hong Kong in early 1968.
Later that year, the virus spread to the United States, where it claimed approximately 34,000
lives (Kilbourne, 2006). Influenza A (H3N2) viruses are still circulating today.
Avian Influenza A (H5N1) Outbreaks, 2003–2017
Until 1997, the risk of avian influenza was considered rare in humans. However, confirmed
cases of human infection from several subtypes of avian viruses have been reported since then.
Most of these human cases have resulted from contact with infected domestic poultry (e.g.,
chickens and ducks) or surfaces contaminated with blood and secretions/excretions from
infected birds. Until 2003, the last epidemic of human infection with avian influenza A (H5N1)
occurred in Hong Kong in 1997, with 18 confirmed cases and six deaths (WHO, 2011). In 2003,
an outbreak of avian influenza A (H5N1), a highly pathogenic virus, spread among millions of
birds (mostly chickens) across Southeast Asia. Although the H5N1 virus rarely infects humans,
since 2003, a total of 860 laboratory-confirmed cases of human infection with avian influenza
A(H5N1) virus, including 454 deaths, have been reported to WHO from 16 countries. The
majority of cases were from Egypt, with 359 (79%) cases and 120 deaths, followed by
Indonesia, with 200 cases and 168 deaths, and Vietnam, with 127 cases and 64 deaths (WHO,
2018d, Cumulative number of A(H5N1) cases reported to WH, July 20, 2018.) This was the
largest number of documented cases since the virus first emerged in humans in 1997. Nearly all
of the infections were the result of people having direct or close contact with infected poultry or
contaminated surfaces (WHO, Fact sheet: Influenza [avian and other zoonotic]).
In 2012, Russell and colleagues reported that as few as five amino acid substitutions, or four
with reassortment, might be sufficient for mammal-to-mammal transmission of A (H5N1)
viruses through respiratory droplets. While the technical aspects of the study by Russell and
colleagues are beyond the scope of this text, their “analyses…, using current best estimates,
indicate that the remaining mutations could evolve within a single mammalian host, making the
possibility of a respiratory droplet–transmissible A/H5N1 virus evolving in nature a potentially
serious threat” (p. 1547).
An avian influenza virus can improve its transmissibility among humans by two
mechanisms. The first is antigenic shift, a “reassortment” event, in which genetic material is
exchanged between human and avian viruses during coinfection of a human or an animal such as
a pig. Reassortment could result in a fully transmissible pandemic virus, which could rapidly
spread throughout the world (Fig. 15.4). The second mechanism is a more gradual process of
antigenic drift, an adaptive mutation, whereby the capability of the virus to bind to human cells
increases during subsequent infections of humans. Adaptive mutation, which is expressed
initially as small clusters of human cases with some evidence of human-to-human transmission,
would probably give the world some time to take defensive action. If avian influenza A (H5N1)
viruses gain the ability for efficient and sustained transmission among humans, an influenza
pandemic (an epidemic occurring worldwide) could result, with potentially high rates of illness
and death worldwide. Therefore, the epizootic A (H5N1) virus continues to pose an important
public health threat (CDC, Public health threat of highly pathogenic avian influenza A [H5N1]
virus).
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FIGURE 15.4 Reassortment: A mechanism of antigenic shift. (Adapted from National Institute of
Allergy and Infectious Diseases, National Institutes of Health. Retrieved from
http://www.niaid.nih.gov/topics/flu/research/basic/pages/antigenicshiftillustration.aspx.)
Infection Control for the Prevention of Avian A (H5N1) Influenza
Transmission
Clients with a history of travel within 10 days to a country with avian influenza activity and who
are hospitalized with a serious febrile respiratory illness, or are otherwise being evaluated for
avian influenza, should be managed using isolation precautions. The isolation procedures are the
same as those that were used for SARS-CoV and for suspected or confirmed MERS-CoV. In
addition to standard precautions, which include careful attention to hand hygiene before and
after all client contact or contact with items potentially contaminated with respiratory secretions,
the CDC recommends the following enhanced isolation precautions when avian influenza is
diagnosed or suspected:
Contact precautions
Use gloves and gown for all client contact.
Use dedicated equipment such as stethoscopes, as well as disposable blood pressure cuffs and disposable
thermometers.
Eye protection
Wear goggles or face shields when within 3 ft of the client.
Airborne precautions
Place the client in an airborne isolation room (AIR). Such rooms should have monitored negative air
pressure in relation to corridor, with 6 to 12 air changes per hour (ACH), and exhaust air directly outside,
or have recirculated air filtered by a high-efficiency particulate air (HEPA) filter. If an AIR is
unavailable, a portable HEPA filter should be used to augment the number of ACH.
Use a fit-tested respirator, at least as protective as a National Institute of Occupational Safety and Health
(NIOSH)-approved disposable N95 filtering face piece respirator, when entering the room (CDC, Interim
guidance for infection control within healthcare settings when caring for confirmed cases,…with novel
influenza A viruses associated with severe disease).
Practice Point
Travel history is an important aspect of assessment for emerging and reemerging infectious
diseases such as MERS-CoV and Avian influenza.
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H1N1 Influenza (Swine Flu) Pandemic, 2009–2010
In June 2009, the WHO declared a moderately severe global influenza A H1N1 pandemic,
which was the first global pandemic in 40 years and the first in the 21st century. This declaration
was based on the sustained worldwide spread of H1N1 from person to person, not the severity of
illness caused by the virus. Although the Spanish flu was caused by an A (H1N1) virus, the 2009
virus was a similar but different type of virus. Taubenberger and colleagues (2005) proposed
that the 1918 virus was not a “reassortment,” virus like those that caused the smaller pandemics
of 1957 and 1968. In those cases, avian flu viruses traded some genes with human-adapted flu
viruses to spawn new hybrids. They posit that the 1918 virus was “an entirely avian-like virus”
that somehow adapted to humans. While the 2009–2010 H1N1 virus was by no means as severe
as the 1918 pandemic, it was expected that cases would continue to increase because of the onset
of the influenza season in the Southern Hemisphere at that time. From April 12, 2009 to April
10, 2010, the CDC estimated that there were 60.8 million cases, 274,304 hospitalizations, and
12,469 deaths in the United States due to the A (H1N1) 2009 virus. The CDC estimated that
between 151,700 and 575,400 people worldwide died from 2009 H1N1 virus infection during
the first year the virus circulated. Globally, CDC estimated that 80% of (H1N1) 2009 virus–
associated deaths were in people younger than 65 years of age, which differs from typical
seasonal influenza epidemics during which about 70% to 90% of deaths are estimated to occur
in people 65 years of age and older (CDC, Past pandemics).
Though this most recent influenza pandemic primarily affected children and young and
middle-aged adults, the impact of the (H1N1) 2009 virus on the global population overall during
the first year was less severe than that of previous pandemics.
The Department of Health and Human Services updated its pandemic influenza operational
plan (DHHS, 2009) and was used during the 2009 H1N1 pandemic to describe progression of
the pandemic and to help guide the response. The revised plan also incorporated the recently
developed Influenza Risk Assessment Tool (IRAT). The IRAT makes an assessment of potential
pandemic risk for a novel virus (i.e., new in humans) on the basis of the likelihood of emergence
and the public health impact if it were to emerge, and acquire the ability to spread easily and
efficiently in humans. Public health impact refers to the potential severity of human disease
caused by the virus (e.g., deaths and hospitalizations), as well as the impact on society (e.g.,
missed workdays, strain on hospital capacity and resources, and interruption of basic public
services) if a novel influenza virus were to begin spreading efficiently and sustainably among
humans (CDC, Interim guidance on use of intervals, triggers, and actions for novel influenza A
[H1N1] response [Updated 29 April 2009]). The CDC also developed a new tool for evaluating
the potential effects of an emerging pandemic, the Pandemic Severity Assessment Framework
(PSAF). Once a novel influenza A virus is identified by IRAT and is spreading from person-to-
person in a sustained manner, public health officials use the PSAF to determine the impact of the
pandemic, or how “bad” the pandemic will be. There are two main factors that can be used to
determine the impact of a pandemic. The first is clinical severity, or how serious is the illness
associated with infection. The second factor is transmissibility, or how easily the pandemic virus
spreads from person-to-person. These two factors combined are used to guide decisions about
which actions CDC recommends at a given time during the pandemic (CDC, Pandemic Severity
Assessment Framework [PSAF]). Results of the PSAF help public health officials and healthcare
professionals make timely and informed decisions, and to take appropriate actions. Using the
PSAF, the 1918 pandemic can be characterized as one with very high transmissibility and very
high clinical severity, while a mild or moderate pandemic, such as the 2009 H1N1 pandemic, is
characterized by low to medium transmissibility and clinical severity (Fig. 15.5).
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FIGURE 15.5 Pandemic Severity Assessment Framework (PSAF) for the initial assessment of the
effects of an influenza pandemic.
To prevent/reduce the effects of a future pandemic, the CDC and the DHHS (2017) have
recommended nonpharmaceutical mitigation strategies that can be implemented early and
throughout a pandemic event (Table 15.1). The CDC also has developed checklists that identify
important, specific activities that each state and local community can implement to prepare for a
possible pandemic. Nurses practicing in the community should be aware of what some of these
guidelines are. Many of these activities are specific to pandemic influenza, but many also pertain
to any public health emergency. The CDC website at https://www.cdc.gov/flu/pandemic-
resources/index.htm will have the latest guidelines to follow in the event of an influenza
outbreak.
Practice Point
Stress the personal steps that everyone can take to reduce the spread of acute respiratory
infection:
Recognize symptoms of the flu and see a healthcare provider immediately if you have:
A temperature of greater than 100°F
A cough
A sore throat
An underlying condition that increases risk
Cover your cough or sneeze
Wash hands often and keep hands away from your face
Stay home and do not travel if you are ill
Be prepared for increased illness in your schools and community
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TABLE 15.1 Nonpharmaceutical Interventions (NPIs) to Prevent and Control
Pandemic Influenza
NPI Category Recommended NPIs Timing
Personal NPIs
Personal protective
measures for
everyday use
Voluntary home isolation of ill persons (staying home when ill)
Respiratory etiquette
Hand hygiene
Recommended
at all times
Personal protective
measures
reserved for
pandemics
Voluntary home quarantine of exposed household members (staying
home for up to 3 days when a household member is ill). If the next
pandemic influenza virus transmission period is longer or shorter than
3 days, CDC will amend the recommendation.
Use of face masks in community settings when ill.
Reserved for
pandemicsa
Community NPIs
School closures and
dismissals
School closures and dismissals. A school closure involves closing a
school and sending all the students and staff members home. A
school dismissal could involve a school staying open for staff
members while the students stay home.
Temporary, preemptive, coordinated dismissals of child care facilities
and schools for grades K–12 (preemptive, coordinated dismissals
might be implemented early during a pandemic to decrease the
spread of influenza before many students and staff members become
ill).
Selective dismissals might be implemented by schools that serve
students at high risk for complications from infection with influenza.
Reactive dismissals might be implemented when many students and
staff members are ill and not attending school or when many students
and staff members are arriving at school ill and being sent home.
Selective and reactive dismissals do not help slow disease
transmission in the community.
Reserved for
pandemicsa
Social distancing
NPI examples
Dividing classes into smaller groups and creating opportunities for
distance learning (e.g., via the internet or local television or radio
stations).
Telecommuting and remote-meeting options in workplaces.
Mass gathering modifications, postponements, or cancellations.
Reserved for
pandemicsa
Environmental
NPIs
Routine cleaning/disinfection of frequently touched surfaces and objects
in homes, child care facilities, schools, and workplaces.
Recommended
at all times
aThe CDC will use the Pandemic Severity Assessment Framework (PSAF) to assess pandemic severity (low to moderate, high, very high) to provide early and
continuing guidance on use of NPIs to help slow the transmission of a novel virus.
Source: Adapted from Qualls, N., Levitt, A., Kanade, N., Wright-Jegede, N., Dopson, S., Biggerstaff, M.,…Uzicanin, A. (2017). Community mitigation
guidelines to prevent pandemic influenza —United States, 2017. Morbidity and Mortality Weekly Report, 66 (RR.1), 1–34. Retrieved on August 21, 2017, from
https://www.cdc.gov/mmwr/volumes/66/rr/rr6601a1.htm.
In Case 1, when the WHO declared that A (H1N1) influenza was pandemic in 2009, early
available data suggested that the H1N1 pandemic virus was highly transmissible, and
was caused by a new virus that occurred in addition to influenza viruses that circulate
every year. It caused severe outcomes mostly among children, young adults, and specific
groups at high risk for complications (e.g., pregnant women) rather than in adults aged
≥65 years, the group most at risk from seasonal influenza. The number of deaths among
children also was more than twice as high as during a regular influenza season. Based on
these data, in August 2009, the Advisory Committee on Immunization Practices
recommended that children be placed higher on the priority list for receiving the new
monovalent H1N1 vaccine, which became available in October 2009.
How was the 2009 H1N1 influenza pandemic similar to the 1918 “Spanish flu?”
How was the 2009 H1N1 influenza virus different from regular seasonal influenza virus?
Why were children placed higher on the priority list for receiving the 2009 H1N1 vaccine?
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Novel Avian Influenza A (H7N9) Virus, 2013–2017
Influenza A (H7N9) is one of a subgroup of influenza viruses that normally circulate among
birds. This virus has not been previously seen in humans; however, human infections with the
H7N9 virus have now been detected in China (WHO, WHO risk assessment: Human infections
with avian influenza A [H7N9] virus). During the first wave from February to May of 2013, a
total of 133 human cases and 43 deaths occurred. The second wave, which occurred from
October 2013 through early June 2014, had many more cases than the first wave, with 313 cases.
The total number of laboratory-confirmed cases of human infection with avian influenza A
(H7N9) virus reported to WHO as of June 2014 was 450, including 165 deaths (WHO, WHO
risk assessment: Human infections with avian influenza A [H7N9] virus). By February 2015,
there were a total of 571 laboratory-confirmed cases of human infection with avian influenza A
(H7N9) virus, including 212 deaths; 568 of the cases were from China (WHO, Human infection
with avian influenza A [H7N9] virus—China). Reports of family clusters of H7N9 have been
rare, providing evidence that the virus is not easily spread from person to person. Although most
cases had contact with live poultry or had visited live-animal markets before the onset of illness,
the source of infection remained unclear. While the second wave of H7N9 infections had tapered
off by June 2014, experts felt that cases would continue to emerge since the virus appears to be
present in poultry and their environments. A fifth epidemic wave that has occurred since
October 2016 has been greater than earlier waves. On August 4, 2017 the National Health and
Family Planning Commission of China notified WHO of an additional laboratory-confirmed
case of human infection with avian influenza A (H7N9) virus in China. This suggests that the
virus continues to spread, and emphasizes that further intensive surveillance and control
measures in both the human and animal health sectors remain crucial (WHO, Influenza at the
human-animal interface. Summary and assessment, April 21, 2017 to May 16, 2017). During
October 1, 2016 to August 7, 2017, the National Health and Family Planning Commission of
China; CDC, Taiwan; the Hong Kong Centre for Health Protection; and the Macao CDC
reported 1,557 human infections with Asian H7N9 viruses, including 605 (39%) deaths, to the
WHO, making this the largest of the five epidemics of Asian H7N9 infections that have
occurred since 2013 (Kile et al., 2017). As of September 2018, a total of a total of 1,567
laboratory-confirmed human cases, including at least 615 deaths, have been reported to WHO.
In the latest wave (the sixth wave since October 2017), only three human cases have been
detected. Also, there have been fewer A (H7N9) virus detections in poultry and environmental
samples according to various reports from mainland China and the Hong Kong Special
Administrative Region, China (WHO, 2018c, Human infection with avian influenza A[H7N9]
virus—China: Updated on 5 September 2018).
Findings from this latest emerging influenza virus highlight the importance of zoonotic
viruses on global health. Li and colleagues (2014) conducted an epidemiologic study of A
(H7N9) influenza using the 2006 WHO case definition for human infections with A (H5N1)
virus and identified through the Chinese surveillance system for pneumonia of unknown origin.
A total of 139 cases with confirmed H7N9 infection had a median age of 61 years (range: 2 to
91 years), 71% were male, 73% were urban residents, and 9 were poultry workers. Except for
four case clusters among family members who had provided care to case patients, most of the
cases were epidemiologically unrelated. Of the data available among 131 patients, 82% had a
history of exposure to live animals, including chickens. Ninety-nine percent (n = 137) were
hospitalized with pneumonia or respiratory failure, with a 34% fatality rate. Analysis of 2,675
close contacts of case patients, 28 (1%) developed respiratory symptoms. However, all 28 close
contacts tested negative for the H7N9 virus. Using available data and identifying the date of
exposure to live poultry among 111 early cases of A (H7N9) influenza, Gao and colleagues
(2013) estimated the incubation period of A (H7N9) to be 5 days.
Early in the outbreak of novel A (H7N9) bird flu, Hu and colleagues (2013) found an
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emergence of antiviral resistance to oseltamivir (Tamiflu) in 3 of the 14 patients studied. While
early treatment of suspected or confirmed cases of A (H7N9) with oseltamivir was advised,
Wang and colleagues (2014) developed an assay to help clinicians monitor emergence of
oseltamivir resistance in the A (H7N9) virus. Hu and colleagues warned: “The apparent ease
with which antiviral resistance emerges in A/H7N9 viruses is concerning; it needs to be closely
monitored and considered in future pandemic response plans” (p. 6).
Pure bird flu strains, such as the new H7N9 strain and the H5N1 virus, where the latter virus
killed 59% of people it infected since 2003, are generally more deadly for humans. All of the
reported cases of A (H7N9) up to 2016 had been from China (WHO, WHO risk assessment:
Human infections with avian influenza A [H7N9] virus). However, ongoing surveillance can
identify reassortment of zoonotic viruses that can spread human-to-human transmission, leading
to a pandemic. While there may be limited person-to-person spread of the A (H7N9) virus, many
people travel between China and the United States; therefore, the CDC has issued a public
health alert for healthcare providers to be aware of patients who present with acute respiratory
illness and a travel history to countries where the A (H7N9) virus has been confirmed (CDC,
Influenza: H7N9). Recommendations for infection control for A (H7N9) may be found at the
CDC website: https://www.cdc.gov/flu/avianflu/healthprofessionals.htm
Case 1: A goal of the U.S. Department of Health and Human Services (DHHS) in its
Pandemic Influenza Plan 2017 Update was to sustain momentum and improve
implementation of community mitigation measures. Such measures may be used from the
earliest stages of an influenza pandemic, including the initial months when the most
effective countermeasure, for example, a vaccine against the new pandemic virus, might
not yet be broadly available.
To meet this goal, the following objective was developed: Improve public awareness
and implementation of nonpharmaceutical interventions (NPIs) to slow the spread of
influenza.
Based on the data outlined in see Table 15.1, what NPIs would you consider appropriate
for the 2009 A (H1N1) influenza pandemic?
West Nile Virus
Human cases of West Nile virus (WNV) infection appeared for the first time in the Western
Hemisphere in New York in 1999, and by 2003, an epidemic of WNV had expanded across the
United States from eastern United States to the west coast within a 3-year period. WNV has now
become endemic in the United States, and its continued expansion indicates that it is
permanently established in the Western Hemisphere. As of January 17, 2017, a total of 2,038
cases of WNV disease in people have been reported to CDC. Of these, 1,140 (56%) were
classified as neuroinvasive disease (such as meningitis or encephalitis) and 898 (44%) were
classified as non-neuroinvasive disease. In 2016, 47 states and the District of Columbia had
reported WNV infections in people, birds, or mosquitoes (CDC, West Nile virus, preliminary
maps and data for 2016). Although the incidence of WNV outside North America is low, the
virus has been found in Central America, parts of South America, and the Caribbean. Recent
reports have even found WNV in the Artic (ISID, 2013).
Transmission of WNV involves animals. The most common route of transmission is from
the bite of an infected mosquito. Mosquitoes become infected when they feed on infected birds
and then spread the disease to humans and other animals when they bite them. Symptoms
typically develop between 3 and 14 days after the infected mosquito bites someone. The
majority of WNV cases occur among males, with the date of onset ranging from late March to
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early October. However, in warmer climates, WNV infections can occur year-round.
Symptoms of WNV vary. Approximately 80% of infected people (about four out of five) do
not have any symptoms. Another 20% of those who become infected have symptoms such as
fever, headache, body aches, nausea, vomiting, and sometimes swollen lymph glands or a skin
rash on the chest, stomach, and back. Symptoms can last for as short a period as a few days;
however, some healthy people have become sick for several weeks. About 1 in 150 people
infected with WNV develops severe illness, with severe symptoms that can include high fever,
headache, neck stiffness, stupor, disorientation, coma, tremors, convulsions, muscle weakness,
vision loss, numbness, and paralysis. These symptoms may last for several weeks, and
neurologic effects may be permanent. People older than 50 years are more likely to develop
serious symptoms of WNV if they do become sick; therefore, they should take special care to
avoid mosquito bites (CDC, West Nile virus).
In the 2002 WNV outbreak, nonvector routes of transmission were identified, including
blood transfusions, organ transplantation, and vertical transmission in utero. Nonvector WNV
transmission has also been reported in laboratory workers and poultry farm workers. Because of
the transfusion-related cases of WNV in 2002, the CDC has established a mechanism through
state and local health departments for reporting WNV infection occurring in people who have
received blood component transfusions within 4 weeks prior to onset of illness. Therefore, WNV
disease should be considered in any person with a febrile or acute neurologic illness who has
had recent exposure to mosquitoes, blood transfusion, or organ transplantation, especially during
the summer months in areas where virus activity has been reported. Of the 2,038 reported WNV
cases in 2016, 275 were presumptive viremic blood donors (PVDs). People who had no
symptoms at the time of donating blood through a blood collection agency, but whose blood
tested positive when screened for the presence of WNV are considered PVDs. Some PVDs
develop symptoms after donation. The diagnosis of WNV should also be considered in any
infant born to a mother infected with WNV during pregnancy or while breast-feeding (CDC,
West Nile virus).
Prevention of WNV Infection
WNV is not transmitted from person to person. No isolation precautions are indicated other than
standard precautions. The CDC guidelines emphasize avian, animal, mosquito, and human
WNV surveillance, along with control and elimination of mosquito breeding sites such as
standing water in flowerpots, buckets, and old tires.
There is no vaccine to prevent WNV infection, and although various drugs have been
evaluated or empirically used for WNV disease, none have shown specific benefit to date. To
prevent WNV, the CDC recommends using an insect repellant such as DEET (N, N-diethyl-m-
toluamide) or picaridin when outdoors, following the directions on the package. Because
mosquitoes are most active at dusk and dawn, in addition to an insect repellant, long sleeves and
pants should be worn when outdoors during these hours. Screens on windows and doors will
keep mosquitoes out (CDC, West Nile virus).
WNV disease is a nationally notifiable condition. All cases should be reported to local public
health authorities. Reporting can assist local, state, and national authorities to recognize
outbreaks and to implement control measures to reduce future infections. More information on
WNV is available at the CDC website at http://www.cdc.gov/westnile/index.html
Practice Point
Community and public health nurses should educate the public about how to prevent WNV
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infection:
Use of Food and Drug Administration (FDA)-approved repellants for skin and/or clothing for
protection from mosquito-borne diseases.
When weather permits, wear long-sleeved shirts and long pants outdoors.
Place mosquito netting over infant carriers when outdoors with infants.
Consider staying indoors at dawn, dusk, and early evening, which are peak mosquito biting times.
Install or repair window and door screens so that mosquitoes cannot come indoors.
Lyme Disease
Epidemiology of Lyme Disease
Lyme disease was first described in the late 1970s by Dr. Allen Steere. He recognized it as an
important emerging infection when it appeared in a cluster of children in the Lyme, Connecticut,
area, who were thought to have juvenile rheumatoid arthritis. However, it became apparent that
Lyme arthritis was a late manifestation of a multisystem disease, of which some symptoms had
been recognized previously in Europe and America (Steere, Coburn, & Glickstein, 2004).
Lyme disease, which is caused by a bacterium and transmitted by ticks, is the most
commonly reported vector-borne disease in the United States. In 1981, Burgdorfer and
colleagues discovered a previously unidentified spirochetal bacterium, subsequently named
Borrelia burgdorferi (as noted in a previous Evidence for Practice feature). The spread of Lyme
disease and its vectors have developed from the recent proliferation of deer and the process of
reforestation now taking place. As a result, increasingly large numbers of people live where risk
of Lyme disease is increased. The agents of these infections, which once were transmitted by an
exclusively rodent-feeding vector, have now become zoonotic. The deer tick (I. scapularis in the
northeastern and north central United States; I. pacificus in the western United States) is an
important vector in human Lyme borreliosis along with the white-tailed deer, the preferred host
of the adult deer tick. The white-tailed deer populations seem to be critical for the survival of the
ticks. However, the deer is not involved in the life cycle of the spirochete (Steere et al., 2004).
The life cycle of the Ixodes tick takes 2 years. Once a tick becomes infected with Borrelia
burgdorferi, it remains infected for life and can transmit the organism to new hosts.
In 2015 (latest available data), the CDC reported 28,453 confirmed cases and 9,616 probable
cases of Lyme disease in the United States, at an incidence rate of 8.9 per 100,000 population,
and it was the sixth most common nationally notifiable disease that year. The majority (95%) of
Lyme disease cases in 2015 were reported from 14 states in New England, the mid-Atlantic
states, and the upper Midwest. Lyme disease does not occur nationwide and is concentrated
heavily in the Northeast and upper Midwest (CDC, Lyme disease). Although the incidence of
human Lyme disease in the northeastern United States is more than twice that in the Midwest,
the prevalence of Borrelia burgdorferi in the tick vector is nearly identical in the two regions
(Brisson, Vandermause, Meece, Reed, & Dykhuizen, 2010). Lyme disease is spreading
throughout the world. Cases have been found on all continents except Antarctica. The incidence
rates of Lyme disease in 2002 and 2015 were 8.2 per 100,000 and 8.9 per 100,000 population,
respectively. The overall incidence rate of Lyme disease in the United States in 2015 had
reached the Healthy People 2010 targeted rate of 9.7 new cases per 100,000 population where
the disease is endemic (DHHS, 2000); however, the rates were still more than five times higher
in some northeastern states (Connecticut, Maine, Pennsylvania, Rhode Island, Vermont) (CDC,
Lyme disease).
A recent study by Hersh and colleagues (2014) found that humans in the northeastern and
midwestern United States are at increasing risk of not only Lyme disease, but also coinfection
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with two emerging pathogens Anaplasma phagocytophilum and Babesia microti. Borrelia
burgdorferi, Babesia microti, and Anaplasma phagocytophilum are transmitted by the same tick
vector, I. scapularis. Although coinfection with the gram-negative bacterium Anaplasma
phagocytophilum was found to be less common in the ticks they studied, 83% were found to be
coinfected with Borrelia burgdorferi and Babesia microti. Human babesiosis, caused by Babesia
microti, a protozoan blood parasite, has been increasing in prevalence, especially in the
Northeast. Babesiosis can be asymptomatic or present with flu-like symptoms (e.g., fever, chills,
body aches, weakness, and fatigue) that may not appear for weeks or months after exposure to
Babesia microti. In addition, Krause and colleagues (2014) found that Borrelia miyamotoi is
prevalent in southern New England. Therefore, healthcare providers should be aware that acute
Borrelia miyamotoi infection may be misdiagnosed as Lyme disease. They also should keep in
mind an increased risk of coinfection with Borrelia burgdorferi and Babesia microti when
diagnosing and treating tick-borne illness. Babesiosis became a notifiable disease in 2011 (CDC,
Babesiosis).
Symptoms and Signs of Lyme Disease
Lyme disease is diagnosed based on symptoms, physical findings (e.g., a “bull’s-eye rash,”
which is the hallmark symptom of Lyme disease), and the possibility of exposure to infected
ticks; laboratory testing is helpful if used correctly and performed with validated methods.
Exposure to Lyme disease is defined as having spent time (less than or equal to 30 days
before onset of the initial skin lesion) in wooded, brushy, or grassy areas (i.e., potential tick
habitats) in a county in which Lyme disease is endemic. A history of tick bite is not required. A
county in which the disease is endemic is one in which at least two confirmed cases have been
previously acquired or in which established populations of a known tick vector are infected with
Borrelia burgdorferi (CDC, Lyme disease).
The best clinical marker of Lyme disease is the initial skin lesion (i.e., erythema migrans),
which occurs in 60% to 80% of people with the disease. For purposes of surveillance, erythema
migrans is defined as a skin lesion that typically begins as a red macule or papule and expands
over a period of days to weeks to form a large round lesion, often with partial central clearing.
Within 1 to 2 weeks of being infected with Borrelia burgdorferi, people may have the bull’s-eye
rash with fever, headache, and muscle or joint pain. Some people have Lyme disease and do not
have any early symptoms. Other people have fever and other flu-like symptoms without a rash
(CDC, Lyme disease). Figure 15.6 (CDC, Two-tier testing for Lyme disease).
After several days or weeks, the bacteria may spread throughout the body of an infected
person. Symptoms such as rashes in other parts of the body, pain that seems to move from joint
to joint, and signs of inflammation of the heart or nerves may occur. If the disease is not treated,
additional symptoms, such as swelling and pain in major joints or mental changes, months after
becoming infected, may occur in a few cases. People who are treated with antibiotics early in the
infection generally recover quickly and completely, as do those in the later stages of the
infection. Antibiotics commonly used for oral treatment include doxycycline, amoxicillin, or
cefuroxime axetil. Patients with certain neurologic or cardiac forms of illness may require
intravenous treatment with drugs such as ceftriaxone or penicillin (CDC, Lyme disease). For
detailed recommendations on treatment of Lyme disease, consult the 2006 guidelines for
treatment of Lyme disease developed by the Infectious Diseases Society of America (IDSA,
2006) at https://doi.org/10.1086/508667
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FIGURE 15.6 Two-tier testing decision tree describing the steps required to properly test for Lyme
disease. Source: CDC. Two-tier Testing for Lyme Disease. Retrieved on August 15, 2017 from
https://www.cdc.gov/lyme/healthcare/clinician_twotier.html.
Student Reflection
When I was in high school, I went to an Outward Bound camp in Connecticut. It was great—
we were outdoors hiking or riding almost all day, and slept outside most of the time. It was
one of the most memorable times of my life. The day before we left for home, though, I
found a fat tick on my thigh. We were warned about bug bites and used a spray when we
remembered. I went to the camp nurse and she cleaned it out really well, so I forgot about it.
After a couple of weeks, I got a nasty headache, had a fever, and felt like I was coming
down with the flu. My mom made me go to a doctor when she saw that I had a large red
sore at the site of the tick bite. The doctor found several red sores on my legs and tested
me for Lyme disease. I had to be on antibiotics for 3 weeks, and then I felt fine. That
experience made me very interested in infectious diseases and nursing as a career.
Prevention of Lyme Disease
Steps to prevent Lyme disease include using insect repellant, identification and removal of deer
ticks promptly, applying pesticides, and reducing tick habitat. Nymphal deer ticks are the size of
poppy seeds, and adult deer ticks are the size of apple seeds (Fig. 15.7). Although interventions
are inexpensive, are unlikely to be harmful, and have probably slowed the increase in Lyme
disease in the United States, the epidemic continues to gain momentum.
According to the American Lyme Disease Foundation, the best precaution against Lyme
disease in tick-infested areas is to avoid contact with soil, leaf litter, and vegetation as much as
possible. People who garden, hike, camp, hunt, work outdoors, or otherwise spend time in brush,
overgrown fields, or the woods should use the precautions listed in Box 15.2 to reduce their risk
of getting Lyme disease (American Lyme Disease Foundation, Lyme disease).
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FIGURE 15.7 Tick ID card.
15.2 Lyme Disease Combined Prevention Techniques
Know how to identify deer ticks.
Wear enclosed shoes and light-colored clothing with a tight weave to make it easier to spot ticks.
Scan clothes and any exposed skin frequently for ticks while outdoors.
Stay on cleared, well-traveled trails.
Use insect repellant containing diethyl-meta-toluamide (DEET) on skin or insect repellant for clothes.
Avoid sitting directly on the ground or on stone walls since they are havens for ticks and their hosts.
Keep long hair tied back, especially when gardening.
Do a final, full-body tick check at the end of the day for adults, children, and pets.
Ticks tend to climb to warm, hidden areas of the head and neck if not intercepted first.
Performed consistently, this is the most effective current prevention technique.
Shower and shampoo on returning home; crawling ticks may be removed, but not attached ticks.
Spin clothes in a dryer for 20 minutes to kill any unseen ticks.
Source: Adapted from American Lyme Disease Foundation. Lyme disease. Retrieved on August 21, 2017, from http://www.aldf.com/lyme.shtml.
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Practice Point
Community and public health nurses must be prepared to educate the public about the signs
and symptoms of Lyme disease and other tick-borne diseases, as well as the prevention of
these diseases. Because the population density and percentage of infected ticks that may
transmit Lyme disease and other tick-borne infections vary markedly from one region of the
country to another, people should know whether infected deer ticks are active in their area or
in places they may visit. There is even great variation from county to county within a state
and from area to area within a county. For example, less than 5% of adult ticks south of
Maryland are infected with Borrelia burgdorferi, whereas up to 50% are infected in areas with
a high tick infection rate in the Northeast. The tick infection rate in Pacific coastal states is
between 2% and 4% (American Lyme Disease Foundation). As noted above, healthcare
providers should also be aware of an increased risk of coinfection with Borrelia burgdorferi,
Babesia microti, and Borrelia miyamotoi.
Escherichia coli O157:H7
E. coli O157:H7, a Shiga toxin–producing E. coli (STEC), may also be referred to as
verocytotoxin-producing E. coli (VTEC) or enterohemorrhagic E. coli (EHEC). This deadly
toxin-producing bacterium is the one most commonly heard about in the news in association
with food-borne outbreaks in the United States, and have led to national recalls of several food
products (CDC, E. coli). It produces symptoms of severe abdominal cramps, bloody and
nonbloody diarrhea, and vomiting, which generally resolve within 7 to 10 days.
Most people recover fully from an E. coli infection in 2 or 3 days; however, E. coli O157:H7
can cause fatal hemolytic-uremic syndrome (HUS) and renal failure in the very young and the
elderly, and clients may require dialysis. HUS generally occurs up to a week after a
gastrointestinal infection with E. coli. In these cases, HUS develops when the bacterial toxins
enter the bloodstream and destroy red blood cells (CDC, E. coli).
Freedman and colleagues (2016) report that treating STEC infections frequently prompt
consideration of antibiotic treatment, prior to or after culture results are known. However, they
concluded that “such treatment may increase the risk of developing HUS. Given the lack of
literature support for the value of early-in-illness antibiotics in STEC infections, and the
potential for harm associated with their administration in such instances, these results can be
used to promote a more unified public health recommendation against using antibiotics in
individuals infected with STEC” (Freedman et al., 2016).
Practice Point
E. coli O157:H7 infections can also be caused by zoonotic transmission through contact with
animals that carry the organism.
Recent cases of HUS have been associated with outbreaks of E. coli O157:H7 infections,
which were apparently caused by contact with animals, including fairs, farm tours, and
petting zoos. In July 2017, an outbreak of E. coli O157:H7 killed two children and sickened
10 other people in a remote community on the Utah-Arizona border. Infected farm animals
followed by person-to-person contamination were the likely cause. Public health officials
report that the outbreak was likely caused by animal manure containing E. coli O157:H7
bacteria being spread by humans (Luna et al., 2018). Experience from these and previous
outbreaks underscores the necessity for adequate control measures to reduce zoonotic
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transmission. The CDC has developed standardized recommendations for public health
officials, veterinarians, animal exhibitors, and visitors to animal exhibits; it established that
handwashing is the single most important prevention step for reducing the risk for disease
transmission. Other critical recommendations for venues with animals are the inclusion of
transition areas between animal and nonanimal areas (e.g., where food is sold) and proper
care and management of animals in public settings. In addition, as discussed in Chapter 14,
the CDC recommends educating the operators and staff of animal venues, as well as visitors,
about the risk of disease transmission if animal contact is possible (CDC, 2005a). More
information about transmission of E. coli O157:H7 can be found in Chapter 14.
Tuberculosis
Epidemiology of Tuberculosis
Tuberculosis (TB) is a disease caused by Mycobacterium tuberculosis that is spread from person
to person through the air when a person with TB disease of the lungs or throat coughs, sneezes,
speaks, or sings. The TB bacteria (droplet nuclei) can stay suspended in the air for several hours,
depending on the environment. Persons who breathe in the air containing these TB bacteria can
become infected. The bacteria usually attack the lungs, but they can attack any part of the body
such as the kidney, spine, and brain. If not treated properly, TB disease can be fatal (CDC,
Tuberculosis). Tuberculosis remains one of the most common infectious diseases worldwide.
According to the WHO, TB killed fewer people between 2000 and 2015, but was still among the
top 10 causes of disease. There was an estimated 10.4 million new TB cases worldwide in 2015,
and a death rate of 1.4 million among HIV-negative people, with an additional 0.4 million
deaths among people living with HIV. Of the 10.4 million new TB cases in 2015, 5.9 million
(56%) were among men, 3.5 million (34%) among women, and 1.0 million (10%) among
children. People living with HIV accounted for 1.2 million (11%) of all new TB cases. Six
countries accounted for 60% of the new cases: India, Indonesia, China, Nigeria, Pakistan, and
South Africa. There also were an estimated 480, 000 new cases of multidrug-resistant TB
(MDR-TB) and an additional 100,000 people with rifampicin-resistant TB (RR-TB) who were
also newly eligible for MDR-TB treatment (WHO, 2016b).
Tuberculosis was once the leading cause of death in the United States. After approximately
30 years of decline, the number of reported cases of TB increased 20% between 1985 and 1992.
This led to a renewed emphasis on TB control and prevention in the 1990s and actions that
reversed the increase in cases.
A total of 9,557 TB cases (a rate of 3 cases per 100,000 population) were reported in the
United States in 2015 and had remained at that rate for the past 3 years. However, a total of
66.4% of reported TB cases in the United States occurred among foreign-born persons in 2015.
The case rate among foreign-born persons (15.1 cases/100,000 persons) was approximately 13
times higher than among U.S.-born persons (1.2 cases/100,000 persons). The majority of these
cases are among persons who have been in the United States 5 years or longer. While the rate of
TB among whites in the United States was 0.6 cases per 100,000 persons in 2015, racial and
ethnic minorities and foreign-born persons continue to be disproportionately affected by TB. In
2015, the highest TB rates in the United States occurred among persons who were Asian (18.2
cases/100,000), native Hawaiians and other Pacific Islanders (18.2 TB cases/100,000), black or
African American (5 cases/100,000), Hispanic/Latino (4.8 cases/100,000 persons), and
American Indian or Alaskan Native (6.1 cases/100,000). In addition, MDR-TB remains a threat
among foreign-born people. Of the total number of reported primary MDR-TB cases overall, the
percentage of MDR-TB cases decreased slightly from 1.3% (94 cases) in 2014 to 1.2% (89
cases) in 2015. Of the total number of reported MDR-TB cases, the proportion occurring among
foreign-born persons increased from 31% (149 of 484) in 1993 to 85% (76 of 89 cases) in 2015
(CDC, TB facts). MDR-TB, defined as resistance to the two most potent “first-line” anti-TB
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agents, is discussed further below.
Despite successful declines in TB cases and case rates over the past 60 years, the goal of
Healthy People 2020 (DHHS, 2010) to reduce TB in the United States to 1 case per 100,000
population has not been met. As can be seen by the 2015 data above, that target has not been met
yet. The improvement of TB control among racial/ethnic minorities and foreign-born persons is
essential as the United States strives to prevent TB transmission and meet TB elimination goals.
Vigilance for TB among homeless persons is also crucial for maintaining progress toward TB
elimination among the U.S.-born population (CDC, 2015).
Practice Point
M. tuberculosis is an example of an infectious agent that can cause an infection in an
individual, but not be contagious at all times.
M. tuberculosis infection occurs when a susceptible person inhales airborne droplet nuclei
containing the TB bacilli, which pass through the upper respiratory tract and bronchi. When
the bacilli reach the alveoli of the lungs, they are taken up by macrophages and spread
throughout the body. Generally, 2 to 10 weeks after initial infection with M. tuberculosis, an
immune response limits additional multiplication and spread of the bacilli. M. tuberculosis
generally affects the lungs but can attack any part of the body such as the kidney, spine, and
brain. If not treated properly, TB can be fatal. However, some of the TB bacilli remain
dormant and viable for many years and are defined as latent TB infection. People with latent
TB infection usually have a positive tuberculin skin test (TST) but no symptoms of active TB
and therefore are not contagious. In many people who have latent TB infection, the M.
tuberculosis bacteria remain inactive for a lifetime without causing active TB disease. But in
other people, especially those who have weak immune systems, the bacteria become active
and cause TB disease (CDC, Tuberculosis). Table 15.2 for the difference between latent TB
infection and active TB disease.
Symptoms and Signs of TB
Active TB infection is characterized by a chronic productive cough, low-grade fever, night
sweats, and weight loss, along with a positive Mantoux tuberculin skin test (TST), which is the
standard method of determining whether a person is infected with M. tuberculosis. People with
active TB are contagious. However, certain people who are anergic (lack an immune response to
an antigen) may not have a positive TST (e.g., persons with HIV) (CDC, Tuberculin skin
testing).
Evidence for Practice
A nurse case-managed intervention, with incentives and tracking procedures to increase
adherence to treatment of latent TB infection, was evaluated to determine the efficacy of the
program. Twelve homeless subgroups were chosen that had characteristics previously
identified in the literature as predictive of nonadherence to treatment. These characteristics
included female gender, African American ethnicity, history of military service, lifetime
injection drug use, daily alcohol and drug use, poor physical health, and a history of poor
mental health. Five hundred twenty homeless adults in homeless shelters in Los Angeles
were followed prospectively over a period of 5 years. The intervention achieved a 91%
completion rate for homeless shelter residents, and there was significantly improved latent
TB infection treatment adherence in 9 of the 12 subgroups. However, daily drug users,
participants with a history of injection drug use, daily alcohol users, and people who were
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not African American had particularly poor completion rates. It was concluded that nurse
case management with incentives appears to be a good foundation for improving
adherence to treatment for latent TB infection, especially for sheltered homeless
populations (Nyamathi et al., 2008).
Latent TB and HIV Infections
People infected with HIV, especially those with low CD4+ cell counts, develop TB disease
rapidly after becoming infected with M. tuberculosis. Because HIV infection weakens the
immune system, people with prior untreated latent TB infection and HIV infection are at very
high risk of developing active TB disease (CDC, TB and HIV coinfection). Therefore, all people
with HIV infection should be tested to find out if they have latent TB infection. If they have
latent TB infection, they need treatment as soon as possible to prevent them from developing
active TB disease. If they have active TB disease, they must take medicine to cure the disease
(Lewinsohn et al., 2017; CDC, Treatment regimens for latent TB infection).
TABLE 15.2 Symptomatic Differences Between Latent Tuberculosis (TB)
Infection and Active TB Disease
A Person With Latent TB Infection A Person With Active TB Disease
Has no symptoms
Does not feel sick
Cannot spread TB to others
Usually has a positive skin test or QuantiFERON-TB
Gold In-Tube test (QFT-GIT)
Has a normal chest x-ray and sputum test
Has symptoms that may include the following:
A bad cough that lasts 3 weeks or longer
Pain in the chest
Coughing up blood or sputum
Weakness or fatigue
Weight loss
No appetite
Chills
Fever
Sweating at night
May spread TB to others
Usually has a positive skin test or QFT-GIT
May have an abnormal chest x-ray or positive sputum
smear or culture
Notes: QuantiFERON-TB Gold In-Tube test (QFT-GIT) is an FDA-approved indirect blood test for M. tuberculosis infection (including infection resulting in
active disease) when used in conjunction with risk assessment, radiography, and other medical and diagnostic evaluations.
Sources: Centers for Disease Control and Prevention (CDC). Tuberculosis fact sheets. Retrieved from http://www.cdc.gov/tb/topics/testing.htm; Centers for
Disease Control and Prevention (CDC). (2010). Updated guidelines for using interferon gamma release assays to detect Mycobacterium tuberculosis infection—
United States, 2010. Morbidity and Mortality Weekly Report, 59(RR05), 1–25; Centers for Disease Control and Prevention (CDC). Latent tuberculosis infection:
A guide for primary healthcare providers. Retrieved from https://www.cdc.gov/tb/publications/ltbi/diagnosis.htm.
Prevention and Control of TB
TARGETED TUBERCULIN TESTING AND TREATMENT OF LATENT TB INFECTION
In the United States and other countries with a low incidence of TB, most new, active cases have
occurred in people with latent TB infection who later developed active TB. Targeted
identification and treatment of infected people at highest risk for developing disease benefits
both infected people and susceptible people. Because health departments often lack access to
high-risk populations and the resources necessary to undertake targeted testing programs, the
participation of other healthcare providers is essential to ensure the successful implementation of
community efforts to prevent TB in high-risk groups. Community sites where healthcare
professionals may find people at high risk for TB and where targeted testing programs have been
evaluated include neighborhood health centers, jails, homeless shelters, inner-city areas,
methadone clinics, syringe/needle-exchange programs, and other community-based social
service facilities (Lewinsohn et al., 2017). The WHO recommends directly observed therapy
(DOT), using the most effective standardized, short-course regimens, and of fixed-dose TB drug
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https://www.cdc.gov/tb/publications/ltbi/diagnosis.htm
combinations as an approach to TB control (WHO, The five elements of DOT).
Treating latent M. tuberculosis infection (LTBI) is a cornerstone of the U.S. strategy for TB
elimination. Randomized controlled studies have shown that a new combination regimen of
isoniazid (INH) and rifapentine administered weekly for 12 weeks as DOT is as effective for
preventing TB as other regimens and is more likely to be completed than the U.S. standard
regimen of 9 months of INH daily without DOT. These “first-line” treatment drugs are highly
effective against nonresistant TB but much less so against MDR-TB. The new regimen is
recommended as an equal alternative to the 9-month INH regimen for otherwise healthy patients
aged 15 years or older who have LTBI and factors that are predictive of TB developing (e.g.,
recent exposure to contagious TB) (CDC, Treatment regimens for latent TB). Box 15.3 for
people at high risk for progressing from latent TB infection to active TB disease.
TREATMENT OF ACTIVE TB
Active TB disease can be treated by taking several drugs for 6 to 9 months. There are 10 drugs
currently approved by the FDA for treating TB. Of the approved drugs, the first-line anti-TB
agents that form the core of treatment regimens are isoniazid (INH), rifampin (RIF), ethambutol
(EMB), and pyrazinamide (PZA). Drug-susceptible TB disease treatment consists of an
intensive phase of 2 months of isoniazid (INH), rifampin (RIF), pyrazinamide (PZA), and
ethambutol (EMB) followed by a continuation phase of 4 months of INH and RIF. Because of
the relatively high proportion of adults with TB caused by organisms that are resistant to INH,
four drugs (INH, RIF, PZA, EMB) are necessary in the intensive phase to be maximally
effective. However, EMB can be discontinued as soon as the results of drug susceptibility
studies demonstrate that the isolate is susceptible to INH and RIF. Pyridoxine (vitamin B6)
should be given with INH to all persons at risk of neuropathy (e.g., pregnant women;
breastfeeding infants; persons infected with HIV; patients with diabetes, alcoholism,
malnutrition, or chronic renal failure; or those who are of advanced age (Nahid et al., 2016).
15.3 Factors That Influence Progression From Latent Tuberculosis (TB)
Infection to Active TB Disease
People infected with HIV
People infected with Mycobacterium tuberculosis within the previous 2 years
People with a history of untreated or inadequately treated TB disease, including people with chest
radiograph findings consistent with previous TB
Infants and children aged <5 years who have a positive TB test result
People with any of the following clinical conditions or other immunocompromising conditions:
Silicosis
Diabetes mellitus
Chronic renal failure
Certain hematologic disorders (leukemias and lymphomas)
Other specific malignancies (e.g., carcinoma of the head, neck, or lung)
Body weight >10% below ideal body weight
Prolonged corticosteroid use
Other immunosuppressive treatments
Organ transplant
End-stage renal disease
Intestinal bypass or gastrectomy
Source: Centers for Disease Control and Prevention (CDC). Latent tuberculosis infection: A guide for primary healthcare providers. Retrieved on August 22,
2017, from https://www.cdc.gov/tb/publications/ltbi/targetedtesting.htm#identifyingTBDisease.
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A pediatric TB expert should be involved in the treatment of TB in children and in the
management of infants, young children, and immunocompromised children who have been
exposed to someone with infectious TB disease. It is very important that children or anyone
being treated for latent TB infection or TB disease finish the medicine and take the drugs exactly
as instructed (CDC, TB treatment for children).
Drug susceptibility tests should be performed on initial isolates from all clients to identify
what should be an effective anti-TB regimen. In addition, drug susceptibility tests should be
repeated if the client continues to produce culture-positive sputum after 3 months of treatment or
develops positive cultures after a period of negative cultures (Nahid et al., 2016).
Directly observed therapy (DOT) is one in which healthcare professionals observe clients
to ensure that they ingest each dose of anti-TB medication to maximize the likelihood of
completion of therapy. Programs using DOT as the central element in a comprehensive, client-
centered approach to case management (enhanced DOT) have higher rates of treatment
completion than less intensive strategies. Each client’s management plan should be
individualized to incorporate measures that facilitate adherence to the drug regimen. Such
measures may include, for example, social service support, treatment incentives and enablers,
housing assistance, referral for treatment of substance abuse, and coordination of TB services
with those of other providers (Nahid et al., 2016; WHO, The five elements of DOT). There is no
need to hospitalize a person solely because they are infectious. Outpatients should be instructed
to remain at home, without visitors, until they are no longer thought to be infectious. Also,
people who are particularly susceptible to developing TB disease if they become infected (small
children, immunocompromised people) should not visit or live with an infected client while he
or she can transmit the TB bacterium (CDC, Treatment for TB disease; Lewinsohn et al., 2017;
Nahid et al., 2016).
DIAGNOSTIC AND PUBLIC HEALTH EVALUATION OF TB CONTACTS
By law and regulation, cases of active TB in the United States must be reported to the local
health department. Reporting is essential for action by TB control programs at local, state, and
national levels. TB case finding is important for understanding the magnitude and the
distribution of the disease in the United States. Therefore, reporting of TB suspects promptly
(prior to bacteriologic confirmation) is important. Public health services are available for
epidemiologic evaluation, including the identification and examination of source cases and
contacts (Lewinsohn et al., 2017).
The probability that a person who is exposed to M. tuberculosis will become infected
depends primarily on the concentration of infectious droplet nuclei in the air and the duration of
exposure to a person with infectious TB disease. The closer the proximity and the longer the
duration of exposure, the higher the risk of becoming infected. Close contacts are people who
share the same air space in a household or other enclosed environment for a prolonged period
(days or weeks, not minutes or hours) with a person with pulmonary TB disease. A suspect TB
client is a person in whom a diagnosis of TB disease is being considered, whether or not anti-TB
treatment has been started. People generally should not continue to be suspected of having TB
for more than 3 months (Lewinsohn et al., 2017).
Initial assessment of contacts should be accomplished within 3 days of reported exposure to
a person who has active TB disease. During that initial assessment, a history of previous M.
tuberculosis infection or disease and treatment should be taken along with any current symptoms
of TB illness and medical conditions that increase the risk of TB infection. The type, duration,
and intensity of exposure should be documented to provide data for high- and medium-priority
contact follow-up with diagnostic tests and possible treatment. All high- and medium-priority
contacts who do not have a documented previous positive TST or previous TB disease should
receive a baseline Mantoux TST. The reaction to the intracutaneously injected TST is the classic
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example of a delayed (cellular) hypersensitivity reaction, which induces induration. Induration
of 5 mm or more is considered a positive result in people who have an initial induration of 0 mm
(CDC, TB testing & diagnosis). See Figure 15.8 for factors to consider when initiating TB
contact investigation (CDC, 2005b).
Some people infected with M. tuberculosis may have a negative reaction to the TST if many
years have passed since they became infected. They may have a positive reaction to a
subsequent TST because the initial test stimulates their ability to react to the test. This is
commonly referred to as the “booster phenomenon” and may incorrectly be interpreted as a skin
test conversion (going from negative to positive). For this reason, the “two-step method” is
recommended at the time of initial testing for individuals who may be tested periodically (e.g.,
healthcare workers). If the first TST result in the two-step baseline testing is positive, consider
the person infected and evaluate and treat the person accordingly. If the first test result is
negative, the TST should be repeated in 1 to 3 weeks. If the second test result is positive,
consider the person infected and evaluate and treat the person accordingly; if both steps are
negative, consider the person uninfected and classify the TST as negative at baseline testing
(Fig. 15.9). Note: When Interferon–Gamma Release Assays (IGRAs) are used for serial testing,
there is no need for a second test because boosting does not occur (CDC, Latent tuberculosis
infection: A guide for primary healthcare providers).
Practice Point
Nurses in health departments and in community and public health settings may be
responsible for conducting TB contact investigations. By taking a careful contact history,
nurses are able to determine which contacts are at greatest risk for TB exposure. Nurses
also administer a TST during evaluation of exposure. Reliable administration and reading of
the TST requires standardization of procedures, training, supervision, and practice.
Questions often arise about the interpretation of TST results in people with a history of
bacillus Calmette–Guérin (BCG) vaccine, HIV infection, and recent contacts with an
infectious case of TB. History of BCG vaccine administration is not a contraindication for
tuberculin testing. If more than 5 years have elapsed since administration of BCG vaccine, a
positive tuberculin test reaction is most likely a result of M. tuberculosis infection (CDC,
Tuberculosis).
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FIGURE 15.8 Decision-making factors when initiating a tuberculosis (TB) contact investigation.
AFB, acid-fast bacilli; CXR, chest radiograph; NAA, nucleic acid assay. Approved indication for
NAA. (From Centers for Disease Control and Prevention [CDC]. [2005b]. Guidelines for the
investigation of contacts of persons with infectious tuberculosis. Morbidity and Mortality Weekly
Report, 54[RR15], 1–37.)
TB DIAGNOSTIC TESTS
The majority of experience with diagnosing M. tuberculosis infection, primarily in contacts, has
been with the Mantoux TST. In 2005, the CDC issued guidelines for using the FDA-approved
QuantiFERON-Gold (QFT-G) test for diagnosing M. tuberculosis infection, including both
active TB disease and latent TB infection. The 2005 guidelines indicated that QFT-G may be
used in all circumstances in which a TST test was recommended, including contact
investigations, evaluation of recent immigrants, and serial-testing surveillance programs for
infection control (e.g., those for healthcare workers). However, the guidelines provided cautions
for testing persons from selected populations, including persons at increased risk for progression
to active disease if infected (CDC, 2005b).
Two new interferon gamma (IFN-γ) release assays (IGRAs) were later approved by the Food
and Drug Administration (FDA) as aids in diagnosing M. tuberculosis infection, both latent
infection and infection manifesting as active tuberculosis. These tests are the QuantiFERON-TB
Gold In-Tube test (QFT-GIT) (Cellestis Limited, Carnegie, Victoria, Australia) and the T-SPOT
TB test (T-Spot) (Oxford Immunotec Limited, Abingdon, United Kingdom). The antigens,
methods, and interpretation criteria for these assays differ from those for IGRAs approved
previously by FDA. Control materials and antigens for QFT-GIT and T-Spot are contained in
special tubes used to collect blood for the test, thus allowing more direct testing of fresh blood.
Both tests are approved as indirect tests for M. tuberculosis infection (including infection
resulting in active disease) when used in conjunction with risk assessment, radiography, and
other medical and diagnostic evaluations. The FDA-approved indications for QFT-GIT and T-
Spot are similar to indications for QFT-G and TST. Because of administrative and logistic
difficulties associated with the TST skin test, IGRAs are attractive diagnostic aids for detecting
M. tuberculosis infection. Unlike the TST, IGRA results can be available within 24 hours
without the need for a second visit. As laboratory-based assays, IGRAs are not subject to the
biases and errors associated with TST placement and reading. However, the cost for an IGRA is
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substantially greater than that for a TST. Nonetheless, this additional cost might be offset by
decreasing the number of persons testing positive and the associated costs of evaluating and
treating persons with positive test results. Because of these new IGRAs, the CDC updated the
2005 guidelines to include these new IGRAs in 2010, which state that TSTs and IGRAs (QFT-
G, QFT-GIT, and T-Spot) should be used as aids in diagnosing infection with M. tuberculosis.
These tests may be used for surveillance purposes or to identify persons likely to benefit from
treatment, including persons who are or will be at increased risk for M. tuberculosis infection or
for progression to active tuberculosis if infected (CDC, 2010).
FIGURE 15.9 Two-step TST testing. Source: CDC. Two-step TST testing. In Latent Tuberculosis
Infection: A Guide for Primary Health Care Providers. Retrieved from
https://www.cdc.gov/tb/publications/ltbi/diagnosis.htm.
In 2017, the CDC, the American Academy of Pediatrics, the American Thoracic Society, and
the Infectious Disease Society of America coordinated development of updated guidelines for
using IFN-γ assays for U.S. public health officials, healthcare providers, and laboratory workers
to detect TB infection. They recommend performing an interferon-γ release assay (IGRA) rather
than a TST in individuals 5 years or older who meet the following criteria: (1) are likely to be
infected with M. tuberculosis, (2) have a low or intermediate risk of disease progression, (3) it
has been decided that testing for LTBI is warranted, and (4) either have a history of BCG
vaccination or are unlikely to return to have their TST read. However, a TST is an acceptable
alternative, especially in situations where an IGRA is not available, too costly, or too
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burdensome. They suggest performing a TST rather than an IGRA in healthy children less than
5 years of age for whom it has been decided that diagnostic testing for LTBI is warranted.
However, in situations in which an IGRA is deemed the preferred diagnostic test, some experts
are willing to use IGRAs in children over 3 years of age.
While both IGRA and TST testing provide evidence for infection with M. tuberculosis, they
cannot distinguish active from latent TB. Therefore, the diagnosis of active TB must be
excluded prior to embarking on treatment for LTBI. This is typically done by determining
whether or not symptoms suggestive of TB disease are present, performing a chest radiograph
and, if radiographic signs of active TB (e.g., airspace opacities, pleural effusions, cavities, or
changes on serial radiographs) are seen, then sampling is performed and the patient managed
accordingly. They also recommend that acid-fast bacilli (AFB) smear microscopy be performed,
and performing a diagnostic nucleic acid amplification test (NAAT), on the initial respiratory
specimen from patients suspected of having pulmonary TB (Lewinsohn et al., 2017).
Generally, persons at high risk for developing TB disease fall into two categories:
Persons who have been recently infected with TB bacteria
Persons with medical conditions that weaken the immune system
Persons who have been recently infected with TB bacteria include:
Close contacts of a person with infectious TB disease
Persons who have emigrated from areas of the world with high rates of TB
Children <5 years of age who have a positive TB test
Groups with high rates of TB transmission, such as homeless persons, injection drug users, and persons
with HIV infection
Persons who work or reside with people who are at high risk for TB in facilities or institutions such as
hospitals, homeless shelters, correctional facilities, nursing homes, and residential homes for those with
HIV
Persons with medical conditions that weaken the immune system (including babies and young children
who often have weak immune systems).
Other people also can have weak immune systems, especially people with any of these
conditions:
HIV infection (the virus that causes AIDS)
Substance abuse (including alcohol)
Silicosis
Diabetes mellitus
Severe kidney disease
Low body weight
Organ transplants
Head and neck cancer
Medical treatments such as corticosteroids or organ transplant
Specialized treatment for rheumatoid arthritis or Crohn disease (CDC, TB risk factors).
Case 2: The subsequent investigation in the Illinois TB outbreak found that all patients
were homeless and had been overnight shelter guests. Excess alcohol use was common
(82%), and two bars emerged as additional sites of potential transmission. Patients with
outbreak-associated TB were treated successfully for TB disease.
What screening measures would public health officials have used in this case?
What were the risk factors in this case?
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Practice Point
Best-practice nursing interventions must be tied into the role of community and public health
nurses in the care and supportive aspects of TB case management. The American Thoracic
Society, the CDC, and the Infectious Diseases Society of America support client-centered
case management with an emphasis on evidence-based DOT options.
Multidrug-Resistant TB
Although effective drugs exist, a major reason for the failure to stem the spread of TB lies in the
rise of drug-resistant strains of M. tuberculosis. Some strains are resistant to several drugs.
MDR-TB is defined as resistance to the two most potent “first-line” anti-TB agents. MDR-TB is
difficult and expensive to treat and fails to respond to the two most potent anti-TB agents (INH
and RIF). In addition, extensively drug-resistant TB (XDR-TB), another emerging threat, is a
rare type of MDR-TB that is resistant to the first-line TB drugs, plus resistance to any
fluoroquinolone and at least one of three injectable second-line drugs (CDC, Tuberculosis fact
sheets).
Globally in 2015, there were an estimated 480,000 new cases of MDR-TB and an additional
100,000 people with RR-TB who were also newly eligible for MDR-TB treatment. Drug
resistance surveillance data show that 3.9% of new and 21% of previously treated TB cases were
estimated to have had MDR/RR-TB in 2015. As in 2014, MDR-TB accounted for 3.3% of new
TB cases. MDR/RR-TB caused 250,000 deaths in 2015. Most cases and deaths occurred in Asia.
About 9.5% of MDR-TB cases had additional drug-resistance, XDR-TB. To date, 117 countries
worldwide have reported at least one XDR-TB case (WHO [2016b], MDR-TB 2016 update).
In contrast to the 2011 WHO recommendations, the current WHO treatment guidelines for
drug-resistant tuberculosis 2016 update did not update the policy on the use of rapid diagnostics
for RR-TB, the monitoring of response to treatment, the duration of longer MDR-TB regimens,
the delay in starting antiretroviral therapy in MDR-TB patients with HIV infection and models
of care. For these aspects of the programmatic management of drug-resistant TB, the 2011
guidelines for the programmatic management of drug-resistant tuberculosis (WHO, 2011)
continue to apply until future evidence shows a need for revision.
The main changes in the 2016 WHO recommendations are as follows:
A shorter MDR-TB treatment regimen is recommended under specific conditions.
Medicines used in the design of longer MDR-TB treatment regimens are now regrouped differently based
upon current evidence on their effectiveness and safety. Clofazimine and linezolid are now recommended
as core second-line medicines in the MDR-TB regimen while p-aminosalicylic acid is an add-on agent.
MDR-TB treatment is recommended for all patients with RR-TB, regardless of confirmation of isoniazid
resistance.
Specific recommendations are made on the treatment of children with RR-TB or MDR-TB.
Clarithromycin and other macrolides are no longer included among the medicines to be used for the
treatment of MDR/RR-TB.
Evidence-informed recommendations on the role of surgery are now included. Bedaquiline and
delamanid have now been assigned to a specific subgroup of add-on agents. In October 2016, the WHO
published its new policy on delamanid. Delamanid may now also be used alongside longer MDR-TB
regimens in patients aged 6 to 17 years. Bedaquiline is still only recommended for adults (WHO, 2016b).
More information on the changes in the 2016 MDR-TB recommendations can be found at
WHO treatment guidelines for drug-resistant tuberculosis: http://www.who.int/tb/areas-of-
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work/drug-resistant-tb/treatment/resources/en/
In Case 2, the average length of stay at the homeless shelter for guests was 2 weeks.
During contact investigations and four mass screenings at the shelter during May 2010 to
June 2011, public health officials evaluated 386 persons recently exposed to a person
with an infectious outbreak case, finding six (2%) additional TB cases. As of September
2011, a total of 28 outbreak-associated cases involving shelter guests, dating back to
2007, had been recognized, indicating ongoing M. tuberculosis transmission among
guests at the homeless shelter.
To prevent future cases of TB, what treatment program should public health officials
have implemented in this high-risk population?
TB Infection Control Guidelines for Healthcare Settings
The CDC updated the TB infection control guidelines for healthcare settings in 2005 (CDC,
2005c). These recommendations reflect shifts in the epidemiology of TB, advances in scientific
understanding, and changes in healthcare practice that have occurred in the United States during
the preceding decade. The updated TB infection control guidelines emphasize actions to
maintain momentum and expertise needed to avert another TB resurgence and to eliminate the
lingering threat to healthcare personnel, which is mainly from clients or others with unsuspected
and undiagnosed infectious TB disease. A sample recommendation is that the term “tuberculin
skin tests” (TST) be used rather than “PPD.” The scope of settings in which the guidelines apply
has been broadened to include laboratories and additional outpatient and nontraditional
healthcare settings.
These recommendations also apply to an entire healthcare setting rather than to areas within
a setting. New terms such as “airborne infection precautions” (airborne precautions) and
“airborne infection isolation (AII) room” have been introduced. One of the most critical risks for
healthcare-associated transmission of M. tuberculosis in healthcare settings is from clients with
unrecognized TB disease who are not promptly handled with appropriate airborne precautions or
who are moved out of an AII room too soon (e.g., clients with unrecognized TB and MDR-TB).
The CDC Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-
Care Settings can be found at http://www.cdc.gov/mmwr/PDF/rr/rr5417
Ebola Virus Disease
Ebola first appeared in 1976 during two simultaneous outbreaks in Nzara, Sudan, and in
Yambuku, Democratic Republic of Congo. It was named from the Ebola River, which is located
in Yambuku. The Ebola virus is a member of the Filoviridae family (filovirus), and has five
distinct species:
Bundibugyo ebolavirus (BDBV)
Reston ebolavirus (RESTV)
Sudan ebolavirus (SUDV)
Taï Forest ebolavirus (TAFV)
Zaire ebolavirus (EBOV) (WHO, Ebola virus disease)
Ebola virus disease (EVD), previously called Ebola hemorrhagic fever, is a severe, often
fatal illness with a reported case fatality rate as high as 100%. The virus can be brought into
human populations through close contact with blood, secretions, or other body fluids and organs
of infected animals such as chimpanzees, gorillas, fruit bats, monkeys, forest antelope, and
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porcupines. It can be spread from person-to-person through direct contact (through broken skin
or mucous membranes) with blood, secretions, excretions, or other body fluids of an infected
person. Ebola virus has been found in semen up to 61 days. The virus can also be spread by
indirect contact through medical equipment and the contaminated environment in contact with
these fluids. Large outbreaks of EVD in Africa have been associated with BDVD, BDBV,
EBOV, and SUDV since 1976, but not RESTV and TAFV. Although RESTV has been reported
in China and the Philippines, it has not caused illness or death in humans to date (WHO, Ebola
virus disease).
Large outbreaks of EVD have been reported in Africa since 1976. The last reported outbreak
of EVD had occurred in the Democratic Republic of Congo in 2012. However, in the spring of
2014, an outbreak of EVD was reported in the forested areas of southeast Guinea and quickly
spread to several districts. This was the first time EVD had been detected in West Africa.
Confirmed cases were reported in Guinea, Liberia, and Sierra Leone. The WHO confirmed that
this outbreak was caused by the Zaire ebolavirus (EBOV). The Ebola virus had been introduced
into Nigeria in July 2014 by a Liberian traveler, resulting in a total of 20 cases and eight deaths.
But by late October 2014, WHO had declared that Nigeria was free of Ebola virus transmission
(WHO [2014b], Nigeria ends Ebola).
However, intense transmission of the Ebola virus continued in Guinea, Liberia, and Sierra
Leone. And by the spring of 2016, the total number of reported cases of EVD in the four West
African countries (Guinea, Liberia, Sierra Leone, and Nigeria) was 28,652. Of these, 15,261
were laboratory-confirmed cases; total deaths were 11,325 (case fatality rate: 39.5%), making it
the worst EVD outbreak in history. Most of the later cases reported had occurred in Guinea,
Liberia, and Sierra Leone, with Liberia reporting the highest death rate at 45% (CDC, 2014–
2016 Ebola outbreak in West Africa). A small number of cases of Ebola infection had been
reported in the Democratic Republic of the Congo, but was not related to the ongoing outbreaks
in Guinea, Liberia, and Sierra Leone (CDC, Ebola in Democratic Republic of the Congo).
The first imported case of Ebola infection in the United States occurred in Dallas, Texas, in
September 2014 in a man who had traveled from Liberia. Two healthcare providers who had
cared for that patient, who died, became ill with the Ebola virus and have since recovered. A
third U.S. case of Ebola infection occurred in October 2014 in a doctor who had worked treating
Ebola patients with Doctors without Borders in Guinea. He was hospitalized in New York City,
and has recovered (CDC [2014b], Cases of Ebola diagnosed in the United States).
Although the Ebola virus posed little to no risk to the U.S. general population, in July 2014,
the CDC issued a level 3 travel alert (Avoid Nonessential Travel) for Sierra Leone, Guinea, and
Liberia and reminded all healthcare providers to take a good travel history to identify patients
who had traveled to/from West Africa (CDC, Travel Health Notices, 31 July 2014).
Postarrival monitoring by state and local public health departments was an additional
safeguard to exit screening of all travelers for 21 days from the date of their departure from the
affected countries.
In May 2017, the WHO was notified by the Ministry of Public Health of the Democratic
Republic of the Congo (DRC) of a cluster of undiagnosed illnesses and deaths with signs of
EVD in the Likati Health Zone, a remote area that shares borders with the Central African
Republic and two other provinces of the DRC. Cases of the disease were reported in four health
districts. This was the DRC’s eighth outbreak of EVD since the discovery of the virus in the
country in 1976. By July 2017, WHO had declared the end of this most recent outbreak. The
announcement came 42 days (two 21-day incubation cycles of the virus) after the last case of
EVD. Eight cases of EVD were identified during the outbreak, with five cases laboratory-
confirmed; four people died. A total of 583 contacts were closely monitored, but no known
contacts developed signs or symptoms of EVD. Enhanced surveillance in the country continued,
as well as strengthening of preparedness and readiness for Ebola outbreaks (WHO [2017],
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Declaration of the end of Ebola virus disease outbreak in the Democratic Republic of the
Congo, 2 July 2017).
Less than a year later, in May 2018, the Ministry of Health of the DRC declared an outbreak
of EVD in the Bikoro Health Zone, Equateur Province, which is 250 km from Mbandaka, the
capital of Equateur Province, in an area of the country that is very hard to reach. Ebola had
spread to Mabalako, a city with more than 1 million people by June 2018. This was the ninth
outbreak of EVD over the last four decades in the DRC, with the eighth outbreak occurring in
May 2017. The risk of more rapid spread was likely given that EVD had been found in the large
urban area of Mabalako, which is right on the Congo River. With the city’s location on the river
along with its road and air links, the confirmation of Ebola cases there increases the risk of both
local propagation and further spread within the DRC and to neighboring countries. At the time
of this latest outbreak, the WHO assumed that 100 to 300 cases of EVD could occur in the DRC
by July 2018 (WHO [2018e], Strategic response plan for the Ebola virus disease outbreak,
Democratic Republic of the Congo).
By August 2018, the Ministry of Health of the DRC declared the second outbreak of EVD in
the country that year in North Kivu Province, less than 2 weeks since the previous outbreak, in
nearby Equateur province, was declared over (UNICEF, The Government of the Democratic
Republic of the Congo announced the end of the Ebola epidemic in the Equateur Province on 25
July 2018). North Kivu, in the eastern part of the country, is among the most populated
provinces in the country, shares borders with Uganda and Rwanda, and experiences conflict and
insecurity, with over one million internally displaced people and migration of refugees to
neighboring countries. By Mid-December 2018, WHO epidemiological data on EVD in the
DRC, indicated that since the beginning of the epidemic, the cumulative number of cases was
529, with 481 confirmed and 48 probable cases. In total, there have been 311 deaths (263
confirmed and 48 probable), with a case-fatality rate of 59%, and 183 patients had recovered.
An increase in the case fatality rate may rise as long as the risk of the outbreak spreading to
other provinces in the Democratic Republic of the Congo. This possibility remains very high as
long as unrest prevents healthcare workers to identify cases and contacts (International Society
for Infectious Diseases, December 15, 2018). Cumulatively, since June 2018, 19 health workers
had been affected (18 confirmed and one probable), three of whom have died. All health
workers’ exposures occurred in health facilities outside the dedicated Ebola treatment centers
(WHO, Ebola virus disease, DRC External Report 7). The WHO and partners continued to work
with health workers and communities to increase awareness on infection prevention and control
measures, as well as vaccinate those at risk of infection (WHO, Ebola virus disease: Democratic
Republic of the Congo. 3 August 2018).
The current Ebola outbreak in the DRC demonstrates the infectious disease risks posed by
globalization and rapid travel. In previous outbreaks in the DRC, the virus was confined to
villages and small towns so remote that infected humans didn’t travel far enough to spread the
disease. Case finding had been difficult due to community resistance. Some families were
concealing potential or probable Ebola cases among them. Even after some probable cases had
been identified at home, their families were refusing to allow the affected family member to be
quarantined and cared for in the Ebola treatment centers. Other contacts were refusing
vaccination (International Society for Infectious Diseases, Ebola update (82), ProMED Mail,
September 5, 2018).
Several weeks after the second outbreak occurred in the DRC, there were still significant
threats for further spread of the disease. The Ebola outbreak in North Kivu and Ituri provinces
remained active, but continued to be closely monitored, with the Ministry of Health, WHO and
partners making progress in response to the outbreak. Current reports indicated that control
measures were working. However, additional risks remained following the movement of several
cases from Beni and Mabalako to other health zones. Continued challenges included contacts
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lost to follow-up, delayed recognition of EVD in health centers, poor infection control in health
centers, and cases leaving health centers and refusing transfer to Ebola treatment centers
(International Society for Infectious Diseases, Ebola update (93). ProMED Mail, September 20,
2018).
At the same time, attacks by armed rebels continued in Beni territory, following a clash
between the Congolese army and the Ugandan Islamist rebels of the Allied Democratic Forces,
resulting in the deaths of two Sudanese UN peacekeepers on September 3, 2018 (International
Society for Infectious Diseases, Ebola update (82). ProMED Mail, September 5, 2018. Retrieved
on September 21, 2018, from http://www.promedmail.org). Field activities were suspended in
Beni in late September 2018, following clashes between rebels and the Congolese armed forces,
but were to continue when calm returned to the city (International Society for Infectious
Diseases, Ebola update (96). ProMED Mail, September 24, 2018).
Although there had been no declared travel ban to the Democratic Republic of the Congo by
the WHO, and the Ebola virus posed little to no risk to the United States, the CDC reminded all
healthcare providers to (1) take a good travel history to identify patients who traveled to/from
affected area in the past 3 weeks, (2) know the signs and symptoms of EVD, and (3) follow
infection control precautions for suspected and symptomatic cases of EVD to prevent the spread
of the Ebola virus (CDC, Travel Health Notices).
Signs, Symptoms, and Diagnosis of EVD
EVD has an incubation period from 2 to 21 days, but the average is 8 to 10 days. Early
symptoms include sudden onset of fever, muscle pain and weakness, headache, and sore throat.
These symptoms are followed by vomiting, diarrhea, rash, compromised liver and kidney
function, and in some cases, internal and external bleeding (CDC, EVD signs and symptoms).
Before the diagnosis of EVD is made, other diseases should be ruled out, such as malaria,
influenza, and typhoid fever, since these diseases may have similar signs and symptoms.
Laboratory tests for a definitive diagnosis of EVD include ELISA, antigen detection tests, PCR
assay, and culture isolation of the virus (CDC, EVD diagnosis). Studies have shown that the
Ebola virus remains in semen for longer than 2 years after recovery from EVD (Fischer et al.,
2017).
Prevention and Control of EVD
There is currently no vaccine against EVD; however, results of Phase I clinical trials for two
vaccine candidates, developed by GlaxoSmithKline (GSK) in collaboration with the U.S.
National Institute of Allergy and Infectious Diseases (NIAID), and by NewLink Genetics and
Merck Vaccines USA in collaboration with the Public Health Agency of Canada, were
published in 2016. Both vaccine candidates have been shown to be safe and well tolerated in
humans (Agnandji et al., 2016).
Despite there being no licensed vaccine against EVD, vaccination played an integral part in
the response to the 2018 Ebola outbreak in the DRC. The WHO Strategic Advisory Group of
Experts on Immunization recommended in April 2017 that the Ebola vaccine be promptly
deployed under the Expanded Access framework, with informed consent and in compliance with
“Good Clinical Practice,” if an Ebola disease outbreak occurred before the candidate vaccine
was licensed. The WHO sent vaccine developed by Merck to the DRC. Two key international
actors, Doctors without Borders and the WHO, tested an Ebola vaccine during the current
outbreak in DRC, in collaboration with the ministry of health. The DRC has had, as well as
controlled, multiple Ebola outbreaks. The country has experienced public health teams and has
had excellent collaborations with Médecins Sans Frontières (MSF) and other international
organizations for many years. Fortunately, the Ministry of Health, Doctors without Borders, and
the Epicenter team started preparing for such an effort before the last DRC epidemic in 2017.
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http://www.promedmail.org
Because it is impossible to conduct a randomized placebo-controlled trial, Doctors Without
Borders ran an open-label, single-group study to provide additional information on the vaccine’s
safety and effectiveness. All participants who consented to take part were included, and
followed for at least 42 days (twice what is often considered to be the maximum incubation
period of EVD. The plan was to start as soon as possible after the teams were on the ground in
the DRC. The WHO teams started using the Ebola vaccine in the DRC in May 2018, with
healthcare personnel operating in affected areas of the Ebola outbreak to be the first to be
vaccinated (Haug et al., 2018).
In addition to the vaccine developed by Merck, the National Institute of Allergy and
Infectious Diseases shipped 100 doses of an experimental Ebola virus treatment to the DRC,
filling a request from health officials there to use the treatment in a clinical trial during the
current outbreak. According to NIAID Director, Dr. Anthony Fauci, “That’s not unusual in an
emergency situation. If they use it in a trial or under compassionate use, informed consent would
have to make it very clear that it hasn’t completed a phase 1 trial” (Healio, Infectious Disease
News, May 25, 2018).
As of mid-September 2018, 58 vaccination rings (as used in the Phase 3 study in Guinea, but
randomization was discontinued), plus 24 rings of health and frontline workers had been
defined. By December 15, 2018, 46,887 people had been vaccinated, including healthcare and
frontline workers, and children (International Society for Infectious Diseases. Ebola update,
December 15, 2018). There was one area in Ndindi where the implementation of vaccination
was hampered due to community resistance (WHO, Ebola virus disease, DRC External Report
7).
In the absence of a licensed human vaccine and lack of effective treatment for EVD, the
CDC has outlined epidemiologic risk factors, ranging from “High Risk” to “No Identifiable
Risk,” that should be considered when evaluating a person for EVD, classifying contacts, or
considering public health actions such as monitoring and movement restrictions based on
exposure. For example, use of standard contact and droplet precautions and other infection
control measures in healthcare settings to prevent exposure to blood and body fluids and the
potentially contaminated environment when caring for patients with suspected or confirmed
EVD. It should be noted that Ebola virus can be detected in semen for months after recovery
from the disease. Unprotected contact with the semen of a person who has recently recovered
from Ebola may constitute a potential risk for exposure (CDC, Epidemiologic risk factors to
consider when evaluating a person for exposure to Ebola virus).
Travelers to or are in an area affected by an Ebola outbreak, should be aware of the
following:
Practice careful hygiene. For example, wash your hands with soap and water or an alcohol-based hand
sanitizer and avoid contact with blood and body fluids (such as urine, feces, saliva, sweat, urine, vomit,
breast milk, semen, and vaginal fluids).
Do not handle items that may have come in contact with an infected person’s blood or body fluids (such
as clothes, bedding, needles, and medical equipment).
Avoid funeral or burial rituals that require handling the body of someone who has died from Ebola.
Avoid contact with bats and nonhuman primates or blood, fluids and raw meat prepared from these
animals (bushmeat) or meat from an unknown source.
Avoid contact with semen from a man who had EVD until you know the virus is gone from the semen.
Avoid facilities where Ebola patients are being treated.
These same prevention methods apply when living in or traveling to an area affected by an
Ebola outbreak. After returning from an area affected by Ebola, monitor health for 21 days and
seek medical care immediately if you develop symptoms of EVD (CDC, Travel Health. Ebola in
Democratic Republic of the Congo. [Updated September 14, 2018]).
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In 2015, the CDC published Infection Prevention and Control Recommendations for
Hospitalized Patients under Investigation (PUIs) for Ebola Virus Disease in U.S. Hospitals. For
historical and informational purposes, these recommendations are available at
https://www.cdc.gov/vhf/ebola/healthcare-us/hospitals/infection-control.html (Last reviewed:
August 30, 2018).
Zika Virus Disease
Zika is caused by the Zika virus, which is transmitted primarily through a bite from an infected
vector, the Aedes species mosquito (Aedes aegypti and Aedes albopictus). Zika virus also can be
transmitted through sexual contact and possible blood transfusion; however, the virus remains in
semen longer than in blood. Several cases of sexually transmitted Zika infections have been
reported.
The Zika virus was first discovered in 1947 and its name came from the Zika Forest in
Uganda. In 1952, the first human cases of Zika were detected and since then, outbreaks of Zika
have been reported in tropical Africa, Southeast Asia, and the Pacific Islands. Zika virus
emerged in the Region of the Americas on Easter Island, Chile, in 2014 and in northeast Brazil
in 2015. In May 2015 in response, to the Zika outbreak, the Pan American Health Organization
(PAHO), which serves as the Regional Office of the Americas for the WHO, issued
recommendations to enhance surveillance for Zika virus. Subsequently, Brazilian investigators
reported Guillain–Barré syndrome, which had been previously recognized among some patients
with Zika virus disease, and identified an association between Zika virus infection during
pregnancy and congenital microcephaly (CDC, Zika virus).
In February 2016, the WHO declared Zika virus–related microcephaly clusters and other
neurologic disorders a Public Health Emergency of International Concern. In March 2016,
PAHO developed case definitions and surveillance guidance for Zika virus disease and
associated complications. Analysis of reports submitted to PAHO by countries in the region or
published in national epidemiologic bulletins revealed that Zika virus transmission had extended
to 48 countries and territories in the Region of the Americas by late 2016. Reported Zika virus
disease cases peaked at different times in different areas during 2016. Because of ongoing
transmission and the risk for recurrence of large outbreaks, response efforts, including
surveillance for Zika virus disease and its complications, and vector control and other prevention
activities, needs to be maintained (CDC [2017c] Zika virus transmission—Region of the
Americas). In March 2016, the WHO updated its travel recommendations to advise pregnant
women not to travel to areas with ongoing Zika virus outbreaks.
By the fall of 2016, 73 countries and territories had reported evidence of mosquito-borne
Zika virus transmission to the WHO. Twelve countries, including the United States had reported
evidence of person-to-person transmission of Zika virus, and 23 countries or territories reported
microcephaly and other CNS malformations potentially associated with Zika virus infection, or
suggestive of congenital infection. Most of these cases were from Brazil at 2,063 (WHO,
Situation report, Zika virus, October 27, 2016). By March 2017, the overall global risk
assessment had not changed. Zika virus continued to spread geographically to areas where
competent vectors are present. Eighty-four countries, territories, or subnational areas were
reporting evidence of vector-borne Zika virus transmission, with additional cases of
microcephaly and other CNS malformations being reported. Although a decline in cases of Zika
virus infection had been reported in some countries, or in some parts of countries, vigilance
remained high (WHO, Situation report, Zika virus, March 10, 2017).
Although Zika was not a nationally notifiable disease in the United States in 2015, cases
could be reported to ArboNET, the national surveillance system for arthropod-borne diseases.
There were 61 symptomatic Zika virus disease cases reported in 2015 from travelers returning
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from affected areas. There were no cases acquired through presumed local mosquito-borne
transmission, and no cases acquired through other routes (e.g., sexual, laboratory, or blood borne
transmission). In 2015, the U.S. territories, reported nine symptomatic Zika virus disease cases,
with one case in a traveler returning from an affected area, eight cases acquired through
presumed local mosquito-borne transmission, and no cases acquired through other routes (CDC,
Cumulative Zika virus disease case counts in the United States, 2015–2017). In 2016, Zika virus
disease became a nationally notifiable condition. Cases are reported to CDC by state, territorial,
and local health departments using standard case definitions. In February 2016, the United States
reported two sexually transmitted cases of Zika virus. That year, there were 5,102 symptomatic
Zika virus disease cases reported. Of these, 4,830 cases were in travelers returning from affected
areas, 224 cases acquired Zika virus through presumed local mosquito-borne transmission in
Florida (n = 218) and Texas (n = 6), and 48 cases were acquired through other routes, including
sexual transmission (n = 46). Thirty-seven (80%) of these latter cases were from presumptive
viremic blood donors. One case of Zika virus disease occurred through laboratory transmission,
and one person-to-person case was through an unknown route. Most of the cases occurred in
Florida (n = 1,115), New York (n = 1,001), and California (n = 421). In the U.S. territories, there
were 36,079 symptomatic Zika virus disease cases reported in 2016, with 142 cases in travelers
returning from affected areas, 35,937 cases acquired through presumed local mosquito-borne
transmission. Almost (97%) of the cases occurred in Puerto Rico (n = 34,963), 322 of the cases
were from presumptive viremic blood donors (CDC, Cumulative Zika virus disease case counts
in the United States, 2015–2017).
By September 2017, the CDC reported a decline in the number of Zika virus cases in the
United States at 231 symptomatic Zika virus disease cases reported, with 229 cases in travelers
returning from Zika-affected areas, no cases acquired through presumed local mosquito-borne
transmission, and two cases acquired through sexual transmission, and nine cases were from
presumptive viremic blood donors. Most of the cases were in New York (n = 44), Florida (n =
31), California (n = 25), and Texas (n = 22). In the U.S. territories, there were 554 symptomatic
Zika virus disease cases reported, 554 cases acquired through presumed local mosquito-borne
transmission, and no cases in travelers returning from affected areas; however, three cases were
from presumptive viremic blood donors were identified in Puerto Rico. Again, Puerto Rico
reported the most cases at 474 (CDC, Cumulative Zika virus disease case counts in the United
States, 2015–2017).
None of the 2015–2017 Zika virus disease cases reported above included congenital Zika
disease cases. Pregnant women and infants who meet the following criteria are eligible for the
U.S. Zika Pregnancy Registry: Pregnant women in the United States with laboratory evidence of
Zika virus infection (positive or equivocal test results, regardless of whether they have
symptoms) and periconceptionally, prenatally, or perinatally exposed infants born to these
women. Infants with laboratory evidence of congenital Zika virus infection (positive or
equivocal test results, regardless of whether they have symptoms) and their mothers are eligible
for the U.S. Zika Pregnancy Registry. As of August 2017, there were 1,862 completed
pregnancies with or without birth defects in the Zika Registry. Of these there were 95 live-born
infants with birth defects, and eight pregnancy losses with birth defects. In the U.S. territories,
there were 3,258 completed pregnancies with or without birth defects, 132 live-born infants with
birth defects, and seven pregnancy losses with birth defects. The data collected through the Zika
pregnancy and infant registries are used to update recommendations for clinical care, to plan for
services and support for pregnant women and families affected by Zika virus, and to improve
prevention of Zika virus infection during pregnancy (CDC, Outcomes of pregnancies with
laboratory evidence of possible Zika virus infection in the United States).
Signs, Symptoms, and Diagnosis of Zika Disease
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Many people infected with Zika virus won’t have symptoms or will only have mild symptoms.
The most common symptoms of Zika are:
Fever
Rash
Headache
Joint pain
Red eyes
Muscle pain
Symptoms can last for several days to a week. People usually don’t get sick enough to go to
the hospital, and they very rarely die of Zika. Once a person has been infected with Zika, they
are likely to be protected from future infections (CDC, Zika overview).
Prevention and Control of Zika Disease
In July 2017, CDC issued updated interim guidance for healthcare providers caring for pregnant
women with possible Zika virus exposure (CDC [2017b], Update: Interim guidance for
healthcare providers caring for pregnant women with possible Zika virus exposure—United
States [including U.S. territories]). However, CDC is continually updating this information.
Because Zika infection during pregnancy can cause severe birth defects, pregnant women should
not travel to the areas where the Zika virus is circulating. The CDC has provided areas identified
as Alert Level 2 (Practice Enhanced Precautions). For a list of all Zika virus travel notices for
travelers to international destinations, U.S. territories, and within the United States, see Zika
travel information at https://www.cdc.gov/zika/geo/index.html
As of February 2018, the WHO Classification scheme for travelers included four categories
of Zika virus transmission, which are defined as follows:
Category 1. Area with new introduction or re-introduction with ongoing transmission
Category 2. Area either with evidence of virus circulation before 2015 or area with ongoing transmission
that is no longer in the new or re-introduction phase, but where there is no evidence of interruption
Category 3. Area with interrupted transmission and with potential for future transmission
Category 4. Area with established competent vector but no known documented past or current
transmission. For the latest (February 2018) country category status update, see WHO. Zika virus
classification at: http://apps.who.int/iris/bitstream/handle/10665/260419/zika-lassification-15Feb18-
eng ?sequence=1.
More than 40 Zika vaccine candidates are in the pipeline and five are entering Phase I trials,
where the vaccine’s safety and ability to produce an immune response will be evaluated. In the
meantime, the best way to prevent diseases spread by mosquitoes is to be protected from
mosquito bites:
Use Environmental Protection Agency (EPA)-registered insect repellants.
Wear long-sleeved shirts and long pants when outdoors.
Sleep under a mosquito bed net if air conditioned or screened rooms are not available or if sleeping
outdoors.
Prevent sexual transmission of Zika by using condoms or not having sex (CDC, Zika overview).
Evidence for Practice
The diagnosis of Zika is based on a person’s recent travel history, symptoms, and test
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https://www.cdc.gov/zika/geo/index.html
http://apps.who.int/iris/bitstream/handle/10665/260419/zika-lassification-15Feb18-eng ?sequence=1
results.
A blood or urine test can confirm a Zika infection. The CDC has updated the interim
guidance for U.S. healthcare providers caring for pregnant women with possible Zika virus
exposure. As the prevalence of Zika virus disease declines, the likelihood of false-positive
test results increases. In addition, emerging epidemiologic and laboratory data indicate that
Zika virus IgM antibodies can persist beyond 12 weeks after infection. Therefore, IgM test
results cannot always reliably distinguish between an infection that occurred during the
current pregnancy and one that occurred before the current pregnancy, particularly for
women with possible Zika virus exposure before the current pregnancy. These limitations
should be considered when counseling pregnant women about the risks and benefits of
testing for Zika virus infection during pregnancy.
Key recommendations include the following:
1. All pregnant women in the United States and U.S. territories should be asked about
possible Zika virus exposure before and during the current pregnancy, at every prenatal
care visit. CDC recommends that pregnant women not travel to any area with risk for
Zika virus transmission. It is also recommended that pregnant women with a sex partner
who has traveled to or lives in an area with risk for Zika virus transmission use condoms
or abstain from sex for the duration of the pregnancy.
2. Pregnant women with recent possible Zika virus exposure and symptoms of Zika virus
disease should be tested to diagnose the cause of their symptoms. The updated
recommendations include concurrent Zika virus nucleic acid test (NAT) and serologic
testing as soon as possible through 12 weeks after symptom onset.
3. Asymptomatic pregnant women with ongoing possible Zika virus exposure should be
offered Zika virus NAT testing three times during pregnancy: at the initiation of prenatal
care, and if Zika virus RNA is not detected on clinical specimens, two additional tests
should be offered during the course of the pregnancy coinciding with prenatal visits.
4. Pregnant women who have recent possible Zika virus exposure and who have a fetus
with prenatal ultrasound findings consistent with congenital Zika virus syndrome should
receive Zika virus testing to assist in establishing the etiology of the birth defects. Testing
should include both NAT and IgM tests.
5. Asymptomatic pregnant women who have recent possible Zika virus exposure (i.e.,
through travel or sexual exposure) but without ongoing possible exposure are not
routinely recommended to have Zika virus testing.
Sources: CDC. Zika: Clinical Evaluation & Disease. Retrieved on September 1, 2017, from https://www.cdc.gov/zika/hc-providers/preparing-for-
zika/clinicalevaluationdisease.html; Centers for Disease Control and Prevention. (2017b). Update: Interim guidance for healthcare providers caring for pregnant
women with possible Zika virus exposure—United States (including U.S. territories), July 2017. Morbidity and Mortality Weekly Report, 66(29), 781–793.
REEMERGING VACCINE-PREVENTABLE DISEASES
The United States has been able to eliminate many infectious diseases because of its effective
vaccination programs, which achieve high vaccine coverage in children and a strong public
health system for detecting and responding to new cases and outbreaks. However, the
reemergence of vaccine-preventable disease outbreaks continue to occur in the United States
despite these vaccination programs. People who are unvaccinated for any reason, including
those who refuse vaccination, risk getting infected and spreading these infectious diseases to
others, including those who cannot get vaccinated because they are too young or have specific
health conditions.
Measles, Mumps, and Rubella
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Measles
In 2000, the United States declared that measles was eliminated from this country (the absence
of endemic transmission for 12 months or more). Nonetheless, since measles cases are still
common in many other countries, this disease will continue to be brought into the United States.
Measles is highly contagious, so anyone who is not protected against the disease is at risk of
becoming infected. Measles is more likely to spread and cause outbreaks in U.S. communities
where groups of people are unvaccinated. Several recent outbreaks of measles have been
reported in the United States. The majority of people who got measles were unvaccinated.
People who are unvaccinated for any reason, including those who refuse vaccination, risk
getting infected with measles and spreading it to others, including those who cannot get
vaccinated because they are too young or have specific health conditions (CDC, Measles
(Rubeola) for healthcare professionals).
Outbreaks in countries to which Americans often travel can directly contribute to an increase
in measles cases in the United States. In 2011, more than 30 countries in the WHO European
Region reported an increase in measles, and France was experiencing a large outbreak.
At the end of 2017, 118 cases of measles from 15 states and the District of Columbia were
reported to the CDC. By mid-August 2018, a total of nine outbreaks (defined as three or more
linked cases) and 124 individual cases of measles had been confirmed in 22 states and the
District of Columbia. But the CDC warned at that time that there was no current multistate
measles outbreak in the United States. However, while this case count was preliminary and with
four more months before the end of that year, it had already exceeded the total number of
measles cases for 2017 (CDC, Measles cases and outbreaks. [Last updated: August 22, 2018]).
Travelers with measles continue to bring the disease into the United States, and it can spread
when it reaches communities where groups of people are unvaccinated. Maintaining 95%
vaccine coverage is critical to public health and elimination of measles transmission.
Vaccination hesitancy and movement of populations due to economic hardship are preventing
this goal from being reached globally, leading to measles outbreaks. Before any international
travel, infants 6 months through 11 months of age should receive one dose of MMR vaccine.
Children 12 months of age and older should receive two doses of MMR vaccine separated by at
least 28 days. Teenagers and adults who do not have evidence of immunity against measles
should get two doses of MMR vaccine separated by at least 28 days (CDC, Measles (Rubeola)
for healthcare professionals).
Mumps
Before there was a vaccine against mumps, the disease was a common disease in the United
States and caused severe complications. Vaccination is the best way to prevent mumps. Since a
vaccine became available, mumps is no longer a very common infection in the United States.
However, outbreaks still occur from year to year, with many cases occurring on college
campuses. Therefore, young adults and teenager immunizations should be up to date (CDC,
Mumps for healthcare professionals).
Rubella
Rubella was a common disease that occurred primarily among young children before the rubella
vaccine was licensed in the United States in 1969. Epidemics occurred every 6 to 9 years, with
the highest number of cases during the spring. Rubella was declared eliminated from the United
States in 2004 (the absence of endemic transmission for 12 months or more). However, it is still
commonly transmitted in many parts of the world. As a result, less than 10 cases (primarily
import-related) have been reported annually in the United States since elimination was declared.
Because rubella continues to circulate in other parts of the world, an estimated 100,000 infants
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are born with congenital rubella syndrome annually worldwide (CDC, Rubella [German
measles, three-day measles] for healthcare professionals).
Pertussis
Pertussis (whooping cough) is a common (endemic) disease in the United States, with peaks in
reported disease every 3 to 5 years and frequent outbreaks. Before the availability of pertussis
vaccine in the 1940s, public health experts reported more than 200,000 cases of pertussis
annually. Since widespread use of the vaccine began, incidence has decreased more than 75%
compared with the pre-vaccine era. However, since the 1980s, there has been an increase in the
number of reported cases of pertussis. In 2012, the last peak year, CDC reported 48,277 cases of
pertussis in the United States. In the summer of 2017, an outbreak of pertussis occurred in St.
Joseph County, MI, which began with one Amish family and spread throughout the community.
There were 233 cases who were treated with antibiotics by the end of August. Amish religious
doctrine does not prohibit vaccination; however, coverage levels for routine childhood
vaccination remain low in many Amish communities. In the Michigan case, an Amish family
opened their home for an immunization clinic. The Amish community also offered its
community building for monthly immunizations (ISID, 2017).
The CDC believes that much of pertussis disease goes unrecognized and unreported. The
best way to prevent pertussis is vaccination. There are vaccines for babies, children, preteens,
teens, and adults. The childhood vaccine is called DTaP (Diphtheria, Tetanus, and Pertussis),
and the pertussis booster vaccine for preteens, teens, and adults is called Tdap (Tetanus,
diphtheria, and pertussis) vaccine (CDC, Pertussis [whooping cough]).
Immunity to pertussis wanes despite receiving vaccine as children. The Advisory Committee
on Immunization Practices (ACIP, 2017a) currently recommends that adults and adolescents
receive one dose of the (Tdap) booster vaccine to protect against whooping cough. A dose of
Tdap is recommended for adults who expect to have close contact with an infant younger than
12 months of age. Adolescents who have already received a booster dose of Td are encouraged
to receive a dose of Tdap. A 5-year interval from the last Td dose is encouraged, but an interval
as short as 2 years may be used if pertussis immunity is needed. All adults should receive a
booster dose of Td every 10 years. Tdap is licensed for only one lifetime dose per person. Adults
who have never received a dose of Tdap should substitute it for their next booster dose. New
mothers who have never received Tdap should get a dose as soon as possible after delivery. If
vaccination is needed during pregnancy, Td is usually preferred over Tdap. Healthcare providers
who have direct patient contact should receive a dose of Tdap. Adolescents and adults who
require a tetanus-containing vaccine as part of wound management should receive a dose of
Tdap instead of Td if they have not previously received Tdap. If Tdap is not available or was
previously administered, Td should be administered (CDC, Pertussis [whooping cough]).
Eliminating Vaccine-Preventable Diseases
An objective of Healthy People 2020 (DHHS, 2010) is to reduce, eliminate, or maintain
elimination of cases of vaccine-preventable diseases. However, as discussed above, these
diseases continue to cause outbreaks in the United States. Unvaccinated adults and children who
travel to and from foreign countries are at risk of acquiring one of these diseases. In 2017, global
vaccination coverage had stalled at 86%, with no significant changes made over the previous
year. An estimated 19.5 million infants worldwide were still missing out on basic vaccines in
2017 (WHO, Immunization coverage). In October 2016, the ACIP (2017a, 2017b) approved the
2017 recommended immunization schedule for children under age 18 years or younger and for
adults age 19 years or older in the United States. These ACIP recommendations were revised in
February 2017, some of the recommendations included new or revised recommendations for
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influenza, human papillomavirus, hepatitis B, and meningococcal vaccines. The revised ACIP
recommendations are available at http://www.immunize.org/acip/
Evidence for Practice
Immunization prevents illness, disability, and death from vaccine-preventable diseases.
Health departments all over the United States monitor vaccination coverage to understand
how well communities are protected from vaccine-preventable diseases. Vaccination
coverage information is used to identify areas and groups with lower vaccination coverage
so public health departments, healthcare partners, and schools can take action to help
improve vaccination coverage and protect everyone from vaccine-preventable diseases.
The 13th edition of Epidemiology and Prevention of Vaccine-Preventable Diseases, (a.k.a.
the “Pink Book”) offers healthcare providers the most comprehensive information on
routinely used vaccines and the diseases they prevent (CDC, 2017a).
Practice Point
For better or for worse, invisible invasive organisms have been a part of life since life began.
Their life cycles are so short in comparison with ours that they have multiple generations to
react to obstacles in their environment, adapt to adverse conditions, and increase their
strength and capacity to reproduce. Therefore, the public health system must continue to be
vigilant.
ANTIBIOTIC-RESISTANT MICROORGANISMS
This chapter on emerging infectious diseases would not be complete without a discussion of
emerging antibiotic-resistant pathogens. Microbial adaptation and change has led to the rapid
evolution of these microorganisms, which are a result of the overuse of antibiotics and
consequent accumulation in the environment. Nearly 2 million people become infected with
microorganisms that are resistant to antibiotics, and at least 23,000 die each year as a direct
result of these infections. Antibiotic-resistant microorganisms are now found in the community
as well as in healthcare settings (CDC, Antibiotic/antimicrobial resistance).
Antibiotics/antimicrobials are among the most commonly prescribed drugs used in healthcare
and can be life-saving. However, as much as 50% of the time they are not correctly prescribed,
and often are given when not necessary. Antibiotic use in food-producing animals also has
contributed to the increase in antibiotic-resistance. In 2013, the CDC outlined the top 18
antimicrobial-resistant threats in the United States. These are categorized as:
Urgent threats
Serious threats
Concerning threats
Three microorganisms that pose an urgent threat because they have the potential to become
widespread without public health attention to identify infections with these microorganisms and
limit their transmission. They are:
Clostridium difficile (CDIFF)
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Carbapenem-resistant Enterobacteriaceae (CRE)
Neisseria gonorrhoeae (CDC, Antibiotic/antimicrobial resistance)
As discussed in Chapter 14, sexually transmitted diseases are a significant challenge in the
United States, particularly among adolescents and young adults. Due to concerns about the
development of antibiotic-resistant N. gonorrhoeae, the CDC recommends only one treatment
regimen for gonorrhea in the United States: Dual therapy with ceftriaxone and azithromycin
(CDC, Sexually transmitted diseases). CRE, a family of microorganisms that include Klebsiella
species and E. coli, are untreatable and/or hard-to-treat. Healthy people usually do not get CRE
infections, and they usually happen to patients in hospitals, nursing homes, and other healthcare
settings. Patients whose care requires devices like ventilators, urinary catheters, or intravenous
catheters, and patients who are taking long courses of certain antibiotics are most at risk for CRE
infections. Some CRE bacteria have become resistant to most available antibiotics.
Consequently, infections with these bacteria are very difficult to treat, and can be deadly (CDC,
Carbapenem-resistant Enterobacteriaceae). One report cites CRE are associated with an
increase in mortality (Gupta, Limbago, Patel, & Kallen, 2011).
Clostridium difficile (CDIFF) causes life-threatening diarrhea that most frequently occurs in
people who have been recently under medical care and received antibiotics. Infections with
CDIFF are a major cause of healthcare-associated infections worldwide. It is associated with
high rates of mortality and illness, and has a case-fatality rate of up to 14% within 30 days after
diagnosis. Disease recurrence further increases illness rates, reduces quality of life, and might
occur in up to 27% of the incident cases. These features place a major burden on healthcare
systems. The disease burden of CDIFF has been well studied in Europe and North America.
Although antimicrobial drug stewardship programs have contributed to a decrease in incidence
in some countries, CDIFF is still a major health burden in other countries (Ho et al., 2017).
Recent reports have found that as many as 350 patients at 41 healthcare facilities in the United
States and worldwide were infected or exposed to CRE from tainted endoscopes between
January 2010 and October 2015 (ISID, 2016). Serious antibiotic-resistant threats include several
microorganisms that, albeit are declining in incidence of resistance and currently have effective
therapeutic agents to treat them, they may become urgent without ongoing public health
monitoring and prevention activities. Tuberculosis is among the most common infectious
diseases and a frequent cause of death worldwide. As describe earlier in the chapter, an
important worldwide serious threat is drug-resistant TB.
Concerning threat microorganisms have a low threat of antibiotic resistance and/or have
multiple therapeutic options. However, these pathogens cause severe illness and require
monitoring and rapid outbreak response. The current list of all microorganism “threats” is posted
on the CDC website at https://www.cdc.gov/drugresistance/biggest_threats.html
Antibiotic Stewardship
Antibiotic stewardship refers to a set of coordinated strategies to improve the use of
antimicrobial medications with the goal of enhancing patient health outcomes, reducing
resistance to antibiotics, and decreasing unnecessary costs.
Antimicrobial resistance has emerged as a significant healthcare quality and patient safety
issue in the twenty-first century that, combined with a rapidly dwindling antimicrobial
armamentarium, has resulted in a critical threat to the public health of the United States.
Antimicrobial stewardship programs optimize antimicrobial use to achieve the best clinical
outcomes while minimizing adverse events and limiting selective pressures that drive the
emergence of resistance and may also reduce excessive costs attributable to suboptimal
antimicrobial use. Fishman et al., 2012
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In 2015, the White House hosted a Forum on antibiotic stewardship. It brought together
more than 100 key leaders in healthcare and industry to develop, promote, and implement
activities to ensure appropriate use and prescription of antibiotics. As early as 2012, the Society
for Healthcare Epidemiology of America, the Infectious Diseases Society of America, and the
Pediatric Infectious Diseases Society had issued a joint policy statement on antimicrobial
stewardship. It can be accessed at http://www.shea-online.org/index.php/practice-
resources/priority-topics/antimicrobial-stewardship/shea-policy-statement
CONCLUSIONS
By the middle of the 20th century, many researchers regarded the threat of infectious diseases to
be significantly diminished. However, in the globally interconnected world of the 21st century,
it has become clear that the threat of epidemics and pandemics remains a current and pressing
possibility. Recent concerns about the potential for the influenza A (H7N9) virus to mutate so
that it poses the highest potential pandemic risk has highlighted the broader problem: Conditions
around the globe are set for the possible development of epidemics of zoonotic diseases that
have the potential to become pandemic. Unlike other public health threats such as TB and
malaria, the emergence of these zoonotic diseases represents the potential of rare events with
catastrophic consequences, as seen in the 1918 influenza pandemic and the more recent HIV
epidemic. To date, scientists and public health advocates have focused on surveillance as the
critical tool for detecting and monitoring outbreaks of zoonotic diseases in human and animal
populations, but questions remain as to how to make zoonotic disease surveillance more
comprehensive and timely in human and animal populations in order to prevent or minimize the
potential for outbreaks to occur in human populations. Scientists have been concerned for some
time about climate change and its effect on zoonotic diseases in human and animal populations.
To address this problem, in 2010, the IOM and the National Research Council convened an
expert committee. The committee’s task was to provide consensus advice on the challenge of
achieving sustainable global capacity for surveillance and response to emerging diseases of
zoonotic origin such as avian influenza, and ways to protect the public from them. The 2-day
workshop by the Committee can be summarized by the following statement: “Because it would
be impossible to test every species…, the strategy must be to focus on so-called hotspots—areas
with high biodiversity as well as high human population density—where zoonoses are most
likely to be found.” Several options are available to monitor and track emerging zoonotic
diseases in humans. By conducting “smart surveillance,” scientists will be able to target their
resources and efforts in areas where human–animal interaction is most likely to provide
conditions favorable to zoonotic diseases (IOM, 2010).
Most of the world, including the United States, lacks a skilled workforce to combat
emerging diseases. There is a call to increase educational programs in applied epidemiology and
infectious disease prevention and control. Nurses are the largest group of healthcare
professionals; therefore, they are in a position to take leadership initiatives. Hands-on
experience, such as those obtained through the CDC Epidemic Intelligence Service (EIS) 2-year
postgraduate program, can equip nurses with surveillance skills.
KEY CONCEPTS
Factors that influence the emergence or reemergence of infectious diseases are multiple, complex, and
interrelated.
Epidemics and pandemics can place sudden and intense demands on healthcare systems.
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In addition to morbidity and mortality, outbreaks of emerging and reemerging infections can disrupt
economic activity and development.
Certain zoonotic diseases can be transmitted to humans through contact with animals, birds, and insects
like ticks or mosquitoes.
The goal of Healthy People 2020 (DHHS, 2010) to reduce TB in the United States to 1 case per 100,000
population has not been met.
An objective of Healthy People 2020 is to reduce, eliminate, or maintain elimination of cases of vaccine-
preventable diseases. However, vaccine-preventable diseases are reemerging in the United States.
The CDC’s top priority for the public health response to Zika is to protect pregnant women because of the
risks associated with Zika virus infection during pregnancy.
Microbial adaptation and change has occurred in the rapid evolution of antibiotic-resistant pathogens.
The CDC has outlined the top 18 antimicrobial-resistant threats in the United States.
Antibiotic stewardship involves coordinated interventions designed to improve and measure the appropriate
use of and prescriptions for antimicrobials.
The Society for Healthcare Epidemiology of America, the Infectious Diseases Society of America, and the
Pediatric Infectious Diseases Society have developed a joint policy statement on antibiotic stewardship.
There is a worldwide need for a skilled public health workforce to combat emerging diseases.
Nurses must be able to recognize new and reemerging infectious diseases, identify the conditions that
foster their development, and act to protect the health of the public.
CRITICAL THINKING QUESTIONS
1. You spent last weekend hiking in the woods but forgot to bring insect repellant. Two days ago, a circular
flat rash with a white center appears high on the back of your calf. It does not hurt; therefore, you decide
to forget about it. Today, you develop a fever, are fatigued, and have a headache along with muscle and
joint pain.
a. Explain what may have happened.
b. Outline your plan of action.
c. How would you prevent similar occurrences?
2. A neighbor, who is 3 months pregnant, asks to talk to you because she has felt tired for the last 2 days,
has a headache, a rash, and does not feel like eating. You take her vital signs and find that she has a low-
grade fever. She has recently traveled to an area where there is risk for Zika virus disease.
a. To what could your neighbor have been exposed, and how could the exposure have occurred?
b. What advice would you give your neighbor?
3. Outline the factors that have contributed to the emergence or reemergence of each of the following
infectious diseases. Explain how these factors differ with each disease.
a. Lyme disease
b. Zika virus
c. E. coli O157:H7
4. Identify at least two vaccine-preventable diseases that have not met the Healthy People 2020 target.
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WEB RESOURCES
Please visit thePoint web resources for up-to-date information on this topic.
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Chapter 16
Violence and Abuse
Annie Lewis-O’Connor, Aitana Zermeno, and Kiara
Manosalvas
For additional ancillary materials related to this chapter. please visit thePoint
If you and I are having a single thought of violence or hatred against anyone in the world at
this moment, we are contributing to the wounding of the world.
Deepak Chopra
Those who make peaceful revolution impossible will make violent revolution inevitable.
John F. Kennedy
You cannot shake hands with a clenched fist.
Golda Meir
From pacifist to terrorist, each person condemns violence—and then adds one cherished case
in which it may be justified.
Gloria Steinem
Violence is immoral because it thrives on hatred rather than love. It destroys community and
makes brotherhood impossible. It leaves society in monologue rather than dialogue.
Dr. Martin Luther King, Jr.
CHAPTER HIGHLIGHTS
Overview of violence in U.S. communities
School violence
Mandatory reporting of elder abuse, child maltreatment, and abuse of people with disabilities
Intimate partner violence (IPV)
Health consequences of exposure to IPV in children
Model of care for victims of intentional crimes
IPV as a major women’s health problem, including impact on pregnancy
Screening and intervention in IPV
Risk and lethality assessment in IPV
Role of healthcare providers: assessing for and intervening in violence and abuse
OBJECTIVES
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Identify the incidence and prevalence of intimate partner violence (IPV).
Understand the health consequences that violence has on the health of patients and families.
Explain the effects of IPV on adults and children.
Summarize the models of care that have evolved in caring for victims of intentional violence.
Describe interventional strategies (screening) and the limitations of measuring the effects of these
interventions.
Summarize the tenets of mandatory reporting laws.
Apply nursing process in caring for and screening for IPV.
KEY TERMS
Femicide: A term used to refer to a homicide of a female person that occurs in the context of
intimate partner violence (IPV).
Gender-based violence: A term used to distinguish violence which targets people, or groups of
people, on the basis of their gender from other forms of violence (United Nation’s Convention
on the Elimination of All Forms of Discrimination against Women). It includes any act that
results in, or is likely to result in, physical, sexual, or psychological harm such as rape, torture,
mutilation, sexual slavery, forced impregnation, and murder.
Human rights: Basic rights and freedoms to which all humans are entitled.
Incidence: The number of cases of disease with an onset during a prescribed period of time;
often expressed as a rate (e.g., the incidence of measles per 1,000 children 5 to 15 years of
age during a specified year).
Intimate partner violence (IPV): A pattern of assaultive and coercive behaviors which may
include inflicted physical injury, psychological abuse, sexual assault, progressive social
isolation, deprivation, intimidation, and threats. These behaviors are perpetrated by someone
who is, was, or wishes to be involved in an intimate or dating relationship with an adult or
adolescent, and they are aimed at establishing control by one partner over the other (Family
Violence Prevention Fund, 1999).
Lethality assessment: An assessment that identifies high-risk factors for IPV.
Perpetrate: To be responsible for; commit, as in a crime.
Prevalence: Number of cases of a disease, infected persons, or people with some other attribute
present during a particular interval of time; often expressed as a rate (e.g., the prevalence of
diabetes per 1,000 persons during a year).
Violence: Framed in the context of “intentional” violence, or stated another way, that which is
carried out by a person or persons against another person or persons when there is a
conscious choice to act in a violent manner.
CASE STUDY
References to the case study are found throughout this chapter (look for the case study icon).
Readers should keep the case study in mind as they read the chapter.
Kathy is a 28-year-old married woman with three children who are all younger than 6 years. The
middle child has autism. Last year, Kathy had a miscarriage at 20 weeks following a fall down the
stairs. She has not worked outside the home since the birth of her first child and is financially
dependent on her husband. Her relationship with her husband has always been emotionally
abusive, and although signs of physical abuse have been present during visits to Laura, a nurse
practitioner and healthcare provider, Kathy has denied serious physical abuse except for an
occasional push or shove. Sometimes, she has presented with bruises, which she has always said
were accidental. After the birth of each child, Kathy has become quieter and seems sadder, and
she has been noticeably depressed since her miscarriage. Recently, Kathy has admitted to Laura
that she trusts her and needs her help because her husband’s behavior is becoming worse and she
is not sure what to do. Kathy does not wish to go to the police at this point. She denies direct harm
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to her children, yet she says “they must hear us arguing and fighting.”
What should Laura do to help Kathy?
What should she consider about the safety of Kathy’s children?
What should Laura do if she becomes ambivalent about her disclosure?
Kathy has voiced her concerns related to finances, housing, and fear of retaliation by her partner—
very personal information. There are several questions to consider: Does the state Kathy lives in
have a mandatory reporting law for abuse against women (only six states do)? If Kathy is not ready
to report the intimate partner violence to the police, what safety precautions can Laura address? If
Kathy does report the violence to the police and her husband is arrested, there will be no income—
how should Laura help Kathy address her economic concerns? (Also, the state budget has recently
cut many services that were once available for victims of abuse.) Kathy may become homeless and
unemployed, with no income for three small children and a partner who may retaliate. In addition to
safety issues, there are many ethical and legal responsibilities which Laura needs to consider in
developing a plan of care with the patient. It is essential that she also respects Kathy’s autonomy.
OVERVIEW OF VIOLENCE
Violence in the United States is pervasive. In this chapter, violence is considered to be
“intentional;” that is, violence is an act committed by a person or persons against another person
or persons in which there is a conscious choice to act violently. When caring for the client’s
immediate needs, nurses should consider the cumulative exposures to violence over time and the
far-reaching effects of violence on the family and the community at large. More than three
decades of evidence is available to inform health practice and policy. The healthcare community
is in a pivotal position to have a significant impact on the lives of clients affected by violence.
Violence has an adverse impact on society. It is estimated to cost billions of dollars per year
(Dolezal, McCollum, & Callahan, 2009; Waters et al., 2004). These costs include direct medical
care and rehabilitation and losses to the workforce (Corso, Mercy, Simon, Finkelstein, & Miller,
2007). The impact on families and the larger community is notable. Healthy People 2020 has
targeted injury and violence prevention as a priority. The injury prevention objectives of Healthy
People 2020 include (1) prevention and reduction of firearm-related deaths; (2) identification of
improper firearm storage in homes; (3) surveillance of external causes of injury in emergency
departments; (4) decreased incidents of homicide, child maltreatment, and physical assaults; (5)
prevention and reduction of sexual assaults; and (6) elimination of weapon possession by
adolescents on school property (Healthy People 2020). Such efforts require a multifaceted
approach to public health that targets many settings and recognizes that social determinants of
health such as exposures to violence result in poor health. Viewing violence from the many
vantage points from which nurses deliver care (hospitals, home, clinics, schools, etc.) provides
unique and complimentary healthcare to people experiencing violence and abuse.
Violence—look, we live in a violent world, man. This country was founded on violence.
Who’s kidding who? Bruce Willis
All forms of violent behavior can be attributed to the need for power and control. A number
of factors have contributed to the prevalence of violence in the United States. Primary among
those factors are the acceptability of violence in U.S. culture; racism, classism, and sexism;
availability and accessibility of firearms; and lack of accountability.
Nothing is more despicable than respect based on fear. Albert Camus
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Guns
The United States is facing an escalating and unprecedented gun crisis. Each year, more than
32,000 persons die as a result of firearm-related violence, suicides, and accidents in the United
States; this far surpasses the number of gun-related deaths in any other industrialized country
(Richardson & Hemenway, 2011). In fact, America’s gun homicide rate is more than 25 times
the average of other high-income countries (Grinshteyn & Hemenway, 2016). Additionally, this
violence comes at a substantial price to our nation, with a total societal cost of $174 billion in
2010 (Miller, 2015).
Firearms are the second leading cause of death due to injury after motor vehicle crashes for
adults and adolescents. In 2014, there were 33,594 firearm deaths and 33,736 motor vehicle
deaths, and while motor vehicle deaths in aggregate are higher than firearms deaths, firearm-
related deaths outpaced motor vehicle deaths (CDC, 2016a). Box 16.1 lists several states where
gun related deaths are higher than deaths from motor vehicle accidents.
16.1 Gun-Related Deaths Versus Motor Vehicle Deaths, by State, 2014
Alaska: 145 gun deaths, 87 motor vehicle deaths
Arizona: 927 gun deaths, 857 motor vehicle deaths
Colorado: 663 gun deaths, 545 motor vehicle deaths
District of Columbia: 86 gun deaths, 37 motor vehicle deaths
Illinois: 1,179 gun deaths, 1,075 motor vehicle deaths
Louisiana: 896 gun deaths, 807 motor vehicle deaths
Maryland: 546 gun deaths, 480 motor vehicle deaths
Michigan: 1,095 gun deaths, 1,014 motor vehicle deaths
Nevada: 429 gun deaths, 319 motor vehicle deaths
Oregon: 497 gun deaths, 380 motor vehicle deaths
Utah: 337 gun deaths, 261 motor vehicle deaths
Virginia: 899 gun deaths, 789 motor vehicle deaths
Washington: 702 gun deaths, 583 motor vehicle deaths
Source: Data from http://www.vpc.org/studies/gunsvscars16 .
The data on firearms is daunting. Nationwide, the overall gun death rate (suicides,
homicides, and unintentional shootings) increased from 10.21 per 100,000 in 2009 to 11.96 per
100,000 in 2016. According to data from the CDC (2016b), on average, 96 Americans are killed
every day by gun shot. Moreover, states with higher rates of gun ownership and weak gun
violence prevention laws had the highest overall gun death rates in the nation (Violence Policy
Center, 2017),
Dr. David Hemenway, director of the Harvard Injury Control Research Center, notes in his
2004 book Private Guns, Public Health, “The time Americans spend using their cars is orders of
magnitude greater than the time spent using their guns. It is probable that per hour of exposure,
guns are far more dangerous. Moreover, we have lots of safety regulations concerning the
manufacture of motor vehicles; there are virtually no safety regulations for domestic firearms
manufacturers.” Nurses should be vigilant in assessing whether there is a gun present in the
home and whether it is safely stored away from children (Fig. 16.1). Nurses are in key positions
—in schools, clinics, offices, and hospitals—to inquire about guns in the home and provide
anticipatory guidance on safety when a gun is stored in the home.
Other factors that contribute to homicides related to guns are low income, discrimination,
lack of education, and lack of employment opportunities. Most often, males are the victims as
well as the perpetrators of homicides. African American males are affected most frequently; in
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http://www.vpc.org/studies/gunsvscars16
fact, African Americans are eight times more likely than white males to be murder victims
(Quickstats, 2017). While African Americans constitute 14% of the population, they account for
50% of all homicide victims (Violence Policy Center, 2017). Although there has been a decline
in the homicide of intimate partners, including spouses, partners, boyfriends, and girlfriends,
over the past decade, this problem remains significant and warrants conscious attention.
FIGURE 16.1 Firearm and motor vehicle deaths, 1999 to 2010. (From Centers for Disease Control
and Prevention, National Center for Injury Prevention and Control, Division of Violence Prevention,
2008.)
Abuse a man unjustly, and you will make friends for him. Douglas Horton
School Violence
Over the past decade, the unthinkable has happened; children have been killed while at school.
In December of 2012, the nation watched in horror as the news broke that Adam Lanza, 20,
fatally shot 20 young elementary school children and six adult staff members in a mass murder
at Sandy Hook Elementary School in Newtown, CT. Before driving to the school, Lanza had
shot and killed his mother Nancy at their Newtown home. As first responders arrived, he
committed suicide by shooting himself in the head. This event stimulated new debates about gun
control and safety and mental health.
Five years later, the country continues to be plagued by tragic school shootings and
persistent gun violence. On Wednesday, February 14, 2018, a gunman and fellow student shot
and killed at least 17 students and staff at Marjory Stoneman Douglas High School in Parkland,
FL. This act of senseless murder has now been marked as the deadliest school shooting since
Sandy Hook. Homicide is the second leading cause of death among youths aged 5 to 18. Data
from the school-associated violent death study illustrate that 1% to 2% of these deaths occur on
school grounds or on the way to and from school. This underscores the importance of preventing
violence in both schools and communities (Anderson et al., 2001). Firearms used in school-
associated homicides and suicides came primarily from the perpetrator’s home or from friends
or relatives (CDC, 2003). School shooting in the United States is a major public health concern;
Kalesan and colleagues (2017) documented 154 school shootings between January 1, 2013 to
December 31, 2015. However, the empirical evidence on this topic has often neglected to
address two important domains—strong sentiments surrounding the Second Amendment and the
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culture of gun ownership in this country. Utilizing this lens, recent research has revealed that
states with background check laws on firearm and ammunition purchases, higher capita mental
health and K-12 education expenditures, and higher percent urban population have lower school
shooting incidence rates (Kalesan et al., 2017).
Nurses working in educational settings must remain vigilant to the omnipresent risk factors
that perpetuate violence in students. According to the data obtained from the Youth Risk
Behavior Surveillance (Kann et al., 2016), 6% of students reported being threatened or injured
with a weapon on school property in the preceding 12 months. Additionally, 5.6% of students
reported not attending school on at least 1 day of the 30 days before the survey because they felt
they would be unsafe at school or on their way to or from school. There were 20.2% of students
who reported being bullied while at school in the past year, while 15.5% reported being
electronically bullied via e-mail, chatrooms, instant message, websites, or texting. Finally,
15.5% of all public schools experienced one or more serious violent crimes such as rape, sexual
assault, threatened or actual physical attack with a weapon, and robbery with or without a
weapon. Sixty-nine percent of schools reported one or more violent incidents (Diliberti, Jackson,
& Kemp, 2017). Since 1992, the Centers for Disease Control and Prevention (CDC) in
partnership with the Departments of Education and Justice has been conducting surveillance on
school-related deaths (Fig. 16.2). Data from a number of the current national surveys are in
process from collection to analysis to publication (Anderson et al., 2001; CDC, 2001, 2003;
Robers, Zhang, Truman, & Snyder, 2012).
FIGURE 16.2 Trends in school-associated violent deaths—1992 to 2010. (Data from Centers for
Disease Control and Prevention, National Center for Injury Prevention and Control (NCIPC),
http://www.cdc.gov/violenceprevention/youthviolence/schoolviolence/savd.html.)
Because in the 2 months since Newtown, more than a thousand birthdays, graduations,
and anniversaries have been stolen from our lives by a bullet from a gun. President
Barack Obama
School nurses play a pivotal role in recognizing both children who are being victimized and
those who are perpetrating violence. School nurses working with teachers, school
administrators, and school psychologists are in a unique position to create an environment that
promotes primary prevention and intervention. By addressing and discussing with students the
root causes of violence through their educational curriculum, school nurses and educators might
be able to shift the paradigm to a less violent one. Schools are fertile climates for education
about prevention of violence. Violence prevention should start at home and continue in school
(see Chapter 22).
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http://www.cdc.gov/violenceprevention/youthviolence/schoolviolence/savd.html
Education is a vaccine for violence. Edward James Olmos, Mexican American actor
Practice Point
Thinking about the root causes of violence helps nurses develop primary prevention
strategies (raising awareness about violence), along with secondary (identifying those at risk
for being abused or perpetrating abuse) and tertiary prevention interventions (identified victim
or perpetrator).
INTIMATE PARTNER VIOLENCE
Intimate Partner Violence: A Major Women’s Health Problem
The phenomenon of intimate partner violence (IPV) differs depending on culture, discipline,
theoretical framework, and philosophical perspectives. Gradually, violence against women has
been recognized globally as a human rights violation with significant consequences for the
individual, family, and community. IPV does target an individual person, but the effects on
bystanders are far reaching, affecting local, state, public, and private sectors through loss of
productivity, and contributing to medical and mental health costs. Although data support the
belief that men are generally the perpetrators of IPV, most healthcare providers and researchers
recognize that women may also, though rarely, perpetrate violence against their intimate
partner. In the early 1990s, the international community adopted the term gender-based
violence when referring to violence against women and girls (United Nations, 1993). This
terminology appears to reflect the evolution of researchers who have sought to understand the
nature of abuse that is perpetrated against females. Although there have been variations in the
definition of IPV among researchers, over the past decade, these definitions have become
increasingly similar. Healthcare providers see victims of IPV daily in their practice, and
identification can lead to interventions that may help to decrease morbidity and mortality.
One of the speakers asked how many women had been harassed or abused sexually in
their life? There were thousands of women in the audience, and almost every one of them
raised her hand. Cheryl James (Salt), American rapper
Investigators conducting population-based studies in the United States over the past several
years have consistently reported a lifetime prevalence of IPV against women to be between
25% and 30%, with an annual prevalence between 2% and 12% (Black, Basile, & Breiding,
2011; Humphreys, Parker, & Campbell, 2001; Jones et al., 1999; Tjaden & Thoennes, 2000;
Wilt & Olson, 1996). More recently, using a population-based national sample of women older
than 18 years (n = 1,800) and calculating adult lifetime and prior-year prevalence of violent
experiences, Moracco, Runyan, and Butts (2003) found that 60% of respondents experienced at
least one form of violence since the age of 18, with 10% reporting violence in the previous year.
Adult lifetime and prior-year prevalence varies by type of violence and respondents’
sociodemographic characteristics. Some of the inconsistencies reported in the literature are due
to variations in defining the nature of the abuse (e.g., stalking, rape, emotional abuse, or verbal
abuse) and limitations in sampling. Often, purposeful and convenient sampling was used in these
studies.
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Extent of Intimate Partner Violence
The literature on IPV is substantial and has evolved exponentially over the past two decades.
The World Health Organization’s world report on violence and health (Krug, Dahlberg, Mercy,
Zwi, & Lozano, 2002) found that in 48 population-based surveys from around the world,
between 10% and 69% of women reported being physically assaulted by an intimate male
partner at some point in their lives. This is important for nurses to recognize. Many women who
have immigrated to the United States have long been exposed to violence in their country of
origin, and awareness of this fact has significant implications for nursing plans of care. In
addition, nurses need to know that half of all female homicide victims are murdered by their
intimate partners (Petrosky et al., 2017). The majority of women killed with a gun were killed by
their intimate partners (Bailey et al., 1997; Hemingway, 2004; Moracco et al., 2003). The report,
which looked at 10,000 homicides between 2003 and 2014, revealed that one in 10 victims of
intimate partner violence–related homicide experienced some form of violence in the month
prior to being killed.
Research in the area of homicides has helped to inform nursing practice, particularly in
relation to the risk to children. In a 10-city study of risk factors for intimate partner femicide
(murder of women) or attempted femicide, Lewandowski, McFarlane, Campbell, Gary, and
Barenski (2004) found that 59% of domestic violence victims had children. About 33% of the
children had witnessed the incident, and 43% were the first to find the mother’s body. Nurses
must be aware that some 35% to 60% of children who live in homes where there is IPV are
themselves physically or sexually abused (Edelson, 1999), with fathers as the most common
perpetrators (McCloskey, Figueredo, & Koss, 1995).
In the context of family-centered care, it is imperative that Laura considers the safety of
the children. In the hopes of preventing further abuse in Kathy’s situation, Laura should
know about resources in the community. If Kathy has the phone numbers of local
women’s shelters, food banks, mental health agencies, unemployment offices, and the
Women, Infants, and Children (WIC) program, she will be able to use these resources
when she is ready to do so. By providing these resources, Laura hopes to give Kathy the
confidence, with the support behind her, to make the right decisions for her family. Also,
and equally important, Laura gains a better understanding of the factors that affect a
victim’s ability to make well-informed decisions.
Dr. Jacquelyn Campbell, a pioneer nurse researcher in the area of IPV, published the earliest
data on the health consequences of IPV (Campbell, 2002) and has developed and implemented a
multilanguage lethality assessment (Campbell, 1981, 1986, 1992, 1995a, 1995b, 1995c;
Campbell et al., 2003a) tool for homicide. Dr. Campbell’s research indicates that factors such as
access to a firearm, the abuser’s use of illicit drugs, unemployment, control of daily activities,
stepchildren in the home, and threats to kill the victim pose serious risks for homicide for a
woman (Table 16.1; Box 16.2). In particular, the presence of a firearm in the home is a risk
factor for homicide in women (Campbell et al., 2003a; Kellerman & Heron, 1999; Sorenson &
Wiebe, 2004; Wiebe, 2003). These data underscore the necessity for nurses to screen clients for
access to and/or presence of a gun in the home, and to provide education about safe storage.
While assessing how the abuse is affecting Kathy and her children, it is important to
explore lethality risks (Box 16.3). Although the presence of lethality risk factors does not
imply that Kathy is in imminent danger, the presence of these factors does warrant an in-
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depth assessment, such as a multilanguage danger assessment tool that is reliable and
valid. Such in-depth assessments are dependent on the practice environment and the
availability of social services. It is important to know what in-house and community
referral resources are available.
In response to the evidence that IPV profoundly affects the health of victims and children,
many professional organizations, such as the American Medical Association Council on
Scientific Affairs (1992), American Nurses Association (ANA) (1991), the American College of
Obstetricians and Gynecologists (1993), and the Association of Women’s Health, Obstetric, and
Neonatal Nurses (AWHONN) established screening and routine assessment guidelines for IPV
as the standard of practice. Valuable websites like Futures Without Violence
(www.futureswithoutviolence.org), Academy on Violence (www.AVA.org), and National
Health Collaborative on Violence and Abuse (www.Nhcva.org) provide much information for
healthcare providers.
TABLE 16.1 Risk Factors for Intimate Partner Violence
Individual risk factors Low self-esteem
Low income
Low academic
achievement
Young age
Aggressive
behavior as a child
Heavy
alcohol/drug use
Depression
Anger and hostility
Antisocial
personality traits
Borderline
personality traits
History of being
physically abused
Few
friends/isolation
and abused
Unemployment
Emotional
dependence and
insecurity
Belief in strict
gender roles
Desire for power
and control
Perpetrating
psychological
aggression in
relationships
Victim of physical
or psychological
abuse as a child
Experiencing poor
parenting
Experiencing
physical discipline
as a child
Relationship factors Economic stress
Marital conflicts
(e.g., fights)
Marital instability
(e.g.,
divorce/separation)
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http://www.futureswithoutviolence.org
http://www.AVA.org
http://www.Nhcva.org
Dominance/control
of relationship by
one partner over
another
Unhealthy family
relationships and
interactions
Community factors/societal factors Poverty and
associated factors
(e.g.,
overcrowding)
Low social capital
—lack of
institutions,
relationships, and
norms that shape
a community’s
social interactions
Weak community
sanctions against
intimate partner
violence (e.g.,
unwillingness of
neighbors to
intervene when
violence is
witnessed)
Traditional gender
roles (e.g., women
should stay at
home, be
submissive, not
enter the
workforce; men
support the family
and make the
decisions)
16.2 Risk Factors That Indicate Significant Concern for the Safety of the
Children
Threats to kill the caretaker, children, and/or self; caretaker fears for the children’s safety.
A child was physically injured in an incident when the caretaker was the target.
A child was coerced to participate in or witness the abuse of the caretaker.
A weapon was used or threats were made to use a weapon, and the caretaker believed that there was intention and
ability to cause harm.
Student Reflection
I had never been involved in screening for routine assessment guidelines until I needed
some minor surgery in my sophomore year in college. In the preoperative phase of the
process, a nurse asked me whether I felt safe where I lived. (My boyfriend was waiting for
me in a coffee shop at the medical center where I was having my surgery.) At first, I did not
expect the question, but then I understood that the nurse was asking me about IPV, and
whether I was at risk. It made me really happy to see that a nurse was asking such an
important assessment question. Although this situation did not apply to me, I could see how
this could be an opportunity for a client to obtain help or advice. However, I also realize that
552
this could lead to breaking emotional or financial ties with another person or dealing with the
children who resulted from a relationship that has become abusive.
High rates of IPV have long been detected in emergency departments (Abbott, Johnson,
Koziol-McLain, & Lowenstein, 1995; Kothari et al., 2015), prenatal clinics (Fletcher, Clements,
& Bailey, 2016; Helton, McFarlane, & Anderson, 1987; Martin & Clements, 2002; McFarlane,
Parker, Soeken, & Bullock, 1992); internal medicine practices, health maintenance organizations
(Gin, Rucker, Frayne, & Cygan, 1992; Hamberger, Saunders, & Hovey, 1992; Jones et al.,
1999), and hospitalizations when clients are admitted for behavioral health disorders, substance
abuse, and suicidality (Kernic, Wolf, & Holt, 2000).
16.3 Lethality Risks
Is there a gun in the house?
Is the woman’s partner unemployed?
What is the worst thing the partner has ever done to the victim?
Does the victim feel that the partner is capable of hurting her? Of carrying out his threats?
Has the woman’s partner ever been arrested?
Is the woman’s partner using drugs? Drinking excessively?
The literature has well documented the risks of IPV and pregnancy (Chang, Berg, Herndon,
& Saltzman, 2005; Sarkar, 2008). Depression before, during, and after birth has been strongly
correlated with IPV (Ogbonnaya, Macy, Kupper, Martin, & Bledsoe-Mansori, 2013). In a
National Institutes of Health (NIH)-supported population analysis of 5 million records of
California women over a 10-year period, researchers found that pregnant women who are
assaulted by an intimate partner are at increased risk of giving birth to infants of reduced weight
(NIH News, 2011). Although the results showed a pattern of low-weight births among women
who experienced an assault, the study was not designed to establish cause and effect or explain
the biologic factors for how violence against an expectant mother might cause her to deliver a
low–birth-weight infant. It is now standard of practice that all pregnant women are screened for
IPV during each trimester of their pregnancy, following the birth of the infant, and in cases in
which there are concerns (see ACOG,
http://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Health_Care_for_Underserved_Women/Intimate_Partner_Violence#11a
Women victimized by abuse are more likely to be diagnosed with serious health problems,
including depression and panic attacks, as well as migraine headaches, chronic pain, arthritis,
high blood pressure, gastrointestinal problems, inconsistent use of birth control, and delayed
entry into prenatal care (Campbell & Lewandowski, 1997; Weiss, Lawrence, & Miller, 2002). In
fact, much has been learned about how reproductive coercion—pressuring partners to get
pregnant and direct interference with contraception—is a significant factor in relationships in
which IPV is of concern (Miller, et al., 2010). National data show approximately 9% (or 10.3
million) women experience reproductive coercion; this number is estimated to be higher in
women seeking reproductive health services (Clark, Allen, Goyal, Raker, & Gottlieb, 2014). It is
essential to ask a woman about her ability to control her fertility issues and desires during
reproductive healthcare visits.
In addition, women affected by IPV are more likely to engage in high-risk behaviors such as
tobacco use, substance abuse, and sexual risk-taking (e.g., multiple sexual partners) (Silverman,
Raj, & Clemens, 2004; Silverman, Raj, Mucci, & Hathaway, 2001). Nurses who recognize the
significant impact of IPV, both acute and chronic, may be more influential in developing
treatment plans with their patients that seek to intervene early, thus preventing some of the long-
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http://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Health_Care_for_Underserved_Women/Intimate_Partner_Violence#11a
term mental and physical effects that are associated with IPV.
I had been, you know, held in the closet for two months and, you know, abused in all
manner of ways. I was very good at doing what I was told. Patty Hearst, kidnap ping
victim
Evidence for Practice
Validation of many of the findings from research on the long-term effects of experiencing or
witnessing IPV were validated by the adverse childhood experiences (ACEs) study, one of
the largest studies of its kind. This study has been a decade-long collaboration between the
Division of Adult and Community Health at the CDC and Kaiser Permanente’s Department
of Preventive Medicine in San Diego. The researchers designed the study to examine the
health and social effects of ACEs throughout the lifespan. It involved 17,337 middle-class
members of the Kaiser Permanente Medical Care Program in San Diego who agreed to
participate during the course of a comprehensive medical evaluation (Anda et al., 1999;
Dube, Felitti, Dong, Giles, & Anda, 2003; Edwards et al., 2005; Felitti et al., 1998). It is
important to note that this was a homogenous sample of middle-class Caucasians.
However, the findings are significant and have important implications for practice (see
www.acesconnections.com).
In this study, researchers assessed 10 categories of stressful or traumatic childhood
experiences (Dong et al., 2004). They chose a broad range of ACEs that had been shown
to have significant adverse health or social implications. Examples of ACEs are as follows:
Childhood abuse (emotional, physical, and sexual)
Neglect (emotional and physical)
Growing up in a seriously dysfunctional household (battered mother, substance abuse, or
mental illness in the home; parental separation or divorce; or a criminal household member)
In the case of participants who had a battered mother, 95% reported at least one
additional ACE. The researchers also studied the relationship of childhood physical or
sexual abuse, or growing up with a battered mother, to the risk of being a victim (among
women) or perpetrator (among men) of IPV as an adult (Whitfield, Anda, Dube, & Felitti,
2003). Each of these three ACEs is associated with the risk of IPV; as the number of these
violent childhood experiences increased, the risk of IPV also increased (CDC, 2008).
The history of Kathy’s childhood or that of her husband is unknown. How an ACE score
affects the ability to parent and to participate in healthy relationships is not known. The
ACE score specifically considers the relationship between ACEs and health indicators,
such as chronic obstructive pulmonary disease, hypertension, risky behaviors, weight,
and mental health issues. It can be postulated from the ACE study that if Kathy’s children
remain in a home where violence is present, they would be at risk for health issues as
adults.
Healthy People 2020 emphasizes a need to prevent violence and the sequelae known to
result from exposure to violence, recognizing that violence leads to the following:
Premature death
Disability
Poor mental health
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http://www.acesconnections.com
High medical costs
Lost productivity
The objectives of violence prevention identified by Healthy People 2020 are to reduce fatal
and nonfatal injuries, fatal and nonfatal traumatic brain injuries, homicides, firearm injuries, and
physical and sexual assaults. Preventing violence and recurrence of violence requires targeting
efforts at all three levels of prevention: primary, secondary, and tertiary. There has been a great
debate over the benefits of primary and secondary prevention because measuring the benefits of
outcomes has intrinsic methodologic issues. However, when the United States Preventive
Services Task Force (USPSTF) reviewed the literature on interventions in 2010, they found
sufficient evidence to support inquiry and brief counseling for patients. The USPSTF (Moyer,
2013) recommends that clinicians screen women of childbearing age for IPV, and provide
intervention services or refer women who screen positive to intervention services
(http://www.uspreventiveservicestaskforce.org/uspstf12/ipvelder/ipvelderfinalrs.htm#summary).
It is well known that IPV occurs within all socioeconomic groups. Many victims and
perpetrators of IPV differ in their opinions of what constitutes abuse. Opinions may be
dependent on many factors: prior exposures, cultural identification, family and peer opinions,
and education. Efforts to educate must be persistent, constant, multilingual, and culturally aware
and must target both potential victims and potential perpetrators. Secondary prevention occurs
through generalized screening and inquiry with high-risk populations.
Decades of research have indicated that some women have a higher risk of IPV (see Table
16.1). The model most widely used to understand violence is the ecologic model. This model
proposes that violence is a result of factors operating at four levels: individual, relationship,
community, and societal (Krug et al., 2002). Risk factors include age less than 45, low income,
lack of employment, recent separation or divorce, education at the high school level or lower,
and having young children (Campbell et al., 2003b). Currently under debate is how to
implement policies and procedures for the identification of perpetration of violence. Issues such
as safety, what to do when a person states he or she is hurting someone, and ethical
considerations require in-depth discussions with collaborative community participation.
Kathy has risk factors for IPV: a long-term emotionally abusive relationship, isolation,
stressors related to having a child with autism, and financial dependence on her husband.
In the context of a healthcare setting, a woman may feel that she is able to trust her
provider, and thus, with proper inquiry, interventions may be offered which would assist
Kathy.
Tertiary prevention (caring for victims affected by, or currently experiencing, violence) has
been a major focus in the health system, and has been driven by The Joint Commission. Prior to
The Joint Commission’s 1998 mandate to implement policies and procedures, victims of abuse
received less than optimal care within the healthcare system (The Joint Commission on
Accreditation of Healthcare Organizations, 1995). Over several years, The Joint Commission
required all clinical settings such as community health centers, primary care, emergency
departments, and operating rooms to implement identification and interventions for victims of
abuse. This was the catalyst for change within the healthcare system. Advocates working in
healthcare found that this was the incentive they needed to move forward and to provide quality
services for victims and their family members within the context of a healthcare environment.
This movement continues to evolve today, with many hospitals and healthcare facilities
employing advocates and organizing formal programs (Hathaway, Zimmer, Willis, &
Silverman, 2008).
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Victims of violence and abuse may often face barriers when seeking help, either
immediately afterward or months or years later when the previous violence begins to affect their
health. Successful programs in primary, secondary, and tertiary prevention are a critical element
necessary for preventing abuse and helping victims recover while mitigating the health
consequences.
Intimate Partner Violence: Health Consequences in Children
Who Witness Abuse
It is alarming to consider how many children may be exposed to IPV. The most recent National
Survey of Children’s Exposure to Violence found that 25% of older children surveyed had
witnessed a parent assault another parent (or parental partner) in their lifetime, and 5.8% had
witnessed such an assault in the past year (Finkelhor, Turner, Shattuck, & Hamby, 2015). Very
young children are more likely to be disproportionately represented in studies because disclosure
and identification are limited due to their development and age. These young children are not
always able to get out of harm’s way. Adolescents often try to intervene to protect the parent
being abused. Younger children, from birth to 3 years of age, have received far less attention,
and thus, their responses to the IPV directed toward their mothers are less well understood
(Berman, Hardesty, & Humphreys, 2004). However, author and social worker Betsy McAlister
Groves succinctly addressed the impact of violence on children 8 years of age and younger in
her book Children Who See Too Much (2002). Groves found that young children exposed to IPV
during this early period have experienced physical, intellectual, emotional, and behavioral
problems.
Exposure to IPV has long-lasting effects on child development, including adverse health
outcomes and adjustment problems such as aggression (Bair-Merritt et al., 2015; Piotrowski,
Tachie, & Cameranesi, 2017; Vu, Jouriles, McDonald, & Rosenfield, 2016). Health
consequences and behavioral issues may not become prominent until long after the initial
exposure to IPV, denoted as the “sleeper effect” (Vu et al., 2016). In the landmark ACEs study,
a strong relationship was established between childhood trauma and adult health risk behaviors
responsible for many of the leading causes of death (Felitti et al., 1998). This evidence demands
that IPV be treated as a serious health risk for children.
It has been documented that IPV duration is longer when the couple has children, and
children are often the reason mothers remain in, leave, or return to an abusive relationship
(Nouer, Mackey, Tipton, Miller, & Connor, 2014). Children influence IPV victims’ decisions to
seek service providers’ aid; therefore, pediatricians are encouraged to intervene in an empathetic
and skillful manner (Nouer et al., 2014). The American Academy of Pediatrics (2010) has not
found sufficient evidence to recommend a universal or case-by-case approach over another.
However, routinely assessing for IPV leads to increased identification of victims, and disclosure
is not necessary for providers to inform patients of available resources in an offensive manner.
Several screening tools exist, many of which have been validated (Thackeray, Hibbard, Dowd,
et al., 2010). Safely carrying out screening requires that providers be aware of issues unique to
the pediatric setting: the parent is not the client and documentation in the medical record may
provide information to a potential abusive partner. Moreover, the conversation should be held in
private, as even small children can be affected by hearing troubling information. Creative
strategies have been explored to address these issues and promising practices have been
identified that include the following:
Opening the conversation with a statement such as, “Because we know that exposure to violence is so
common and has negative effects on health, I talk to all my families about safety in their homes.”
Asking mothers with a self-administered tool (written questionnaire, computer survey)
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Asking mothers directly, without the child present
Having providers inform parents about mandatory reporting laws prior to asking questions
Being able to screen for safety and dangerousness of the situation
Being aware of resources and referrals (Lewis-O’Connor, 2007)
Practice Point
Some strong evidence suggests that living in a violent home has detrimental effects later in
life. Knowing this and integrating this into practice help the nurse recognize and prevent long-
term healthcare issues.
Screening for Intimate Partner Violence
In 2012, the USPSTF issued a recommendation in support of IPV screening and counseling
(Nelson, Bougatsos, & Blazina, 2012). However, some researchers continue to have opposing
views (MacMillan et al., 2009). For instance, there is no direct evidence that screening results in
decreased disability or premature death.
The Affordable Care Act (ACA)—the health insurance reform legislation passed by
Congress and signed into law by President Obama on March 23, 2010—helps make prevention
affordable and accessible for all Americans. The ACA requires health plans to cover preventive
services for women by eliminating cost sharing. Preventive services have proven evidence of
improved health outcomes. Under the ACA, women’s preventive healthcare screening and
counseling for interpersonal and domestic violence are among eight preventive measures
(http://www.hrsa.gov/womensguidelines/). The Institute of Medicine found that after reviewing
the literature, there was sufficient evidence to support screening and brief counseling for IPV.
When screening for IPV and assessing for risk, nurses need to make these questions a normal
and routine part of healthcare assessment that fits in the context of the visit. Experts have found
that wallet-size cards with information about IPV and resources can serve as a time-efficient
clinical prompt from a universal education approach (Miller et al., 2010).
Screening without being prepared for a positive disclosure could be more harmful than
helpful. It is important to know what resources are available and how to respond to the needs of
the client before asking questions. Box 16.4 presents a sampling of questions that can be asked.
Ideal screening includes questions not only about physical and sexual abuse, but also about
emotional and financial abuse. Nurses should use their own language in asking these questions,
need to ensure that the questions are developmentally and culturally appropriate, and use
language appropriate to the client’s level of comprehension.
16.4 Inquiry and Assessment for Intimate Partner Violence
Assessment for Intimate Partner Abuse
To begin the conversation about IPV, you may say “I now ask all my clients about past or current abuse
in their lives because I recognize its impact on one’s well-being. I ask so that I can help my clients
identify help and support.” Screening questions need to be culturally and developmentally framed. Such
questions include the following:
Are you currently experiencing or have you ever experienced physical or emotional harm/abuse in an intimate
relationship? Has anyone ever forced you to engage in sexual activity that you did not want to participate in?
Has your current partner ever pushed, shoved, slapped, or otherwise physically hurt you?
Every couple has arguments and disagrees—what happens when you and your partner disagree?
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Does your partner ever make you feel afraid or scared? Tell me more.
Are you currently being hurt by someone? Are you in a safe or unsafe situation? (When I see a client with a bruise
such as this, I want to make sure he or she is safe.)
Follow-Up Questions When a Woman States That She Is Being Abused
Can you tell me the worst thing that has ever happened? What happened? When did it happen? Where did it
happen? Where were the children? Was a weapon used?
Do you feel your partner is capable of hurting you or your children?
What actions have you taken?
What are your fears? What would you like me to help you with? Please help me understand what is happening. I
would like to help.
Are you in danger now? Can you tell me more about this?
Have you ever needed emergency medical care as a result of how you were hurt? Can you tell me more about this?
How has the abuse affected you? Do you ever think about hurting yourself, cutting, stopping eating, or purging
food?
Have you ever thought about or been granted a restraining order? What happened?
Have you ever left? What happened? What obstacles did you face?
What are your fears about your children? Are you worried about their safety?
Evidence for Practice
Working with victims of violence is best approached using the principles of trauma-informed
care, which recognizes that patients with a history of traumatic events may feel triggered
and retraumatized when accessing healthcare. Trauma survivors have reported barriers
such as disjointed or chaotic care and receiving conflicting or misinformation from different
providers (Lewis-O’Connor & Chadwick, 2015). To minimize distress and remove the need
for the patient to retell their story, experts emphasize the need to coordinate care with warm
referrals amongst multidisciplinary collaborators who are well-versed in trauma-informed
care (Reeves, 2015).
People have all grown up with internalized myths, and it is imperative that healthcare
providers be aware of clients’ beliefs and work actively to dispel those myths so that healthcare
interventions do not retraumatize clients. Victims and survivors of IPV are sensitive to nuances
of words, tone of voice, and body language; so, providers must guard against making judgmental
gestures, even if subtle and unintentional, because they may have an impact on the interaction
between clients and providers. Healthcare professionals must take every precaution to avoid
blaming victims of IPV. Victims have often lost trust in relationships, so nurses must work to
build trust and not assume its existence.
Nurses can best implement the principles of trauma-sensitive care by actively listening,
validating, and supporting clients as they tell their story (Box 16.5) (Elliott, Bjelajac, Fallot,
Markoff, & Reed, 2005). It is imperative to keep safety issues for the victims (and children) in
the forefront. Given that at the core of abusive relationships are the issues of power and control,
nurses must make efforts to maximize patient autonomy. An example is explicitly asking for
consent before and at each step of a sexual assault examination (Lewis-O’Connor & Chadwick,
2015). Nurses should not try to “rescue” clients; rather, they should seek to empower clients to
be able to make informed decisions. It is essential to always be honest about what nurses can
and cannot do, especially regarding confidentiality and mandatory reporting. Nurses should
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never make promises about circumstances over which they have no control, as this may cause
more harm than good.
16.5 Trauma-Sensitive Care: Principles
Demonstrate respect.
Establish and maintain rapport.
Share control.
Share information.
Respect boundaries.
Foster a mutual learning process.
Show compassion and avoid passing judgment.
Practice Point
The nurse’s role needs to focus on sensitive communication, active listening, providing
information and choices, risk assessment, medical and psychological treatment, safety
planning, referral, and follow-up. Providers should be familiar with protocols that promote
patient-centered assessment and interventions. When a client screens positive for IPV, it is
imperative to assess for his or her safety and risk of harm. Communicating concern by
validating the client’s story builds trust between client and provider. Statements such as
“Donna, I am so sorry that this is happening; help is available,” “Thank you for sharing this
with me; I would like to ask you some safety questions so that I can better understand your
situation,” “You are not alone and you deserve better,” “This must be so difficult for you,”
“This is not your fault,” and “I am here to help you unconditionally” are appropriate
responses. We need to create systems with our patients rather than asking our patients to fit
into our existing systems. While further outcomes research is warranted, centering a practice
on trauma-informed principles ensures that the unique needs of this vulnerable population
are met.
So many people suffer from abuse, and suffer alone. Pamela Stephenson, Australian
clinical psychologist
Safety Assessment and Planning in Intimate Partner Violence
How an in-depth safety assessment is conducted depends on the practice environment and staff
model. Whoever is conducting the safety assessment needs to seek advanced training on risk
assessment, and needs to be aware of community resources. The most validated and used
instrument to assess for safety is the tool developed by Campbell (1986), the lethality
assessment tool. It is a 20-item tool available on the internet in English, Spanish, Portuguese,
and French Creole, and recent analyses indicate it has high sensitivity (92% to 93%) and
predictive value (93% to 96%) (Messing, Campbell, Sullivan Wilson, Brown, & Patchell, 2017).
Campbell developed this instrument to identify women at risk of being murdered by their
intimate partners. It often heightens a woman’s awareness about her safety. Once the safety
issues are identified, the healthcare provider can present intervention options to the client.
Safety planning involves nurse suggestions and client choices (e.g., does the client feel she is
able to keep herself safe? Does she have friends or family members who could help? Does she
have a supportive employer?). Components for safety planning include a crisis/disaster plan, a
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place to go, how to get there, and other considerations (e.g., if the abused victim stays and the
abuser leaves, if victim and the abuser stay together, or if the victim decides to leave). Safety
planning involves discussing measures that the client may not have considered. For example, if
an argument occurs at home, the woman should stay away from (1) the kitchen because sharp
instruments are there and (2) from the bathroom because the space is small and contains many
hard surfaces. She should go to a room with a window or door, carry her cell phone with 911 set
to speed dial, and tell family members and neighbors. Healthcare organizations should actively
partner with local shelters and court advocates, as they can assist with safety plans.
MANDATORY REPORTING OF ABUSE
When any healthcare provider suspects that abuse of an elderly person, a child, or a person with
a disability has occurred, he or she is mandated to report the abuse to the appropriate agency
(Box 16.6). It must be kept in mind that the data reflects the number of reported cases and not
the actual number of abused people as some cases may have had multiple reports.
Elder Abuse
Starting in 2011, the Baby Boom generation (those born between 1946 and 1964) entered into
the cohort of those aged 65 years and older. In 2010, there were 40.3 million people aged 65 or
over. To put this in some perspective, this is 12 times the number of persons who were over the
age of 65 in 1990
(https://www.census.gov/content/dam/Census/library/publications/2014/demo/p23-212 ).
Elder mistreatment (i.e., abuse and neglect) is defined as intentional actions that cause harm
or create a serious risk of harm (whether or not harm is intended) to a vulnerable elder by a
caregiver or other person who stands in a trust relationship to the elder. This includes failure by
a caregiver to satisfy the elder’s basic needs or to protect the elder from harm (Bonnie &
Wallace, 2003). Valid incidence and prevalence rates for elder abuse and neglect are not
available. The CDC website states, “While the National Center on Elder Abuse (NCEA) has
collected and analyzed state adult protective services data, the number of additional data
elements that might be available through healthcare, long-term care, criminal justice, fiduciary,
and legal services networks has remained largely unexplored”
(https://www.cdc.gov/violenceprevention/elderabuse/datasources.html).
16.6 Considerations When Making a Mandatory Report
Talk with the adult victim about the possibility of filing a mandatory report.
Consider the safety concerns of filing.
Determine how the perpetrator may respond to a report being filed.
Determine whether it will be safe to inform the children about the report.
Identify resources available to victim (family, friends, clergy, coworkers).
Consider filing in concert with the adult victim.
Share concerns of safety with the child protective agency.
Address safety planning with the nonoffending victim.
Ask about the perpetrator’s behaviors: What is the worst thing he or she has done? Does he or she own a gun? Has
he or she been arrested? Does he or she use drugs? Do you think he or she is capable of hurting you or your
children?
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https://www.census.gov/content/dam/Census/library/publications/2014/demo/p23-212
https://www.cdc.gov/violenceprevention/elderabuse/datasources.html
From available data, it does appear that female elders (those aged 60 years and older) are
abused at a higher rate than males and that the older one is, the more likely one is to be abused
(Teaster et al., 2004). The number of aging Americans will likely continue to increase.
Therefore, concern for abuse and victimization of this population will require effective proactive
programs to identify elder abuse, and provide the necessary resources to prevent and treat this
vulnerable population.
As a nurse, it is essential to know both the mandatory reporting laws in the state in which the
nurse practices, and the policies and procedures to be followed within the workplace. Although
the nurse may view the decision to report as “damaging” to the nurse–client relationship, he or
she has a duty to report the abuse as mandated by the state. It is necessary to regard mandatory
reports in the context of acting for the safety of the abused person, rather than reporting against
the alleged perpetrator.
Child Maltreatment
Although elder abuse has been acknowledged and addressed only more recently, child
maltreatment has been prevalent for centuries. The federal Child Abuse Prevention and
Treatment Act (CAPTA) (42 U.S.C.A. §5106g), as amended by the Keeping Children and
Families Safe Act of 2003 (U.S. Department of Health and Human Services, 2003), defines
child abuse and neglect as follows:
Any recent act, or failure to act, on the part of a parent or caretaker which results in death, serious
physical or emotional harm, sexual abuse, or exploitation; or
An act or failure to act which presents an imminent risk of serious harm
According to the most recent data available from the U.S. Department of Health and Human
Services, Administration for Children and Families (2017), our rates of child maltreatment
continue to be disturbing. These data report an increase, citing 676,000 cases of child
maltreatment, up from 656,000 in 2012. Neglect remains the highest form for maltreatment
(74.8%), with 18.2% reporting physical abuse and 8.5% reporting sexual abuse. The nationally
estimated death rate for abuse and neglect stands at 2.36 per 100,000 children
(https://www.acf.hhs.gov/sites/default/files/cb/cm2016 ). School nurses, visiting nurses,
public health nurses, and pediatric nurses must be familiar with signs and symptoms for children
at risk. Early identification and intervention are key to mitigating the effects on child
development and well-being.
Prevention strategies that address child maltreatment offer the best hope for reducing the
incidence of child abuse or neglect. Early identification may help prevent significant morbidity
and mortality. Over the past decade, much attention has been given to the effects of children
witnessing violence in the home. Researchers indicate that witnessing violence in the home can
have significant developmental and psychological sequelae and affect health subsequently, even
into adulthood (Dube et al., 2003; Groves, 2002).
I was angry about the fact that my father would beat my mother on a daily basis, that my
mother would take it in turn and beat on me. I was an abused child. I was mad about all
those things, very bitter and very angry. Rick James, American singer, songwriter,
musician
Often, the strongest protective factor in the lives of children who are exposed to domestic
violence is support for the nonoffending parent. Futures Without Violence produced a document
entitled The Facts on Children and Domestic Violence (2008). This is an excellent resource for
healthcare providers. A safe, stable, and nurturing relationship with a caring adult can help a
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child overcome the stress associated with IPV (Middlebrooks & Audage, 2008).
As the nurse caring for Kathy, Laura needs to assess the following, using observation
skills and appropriate questioning:
Her children’s current functioning
Changes in her children’s behavior
Changes in her children’s functioning as a result of the perpetrator’s actions
Laura uses Boxes 16.2 and 16.6 to assess whether there is significant concern about
the safety of Kathy’s children. After reviewing the data and consulting with team
members, Laura may decide to file a report with the child protective agency. Laura would
want to share this with Kathy as a resource that could assist her.
Deciding whether a particular case may involve abuse that requires reporting is often
difficult. Collaborating with others on the healthcare team ensures a well-informed decision.
Nurses should remember that when they file a report for concern of child maltreatment, they are
filing on behalf of the child, not against an individual person. If no report of child maltreatment
is necessary, nurses should still encourage the affected mother to express her family’s immediate
needs, seek the support of a community domestic violence advocate, tell her about family
services that meet their immediate needs, identify the family’s support system, assist her in
developing a safety plan, and consult with child protection experts and/or other domestic
violence providers.
Abuse of Disabled People
Although overall trends in violence and abuse seem to be decreasing, Americans with
disabilities seem to experience abuse disproportionately. In fact, research and the anecdotal
experience of those who work with people with disabilities suggest that this population is
experiencing a heightened risk of becoming victims of violence and abuse; however, research on
this population is sparse.
Only limited and dated information that addresses the issues affecting this group can be
found. One study found that more than 70% of women with developmental disabilities are
sexually assaulted in their lifetime, which represents a 50% higher rate than the rest of the
population (Sobsey & Doe, 1991; Sobsey, 1994). In another frequently cited study, Young,
Nosek, Howland, Chanpong, and Rintala (1997) found that women with physical disabilities
appear to be at risk of emotional, physical, and sexual abuse to the same extent as women
without physical disabilities. It appears that people with cognitive disabilities, who have a desire
to be accepted and “fit in,” may acquiesce to behaviors they are not quite comfortable with
because of fear of social isolation. Often, a person with a disability is dependent on another, and
that dependency prevents him or her from recognizing abuse and seeking help. Even when a
person with a disability reports a crime, the victim is often not believed, and is viewed as not
credible. It was only in 1998 that Congress passed the Crime Victims with Disabilities
Awareness Act. This represented the first piece of national legislation in U.S. history to address
the issue of abuse of persons with disabilities. Such legislation draws attention at many levels—
policy, research, advocacy, and law enforcement.
Awareness of the risks to persons in the disabled population should guide nursing practice
through the tasks of assessing clients at risk, discussing prevention strategies with clients and
their caregivers, and reporting concern for abuse to the local designated social service agency.
Knowing the risks to this vulnerable population may help detect early signs of abuse and provide
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services to intervene.
Student Reflection
Long ago, I remember hearing in the news about a woman in a nursing home. Although she
was in a coma, she became pregnant; a male attendant raped her. I was shocked, but
thought how sensational and out of the norm this event really was. However, in thinking
about vulnerability, it seems that abuse of people who are disabled, or of people who are
unable to make their desires and needs known, is all too common. Becoming
knowledgeable about how vulnerability can make certain groups of people more at risk for
abuse helped me understand how assessment and follow-up is critical. It is as if nurses are
the voice of the voiceless in many ways. Today, I asked an elderly person, who is
wheelchair-bound in her private home, whether she felt safe; she thought I meant from
burglars. I felt awkward in probing more about her physical, mental, and emotional safety,
and I did not want to scare her. What I did do was help her develop a safety plan in the
event she needed help, and helped her feel comfortable by giving her examples of how
some community dwellers develop systems to protect their interests. Some useful examples
might include sharing some routines with neighbors and having daily contact with a family
member or friend via phone. I felt as though I had empowered her. It felt good.
INTERVENTION
Ideally, preventing exposures to violence and abuse offers the best outcomes for an individual’s
biopsychosocial well-being. Research on interventions has been predominately quasi-
experimental and descriptive designs, as the research community is cautious about the use of
randomized controlled trials (RCTs), since withholding services and/or interventions that could
provide safety and well-being is contraindicated and poses ethical and moral discussions.
Despite the limitations of RCTs, there is notable evidence that supports interventions for women
exposed to violence.
One rigorous longitudinal RCT is the Nurse–Family Partnership program, which has been in
practice for decades. The outcomes of this home visiting program for first-time mothers and
babies have proven its effectiveness. Positive outcomes include improved prenatal health, fewer
childhood injuries, fewer subsequent pregnancies, increased intervals between births, increased
maternal employment, and improved school readiness. Most recently, a 19-year follow-up study
on the program showed that it resulted in fewer girls born to high-risk mothers later entering the
criminal justice system (Eckenrode et al., 2010).
Another study, the Domestic Violence Enhanced Home Visitation (DOVE) Program, which
used three different designs in three different settings, showed improved outcomes with the use
of perinatal home visitors (Sharps et al., 2016). In an effort to build on earlier research of
evidence-based empowerment, researchers explored what facilitators and barriers exist to
implementing home visiting interventions. Kilburn and colleagues (2008) developed and tested a
“town and gown” partnership to assist pregnant women who were in a violent relationship based
on the DOVE Program (Parker, McFarlane, Silva, Soeken, & Reel, 1999). This empowerment
intervention utilized prenatal visitors (town partners) with a research-driven strategy (gown
intervention). The DOVE intervention includes the following:
A structured, tailored brochure with information regarding the cycle of violence, designed to meet each
women’s special needs
Risk factors associated with increased risk of homicide
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Options available to women
Safety planning
IPV resources specific to their locales
National hotline numbers
Barriers and facilitating factors to the working partnership were identified in focus groups
conducted with home visitors. Barriers include the lack of knowledge and training received by
healthcare professionals related to recognizing violence and warning signs, how to ask about
violence, and legal options and social services. Also, issues related to the rural communities
were identified, such as limited services, lack of anonymity, and the home visitor and the
women knowing one another. The town/gown partnership provides home visitors with evidence-
based knowledge and the hands-on experience needed to assist and empower the women they
are working with. Research findings related to the effectiveness of home visiting programs with
related improved health outcomes, safety, and well-being are worth replicating and
implementing into practice (Eckenrode et al., 2000; Sharps et al., 2016; Olds et al., 2014; Olds,
Henderson, Chamberlin, & Tatelbaum, 1986) (see more at
http://www.nursefamilypartnership.org/proven-results/published-
research#sthash.k55hBbXe.dpuf).
One major intervention that health providers can address with their patients is safety and risk
for harm. Feder and associates (2011) conducted a cluster RCT aimed at IPV training for
providers with a focus on Identification and Referral to Improve Safety (IRIS) for women
experiencing domestic violence and seeking primary care. Researchers randomized 51 (61%) of
84 eligible general practices in Hackney (London) and Bristol (United Kingdom). Of these, 24
received a training and support program; 24 did not receive the program, and three dropped out
before the trial began. Following the second training session, the 24 intervention practices
recorded 223 referrals of patients to advocacy and the 24 control practices recorded 12 referrals
(adjusted intervention rate ratio 22.1 [95% CI 11.5 to 42.4]). Intervention practices recorded 641
disclosures of domestic violence and control practices recorded 236 (adjusted intervention rate
ratio 3.1 [95% CI 2.2 to 4.3]). These findings strongly support training primary care clinicians
on assessment of IPV, and referral to community resources that provide services to victims of
IPV.
In the clinical setting, nurses need not place pressure on themselves to take on the entire
burden of safety planning for a patient, especially when it is beyond their training. The role of
the healthcare provider is primarily clinical care and follow-up, discussion of the health effects
of violence, referral to resources, and empathetic emotional support (Bair-Merritt et al., 2014;
García-Moreno et al., 2015). This first-line support includes attentive listening that is validating,
and nonjudgmental provision of referrals to trusted resources for legal protection and housing, if
needed. It is up to the patient to decide her own trajectory to safety, even if it is not a linear path.
Another promising practice is the use of in-clinic IPV advocates. Using a quasi-experimental
design, investigators explored the efficacy of clinic-based advocacy for IPV to increase help-
seeking, reduce violence, and improve women’s well-being (Coker et al., 2012). Eligible and
consenting women attending one of six selected clinics in the rural Southern United States were
assessed for IPV. Consenting women disclosing IPV were offered either an in-clinic advocate
intervention or usual care, depending on the clinic they attended and were followed for up to 24
months. Over follow-up time, both IPV scores and depressive symptoms trended toward greater
decline among women in the advocate intervention clinics relative to the usual care. In some
areas of the country, such as Boston, MA, every teaching hospital employs in-house advocates.
HUMAN TRAFFICKING
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Attention to human trafficking in the healthcare field has exploded in recent years due to
increased awareness and research efforts. Human trafficking is defined as the recruitment,
harboring, transportation, provision, or obtaining of a person for the purpose of a commercial
sex act, labor, or services (UN General Assembly, 2000).
Devastatingly, human trafficking is the fastest growing industry in the world, with the
United States as the second largest market for women and children trafficked into sex work
(behind Germany) (Sabella, 2011). The majority of victims are women and girls, and over half
of victims trafficked into the United States are children. Trafficking flourishes in situations of
poverty, war, and other crises, which weaken law enforcement and increase demand for cheap
labor. For minors, childhood maltreatment trauma and running away from home are the most
important risk factors for domestic minor sex trafficking victimization (Choi, 2015).
Contrastingly, there is minimal and conflicting evidence on demographic risk factors, so at this
time they are not considered strong predictors (i.e., people of all genders, sexual orientations,
races, and educational levels are at risk). In response to the rise in human trafficking, the
Victims of Trafficking and Violence Protection Act, which was signed into law in October 2000
and has since undergone revision, takes steps to prevent trafficking, protect victims from
revictimization and deportation, and prosecute traffickers.
Common health concerns for trafficking victims include mental health issues such as PTSD,
anxiety, depression, and suicidality, as well as physical health issues such as drug abuse, STDs,
urinary tract infection, infertility, unintended pregnancy, trauma to the vaginal area or other
places on the body, cigarette burns, and jaw and neck disorders (Choi, 2015; Sabella, 2011).
Victims often characterize the psychological damage of trafficking as more difficult to recover
from than physical harm. Because exposing these health issues is risky for the trafficker, victims
are usually only granted care when their condition becomes serious. Though there is no one “red
flag” that will automatically point to trafficking, clinicians should be aware of the following
potential indicators (Sabella 2011):
Person doesn’t speak English and accompanying person is speaking for him or her; accompanying person
appears to be supervising and resists leaving him or her alone
Person doesn’t seem to know where her or she is, can’t give you a home address, or his or her story about
what her or she is doing in this country or his or her job doesn’t make sense
Person doesn’t have ID or spending money, or someone else is holding it
Signs of physical abuse or neglect, or signs of malnutrition, dehydration, drug use, or poor hygiene
Signs of prolonged exposure to chemicals or airborne contaminants (in the case of labor trafficking)
(Peternelj-Taylor, 2016)
Person has a tattoo that resembles branding (e.g., “Property of __”)
There are many reasons trafficking victims are unlikely to ask for help, including threats of
violence to themselves or their family/friends, fear of arrest or deportation, language barrier,
lack of knowledge about availability of help, shame and belief that they have put themselves in
this situation, or fear that the trafficker is “testing” them by employing someone in the league to
go undercover and make false offers of escape.
Despite these barriers, nurses are well positioned to identify cases of human trafficking since
they are active in many health delivery settings. Forensic nurses can play an especially important
role, since they are trained to perform post-trauma examinations and to testify as expert
witnesses in legal cases. Internationally renowned trafficking expert Hanni Stoklosa, emphasizes
that health professionals have an important role to play in identifying and caring for trafficking
victims, and encourages providers to educate themselves on the topic (Chisolm-Straker &
Stoklosa, 2017). In January 2018, the U.S. Department of Health and Human Services released a
trafficking toolkit for healthcare providers, based on the latest research and best practices for
recognizing and responding to trafficking cases (Marcias-Konstantopoulos & Owens, 2018).
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The screening tool is available free of charge online and consists of eight minimally invasive,
close-ended questions with a focus on the core elements of trafficking: force, fraud, and
coercion. The areas of inquiry concern recruitment, personal identification and travel
documents, working conditions, living conditions, and violence, coercion, or threats.
Asking directly whether a person has been trafficked is usually not helpful, and it is
important to talk with the person alone before asking questions that could lead to a disclosure.
While the potential to uncover a human trafficking case may seem intimidating, the role of the
healthcare provider is not to get a detailed account or to prove that trafficking is occurring, but
rather to act on reasonable suspicion by calling a professional at a trafficking resource center for
guidance.
At an organizational level, nurses can address human trafficking by staying up-to-date on
trafficking research and sharing this information by hosting a seminar, providing literature to
colleagues, or displaying hotline numbers in their clinic. Efforts to respond to human trafficking
are most successful when coordinated amongst an interdisciplinary team, so nurses should seek
out collaborators in other relevant sectors (e.g., law enforcement, faith, and education)
(Peternelj-Taylor, 2016). Nurses have already paved the way in such advances and have great
potential to improve efforts to end human trafficking.
MODEL OF CARE FOR VICTIMS OF INTENTIONAL
CRIMES
In the past, approaches to acute care of sexual assault victims, domestic abuse victims, and
victimized children were inconsistent and suboptimal. Victims of intentional violence often
found provider services degrading and received victim-blaming treatment; these experiences
would often exacerbate the victim’s physical and mental distress (Campbell, Wasco, Ahrens,
Sefl, & Barnes, 2001). However, in the past 25 years, significant reform in providing acute
forensic medical examinations has occurred, and evidence-based practice has evolved
exponentially. Caring for victims of sexual assaults has evolved with the development of
nationally certified Sexual Assault Nurse Examiner (SANE) programs. Model programs such as
the C.A.R.E Clinic at Brigham and Women’s Hospital in Boston, MA, seeks to create innovative
approaches to healthcare delivery that mitigate the health consequences cause by violence,
trauma, and abuse (www.brighamandwomens.org/careclinic).
I can be changed by what happens to me but I refuse to be reduced by it. Maya Angelou
In response to child maltreatment and in recognizing the special needs of these children, in
June 2009, the American Academy of Pediatrics developed a clinical specialty leading to board
certification in child maltreatment. Most pediatric academic hospitals in the United States have
child protection or children-at-risk teams made up of physicians, nurses, and social workers.
Such teams evaluate cases for child maltreatment, work with state child social service agencies
and law enforcement, provide education to a broad audience, and conduct research. Over the
next decade, this area of specialty practice is likely to expand significantly.
Assisting Kathy will require multiple practice disciplines coordinating and prioritizing her
needs and those of her children. In Laura’s institution, it is important that she be aware of
policies and procedures related to IPV, child maltreatment, and abuse of the person with
disabilities, as well as any resources for management of these problems. Knowing
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forensic nurse experts in the community will be useful for consultation.
FORENSIC NURSING
Nurses have been providing forensic-type services for centuries. From a formal educational
perspective, it was not until recently that specific education in forensic nursing was offered
through a traditional nursing college or university. Graduate programs in forensic nursing are
likely to impact the field of forensic nursing in the future. Some nurses in the SANE program
have received broader instruction; trained as forensic nurse examiners, they care for victims of
all types of intentional violence. Nurses working in these areas receive advanced training that
includes a didactical component and clinical practicum, which leads to eligibility for board
certification.
Forensic nurses offer victims compassionate, trauma-sensitive, evidence-based care.
Advanced training focuses on taking a history of the assault, collecting evidence, and providing
treatment and follow-up. The field of forensic nursing is growing rapidly, with forensic nursing
programs developing in all regions of the country. Forensic nurses are employed in the
following areas: emergency departments, police departments, medical examiners offices,
homeland security offices, correctional institutions, and mental health facilities. As the evidence
grows and the field of forensic nursing evolves, options for nurses to work within a collaborative
community team offer interesting opportunities for nursing professionals. Forensic nursing
focuses not only on providing client care, but its practitioners also collect evidence, counsel
clients, and communicate with professionals in legal systems. Employers are asking for
forensically prepared nurses who can screen and treat clients, as well as testify in court.
As with any relatively new science, it takes time to build a body of knowledge. The Journal
of Forensic Nursing (https://journals.lww.com/forensicnursing/pages/default.aspx), a peer-
reviewed journal, is now recognized as a scholarly scientific journal. The ANA and the
International Association of Forensic Nurses (IAFN) released Forensic Nursing: Scope and
Standards of Practice (2009), a comprehensive reference guide that identifies and defines the
expectations for the role and practice of the forensic nurse.
A panel of nurse experts convened by the ANA and the IAFN developed the standards for
forensic nurses. The guide outlines six standards for forensic nursing practice and nine standards
for professional performance. Forensic nurses are among the most diverse groups of clinicians in
the nursing profession with respect to client populations served, practice settings, and forensic
and healthcare services provided. Forensic nurses apply a unique combination of processes
rooted in nursing science, forensic science, and public health to care for clients. In addition to
recommended standards of professional performance, the IAFN book’s summary discussion of
the scope of forensic nursing practice—including characteristics, trends, education, practice
environments, and its ethical and conceptual bases—lends an informative and broad context for
the reader’s understanding and use of these standards.
KEY CONCEPTS
Violence against women is a form of gender-based violence that can result in physical, sexual, or
psychological harm for both the direct victims and also their dependents (children).
Intimate partner violence is fundamentally based on the desire for control on the part of the perpetrator.
Empowering victims of intentional violence to care for themselves and get help is assumed to be a
welcomed opportunity. For many, however, it is a difficult context that has brought them to violent, abusive
relationships, and it is a difficult context which will release them from the situation.
Although abuse and violence can be unintentional, it is the intentional violence which impels nurses to
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become members of a healthcare team involved in assessing and addressing policy as a way of
decreasing the incidence of such acts in communities.
CRITICAL THINKING QUESTIONS
1. You live in a state that has no mandatory laws requiring professionals to report elder abuse. How would
you develop support of the individual clients, families, and the community to work toward a system of
mandatory reporting?
2. A mother in a pediatric setting becomes very upset when indirect questions are asked about her children’s
safety at home. How would you address her feelings?
3. Discuss the positives and negatives of domestic violence shelters for women and children.
4. Compare and contrast violence in the context of heterosexual and lesbian, gay, bisexual, transsexual, and
queer relationships. Are preventive solutions the same in these groups?
COMMUNITY RESOURCES
Through networking and attending local conferences on domestic violence, one can begin to build a
resource directory of community partners—knowing the following resources is imperative.
Women’s shelters
Churches/synagogues/temples
Food banks
Women, Infants, and Children (WIC) program
Mental health agencies
Unemployment offices
Law enforcement agencies
Advocacy centers
Justice centers
Support groups
Batterer’s intervention groups
Forensic nurses
HEALTHY PEOPLE 2020 LEARNING ACTIVITY
Injury and Violence Prevention
Healthy People 2020 provides a blueprint that identifies nationwide health improvement priorities. This
national consensus plan includes 42 topics, with a subset of 12 leading health indicators (LHI) and over
1,200 objectives. It offers a framework for strategic planning to promote health improvement and achieve
health equity through measurable objectives and deliberate actions. The Healthy People 2020 website is
dense with important information on the development, implementation, and progress of this national plan.
Learning to navigate the website to access the rich materials offered is vital to gaining a deep
understanding of the national health improvement priorities, specific objectives, and initiatives seeking to
achieve the national goals and objectives.
Injury and Violence Prevention is a topical area identified as a priority in Healthy People 2020. To learn
more about this topic go to https://www.healthypeople.gov
Click on “Topics & Objectives”: Topics are listed alphabetically, scroll down to “I” and click on Injury
and Violence Prevention.
Click on the “Overview” and find the answers to the following questions:
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What is the goal for this topic?
What are some examples of health consequences of violence?
What factors affect the risk of unintentional injury and violence?
Click on “Objectives” and select five objectives: Analyze the data, looking specifically at any disparities,
progress made, and thinking about continued barriers to achievement.
Click on “Interventions & Resources” and select three resources: Review the resources to explore how
community and public health groups are working to address and improve services related to injury violence
prevention across the nation.
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WEB RESOURCES
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http://thepoint.lww.com/vitalsource/ebook/9781975111694
Chapter 17
Substance Use
Judith Shindul-Rothschild
For additional ancillary materials related to this chapter. please visit thePoint
The basic thing nobody asks is why do people take drugs of any sort? Why do we have these
accessories to normal living to live? I mean, is there something wrong with society that’s
making us so pressurized, that we cannot live without guarding ourselves against it?
John Lennon
Man is the only creature that refuses to be what he is.
Albert Camus
Drugs? Everyone has a choice and I choose not to do drugs.
Leonardo DiCaprio
Reality is just a crutch for people who can’t cope with drugs.
Robin Williams
CHAPTER HIGHLIGHTS
Factors affecting prevalence rates of substance use: age, gender, race, socioeconomic level, urban or rural
settings
Population-based interventions to decrease substance use
Evidence-based treatment protocols for substance abuse that should be incorporated by community health
nurses in all practice settings
Self-help groups: a highly effective community-based treatment with proven efficacy in sustaining
recovery
OBJECTIVES
Define substance use, substance abuse, and addiction.
Describe the impact of substance abuse and addiction on individual people and their families,
communities, and nations.
Identify risk factors for substance misuse and abuse in individual people and populations.
Apply evidence-based practice in the nursing care of populations most at risk for substance use disorders.
Apply evidence-based interventions in providing nursing care in the community for clients with
substance abuse.
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KEY TERMS
The World Health Organization (WHO) has compiled a list of terms and definitions commonly
used in population surveys and WHO research publications on substance use. The list is entitled
“Lexicon of alcohol and drug terms published by the World Health Organization” and is available
online. Other terms are defined by the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) compiled by the American Psychiatric Association (APA, 2013).
Abstinence: No use of illicit substances or alcohol in the preceding 12 months; a person is
considered “abstinent.”
Addiction: A term, along with habituation, which the WHO recommends be substituted with
substance dependence. However, clients and practitioners commonly use addiction.
Craving: A very strong urge or desire to seek the euphoric feeling achieved by using substances
(DSM-5).
Intoxication: A reversible syndrome that appears after ingestion of a specific substance that
results in clinically significant problematic behavioral or psychological changes (e.g.,
belligerence, mood lability, impaired judgment, disturbances of perception, psychomotor
behavior, and interpersonal behavior [DSM-5]).
Remission: Early remission is defined in DSM-5 as occurring when a person has previously met
criteria for a substance use disorder but has not met the criteria for 3 to 12 months. Sustained
remission occurs when a person no longer meets the criteria for substance use disorder for 12
months or more.
Substance use (in this chapter): The use of alcohol, illicit drugs, and nonmedical use of
prescription medications. Illicit drugs include cannabis, cocaine, heroin, hallucinogens,
inhalants, and methamphetamine. Prescription medications used nonmedically include pain
relievers, tranquilizers, stimulants, and sedatives.
Substance use disorders (SUD): In DSM-5, SUD includes separate criteria for alcohol,
anxiolytics, caffeine, cannabis, gambling, hallucinogens, hypnotics, opioids, phencyclidine
(PCP), sedatives, stimulants, and tobacco.
Tolerance: Diminished physical and/or psychological response to effects of alcohol or illicit
substances. A person develops tolerance when he or she needs to use higher doses of
alcohol or illicit substances to achieve the desired euphoric effect (DSM-5).
Withdrawal: A reduction in prolonged substance use that results in problematic behavioral,
physiologic, and cognitive changes. Withdrawal causes significant impairment in social,
occupational, and interpersonal functioning and is usually associated with an urge to
readminister the substance to reduce the symptoms (DSM-5).
CASE STUDY
References to the case study are found throughout this chapter (look for the case study icon).
Readers should keep the case study in mind as they read the chapter.
James Campbell, a 63-year-old African American man, is retired from the Boston Fire Department.
His wife died 6 months ago from breast cancer, and he now lives alone next to his adult daughter.
Since his wife died, Mr. Campbell has been increasingly relying on his daughter’s assistance to
manage his home. His daughter, who works full-time and has four children of her own, has not
been able to spend as much time with her father as she would like, but she checks with him daily.
Recently, she has noticed that her father’s appetite seems to have decreased; he has lost so much
weight that his pants are very loose around his waist. At his daughter’s insistence, Mr. Campbell
agrees to see a nurse practitioner at a Boston clinic for a thorough evaluation.
In the meeting with the nurse, the daughter says that she is worried about her father becoming
depressed. Mr. Campbell does admit to having difficulty sleeping and says that he takes a “shot” of
whiskey to help him relax. He injured his back before he retired, and sometimes, his back pain is so
severe that he takes a “pain pill” that his wife was given to manage her cancer pain. Mr. Campbell’s
daughter believes that her mother took oxycodone (OxyContin). Mr. Campbell vehemently denies
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changes in mood but does admit that he gets the “jitters” during the day for no apparent reason and
takes one alprazolam (Xanax), which his wife’s physician prescribed for him when she was first
diagnosed with cancer. His daughter says that it seems she has been filling the Xanax prescription
more frequently lately.
INTERNATIONAL ASPECTS OF SUBSTANCE ABUSE
Substance use affects societies in many ways, and countries have used different models to
address the impact on populations. Approaches range from strict prohibition and criminalization
to the harm reduction model, which is based on public health principles. When substances that
can alter mental states are believed to lead to addiction and social harms or dysfunction, some
governments respond by enacting laws that support strict drug prohibition. The harm reduction
approach focuses on the reduction of the harmful effects of drug use and addiction without
necessarily achieving abstinence. Most countries actually apply a model combining both harm
reduction strategies and criminalization (WHO, 2014a).
Scope of Substance Use
Worldwide, mental and substance use disorders (SUD) are the leading cause of all nonfatal
disease burdens, and most deaths (81%) are attributable to SUD (Whiteford et al., 2013). It is
important for community health nurses to appreciate the cultural norms and differences in the
use of illicit and licit substances. For example, in some cultures, such as the United States,
alcohol use is viewed as normative, while in other cultures, the use of alcohol is strictly
forbidden and viewed as a behavior that is one of the most stigmatized of all health conditions
(WHO, 2014a). Globally, public health models that address drug and alcohol abuse focus on
interventions at three points: the agent (the distributor of the substance), the host (the addicted
person), and the environment (local, national, or international).
The real problems are cultural. The problems of the people who take drugs are a cultural
trap—I think there’s a real problem there, the crack stuff, the hopelessness of the junkie.
The urban angst. Jerry Garcia
Global Public Health Policies to Minimize Harms From
Substance Use
Alcohol misuse is a global public health threat that poses significant social and economic costs
to healthcare systems, criminal justice authorities, and social welfare systems (Fig. 17.1) (WHO,
2014a). Successful global and multinational policies aimed at reducing social harms associated
with alcohol consumption focus on availability, marketing, pricing, drinking and driving,
prevention, and treatment in healthcare systems (WHO, 2014a). These aspects of a public health
model are reflected in the WHO’s “Guiding public health principles to reduce the harmful use of
alcohol” (Box 17.1). The most common public health policies are national awareness campaigns
that educate populations about the social harms associated with alcohol misuse, especially
drinking and driving (WHO, 2014a).
17.1 WHO Public Health Principles Guiding Development and Implementation of
Alcohol Policies
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a. Public policies and interventions to prevent and reduce alcohol-related harm should be guided and
formulated by public health interests and based on clear public health goals and best available
evidence.
b. Alcohol policies should be equitable and sensitive to national, religious, and cultural contexts.
c. Protection of populations at high risk for alcohol-related harm and those exposed to the harmful
effects of drinking by others should be an integral part of public health policies.
d. Populations affected by the harmful use of alcohol should have access to affordable and effective
prevention and care services.
Source: World Health Organization (WHO). (2014). Global status report on alcohol and health. Luxembourg: World Health Organization.
FIGURE 17.1 Global alcohol-attributable causes of death, disease, and injury, 2012. (From WHO.
[2014]. Global status report on alcohol and health [p. 47]. Luxembourg: World Health
Organization.)
Evidence-based policy options related to health services delivery include population
screening and brief intervention with referral to treatment (SBIRT), especially for high-risk
populations including children, adolescents, pregnant women, and older adults (WHO, 2014a).
Population-based policies designed to limit the availability of alcohol include laws regulating
the minimum drinking age, licensing restrictions, marketing restrictions, and increased pricing
through taxation. Other examples of policies enacted by nations or states to minimize the harm
to populations from alcohol use include blood alcohol limits on driving and warning labels on
alcohol beverages about the adverse effects on health (WHO, 2014a).
At the community level, strategies to reduce the harmful use of alcohol include developing
policies designed for specific community events such as sporting events or festivals where
subpopulations, especially youth, maybe at risk for harm from excessive substance use.
Community-based policies may include restrictions on public consumption of alcohol,
restrictions on the hours establishments can serve alcohol, and mandatory training for hospitality
providers.
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Globally, approximately 29.5 million people suffer from drug use disorders (United Nations
Office on Drug and Crime [UNODC], 2017). From a public health perspective, self-
administered injection of illicit substances poses the greatest risk for population health and
social harms (UNODC, 2012). The United States alone accounts for almost one quarter of all
opioid overdose deaths worldwide (UNODC, 2017). New synthetic derivatives of opioids such
as fentanyl which vary in potency have escalated the rates of opioid-related deaths.
Hepatitis C, HIV, and tuberculosis are the leading causes of morbidity among people who
inject drugs. Public health programs including opioid substitution treatment and syringe
exchange programs are harm reduction strategies used in both developed and developing
countries to combat the spread of hepatitis C and HIV. Opioid substitution treatment consists of
administering methadone or buprenorphine in prescribed doses in programs administered by
governments. There is widespread agreement among public health experts in both developed and
developing countries that opioid substitution treatment programs are an effective public health
strategy to reduce the social harms associated with illicit opioid use, such as prostitution,
shoplifting, theft, and property crime.
The WHO recommends that public health programs for people who inject drugs be
integrated into healthcare delivery systems to avoid fragmentation of services and promote
implementation of evidence-based treatments. The UNODC’s Global Youth Network provides
information and materials to prevent drug abuse at the individual, family, school, and
community level. The UNODC/WHO’s Global Initiative on Primary Prevention of Substance
Abuse provides information on evidence-based practices to assess substance abuse, plan
prevention programs, and evaluate effectiveness of programs on preventing substance abuse.
More information is available at the UNODC’s websites.
In many countries, evidence-based prevention and treatment strategies have not been widely
disseminated nor adequately funded by governments. Antiviral treatment for hepatitis C has
been hampered by the high cost of pharmaceuticals. For marginalized populations such as the
homeless, those in prison, or sex workers who maybe at greatest risk for harms associated with
injection drug use, substance use treatment is often not equivalent to services available in the
general population (UNODC, 2017).
National Scope of Substance Use
The United States leads the world in the portion of its citizens who abuse or are dependent on
alcohol or illicit substances and is the country with the largest illicit drug market. Most
Americans (65.7%) use alcohol and 17.8% report use of illicit drugs (U.S. Department of Health
and Human Services [USDHHS], Office of the Surgeon General, 2016). From 2002 to 2015,
deaths involving heroin increased 6.2-fold and is the leading cause of accidental deaths in the
United States (National Institute on Drug Abuse [NIDA], 2017a; Presidents Commission on
Combating Drug Addiction and the Opioid Crisis, 2017). Overdose deaths involving heroin or
synthetic opioids increased for all demographic groups, regions, and in 30 states (Fig. 17.2)
(Rudd, Seth, David, & Scholl, 2016).
If current trends continue, it is estimated that 1 in 23 women and 1 in 36 men who inject
drugs will be infected with HIV in the United States (Fig. 17.3) (Centers of Disease Control and
Prevention [CDC], 2016). Injection drug use, especially in rural regions of the United States, has
created new public health challenges for the prevention of HIV. The CDC has embarked on a
high-impact prevention strategy that includes directing federal grants, pharmaceutical treatment,
and intervention programs to communities most at risk. Included in the CDC prevention
strategies are culturally appropriate public service messages, syringe services, comprehensive
recovery services, pre-exposure prophylaxis (PrEP), post-exposure prophylaxis (PEP), and
antiretroviral therapy (ART) to treat HIV (CDC, 2016).
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In the United States, rates of substance use are higher among native-born populations than
immigrants. Public health researchers theorize that the “immigrant paradox” for substance use
disorders is related to protective factors, such as community safety and family cohesion, which
contribute to lower rates of substance use among immigrants upon arrival to the United States
(Qureshi et al., 2014; Salas-Wright & Vaughn, 2014; Savage & Mezuk, 2014). As immigrants’
length of residence in the United States increases, the rate of substance misuse also increases,
suggesting that sociocultural exposures, including acculturation and discrimination, play a direct
role in increasing risk among immigrants (Savage & Mezuk, 2014). Immigrant youth in
particular are more susceptible to peer influence and acculturation stress and are more likely to
adopt unhealthy substance use behaviors than immigrant adults (Li & Wen, 2015).
FIGURE 17.2 National overdose deaths from heroin and illicit opioids. (From National Institute on
Drug Abuse (NIDA). [2017]. National overdose deaths—2015 [p. 5]. Retrieved from
https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates.)
Practice Point
A challenge for community health nurses caring for immigrant populations, especially youth,
is to preserve protective factors to minimize the risk of substance misuse associated with
longer residency in the United States.
I bought a gun and chose drugs instead. Kurt Cobain
Evidence for Practice
Lexicon for Behavioral Health and Primary Care Integration (Peek & The National
Integration Academy Council [NIAC], 2013).
WHAT: Integrated primary and behavioral healthcare that addresses mental health and
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https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates
substance use, health behaviors, and life stressors for a defined population. Medical,
behavioral health, and substance use treatment are core components of primary care
services and are integral to improving health outcomes.
GOAL: To integrate primary and behavioral healthcare to a population so there is “no
wrong door” for seeking treatment
Role of Community Health Nurses in Collaborative Care Models:
1. Screening and implementation of prevention measures
2. Promotion of health behavior change
3. Psychological support and crisis intervention
4. Chronic or complex illness case management
5. Outcome measurement of clinical, functional, and quality of life
6. Outreach to patients or families who do not follow-up and to high-risk populations
FIGURE 17.3 HIV diagnoses attributed to injection drug use by race/ethnicity and gender, 2015.
(From Centers for Disease Control and Prevention [CDC]. [2016]. HIV and injection drug use: Fast
facts [p. 1]. Retrieved on August 24, 2017, from https://www.cdc.gov/hiv/pdf/risk/cdc-hiv-idu-fact-
sheet .)
Alcohol
Alcoholism is the only disease that you can get yelled at for having. Mitch Hedberg
The age at which Americans first use alcohol is a significant risk factor for future dependence or
addiction to alcohol. Children who initially use alcohol at 14 years of age or younger are seven
times more likely to become dependent on alcohol or abuse it than those who initially use
alcohol when they are 21 years of age or older. Rates of alcohol use are now equivalent in
adolescent males and females (13.3% and 13.3%, respectively), and the rates of alcohol
dependence and abuse are now equivalent in adolescents (Substance Abuse and Mental Health
Services Administration [SAMHSA], 2012a). Underage drinking is highest among those
reporting two or more races as their ethnic heritage (17.5%), among Native Americans (15.2%),
and among white youth (14.6) (SAMHSA, 2012a). Lower socioeconomic status and educational
opportunities are two of the social factors associated with increased risk among Native
Americans, but a comprehensive understanding of the root social causes is lacking (Stanley,
Harness, Swaim, & Beauvais, 2014).
Drinking and driving is a serious public health concern. A positive trend is that the
percentage of all Americans who reported drinking and driving continues to decline from 2002.
Strict law enforcement and population-based strategies such as school-based education programs
and community-based programs are credited with contributing to a decrease in the portion of
Americans reporting they engaged in drinking and driving. Laws include mandatory alcohol
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testing for automobile drivers, sobriety checkpoints, social host laws to reduce teenage alcohol
consumption by imposing liability on adults who provide alcohol to underage drinkers, lower
blood alcohol levels for driving under the influence (DUI), immediate license suspension for
DUI, and age-21 minimum legal drinking age restrictions. A subpopulation that continues to be
at high risk for drinking and driving is young adults (18 to 25 years of age) who have almost
double the rate of driving impaired than the general population (18.6%) (SAMHSA, 2012a).
Binge drinking is defined by the National Institute on Alcohol Abuse and Alcoholism
(NIAAA) as five or more drinks on the same occasion for 1 day during the preceding month for
men and four or more drinks on the same occasion for women. Over the past decade, there has
been a steady decline in binge drinking among youth who participated in substance prevention
programs (SAMHSA, 2012a). Yet, almost one fourth of all Americans over the age of 12 who
drink alcohol (22.6%) still meet criteria for binge drinking (SAMHSA, 2012a).
Binge drinking peaks during young adulthood (ages of 18 and 25 years), with 39.8% of users
reporting binge drinking behavior (SAMHSA, 2012a). Rates of binge alcohol use vary by race
and ethnicity and are highest among American Indians (AIs) or Alaska Natives (ANs) (24.3%)
(SAMHSA, 2012a). A major risk factor for problem drinking in young adults is enrollment in
college. The significant difference (p < 0.05) in binge and heavy drinking between college
students (39.1%) and their peers (35.4%) not enrolled in college has remained unchanged over
the past decade and suggests campus cultural norms are a strong factor contributing to
significantly higher health risks (SAMHSA, 2012a).
The nurse practitioner, Katherine, can see that Mr. Campbell has many of the risk factors
for abuse of or dependence on illicit drugs but does not want to stereotype him or falsely
assume that he has a drug problem. He may be depressed or in need of proper pain
management. She determines that it would be appropriate to begin an evaluation of Mr.
Campbell by assessing his mood, especially if he has had any suicidal ideation. In
addition, he needs an evaluation for his back pain and sleep disorder.
Cannabis
Cannabis is the most frequently used illicit substance in the United States. There has been a
gradual decline in cannabis use over the past 5 years in youth aged 12 to 17 years (SAMHSA,
2017a). Public health prevention strategies recognize that perceived risk can effect when, or if,
an individual initiates use of an illicit substance. As states have legalized the recreational and
medicinal use of cannabis, adolescents’ perception that there are risks associated with smoking
cannabis has decreased (NIDA, 2017b). Among adolescents who smoked cannabis in the past
month, the majority (73.7%) perceived there was no physical or other risks associated with
cannabis (SAMHSA, 2017a). One protective factor is that the use of cannabis is six times lower
in youth who perceive parental disapproval compared to youth who perceive strong parental
approval.
Tobacco
Over the past decade, the use of tobacco in the United States has continued to significantly
decline (SAMHSA, 2012a). The number of Americans reporting daily cigarette smoking
continues to decline across all racial/ethnic groups and ages (SAMHSA, 2017a). Over 90% of
adolescents strongly disapprove of cigarette smoking by their peers (SAMHSA, 2012a). A
disturbing trend is the increasing use of nonconventional tobacco products, such as e-cigarettes
or hookahs among youth. Public health experts attribute the increased use of nonconventional
tobacco products to a lower perceived risk of harm and confusing public health messages
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(Mermelstein, 2014). Past month use among teens is now higher for e-cigarettes (12.5%), than
for cigarettes (10.5%) (NIDA, 2016). In educating populations, especially youth, about the risks
of tobacco use, community health nurses must expand their public health interventions to
include nonconventional tobacco products.
Illicit Drugs
In addition to perceived risk, public health studies have found that the availability of drugs and
the ease of obtaining illicit substances are associated with initiation and use (Lipari, Williams,
Copello, & Pemberton, 2016). In 2015, 27 million Americans used illicit substances or abused
drugs including cocaine, opioids (i.e., heroin), hallucinogens (i.e., lysergic acid diethylamide
[LSD], phencyclidine [PCP], peyote, mescaline, psilocybin mushrooms, “ecstasy” [also known
as MDMA]), inhalants (i.e., nitrous oxide, amyl nitrite, cleaning fluids, gasoline, spray paint,
other aerosol sprays, and glue), pain relievers (i.e., oxycodone and propoxyphene),
benzodiazepines (i.e., alprazolam and lorazepam), stimulants (i.e., methamphetamine), and
sedatives (i.e., phenobarbital, Seconal) (President’s Commission Combating Drug Addiction and
the Opioid Crisis, 2017). The rate of illicit drug use peaks in young adulthood and then declines
with age (SAMHSA, 2017a). Use of any illicit substance is highest among native Hawaiians or
other Pacific Islanders (OPI) and AIs or ANs (Fig. 17.4).
Beginning in the 1990s, there was a shift in the pharmacologic treatment of chronic pain by
clinicians spearheaded by the designation of pain as the “fifth vital sign.” This shift spurred a
rapid escalation in the prescription opioids leading to three times as many prescriptions for
opioids in 2015 than in 1999 and the total number of prescriptions (239 million) approximating
the entire population of the United States (Brady, McCauley, & Back, 2016; Guy et al., 2017).
Over half of nonmedical users of stimulants, tranquilizers, sedatives, and pain relievers received
the drug from a friend or relative for free, and four out of five stated that the drug was prescribed
by one physician (SAMHSA, 2012a).
There are important public health implications for the rapid escalation and wide regional
variation in opioid prescribing practices (Fig. 17.5). Prescription of opioids is significantly
higher in nonmetropolitan cities and towns with higher densities of physicians, percentages of
non-Hispanic whites, unemployment, and Medicaid enrollment (Guy et al., 2017). This
geographic variation suggests inconsistent adherence to evidence-based treatments, including
the use of nonopioid analgesics and nonpharmacologic interventions, such as exercise therapy
and cognitive–behavioral therapy, to manage chronic pain. To reduce the risks associated with
long-term opioid use, in 2016, CDC issued guidelines for the prescription of opioids for chronic
pain not associated with palliative or end-of-life care (Dowell, Haegerich, & Chou, 2016). Many
states also recently enacted public health policies mandating that prescribers participate in
Prescription Drug Monitoring Programs and have imposed stricter regulations of pain clinics
(Guy et al., 2017). Public health initiatives at both the national (Box 17.2) and state level are
credited with recent reductions in prescription opioid–involved deaths and lowering the number
of persons exposed to opioids (Dowell, Zhang, Noonan, & Hockenberry, 2016).
The most recent epidemiologic surveys on substance use in the United States help
community health nurses identify populations at greatest risk for abuse and addiction. Some
trends have remained stable over many years. But the latest surveys also warn of emerging
trends that will pose new challenges for community health nurses. One of the greatest challenges
will be faced by nurses in the community who provide nursing care to at-risk populations. For
example, populations at greatest risk for prescription opioid overdose are white males between
the ages of 35 and 44 years with a history of substance use disorder or psychiatric disorder
(Brady, Giglio, Keyes, DiMaggio, & Li, 2017). How community health nurses can identify
people at risk across the lifespan and intervene with evidence-based programs aimed at
prevention is the focus of the next section of this chapter.
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FIGURE 17.4 Past year illicit drug use disorder among individuals aged 12 or older by gender,
race/ethnicity, and age group, 2015. NH, non-Hispanic. (From Substance Abuse and Mental
Health Services Administration [SAMHSA]. [2017]. Behavioral health barometer: United States,
Volume 4: Indicators as measured through the 2015 National Survey on Drug Use and Health and
National Survey of Substance Abuse Treatment Services [p. 16]. HHS Pub No. SMA-17-BaroUS-
16. Rockville, MD: SAMHSA.)
FIGURE 17.5 Opioids prescribed per person in U.S. counties, 2015. (From CDC Vital Signs, July
2017. Retrieved from https://www.cdc.gov/vitalsigns/opioids/infographic.html#graphic-b.)
HEALTH PROFILES AND INTERVENTIONS FOR HIGH-
RISK POPULATIONS
Pregnant Women
Fetal alcohol syndrome (FAS) is the leading cause of preventable developmental disability in the
world (Hoyme et al., 2016). In 1981, the U.S. Surgeon General issued the first public health
advisory warning about the association of alcohol use during pregnancy and fetal disabilities. An
Act of Congress followed, ordering warning labels to be added to all products containing alcohol
(Bertrand, Floyd, & Weber, 2005). Federal agencies have supported several public health
measures to warn women about the serious adverse health effects of maternal drinking on
unborn children. Alcohol use during pregnancy is a serious public health concern because of the
multiple deleterious, lifelong effects of alcohol on the fetus including low IQ, hyperactivity,
short attention span, distinctive facial anomalies, and structural brain defects. Given the severity
of developmental disabilities associated with FAS, the WHO (2014b) issued guidelines
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recommending that all healthcare providers ask all pregnant women about their use of alcohol
and other substances as early as possible in the pregnancy and at every antenatal visit (Box
17.3). If pregnant women are using alcohol or drugs, the WHO (2014b) recommends brief
intervention and immediate referral to detoxification services and psychosocial care.
The American College of Obstetricians and Gynecologists and the CDC also recommend
screening all women of childbearing age for substance use (Reddy, Davis, Ren, & Greene,
2017). When screening women for alcohol use, community health nurses should ask women to
respond to questions in the validated T-ACE questionnaire as they would before they learned
that they were pregnant. Nurses should also inquire about the stage of pregnancy at which the
woman reduced or eliminated her alcohol consumption. At this time there are no validated
screening instruments available for illicit substance use. Urine toxic screens can supplement
face-to-face interviews and provide information about the use of polysubstances, but laboratory
tests must be interpreted cautiously because a negative result does not rule out past use or the
intensity of past use (Reddy et al., 2017).
The rise in opioid use has resulted in a fivefold increase in neonatal abstinence syndrome
(NAS) over the past decade (Reddy et al., 2017). Infants born to mothers who inject drugs are
also at increased risk for hepatitis C and HIV. Practice guidelines recommend pregnant women
with substance use disorder should also be screened for hepatitis C and HIV at the first prenatal
visit. The WHO and the American Society of Addiction Medicine endorse medication-assisted
treatment with methadone and buprenorphine over supervised opioid withdrawal for pregnant
women to minimize the risk of relapse and nonadherence to prenatal care.
Opioid withdrawal symptoms in neonates may present in the first 48 hours or a week after
birth with symptoms ranging from irritability to life-threatening seizures. Newborns with NAS
may remain hospitalized for weeks after mothers have been discharged potentially impeding the
opportunities for mother–infant bonding. Innovative models provide additional resources for
community-based care, so newborns maybe discharged home with their mothers and if
indicated, receive medication-assisted treatment for detoxification. Best practices for care of
infants recovering from NAS in the home include the use of a transitional care nurse to
coordinate care across healthcare settings and providers (Gregory, 2014). Families and
caregivers should be provided with education to recognize the symptoms of NAS and guidance
on nonpharmacologic interventions (Reddy et al., 2017). The severity of NAS symptoms can be
minimized by a quiet, lowly lit, nonstimulating environment. Other infant comfort measures
include swaddling, nonnutritive sucking, rocking, and gentle massage (MacMullen, Dulski, &
Blobaum, 2014). Unless contraindicated, nurses should encourage women prescribed methadone
or buprenorphine to breastfeed. A home safety assessment by nurses is critical to assure
medication-assisted treatments are safely stored and administered.
17.2 CDC Recommendations for Prescribing Opioids for Chronic Pain Outside
Palliative and End-of-Life Care
Determining When to Initiate or Continue Opioids for Chronic Pain
1. Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain.
Clinicians should consider opioid therapy only if expected benefits for both pain and function are
anticipated to outweigh risks to the patient. If opioids are used, they should be combined with
nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.
2. Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all
patients, including realistic goals for pain and function, and should consider how opioid therapy will
be discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy only if
there is clinically meaningful improvement in pain and function that outweighs risks to patient
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safety.
3. Before starting and periodically during opioid therapy, clinicians should discuss with patients known
risks and realistic benefits of opioid therapy and patient and clinician responsibilities for managing
therapy.
Opioid Selection, Dosage, Duration, Follow-Up, and Discontinuation
4. When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids
instead of extended-release/long-acting (ER/LA) opioids.
5. When opioids are started, clinicians should prescribe the lowest effective dosage. Clinicians should
use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual
benefits and risks when considering increasing dosage to ≥50 morphine milligram equivalents
(MME)/day, and should avoid increasing dosage to ≥90 MME/day or carefully justify a decision to
titrate dosage to ≥90 MME/day.
6. Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute
pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should
prescribe no greater quantity than needed for the expected duration of pain severe enough to require
opioids. Three days or less will often be sufficient; more than 7 days will rarely be needed.
7. Clinicians should evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid
therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of
continued therapy with patients every 3 months or more frequently. If benefits do not outweigh
harms of continued opioid therapy, clinicians should optimize other therapies and work with patients
to taper opioids to lower dosages or to taper and discontinue opioids.
Assessing Risk and Addressing Harms of Opioid Use
8. Before starting and periodically during continuation of opioid therapy, clinicians should evaluate
risk factors for opioid-related harms. Clinicians should incorporate into the management plan
strategies to mitigate risk, including considering offering naloxone when factors that increase risk
for opioid overdose, such as history of overdose, history of substance use disorder, higher opioid
dosages (≥50 MME/day), or concurrent benzodiazepine use, are present.
9. Clinicians should review the patient’s history of controlled substance prescriptions using state
Prescription Drug Monitoring Program (PDMP) data to determine whether the patient is receiving
opioid dosages or dangerous combinations that put him or her at high risk for overdose. Clinicians
should review PDMP data when starting opioid therapy for chronic pain and periodically during
opioid therapy for chronic pain, ranging from every prescription to every 3 months.
10. When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting
opioid therapy and consider urine drug testing at least annually to assess for prescribed medications
as well as other controlled prescription drugs and illicit drugs.
11. Clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently
whenever possible.
12. Clinicians should offer or arrange evidence-based treatment (usually medication-assisted treatment
with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid
use disorder.
All recommendations are category A (apply to all patients outside of active cancer treatment, palliative care, and end-of-life care) except recommendation 10
(designated category B, with individual decision making required); see full guideline for evidence ratings.
Source: Dowell, D., Haegerich, T. M., & Chou, R. (2016). CDC guideline for prescribing opioids for chronic pain – United States, 2016 [p. 16]. Morbidity and
Mortality Weekly Report, 65(1), 1–50.
17.3 Assessment Guideline for Identifying Fetal Alcohol Syndrome
Facial dysmorphia
Smooth philtrum
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Thin vermillion border
Small palpebral fissures
Growth problems
Postnatal height, weight, or both <10th percentile
Central nervous system abnormalities
Structural
Head circumference <10th percentile
Reduced size or change in shape of corpus callosum, cerebellum, and basal ganglia seen on MRI
Neurologic
Motor problems
Seizures
Functional
Cognitive or intellectual deficits <3rd percentile
Functional deficits <16th percentile in three of the following:
1. Cognitive development
2. Executive functioning
3. Motor functioning delays
4. Problems with attention or hyperactivity
5. Problems with social skills
6. Sensory, language, or memory problems
Source: Bertrand, J., Floyd, R. L., & Weber, M. K. (2005). Guidelines for identifying and referring persons with fetal alcohol syndrome. Morbidity and Mortality
Weekly Report Recommendations and Reports, 54(RR11), 1–14.
One of the most widely used and scientifically proven programs to improve health outcomes
for at-risk first-time mothers is the Nurse–Family Partnership (NFP) program (Dawley, Loch, &
Bindrich, 2007; Donelan-McCall, Eckenrode, & Olds, 2009). The NFP pairs at-risk new mothers
with community health nurses who provide hour-long visits every 2 weeks in the home for the
first 2 years of an infant’s life. Health education and interventions provided by the community
health nurses include avoiding alcohol and drug use, nutritional counseling, smoking cessation,
parenting skills, case management regarding pediatric care for their infant and primary care for
the mothers, and vocational counseling to promote economic self-sufficiency (Dawley et al.,
2007).
Donelan-McCall and colleagues (2009) note that the NFP has the strongest support to date of
any nurse home-visiting program; scientific evidence shows that it can improve the health
outcomes of children born to at-risk mothers and is cost-effective. The savings realized by the
NFP programs in decreased adverse health events, emergency department visits, and the like
(approximately $18,000) are twice as much as the cost per family for 2 years of nurse home
visits (approximately $9,000) (Donelan-McCall et al., 2009; Lee, Aos, & Miller, 2008). Begun
in 1977 by Dr. David Olds with community health nurses in Elmira, New York, today NFP is in
350 counties nationally and is supported by funding from federal or state healthcare and social
service grants as well as private foundations. NFP is a compelling example of how investing in
preventive healthcare provided by community health nurses improves health outcomes in a cost-
effective manner. SAMHSA has developed a National Registry of Evidence-based Programs
and Practices, including NFP, to identify scientifically proven programs to prevent or treat
mental and/or substance abuse disorders and facilitate their implementation in communities
across the United States (Box 17.4). An example of a culturally tailored model using health
educators indigenous to the population is Family Spirit, an organization in which trained health
educators provide home-visiting intervention for AI teenage mothers (Box 17.5).
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17.4 The Nurse–Family Partnership
Nurse–Family Partnership (NFP) is a prenatal and infancy nurse home visitation program that aims to
improve the health, well-being, and self-sufficiency of low-income, first-time parents and their children.
Nurses follow a detailed, visit-by-visit guide that provides information on (tracking) dietary intake;
reducing cigarette, alcohol, and illegal drug use; identifying symptoms of pregnancy complications and
signs of children’s illnesses; communicating with healthcare professionals; promoting parent–child
interactions; creating safe households; and considering educational and career options. Program
objectives include decreased substance use, improved maternal economic self-sufficiency, fewer
subsequent unintended pregnancies, reduced child abuse and neglect, and improved school readiness of
the children. Individual programs serve a minimum of 100 to 200 families and are supported by 4 to 8
trained registered nurse home visitors (each carrying a caseload of 25 families), a nurse supervisor, and
administrative support. Nurse home visits begin early in pregnancy and continue until the child’s second
birthday. The frequency of home visits changes with the stages of pregnancy and infancy and is adapted
to the mother’s needs, with a maximum of 13 visits occurring during pregnancy and 47 occurring after
the child’s birth.
The NFP targets women in urban, suburban, rural, and frontier areas. Races and ethnicities who have
received the NFP interventions include Asian, black or African American, Hispanic or Latino, and
white.
Readiness for dissemination ratings by criteria = 3.7 (0.0–4.0 scale)
Implementation materials = 3.5
Training and support = 4.0
Quality assurance = 3.5
Source: Substance Abuse and Mental Health Services Administration (SAMHSA). (2017). Using Prevention Research to Guide Prevention Practice. SAMHSA’s
Center for the Application of Prevention Technologies, 34. Retrieved on December 17, 2018, from
https://www.samhsa.gov/capt/sites/default/files/resources/preventing-youth-marijuana-use-programs-strategies-2017 .
Given the marked risk for teratogenesis and obstetric complications, the American Society
on Addiction Medicine recommends that pregnant women in need of substance use treatment be
given the highest priority for admission and treatment (Haug, Duffy, & McCaul, 2014). Six new
objectives have been added to Healthy People 2020, including abstinence from drinking or
smoking in preconception.
17.5 Family Spirit
Family Spirit is a culturally tailored home-visiting intervention for American Indian teenage mothers—
who generally experience high rates of substance use, school dropout, and residential instability—from
pregnancy through 36 months postpartum. The intervention is designed to increase parenting
competence (e.g., parenting knowledge and self-efficacy), reduce maternal psychosocial and behavioral
risks that could interfere with effective parenting (e.g., drug and alcohol use, depression, externalizing
problems), and promote healthy infant and toddler emotional and social adjustment (i.e., internalizing
and externalizing behaviors). It also aims to prepare toddlers for early school success, promote parents’
coping and life skills, and link families to appropriate community services.
Family Spirit is based on Patterson’s social interaction learning model, which suggests that a
parent’s stressful life circumstances (e.g., unstable housing, poverty, weak family support, mental health
and substance abuse issues) trigger a high level of coercive parenting associated with early childhood
behavior problems that predict poor outcomes in middle and later childhood. The intervention consists
of 63 structured lessons delivered one-on-one by health educators in participants’ homes, starting at
about 28 weeks of gestation and continuing to 36 months postpartum. The lessons, designed to
correspond to the changing developmental needs of the mother and child during this period, address
topics such as prenatal care, infant care, child development, family planning, and healthy living. Each
home visit lasts about an hour and includes a warm-up conversation, lesson content, question-and-
answer period, and review of summary handouts. Health educators, trained American Indian
paraprofessionals, deliver the lessons using illustrated tabletop flipcharts. The bond formed between the
health educator and mother is intended to facilitate the mother’s progress toward goals. The 63 lessons
can be delivered in 52 home visits, which occur weekly through 3 months postpartum and gradually
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become less frequent thereafter.
Family Spirit targets American Indian or Alaska native women in rural and frontier areas.
Readiness for dissemination ratings by criteria = 4.0 (0.0–4.0 scale)
Implementation materials = 4.0
Training and support = 4.0
Quality assurance = 4.0
Source: Substance Abuse and Mental Health Services Administration (SAMHSA). (2017). Using Prevention Research to Guide Prevention Practice. SAMHSA’s
Center for the Application of Prevention Technologies, 18. Retrieved on December 17, 2018, from
https://www.samhsa.gov/capt/sites/default/files/resources/preventing-youth-marijuana-use-programs-strategies-2017 .
Evidence for Practice
A study by Jarlenski and colleagues (2017) of reproductive age women (n = 4498) from
2005 to 2014 found 2% reported nonmedical opioid use in the last 30 days. Among a
subsample of pregnant women who reported nonmedical opioid use, 42% smoked 5 or
more cigarettes a day and 51.2% ingested 5 or more alcohol drinks per day. The authors
note that given these findings, public health programs need to expand polysubstance use
treatment to women of reproductive age to promote recovery from substance use disorder
and improve pregnancy outcomes.
Evidence for Practice
The Dartmouth-Hitchcock Medical Center Perinatal Addiction Treatment Program integrates
prenatal care and postpartum care with evidence-based substance use treatment services
consistent with models of integrative care endorsed by the Agency for Healthcare Research
and Quality (AHRQ) and the Institute of Medicine (Goodman, 2015). Regular
multidisciplinary meetings between maternity and pediatric providers in both the hospital
and outpatient clinic facilitate the coordination of care for pregnant women and their infants,
improve patient satisfaction, and increase attendance at prenatal visits. Maternity providers,
including certified nurse midwives, nurse practitioners, and neonatal nurses, receive training
in screening and brief interventions for SUD. Neonatal nurses participate in outpatient
addiction recovery groups to provide education to pregnant women about the care of
newborns with NAS. Colocation of midwifery services in a dedicated substance use
treatment program is cost-effective and improves health outcomes for both women and
newborns (Goodman, 2015).
The criminalization of health behaviors raises serious ethical questions for community health
nurses who provide healthcare to people who may become targets of criminal investigations. In
the case of Ferguson v. the City of Charleston (South Carolina) (99–936), the Fourth Circuit
Court of Appeals upheld the conviction of a pregnant woman who tested positive for cocaine
and was reported to law enforcement authorities on the basis of a hospital policy adopted at the
University of South Carolina Medical Center. The case was ultimately heard by the U.S.
Supreme Court. Professional healthcare organizations such as the American Nurses Association
(ANA), the American Public Health Association, and the American College of Obstetricians and
Gynecologists submitted written testimony, termed an amicus curiae brief, in support of the
defendant. Subsequent to the ruling of the U.S. Supreme Court, the ANA joined over 140
organizations and researchers in a public letter to the U.S. Surgeon General stating, “The ANA
recognizes alcohol and other drug problems as treatable illnesses. The threat of criminal
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prosecution is counterproductive in that it prevents many women from seeking prenatal care and
treatment for their alcohol and other drug problems” (Tillett & Osborne, 2001, p. 6).
In 2001, the U.S. Supreme Court decided in a 6-to-3 ruling that the defendant’s Fourth
Amendment rights had been violated, and overturned the conviction. In an analysis of the
Supreme Court ruling of Ferguson v. the City of Charleston, the noted medical ethicist George
Annas (2001) observed that the more the lines between the professional duties of physicians and
nurses are blurred with those of law enforcement, the more that trust between clients and
healthcare providers is eroded, and the greater the likelihood that women who are in need of
prenatal care will not seek care at all.
More recently, the Child Abuse Prevention and Treatment Act was amended in 2016 (P.L.
114–198) to require states develop discharge plans for newborns born with NAS or FAS that
assure adequate community resources are in place for mothers to appropriately care for their
newborns in their home (USDHHS, 2016). The intent of the 2016 amendment was to assure the
safety and well-being of newborns who may be at risk from alcohol or opioid exposures during
pregnancy. However, Terplan and Mindoff (2017) note that the effect of the 2016 amendments
to the Child Abuse Prevention and Treatment Act may be to trigger a response beyond
addressing the health needs of substance-exposed newborns to removal of children and
prosecution of mothers for illicit substance use. Community health nurses conduct assessments
and validated screenings of pregnant women to identify populations at risk and provide
evidence-based interventions to minimize harm to an unborn child. Yet the very act of
professional nursing practice raises complicated ethical questions about duty to patient’s
confidentiality and autonomy given federal reporting mandates.
Substance Use at an Early Age
Individual, family, and community influences all contribute to the use of substances by underage
children and adolescents. How much of the increased risk is due to nature (genetic
vulnerabilities) or nurture (environmental influences) can partially be illuminated by studies of
twins, adopted children, and genetic research. Monozygotic twin and adoption studies estimate
the risk of inheritability of alcoholism at approximately 50% (Gray & Squeglia, 2018). Thus, at
least half the risk of developing alcoholism may be due to factors in communities, schools, or
families.
Developmental or peer influences also play a role. It is known that most adults with
addiction or substance abuse disorders began using alcohol or illicit substances while in middle
school. Since 2011, the percentage of adolescents initiating alcohol, marijuana, and cigarette use
has declined suggesting that public health education initiatives maybe having a positive effect on
delaying substance use (SAMHSA, 2017a). Despite growing rates of opioid use and deaths in
adults, misuse of all prescription opioids among 12th graders in 2016 markedly declined by 45%
over the past 5 years (NIDA, 2016). Personality attributes such as poor impulse control,
attention deficits, conduct disorders, and general psychological dysregulation are individual
factors that have been associated with early-onset substance use. In adolescents with substance
use disorder there is often a high comorbidity with the early onset of anxiety disorders,
posttraumatic stress disorder, and major depression (Gray & Squeglia, 2018). However
especially among youth, access to substances continues to play a central role in initiation of
substance use. For example, marijuana use by adolescents is higher in states legalizing medical
and recreational marijuana use compared to states where marijuana use remains illegal (NIDA,
2016). It is critical that community health nurses recognize that during middle school, risk is
greatly increased if a child has any friends who have used alcohol in the past year (Strobbe,
2013). How individual vulnerabilities, social experiences, or community influences coalesce to
the point where 12 to 14 year olds are initiating alcohol use is the focus of public health
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research.
A thorough family history for substance use and screening youth for risk factors associated
with early substance use is a critical first step. The United States Preventive Services Task Force
(USPSTF, 2014) recommends primary care and community-based health professionals screen
youths to identify patients at risk for substance misuse. The American Academy of Pediatrics
recommends the CRAFFT screening tool specifically designed for use in adolescent populations
(Box 17.6). Integrative primary care and schools are ideal locations for nurses to introduce
prevention and early intervention programs (Curtis, McLellan, & Gabellini, 2014).
17.6 CRAFFT Drug Screening Questionnaire for Use in Adolescents
1. Have you ever ridden in a Car driven by someone (including yourself) who was “high” or had been
using alcohol or drugs?
2. Do you ever use alcohol or drugs to Relax, feel better about yourself, or fit in?
3. Do you ever use alcohol or drugs while you are by yourself, Alone?
4. Do you ever Forget things you did while using alcohol or drugs?
5. Do your family or Friends ever tell you that you should cut down on your drinking or drug use?
6. Have you gotten into Trouble while you were using alcohol or drugs?
Scoring: A “Yes” answer to two or more questions indicates the need for active intervention.
Source: Substance Abuse and Mental Health Services Administration (SAMHSA). TIP 31: Screening and assessing adolescents for substance use disorders.
Retrieved on July 29, 2009, from http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.54841.
While peer influences play a role in substance use, numerous studies have found strong
associations between parenting style and health risk behaviors in children. Parents who are
engaged with their child, supervising and monitoring their activities, providing appropriate
discipline, and sustaining positive parent–child bonds throughout adolescence can have a
notable effect on adolescent substance use (Allen et al., 2016). The majority of adolescents who
abuse prescription medication acquired the medication from a friend or family member (Allen et
al., 2017). It is critical for community health nurses to screen for family or social experiences
that are associated with the misuse of alcohol, illicit drugs, and prescription opioids in children
and adolescents. Nurses can ask whether there is excessive consumption by family members and
peers, if the adolescent or child has access to alcohol or prescription opioids, and if there are
peers or family members who willingly provide them with access to these substances. It is the
early initiation of substance misuse that is most strongly predictive of addiction in adulthood.
I mean, I inherited the disease of alcoholism, and I learned early to get help when I
needed it. Liza Minnelli
Evidence for Practice
The SAMHSA (2017b) has developed a practical guide to provide nurses in community-
based settings information to plan and deliver prevention strategies based upon SAMHSA’s
Strategic Prevention Framework. The Strategic Prevention Framework is a five-step
process that describes evidence-based prevention strategies and tools communities can
use to successfully implement prevention programs. Step One is to correctly assess the
substance use, risk and protective factors, and readiness in the community to act. Step Two
is to build coalitions with key stakeholders and train individuals to sustain the mission of the
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program. Step Three is to develop an evidence-based prevention plan that identifies
outcomes for evaluating performance. Step Four is to implement culturally competent
programs and policies with proven effectiveness in the community. Step Five is to evaluate
program outcomes, assess the quality of the services, and identify areas for improvement.
Sample materials include a pitch letter to organizations and stakeholders; sample public
service announcements; sample feature articles; media kits; and detailed “how-to” plans to
guide implementation of a prevention program targeting substance use among youth. To
learn more about SAMHSA’s Focus on Prevention: Strategies and Programs to Prevent
Substance Use, see http://www.samhsa.gov.
The difference in substance use among Native American youth and the general adolescent
population is especially pronounced among the youngest adolescents. Substance misuse is a
major public health concern for Native American youth on reservations where over half of
eighth graders report alcohol and cannabis use, a pronounced increase from overall national
prevalence rates for eighth graders of all ethnicities (Stanley et al., 2014). While there is no
causal model to explain the higher rates of substance use among youth on reservations, social
factors including greater availability from local cannabis farms, proximity to Mexico and drug
gangs, lower socioeconomic status, and lower academic attainment are some of the social
conditions that researchers have associated with this pronounced health disparity (Stanley et al.,
2014).
Although less than 1% of adolescents report using inhalants to get high, the effects, even
with first-time use, can be deadly (Lipari, 2017). The 2015 National Survey on Drug Use and
Health found no differences in inhalant use by region, race, or ethnicity. Inhalant use peaks in
young adolescence and diminishes with age with significantly more girls reporting inhalant use
than boys (Lipari, 2017). Typical inhalants used by adolescents are common household items
that contain volatile solvents such as felt-tip markers, glues, or paint thinners; computer cleaner;
butane, propane, or gasoline. Fumes may be inhaled through the mouth, referred to by
adolescents as “huffing,” or the nose (sniffing), to achieve a short-term state of intoxication
similar to alcohol. Adolescent inhalant users are at increased risk for delinquency, depression,
suicide, and drug and alcohol use (Lipari, 2017). Given the morbidity and mortality associated
with inhalant use, it is important for nurses in the community to educate adolescents, parents,
teachers, and other adults interacting with youth about the serious health hazards associated with
inhalant use.
Evidence for Practice
The LifeSkills Training program, an evidence-based program for prevention of drug and
alcohol abuse, has been implemented in 33 rural public schools located in communities
prone to methamphetamine abuse. Outcome studies of LifeSkills Training have reported
statistically significant and sustained decreases in all forms of substance use, especially for
higher-risk subpopulations of adolescents, including those in rural and frontier regions of the
United States (Spoth, Randall, Trudeau, Shin, & Redmond, 2008, p. 66). These scientifically
validated prevention efforts appear to be having an effect. In 2012, the number of
Americans 12 years of age or older who used methamphetamine for the first time (133,000)
was less than half the number of new users reported in 2004 (318,00). (SAMHSA, 2012a).
These statistics suggest that comprehensive public health and law enforcement efforts are
making a significant difference in decreasing the methamphetamine use in the United
States. SAMHSA’s National Registry of Evidence-Based Programs and Practices has given
LifeSkills Training its highest rating for efficacy and readiness of dissemination (Box 17.7).
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http://www.samhsa.gov
17.7 LifeSkills Training
LifeSkills Training (LST) is a school-based program that aims to prevent alcohol use, tobacco use, illicit
substance use, and violence by targeting the major social and psychological factors that promote the
initiation of substance use and other risky behaviors. LST addresses multiple risk and protective factors
and teaches personal and social skills which build resilience and help youth navigate developmental
tasks, including the skills necessary to understand and resist prodrug influences. LST is designed to
provide information relevant to the important life transitions that adolescents and young teens face,
using culturally sensitive and developmentally and age-appropriate language and content. Facilitated
discussion, structured small group activities, and role-playing scenarios are used to stimulate
participation and promote the acquisition of skills. Separate LST programs are offered for elementary
school (grades 3–6), middle school (grades 6–9), and high school (grades 9–12).
LST targets adolescents in urban, suburban, rural, and frontier areas. Races and ethnicities who have
received LST include American Indian or Alaska native, Asian, black or African American, Hispanic or
Latino, and white.
Readiness for dissemination ratings by criteria = 4.0 (0.0–4.0 scale)
Implementation materials = 4.0
Training and support = 4.0
Quality assurance = 4.0
Source: Substance Abuse and Mental Health Services Administration (SAMHSA). (2017). Using Prevention Research to Guide Prevention Practice. SAMHSA’s
Center for the Application of Prevention Technologies, 26. Retrieved on December 17, 2018, from
https://www.samhsa.gov/capt/sites/default/files/resources/preventing-youth-marijuana-use-programs-strategies-2017 .
Population-based interventions to decrease substance use among adolescents can be
conceptualized in four categories: regulatory, developmental prevention, early screening, and
harm reduction (Toumbourou et al., 2007). Minimum age laws for drinking alcohol, strict
enforcement of laws prohibiting drinking and driving, and enforcement of youth possession laws
have proved to be effective deterrents to underage substance use (Toumbourou et al., 2007).
Developmental prevention programs can be effective in deterring substance use in adolescents
as well, if such prevention programs are sensitive to the significant variations in substance use in
adolescence by age, ethnicity, geographic location, and gender.
Research shows that parents are the single biggest influence on children—if you are
worried about your teen and drugs, talk to them. John Walters
In contrast to screening and education of entire populations of adolescents, a public health
approach demonstrating improved efficacy with adolescents is screening with the CRAFFT tool
to identify youth at risk followed by tailored brief interventions and referral to specialty
treatment based upon the severity score. This approach, termed SBIRT (screening, brief
intervention, referral to treatment) has been implemented in primary care, emergency rooms,
school-based settings, and in shelters with homeless youth (Mitchell, Gryczynski, O’Grady, &
Schwartz, 2013). In the SBIRT model, interventions are specifically targeted based on the
severity of symptoms and it includes brief interventions for even mild symptoms in populations
considered at-risk. The brief interventions in SBIRT consist of the chief components of
motivational interviewing.
Motivational interviewing is particularly effective with adolescents because it respects the
adolescents’ developmental need for autonomy (Mitchell et al., 2013). The nurse partners with
the adolescent to identify the harms associated with substance misuse in a nonjudgmental
manner, and the nurse objectively points out inconsistencies with the adolescent’s personal goals
and aspirations. The nurse thoughtfully negotiates with the adolescent about the possibility of
changing harmful behaviors and assists the adolescent in setting realistic goals achievable in a
brief period of time. For example, a goal may be slightly decreasing the amount of alcoholic
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beverages consumed in a week or the weekend by a goal self-selected by the adolescent. In
follow-up sessions, the nurse reinforces health promoting behaviors and the achievement of
goals. Key to the successful implementation of brief interventions is that the goals be self-
selected by the adolescent, that they be achievable, and that the nurse provides immediate
reinforcement and encouragement for achieving the goal.
Evidence for Practice
SBIRT was implemented in two urban New York public schools during nonacademic
classes (Curtis et al., 2014). All 6th- to 12th-grade students were screened with an
interactive computer tool that included the CRAFFT scale. Adolescents with a CRAFFT
score of zero (no use) would be given factual information and support for continuing health
promoting behaviors. Those scoring 1 or 2 on the CRAFFT screen (low-risk use) would be
given a motivational interview lasting between 15 and 30 minutes. Adolescents with a
CRAFFT score of 3 or greater with significant levels of substance use were provided a brief
intervention emphasizing the severity of substance use, telephone notification of parents,
and options for referral to treatment.
In summary, community health nurses should follow the guidelines of the American
Academy of Pediatrics that recommend all adolescents be screened for alcohol and drug use and
that at-risk adolescents be given brief interventions and in the cases of severe misuse, referred
for treatment by specialists (USPSTF, 2014). In formulating culturally appropriate evidence-
based interventions, studies suggest that Hispanic youth have better outcomes when paired with
Hispanic healthcare providers, and gang youths or youth with severe substance use and complex
behavioral issues benefit from family-based therapies that broadly examine social issues within
the family, school, peer relationships, and the juvenile justice system (Hogue, Henderson,
Ozechowski, & Robbins, 2014).
College Students and Binge Drinking
Binge drinking is defined as a consumption of alcohol that brings the blood alcohol level to
0.08% or above, which typically occurs after women consume four alcoholic beverages or men
five alcoholic beverages in 2 hours (NIAAA, 2015). Although alcohol use has declined in high
school students and young adults not in college, students in college deviated from similarly aged
cohorts with continued high use of alcohol, especially, binge drinking (Johnston, O’Malley,
Bachman, Schulenberg, & Miech, 2016). These findings suggest that the environmental
influence of attending college is a significant risk factor in hazardous use of alcohol for young
adults. Unlike their younger peers, who may use alcoholic beverages to cope with family
dysfunction, violence, or painful emotions, college students are more likely to engage in heavy
or binge drinking to enhance their mood or affective state.
Of the 60% of college students who reported consuming alcohol in the past month,
approximately two out of three college students report binge drinking (NIAAA, 2015). That the
majority of college students who consume alcohol engage in high-risk patterns of consumption
is a major public health issue on college campuses. Binge drinking by college students is
associated with a life altering health risks including physical and sexual assault, alcohol
poisoning, and alcohol-related deaths. Rates of binge drinking vary by race, gender, and peer-
group affiliation, suggesting that cultural and environmental influences play a strong role in the
patterns of drinking behavior by college students.
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That’s all drugs and alcohol do, they cut off your emotions in the end. Ringo Starr
In 2002, the NIAAA Task Force on College Drinking received a mandate to review and
disseminate evidence-based strategies to decrease alcohol use on college campuses. The NIAAA
Task Force compiled their findings in a report entitled A Call to Action: Changing the Culture of
Drinking at U.S. Colleges, which was distributed to college administrators across the United
States. The NIAAA Task Force continues to systematically review the scientific evidence for
programs or initiatives with demonstrated efficacy and provides periodic updates of new
evidence-based programs on its website entitled “College AIM” (Alcohol Intervention Matrix)
(Table 17.1).
The NIAAA (2017) created “College AIM” to provide universities and healthcare providers
a matrix on individual and environmental evidence-based interventions effective for the general
population of college students (see Table 17.1). Interventions that target individual students at
high risk include first year students, student athletes, members of Greek organizations, and
mandated students. Consistent with recommendations from the USPSTF, one of the
recommended individual-level interventions College AIM is that alcohol screening be included
as a standard practice in all university student health services. To detect high-risk drinking in
college students, community health nurses and physicians should specifically assess for the
quantity and frequency of heavy episodic drinking. Computerized screening surveys in routine
health screening may also be a useful tool for community health nurses to identify students who
may be at risk. Given the wide variation among college students in their patterns of binge
drinking behavior, multiple screenings are advised. An individual-level intervention relevant to
nurse practitioners and physicians is the prescription of naltrexone, acamprosate, and disulfiram
approved by the Food and Drug Administration (FDA) for the treatment of alcohol use disorder.
College AIM also endorses the USPSTF recommendation for brief counseling sessions to reduce
the frequency and intensity of alcohol use.
Evidence for Practice
Research compiled by the NIAAA has found that patterns of hazardous drinking varied by a
number of demographic and environmental factors, including year in school, week in the
semester, and whether the student was in residential housing on or off campus. For
example, women drink more intensely in their freshman year, whereas men drink more
intensely in their senior year (Kelly-Weeder, 2008). In both heavy and moderate college
drinkers, drinking patterns are cyclical, with peaks 3 weeks into the semester, over holidays,
and spring break (Greenbaum, Del Boca, Darkes, Wang, & Goldman, 2005). Despite the
substantial patterns of alcohol abuse, studies have found that nurses and physicians screen
for alcohol use in less than one third of university health services and that only 12% use
standardized instruments (Foote, Wilkens, & Vavgiakis, 2004).
Practice Point
One consequence of the failure to identify high-risk students in the freshman year in college
is the increased likelihood for academic failures. Wilhite, Ashenhurst, Marion, and Fromme’s
(2017) longitudinal study of college students found that binge drinking was a significant
predictor of time to college graduation and lower odds of achieving developmental milestones
in adulthood. The researchers note that these alcohol-related effects may indicate a lack of
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academic engagement or the neurodegenerative effects of heavy drinking on diminishing
students’ cognitive functioning and development. A study by West, Graham, and Temple
(2017) of binge drinking episodes over the past year by college students with learning,
physical, psychiatric, sensory, or developmental disabilities, found higher rates than their
nondisabled college peers. Amphetamine use was the strongest predictor of increasing the
likelihood of binge drinking among students with disabilities while nursing or pre-med majors
were less likely to binge drink than students in all other majors (West et al., 2017). The
authors strongly recommend colleges intervene early in college orientation activities to
promote safer patterns of alcohol consumption (Wilhite et al., 2017) and design programs
that address the unique risks of specific populations (West et al., 2017).
TABLE 17.1 National Institute on Alcohol Abuse and Alcoholism (NIAAA)
Evidence-Based Programs to Decrease Binge Drinking on College Campuses
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Nurses in university health services are ideally positioned to identify at-risk students and use
motivational interviewing to ascertain the students’ readiness to change their behavior (Kelly-
Weeder, 2008). Motivational interviewing begins by establishing trust, being an empathic
listener, and instilling hope and positive regard—communication skills familiar to nurses, which
are the foundation of the nurse–client relationship. Once the nurse establishes rapport, brief
motivational interviewing consists of specific cognitive strategies such as eliciting feelings about
how the drinking behavior is affecting the student’s life, noting discrepancies between attitudes
toward alcohol and alcohol-associated harms, emphasizing strengths, supporting life goals, and
empathically supporting the student on ways to implement change, or remaining neutral when
met with ambivalence (Schaus, Sole, McCoy, Mullett, & O’Brien, 2009). Outcomes studies
have demonstrated that at-risk students who received brief motivational interviewing at a
university health service drink less alcohol and report fewer alcohol-related harmful incidents
(Ehrlich, Hague, Swisher-McClure, & Helmkamp, 2006; Schaus et al., 2009).
Decreasing underage drinking requires sustained partnerships between government agencies,
schools and colleges, parents, and local communities. The role of nurses in decreasing alcohol-
related events involving students of all ages may begin in school-based health services. It also
includes a coordinated effort among nurses in counseling services, health clinics, primary care
offices, public health agencies, and hospital emergency departments to identify students’ at-risk
behaviors, implement evidence-based treatments, and educate students and others. Evidence-
based programs most effective in decreasing alcohol-related harms to underage populations
include (1) developmental prevention programs, (2) early screening and brief intervention, (3)
government laws and school policies to reduce harmful incidents, and (4) tertiary treatments for
those who meet criteria for substance use disorder or other associated mental disorders (to be
reviewed later in this chapter) (Toumbourou et al., 2007). The midcourse review of Healthy
People 2020 suggests that concerted public health efforts are lowering the rates of binge
drinking in the past 2 weeks by college students from 41.1% in 2007 to 35.4% in 2014,
exceeding the 2020 target (National Center for Health Statistics [NCHS], 2016).
Older Adults
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Katherine takes some time to ask Mr. Campbell how he thinks he is doing. She wants to
begin with an open-ended question to assess how he feels about his health status. But he
only responds by saying “I’ve got nothing to complain about” and smiles weakly. To
Katherine, he appears sad and depressed. She asks him whether he has noticed that he
has lost some weight, and he agrees that he has not been eating as he should. When she
asks him why he thinks his appetite has changed, he says, “I really miss cooking for all
the guys in the firehouse, and now that my wife is gone, I just don’t have the motivation to
cook for myself.”
It is clear that Mr. Campbell is undergoing some major life transitions, which indicates
to Katherine that she needs to screen for substance use using the Short Michigan
Alcoholism Screening Test—Geriatric Version (SMAST-G). She also asks Mr. Campbell’s
daughter to put all the prescription medications and over-the-counter medications that her
father takes at home in a brown bag and bring them to his next appointment.
Evidence for Practice
The National Guideline Clearinghouse has 68 evidence-based treatment protocols for
substance abuse, including screening and treatment of older adults. The protocols
recommend screening for alcohol and prescription drug use yearly for all older adults and
more frequent screening if there are any major life changes or transitions, or if physical
symptoms suggestive of substance abuse appear. Recommended screening instruments
for older adults include the Michigan Alcoholism Screening Test—Geriatric Version (MAST-
G), the CAGE questionnaire, and the Alcohol Use Disorders Identification Test (AUDIT)
(Naegle, 2008). (Geriatric Nursing Resources for Care of Older Adults has more information
available online.) Evidence-based practice protocols may be effective for evaluation of older
adults for substance misuse or alcohol abuse (the National Guideline Clearinghouse’s
website has additional information). To assess prescription and nonprescription medication
use among older adults, the protocols recommend the “brown bag approach”—asking the
older adults to bring in all the medications they take to the practitioner in a brown bag.
Substance misuse is emerging as a major public health concern for older Americans. The “baby
boom” generation, the cohort with the greatest lifetime use and dependence on both alcohol and
illicit substances, is now entering older adulthood. Not only will the “baby boomers” strain
healthcare services because of their sheer numbers, but unlike previous generations,
epidemiologists predict the rates of substance use disorder will greatly increase given the “baby
boomers’” past patterns of drug and alcohol use (Mattson, Lipari, Hays, & Van Horn, 2017).
Older adults who are most at risk of being diagnosed with substance abuse disorders are those
who began drinking alcohol or using illicit drugs when they were 16 years of age or younger
(Han, Gfroerer, Colliver, & Penne, 2009). The number of older adults with substance abuse
disorders is expected to more than double from approximately 2.8 million in 2002 to 5.7 million
in 2020 (Han et al., 2009).
Evidence for Practice
A study examining trends in opioid prescriptions for noncancer pain in Medicare Part D
recipients who are 65 years of age or older, found the rate of prescriptions almost doubled
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from 2007 to 2012 (Kuo, Raji, Chen, Hasan, & Goodwin, 2016). Prolonged prescription of
opioids to Medicare Part D recipients for more than 90 days significantly increased the odds
of opioid overdose requiring emergency department evaluation and hospitalization by 60%.
Prescription of opioids to Medicare Part D recipients without cancer was lower in states with
laws regulating pain clinics (Kuo et al., 2016). States with Prescription Drug Monitoring
Programs also saw prescriptions to Medicare Part D recipients for high-potency opioids
(e.g., oxycodone) decrease and the length of opioid treatment shortened (Moyo et al.,
2017). The findings of these studies suggest that state regulations are having a measurable
effect on decreasing the volume of opioid prescriptions to older adults for noncancer pain.
Practice Point
Chronic health conditions in older adults, such as cardiac, respiratory, kidney, and liver
disorders can all be adversely affected by drug and alcohol abuse. Drug and alcohol use also
puts the older adult at greater risk for neurocognitive symptoms that can precipitate falls or
other accidents that can cause skeletal injuries and hip fractures. In recognition of the unique
needs and risks of substance misuse among older adults, The New Jewish Home in New
York established the first in the nation nursing home–based recovery program for older
adults. The program offers team-focused treatment with integrated care among medical,
nursing, mental health, and addiction professionals as well as self-help groups such as
Alcoholics Anonymous. Evidence-based interventions are all provided within the Jewish
Home’s Geriatric Substance Abuse Program for co-occurring medical, substance, and mental
disorders with sensitivity to culturally diverse populations. When a resident is discharged,
continuity of care to support sustaining recovery is provided by The Jewish Home’s Senior
Day Care and certified home care services. For more information, see
https://jewishhome.org/substance-abuse/
The SAMHSA National Clearinghouse for Treatment Improvement Protocols advises that
men older than 65 years drink no more than one drink a day, or two drinks in any one occasion,
and that women older than 65 years drink even less (SAMHSA Treatment Improvement
Protocol for Substance Abuse Among Older Adults, available online). However, comorbid
medical conditions may substantially reduce levels of acceptable drinking in the older adult, and
even much lower rates of alcohol consumption may put the older adult at risk.
Nurses should regularly screen for alcohol use using the MAST-G, which has been
demonstrated to be a reliable and valid measure in older adult populations (Naegle, 2008). As of
August 2016, the USPSTF is reviewing routine screening for illicit drug use across all age
cohorts (USPSTF, 2016, update available online). Nurses can assess for illicit and prescription
drug use by conducting a thorough health history, examining urine and blood toxicology values,
as well as systematically assessing older adults for symptoms suggestive of either intoxication or
withdrawal symptoms from illicit substances and multiple classes of prescription medications,
including benzodiazepines, opioids, and sedative hypnotics. In addition, nurses should inquire
whether older adults are using over-the-counter preparations with caffeine (such as diet aids),
cold remedies that have anticholinergic side effects or include alcohol, and herbal remedies that
can have interactive effects with either prescription or nonprescription substances.
According to SAMHSA’s Treatment Protocols for Substance Abuse Among Older Adults,
benzodiazepines should not be prescribed for longer than 4 weeks, sedative hypnotics should not
be prescribed for longer than 7 to 10 days, and antihistamines should be avoided completely
because of changes in mental status that can result from anticholinergic effects. Misuse or
excessive use of prescription as well as nonprescription medication may be a function of
diminished cognitive capacity, poor vision, language barriers, lack of understanding about drug
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interactions, or the propensity for schedule II medications to cause dependence and tolerance.
SAMHSA has characterized substance abuse among older adults as an “invisible epidemic”
(Lofwall, Schuster, & Strain, 2008, p. 898). Treatment Improvement Protocol for Substance
Abuse Among Older Adults recognizes that there are many barriers to care for the older adult
which are similar to those of other age groups such as language barriers, poor access to
transportation, lack of health insurance, living in rural regions, and insensitivity of healthcare
practitioners to the needs of racial and ethnically diverse populations (SAMHSA, 2012b). Other
barriers noted by SAMHSA (2012b) as specific to older adults are a lack of substance disorder
programs targeting the unique needs of older adults, as well as a lack of public awareness about
the extent of substance abuse in older populations, including among healthcare providers. In the
face of these challenges, Sorrell (2017) emphasizes that nurses are ideally positioned in their
roles as advocates and providers to address the gaps in substance use care for older adults
especially in long-term care facilities.
Evidence for Practice
The USPSTF has found sufficient scientific evidence to recommend that positive screens
for alcohol abuse be followed up with brief alcohol counseling in the primary care setting
(USPSTF, 2013). It has described behavioral counseling of alcohol abuse in terms of the
five As: (1) assess using standardized screening instruments; (2) advise the older adult to
reduce alcohol consumption to moderate levels; (3) agree on goals for reducing alcohol use
or for increasing abstinence; (4) assist clients with acquiring the motivations, self-help skills,
or supports needed for behavior change; and (5) arrange follow-up counseling and
treatment (USPSTF, 2013).
Practice Point
SAMHSA (2017c) has developed a toolkit entitled “Get Connected” with detailed resources
for community health nurses to address the unique needs of older adults with respect to
SUD. Support materials include educational curricula for healthcare providers and older
adults as well as fact sheets that include tips for older adults and evidence-based treatment
recommendations for clinicians.
Nurses and other health providers may mistakenly attribute the presenting signs and
symptoms of substance use disorder in older adults to depression, dementia, or other medical
conditions. The nursing assessment of older adults may also be complicated by the inclination of
many older adults to mask their symptoms and deny that they need treatment (Han et al., 2009).
Nurses in all settings must be cognizant that the symptoms of delirium in the older adult may be
related to polysubstance intoxication or withdrawal. The changing profile in substance use
among older adults, from alcohol to polysubstance abuse, in combination with a precipitous
increase in the sheer numbers of older adults needing substance use treatment, has profound
clinical and public health implications (Lofwall et al., 2008, p. 902). As health educators,
community health nurses have an important role in communicating to older adult populations
that the national recommendations about acceptable levels of alcohol consumption decrease as
they age.
Self-help programs are widely used community-based treatments that have proven efficacy
in sustaining recovery for people with substance abuse disorders. Alcoholics Anonymous (AA)
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and Narcotics Anonymous (NA) are the two largest self-help groups for substance dependence
or abuse, and both have local peer-support groups throughout the United States. To encourage
participation by older adults, AA has developed an education pamphlet that includes
testimonials by older adult members entitled AA for the Older Alcoholic—Never Too Late
(available online).
Persons Who Inject Drugs
Beginning in the 1980s, proponents of syringe exchange programs argued that by providing
sterile needles to people who inject drugs, pathogens transmitted by sharing needles would be
lessened, slowing the spread of HIV, hepatitis, and other blood-borne diseases. In the ensuing
years, as scientific evidence accumulated demonstrating the efficacy of syringe exchange
programs in decreasing the spread of HIV, the CDC, medical associations, public health
agencies, and the ANA all formally endorsed syringe exchange programs as a sound public
health initiative (Bluthenthal, Heinzerling, Anderson, Flynn, & Kral, 2008; Villarreal & Fogg,
2006). Syringe exchange programs are one component credited in public health prevention
strategies that lowered the rate of HIV transmission in people who injected drugs in the 1980s
(Paz-Bailey, 2016).
More recently with the incidence of heroin use increasing, accompanied with a rise in young
people injecting drugs, there has been a resurgence of HIV and hepatitis C infection in some
communities lacking public health prevention programs (Paz-Bailey, 2016). Syringe Service
Programs (SSPs) have proven effectiveness in protecting people who inject drugs from blood-
borne illnesses, but as of 2013 the approximately 2,000 SSPs were primarily located in
metropolitan areas with few in rural or suburban communities (Paz-Bailey, 2016). To promote
the expansion of SSPs in regions vulnerable to outbreaks of blood-borne diseases from injection
drug use, the Consolidated Appropriations Act of 2016 provided federal funds to underwrite the
costs of SSPs including staffing and treatment for medical, mental health, and substance use
care. It is important to note that the federal funds may not be used for the purchase of sterile
syringes for injection of illicit drugs (Fig. 17.6).
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FIGURE 17.6 Syringe service programs: A vital part to combat opioid, HIV, and hepatitis
epidemics (December 2016). (From CDC Vital Signs. Retrieved on September 5, 2017, from
https://www.cdc.gov/hiv/pdf/risk/cdc-hiv-syringe-services-programs .)
Evidence for Practice
A quality improvement (QI) project initiated by public health nurses reflects the challenges
of implementing the core components of SSPs. An audit of 46 client medical records in an
opioid treatment program found the majority of records did not reflect referral of patients
with positive HIV, STD, or PPD screens (Gadbois, Chin, & Dalphonse, 2016). Clinic nurses
identified time constraints and difficulties with the electronic medical record limiting their
ability to make referrals. The QI project team collaborated with administrators and clinic
nurses to implement new systems for referrals and shared documentation to facilitate
communication between clinic nurses and the agency’s STI/HIV Prevention Program.
Medication reconciliation was improved by having all prescribers in the opioid treatment
program enroll in the state’s Prescription Monitoring Program. The opioid treatment program
added new staff including primary care providers within the program to minimize referrals of
clients to a local healthcare center and a nurse case manager to coordinate patient-
centered care. The findings of the QI project highlight the key role of public health nurses to
assure evidence-based, patient-focused care in opioid treatment facilities (Gadbois et al.,
2016).
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Numerous studies have demonstrated that the safest and most effective treatment for
injection drug users is opioid substitution treatment with long-acting opioids such as methadone
or buprenorphine (Gerra et al., 2009; Mattick, Kimber, Breen, & Davoli, 2008). Unfortunately,
access to opioid substitution treatment in the United States has been limited by a lack of
methadone maintenance programs or waiting lists for those that do exist. Office-based treatment
with buprenorphine can also potentially expand the availability of opioid substitution treatment,
but up until the passage of the Comprehensive Addiction and Recovery Act (CARA) of 2016,
the number of physician participants was constrained by FDA requirements for training and
accreditation. CARA temporarily expanded the eligibility to prescribe buprenorphine for SUD to
nurse practitioners (NPs) and physician assistants (PAs) who complete the FDA requirements
for training and are supervised by a physician who is certified to prescribe buprenorphine
(Leahy, 2017). Healthy People 2020 midcourse review (NCHS, 2016) reported admissions for
injection drug use treatment increased from 255,374 in 2006 to 300,230 in 2011 and that 19.5%
of the people who needed treatment for illicit drug use, received treatment exceeding the target
of 17.6%.
Methamphetamine Users
Methamphetamine is a highly addictive stimulant. From 2010 to 2014, the rate of
methamphetamine overdose deaths more than doubled and nearly 20% of those deaths also
involved heroin (Warner, Trinidad, Bastian, Minino, & Hedegaard, 2016). Persons who inject
drugs may co-inject methamphetamine, a stimulant, with heroin to counteract heroin’s
depressant effects. Co-injection of methamphetamine with heroin greatly increases the risk of
overdose and death because methamphetamine has a shorter half-life than heroin (Meacham et
al., 2016). Methamphetamines increase libido and are associated with high-risk sexual behaviors
that may in turn increase the risk of HIV and STD transmission (Warner et al., 2016). Public
health prevention programs for people who inject drugs described previously are an important
component of treatment for methamphetamine users.
Methamphetamine maybe produced in home “laboratories” by cooking readily available
ingredients (e.g., drain cleaner, fertilizer, starter fluid, and pseudoephedrine) at high heat (CDC,
2005; Denehy, 2006; McGuinness, 2006). The process is extremely hazardous and noxious
odors from the toxic chemicals released in the manufacturing process can disperse and threaten
the health of communities (Denehy, 2006). In contrast to other incidents involving the release of
hazardous fumes or materials in communities, adverse events associated with methamphetamine
“laboratories” have a much greater percentage of injured victims (31%) with most being police
officers (56%) and the general public (33%) (CDC, 2005). First responders (60%) and the
general public (34%) were also the most likely to require decontamination from hazardous
toxins emanating from methamphetamine “laboratories” (CDC, 2005).
It is important to note that children have been found in 20% of the homes containing
methamphetamine “laboratories” (CDC, 2005). Children who are chronically exposed to acetone
or ammonia fumes are at grave risk for neurologic, psychological, and physical harm (Denehy,
2006; McGuinness, 2006). In addition to the signs of abuse and neglect, a distinguishing
characteristic of children exposed to ammonia fumes released in methamphetamine production
is a smell like the odor of cat urine (Denehy, 2006). Chemicals used in the manufacture of
methamphetamine are highly explosive, and anyone in proximity to the methamphetamine
“laboratory” is in danger of sustaining severe burns (Mitka, 2005). Toxic and hazardous
chemicals used to manufacture methamphetamine may contaminate local neighborhoods and
have necessitated the evacuation of surrounding residences (CDC, 2005).
The danger methamphetamine poses to individual people, families, and communities
requires a multifaceted prevention strategy that incorporates public health and law enforcement
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agencies. To disrupt the availability of ingredients needed to manufacture methamphetamine, in
2000, the Methamphetamine Anti-Proliferation Act put restrictions on the amounts of
pseudoephedrine that could be purchased over the counter and regulated the distribution of other
key ingredients used in the manufacture of methamphetamine (Birckmayer, Fisher, Holder, &
Yacoubian, 2008). Departments of Health in states with high rates of methamphetamine
manufacture and addiction, launched public health education efforts using media campaigns
which depict the ravaged faces of young methamphetamine addicts to graphically illustrate the
morbidity associated with methamphetamine use. A pamphlet available through the National
Clearinghouse for Alcohol and Drug Information entitled Tips for Teens: The Truth About
Methamphetamine, states bluntly in bold letters, “Methamphetamine can kill you. An overdose
of meth can result in heart failure. Long-term physical effects such as liver, kidney, and lung
damage may also kill you.”
Practice Point
Denehy (2006) urges all school nurses to be part of the solution to the methamphetamine
epidemic through education of children, families, and the community about the effects of
methamphetamine use, and through advocacy for prevention and treatment programs.
IMPACT ON THE COMMUNITY
The NIDA (2017c) estimates that costs to the United States from substance abuse has risen
substantially over the past decade to a staggering $740 billion annually. Communities hit hardest
by substance use are often ill equipped to combat the adverse effects on the quality of life in
their neighborhoods, homes, and schools. The states spend $81.3 billion on substance abuse–
related services, including prevention programs, family assistance, mental health, public safety,
criminal justice, and healthcare (SAMHSA, 2008). The Paul Wellstone and Pete Domenici
Mental Health Parity and Addiction Equity Act (MHPAEA) and the Affordable Care Act have
improved private insurance coverage for substance abuse treatment (SAMHSA, 2016).
Nonetheless, with the marked increase in demand for treatment, without added federal monies or
private insurance reforms, the added burden on states and local government to assume the bulk
of costs for substance abuse treatment may result in less access to services.
Evidence for Practice
The National Institute on Drug Abuse (2012) estimates that every dollar invested in
addiction treatment programs yields a savings of between $4 and $7 in reduced drug-
related crime, criminal justice costs, and theft. When savings related to healthcare are
included, total savings can exceed costs by a ratio of 12 to 1.
PUBLIC HEALTH MODELS FOR POPULATIONS AT
RISK
Community health nurses play a critical role in screening populations at risk for preventable
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disease. Population research suggests that there is a window of vulnerability for later
development of addiction if initial substance use precedes age 15 (Crome & McLellan, 2013). A
challenge in identifying people at risk for substance abuse is that many healthcare practitioners
in primary care do not directly, or routinely, ask about alcohol or drug use across all age groups
when collecting information about a person’s health history. Reliable and valid screening
instruments that are easy to administer are important tools to aid community health nurses in
evaluating populations and individual people at risk for substance abuse. In 2004, the USPSTF
issued a national recommendation that all adults in primary care should be routinely screened for
alcohol use with the AUDIT-C or CAGE questionnaires (Box 17.8). The AUDIT-C, CAGE, and
SMAST-G screening instruments are now available in a pocket-sized brochure to facilitate use
in all primary care settings. (The SAMHSA website provides further information.)
Screening for substance use is the first step in assessing whether a person has substance use
disorder. The efficacy of screening instruments is highly dependent on the candor of client
responses. Putting the client at ease with a nonconfrontational request to ask a series of
questions about health behaviors and beginning the conversation with less-threatening questions
about diet, sleep, and exercise are helpful transitions to questions pertaining to alcohol use.
17.8 AUDIT-C and CAGE Screening Instruments for Alcohol Abuse
1. How often do you have a drink containing alcohol?
0 = Never
1 = Monthly or less
2 = 2 to 4 times per month
3 = 2 to 3 times per week
4 = 4 or more per week
2. How many drinks containing alcohol do you have on a typical day?
0 = None
1 = 1 or 2
2 = 3 or 4
3 = 5 or 6
4 = 7 or more
3. How often do you have…
[MEN]—five or more drinks on one occasion
[WOMEN]—four or more drinks on one occasion
0 = Never
1 =
–> Mental health 5,042
–> Primary care 7,176
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https://data.hrsa.gov/topics/health-workforce/shortage-areas
https://datawarehouse.hrsa.gov/topics/shortageAreas.aspx
Medically underserved areas/populations Designated medically underserved
areas/populations
4,235
Evidence for Practice
Area Health Education Centers (AHEC, 2018) focus on strengthening the supply and
distribution of primary care providers in rural and underserved areas. As noted by the Rural
Health Information Hub (www.ruralhealthinfo.org), AHECs “act as community liaisons with
academic institutions and assist in arranging training opportunities for health professions
students” (RHIhub, 2018), prepping students for rural healthcare via:
the recruitment and training of minority students and those from disadvantaged
backgrounds
the use of student placements in community-based clinical practices settings (with a focus
on primary care)
improvement in quality of care by promoting interprofessional education and collaboration
facilitation of programs and continuing education resources for health professionals in rural
and underserved areas
pipeline activities that expose high school students to health careers (RHIhub, 2018)
A state directory of all AHECs is available via the National AHEC website, which lists 56
current programs (and more than 235 centers nationwide). These centers, which are funded
federally via the HRSA Bureau of Health Workforce (and use other options to match their
federal funding), collaborate with approximately 600 nursing and allied health schools and
120 medical schools.
Among the successful programs and activities that AHECs have created are the
following (which have been tailored to the needs of the region):
Rural Experiences for Health Professions Students (REHPS), based in the Yankton
Rural Area Health Education Center, which placed health professions students in rural or
frontier areas of South Dakota, helping to raise awareness of healthcare needs in those
areas of the state
The Naloxone Education Empowerment Distribution Program, organized by the San
Luis Valley Area Health Education Center, operated a training and certification program
(which ended in September 2016) for the administration of naloxone by healthcare workers
and community members
Project PROMISE (Providing Rural Opportunities in Medicine through Inspiring
Service and Education) from North Carolina, which gave high school seniors the
opportunity to have medical academic training, mentor relationships, and experience in
working in rural medical facilities
The Targeted Rural Underserved Track (TRUST) program, in locations throughout
Washington, Wyoming, Alaska, Montana, and Idaho, which enabled students to return on a
regular basis to learn and work in the same community
The Forward NM Pathways to Health Careers program, which supported comprehensive
workforce pipeline programs for middle and high school students, undergraduates, medical
students, graduate students, and resident physicians
The MU-AHEC (University of Missouri Area Health Education Center) Summer
Community Program, which allowed second-year medical students to work under rural
community-based physicians (in 4- to 8-week programs)
Source: Rural Health Information Hub (RHIhub). (2018). Area Health Education Centers (AHEC). Retrieved from
https://www.ruralhealthinfo.org/topics/workforce-education-and-training#ahec.
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http://www.ruralhealthinfo.org
https://www.ruralhealthinfo.org/topics/workforce-education-and-training#ahec
Lydie lived in a nonmetropolitan, rural area that was technically classified as an MUA. As
such, she inherited many prospective problems despite the numerous benefits. By
moving to a less populated area, she had more privacy, cleaner air, and less automobile
traffic in a natural, country setting. However, when she became ill, shortages related to
the availability of qualified, local healthcare personnel contributed significantly to primary,
secondary, and tertiary prevention and her growing list of comorbid conditions and her
eventual death.
Can you determine what areas of this country are designated as MUPs, MUAs, and HPSAs?
Does the HRSA offer scholarships for healthcare personnel to obtain their respective degrees for
entry to practice?
If the HRSA does offer support, are there contingencies? What are they?
How would a community and public health nurse begin to address the notion of assurance for a
population of interest?
Evidence for Practice
Wines (2016) describes the challenges that need to be considered to deliver an educational
program in nursing (Baccalaureate Program) to those men and women who want to
become nurses who live in rural areas. The author advises that rural teaching in distance
programs takes motivated faculty who are willing to approach challenges using innovative
techniques and exceptional communication skills. Faculty must look beyond the common
hospital placements for clinical sites when in the rural environment and need to create
innovative opportunities using synchronous distance learning methods and unique clinical
applications. There is evidence that supports that making the effort to identify and educate
motivated faculty can yield exceptional results. The challenges of creating and delivering
rural programs to those who know the area and culture the best can be overcome with effort
and creative approaches to the traditional profession education modalities.
Morbidity and Mortality Issues
From an epidemiologic perspective, rural population trends indicate a primarily aging
population related to outward migration of youth. Despite a net loss of all levels of population
leaving rural areas over the last 60 years from out-migration, more recently older retired adults
and young people with families have returned to rural areas (Smith, Winkler, & Johnson, 2016).
In rural areas, there is less racial diversity (residents are mostly Caucasian), although there are
pockets of population diversity (Hispanics in Texas, Native Americans in Arizona and New
Mexico). Other characteristics of people who live in rural areas are less college education,
higher high school dropout rate, and decreased income (and thus lower socioeconomic status).
On the other hand, the cost of living is lower. Families struggle with homelessness and poverty.
Females head many families. Employment opportunities are few. Because of the various
constraints mentioned, women and children often are the most vulnerable and suffer the most in
terms of lack of adequate healthcare. Box 18.3 for more detailed information.
Bolin and colleagues (2015) describe how rural health priorities have changed little in the
last decade. The health of rural America is more important than ever to the health of the United
States and the world. Rural Healthy People 2020 was to serve as a counterpart to Healthy
People 2020, providing evidence of rural stakeholders’ assessment of rural health priorities and
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allowing national and state rural stakeholders to reflect on and measure progress in meeting
those goals. The specific aim of the Rural Healthy People 2020 national survey was to identify
rural health priorities from among the Healthy People 2020’s (HP2020) national priorities (Box
18.4).
18.3 Health Factors and Effects of Living in Rural Geopolitical Areas
Only about 10% of physicians practice in rural America despite the fact that nearly one fourth of the population
lives in these areas.
Rural residents are less likely to have employer-provided healthcare coverage or prescription drug coverage, and
the rural poor are less likely to be covered by Medicaid benefits than their urban counterparts.
Although only one third of all motor vehicle accidents occur in rural areas, two thirds of the deaths attributed to
these accidents occur on rural roads.
Rural residents are nearly twice more likely to die from unintentional injuries, other than motor vehicle accidents,
than urban residents. Rural residents are also at a significantly higher risk of death by gunshot injuries than urban
residents.
Rural residents tend to be poorer. On the average, per capita income is $7,417 lower than in urban areas, and rural
Americans are more likely to live below the poverty level. The disparity in incomes is even greater for minorities
living in rural areas. Nearly 24% of rural children live in poverty.
People who live in rural America rely more heavily on the federal Food Stamp Program, according to the Carsey
Institute at the University of New Hampshire. The institute’s analysis found that although 22% of Americans lived
in rural areas in 2001, a full 31% of the nation’s Food Stamp beneficiaries lived there. In all, 4.6 million rural
residents received Food Stamp benefits in 2001, the analysis found.
There are 2,157 health professional shortage areas (HPSAs) in rural and frontier areas of all states and U.S.
territories compared with 910 in urban areas.
Abuse of alcohol and use of smokeless tobacco is a significant problem among rural youth. The rate of driving
under the influence (of alcohol) arrests is significantly greater in nonurban counties. Forty percent of rural 12th
graders reported using alcohol while driving compared with 25% of their urban counterparts. Rural 8th graders are
twice as likely to smoke cigarettes (26.1% vs. 12.7% in large metro areas.)
Anywhere from 57% to 90% of first responders in rural areas are volunteers.
There are 60 dentists per 100,000 population in urban areas vs. 40 per 100,000 in rural areas.
Cerebrovascular disease was reportedly 1.45 times higher in nonmetropolitan statistical areas (non-MSAs) than in
MSAs.
Hypertension was also higher in rural than in urban areas (101.3 per 1,000 people in MSAs and 128.8 per 1,000
people in non-MSAs.)
Twenty percent of nonmetropolitan counties lack mental health services vs. 5% of metropolitan counties. In 1999,
87% of the 1,669 mental HPSAs in the United States were in nonmetropolitan counties and home to over 30
million people.
The suicide rate among rural males is significantly higher than in urban areas, particularly among adult men and
children. The suicide rate among rural women is escalating rapidly and is approaching that of men.
Medicare payments to rural hospitals and physicians are dramatically less than those to their urban counterparts for
equivalent services. This correlates closely with the fact that more than 470 rural hospitals have closed in the past
25 years.
Medicare clients with acute myocardial infarction (AMI) who were treated in rural hospitals were less likely than
those treated in urban hospitals to receive recommended treatments and had significantly higher adjusted 30-day
post-AMI death rates from all causes than those in urban hospitals.
Rural residents have greater transportation difficulties reaching healthcare providers, often traveling great distances
to reach a doctor or a hospital.
Accidents resulting in death and serious injury account for 60% of total rural accidents vs. only 48% of urban. One
reason for this increased rate of morbidity and mortality is that in rural areas, prolonged delays can occur between a
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crash, the call for emergency medical services (EMS), and the arrival of an EMS provider. Many of these delays
are related to increased travel distances in rural areas and personnel distribution across the response area. National
average response time from motor vehicle accident to EMS arrival in rural areas was 18 minutes, or 8 minutes
greater than in urban areas.
Source: National Rural Health Association (NRHA). (2018). What’s different about rural health care? Retrieved from
http://www.ruralhealthweb.org/go/left/about-rural-health.
Access to healthcare continues to be the most frequently identified rural health priority.
Within this priority, emergency services, primary care, and insurance generate the most concern.
A total of 926 respondents in this study identified access as the most pressing priority, followed
by nutrition and weight status (n = 661), diabetes (n = 660), mental health and mental disorders
(n = 651), substance abuse (n = 551), heart disease and stroke (n = 550), physical activity and
health (n = 542), older adults (n = 482), maternal infant and child health (n = 449), and tobacco
use (n = 429).
Identifying challenges is a critical aspect of rural health assessment. Creative solutions to
key challenges related to access to care with the input and participation of the populations
affected are critical. For example, veterans who are aging and live in rural areas are being served
through a geriatric scholar program (GSP), a Department of Veterans Affairs’ workforce
development program directed to all disciplines working with veterans who are aging. The intent
of the program is to infuse geriatric competencies in primary care using a multimodal
educational program to target primary care providers and ancillary staff who work in Veteran
Administration–sponsored rural clinics. GSP uses didactic presentations, webinars, audio
conferences, clinical practica, and mentoring in these programs (Tumosa et al., 2012).
Interprofessional teams that contain nurses are starting to make a difference in addressing the
needs of people and their families in rural areas.
18.4 Ranking of Rural Health Priorities (Healthy People 2010 and Healthy People
2020 Goals)
1. Access to quality healthcare
2. Heart disease
3. Diabetes
4. Mental health and mental disorders
5. Oral health
6. Tobacco use
7. Substance abuse
8. Education and community-based programming
9. Maternal, infant, and child health
10. Nutrition and overweight
11. Cancer
12. Public health infrastructure
13. Immunization and infectious disease
14. Injury and violence prevention
Evidence for Practice
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http://www.ruralhealthweb.org/go/left/about-rural-health
1. Researchers tested a computer-based electronic screening tool (eScreening) for
depression and alcohol use as a way to evaluate primary care needs of rural residents
(Farrell et al., 2009). eScreening uses a portable computer-based format. The study
involved (1) a focus group with providers, (2) usability testing with selected rural clients
using a computerized touch screen, and (3) implementation of the touch screen platform
with a small sample in primary care to determine feasibility. Consumer response was
extremely positive.
2. One study explored the incidence of depression in a sample of 48 people visiting a
primary care clinic in rural southeastern North Carolina (Kemppainen, Taylor, Jackson,
Kim-Godwin, & Kirby, 2009). Forty percent of the participants met the criteria of clinical
depression according to the Center for Epidemiologic Studies Depression Scale (CES-D).
Depression was highest in single, African American men who were employed, with
adequate health insurance. Researchers attributed this primarily to work-related stressors
in dealing with overwhelming social problems of other rural residents and their own
economic problems. Critical incident interviews identified self-management strategies for
depression and sources of social support.
3. A program intended to encourage relationship building, called the Rural Health
Roundtable Project, has prompted change in rural communities (Pennel, Carpender, &
Quiram, 2008). This project involves identifying culturally relevant, sensitive topics. In
an informal, social environment where participants feel comfortable sharing, targeted
questions engage participants and empower local residents. Follow-up is part of the Rural
Health Roundtable Project, which has demonstrated its value as an effective tool in
working with rural communities. These communities, which have fewer human and
financial resources at their disposal, can use the project strategies to identify and make the
most of their unique strengths when responding to public health emergencies and natural
disasters. Initiated in 1999, the methodology has been refined and enhanced over the past
8 years to more effectively reach participants, promote sharing and discussions, build
stakeholder networks, and encourage continued communication and collaboration. The
Rural Health Roundtable Project has significant potential for replication and application
to all areas of rural public health.
Elderly People
Elders, who are diverse in culture and ethnicity, face many challenges as they age in rural
settings. According to Krout and Kinner (2007), most elders do not live on farms. They may be
isolated in a variety of housing situations, including family homes in which they brought up
their families; the children may have left the area and the parents may live as widows or
widowers. They have incomes that can be up to 20% lower than that of their urban counterparts
because of lower social security payments, smaller levels of assets in the bank or in property,
less pension coverage, and less opportunity to make up the difference because of lack of part-
time employment possibilities (Krout & Kinner, 2007). In many cases, fewer options for leisure
and recreation are available to these older people.
What complicates these issues are the healthcare service components that are lacking, or are
created on the basis of the primary mechanism of payment (i.e., Medicaid). Generally, there are
fewer healthcare professionals—physicians, nurses, occupational therapists, and physical
therapists—in rural areas, especially with expertise in gerontology, palliation, and end-of-life
care. Lack of public transportation puts a burden on the elderly to find private transportation. If
they are disabled or cannot drive, dependence for transportation rests on the network of
friendships or connection to relatives that may or may not be in place.
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It was once said that the moral test of government is how that government treats those
who are in the dawn of life, the children; those who are in the twilight of life, the elderly;
and those who are in the shadows of life, the sick, the needy, and the handicapped.
Hubert H. Humphrey
In Lydie’s case, she had no relatives or friend networks available to help, primarily
because she chose to live a solitary life that she thought was health promoting for her. In
the end, her approach isolated her so much that she had little recourse but to deal with
her healthcare issues from a preventive perspective; she prided herself on “not needing
those doctors and nurses” and not seeking any primary care treatment. In her mind,
toughness in not doing this was a sign of personal and spiritual strength.
When it comes to elder care in rural communities, seven factors compound disease
prevention and health promotion efforts to identify and reduce modifiable risk: (1) availability,
(2) accessibility, (3) affordability, (4) awareness, (5) adequacy, (6) acceptability, and (7)
assessment. These are defined in Box 18.5. Community and public health nurses should discover
how to deal with these issues. They should realize that they can use meeting places that seem to
draw the greatest group of citizens to good effect. The nurses can work toward developing an
education infrastructure to help rural citizens at least understand what modifiable risks they may
be facing and how they may receive help if a coalition of requested services can be initiated. For
example, in MUPs in inner cities, healthcare professionals often reach elders through churches.
In rural areas, solutions may begin through education in a church, post office, or grocery store.
In addition, public health nurses, in collaboration with interested citizens and other professional
disciplines, can work together developing networks of volunteers to help with transportation
needs or other needs that may be identified from a thorough assessment.
Student Reflection
I will never forget my experience in the rural part of a county where I volunteered one
summer to help the elderly. Although I was going into my senior year in nursing school and
had explained that I wanted to help the elderly with healthcare teaching, I was initially
dismayed to know that I would have to go door-to-door with a team of young adults like
myself and ask whether there was any need for minor home repairs. My teammates were a
physical therapy student and an occupational therapy student. The idea was to help in a
practical way with minor issues in the elders’ homes, and while doing this work, to take the
opportunity to assess health needs and provide health education. It was the best time I had
as a nursing student. I really felt as though we students were preventing problems from the
beginning and dealing with problems that we found from a health and safety perspective,
without shaming elders into thinking they were weak or unable to care for their needs.
18.5 Factors That Compound Disease Prevention and Health Promotion
1. Availability: Insufficient number and diversity of formal services and providers; lack of acceptable
services and human service infrastructure
2. Accessibility: Shortages of adequate, appropriate, and affordable transportation; cultural and
geographic isolation
3. Affordability: Poverty and inability to pay for services
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4. Awareness: Low levels of information dissemination; literacy issues
5. Adequacy: Lack of service standards and evaluation; evidence-based practice compromised
6. Acceptability: Reluctance to ask for help
7. Assessment: Lack of basic information on what is needed using research rigor and analyses
Source: Krout, J. A., & Kinner, M. (2007). Sustaining geriatric rural populations. In L. L. Morgan & P. S. Fahs (Eds.). Conversations in the disciplines:
Sustaining rural populations (pp. 63–74). Binghamton, NY: Global Academic Publishing.
Occupational and Environmental Health Problems
Occupational health is of particular concern in rural communities, where farmers live. Although
the number of people who choose farming as a lifestyle choice has been decreasing steadily over
the years, people who do select it as an occupation are exposed to many dangerous conditions in
an environment that puts them at risk for injury or death. Farming is a hazardous profession. The
total number of agricultural fatalities has been decreasing in recent years, but according to the
Bureau of Labor Statistics (2016), the only group with higher fatalities at work than those
civilians working as driver/sales workers/truck drivers were farmers, ranchers, and other
agricultural managers.
From a family perspective, it is often the case that parents and children help with the work
on the farm so there is variability in experience and developmental knowledge. This lifestyle
may contribute to injuries and a larger effect on families in general.
Finally, community and public health nurses evaluating safety must consider that farmers
and their families work outdoors throughout the year in all sorts of weather and are exposed to a
variety of conditions (extremes of heat and cold, snow, sleet, rain, tornados, and drought).
Possible contact with chemical treatments applied to the land (e.g., pesticides, fertilizers) also
adds variability to the direction of health promotion and injury prevention.
Evidence for Practice
Nilsson (2016) collected data in an international study through interviews from 20 parents of
children who own and work on farms. This study examined farming parents’ attitudes and
experiences regarding having their children grow up on farms, focusing on four themes: (a)
the most dangerous places and situations on the farm; (b) children’s tasks on the farm; (c)
children as a safety risk on the farm; and (d) farm risk education for children. Nilsson
concluded that most farming parents were aware of the risks on the farm; however, the
parents could be sometimes careless when they worked under stress or exhaustion. Some
parents wanted more information, and “some wanted compulsory preventative or safety
measures by manufacturers, e.g. a safety belt as standard on the extra seat in tractors.
Children’s friends were described as one of the greatest risks for injury due to peer
pressure. Some parents mentioned that people who grow up on farms are sometimes ‘blind’
to the dangers. Other parents seemed to overlook the risks and had their children carrying
out tasks for which they were not mentally or physically equipped. It is thus important for
farming parents to be repeatedly reminded of the risks to their children and to increase their
awareness of how to prevent and eliminate risks in order to avoid accidents on the farm”
(Nilsson, 2016, p. 1).
Although this chapter does not explicitly address migrant or seasonal workers’ conditions on
farms, these circumstances have come under scrutiny in terms of sanitation, emergency
healthcare, and primary care during the time of high harvest intensity. Although workers and
families who are involved in farming may vary by age and education, it is consistently the case
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that language barriers, health literacy, and generally lower educational status compound efforts
to promote health and advance prevention by those involved with rural health initiatives.
Evidence for Practice
1. In many national and international settings, a relevant and sensitive approach to helping
population groups obtain healthcare assistance and guidance, involves the use of health
promoters or navigators. These key people can relate to specific groups with particular
healthcare needs (Pereira, Enard, Nevarez, & Jones, 2011). There were 11 million
unauthorized immigrants in the United States in 2015, a small but statistically
significant decline from the estimated 11.3 million in 2009 (Pew Research Center, 2018).
The Pew Research Center’s preliminary estimate of the unauthorized immigrant
population in 2016 was 11.3 million, a number statistically no different from the 2009 or
2015 estimates. Unauthorized immigrants represented 3.4% of the total U.S. population in
2015 (Pew Research Center, 2018). Per Pew’s research, the number of unauthorized
immigrants reached a peak in 2007 at 12.2 million, with that group then representing 4%
of the U.S. population.
Not all people living within the U.S. borders benefit from the healthcare system in the
United States, as many Americans are without health insurance coverage despite state and
federal efforts to make this not the case. For this reason, many people use emergency
departments for all of their health needs. Only one in five farm workers is able to obtain
health insurance through either his or her employer or the state or federal government
(Pew Research Center, 2018). The lack of health insurance makes it increasingly difficult
for the uninsured and undocumented populations to obtain healthcare, and more than two
thirds of this population is living in poverty.
2. Another article has described a model of risk for HIV and problem drinking in Latino
labor migrants in the United States (Sanchez, Silva-Suarez, Serna, & De La Rosa, 2012).
Specific risks that need to be addressed for this group include stressful living and working
conditions, not just drinking behaviors that may compromise safe sex practices. The
broader environmental risk in this unique population of Latinos needs to be addressed
with a new model for interventions.
In most rural areas, the issue of access has been addressed with managed care organizations
(MCOs) since 2008 (Willging, Waitzkin, & Nicdao, 2008). MCOs build provider networks and
encourage community health plans so that local providers of healthcare can control cost. Mobile
clinics, school-based health programs, and telehealth systems (programs that use wireless and
nonwireless electronic devices to communicate health information for educational or diagnostic
purposes) are other ways by which distance between healthcare providers and family members
can be addressed. At the local level, transportation volunteers and parish or church visitors can
help decrease isolation and help families share health resources with adjacent rural areas. There
needs to be a concentrated focus on prevention with particular emphasis on decreasing or
eliminating smoking behaviors; decreasing sun exposure; reducing fat intake; and educating
families about the signs and symptoms of depression, heart disease, diabetes, and cancer.
From a professional perspective, working in rural areas can have positive and negative
aspects. In areas where people and communities have problems maintaining connections, it is
important to create a way to interact, or network, with other professionals for professional
support and diagnostic assistance. Working in a rural area offers opportunities to be creative and
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to “think outside the box” and not merely consider the usual care methodologies. Community
and public health nurses have to use limited resources effectively.
The work of healthcare professionals in rural areas may not be as intensive as would be the
case in a large medical center in an urban setting, or even in a community-based service in an
urban setting. In areas where healthcare is intensive, there are also many opportunities to learn a
specific discipline. What is intriguing and perhaps attractive in rural settings is the slower pace,
with the opportunity to engage in relationships with communities that could be long-lasting and
ultimately might prove more rewarding. Roles and disciplines are more blurred in rural areas
because of lack of resources. So it may be the case that collaboration, interprofessional work,
and self-care within the context of caregiving all become matters of pragmatic healthcare and
intervention.
CORRECTIONAL HEALTH: UNDERSERVED
POPULATIONS IN JAILS AND PRISONS
In the United States, detention centers, jails, and prisons are places that provide safety to the
public by incarcerating people who have committed crimes and who are deemed a threat to
society. There are a variety and levels of jails and prisons, ranging from detention centers, where
inmates await arraignment or care decisions and where there is high turnover, to minimum- or
maximum-security prisons, where there are longer lengths of stay for inmates in some cases.
Generally, minimum- and maximum-security prisons are administered by the states, and
penitentiaries are federally administered prisons in which inmates are incarcerated for crimes
against the government. In correctional institutions, there is a disproportionate number of
persons of color, regardless of youth, gender, and age (Nellis, 2016). Incarceration may be
socially determined, but in the final analysis, the health of the people in this system is
compromised. Many reports contain evidence that illness and injury arrive at institutions with
the inmates or detainees, occur in these areas, and recycle back into neighborhoods when
inmates and detainees leave.
Maybe I won’t stay out of prison. Who knows? Jack Kevorkian
All levels of prevention need to be addressed for all people in correctional facilities. For
example, the Children’s Defense Fund (CDF) has taken a leadership role in addressing the issues
of children being in a “pipeline” spiraling into lives of violence and crime because of a variety
of negative contributing variables leading to arrest, conviction, incarceration, and death (CDF,
2009). The CDF supports initiatives at the individual, family, community, organizational, and
government levels (Box 18.6). The Cradle to Prison Pipeline is a CDF campaign designed to
bring public attention to this issue.
Where do you see community public health nurses contributing care and healing that
relates to Saliha (see Box 18.5)? Give specific examples.
Most inmates are males who are African American or Latino. The average age of inmates is
37. Prisoners who are incarcerated for violent crimes have been involved in rape, murder,
sodomy, kidnapping, armed robbery, and sexual offenses, and 34% are in high- or maximum-
security facilities, and 40% are serving sentences of more than 10 years. However, 75% of all
prisoners are nonviolent and have been incarcerated for drug possession and trafficking, bribery,
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and extortion. Of those who are African American, 14.5% are women and 52% are incarcerated
primarily on drug possession or prostitution charges (U.S. Department of Justice, Bureau of
Justice Statistics, 2018).
Many have conjectured that poverty, violence and abuse as children, lack of education, and
poor self-esteem have made incarceration an area where those who are oppressed are further
oppressed and exposed again to violence, mental health problems, and physical morbidities.
Issues that face inmates, their families, and healthcare providers who work in prisons include
security issues; despairing attitudes; overcrowding; the increased risk of communicable diseases
such as tuberculosis, HIV infection, sexually transmitted infections (STIs), and hepatitis C; and
fragmentation of families. Community and public health nurses may find conflicts with the will
of the warden or person in charge of the area of incarceration and the standards of nursing
practice. For example, state nurse practice acts are in direct conflict with participation in the
highly politicized issue of capital punishment. Despite the autonomous nature of nursing
practice and medicine, the decision maker in jails and prisons is often the warden or director.
Thus, conflicts of interest and philosophy can and do occur (Nolan & Walsh, 2012).
After release from incarceration, inmates often face social injustices and economic problems.
The ability to find appropriate shelter at a reasonable cost is becoming very difficult, as is
finding social support that prevents recidivism. Trying to help families reconnect with adequate
financial and rehabilitation support is extremely difficult. Literacy and job training are important
family-centered approaches to maintaining a productive and financially stable life. Many men
and women describe how repeating crimes that put them back in jail or prison is a way to bring
them to a place where they feel protected and escape the painful realities they face on release
(Nellis, 2016).
What is critical to understand about those in prison returning to their home communities is
how important it is to understand the integral connection and responsibility that is mutually
shared. Those in charge of prison health and those in charge of health in communities need to
help each other in creating the best opportunities for all types of success for citizens. Those
citizens who have health problems “upstream” will bring them “downstream” and vice versa.
Probably the only place where a man can feel really secure is in a maximum-security
prison, except for the imminent threat of release. Germaine Greer, Australian author
18.6 Solution Pyramid for Youth (Children’s Defense Fund)
Individual People
Mentor a child.
Volunteer at an after-school program for youth.
Vote in every election and advocate for children.
Educate elected officials about the Cradle to Prison Pipeline.
Host a house party to educate others about the Cradle to Prison Pipeline and what they can do to dismantle it.
Volunteer with children who are homeless or in foster care.
Organize a forum on incarcerated youth and the funding disparities between prisons and education in our nation.
Volunteer your talents or professional services to help a single-parent, kinship care, or foster care family by
babysitting, inviting them to events with their children, or providing transportation.
Invite youth to events at the next educational level (i.e., taking a high school student to a college basketball game).
Families
Spend quality time with your family (i.e., family game night, eating meals together).
Join the Parents Teachers Association (PTA), a parent support group, or other school group.
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Attend school activities and/or volunteer in the classroom.
Consistently praise your child’s achievements in school and extracurricular activities.
Establish and maintain a supportive home learning environment.
Create daily homework routines and limit television viewing.
Offer tutoring and homework help to your children or younger siblings.
Offer to run errands or help around the house.
Communicate with and listen to your child.
Talk and actively listen to children within your extended family.
Show affection, love, and respect to your child every day.
Do something fun with your child or sibling.
Adopt a foster child or become a foster parent.
Communities
Institute a “cradle roll” within your faith-based institution or community, linking every child to a permanent, caring
family member or adult mentor who can keep them on track and get them back on track if and when they stray.
Promote learning by starting an after-school program for children.
Ensure that at least one caring community member attends every public school student suspension meeting or court
hearing.
Encourage families to spend quality time together by hosting a movie or game night at your church.
Start a support group for single-parent or kinship care families.
Provide job opportunities and guidance for families and youth in need.
Create college scholarships for children from disadvantaged, foster care, and kinship care families.
Work with school officials to develop and adopt more child-appropriate discipline policies and procedures.
Reach out to youth who are homeless or in foster care.
Prepare care packages of new clothes, personal toiletries, and/or a welcome gift for children placed into foster care
homes.
Hold events to celebrate the strengths of our children and provide college scholarships and leadership opportunities
to youth.
Start a halfway house and counseling program for youth who have run away.
Create a summer job opportunity for a youth.
Create and distribute a community resource manual so that parents know where to turn for help for their families.
Organizations
Invest in prevention and early intervention.
Host a health fair to ensure that all children who are eligible for Medicaid or your state children’s health insurance
program are enrolled.
Provide free tax filing assistance to low-income working families.
Educate families about how they can apply for food stamps, Head Start, federal nutrition programs, and other
similar benefits.
Create and distribute a calendar of free family-friendly community events.
Start a parent education program to familiarize parents about conflict resolution in the home and how to advocate
for their children.
Encourage alternatives to incarceration such as restitution, community service, electronic monitoring, drug
rehabilitation treatment, or placement in a “staff secure” (but not locked) community corrections facility.
Work to ensure that counseling, social services, education, and health and mental health services are provided to at-
risk youth.
Fund reinvestment in urban communities, such as parks, schools, and roads.
Write annual child and gun violence reports to track the killing of children and call for effective gun control
measures and nonviolent conflict resolution training.
Host a Cradle to Prison Pipeline summit to connect and educate others about this “pipeline” and ways to dismantle
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it.
Government Agencies
Bring other elected officials and leaders together to gain firsthand awareness of the status of your local children;
demonstrate what is working and what is not.
Ensure children in foster care and detention receive quality treatment to address their mental, behavioral, and
emotional needs.
Promote high-quality children’s television programming and access to other quality electronic media.
Provide high-quality early childhood development programs for all.
Ensure all children and pregnant women access to affordable, seamless, comprehensive health coverage and
services.
Establish policies that emphasize prevention and rehabilitation to keep children out of or rescue them from the
pipeline.
Expand “second chance” programs for high school dropouts, ex-offenders, and at-risk youth to secure General
Equivalency Degrees (GEDs), job training, and employment.
Reduce repeat offender rates by focusing on treatment- and family-oriented approaches.
Make sure that every child can read at grade level by fourth grade and graduate from high school able to succeed in
postsecondary education and/or work.
Organize state and local leadership councils or committees to create strategic plans to address the learning and
developmental needs of children.
Invest money in community-based rehabilitation centers and treatment programs to serve as an alternative to
juvenile detention and prison.
Stop the criminalization of children at increasingly younger ages.
Create partnerships with local businesses, schools, and/or churches to create quality exit programs for those leaving
the juvenile justice system as a way to start them on the “Pipeline to Success.”
Source: Children’s Defense Fund (CDF). Cradle to Prison Pipeline campaign—Key immediate action steps. Retrieved from
http://www.childrensdefense.org/helping-americas-children/cradle-to-prison-pipeline-campaign/action-steps.html.
Practice Point
In the context of healthcare prevention education, one of the most important functions nurses
can address when caring for people who have left correctional institutions is to discern
whether the client has a health literacy challenge. Direction and encouragement of where to
obtain support to advance education through a variety of extension programs and special
projects can be important to preventive work at the individual, family, and community level.
Sixty percent of people entering prison today are illiterate. Jeffrey Archer
Evidence for Practice
Out of concern that standards for pregnancy-related healthcare in jails and prisons need to
be established, followed, and accredited regularly, a study specifically examined the
healthcare practices of pregnant women in state prisons using a survey with 62 multiple
choice questions and four open-ended questions. Wardens of 50 women’s state
correctional facilities were contacted to involve them in the process. Of the 50 contacted, 19
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http://www.childrensdefense.org/helping-americas-children/cradle-to-prison-pipeline-campaign/action-steps.html
completed the survey, a 38% response rate. The findings of this study gave evidence that
substandard care does exist for pregnant incarcerated women in correctional facilities. More
specifically, nutritional recommendations for a healthy pregnancy are not met, adequate rest
is compromised, and lower bunks are not required. Psychosocial support and education are
minimal and the use of restraints, which can compromise the health and safety of the
woman and her baby, continue, including during labor and delivery. A key finding was that
best practices are not used generally and there is a serious need to address the unmet
healthcare needs of this marginalized population, and support legislation to limit the use of
restraints with pregnant incarcerated women (Ferszt & Clarke, 2012).
Criticism abounds in terms of the quality of care offered at correctional institutions. People
who end up in prison systems almost always struggle with chronic, difficult-to-change
healthcare problems such as chronic mental health issues, substance addiction, proclivity to
violent acts, and risky behaviors, leaving them vulnerable to STIs in general and HIV/AIDS in
particular. Although part of the reason for lack of quality care relates to maintaining qualified
and inspired healthcare personnel, the more formidable issue is public financing of the growing
numbers of inmates’ healthcare needs. Box 18.7 for commentary of a medical director in
Michigan concerning prison inmates.
According to van den Bergh, Gatherer, Fraser, and Moller (2011), from a local and global
perspective there are also serious concerns related to the need for gender sensitivity directed to
the care of women and their experience in prisons. Women prisoners, although a minority within
all prison systems, have special health needs that are frequently neglected. The evidence in the
literature includes a lack of gender sensitivity in policies and practices in prisons, violations of
women’s human rights, and failure to accept that imprisoned women have more and different
healthcare needs compared with male prisoners. Many of these violations are related to
reproductive health issues, mental health problems, drug dependencies, and histories of violence
and abuse. Additional needs stem from their frequent status as a mother and usually as the
primary caregiver for her children.
18.7 Summary of Study Criticizing Prison Healthcare
The medical director for a Grand Rapids clinic serving low-income patients was the technical adviser to
Michigan’s prisons.
Findings released indicate 32 changes needed to improve healthcare in the prisons.
Infectious diseases, such as hepatitis C, need treatment.
Inadequate care during incarceration must be addressed to face current burden in hospitals and other healthcare
providers in the community on release.
Report recommends reviving the Legislative Corrections Ombudsman, a position the legislature eliminated in
2003, and creating a permanent legislative committee to oversee prison medical care and mental healthcare.
Source: Adapted from Shellenbarger, P. (2008). Study criticizes prison health care. The Grand Rapids [Michigan] Press. Retrieved from
http://blog.mlive.com/grpress/2008/02/study_criticizes_prison_health.html.
In Michigan, a for-profit MCO called Correctional Medical Services has been hired to
address the healthcare needs of inmates in the state’s correctional system. Use of this kind of
organization often occurs because many healthcare professionals find it difficult to work in the
conditions of correctional institutions. From a community and public health perspective,
students and licensed nurses should consider the contribution they could make in these settings
with regard to primary, secondary, and tertiary prevention. Whatever improvements nurses
engender concerning mental health, communicable disease, and physical wellness will
eventually be a positive contribution to a family, a neighborhood, and a community.
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http://blog.mlive.com/grpress/2008/02/study_criticizes_prison_health.html
Student Reflection
It was really exciting to work with my nursing professor, who is not only a clinician but also a
researcher in a project about the nursing care of incarcerated women, in a detention facility
for women. We worked together over a 10-week period using yoga exercise as an
intervention to effect perceptions of well-being. In the first week, we measured vital signs
and completed a health history, measured depression on a self-report inventory, and also
asked questions about perceptions of wellness. Then we met weekly and helped the women
participate in yoga. Following these meetings, we took the measurements again. Some
important changes took place in perceptions of wellness, especially mental health. But what
really struck me was how happy the women were to be able to do something and
accomplish something while they were in prison. As I got to know them, I felt very sad that
many were in jail for crimes they committed to keep themselves from becoming even poorer
(sex work, selling drugs). They were poor women trying to survive, not mass murderers.
Many of them talked about their children, who were in foster care or with family members.
All I could think was that these women not only had to heal themselves when they left jail
but also their families, or the cycle will continue.
GAY, LESBIAN, BISEXUAL, TRANSGENDER, AND
QUEER COMMUNITY
Not all people are attracted to people of the opposite sex all the time. Some belong to the
LGBTQ community. Many people in this community have experienced actual or perceived
discrimination. Part of the discrimination is not intentional but comes from a lack of thoughtful
sensitivity on the part of healthcare providers in not examining the assumptions made about
lifestyles based on stereotypes. Some of the problem stems from assessing and offering
interventions related to health issues using the standards of heterosexual patients. Healthcare
providers working with LGBTQ clients need to understand that not all of these people are
openly “out of the closet” and that confidentiality is extremely important in light of active
discrimination. Such discrimination may involve work, housing, health insurance, and financial
support if the client is in a domestic partnership with another person.
Gay people are the sweetest, kindest, most artistic, warmest, and most thoughtful people
in the world. And since the beginning of time all they’ve ever been is kicked. Little
Richard
Jan is a good example of someone who is trying to approach her health in good faith, with
a preventive orientation, but who may easily be persuaded to not to return to a primary
care physician because of lack of consideration of her specific needs.
How would you address the needs of healthcare professionals who wish to understand the specific
needs of unique populations?
Are there best practices that can help inform healthcare professionals related to how to assess
what the specific needs may be?
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Student Reflection
Several months ago, I was involved as a leader in an education discussion about prevention
of STIs with a group of women in a drop-in center in the inner city. Boy, was I embarrassed!
I assumed that everybody in the group was heterosexual. In reality, four of the women there
were lesbians and had brought their significant others with them. All of the information I
shared was regarding risk related to intercourse or oral sex between a man and a woman
alone. After the session was over, I was really horrified when the two couples told me about
the sexual orientation of people in the group. I felt as though I perpetuated assumptions
about sex and did not provide helpful statistics about risk.
My instructor and I came up with a solution. We were able, with these couples’
permission, to recontact some members of the group who had attended originally and asked
if they would like to bring some of their friends who may be in the same type of relationship
with them so we could specifically address their needs in a tailored session of prevention
messages. So about a month later, we had a lesbian/bisexual safe sex session that was
uniquely constructed just for these people. It was so successful that many members of the
group, who vary in age from 24 to 60 years, continue to meet in a supportive capacity. It has
been a bonus to see the intergenerational sharing and support.
Student Reflection
I had no idea what the “Q” meant in the LGBTQ community. I consulted my clinical faculty
member and he explained that when the “Q” for QUEER is used it means an individual is
questioning their identity and is uncertain of their orientation. My clinical faculty helped me
understand that not everybody is sure of their identity which may make them more
vulnerable in opening up and being honest with clinicians about what they are experiencing
or thinking about the life’s past, present, and future. Not everybody is clear about where
they stand in the alphabet of LGBTQ. One of the things that I remember from this
conversation is that although the word “queer” may be offensive to providers because they
don’t understand what it means, it is also important to let patients self-identify their
orientation followed by caring acceptance on the part of the provider. Being identified as
“queer” can mean different things to different people, so the best thing to do is just to say
that you would like to understand more about what this means for the patient and what are
the things from a health perspective that are of concern so you can address those issues
directly. Finally, when it comes down to it, using or not using the word “queer” is an
extremely personal choice; the important thing is to let people identify themselves, no matter
what that identity might be. We all deserve the dignity to decide who we are for ourselves.
In the course of assessment, diagnosis, and treatment of LGBTQ people, community and
public health nurses should be aware that partners need to be included in care decisions; be
familiar with key health concerns of this population such as STIs, alcohol and substance abuse,
depression, and suicide; and become comfortable with asking healthcare assessment questions
that include LGBT lifestyles, so that key prevention opportunities are not missed. For example,
during a physical assessment, it is essential to ask a client whether he or she has sex with men,
women, or both; this information is critical in identifying further clarifying questions about
high-risk behaviors and sex. No healthcare provider should assume that a client is homosexual
or heterosexual based on appearance or other factors.
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Evidence for Practice
1. One seminal research article has examined the literature to provide clinicians with
evidence-based recommendations for care of lesbian clients (Roberts, 2006). Data
organization related to specific health problems was noted frequently in the research
articles. Findings and conclusions include that lesbians have previously been invisible in
health services and research. Lesbians are “coming out” more and more with healthcare
providers, which means that data about them can be collected. Data now show that
lesbians are at risk for cancer, heart disease, depression, and alcohol abuse. Adolescent
lesbians are especially at risk for smoking, as well as depression and suicide. However,
screening for these conditions continues to be low in lesbians.
2. In a world where healthcare needs of the LGBTQ population is increasingly important,
healthcare professionals require appropriate academic and clinical training in preparation
for the increased demand for culturally competent care. Nurses are of particular interest,
as they are the core direct caregivers in many healthcare settings. This research study
explored the national climate around LGBTQ individuals. The conclusion is that
educators need to be committed to ensure the development of knowledgeable
practitioners who will be able to implement best practices in LGBTQ patient care.
Attention should be paid to providing students with diverse clinical placements, access to
LGBT interest groups, and clear expectations for LGBTQ-sensitive nursing care plans
and course outcomes selection that promote cultural competence (Lim, Brown, & Jones,
2013).
3. One qualitative study has used ethnography to identify, describe, and classify the effect of
sociostructural factors on men who have sex with men and HIV transmission risk (Natale,
2009). Included are the perceptions of HIV risk in four subgroups: HIV-positive, Latino,
black, and young (18 to 24 years) men who have sex with men. Results classify
participant-perceived transmission factors into sociostructural factors (e.g., social, health,
economic, political, and mental health). This article also addresses significant areas of
social stigma and discrimination—critical areas that need to be addressed to promote the
general health of these men as well as their sexual health. It is also important to prevent
and treat substance use in this population.
4. Families are of critical importance in Latino communities in the United States. Research
has shown that familism—or the cultural ideal that involves reliance on nuclear and
extended family members for emotional support, connectedness, honor, loyalty, and
solidarity—reduces sexual health risks among heterosexual youth, yet this relationship
has not been examined among Latino bisexual teenagers. A complex construct, familism
has a strong potential for providing insights into sexual health practices of bisexual Latino
adolescents. One study examined how familism shapes sexual decision making regarding
behavior and expressions of bisexuality in Latino adolescents living in New York City
(Muñoz-Laboy et al., 2009). Twenty-five in-depth interviews and ethnographic
observations in bisexual males and females (15 to 19 years of age) for 9 months were the
basis for the study. Findings suggested that these bisexual Latinos value closeness to their
families by maintaining family ties and seeking emotional and material support from their
families. For those who wanted to keep their bisexuality private, the constant surveillance
of the family network is a negative.
Bradford and Mayer (2008) have identified 10 summary points of great concern related to
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demographic information and the needs of LGBTQ people. These points are valid and continue
to be relevant today. These points include the following:
The four different subgroups—gay, lesbian, bisexual, and transgender people—have unique needs. There
is little demographic data tailored to each of these separate groups.
Few population-based studies have been conducted in LGBTQ groups, with the exception of HIV-related
research, particularly in men who have sex with men.
Specific questions on surveys related to sexual orientation are lacking.
Recognition of same-sex heads of households has not always been included in survey data.
There is confusion regarding variability of expression of one’s identity, behavior, and attraction.
Cultural contexts vary across age and developmental staging about “coming out of the closet”; some
people (e.g., older gays or lesbians) may not feel comfortable with the word “queer.”
Fluidity of gender and sexual identity changes over time.
LGBT groups tend to experience more serious physical and mental health conditions, including
interpersonal violence and substance addiction.
Particular health concerns from a prevention perspective include obesity, injury, violence, and access to
healthcare facilities.
Health professionals are poised as confidants and trusted people to make significant preventive inroads at
all levels if they approach LGBTQ groups informed, with data.
One of the key goals in community and public health nursing is to begin to understand the
needs of LGBTQ people through specific training that addresses the needs of each particular
group. The assumption that this information is included in healthcare training programs for all
healthcare disciplines is often false. Many times, students need to attend extracurricular
programs that are supported by local initiatives or institutions that care for these populations
because of the unique nature of the information that needs to be shared. For example,
Transgender Awareness Training and Advocacy is an initiative started by Sam Lurie. He is a
transgendered man, or transman, who has used his own experience as a way to help inform
others of the needs of the transgender community (Transgender Awareness Training and
Advocacy, 2009).
Training is meaningful only if community standards are developed so that evidenced-based
practice can progress to assist people in these groups. Box 18.8 for an LGBT health access
project developed and supported by the Massachusetts Department of Public Health
(Massachusetts Department of Public Health, 2018).
Practice Point
When taking a sexual history, always ask whether a client is having sex with men, women, or
both. This clarification is critical in offering prevention, health promotion, and risk advice. It is
crucial that healthcare providers also be respectful by using the term “sexual orientation”
versus “sexual preference.” Although many LGBTQ people are not ashamed of their lives,
many would also admit that their identity, behaviors, and attractions have caused a
significant amount of personal pain related to stigma and isolation (i.e., sexual orientation
may not have been their choice).
It is critical for community and public health nurses to ask questions in order to be sensitive
to the LGBTQ community. This method is a healing approach that may decrease stigma and
isolation.
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VETERANS AND HEALTH
The brave men and women who serve their country and as a result live constantly with the
war inside them exist in a world of chaos. But the turmoil they experience isn’t who they
are; the PTSD invades their minds and bodies. Robert Koger
There are 2 million reintegrated veterans in the civilian sector and 1 million veterans suffering
from nonvisible or visible trauma (Conrad & Armstrong, 2016, 2017). While almost 10,000
veterans who participated in the Global War on Terror (GWOT) are receiving their healthcare in
Veteran’s Administration (VA) hospitals, many of them are receiving care in a variety of
settings from a variety of healthcare providers. In many cases, a veteran admitting they need
care is the first hurdle to entering any healthcare system, only surpassed by the readiness of the
healthcare taskforce to appropriately care for this group. Conrad and Armstrong (2016, 2017)
discuss specific issues related to women veterans as an underserved and unique population but
many of the points made apply to all veterans. The importance of providing cultural sensitivity
in care for deployed veteran men and women is primary (Conrad & Armstrong, 2017) in
addition to continual need for advocacy in care (Conrad & Armstrong, 2016).
18.8 Community Standards of Practice for the Provision of Quality Healthcare
Services to Lesbian, Gay, Bisexual, and Transgender Clients
The Gay, Lesbian, Bisexual, and Transgender Health Access Project is a collaborative, community-
based program funded by the Massachusetts Department of Public Health. The project’s mission is to
foster the development and implementation of comprehensive, culturally appropriate, quality health
promotion policies and healthcare services for lesbian, gay, bisexual, and transgendered (LGBT) people
and their families. Research has indicated that fear of discrimination and stigma cause many LGBT
people to postpone or decline seeking medical care. Others, once in care, sometimes withhold from their
providers personal information that may be critical to their well-being.
Working closely with consumers and clinicians across the state, the Gay, Lesbian, Bisexual, and Transgender
Health Access Project works to confront the insensitivity and ignorance that many LGBT people have experienced
in accessing healthcare and related services.
In addition, the project seeks to support LGBT people in understanding and acquiring the quality care they need.
The need for community standards emerged from several sources, including: (1) a statewide provider survey, (2) a
1997 Gay, Lesbian, Bisexual, and Transgender Health Access Project report, and (3) health concerns of the LGBT
community. Among other things, these reports detailed a serious lack of LGBT awareness and understanding
among healthcare providers in Massachusetts. Some believed that they had no LGBT clients or staff in their
facilities; many were unsure about what their role should be in identifying and addressing LGBT issues; and a few
had policies in place to guide personnel or consumers.
To address these concerns, the Gay, Lesbian, Bisexual, and Transgender Health Access Project convened a
community working group of more than 60 consumers, providers, public, and private agency administrators and
staff. The group worked to develop a framework to improve LGBT access to quality care and to assist clinicians
and their facilities in creating responsive environments. This group’s efforts were guided by four principles: (1) the
elimination of discrimination on the basis of sexual orientation and gender identity, (2) the promotion and
provision of full and equal access to services, (3) the elimination of stigmatization of LGBT people and their
families, and (4) the creation of health service environments where it is safe for people to be “out” to their
providers.
The community standards of practice and quality indicators outlined in this document will guide and assist
providers in achieving these goals. The standards address both agency administrative practices and service delivery
components, including the following areas:
1. Personnel
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2. Client’s rights
3. Intake and assessment
4. Service planning and delivery
5. Confidentiality
6. Community outreach and health promotion
LGBT people live in and seek healthcare and prevention services in every community in Massachusetts.
Eliminating barriers to care requires both an educated and empowered consumer base and a skilled, culturally
competent, sensitive, and welcoming provider community that is openly supportive of LGBT people and their
families. These standards are one tool for achieving greater healthcare for all.
Source: Massachusetts Department of Health. (2013). Gay, lesbian, bisexual and transgender health access project. Retrieved from http://www.lgbthealth.org.
18.9 Common Themes of Underserved Populations
Blaming the victim, healthcare professionals, and others assuming abuse/neglect/incompetence
Making poor choices and having the wrong priorities on the part of individuals, families, and populations
Powerlessness and vulnerability
Nobody cares about injury, infection, screening, preventive care
Civilian nurses need to understand the military culture to address the health needs of the
veteran men and women. Most healthcare providers do not understand the military culture that
contributes to how veterans seek access to healthcare. Veterans undergo intensive training
related to military values, tradition, norms, and expectations. In their training, they focus on the
fundamental indoctrination of military loyalty. After discharge and reunion in the civilian
culture, few veterans forget their military experience, yet they still keep the learned value,
tradition, and norms. As a result, seeking healthcare is considered weakness for some of them.
Moreover, there are specific needs of women in the military. The integration of the veteran
women in the civilian life after discharge from the military is significant since they will face
unique obstacles and challenges, which require appropriate care for smooth transition and
integration. For example, after deployment women veterans face physical, psychological, and
behavioral challenges to their health that often go undiscovered. Additionally, their lower
financial earning potential, lower level of education, higher family responsibility expectations,
racial diversity, poverty, homelessness, and age are all issues that should be considered in care
of this population. To intervene and help veteran women and men facing challenges and
problems, the authors recommend screening veterans receiving care in the healthcare setting by
simply asking if they served in the military or not as a standard of care and an estimate of
potential health risk. Asking this simple question could help the nurses and other health
providers to identify multiple health risks and healthcare needs. Increasing nurses’ awareness of
the needs of all veterans and providing culturally sensitive care is crucial especially in the care
provided to veteran women.
Typical healthcare risks and actual challenges that have been “underserved” in healthcare
systems caring for veterans include PTSD, military sexual trauma, suicide, and
productive/gynecologic/ urinary tract infections for women. Unfortunately, disparities in
treatment received by veteran women when compared with veteran men have been observed.
Examples include variation in treatment for HIV, cancer screening, and lipid-lowering therapy
among others.
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http://www.lgbthealth.org
Evidence for Practice
Johnson and colleagues (2013) explain the unique health problems and issues that are
experienced by the veterans. There is 22.5 million living military veterans. However, 75% of
the veterans in the United States are receiving their healthcare needs in organizations other
than VA hospitals. Therefore, it is important and significant for the non-VA nurses to
understand how to provide appropriate veteran center healthcare service. Empirical data is
provided to demonstrate that more and more veterans are coming into the health system
across time. For example, there had been an increase in the number of veteran women
between 2000 and 2010 (i.e., 1.6 to 1.8 million). This increase resulted in the need for
expanding the health services provided to the veteran women including gynecology and
women’s clinics. The nature of military culture including the veteran identity complicated by
traumatic brain injury, polytrauma, chronic pain, military sexual trauma, substance abuse,
homelessness, suicidality, and hazardous exposure is a formidable list of care need areas
that needs to be addressed with military cultural knowledge. Challenges faced by veterans
as a unique “social determinant of their health” include perceptions of civilians lacking
respect for the veteran, not fitting in the civilian life, and having high expectations of
themselves compared to civilians. In addition, veterans’ physical and psychological injuries
caused during battle affect their transition to the civilian life. Concerns about confidentiality,
embarrassment, lack of awareness about treatment and support resources, and fear of
shame and stigmatization make it particularly difficult to seek out healthcare. In the end,
more research is required to identify the long-term effect of military service on veteran
health as well as to investigate the effectiveness of the nursing interventions.
HUMAN TRAFFICKING
In this great land of the free we call it human trafficking. And so long as we don’t partake in
the luxury, ignoring slavery is of no consequence. It is much easier to look away and
ignore the victims. The person who ignores slavery justifies it by quickly deducing the
victim is a willing participant hampered by misfortune. D’Andre Lampkin
Human trafficking defined as “recruitment and transportation of the people for exploitation”
has severe physical and psychological impact on the survivors including, but not limited to,
depression and anxiety as well as chronic physical pain (Hemmings et al., 2016). It is estimated
that at least 13% of the healthcare providers had been in contact with suspected human
trafficking victims without even knowing it. The healthcare system nationally and globally is
lacking the detailed evidence-based guidelines that describe the assessment, planning, and
application of the appropriate intervention and treatment process that are required by the victims
of human trafficking. Therefore, there is an urgent need to increase the healthcare providers’
readiness and awareness related to the required healthcare needs for the victims of human
trafficking.
Hemmings and colleagues (2016) created a guideline for the healthcare providers to care
survivors of human trafficking. The guideline was created based on a systematic review of peer-
reviewed literature. Key areas that need to be addressed in caring for this group of patients
include promoting disclosure, providing care, ensuring safety, supporting recovery, working in
partnership, physical and psychological indicators needing to be addressed, and developing
ongoing services. Healthcare needs to include detailed needs assessment, securing informed
consent, and providing appropriate trauma care and culture-sensitive opportunities including an
interpreter if necessary. Also noted was the need to establish collaboration and partnership
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relationships with agencies, such as social services and law enforcement, to create a clear
treatment and referral plan for the identified trafficked cases.
Washburn (2018) points out that there are many misconceptions of victims of human
trafficking including but not limited to trafficked persons are only immigrants or foreigners or
the trafficked person will ask for help immediately. In fact, this vulnerable population he
identifies is made up often of children, young homeless and runaway youth, refugees,
immigrants, low-income people, LGBTQ, and others.
The nurse’s role includes vigilance to recognize a victim of human trafficking and respond
based on the approved protocol and procedures in the healthcare setting. When the nurse
suspects a trafficked victim, the priority is to provide appropriate safety and care. To maintain
the safety of the victim and the other healthcare personnel, the nurse should not confront the
trafficking event revealed itself. In a situation where the risk is high, the nurse should notify the
local law enforcement and the security. During the contact with the suspect trafficked person it
is recommended that principles of a safe interview be maintained. An example of interview
question that may help unravel data to create a plan of care include, “Does someone control,
supervise, or monitor your work/actions?” If the screening interview resulted in suspecting an
exploitation, the institution protocol should be followed. Finally, it is imperative that nurses and
healthcare providers develop primary, secondary, and tertiary prevention measures to impact this
evolving phenomenon. Washburn (2018) explained that the nurses could do a lot of things to
develop their awareness and consequently create prevention measures. Nurses can develop anti-
trafficking education program and advocate for it in different public settings. In the nursing
schools, faculty could provide the student with scenarios that include human trafficking to
increase the nursing students’ understanding of the evolving realities of this situation.
HOMELESS POPULATIONS
Was I always going to be here? No I was not. I was going to be homeless at one time, a
taxi driver, truck driver, or any kind of job that would get me a crust of bread. You never
know what’s going to happen. Morgan Freeman
Homeless people include single men, families with children led by single heads of households
(women), single women (bag ladies), and children (<18 years) who lack adult supervision. In
developed countries, the majority of homeless people are male and more likely to be black,
veterans, unemployed, struggle with mental health challenges and/or addictions, and are victims
of domestic violence (National Coalition for the Homeless, 2018). Many of these people take
refuge in homeless shelters, and others live in abandoned buildings, jails, hospitals, parks,
airports, and bus/train stations, as well as under bridges or in the entries to buildings.
Homelessness has many causes. Reasons for homelessness include the deinstitutionalization
efforts of the 1960s to mainstream the mentally ill into society, unemployment and
underemployment, domestic violence, abandonment, natural disasters and fires, disability,
substance abuse and addiction, immigration, and political unrest and wars (National Coalition
for the Homeless, 2018). Historically, many circumstances have led to homelessness, including
freedom from slavery, westward expansion, lumber and railroad work, the Great Depression,
and the aftereffects of war. In recent years, the shortage of affordable housing has been a key
reason (National Coalition for the Homeless, 2018).
I lived rough, by my wits, was homeless, lived on the streets, lived on friends’ floors, was
happy, was miserable. Ben Okri, Nigerian poet and novelist
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Reaching homeless people is difficult. It is not easy to provide care with trained and
experienced interprofessional teams because of the inability to locate clients in the community
by address or phone. Many homeless people have complications from decreased hygiene,
hypothermia, and hyperthermia; suffer from lice and scabies; and have diseases or conditions
such as tuberculosis, HIV infection, substance abuse and addiction, and dental problems. Even
trimorbidity (i.e., substance addiction, mental illness, and another chronic health problem such
as hypertension) is common in the homeless.
It takes much time and energy to build trust with the homeless before the many
comorbidities with which they are burdened can be addressed. Some approaches to
administering healthcare to the homeless have included not just offering shelter, but also
offering harm reduction as a way to keep clients alive without further complicating their serious
situations. For example, offering needle cleaning kits to users of intravenous drugs may decrease
the use of dirty needles at the individual and population level, or providing mobile homeless
units may make healthcare more accessible. Even with these efforts, homeless people may
refuse assistance. To promote accessibility to healthcare for these people, community and public
health nurses should approach homeless people in the following ways:
Show respect and use a positive approach, which builds trust.
Support primary (advocacy), secondary (tuberculosis screening), and tertiary (“detox” treatment)
prevention to make it easier to cope with difficult, challenging lives.
Evidence for Practice
1. Nationally and globally, needle exchange programs and supervised injection facilities,
although controversial, offer a harm reduction approach to intravenous drug users by
offering clean needles for use. Operational and systematic limitations exist, including
acceptable hours of operation, the location of the programs, and transportation needs.
Researchers have described a novel way to measure the effectiveness of supervised
injection facilities in Toronto and Ottawa, Canada. By creating a legally sanctioned place
for supervised consumption of illicit drugs to decrease Hepatitis C and HIV transmission.
The researchers concluded after computing direct healthcare costs and quality-adjusted
life-years (QALYs over 20 years) that $50,000 is the cost-effective threshold that was
maintained in three particular sites (Enns et al., 2016).
2. Researchers found that homelessness predicts attrition but not alcohol abstinence in
outpatients experiencing both alcohol dependence and mental health challenges. The
relationship between housing status and attrition and alcohol abstinence during treatment,
were evaluated in 79 adults diagnosed with alcohol dependence and serious mental
illness. Researchers found that 39% (n = 31) of participants reported being homeless at
baseline. Individuals who were homeless were more likely to drop out of care
management (n = 10, 62.5%) than those who were housed (n = 4, 16.7%), χ2(1) = 8.86, P
< 0.05. It was concluded that individuals experiencing homelessness and co-occurring
alcohol dependence and mental health challenges with care management had higher rates
of attrition, relative to those who were housed (Leickly et al., 2017). In exploring the
experience of people who are homeless, data was collected in homeless shelters and day
centers including those who were actually homeless (n = 28), previously homeless (n =
10), social workers and care providers (n = 48), and staff (n = 40). Experiences of end-of-
life care and opinions about this approach were examined through focus groups and using
qualitative analysis. Participants highlighted that conversations exploring future care
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preferences and palliative care with people experiencing homelessness are rare. Themes
identified as challenges to such conversations included attitudes to death; the recovery-
focused nature of services for people experiencing homelessness; uncertainty regarding
prognosis and place of care; and fear of negative impact (Hudson et al., 2017).
KEY CONCEPTS
In discerning community/public health practices as a nurse, one of the fundamental issues that needs to be
faced are the biases and prejudices that can be barriers to understanding the needs of populations.
Community and family assessments need to be grounded in trusting approaches that are mutually defined
between health professionals and those living in situations that are less than ideal.
Being a caregiver in a community where rural access, prison isolation, discrimination, and continuity of care
are all struggles of great magnitude allows nurses to do what they do best: heal, and not necessarily fix,
healthcare situations.
A key suggestion in carrying out the core values of public health may be to check the common themes or
biases that each of these groups experience “at the door” (Box 18.9).
CRITICAL THINKING QUESTIONS
1. What are the ethical and moral issues that present themselves when communities/cities/states choose to
address or not address the health needs of the populations covered in this chapter?
2. Are there legal obligations that you can identify in relation to rural, correctional, LGBT, or homeless
health? Give specific examples and what your recourse would be to address these issues.
3. Community violence is reported as an issue in all four of the populations described in this chapter. Identify
a coalition-building approach that could unify these communities regarding this issue (refer to Chapter 16
to assist you with this answer).
4. Why is it the case that single men are prominently represented in the homeless? Is there a primary
prevention program that could be a part of a public health initiative that would address this cohort
specifically?
HEALTHY PEOPLE 2020 ACTIVITY
In thinking about mental health, those that are underserved or considered as “vulnerable” populations often
experience many comorbid conditions that include serious mental illness (SMI). In referencing HP2020
objective MHMD 9.1 (Increase the proportion of adults aged 18 years and older with SMI who
receive treatment), identify how you would evaluate the incidence and prevalence of SMI in each of the
populations mentioned in this chapter and how would you go about evaluating access to mental health
treatment? Consider the social determinants of health and experiences of health disparities in your answers.
COMMUNITY RESOURCES
Rural health
Emergency medical services
Faith-based initiatives
Correctional/prison health
Local jails, correctional facilities
Police departments
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Detention centers for youth
Outreach programs directed to correctional facilities
Foster care agencies
Gay, lesbian, transgender, and bisexual populations
Community health and neighborhood centers
Local HIV/AIDS services
Veterans
Veterans Health Administration (U.S. Department of Veterans Affairs)
Human trafficking
The International Organization for Migration
UN Global Initiative to Fight Human Trafficking
Homeless populations and health
City and state housing authorities
Hunger and food assistance programs
Health programs and clinics targeted at this group
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Chapter 19
Environmental Health
Tarah S. Somers*
For additional ancillary materials related to this chapter. please visit thePoint
TEARS OF NATURE (A villanelle)
I think I just heard Mother Nature cry, Or was it one more broken, falling tree? You’d
think we’d learn as time goes speeding by.
They tell us there’s a big hole in the sky, We won’t believe in something we can’t see, I
think I just heard Mother Nature cry.
Coal-fired chimneys reaching up so high, Even though the solar power’s free, You’d
think we’d learn as time goes speeding by.
We develop rocket ships that fly, But still can’t stop pollution of the sea, I think I just
heard Mother Nature cry.
Headlines: One more species set to die, Keep it quiet…use diplomacy, You’d think
we’d learn as time goes speeding by.
Worry on the future? Pass it by! How can preservation start with me? I think I just
heard Mother Nature cry. You’d think we’d learn as time goes speeding by.
—Graeme King
CHAPTER HIGHLIGHTS
Human health and the environment
Assessing contaminants in the environment
Exposure pathways
Assessing the environment of a community
Planning interventions to make communities healthier
Evaluating interventions
Environmental epidemiology
Working toward healthy communities
Environmental justice
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http://thepoint.lww.com/vitalsource/ebook/9781975111694
Global environmental health issues
OBJECTIVES
Comprehend the links between human health and the environment.
Understand how the nursing process of using assessment, intervention, and evaluation can be used to
examine the impact of the environment on human health.
Describe the concept of an exposure pathway.
Describe several environmental conditions to consider when assessing the environment of a community.
Understand the concept of environmental justice.
Identify major global environmental health issues.
KEY TERMS
Bioavailability: The amount of a substance that is absorbed or becomes available at the site of
physiologic activity.
Biomonitoring: Process of measuring contaminants in blood or urine to determine whether a
person has been exposed to a contaminant and how much exposure he or she has received.
Environmental epidemiology: Field of public health science that focuses on the incidence and
prevalence of disease or illness in a population from exposures in their environments.
Environmental health: A field of public health science that focuses on how the environment
influences human health.
Environmental justice: The belief that no group of people should bear a disproportionate share
of negative environmental health consequences (regardless of race, culture, or income).
Exposure: Contact between a contaminant and the body.
Exposure estimate: Estimated amount of contaminant that comes in direct contact with the body
from inhalation, ingestion, dermal contact, or injection.
Exposure pathway: Describes how people are exposed to an environmental contaminant that
originates from a specific source.
Exposure history: Process to help determine whether an individual has been exposed to
environmental contaminants.
Healthy communities: Communities that optimize the physical, social, and economic
environments of the community.
Risk assessment: Process to determine the likelihood or probability that adverse effects such as
illness or disease will occur in a group of people because of an exposure to an environmental
contaminant.
Precautionary principle: If something has the potential to cause harm to humans or the
environment, then precautionary measures should be taken even if there is a lack of scientific
evidence for cause and effect.
Toxicology: The study of the adverse effects of chemicals on people, animals, and the
environment.
*The findings and conclusions in this report are those of the author and do not necessarily represent the
views of the Agency for Toxic Substances and Disease Registry.
CASE STUDY
References to the case study are found throughout this chapter (look for the case study icon).
Readers should keep the case study in mind as they read the chapter.
Chris is a public health nurse in a coastal town with a long, proud history of commercial and
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recreational fishing. Throughout the 20th century, many industries lined the edges of the harbor,
creating additional economic opportunities for the town. From 1940 to the 1970s, polychlorinated
biphenyls (PCBs) were used at the transformer facility that manufactured electrical capacitors and
transformers. As a result, soil and groundwater at the site, as well as at the building, are heavily
contaminated with PCBs. This facility is considered the major source of historic PCB contamination
of the harbor.
The facility is now fenced, and there is no public access to the contaminated soil and buildings.
The community is supplied by public drinking water sources which are not connected to the site’s
groundwater. Commercial fishing in the harbor is banned, and all commercial fishing takes place
out at sea. However, some members of the community frequently fish in the harbor, and they eat
the fish they catch to supplement their diets.
The community around the harbor enjoys seasonal recreational activities along the water and
sometimes boats on the water, but swimming in the harbor is difficult, since the shores are steep
and rocky and there is no beach area. Access to the water can really only happen from community-
owned piers.
INTRODUCTION
The environment can be considered as anything outside of ourselves whether human-made or
natural. Environmental health is the branch of public health science that focuses on how the
environment influences human health.
HUMAN HEALTH AND THE ENVIRONMENT
The environment can affect human health in many ways. Some of these effects are immediate
and obvious, such as when drinking water supplies are contaminated by sewage and flood water
after a hurricane. Other effects, such as contamination of a private well by arsenic, may be more
difficult to discover. Where people live, work, and spend time can have direct consequences on
their health. For example, living and working in highly urban environments may expose people
to higher concentrations of some air pollutants, but living and working in an agricultural setting
may expose them to more pesticides. Exposure occurs when there is contact between people
and an environmental contaminant which can happen from ingesting, breathing, or touching a
contaminant.
Peoples’ environment can have positive or negative effects on their health. Conditions in the
environment may exacerbate existing health conditions. For example, people with asthma may
experience more asthmatic episodes on days when air quality is poor. The poor air quality may
not cause asthma, but it may induce more frequent and severe asthma attacks in people who
already have asthma.
The environment can also help improve people’s health. If residents of a certain town
believe that they can safely walk in their community, they may choose to walk instead of drive
to the store or to schools. This can help increase their activity levels and decrease obesity or
other chronic diseases. It could also lead to less pollution from cars, which, in turn, improves air
quality. In some ways, the built environment can be intentionally designed to help make people
healthier.
What is the use of a house if you haven’t got a tolerable planet to put it on? Henry David
Thoreau
History of Environmental Health
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Historically, people often did not clearly understand the links between environment and health
and did not recognize how humans influenced their environment. As nations became
industrialized, the effects on the quality of air and water became more apparent. People also
began to take note of the impact on ecosystems as plants, animals, or other wildlife began to
disappear. Many industries were loosely, if at all, regulated, and disposal practices of hazardous
materials and industrial by-products were shortsighted. Disposal of waste materials often simply
involved burying or dumping the waste into lakes, rivers, or oceans in the belief that the
“solution to pollution is dilution.” The intent of this improper disposal of contaminants was not
always malicious—people did not understand the impact that the contaminants could have on
human health and ecosystems. Materials such as PCBs and asbestos were commercially
available, essential to certain manufacturing processes, and were not believed to be harmful.
Over time, with the development of more research and understanding, we now realize that many
contaminants and hazardous materials have adverse impacts on human health.
The quality of the environment became a popular topic in the mid- to late 20th century.
Books such as Silent Spring by Rachel Carson (1962) brought to public attention how human
actions and pollution were affecting the quality of air, water, and land. In 1969, because of
debris and oil in the river, the Cuyahoga River in Ohio caught on fire. The river had caught fire
many times in the past, but the 1969 event caught the public’s attention and helped increase
awareness of how polluted some places had become. In July 1970, the White House and
Congress established the Environmental Protection Agency (EPA) in response to the growing
public demand for cleaner water, air, and land. The EPA had the daunting task of repairing the
damage already done to the natural environment and to establish new criteria to making a
cleaner environment a reality. For more information on the creation and current role of EPA,
visit the EPA website. Several important pieces of legislation that helped highlight the
importance of environmental health and protection are still used to help enforce environmental
health and protection (Box 19.1).
19.1 Influential Environmental Laws
Clean Air Act
The Clean Air Act (CAA), passed in 1970, created a national program to control the damaging effects of
air pollution. The Clean Air Act Amendments of 1990 went further to ensure that the air Americans
breathe is safe. The CAA protects and enhances the quality of the nation’s air by regulating stationary
and mobile sources of air emissions. More information is available at https://www.epa.gov/clean-air-act-
overview/clean-air-act-text
Clean Water Act
The Clean Water Act, passed in 1972, focuses on improving the quality of the nation’s waters. It
provides a comprehensive framework of standards, technical tools, and financial assistance to address
the many causes of pollution and poor water quality, including municipal and industrial wastewater
discharges, polluted runoff from urban and rural areas, and habitat destruction. More information is
available at https://www.epa.gov/laws-regulations/summary-clean-water-act
Superfund
Superfund is the name given to the environmental program established to address abandoned hazardous
waste sites. It is also the name of the fund established by the Comprehensive Environmental
Response, Compensation and Liability Act of 1980. It allows the Environmental Protection Agency to
clean up such sites and compel responsible parties to perform cleanups or reimburse the government for
EPA-led cleanups. More information is available at. https://www.epa.gov/superfund/superfund-history
Love Canal started it all. I visited the canal area at that time. Corroding waste disposal
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https://www.epa.gov/clean-air-act-overview/clean-air-act-text
https://www.epa.gov/laws-regulations/summary-clean-water-act
https://www.epa.gov/superfund/superfund-history
drums could be seen breaking up through the grounds of backyards. Trees and gardens
were turning black and dying. One entire swimming pool had been popped up from its
foundation, afloat now on a small sea of chemicals.…Everywhere the air had a faint,
choking smell. Children returned from play with burns on their hands and faces. Eckardt
C. Beck, EPA Regional Administrator
Today, the public has better understanding of the impact of human actions on the
environment and how the environment can in turn affect human health. However, there are still
many environmental health challenges that people must face, including cleaning up past, as well
as ongoing contamination, deciding what to do about newly recognized issues such as climate
change and energy production, and dealing with emerging scientific advances such as
nanotechnology. Even though new research and developments are occurring at a historically
rapid pace, there are still large gaps in peoples’ knowledge about certain subjects:
How do certain contaminants affect human health?
How do we assess exposures to contaminants?
How does the environment influence health?
How do we live as a population while maintaining a healthy environment?
Loads of chemicals and hazardous wastes have been introduced into the atmosphere that
didn’t even exist in 1948. The environmental condition of the planet is far worse than it
was 42 years ago. Gaylord Nelson, politician and principal founder of Earth Day,
1990
The Community Environment
The environment and its effect on human health are often considered in two ways. The first
focuses on how contaminants in the environment, such as asbestos, lead, or radon, influence
human health. The second focuses on how the entire environment surrounding the community,
such as neighborhood safety, climate, access to grocery stores, and community design, affects
health. These two ways of considering the effect of the environment on human health frequently
relate to each other.
For example, lead was used in paint until the 1970s and is often found in houses built earlier.
As the old paint breaks down, lead can be found in dust and old paint chips in homes (CDC,
2014). In communities with older, deteriorating housing, children can be exposed to lead. In
many cases, such housing is found in poorer communities. Many low-income communities also
have fewer full-service grocery stores, and all residents do not have access to necessary healthy,
iron-rich foods. Sufficient blood iron can protect against some of the effects of lead exposure
(EPA, 2001). Some research suggests that the combination of iron deficiency and elevated blood
lead levels may work synergistically to create greater neurologic impacts in children than just
iron deficiency or elevated blood lead levels. The impact of the contaminant, lead, on children’s
health may be greater because of characteristics of the children’s community environment
(CDC, 2002).
In the case of lead-based paint in the environment, it is fairly easy to determine the link
between the environment and health. Sometimes, it can be challenging to determine which
environmental factors have the greatest impact on health. Information about the way many
contaminants affect humans is very limited. People are exposed to thousands of different things
in their environment every day. One person may come into contact with a number of personal
care products (e.g., shampoo, toothpaste, lotions, clothing detergent), food products (artificial
colors, pesticide residue on foods, preservatives), other commercial products (e.g., inks,
gasoline, dry cleaned clothing, flame retardants), and environmental contaminants (e.g., diesel
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particles or indoor air contaminants from cooking or burning wood) every day. In the modern
world, it is nearly impossible to isolate people from all of the exposures they have every day.
The American Chemical Society, which provides the Chemical Abstracts Service (CAS)
database for chemicals, had as of August 2018 in their database over “143 million unique
organic and inorganic chemical substances, such as alloys, coordination compounds, minerals,
mixtures, polymers and salts” (American Chemical Society, 2018, p. 1). Even if only a fraction
of these chemicals eventually finds their way into the environment and humans, the burden of
chemical exposure to everyone in the United States is enormous. We also have only just begun
to understand how exposures to a mixture of chemicals will affect human health.
Only a small number of these chemicals have ever been tested to see how they affect human
health. Many groups have called for the use of the precautionary principle when it comes to
the use of contaminants that find their way into the environment and humans. The precautionary
principle maintains that if something has the potential to cause harm to the environment or
humans, then precautionary measures should be taken if there is a lack of scientific evidence
concerning cause and effect (Kriebel et al., 2001). Applying the precautionary principle to new
technology and chemicals may help protect the environment and human health. For example, the
use of e-cigarettes is perceived by many people as “less dangerous” than smoking traditional
cigarettes. Yet the safety of e-cigarettes and the chemical exposures people may get from using
them is still uncertain (American Lung Association, 2016). By applying the precautionary
principle, nurses can discourage the use of e-cigarettes with their patients and encourage them to
consider the potential health risks. It can also be challenging to prove the existence of direct
links between the environment and health status of community residents. It seems logical that if
sidewalks are built, people will use them, thus improving their cardiovascular health. But is it
possible to measure sidewalk use? If a community could measure sidewalk use, how could it
show that using the sidewalks significantly improves cardiovascular health? Often, there is a
lack of scientific data to determine how exactly the community environment impacts human
health. It is also difficult to determine how genetic and behavioral factors shape the health of an
individual or a population.
Practice Point
Proving causal links between exposure to environmental contaminants and health outcomes,
or links between the community environment and health outcomes, is often very difficult.
Genetic and Behavioral Factors
Understanding the interaction between the environment and genetics as it relates to expression
of disease is still an evolving science. The challenge for nurses is to use the best science
available to assess how the environment affects human health, to formulate evidence-based or
best practice interventions, and to evaluate the effectiveness of these interventions.
Hereditary factors may play an important role. Many scientists believe that there are people
who are more genetically susceptible to a specific disease, but that environmental triggers play a
role in determining who actually develops the disease. The interaction between genetics and the
environment may help explain why some people who are exposed to specific contaminants
develop certain health effects but others do not. A 2014 study showed that the certain genotype
(MET rs1858830CC) and exposure to air pollution may interact to increase the risk of autism
spectrum disorder (Volk et al., 2014). This type of research can help us understand how genetics
and environmental exposures interact to create health outcomes.
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Individual human behaviors may also interact with environmental exposures to influence
human health. For example, radon, a naturally occurring radioactive compound, can be found in
the basements of many homes. Exposure to this substance has been linked to lung cancer.
Research has shown that people who live in a home with radon and who smoke have a greater
risk of developing lung cancer than do nonsmokers who live in homes with radon. The exposure
to cigarette smoke and radon seems to interact to increase the risk of lung cancer. More
information about radon and health can be found on the EPA website.
Nursing and Environmental Health
Scientific understanding of how the environment affects human health has evolved since the
days of Florence Nightingale, but nurses have long recognized that people’s surroundings can
influence their health. Even in the 19th century, nurses realized that clients who had clean food
and water and fresh air had better outcomes than did those who were left in squalid conditions.
Nurses can help lead the way in healthcare by understanding that clients are part of the
environment and that the health of the environment has a direct impact on their health. Nurses
are in a strong position to advocate for healthier environments in both the workplace and
community.
Across the country, there are great examples of nurses working with communities,
conducting research, and leading programs to help promote healthy people in healthy
environments. Nurses are also involved in helping to ensure that the environmental impact of
healthcare practices in the clinical setting and community setting are considered. For example,
the group Health Care Without Harm has worldwide membership from health providers to raise
awareness on issues such as safer chemicals (disinfectants, solvents in laboratories) in
healthcare, green purchasing (less toxic, minimal packaging), and medical waste management.
More information about their work can be found at the Health Care Without Harm website
(Health Care Without Harm, 2017).
19.2 Principles of Environmental Health for Nursing Practice
1. Knowledge of environmental health concepts is essential for nursing practice.
2. The Precautionary Principle guides nurses in their practice to use products and practices that do not
harm human health or the environment and to take preventive action in the face of uncertainty.
3. Nurses have a right to work in an environment that is safe and healthy.
4. Healthy environments are sustained through multidisciplinary collaboration.
5. Choices of materials, products, technology, and practices in the environment that affect nursing
practice are based on the best evidence available.
6. Approaches to promoting a healthy environment respect the diverse values, beliefs, cultures, and
circumstances of clients and their families.
7. Nurses participate in assessing the quality of the environment in which they practice and live.
8. Nurses, other healthcare workers, clients, and communities have the right to know relevant and
timely information about the potentially harmful products, chemicals, pollutants, and hazards to
which they are exposed.
9. Nurses participate in research of best practices that promote a safe and healthy environment.
10. Nurses must be supported in advocating for and implementing environmental health principles in
nursing practice.
Source: American Nurses Association. (2007). Principles of environmental health for nursing practice with implementation strategies. Silver Spring, MD:
American Nurses Association.
The American Nurses Association (ANA, 2007) has created the ANA’s Principles of
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Environmental Health for Nursing Practice with Implementation Strategies. These principles
can help nurses incorporate principles of environmental health into nursing practice (Box 19.2).
Nurses can use their core skills of assessment, intervention, and evaluation when considering the
environment and its impact on individual patients or communities.
ASSESSMENT
Assessing Contaminants in the Environment
Frequently, public health professionals are asked to help assess whether a specific contaminant
or contaminants in the environment are making a person or community sick.
The state public health agency asks Chris to assist with an environmental health
assessment when media attention on PCBs starts drawing public concern. People start
calling their local and state health departments and asking if the PCBs are making their
families sick.
Chris starts by doing research on PCBs. These substances are not naturally
occurring, tend to be heavy, and quickly settle out of the air to the ground or water. Being
hydrophobic, once in the water, they also settle out of water into sediment. They are slow
to break down, and unless they are removed, they remain in soil or sediment for a very
long time. The PCBs can build up in small animals and fish. As larger fish and animals eat
the smaller ones, the PCBs become increasingly concentrated in the food chain. In
general, what would be good sources of information to find out more about PCBs?
If ever we had proof that our nation’s pollution laws aren’t working, it’s reading the list of
industrial chemicals in the bodies of babies who have not yet lived outside the womb.
Louise Slaughter, U.S. Congresswoman
People in communities often want to know their risk of getting sick from known or suspected
exposure to a contaminant. In other words, they want a risk assessment—a process to determine
the likelihood or probability that adverse effects such as illness or disease will occur in a group
of people because of exposure to an environmental contaminant. The amount of risk can be a
difficult thing to determine. There are different methods for conducting risk assessment for
environmental contaminants. A simple way to understand risk is that the amount of risk equals
the hazard plus exposure (risk = hazard + exposure).
The presence of a hazard alone does not determine the amount of risk the hazard poses. If a
substance is hazardous, but there is no exposure to the substance, then a person is not at risk. For
example, think of the sun. It is well known that exposure to too much sun can cause sunburns
and put people at risk for skin cancer. However, if a person eliminates exposure by staying
indoors or in the shade, he or she eliminates the risk. If a person puts on sunscreen or a hat or
stays out of the sun in the middle of the day, he or she modifies the amount of risk by taking
measures to reduce the exposure.
To assess exposure, one method is to think about exposure pathways. An exposure pathway
is a process by which someone is exposed to a contaminant that originates from a specific source
(Agency for Toxic Substances and Disease Registry [ATSDR], 2005). Understanding exposure
pathways is important because if the pathway is not complete or if it can be disrupted, the
contaminant of concern should not affect human health. Frequently, people incorrectly assume
that if a contaminant is near their home, work, or school, they will automatically experience
adverse health effects from the substance. An exposure pathway helps illustrate that proximity to
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a contaminant is not the deciding factor in determining its effect on humans. An exposure
pathway consists of five parts: (1) source of contamination, (2) environmental media and
transport, (3) point of exposure, (4) route of exposure, and (5) receptor population. Figure 19.1
shows how each of these components is related, and the following discussion describes them in
more detail.
Source of Contamination
The source of contamination is used to describe what the contaminants are and from where they
originate. Sometimes, a source of contamination is easy to identify (e.g., mercury coming from a
former thermometer factory site). Other sources can be more difficult to identify, such as vapor
intrusion into a home from contaminated groundwater. Sources of contamination can come from
point or nonpoint sources. Nonpoint sources consist of many diffuse sources while a point
source tends to be one specific identified source. For example, a nonpoint source of
contamination could be if gasoline drips on parking lots and roads from thousands of cars and
then is washed into a neighboring lake when it rains. A tanker truck carrying gasoline that
crashed and spilled its contents into a pond is an example of a point source of contamination.
Knowing the type of contaminant is important to understanding its possible effect on human
health. Some contaminants quickly break down in the environment, whereas others are very
persistent. Contaminants that stay longer in the environment may influence health over a greater
period of time. Generally, contaminants can be thought of in three categories: chemical (lead,
mercury, volatile organic compounds), biologic (mold, anthrax, ricin), and radiologic (radium,
radon). Table 19.1 lists some common environmental contaminants.
Environmental Media and Transport Mechanisms
Environmental media include groundwater, surface water (lakes, ponds, rivers), air, surface soil,
subsurface soil, sediment, and biota (plants and animals). The environmental medium that the
contaminant is in helps determine who is exposed and how they are exposed (Agency for Toxic
Substances and Disease Registry, 2005).
Transport mechanisms describe how the contaminant moves from the source to the point of
exposure to people. For example, if an old drum full of a contaminant is buried and leaking,
knowing how that contaminant moves through the environment helps determine if only the
surrounding soil is contaminated or if the contaminant is volatile and will disperse into the air or
if the contaminant is likely to get into ground water (Agency for Toxic Substances and Disease
Registry, 2005).
Point of Exposure
The point of exposure is the place where people come in contact with the contaminated medium,
which may include food or another item (Agency for Toxic Substances and Disease Registry,
2005). An exposure point can be a home, a playground, a lake, a business, a cloud of diesel
fumes, an abandoned lot, a fish to be eaten, or a park.
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FIGURE 19.1 Exposure pathway. (Data from Agency for Toxic Substances and Disease Registry.
[2005]. Public health assessment guidance manual. Retrieved from
https://www.atsdr.cdc.gov/HAC/phamanual/ch6.html.)
Route of Exposure
The route of exposure is how the contaminant enters the body. Environmental contaminants
enter the body primarily by ingestion, inhalation, or skin contact. Contaminants can come from
groundwater, surface water, soil, and food (Agency for Toxic Substances and Disease Registry,
2005). Most adults do not ingest large amounts of soil. However, children may ingest soil while
playing, from mouthing objects, from not washing their hands, or from pica behaviors.
Contaminants can be inhaled from soil (dust), air, and aerosolized water (e.g., during
showering). Dermal contact from contaminants can come from soil, water, sediment, air, or
food.
Evidence for Practice
In March 2015, a family of four while on vacation in the US Virgin Islands was transported to
the hospital with neurologic symptoms including weakness, severe myoclonus,
fasciculations, altered sensorium, and word-finding difficulty. Three of the four family
members had also vomiting and diarrhea. Three members of the family ended up intubated
with mechanical ventilation. Initially, clinicians suspected ciguatera fish poisoning, however,
others who had eaten the same food were not ill. An investigation revealed that an
unoccupied housing unit beneath where the family was staying was fumigated with the
pesticide methyl bromide two days before the family sought medical care. Methyl bromide is
a pesticide first used in the 1930s but has been phased out of use. It should not be used in
residential settings. In addition to the family of four, 37 other people were identified as
having been potentially exposed to methyl bromide. Six of those exposed reported
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https://www.atsdr.cdc.gov/HAC/phamanual/ch6.html
symptoms such as headache and fatigue which resolved on their own within a few weeks.
Four of the six were emergency responders who had been to the housing complex (CDC,
2015a).
Nurses can apply this knowledge to practice by always considering the possibility of
acute chemical exposure when assessing clinical symptoms and patient history. A family or
group with rapid progression of the same symptoms is highly suspicious. Prompt
recognition of such exposures can aid in clinical treatment, prevent further exposures, and
prevent additional exposures. If a toxic exposure is suspected, those potentially exposed,
such as first responders, should be alerted. Also, nurses can help community members
understand how proper use of pesticides is essential to prevent exposures and health
effects. Pesticides should always be used in accordance with their legal, labeled use and
integrated pest management practices, which decreases the use of chemicals for controlling
pests.
TABLE 19.1 Common Exposure Pathways for Selected Environmental
Contaminants
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Receptor Population
The receptor population is the population of people who are likely to be exposed (Agency for
Toxic Substances and Disease Registry, 2005). It is necessary to carefully consider and
accurately identify the exposed population. For example, if a contaminant is in the groundwater,
then only people with drinking wells supplied by that groundwater are likely exposed to the
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contaminant. People whose wells were fed by another source or people who use public water
systems are not exposed.
When thinking about populations, it is also important to think about whether people are
currently being exposed, whether people were exposed in the past, and whether people will
continue to be exposed in the future. Thinking about when a population was or is exposed can
help determine what interventions may be useful. The exposure pathway is illustrated in Figure
19.1.
Determining the Health Impact of a Completed Exposure
Pathway
A completed exposure pathway does not guarantee that people will become sick. The exposure
may not be great enough to cause a health effect. It is also possible we might not know enough
about the toxicology of certain contaminants to understand their health effects. Given what
experts know about medicine and science, it is difficult to imagine that we cannot determine
with certainty whether exposure to a contaminant will lead to illness. There is often “an
understandable misconception among the public that modern-day health scientists and medical
professionals can precisely determine at what environmental level a particular contaminant
presents a clear and predictable risk to human health future” (De Rosa, Holler, & Mehlman,
2002, p. 149). For most contaminants, toxicologic data are too limited to say for sure whether an
exposure will have an effect. Toxicology is the study of the adverse effects of chemical,
physical, or biologic agents on people, animals, and the environment (Society of Toxicology,
2017). Many of the guiding principles of toxicology will seem familiar to nurses who are
familiar with pharmacology. Toxicology and pharmacology are very similar, since both require
knowledge of the “dose” needed to effect a change (either positive or negative) on a human
system. When people are exposed to multiple chemicals, the effects on health may be magnified;
this concept should also be familiar to nurses who understand that caution must be taken with
combining medications if the medications are targeting the same body systems or can damage
the same organs.
To determine any possible health effects from a contaminant, an exposure estimate is
created. An exposure estimate determines a person’s level of exposure to a contaminant. Several
factors are taken into account when calculating the exposure estimate, including the duration of
the exposure, the concentration of the chemicals, the frequency of exposure, body size, and the
bioavailability of the contaminant. Bioavailability is the amount of a substance that is absorbed
or becomes available at the site of physiologic activity. In pharmacology, the bioavailability of a
drug helps clinicians determine the necessary dose to ensure that the drug is effective. In
toxicology, bioavailability helps toxicologists determine the “dose” of a certain contaminant that
will cause a health effect.
Once toxicologists give an exposure estimate, health professionals compare it with standard
health guidelines. If an exposure estimate is greater than the health guideline, there is a greater
chance that the exposure can cause adverse health effects. Health guidelines are set to protect the
whole population, including those who are most sensitive to potentially hazardous substances,
such as children or the elderly. Health guidelines include safety factors designed to protect even
the most sensitive members of a population; therefore, an exposure estimate above a particular
health guideline does not guarantee that an exposure will cause harm. State health agencies, as
well as federal health and environmental agencies such as the ATSDR and the EPA, develop the
health guidelines.
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Chris considers if there is an exposure pathway that can link the contaminant to people
who live in her town. She creates a table to help her determine if there are completed
exposure pathways of PCBs into people. What would the exposure pathway table below
look like for this site?
The field of toxicology is always evolving. Nurses can consult with professionals trained in
the field of toxicology to help determine whether a specific exposure can lead to a health effect.
State or local health departments usually have an office that deals with environmental health
issues. They are a useful resource for nurses who believe they have identified an environmental
health concern or who need more information about the toxicology of a specific contaminant.
Frequently, when individuals learn they have been exposed to a contaminant, they will ask
their medical provider to “test” them. For some contaminants, clinical tests can determine
whether someone has been exposed. For example, a blood test or urine test can determine the
level of mercury in blood or urine. These levels provide information about how much mercury a
person has in his or her body. These types of tests, referred to as biomonitoring, can be helpful
for determining exposures to individual people and communities. Technology allows medical
professionals to test for many chemicals in the body; however, our understanding of toxicology
has not evolved as quickly as our ability to test for chemicals in a person. As health
professionals we may be able to test for and find a chemical in a person, but we may not have
the ability to tell the person how that level of chemical in them will affect their health. Another
challenge with biomonitoring is that some chemicals may have a short half-life and do not stay
in the body long enough to easily measured. If biomonitoring for a chemical exposure is being
considered, medical professionals first need to be sure that the testing will provide useful clinical
information for treatment of the patient.
If biomonitoring is possible, the results need to be carefully interpreted. For example, many
states require at least one blood lead level be checked in young children (ages 1 to 5 years old)
as part of their wellness visits for children to attend school. A single child’s elevated blood lead
level can alert a nurse to the lead exposure and can allow the nurse to determine whether the
blood lead level is dangerously high. However, the test cannot tell exactly when or where
exposure occurred or what form of lead was involved (e.g., paint chips, lead in soil, lead in
drinking water, lead paint on a toy). If many children in a community have elevated blood lead
levels, it alerts health professionals to a problem in that community, but again, the test alone
cannot determine where exactly the children were exposed. Much information about how lead
affects children is available, and medical professionals know the significance of an individual
blood lead level in terms of the child’s health. However, for many contaminants, even if a
medical test can detect a certain level of a contaminant, data to determine whether detected
levels cause an adverse health effect may be insufficient.
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Evidence for Practice
Young children in Maine are routinely screened for elevated blood lead levels. As a report
by the Centers for Disease Control and Prevention (CDC, 2009a) shows, between 2003 and
2007, the Maine Childhood Lead Poisoning Prevention Program (MCLPPP) identified 55
children with elevated blood lead levels. For 90% of the children, lead exposure was linked
to lead hazards in the children’s homes. However, for six children, there was no evidence of
lead exposure inside the home. As the investigation expanded to outside of the home,
researchers discovered that the six children were exposed to lead dust in their family
vehicles and in child safety seats. Investigators believed that the lead dust entered the
vehicles by cross contamination from family members who had high-risk lead exposure
occupations (e.g., construction, painting and paint removal, metal recycling). The lead dust
on the seats likely came from contamination from either clothing or articles that family
members had placed in the vehicles. This was the first documented report of child lead
poisoning caused by a child’s exposure to lead while in a child safety seat.
Public health nurses can apply this type of information when dealing with families of
children who have elevated blood lead levels. Although lead sources in the house (e.g., old
chipping paint, old lead plumbing fixtures) may be the cause of the majority of lead
exposure in children, nurses may need to consider other unique sources when trying to
determine how children have been exposed. Asking parents about their occupations or
hobbies might help a nurse discover an unexpected exposure pathway.
The CDC’s Fourth National Report on Human Exposure to Environmental Chemicals
(2009c) describes exposures among the US population to many environmental contaminants.
This continuously updated biomonitoring report is a valuable resource for environmental health
professionals. This report includes data made available from CDC’s National Health and
Nutrition Examination Survey (NHANES). It establishes a reference range for typical US
population exposures which can be compared to individual and population measurements made
in other contexts. The report also provides information about trends in US exposures over time
and helps environmental health professionals learn more about the various chemicals to which
Americans are exposed. In addition, it establishes a reference range that these health
professionals can use for comparative purposes (i.e., is an exposure low, medium, or high), to
determine whether exposures are higher in certain groups in the United States, and provides
information about trends in the levels of contaminants in humans over time (CDC, 2009c). The
complete report and updated tables, can be found on the CDC website
(https://www.cdc.gov/exposurereport/index.html). Caution needs to be taken if a nurse wants to
compare an individual’s test results to data found in the CDC report to ensure laboratory
analysis and collection of the samples for the individual were done with the same methodology
as the CDC data.
For many contaminants, there are no medical tests to determine whether an exposure has
occurred or what the health effect of the exposure might be. There are resources and
professionals who work in the field of environmental and occupational health who can help a
nurse decide whether medical testing is necessary or useful for an individual client or for a
community. For example, the Association of Occupational and Environmental Clinics (AOEC)
and the Pediatric Environmental Health Specialty Units (PEHSU) are staffed with medical
providers who specialize in occupational and environmental health. These providers can provide
expert advice when there is a question about a possible environmental exposure and its effects
(Box 19.3.).
19.3 Association of Occupational and Environmental Clinics, Pediatric
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https://www.cdc.gov/exposurereport/index.html
Environmental Health Specialty Units, and American College of Medical
Toxicologists
Established in 1987, the Association of Occupational and Environmental Clinics (AOEC), a nonprofit
organization, has grown to a network of more than 60 clinics and more than 250 individuals committed
to improving the practice of occupational and environmental medicine through information sharing and
collaborative research. All AOEC member clinics are multidisciplinary in staff and meet specific criteria
that promote providing high-quality healthcare and patient rights. More information is available at
http://www.aoec.org.
The Pediatric Environmental Health Specialty Units (PEHSU) form a respected network of experts
in children’s environmental health. The PEHSU were created to ensure that children and communities
have access to, usually at no cost, special medical knowledge and resources for children faced with a
health risk due to a natural or human-made environmental hazard. More information is available at
http://www.pehsu.net/.
The American College of Medical Toxicologists (ACMT) is a professional nonprofit association that
is dedicated to advancing medical toxicology. ACMT has physicians with expertise in medical
toxicology and aims to advance the quality of care for patients poisoned with chemicals or other toxins.
ACMT professionals can help medical providers by providing expert and timely advice on how to care
for patients with poisoning or chemical exposures. More information is available at www.acmt.net.
After determining that there is at least one complete exposure pathway, the next step for
Chris is to determine whether people are being exposed to high-enough levels of PCBs to
make them sick. Chris meets with a member of the state environmental agency and a
toxicologist from the state health department. The state has received data from fish
collected in the harbor. Chris helps the toxicologist try to determine how many fish from
the harbor are being eaten by local residents. With her knowledge of the local population,
Chris believes that people who supplement their diets with fish from the harbor probably
eat two to four fish meals a week during the warmer weather. Based on the PCB levels in
the fish, Chris and the toxicologist determine that if people eat fish from the harbor two to
four meals a week for 5 months a year, their exposure to PCBs is high enough to cause
concern.
Some people may want to be tested to determine if they have been exposed to PCBs
from the harbor. What could you do as a public health nurse to answer their questions
about being tested?
Evidence for Practice
Firefighters use flame-retardant clothing for personal protection while fighting fires.
Antimony oxides are often used in the production of these textiles. In 2008, the CDC
received a report from a fire department chief that there was an outbreak of antimony
toxicity among 30 firefighters who had elevated antimony levels detected in hair samples
(CDC, 2009b). The fire department believed that exposure to the antimony in the
firefighters’ protective clothing caused the outbreak. The CDC administered questionnaires
and collected urine antimony samples from two different groups of firefighters—one group
whose clothing contained antimony and one group whose clothing did not contain antimony.
The CDC found that both the groups had urine antimony levels that were not clinically
significant and that wearing clothing made with antimony did not increase urine antimony
levels. It should be noted that hair testing is not reliable or valid for measuring exposure
antimony in the body (CDC, 2009b).
Public health nurses can apply this information to practice by understanding that only
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http://www.aoec.org
http://www.pehsu.net/
http://www.acmt.net
valid methods of testing for metals or other chemicals in the body should be used to
determine whether people are being exposed to dangerous levels of a substance. Invalid
tests may make people fearful that they are ill now or will be in the future. They may also
lead people to seek inappropriate treatment or delay proper care. Nurses can distribute
timely and accurate risk communication and health communication materials that provide
useful, specific information about environmental exposure and its effects on health.
Assessing the Environment of a Community
Knowing what contaminants are in the environment and whether there are completed exposure
pathways are key steps in determining how people’s health is affected by the environment.
However, many other environmental conditions, aside from environmental contaminants, can
influence disease and injury rates. Some environmental conditions that may be important when
reflecting on the potential impact of the environment on a community’s health are presented in
Table 19.2. This table was designed to consider many different types of communities—urban
and rural, developed, developing and redeveloping—regardless of socioeconomic status.
If a man walks in the woods for love of them half of each day, he is in danger of being
regarded as a loafer. But if he spends his days as a speculator, shearing off those woods
and making the earth bald before her time, he is deemed an industrious and enterprising
citizen. Henry David Thoreau
TABLE 19.2 Community Environment and the Potential Effects on Health
Environmental
Condition
Effects on Health and Examples
Access to healthy housing Age and condition of housing can expose people to contaminants (lead, asbestos,
radon, or mold), pests (cockroaches, rodents, or mosquitoes), and injuries (falls,
electrocution, fire, or carbon monoxide). One major concern with housing is the
quality of indoor air, which can have a direct effect on diseases such as asthma
(see “Indoor air” below). Location of housing can also encourage or discourage how
community members get around in their communities. For example, houses built on
streets that do not connect or streets without sidewalks may encourage people to
drive rather than walk even short distances—this can decrease a person’s physical
exercise, which increases people’s risk for obesity and other health issues.
Access to potable water Most drinking water in the United States comes from public water or private water
supplies such as wells. Public drinking water supplies are tested frequently and
must meet federal standards. Private water supplies are not tested regularly unless
done so by the person who owns or uses the water. Both public and private water
supplies can be contaminated with bacteria or chemicals; however, because public
water supplies are tested regularly, contamination is likely to be identified quickly.
Contaminated water can make people sick quickly or more slowly, depending on
the type of contamination. In some rural communities in the United States and
around the world, access to potable water is still a significant health issue. An
association has also been made between lack of modern water sources and lower
respiratory tract infections in young children. Droughts and floods can also impact
water supplies. Floods may bring contamination into public or private water supplies
and drought can limit the availability of water to communities.
Sanitation and waste
removal
In most parts of the United States, sanitation services and waste removal services are
taken for granted. However, there are some areas where these services are
lacking. For example, in some communities that lack public sewer services, there is
also a lack of septic systems because of cost or difficulty in installing a septic
system. Improper disposal of human waste can create health problems from direct
contact with the waste or can contaminate drinking water supplies. In some poorer
countries, there are virtually no sanitation or waste removal systems. People live in
and around sewage and trash. Improper disposal of trash can also encourage
pests, which can carry diseases and may expose people to contaminants that leach
out of the trash.
Access to green spaces Green spaces such as parks and playgrounds can help encourage people to exercise
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and play. Exercise can have a positive impact on health by helping to control
obesity and providing other health benefits. Exercise can also promote social
development in children and provide a place for the community to gather. Green
space may also help people feel better about the community they live in and have
positive effects on mental health.
Ambient air Tiny airborne particles and ground-level ozone can trigger respiratory problems,
especially for people with asthma. Air pollution can aggravate health problems for
the elderly and others with heart or respiratory diseases. Things to consider for
ambient air include potential pollution from a variety of sources, including industry,
power plants, waste sites, and vehicle traffic. Other issues to consider for ambient
air include local sources of particulate matter from things such as wood burning or
dust from unpaved roads or construction. Air quality is an important issue
worldwide. Many poorer countries lack laws, resources, and programs to help
eliminate air pollution sources, whereas more affluent countries may produce more
air pollution from manufacturing, making electricity, and driving automobiles. Both
situations can create air quality issues that need to be addressed on a global scale.
Indoor air Indoor air quality can often be worse than ambient air quality. Indoor air can contain
high levels of particulate matter from combustion of heating and cooking fuels,
cigarette smoke, and can also contain chemical contaminants from products used
in the home for cleaning and painting or even from items such as carpet or
furniture. Other contaminants such as mold spores and other asthma triggers such
as dust and dust mites are often also found in indoor air. Poor indoor air quality can
affect both poorer and more affluent homes.
Recreational waters Recreational waters can be an excellent resource for communities to engage in
recreational activities for exercise, pleasure or even as a food source such as
fishing. Unfortunately, sometimes recreational water sources can be a place where
people are exposed to chemical (fuel oils, metals, etc.) or biologic contaminants
(such as red tide or bacteria from sewage) that can cause harm. In pools,
sometimes misuse/overuse of chemical pool cleaners can cause chemical
exposures.
Abandoned buildings,
vacant lots, or facilities
Abandoned properties can create physical hazards such as structurally unsound
buildings and trenches where children could be hurt. These places can also
increase criminal activities and may be fire risks. Abandoned cars, tires, or piles of
trash create similar risks. Abandoned properties or trash can also impact resident’s
pride in their community and their sense of well-being. How community pride or a
sense of well-being affects health can be difficult to quantify, but it does affect
quality of life.
Access to healthy and safe
foods
Full-service grocery stores are more likely than small convenience stores or fast food
restaurants to stock healthy foods and fresh fruits and vegetables. If grocery stores
are within easy access, then people may be able to include more healthy foods and
fewer fast foods or processed foods into their diets. Farmers’ markets and
community-supported gardens may be a good source of healthy foods in a
community. Food that is hunted, fished, or gathered may also be a source of
healthy foods. However, all food that is purchased, grown, or gathered can be
contaminated with bacteria or chemicals that can make people sick. Food safety is
a challenge in all communities, and in the United States, there are programs in
place to help keep consumer food products safe. Chemicals used in food
production such as pesticides and herbicides can impact workers and community
members where the chemicals are applied and may end up being consumed by
those who eventually eat the produce. Modern food production using concentrated
animal feeding operations (CAFOs) can increase the need for farmers to use
chemicals and to treat and prevent animal pests and diseases that tend to spread
when many animals are concentrated into small areas. Waste production from
CAFOs can also pollute the environment. Worldwide, food quality and safety are
critical health issues.
Access to physical activity
such as biking, or other
public spaces that
encourage physical
activity
A community that has safe sidewalks, bike paths, and/or jogging trails encourages
people to exercise more, which can have positive health benefits. An absence of
safe ways to walk or bike encourages dependence on automobiles, which can
affect air quality and the amount of exercise that people get during the day. Also, if
people are forced to walk or bike along unsafe streets or highways, there is a
greater risk of pedestrian injuries.
Location of schools, public
facilities, public
transportation, and
entertainment
Schools and other facilities such as libraries, theaters, or stores can help encourage
people to walk or use public transportation rather than driving. Decreasing car
dependency can improve air quality and increase the amount of exercise people
engage in during the day.
Safety and crime If people feel it is unsafe in their community, they may not walk as much or allow their
children to play outside. The impact of stress from living in a community that is
unsafe may also affect people’s physical and mental health.
Animals—strays or pests Stray animals can discourage people from exercising in and around their
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communities. Other animal pests such as rodents may help spread disease.
Vectors Vectors such as mosquitoes or ticks can transmit diseases such as those caused by
the West Nile and Zika virus or Lyme bacteria. Changes in the environment can
help decrease the number of vectors. For example, getting rid of standing or
stagnant water can help decrease the number of mosquitoes.
Access to healthcare
(primary care providers
and services such as
pharmacies)
If a community can easily access primary healthcare services, they may be better
able to manage chronic and acute health issues. For example, if people need to
drive long distances or if public transportation is difficult to use or does not exist,
they may postpone receiving healthcare.
Climate The climate may influence health in many ways. For example, very hot or very cold
weather conditions may affect how often people leave their homes to exercise. Hot
weather may also lead to problems with ambient air quality, which can affect people
with respiratory problems. Cold climates may also affect indoor air quality if heating
sources are not clean and safe. Severe storms, droughts, and flooding can also
create hazards that impact people’s health.
Noise Unwanted sound can have impacts on sleep, concentration, or even conversation.
Some problems related to noise include sleep disruption, high blood pressure, and
loss of productivity.
Ultraviolet (UV) radiation UV radiation comes from the sun. Exposure to UV radiation is directly linked to skin
cancers. Some areas of the world have a greater UV index. Some communities
also spend a greater amount of time outside, which exposes them to greater
amounts of UV radiation.
Subsistence or
supplemental food
gathering and hunting
Some communities may subsist on or supplement their diets with locally gathered
animals or plants. These food sources can help create a healthy diet if the foods
are safe but may also be a source of exposure to contaminants if the foods are not
safe. For example, fish is a good source of healthy protein and fats but fish caught
in contaminated waters may have a negative impact on health.
Cultural practices and
traditions
Some cultural practices such as using herbs or cosmetics can expose people to
contaminants in those products. In some countries, manufacturing processes may
not be carefully regulated to monitor for contaminants being added either
intentionally or unintentionally to the products. Cultural traditions may also expose
some communities to contaminants. For example, a tradition in a community might
be to gather local plants or materials to create products for sale or personal use.
The collection of these items may cause people to be exposed to contaminants if
the plant used to make a product naturally grows in a wetland area and the wetland
water is contaminated.
Natural and human-made
hazards
Some communities are more vulnerable to natural hazards such as hurricanes,
tornadoes, earthquakes, or other storms. These natural events can present physical
hazards or chemical hazards and create community stress. Often, when power is
lost, people use generators to try to heat, cool, or light their homes. Carbon
monoxide poisoning after disasters, although easy to prevent with proper use of
generators, and other CO generating equipment, continues to be a challenge in the
United States.
Community concerns Listening to the concerns of the community about their environment and health can
provide important insight into how the environment impacts the health of the
community. Listening to and addressing the concerns is vital when helping
determine intervention strategies to create healthier community environments.
For a list of up-to-date online resources on these topics, please visit thePoint (http://thepoint.lww.com/DeMarco3e).
Assessing the many ways that the environment of a community can impact health is helpful
to consider before interventions are developed and implemented. For example, even if
community members know that exercise such as walking can help improve their health, if the
town streets lack sidewalks, this discourages walking. Creating a community program to
increase awareness of the benefits of exercise will not do much to increase activity levels until
the issue of the sidewalks or alternative safe exercise spaces, such as parks, is addressed.
The state health department asks Chris to help it discover the steps necessary to develop
interventions to disrupt the exposure pathway and keep people from being exposed to the
PCBs in fish from the harbor. She determines that assessing the environment of the
community may be helpful in planning successful interventions. Chris thinks about the
community who eats fish caught in the harbor. For many people who fish in the harbor,
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fish is a major protein source in their traditional diet and a way to supplement their diets.
In the harbor area, there are several small, locally owned grocery stores, which are easy
to walk to without a car or public transit, and carry other traditional foods. There is also a
larger national grocery store, but one needs a car to get there. English is a second
language spoken by many of the people who patronize these stores.
Why is it important to understand more about the entire environment of the community
and not just about the contaminated site?
Assessment of Individuals: Taking an Exposure History
Often when clients visit a clinic or health provider, the healthcare professional does not ask them
about exposures to hazardous substances or contaminants. Many people also do not associate
exposures at work or home with how they are feeling, and they may not think to tell a provider
about an exposure. For example, a man may come to the clinic complaining about an increase in
the number of times per week that he must use his rescue inhaler for asthma. Unless he is asked
by the clinician about changes at home, work, or with hobbies, he may simply not think to
mention that his hobby of building model planes is occupying more of his time. Without this
knowledge, the practitioner may not know about the increasing exposure to glues and paints,
which could irritate the client’s airways, leading to more asthma symptoms.
Taking an exposure history can help nurses identify current or past exposures, eliminate
exposures, and try to mitigate or reduce a client’s adverse health effects from exposures. The
basic elements of an exposure history are found in Table 19.3.
If an exposure history reveals an exposure of concern, or if a client’s illness is still possibly
linked to an environmental exposure, it is important to refer that client to the appropriate
resources. For example, the AOEC and the PEHSU have many useful documents and guidelines
on their websites (see Box 19.3).
Local and state health departments may also have staff who can assist in finding resources
for community members who have an exposure that warrants additional follow-up. In addition, a
poison control center may also be able to assist with a client who has medical problems related
to a suspected acute exposure, such as exposure to a pesticide.
Practice Point
Poison control centers are staffed by trained professionals who can help you evaluate a
client and also help a medical professional decide on treatment options for specific
exposures. The national phone number is 1-800-222-1222.
INTERVENTIONS
Planning an intervention to address environmental health issues is similar to planning any other
nursing intervention. After assessing the situation, the nurse decides which intervention will best
help protect and improve health. When thinking about contaminants in the environment and
completed exposure pathways, the intervention is most often something designed to interrupt or
break the exposure pathway. For example, if children are playing in an area with contaminated
dirt or soil, placing a fence around the site to keep them away from the site is a reasonable and
likely successful intervention.
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From working at the local health department, Chris knows many of the clients who come
to prenatal clinic and the local Women, Infants, and Children (WIC) program are members
of the harbor community. Chris works with the WIC staff to determine whether women
who use WIC services know about the state fishing ban in the harbor. Chris thinks about
possible interventions to prevent people from eating contaminated fish from the harbor.
Engineering controls such as building a fence or blocking all fishing in the harbor would
be impossible to construct or enforce. The state has already banned fishing within the
harbor, so new fishing bans are not likely to prevent fishing by members of the local
community. State and federal environmental agencies are working to dredge the PCB-
contaminated sediment and remove the PCBs from the harbor, but the process may take
decades to complete.
What types of interventions could be used to help stop people from being exposed
from this site?
TABLE 19.3 Taking an Exposure History
Subject Types of Questions
Present work Where do you work?
At your present work, are you exposed to any types of dusts, fumes, solvents,
radiation, loud noises, pesticides, or other chemicals?
Do you wear personal protection equipment?
Do you wear the clothing you wear at work to home?
Are there any coworkers with similar symptoms?
Past work Where are all the places you have worked in the past?
What was the longest job you held?
In your past jobs, were you ever exposed to any dusts, fumes, solvents, radiation,
loud noises, pesticides, or other chemicals?
Home/residence When was your home/residence built?
What type of heating do you have?
Have you recently done any remodeling?
Where does your drinking water come from?
What types of chemicals do you use at home or in the yard?
Do you have mold, mildew, or water damage issues in your home?
Activities/hobbies In what activities or hobbies do you or your family participate?
Do you hunt or fish?
Do you grow any of your own foods?
Do you burn or melt anything?
Are there any cultural practices or traditional foods?
Concerns Do you have any concerns about current or past exposures?
Do you feel like your health is being affected by past or current exposures?
Have you ever felt sick after coming into contact with chemicals or other substances?
Do any of your symptoms get better when you are away from home or work?
When thinking about interventions to improve the environment of the entire community, it
can be difficult to craft interventions to address some problems. For example, it would be nearly
impossible to replace all the older deteriorating housing in a community, for reasons such as
cost, even if housing quality seems to have a negative impact on health. It would also be very
difficult to rebuild all roads to include sidewalks and bike lanes. However, there may be some
smaller, easier-to-achieve interventions to help improve the environment of a community, such
as a local education campaign to inform people how to get rid of places were mosquitos breed to
help stop the spread of mosquito borne illnesses. Interventions to make a community’s
environment healthier need to include the community input, be as evidence based as possible,
and be feasible given the political and economic limitations. The interventions must be targeted
to the community and consider language and culture.
Some interventions produce measurable results quickly, whereas other interventions might
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take years to produce changes. For complex or large environmental health problems, the
assistance of many different community agencies and organizations, as well as local, state,
tribal, or federal government support may be necessary. It is important to remember that it may
take years for the community to identify a problem, develop a program to solve it (e.g., plan an
intervention), and find the necessary resources, such as state or federal grants, for this program.
For example, consider a community concerned about air quality near schools. One identified
source of air pollution impacting the schools is diesel exhaust from school buses. To address the
problem, the community may not have the money to purchase a fleet of new less-polluting
buses. Working with the local health department, the school board, and the company that is
contracted to run the school buses, the community decides that it can quickly decrease diesel
emissions by implementing a “no idling” policy for school buses. Now buses parked and waiting
to pick up children will no longer idle. For a longer-term solution, the community decides that it
would like to engage in a program such as one suggested by EPA’s website for Clean School
Bus USA. In this example, the community was able to create a quick, cost-effective intervention
to mitigate some exposure while also working on a more permanent solution.
With Chris’s help, the health department decides that an education program aimed at
letting people know why harbor fish are not safe to eat while also providing alternatives to
eating harbor fish could help interrupt the exposure pathway. The education program will
target women of childbearing age and children because they may be most susceptible to
the effects of the PCBs and because work with the WIC staff revealed that many of the
clients who come to WIC were not aware of the hazards of eating fish caught in the
harbor.
What information should the educational materials for this program include? What
other consideration needs to be given to how the materials should be produced? Who
should receive the materials and how will they receive them? How can Chris have
community members participate in the development of the materials?
EVALUATION
Trying to evaluate the effectiveness of an intervention that stops exposures or makes an
environment healthier can be challenging. As previously stated, some interventions may result in
immediate, measurable changes, whereas others may not lead to changes for years. Here are two
examples of measurable interventions:
Suppose a city adopts a program to screen houses for lead and make the homes as lead-free as practically
possible. By the end of a year, the city will be able to determine how many homes were screened and
made safer.
Suppose a town identifies contaminated private wells and decided to bring public water to supply the
homes. At the end of the year, the town could count the number of people who have a safe water supply.
However, even if it is possible to measure some positive changes, it may be very difficult to
measure how the intervention positively impacted people’s health. Think of the lead in housing
example above and consider how a program might be viewed if, after the program was in place
for a year, there was an increase in the total number of children living in the city who had
elevated blood lead levels. Would the increase in numbers indicate the program was a failure?
Or could the increase be caused by an increased awareness of lead as a hazard and a willingness
by parents to have their children’s blood lead levels tested. As more children were tested, more
elevated blood lead levels were discovered. Using only the total number of children with
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elevated blood lead levels within the city might not be the best indicator to prove the
intervention is successful.
An evaluation performed for any intervention should help decide whether the intervention
has achieved its goals and whether improvements or changes need to be made. When
interventions are being funded either from private or public funding sources, the entity funding
the intervention often requires that some type of evaluation be performed. Sometimes, no matter
how successful a program or project is, if the people running the program cannot evaluate it and
communicate the results of their evaluation, the program or project may not receive the funding
needed to continue.
Some types of questions to consider when evaluating an intervention include the following:
Has the exposure pathway been interrupted?
What does the community think about the intervention—are people satisfied?
How has health improved?
How many people did the intervention affect?
Can the intervention demonstrate any cost savings?
Is the intervention sustainable?
It is helpful to consider how an intervention will be evaluated in the process of developing
the intervention. This way, it is possible to think about how to collect the necessary data either
quantitatively or qualitatively to determine whether the intervention resulted in the intended
outcome.
Chris tests the effectiveness of educational materials with the help of the local clinic and
WIC staff. They ask clients for feedback about the materials and ask them whether they
have been able to avoid eating fish from the harbor. A community member suggests that
if information was available in the grocery store, more people might be able to make safer
fish choices while shopping. As a result, there is outreach to owners of local grocery
stores, who are asked if the educational materials can be located in the stores. The
grocery store owners are receptive to posting information because fish sold in their stores
is obtained from commercial fishing sources (not caught in the harbor).
Chris also works with the WIC staff to keep data on the number of clients who receive
information about safe fish consumption. Why is it important to test materials before using
them? Why would you want to keep data about the materials used? What other ways
could be used to determine if the intervention is effective?
ENVIRONMENTAL EPIDEMIOLOGY
Epidemiology is a field of public health science that focuses on the incidence and prevalence of
disease or illness in a population. This field of study is most well-known for helping to identify
outbreaks of infectious diseases. Many basic principles of epidemiologic studies can be applied
to the field of environmental health. Environmental epidemiology can help determine whether
the environment is affecting people’s health. One challenge in environmental epidemiology is
that it is nearly impossible to create an experimental study that is generally considered the most
conclusive form of epidemiologic study. In an experimental study, one group is exposed to
something while another group is not exposed. It is unethical to expose a person or population to
an environmental hazard or contaminant intentionally for the purposes of conducting an
experimental study. For example, if we suspect that a chemical used in water treatment is
harmful to health but do not know how much of an exposure would cause a health effect, it
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would be unethical to put various amounts of the chemical in the water supply of different
communities to watch and see when people become ill. Since experimental designs cannot be
used for most environmental studies, cohort studies, case-control studies, or cluster
investigations are generally used for environmental epidemiology.
Case-control studies and cluster investigations are retrospective studies that first identify
people who have an adverse health condition and then try to determine what exposure or
exposures caused the health effect. Cohort studies are often prospective studies that go forward
in time and document the characteristics or the health effects that occur (see Chapter 8). The
information gained from environmental epidemiologic studies can be very helpful in trying to
identify whether particular exposures have made people ill.
Major challenges to most environmental epidemiology studies include the following:
Limited availability of data on many contaminants and their effect on health
Limited understanding about how exposures to multiple contaminants may sicken people
Latency between exposure and illness can be very long (e.g., even decades).
Difficulty in generating a good exposure assessment
In addition, studies in environmental epidemiology may be
Time-consuming to perform
Resource-intensive in terms of personnel and money
Inconclusive in determining whether X contaminant caused Y illness
Disease clusters occur when there seem to be an elevated number of diseases in a family, in
a community, among coworkers, or among classmates. Epidemiologists who have knowledge of
disease, biostatistics, and public and environmental health investigate these suspected clusters.
Frequently, state or local health departments conduct these investigations. A healthcare
professional should report any suspected disease cluster to the local or state health department.
A variety of factors can create the appearance of a cluster where there is no increased rate of
disease.
Cancer is a frequent concern for community members. For example, the local health
department might receive a report that a specific neighborhood has “a lot of cancer.” When the
health department investigates, it finds that in the neighborhood there are many cases of cancer
but that all the cancers are different types, including breast cancer, bladder cancer, prostate
cancer, leukemia, and colon cancer. Unfortunately, these cancers are common, and to
community members, there is a perception that their community has more cancer than other
areas, but the etiology of each of these cancers is different and not linked to a common cause.
Most states have cancer registries that track all cancers diagnosed within the state. These
registries can be helpful for epidemiologists to determine if a specific area has a higher-than-
expected rate of cancer. However, the information from the registry needs to be considered
carefully. For example, when someone is diagnosed with cancer, where they lived at time of
diagnosis is put into the registry. The registry does not track whether someone just moved to that
location or whether they lived their entire life at one location. Since many environmental
exposures which cause cancer can take years or decades to develop, cancer registries cannot
reliably show a link between cancer and exposure where people live. Other registries are also
sometimes available for birth defects and diseases such as multiple sclerosis (MS) or
amyotrophic lateral sclerosis (ALS). These registries, such as cancer registries, can be used by
public health nurses to gather useful data. Investigating a potential cancer cluster includes (1)
determining the type of cancer that is a primary cancer, (2) determining if there is a statistically
significant increase in the number of expected cancers, and (3) determining if the population and
geographic area which should be included in the cluster investigation (National Cancer Institute,
2014). For many suspected cancer clusters, ultimately no evidence is found to indicate that the
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cases of cancer represent a true cluster. A 2012 study reviewed 487 investigations for cancer
clusters reported from 1990 to 2010. Only three of the investigations could link an increase in
the number of cancers to a hypothesized exposure and only one investigation found a clear cause
(Goodman, Naiman, Goodman, & LaKind, 2012). Because cancer is not one but many diseases,
trying to find a true cancer cluster and link it to a specific environmental exposure is very
challenging.
Practice Point
When thinking about environmental epidemiologic studies, it is important to remember how
they differ from assessing an exposure pathway. An epidemiologic study often starts with
people who are ill or who had a known exposure. The studies try to determine whether the
illness was caused by an environmental exposure or whether people with a known exposure
became sick. Assessing an exposure pathway starts with looking at specific contaminants in
the environment and determining if there is a completed exposure pathway to humans.
WORKING TOWARD HEALTHY ENVIRONMENTS
Healthy Communities
Healthy communities can help mitigate exposure to harmful contaminants and also encourage
good health by incorporating design principles that optimize the physical, social, and economic
environment of the community. In the 20th century, builders of communities did little planning
and did not consider the impact on human health and ecology from this type of development. As
areas around urban centers expanded, the term “urban sprawl” or just “sprawl” described how
communities edged away from urban centers. The concept of sprawl included nonexistent land
use planning, dependence on automobiles, and widespread commercial development along
major roads and residential areas with low population densities. While the U. S. population
nearly doubled from 1950 to 2011, vehicle travel during the same time period increased sixfold
(EPA, 2013). Communities developed as part of sprawl often lacked sidewalks or bike routes,
and there were no routes between residential developments to allow for walking between
neighborhoods.
Healthy communities help combat sprawl, and their design is gaining attention and
acceptance. Terms such as smart growth, healthy communities, green development, built
environment, and healthy community design all try to promote the concept that when health
considerations are incorporated into the planning or redevelopment, the community design itself
can work to make people healthier. Researchers have discovered that well-planned community
growth can help lessen the environmental impacts of development.
More than 38% of carbon monoxide and nitrogen oxide emissions come from highway
vehicles. Stationary sources such as homes and businesses are also significant sources of air
pollution (EPA, 2013). By working to build communities where people can decrease their
transportation needs and by creating more energy-efficient buildings, communities can create
healthier environments for local community members and positively impact the health of the
larger national or global community. Planned, smart-growth communities can improve water
quality by designing green infrastructure for storm water runoff. When rain and storm water hit
impermeable structures such as paved roads, parking lots, and other surfaces, water runs off into
sewer systems or directly into lakes, streams, rivers, and oceans, often taking contamination with
it. Encouraging landscape design and minimizing impervious surfaces can help to keep water
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cleaner. Green roofs, shaded sidewalks and streets, and building with solar reflective materials
can also help mitigate the “heat island” effect that makes cities and urban areas hotter than
surrounding green areas.
As new communities are built or older communities are being redeveloped, nurses and
public health professionals can work with planners, political leaders, developers, bankers, local
boards of public health, and community groups to help ensure that the health impacts (both
positive or negative) of the development are considered. Often, simple design changes can have
significant health effects. For example, if a new school site is being considered, choosing a site
that encourages children to safely walk to school will help increase children’s activity levels and
create less vehicular traffic in the community. Selection of building materials and considering
the entire life cycle of materials (from where and how they are created to how they will
eventually be disposed of) can also help to make communities healthier. More information on
healthy communities and smart growth can be found at the ATSDR Land Reuse Program, CDC
Healthy Places and EPA Smart Growth websites
(https://www.atsdr.cdc.gov/sites/brownfields/overview.html;
https://www.cdc.gov/healthyplaces/; https://www.epa.gov/smartgrowth).
Healthy Homes
Like the concept of healthy communities, the central premise of the healthy homes concept is
that the home has a direct influence on health. Healthy Homes is a coordinated, comprehensive,
and holistic approach to prevent diseases and injuries that result from housing-related hazards
and deficiencies. The focus is to identify health, safety, and quality-of-life issues in the home
environment and to act systematically to eliminate or mitigate problems (CDC, 2015b). The
initiative seeks to provide resources, such as healthy home inspection guidelines, to educate
public health professionals and to promote cross-disciplinary activities at the local, state, tribal,
and federal levels to eliminate housing deficiencies and hazards.
In the past, issues such as lead (paint) and radon dominated discussions about environmental
issues and housing. These topics are still very important and deserve attention, but the more
holistic healthy homes concept has continued to expand. Now, considerations about the
environment and individual homes or community housing involve topics such as indoor air
quality, mold and mildew mitigation and control, green building and green cleaning techniques,
and integrated pest management. In addition, information is available about how older citizens
can safely continue to live in their homes and communities, with new technologies and
assistance that reduce hazards (such as falls and remote medical monitoring) in the home. The
CDC has created a Healthy Housing Reference Manual that is available at the CDC website.
Healthy People 2020 goals include:
10% decrease in homes with lead paint
10% improvement in the number of trips made to work by walking
10% improvement in reducing cockroach and mouse allergens in homes
30% increase in homes with radon mitigation systems.
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CHILDREN’S HEALTH AND THE ENVIRONMENT
Vulnerability to the Environment
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Children may be more vulnerable to environmental exposures than are adults. Several factors
increase children’s vulnerability, including the following:
Children’s body systems are still rapidly developing.
Children eat, drink, and breathe more in proportion to their body size than do adults.
Children’s breathing zone is closer to the ground compared with adults.
Children’s bodies may be less able to break down and excrete contaminants.
Children’s behaviors can expose them to more contaminants. For example, young children, especially,
spend time crawling and placing their hands or other objects in their mouths (EPA, 2013, 2015, 2017).
Children spend time in places (school, day care, play spaces, gyms) outside of their homes where
environmental hazards may exist. For example, children often spend more time playing outside in the dirt
compared with adults.
Nurses should consider children’s unique vulnerabilities to contaminants when assessing an
exposure pathway. For example, lead poisoning is a problem that largely affects young children.
Children living near a site with lead in the soil would likely be at greater risk from lead
poisoning than the adults in the community because, as previously stated, they tend to put their
hands or other objects, which may be contaminated with lead dust, into their mouths. Children
who live in a community with older housing and close to a site with lead-contaminated soil may
be exposed to the metal from multiple exposure pathways. Data show that children living at or
below the poverty line who live in older housing are at greatest risk. There are approximately
500,000 children in the United States aged 1 to 5 with blood lead levels above 5 micrograms per
deciliter (µg/dL), the reference level at which CDC recommends public health actions be
initiated (CDC, 2017a). The CDC has online resources relating to lead poisoning and its
prevention.
Older children and adolescents may also be at risk for exposure to environmental hazards in
a way which adults are not. For example, mercury is a metal that comes from a variety of
sources, including old thermometers and blood pressure cuffs. Metallic mercury is fun to play
with because of the way it rolls around and forms beads. Children who find mercury frequently
like to play with mercury and inadvertently track it from place to place as they share it with their
friends. Most adults realize that mercury can be harmful, but most children may not realize how
dangerous an object of play can be. Unfortunately, mercury has well-known health effects, and
even at low levels, metallic mercury can cause health problems.
Metallic mercury exposure can cause harm before symptoms arise. The vapor from the
mercury when inhaled can cause serious health problems. Even a small amount of liquid
mercury can create enough mercury in the air to close a school, take buses out of circulation, or
force evacuations of homes. There have been incidents where schools have been forced to stay
closed for days while a mercury cleanup, which is difficult and expensive, took place. The Don’t
Mess with Mercury project, a collaboration between ATSDR and EPA, has short videos aimed at
teens to help them realize the danger of mercury. The videos and other materials on mercury can
be found at the website https://www.atsdr.cdc.gov/dontmesswithmercury/index.html.
When an entire community is being assessed, it is important to consider how the
environment affects children, specifically. For example, a lack of safe places to play may affect
children more directly than adults. Children may be at risk for more injuries if they are playing
in streets or other areas that were not designed for safe play. Teens may be more likely to
trespass on contaminated abandoned sites to hang out with friends or engage in activities like
riding bikes. In low-income areas, the playgrounds may have more trash, rusty play equipment,
and damaged surfaces, which could all contribute to an increased injury rate (CDC, 2011).
In 2015, EPA released updates to some indicators in America’s children and the
environment, 3rd edition, which has valuable information on environmental stressors’ effect on
children. This report provides valuable data on environmental exposures to children and trends
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over time. For example, as of 2009, approximately 6% of all children in the United States live
within one mile of a Corrective Action or Superfund site that may not have all human health
protective measures in place. This report and updates can be found at https://www.epa.gov/ace.
Student Reflection
In many respects, I don’t think many of my classmates understand the impact of
contaminants in the home environment. My community health practicum was in an
elementary regional school in a rural setting. One little 7-year-old girl, Rebecca, who did well
in school last year, was reported to have recent attention problems, and difficulty breathing,
especially after recess. After talking to the family, my preceptor and I decided to make an
environmental home assessment to gather more information. We found that the small two-
bedroom, old farmhouse was extremely littered and crowded. All three adults in the family
smoked. The only heat came from a wood stove and a small, old electric heater. There were
four younger children in the house who looked frightened. While we were there, Rebecca
had a coughing spell and looked very pale. Several interventions were necessary.
Ultimately, Rebecca saw a physician who diagnosed asthma, and smoke was a significant
trigger for her attacks. A referral to the county asthma prevention program led to a thorough
assessment. Health professionals presented an educational program about asthma, its
triggers, use of inhalers, and warning signs for complications to both Rebecca and her
parents. By the time my practicum was finished, Rebecca was having much less trouble
breathing on exertion and was doing better in the classroom.
Healthy Schools and Early Care and Education
Given how much time children spend in school and other care settings, these places should be
safe from environmental exposures to the greatest extent possible. More than 55 million children
(prekindergarten through grade 12) were enrolled in school in 2013 and there is an increase in
expected school enrollment through 2025 (National Center for Education Statistics, 2016). Many
school buildings are old and in poor condition, may contain environmental conditions that
inhibit learning, and pose increased risks to the health of children and staff. Many programs and
materials are available to help schools create healthy environments. These programs and
materials deal with issues such as lead to green cleaning techniques, chemical management,
indoor and outdoor air quality, and school site selection. The EPA has a website devoted to
healthy school environments and in 2011 released the EPA Voluntary School Siting Guidelines
to help communities determine the best location for schools. Healthy school information can be
found at https://www.epa.gov/schools.
Environmental exposures to children attending child care and early learning facilities is also
a concern for more than 8 million children (National Association of Regulatory Administrators
[NARA], 2014). Such exposures can come from products used in these facilitates (i.e.,
pesticides, cleaning products, craft materials) as well as from contamination left on site from
past use or adjacent sites. In 2017, ATSDR created Choose Safe Places for Early Care and
Education to bring awareness to the issue of where child care centers and other early education
facilities are located. Information on Choose Safe Places can be found at the ATSDR website
https://www.atsdr.cdc.gov/safeplacesforece/index.html (ATSDR, 2016).
ENVIRONMENTAL JUSTICE
Environmental justice is the belief that no group of people should bear a disproportionate share
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of negative environmental health consequences regardless of race, culture, or income. In 1994, a
White House executive order required that each federal agency makes environmental justice part
of its mission. The Interagency Workgroup on Environmental Justice, established by the
executive order, is charged with reducing disparities in community exposure to lead, toxic
wastes, air pollution, and pesticides. It defines environmental justice as
…the fair treatment and meaningful involvement of all people regardless of race, color,
national origin, or income with respect to the development, implementation, and
enforcement of environmental laws, regulations, and policies. Fair treatment means that
no group of people, including a racial, ethnic, or a socioeconomic group, should bear a
disproportionate share of the negative environmental consequences resulting from
industrial, municipal, and commercial operations or the execution of federal, state, local,
and tribal programs and policies. (CDC, 2008)
More information about the Interagency Workgroup on Environmental Justice is available
online.
Evidence for Practice
The city of Flint, Michigan, is a majority African American city where more than 40% of the
population lives in poverty (Kennedy, 2016). In 2014, the city switched its water source from
the Detroit Water Authority to the Flint Water system. With older water distribution pipes
often containing lead, drinking water can become contaminated with lead when there is
corrosion to the plumbing. With no corrosion control being used at the Flint Water System,
the levels of lead in the Flint tap water increased over time.
From April 2014 to October 2015, approximately 99,000 Flint residents were affected by
the changes in the water quality (CDC, 2016). Reports indicated that after the water change
in April 2014, residents started to complain about their water as early as May 2014;
however, a lead advisory was not issued until September 2015. In October 2015, the city
switched its water systems to return to the Detroit Water Authority. A CDC report found the
proportion of elevated blood lead levels in children were significantly higher during the early
period of the switch to Flint Water System compared to the previous period when residents
consumed water from the Detroit Water Authority (CDC 2016).
Living in poverty and in an area with older housing are both risk factors for children
having elevated blood lead levels (CDC, 2017b). The children living in Flint at the time the
water was switched were already at greater risk for having elevated blood lead levels.
Nurses can apply this knowledge by recognizing how multiple environmental exposures can
disproportionally affect some community members and consider how this may impact the
health of individual patients or whole communities. Nurses can also help advocate for safer
communities for everyone.
Many poorer or minority communities that lack political and economic power bear a
disproportionate burden of environmental hazards. According to the United States Department
of Agriculture (USDA, 2016), approximately 50% of 1.4 million farm workers in the United
States are Hispanic. Through direct exposure to pesticides, farm workers and their families may
face serious health risks. The exact number of pesticide poisonings per year is hard to determine
because many cases go unreported and there is no national surveillance system for acute
pesticide illness. These illnesses may make the workers and their families even more vulnerable
to extreme poverty if their illness prevents them from working. Many farm workers and their
families tend to live close to their work because they have few resources to travel to and from
work. Living close to the field they work in often means they are exposed to pesticides while
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working in fields and while at home. Children may also be exposed because they live close to
where the pesticides are applied. The workers may lack opportunities that would enable them to
seek jobs in other industries. In addition, they may lack resources to make moving possible and
if they complain, they may lose their jobs.
When we talk about environmental justice, we mean calling a halt to the poisoning and
pollution of our poorest communities, from our rural areas to our inner cities. When our
children’s lives are no longer cut short by toxic dumps, when their minds are no longer
damaged by lead paint poisoning, we will stop wasting energy and intelligence that could
build a stronger, more prosperous America. Former President Bill Clinton
Environmental justice is an important consideration when working with tribal communities.
Tribal communities often bear a disproportionate burden of impact from pollution on their tribal
lands (EPA, 2014). Many tribal communities still continue to practice traditional tribal life ways,
including eating traditional foods for either a majority or a portion of their diets. These
traditional practices are often negatively affected by contaminated land and water. For example,
if a tribal community’s traditional fishing grounds are polluted, a state may issue a “no fishing”
advisory, and the community may lose a large part of its traditional diet. The “no fishing”
advisory may affect the tribal community more than it does the nontribal community whose diet
is not as dependent on fish.
GLOBAL ENVIRONMENTAL HEALTH CHALLENGES
Climate change is happening, humans are causing it, and I think this is perhaps the most
serious environmental issue facing us. Bill Nye, American science educator and
television personality
In the 21st century, there is a greater focus on world health. Modern travel and communication
systems make it possible for people to go to all parts of the world. As people begin to feel more
connected to their world, they may feel more vulnerable, because environmental health issues in
one country can affect others. Contamination created in one country does not abide by map
boundaries and may affect neighboring countries. Consumption patterns may create a situation
where one country contaminates its air, water, or land while manufacturing goods for other
countries. If we want to all live in a healthy environment as society moves forward, people will
be forced to confront difficult issues with global consequences.
Clean Water and Sanitation
In the United States, most citizens have access to clean water and sanitation services and often
take these services for granted. Worldwide, however, clean water and sanitation are not
standard. According to the World Health Organization (WHO) in 2015, 844 million people still
lacked basic drinking water services. Those without basic services use unprotected wells or
springs, took water directly from surface water (such as rivers, lakes, ponds), or had to use more
than 30 minutes to collect water. However, there has been improvement in the percent of the
population with access to at least basic drinking water services by an average of 0.49% points
per year between 2000 and 2015 (WHO & UNICEF, 2017). Access to basic sanitation is still a
challenge in some parts of the world. The 2.3 billion people who still lacked a basic sanitation
service practice open defecation, use unimproved facilities such as pit latrines or use sanitation
facilities that are shared with other households (WHO & UNICEF, 2017).
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There are nearly 1.7 billion cases of childhood diarrheal disease worldwide each year and it
is still the second leading cause of death for children under age 5. These illnesses are
preventable and treatable. Improved access to safer drinking water and basic sanitation, along
with education and access to hand washing, can help decrease the burden of these illnesses. As
the world’s population continues to expand, access to clean water and sanitation services is
likely to remain a challenge. The WHO has set goals for worldwide improvement in access to
drinking water, sanitation and, hygiene. More information about these topics and the goals can
be found at the WHO website (http://www.who.int/news-room/fact-sheets/detail/diarrhoeal-
disease).
Air Quality
Outdoor and indoor air quality affects people in all countries. However, people in developing
countries bear more than half of the burden from air pollution on human health. Exposure to
particulate matter and ozone carries serious risks to health. By reducing air toxins, it is possible
to reduce the morbidity and mortality of illnesses such as lung cancer, asthma, respiratory tract
infections, and heart disease (WHO, 2016). As the relationship between air quality and health
has become clearer, the WHO has established guidelines for countries to help decrease air
pollution–related illnesses. However, reaching these guidelines is a challenge; in 2014, 92% of
the world population was living in places where the WHO air quality guidelines levels were not
met (WHO, 2016).
Indoor air quality is a problem, especially in homes where biomass fuel and coal are burned
for heat or cooking. Worldwide, three billion people are forced to burn fuels such as animal
dung, firewood, and coal, which do not combust well and create high levels of particulate matter
and carbon monoxide (WHO 2014). The burden of this exposure falls mostly on women and
children, who often spend more time in the home. In 2014, the WHO set new emissions targets
that will help protect health. Chronic and acute exposure to particulate matter can increase the
risk of cardiovascular and respiratory diseases. Exposure to particulate matter from indoor
heating and cooking sources can increase the risk of acute lower respiratory tract infections and
associated deaths in young children. The 2014 WHO indoor air targets can help decrease the 4.3
million deaths per year that are believed to be linked to indoor air pollution from cooking and
heating (WHO, 2014).
Weather forecast for tonight: dark. George Carlin
Chemical and Contaminant Exposure
Worldwide, people may be exposed to chemicals and other contaminants in ways that are very
different than in the United States. Many countries lack environmental and occupational
protections that we have come to appreciate. For example, mining practices in Nigeria led to an
outbreak of lead poisoning in at least six villages. In this part of Nigeria, people use rudimentary
tools to break apart ore to find pieces of gold. The process creates lots of lead-contaminated
dust, since the ore has a high lead concentration. Much of the work is done near or in family
compounds. In 2010, a multidisciplinary team surveyed two of the affected villages and
collected blood from children younger than 5 years. The team found in just two villages, in the
12 months before the team arrived, 118 out of 463 (26%) children younger than 5 years had
died. Parents reported that 82% of the children who died had convulsions before death, a sign of
severe lead poisoning. Blood samples collected from 205 living children found that 97% had
blood lead levels greater than 45 µg/dL. In the United States, children with a blood lead level of
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45 µg/dL would immediately have chelation therapy started to reduce their blood lead levels.
The blood lead concentrations in the children ranged from 33.3 to 445 µg/dL (CDC, 2010). The
total number of deaths across all villages is not known, but according to the WHO, an estimated
2,000 children need chelation therapy. The WHO has stated of the crisis, “[S]ome children will
require chelation for many months…In addition, capacities within Nigeria for the diagnosis and
management of lead poisoning need further strengthening and support. A further challenge is the
purchase of sufficient chelating agents: these are expensive drugs that are not available as
generics” (WHO, 2011).
This story from Nigeria illustrates the potential deadly consequences when there exists a
combination of limited environmental protections, lack of knowledge concerning environmental
dangers by local community members, and the community members’ need to earn an income.
As we become a more globalized community with natural resources and materials being
produced, shipped, and moved around the world faster than ever before, we need to consider the
impact on the communities that produce those resources and materials and strive to protect their
health as we protect ours in the United States. Just as we consider environmental justice within
the United States, we must consider it on the global scale.
Climate Change
Although the extent and severity of climate change are still topics under debate, most scientists
and governments agree that human activities are influencing global climate. Climate variability
and change affect human health in a variety of ways. Climate change will likely cause a shift in
the number and severity of natural disasters, such as heat waves, floods, and droughts. These
natural disasters will have an immediate, direct impact on human health, but they will also have
wider-ranging impacts on water and food supplies. Food security, already a problem for many
poorer areas, will continue to be a challenge as climate change affects crop patterns.
Changes to water supplies and increased flooding may make some areas more vulnerable to
diarrheal diseases. In addition, many diseases are highly sensitive to changes in climate. Experts
predict that common vector-borne diseases such as malaria and dengue fever will affect larger
geographic areas, as the vectors that carry the diseases find agreeable climates in expanding
areas. Climate change will affect air quality and 300,000 million people with asthma and will
face increased disease burden from asthma triggers such as high ozone levels and pollen.
According to the WHO, between 2030 and 2050, approximately 250,000 additional deaths per
year will be due to climate change. These deaths are primarily from heat exposure in elderly
people, diarrhea, malaria, and childhood undernutrition (WHO, 2017).
It is necessary to realize that the effects of climate on human health will not be evenly
distributed around the world. Populations in developing countries, particularly in the Small
Island Developing States, arid and high mountain zones, and densely populated coastal areas,
are considered to be particularly vulnerable. More than half of the world’s population lives less
than 40 miles from the sea making them more vulnerable to sever storms and flooding (WHO,
2017).
However, it is not only developing countries that will be affected. For example, a heat wave
in Western Europe in 2003 caused approximately 70,000 more deaths that year than had been
caused in previous years. Countries in Europe and the United States will feel the impact of
changes to storm patterns and may also face water and food supply issues if patterns of drought
or excessive rain affect agricultural areas (WHO, 2017).
Climate change has helped illustrate that humans live in a world where the health of all
environments is connected. It is nearly impossible to view global environmental issues as
something that happens “over there.” The industrialization of countries around the world will
have a direct impact on the environmental health of the entire planet. To tackle these issues,
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global cooperation and planning are essential. To find out more information about how climate
change may impact the United States, visit the US Global Change Research Program at
http://www.globalchange.gov/.
Climate adaptation is one way that public health nurses can start thinking about how to help
communities deal with climate change. An example of adaptation is a community preparing to
have cooling stations open for community members to seek relief during a heat wave. The
community may not be able to control the extent and duration of a heat wave but they can put
into place some interventions to help protect health. The CDC developed the Building
Resilience Against Climate Effects (BRACE) framework to help professionals and communities
start developing strategies to prepare for the health effects of climate change (CDC, 2015c). This
framework and additional information can be found at the CDC website
(https://www.cdc.gov/climateandhealth/BRACE.htm).
KEY CONCEPTS
The environment has a direct impact on human health.
The nursing process of using assessment, intervention, and evaluation can be used when thinking about
how the environment affects human health and how health can be protected.
Proximity to a contaminant or hazard is not the only factor in determining whether there is a risk to human
health. For a contaminant to pose a risk, there must be a completed exposure pathway.
When assessing a community’s environment, it is helpful to think about the whole environment to determine
what components are influencing human health.
Environmental justice is important to consider when looking at the impact of the environment on a
community.
A community environment can be built to help positively influence the health of those living in the
community.
Globally, there are still many environmental health challenges that must be faced.
CRITICAL THINKING QUESTIONS
1. You are a public health nurse and receive a call from a resident who stated “many people on Spruce
Street near the old junk yard have cancer.” The resident is concerned. What types of questions would you
think about to begin to determine whether there could be a connection between the cancer and the site?
2. As a local public health nurse, a family is referred to you because their 3-year-old child has a blood lead
level of 26 mg of lead per deciliter. Is this a high lead level? What are the likely sources of lead exposure
for the child? What type of education would you likely do for the family? Consider looking at the Center for
Disease Control and Prevention’s website on lead.
3. The town you live in is considering using a multi-acre abandoned site to build a mixed-use development (it
will have retail facilities, residential buildings, and public space). As a public health nurse, what would you
suggest the designers consider to optimize the environmental health of the development? Consider
looking at the Environmental Protection Agency’s website on smart growth and green building.
4. Think of the community surrounding your school of nursing. Pick two environmental conditions and assess
these conditions. Where do you think you could locate data to support your observations?
5. Why do you think it is important for the government to monitor human exposures across the United
States?
6. Consider an environmental health challenge facing a developing country. What are some economically
feasible interventions that could help protect community members? (Websites such as the CDC Safe
Water System or the WHO Environmental Health websites might help provide some ideas.)
7. Assisting communities to adapt to climate change is a challenge we face. Pick a community near you and
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determine what climate change impacts they may face and what vulnerabilities they may have. Remember
to consider especially vulnerable populations within those communities and identify their specific
challenges. (Websites such as CDC’s Climate and Health or EPA’s Climate Change Adaption Resource
Center might be helpful.)
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Carson, R. (1962). Silent spring. New York: Houghton Mifflin Harcourt.
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Centers for Disease Control and Prevention (CDC). (2009a). Childhood lead poisoning associated with
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WEB RESOURCES
Please visit thePoint for up-to-date web resources on this topic.
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http://www.who.int/mediacentre/factsheets/fs266/en/
http://thepoint.lww.com/vitalsource/ebook/9781975111694
Chapter 20
Community Preparedness:
Disaster and Terrorism
Merrily Evdokimoff and Joy Spellman
For additional ancillary materials related to this chapter. please visit thePoint
DOWN*
down it came
down from the autumn sky
down it came down &
every one rose &
wept in the city (my city) &
some were flying &
some were falling &
some were running &
some were burning
where were you listening
watching then?
in the shattered earth?
in the broken air?
in the oily fire?
in the tainted sea?
where were you listening
watching then when everyone rose &
lookt at the sky lookt at the
sky where they stood in my city &
wept?
—Jesse Glass
CHAPTER HIGHLIGHTS
Public health nurses and disaster response
Types of disasters
Disaster management
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Public health response
Role and responsibility of nurses in disasters
Classification of agents
Field response
Skill building for field activity
OBJECTIVES
Identify disaster types.
Explain the disaster planning process and nursing participation.
Understand nursing participation in a disaster.
Promote increased competency levels through the use of Table Top Exercises (TTX), field drills, and
exercises.
Differentiate between biologic, chemical, and radiologic agents and response to exposure.
Describe the public health response throughout the phases of an emergency response.
KEY TERMS
All-Hazards Vulnerability Study: An integrated approach to emergency preparedness that
addresses a wide spectrum of emergencies.
After-action report: Retrospective analysis used to evaluate emergency response drills.
Decontamination: Process of cleaning to remove biologic, chemical, or radiologic agents.
Evacuation: Moving people from a dangerous place to safety.
Human simulation training (HST): Use of life-like/computerized models for creating increased
reality during a practice scenario
Incident command system (ICS): Common organizational structure implemented to improve
emergency response.
Invacuation: Moving people from one area to another within the same facility.
National Response Framework (NRF): Framework that guides how the nation conducts all-
hazards incident response.
Mass casualty incident (MCI): Any incident in which emergency medical services resources,
such as personnel and equipment, are overwhelmed by the number and severity of
casualties.
Medical Reserve Corps (MRC) or Community Emergency Response Team (CERT):
Community-based program that uses volunteers for emergency preparedness response.
National Incident Management System (NIMS): Structured, flexible framework that guides the
response to disasters at all levels of government, the private sector, and nongovernmental
organizations.
Personal protective equipment (PPE): Clothing and/or equipment used to protect the body
from injury and illness.
Point of distribution (POD) or Emergency dispensing site (EDS): Centralized location where
the public picks up emergency supplies following a disaster.
Real time: The actual time in which something occurs.
Scenario: The sequence of possible events or circumstances.
Shelter in place: The protective action of remaining in current location during an incident.
Simulation: The imitation of the features of an object or anticipated response.
Social Distancing: Action taken by Public Health officials to stop or slow down the spread of a
highly contagious disease by keeping social interactions to a minimum.
Strategic National Stockpile: The supply of potentially lifesaving pharmaceuticals and medical
supplies maintained by the CDC for use in a public health emergency severe enough to cause
lack of local supplies.
Surveillance: A process to document and track changing information to prevent injury and
illness.
Terrorism: The use of threats and/or violence to intimidate or coerce society for political
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purposes.
Weaponize: To convert into a weapon for use in harming others.
*Copyright 2002 by Jesse Glass. Used with permission of the author and of about.com (poetry). Available
online at http://poetry.about.com/library/weekly/aa110901m.htm.
CASE STUDY
References to the case study are found throughout this chapter (look for the case study icon).
Readers should keep the case study in mind as they read the chapter.
Geoff, a nurse educator at the Texas Public Health Department, has played an active role in
providing education and hands-on experiences involving disaster-based scenarios among
community-based nurses throughout the state. Nurses require more specific knowledge about
harmful agents and situations not usually seen in their practice. With state support, the public
health nurses, with Geoff’s leadership, decide that a certificate on biologic, chemical, and radiologic
terrorism will be offered with expanded content that will build new skill sets needed in a field
response. Lessons learned from the response to the aftermath of Hurricane Harvey along the
Texas coast in November 2017 are incorporated into the certificate curriculum.
Geoff will include a module on preparedness operations while working with diverse
communities. The program will be delivered in the spring, followed by an emergency exercise
designed to test the capability of a large city’s response to a deliberate chemical attack. The
community and public health nurses enrolled in the course will be key players in the planning,
execution, and evaluation phases of the drill.
INTRODUCTION
The only difference between reality and fiction is that fiction has to make sense. Tom
Clancy
Between 1900 and 2016 more than 21,000 disasters have occurred in the world (UNDRR, 2015)
FIGURE 20.1 Submerged vehicle on a road outside Beaumont, Texas, in flooding from Hurricane
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Harvey. (Source: FEMA/Dominick Del Vecchio—September 2, 2017. Retrieved October 23, 2017,
from https://www.fema.gov/media-library/assets/images/136115.)
Hurricanes are a major threat for the American continent and can leave behind long-lasting
economic and human consequences. Constant preparedness and disaster risk reduction actions
need to be taken, not only regarding direct consequences of hurricanes but also in regard to the
associated disasters, such as urban flooding and dam bursting.
Hurricanes and cyclones are extreme events that bring high destruction in terms of number
of deaths and economic damages. Damage from the hurricanes of Fall, 2017 included:
Harvey: 69 deaths, 450,000 people affected and 58 billion US$ of damages.
Irma: 83 deaths, 5.7 million people affected and 50 billion US$ of damages.
Maria: 55 deaths/missing, 100,000 people affected and billions US$ of damages.
(EM-DAT, 2017)
Due to numerous natural-, weather-, and terror-related disasters, the United States has
responded to in the past few years, these experiences are being used to hone emergency plans
and include all levels of personnel and the public in the planning and implementation of disaster
management. Recognizing the need for local government, as the first responders, to provide aid
until State and Federal aid can be mobilized, there is a renewed focus on local planning.
Healthcare organizations particularly have been charged with working together with local public
health to be better prepared in a disaster or other mass casualty events. Nurses have a
significant role to play in alleviating the suffering related to these disasters.
There are 2.8 million registered nurses in the United States, as well as the nursing population
worldwide that provide a tremendous untapped resource that can and must be used if the nation
is to adequately prepare for such events (BLS, 2016). In order for nurses to respond
appropriately to mass casualty incidents (MCIs), guidelines and recommendations must be in
place to ensure that they can recognize and respond to potential and occurring emergency
events. Emergency preparedness for nurses begins with the recognition that effective
management of a disaster event requires the integration of activities from multiple community
systems including emergency response, acute and postacute care and public health (APHN,
2014).
Public health nurses (PHNs) have been responding to disasters for more than a century.
Historically, nursing evolved from the actions taken by Florence Nightingale in the Crimean
War. Long before the nursing process was theorized, researched, and established as part of the
nursing profession, Nightingale used her skills of observation and critical thinking to improve
health outcomes. Nightingale implemented principles of evidence-based nursing at that time. As
she strolled through hospital wards, Nightingale was actually documenting environmental
conditions and social determinants of health and their impact on the patients she was charged to
keep well. Nightingale’s analysis of health-related statistics, used to track outcomes, introduced
epidemiology to the healthcare setting (see Chapter 6). Since that time, the PHN has continued
to expand competencies by utilizing interventions that are enlightened by an evidence-based
approach to improve population health. With a public health nursing workforce that understands
and implements evidence-based public health practice, local health department officials and
policymakers will see the benefits of evidence–based decision-making during a disaster. The
Healthy People 2020 goal for preparedness is “To strengthen and sustain communities” abilities
to prevent, protect against, mitigate the effects of, respond to, and recover from incidents with
negative health effects” (Healthy People, 2017).
Community and public health nursing has a broad scope of practice. For example,
population-based practice may have a narrow focus (e.g., six students with diabetes in a middle
school) or a broad one (e.g., a potential H7N9 pandemic). Managing a client load of six certainly
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seems reasonable. Doing the same within a county of 400,000 people is quite different. The role
of nurses within the community is to assess the needs of the populace and ensure that service
breaches are addressed. Nurses accomplish this by calling on existing agencies and institutions
to find ways to serve the needs of the citizens. Collaborative effort is a significant part of
response. For example, local health department nursing personnel, school nurse organizations,
and volunteers from the Medical Reserve Corps (MRC) and Certified Emergency Response
Teams (CERT) have worked in concert to provide in-school H1N1 immunization as well as
engaging in surveillance activities. From that experience, PHNs in Texas are working at putting
the knowledge and skills gained from the 2017 hurricane into evidence-based policies that may
be implemented during the next event. A well-prepared cadre of community and PHNs is
essential to minimize the effects of both immediate and long-range disasters.
The aftermath of the destruction of the World Trade Center in 2001 identified a lack of
trained leaders and workers in all areas of public health service. The event also stimulated a
growing appreciation of those who respond to large-scale events. Increased competency in
disaster response became a new dimension to nursing practice. The Centers for Disease Control
and Prevention (CDC) has called for the mobilization of the public health workforce to ensure
the training and education of communities across the nation regarding biologic, chemical,
radiologic, and explosive device attacks. It is necessary to learn how to prepare for events that
are difficult to imagine, and it is even more challenging to mount a response. Multiple disasters
in Texas, Florida, and Puerto Rico in a short period of time illustrate the importance of having a
coordinated, multidisciplinary response to a culturally diverse population (Douglas et al., 2011).
There cannot be a crisis next week. My schedule is already full. Henry A. Kissinger
Evidence for Practice
Lim, Lim, & Vasu (2013) surveyed physicians and nurses about their perception of their own
and their institutions preparedness for a disaster. While 75% felt their institution was
prepared only 36% felt they as individuals were prepared. Factors that contributed to
personal preparedness included: institutional, peer, and leadership preparedness plus
disaster response training. The study revealed that 80% of professionals polled were willing
to act in response to such an event. Classroom study and field exercise participation among
healthcare workers resulted in a significant increase in their ability and willingness to
respond effectively in a disaster. This research validates the “vision” put forth by Veenema
and colleagues (2016) identifying: (1) increased disaster knowledge base of nurses; (2)
ability to provide direct or indirect support during a disaster; (3) promoting preparedness
among individuals in the community; and (4) participating in disaster planning drills.
What kind of data does Geoff gather in his disaster training needs assessment?
How can these new findings affect the emergency planning process for healthcare
facilities and the community at large? How will the needs of a diverse community be
addressed in the new plan?
EMERGENCIES, DISASTERS, AND TERRORISM
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Response to emergencies and disasters has been a part of the human experience since humans
first walked on the earth. A nation’s capacity to respond to these threats depends in part on the
ability of healthcare professionals and public health officials to rapidly and effectively detect,
manage, and communicate during an event resulting in mass casualties. Emergencies are
considered events that require a swift, intense response on the part of existing community
resources. Disasters are often unforeseen, serious, and unique events that disrupt essential
community services and cause human morbidity and mortality that cannot be alleviated unless
assistance is received from others outside the community. Disasters vary by: (1) the type of
onset (they often occur without warning); (2) the duration of the immediate crisis; (3) the
magnitude or scope of the incident; and (4) the extent to which the event affects the community.
There are three types of disasters: natural, accidental, and terrorist attacks. Nature can wreak
havoc when a tornado touches down or a hurricane obliterates a once-wide sandy beachfront.
Natural disasters are widespread throughout the world. The 2017 catastrophic earthquake in
Mexico is an example. The rapid occurrence in the Caribbean and United States of hurricane’s
Harvey, Irma, and Maria all within a month of each other emphasized the need for local disaster
management organizations to mobilize quickly and deal with rapidly changing developments.
Accidents include human-made disasters such as the Chernobyl meltdown in the former Soviet
Union, which remains a constant reminder of the devastating effects of such a radiologic event.
The near meltdown that occurred in posttsunami Japan in 2011 has been deigned to be a human-
made disaster based on evidence that revealed faulty design elements in the placement of reactor
cooling tanks. The shipwreck of unsafe boats filled with migrants seeking political asylum has
become an increasingly frequent disaster. Active shooter attacks continue to occur throughout
the world on a daily basis, and in the United States, the October 2017 attack by a “lone wolf”
gunman in Nevada reminds us to be prepared for the unexpected.
Natural Disasters
Natural disasters are the result of naturally occurring events that have an impact on the
environment, the economy, and the people who live in the area. Examples include earthquakes,
extreme heat, floods, hurricanes, landslides, tornadoes, tsunamis, volcanic eruptions, wildfires,
and winter weather. All of these conditions are threats to health.
Although many natural disasters are not predictable, it is possible to assess the circumstances
that increase vulnerability to a natural disaster ahead of time and take steps to prevent
complications. For example, as reports of a strengthening tropical storm in October 2017 came
in to Texas state incident command center, experts tracking the storm agreed that “Harvey”
would soon assume full hurricane status. With miles of ocean front coast and several counties
exposed to coastal waters, a storm evacuation plan had been in place and exercised over the
years. Previously identified sites to be used as shelters were activated 2 days before the
hurricane made land fall. County and state health departments, the Red Cross, local and state
law enforcement, and PHNs worked closely to accept the storm victims and assess their needs.
On-site triaging resulted in the transfer of many storm victims for injuries and complications
from existing chronic illnesses. In this instance, rapid assessment of an impending natural
disaster, resource identification, and activation of an often exercised scenario resulted in saving
scores of lives. As public health practitioners gather evidence for practice, it is becoming clear
that in many disaster scenarios, the displacement of people before, during, and after the event
must be considered as plans are developed.
Practice Point
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Many natural disasters are anticipated, such as hurricanes, rising flood waters, and
temperature extremes. Include these events when planning for emergencies—a response
can begin before the onset of disaster. The instillation of early warning signals can also allow
for earlier warnings to take shelter or evacuate. Tornado sirens have become much more
common in the Midwest. Signs of seismic activity that may indicate an impending earthquake
are also being refined. Become familiar with locally designated shelter sites, evacuation
routes, and early warning signals.
Accidental Disasters
Accidental incidents, broadly defined, are those that happen as a result of circumstantial factors
(e.g., road conditions, human error, and physical plant deterioration) and are usually not
deliberate. For example, a truck containing a toxic chemical being transported on a major
highway system overturns when the driver fails to negotiate a clearly marked warning of the
steep incline of the exit ramp. Evacuation of the area takes place. “Accident” implies that the
incident is uncontrollable and/or unpreventable, usually with a negative outcome. But, do
accidents just happen? Or can they be prevented? Over time, epidemiologists have identified
ways to prevent the negative outcomes of unanticipated events by improving preparedness and
awareness training and education. For instance, research findings may suggest that road signage
located well before the steep incline, or consistent driver evaluation, could prevent vehicle
accidents, or at least minimize their severity.
Like natural disasters, accidents may also have an impact on the environment, cost millions
of dollars, and affect the lives of those involved. The 2010 collapse of the oil rig in the Gulf of
Mexico and the consequent destruction of a vast, sensitive ocean environment is a good
example. Preparing for accidental disaster is difficult, largely because of the possibility of
human error and the setting in which it occurs. Certainly, the accidental release of nuclear
materials affecting 1,000,000 people may not be seen in the same light as a medication error on
the part of a nurse. In both cases, assessment of vulnerabilities with subsequent correction,
followed by implementation of a preventive action, might have prevented the accident.
Forgetting to complete a task can also contribute to a disastrous situation. For example, during
review of an evacuation of a long-term care facility as part of a mandatory yearly exercise,
administrators find that contracts with medical transport companies were not renewed, making
effective evacuation impossible. Disaster management planning is now required by Center for
Medicare and Medicaid Services (CMS) for hospitals and postacute entities like clinics, home
health, and dialysis sites as a requirement for receiving Medicare funding.
Evidence for Practice
Planning leaders now recognize it is essential in preparedness activities to collaborate
among all levels of providers in various settings. Clear identification of roles and
responsibilities as the process develops lends itself to effective response. By broadening
the scope of participants in the planning process, details previously overlooked have a
better chance to be included in the disaster response. Coordination within a wider
community coalition assures a workable, reliable mass casualty plan.
The use of simulation supports an evidence-based approach to disaster planning by
identifying methods to use empirical data in the decision-making process. This process will
help emergency response planners to identify hazards and vulnerabilities through a wide
variety of scenarios, learn responses to each, and develop principles or best practices that
apply to a broad spectrum of disaster scenarios. Ultimately, the promotion of injury and
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disease prevention programs and practices will be enhanced.
Terrorism
Although there are difficulties in defining global definition of terrorism, the United Nations
Security Council described it as “criminal acts, including against civilians, committed with the
intent to cause death or serious bodily injury, or taking of hostages, with the purpose to provoke
a state of terror in the general public or in a group of persons or particular persons, intimidate a
population, or compel a government or an international organization to do or to abstain from
doing any act” (Sanchez and Leiden, 2009. P. 67). Section 802 of the Patriot Act defines
Domestic Terrorism as any unlawful act that seeks to: (1) intimidate or coerce a civilian
population; (2) influence the policy of a government by intimidation or coercion; or (3) affect
the conduct of a government by mass destruction, assassination, or kidnapping. (ACLU, 2017).
The inclusion of intention to harm civilians for political purposes is a common thread within
both definitions. The main goals of terrorism are creating fear, causing casualties, and rendering
sites unusable. Fear and intimidation are potent concepts for the human psyche to process. A
recent study by PEW research found that Americans are more fearful now of terrorist attacks
than right after 9/11 (McGill, 2016).
Part of this new world of completely improvisational terrorism is that there were codes of
war that disintegrated in the face of terrorism. Diane Sawyer
DISASTER PREPAREDNESS IN A CULTURALLY
DIVERSE SOCIETY
It is important to integrate a community’s ethnicity, race, culture, and language into emergency
preparedness response and recovery plans. This requires cultural competence across all
disciplines involved in the planning and implementation phases. (Addy, Browne, Blake, &
Bailey, 2015). Outreach to diverse members of every community is critical to assure effective,
inclusive strategies to protect all citizens. PHNs are well versed in identifying vulnerable
populations within the districts in which they serve. Efforts to assure that health professionals
and emergency responders become more culturally competent have gained momentum in the
past few years. An increasing awareness of inequities visited upon ethnically diverse
communities has emerged since Hurricane Katrina hit the Gulf Coast early in the morning of
August 29, 2005. The Office of Minority Health, U.S. Department of Human Services (DHS),
has developed a Cultural Competency Curriculum for Disaster Preparedness and Crisis
Response that offers continuing education for those looking to enhance their skills toward the
provision of competent care in disaster situations (Office of Minority Services, 2017).
Culture is the learned knowledge of values and beliefs of a particular group that are passed
down through generations. These belief systems influence a person’s view of the world,
decisions made, and behaviors tied into those beliefs. The latest data collected in Texas have
identified over 37% of population reporting a Hispanic background and an additional 3% Asian.
(U.S. Census Bureau, 2016). These numbers clearly illustrate the importance of addressing
multicultural influences during a disaster. A person’s culture is a comforting and reassuring
system at the best of times. The degree of community cohesion is seen as a determinant in
survivor support. For instance, a disrupted community will not be able to provide the same level
of support as one that is viewed as cohesive (McKay, 2017). Given the benefit of advanced
warning as Hurricane Harvey fast approached the Texas coastline, public health leaders and
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emergency response teams identified designated shelters for specific county residents in an
attempt to try to maintain a neighbor-to-neighbor environment. Separated family members were
given the opportunity to move to a shelter where they could reunite with family and friends.
Social and economic inequality plays a large part in all areas of life; however, special
attention to minority and disadvantaged neighborhoods must be given during the planning
process. By most accounts, the poor and disenfranchised live in the less-desirable sections of the
city, and the dwellings they occupy are not as resistant to time and natural weather extremes.
They may also lack the transportation options of the more affluent during evacuation, thus
depending on public transportation. PHNs recognize that many immigrant populations are not
only unfamiliar with existing community resources but are reluctant to disclose their
immigration status for fear of deportation.
In developing an inclusive community preparedness plan, it is important to become familiar
with those community institutions that can meet the mental health needs of a diverse population.
Language, and the potential barriers it may present during a disaster response, must be
considered as a first step when mounting a field intervention during an event. As part of state
and local planning in Texas, colleges and universities have identified volunteers who will act as
interpreters for specific ethnic communities. As planning progresses, identify who the cultural
brokers are within a community. By establishing solid working relationships with trusted
organizations, and various cultural group leaders, PHNs can begin to educate the citizenry about
plans, intended response, and community resources well before the beginning of a disastrous
event. Invite leaders to participate in all phases of disaster preparedness, response, and recovery
operations.
Nursing researchers established standards of practice for cultural competency to guide nurses
in their practice across the world to provide “culturally congruent nursing care” (Marion, 2016).
These standards are applicable to all nursing disciplines but are especially useful to PHNs whose
focus is community and populations at large. Danna, Pierce, Schaubhut, Billingsley, & Bennett
(2015) identified education in cultural competency and disaster management to focus on the
most vulnerable populations to include: (1) older adults/seniors; (2) obstetrics/perinatal/neonatal;
(3) medically needy/terminally ill; (4) children/pediatrics; (5) homeless; (6) individuals with
disabilities; (7) individuals living in rural areas; (8) individuals with mental illness; and (9)
individuals with limited English proficiency (LEP) (p.140). Evidence-based practice stresses the
importance of implementing interventions that have proved successful among diverse
populations. In terms of disaster response, although evidence is building within the scope of
public health practice, nurse researchers have a fresh opportunity to test interventions used
during the events surrounding Hurricane Sandy with a focus on the reduction of disparities in
health outcomes among the poorest citizens.
Geoff decides to integrate evidence-based knowledge from his Hurricane Harvey
experiences in 2017 into the preparedness certificate curriculum. Based on the multicultural
makeup of the displaced population he cared for, he is asking each nurse participant to select
two distinct cultural and ethnic groups from within the community he or she serves. What
vulnerabilities, hazards, and special needs will you have identified during the community
planning process? If an evacuation order is given, how will this message be conveyed to these
sectors in the community? Cite specific and special needs these community members may need
once transported to a shelter.
Practice Point
During any disaster scenario, identify yourself as a nurse immediately upon making contact
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with a victim. Nurses are recognized globally for their caring attitude and competency in
difficult times.
DISASTER MANAGEMENT
Disasters have a timeline, often referred to as a life cycle or phases. These include the preimpact
phase (before), the impact phase (during), and the postimpact phase (after). Actions taken during
these phases will affect the illness, injury, and death that occur following the incident. Although
disasters vary significantly, the response to each is similar. All disaster response begins at the
local level—all communities must be prepared for emergencies. The disaster management
continuum illustrates the essential steps in the process (Fig. 20.2).
Just as there are distinct phases of a disaster, so too are there phases of an emergency
management response. These are preparedness, mitigation, response, recovery, and evaluation. It
is important to remember that during the management of any disaster, the activities carried out
will frequently overlap phases. During a disaster, duties and their associated activities often
cross boundaries in order to complete a task at hand.
Preparedness
Disaster preparedness plans are action plans developed in anticipation of disaster scenarios,
providing a framework for response to emergency situations. They are proactive planning efforts
that provide structure to a disaster response before it happens. In an all-hazards event plan, the
response must be a coordinated community effort. This means engaging members of the
community in ongoing preparedness activities. Working relationships can be strengthened by
formalizing mutual aid agreements with regional health, police, and fire departments; volunteer
organizations such as the Red Cross and other local planning groups; healthcare organizations;
schools; and state response coordinators. In addition, signing memorandum of understanding
(MOUs) with local providers is necessary to assure a supply of food and potable water and other
supplies for disaster victims.
To ensure a successful response, steps must be taken before any incident, however minor,
occurs. In this process, the risk for a given disaster is assessed, and the potential impact is
evaluated. Planning for disasters involves data collection in three areas: (1) Risk Assessment (2)
All Hazard Vulnerability Studies; and (3) Federal and State Response Networks. The
effectiveness of the disaster plan is only as good as the data that underlie the planning efforts
and the assumptions (Veenema, 2013). These studies identify all possible hazards,
commonalities of response from the community of interest and appropriate expectations
regarding Federal and State Response Networks.
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FIGURE 20.2 The disaster management continuum. (Adapted from: Veenema, T. G. [2009].
Ready RN handbook for disaster nursing and emergency preparedness. [pp. 3–25]. St. Louis:
Mosby Elsevier.)
The identification of all existing and potentially dangerous situations before disasters occur
is the first step in planning for an effective response.
Risk Assessment
Types and combinations of hazards are unique to a community. They may involve propensity for
natural disasters, chemical or radioactive spills, transportation accidents, congregation of large
groups of people, and numerous other situations. Different circumstances result in different
types of injuries or illness, damage, and disruption of communication and transportation.
Gathering historical data about previous disasters are helpful, and proven successful nursing
interventions can be noted in the growing practice of evidence-based public health. Aerial
photography, satellite imagery, wireless remote sensing devices, and geographic positioning
systems (GPS) are tools commonly used in hazard identification. Computer-generated pluming
software is a proven means of indicating the direction in which a wind-driven chemical release
may head. Once the hazards are identified, the extent of damages, interruption of services, and
threats to health can be estimated. This information can be used in designing a community
emergency plan.
All Hazards Vulnerability Assessment
In this process, the resources of the community that would reduce the impact of a given hazard
should be identified and plans made to strengthen those resources if necessary. Disaster
prevention measures may be instituted that involve the removal of identified hazards, relocation
of at-risk people away from the hazard area, provision of educational materials, institution of
sensors, and development of community early warning systems.
Once the potential hazards are identified, the extent of damages, interruption of services, and
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threats to health can be estimated. Identifying the commonalities among the potential disasters
allows for a more unified approach to planning. Regardless of disaster type, the need to provide
shelter for people and their pets, food, water, and healthcare are universal. The extent and type
of need will vary by disaster. This information can be used in designing a community
emergency plan.
Along with identifying potential unmet needs, it is important to identify those groups who
are most likely to be affected in a variety of disaster events. Vulnerability varies according to the
type of hazard involved, and people who are most likely to suffer injury, death, or loss of
property should be identified for each hazard. In addition, the ability or capacity of the
community to respond to the effects of specific disasters should be assessed. Vulnerability
analysis predicts who will be affected the most and identifies community resources that are
available for a response. To keep emergency plans up-to-date, population and environment
changes need to be documented with changes made to the plan accordingly.
State and Federal Response Networks
When the scope of a disaster extends beyond the capability of local and state governments to
respond, the federal government is asked to provide assistance. The National Response
Framework (NRF), established by the U.S. Department of Homeland Security (DHS), guides
the overall conduct and coordination of all-hazards incident responses. These include all
disasters, whether natural, human made, or a result of terrorism, including threats to resources
such as information technology and energy sources. The NRF presents a unified response that
depends on the mutually supporting capabilities of federal, state, and local resources—all levels
of government—working together. Federal leadership responsibilities are outlined in the NRF;
however, the states have the primary responsibility for coordinating resources and capabilities
and obtaining support from other states and the federal government.
National Incident Management System
The National incident management system (NIMS) is a structured, flexible framework that
guides the response to disasters of governments at all levels, private companies, and
nongovernmental organizations (NGOs). Its goal is to reduce the loss of life, property, and harm
to the environment by helping departments and agencies work seamlessly to prepare for,
prevent, mitigate, respond to, and recover from the effects of incidents—regardless of cause,
size, location, or complexity. This process involves coordination and cooperation between
public and private organizations in various emergency management and incident response
activities. The NIMS is not an operational incident management or resource allocation plan. It
represents a core set of doctrines, concepts, principles, terminology, and organizational
processes that enable effective, efficient, and collaborative incident management. (FEMA, 2017)
In the United States, the DHS is the central organization overseeing many different agencies
that focus on the safety and security of the nation. Their many responsibilities include border
and transportation security; chemical, biologic, and radiologic countermeasures; informational
systems and infrastructure protection; and emergency preparedness (DHS, 2017). Federal
Emergency Management Administration (FEMA), as the lead agency for emergency
management, has divided the states and territories into 10 regions. State, county, tribal, and
municipal governments operate independently of the federal agencies in developing programs.
Surrounding jurisdictions respond to a disaster as needed; thus, mutual aid agreements should be
in place as the planning progresses. If the emergency is determined to be of significant
magnitude that overcomes the capabilities of the state and local governments, the Secretary of
Homeland Security will initiate the NRF to release federal resources to local jurisdictions.
Health departments and emergency management offices use the NIMS to develop a coordinated
response to the disaster.
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20.1 Disaster Preparedness and Management Competencies
Participate in all aspects of the planning process
Contribute to the hazard assessment in the community
Conduct vulnerability and risk assessments, especially with special populations
Identify and locate the agency’s emergency response plan
Understand the agency’s role in responding to emergencies
Understand your role in an emergency
Ensure that the plan is reviewed and updated frequently
Describe the communication process in emergency response both within the agency, with the general public, and
with personal contacts
Recognize deviations from the norm that might indicate an emergency and describe appropriate action
Participate in the development of data, gathering system that addresses morbidity, mortality, mental health, and
infectious disease
Apply creative problem-solving skills and flexible thinking to emergency situations, within the confines of your
role
Identify the limits of your own knowledge, skills, and authority, and referring matters that exceed these limits
Evaluate the effectiveness of every drill and after-action response
Adapted from Gebbie, K. M., & Qureshi, K. (2002). Emergency and disaster preparedness: Core competencies for nurses. American Journal of Nursing, 102(1),
46–51.
The role of state government is to supplement and facilitate local efforts before, during, and
after incidents. Although the state has a crucial coordination role, local officials have the
primary responsibility for community preparedness and response. Local officials are responsible
for ensuring public safety and the welfare of people of that jurisdiction. The local emergency
manager has the day-to-day authority and responsibility for overseeing emergency management
programs and activities. Local hospitals also need to develop an emergency operations plan
(EOP) that will guide the activation of resources in the event of either an internal or external
disaster. The State Emergency Management Agency works closely with FEMA to assure
preparation and planning have occurred on a local and state level.
Using the comprehensive data gathered from the All Hazard Vulnerability and Risk
Assessments, and knowledge of Federal and State Response Networks, the probability of
adverse health effects due to a specific disaster can be calculated. This is often represented as a
low, medium, or high risk.
Point-of-Distribution Plans
A point of distribution (POD) or Emergency Dispensing Site (EDS) is a centralized location
where the public picks up emergency supplies, including food, water, and medications (if
necessary), following a disaster. The plan details the staffing required and procedures to be
followed in the setup and deactivation of a POD/EDS.
20.2 Comparison of MRC and CERT Groups
The Medical Reserve Corps (MRC) is a community-based program that organizes and utilizes local
volunteers for emergency preparedness and response. MRC volunteers include medical and public health
professionals such as physicians, nurses, pharmacists, dentists, veterinarians, and epidemiologists.
Nonhealth professional volunteers are also included. MRCs are overseen by health departments and
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receive their funding through the state health departments.
Community Emergency Response Team (CERT) educates and trains professional and lay volunteers
on disaster preparedness. Liability protections for CERT volunteers may be found in state and federal
volunteer protection acts. Like MRC volunteers, some states have explicitly extended liability protection
to CERT volunteers. CERTs are usually overseen by emergency responders such as police and fire
departments and receive their funding through FEMA.
Local departments of public health determine the need, the staffing, and the location of the
POD, as well as the commodities that are to be distributed. FEMA has developed training
programs to assist in planning for the execution and subsequent deactivation of PODs as a part
of disaster relief efforts. This training helps states and communities coordinate with federal and
nongovernmental groups as they provide much needed supplies to the public in a timely and
consistent manner during and after a disaster event.
Local groups that are often instrumental in developing and running drills for EDSs or PODs
are the MRC or CERT. Communities may have either or both of these groups (Box 20.2).
MRC AND CERT GROUPS
At the completion of the plan, a common way to test its relevance is through a Table Top
Exercise (TTX) and actual drills to prepare participants for their roles and to identify gaps and
elements in the plan that need revision. The TTX involves key personnel discussing simulated
scenarios in an informal setting. It is used to assess plans, policies, and procedures and resolve
issues before an actual disaster occurs.
Planning and practicing for a crisis is the foundation for successful communication and
response. A well-trained frontline response team reduces the impact of an event. Human
simulation training (HST) with computerized models, such as those Geoff used in the training
program, are increasingly used in medical and nursing education. With this technology, trainees
are assisted in applying the techniques learned in the classroom laboratory to actual situations.
During actual drills, a successful exercise using simulation is one in which weaknesses,
mistakes, and ineffective plans are exposed. As a practice event, the opportunity to make
corrections, improve certain skills, or revise disaster response plans should also be seen as a
means to become a competent responder and leader. Nonclinical responders can benefit from
inclusion in a simulation experience with nurses. A clearer understanding of the importance of
the role of the nurse in an emergency event help the multidisciplinary team build competency
and confidence. Frequent, specific-scenario–formulated training prepares the public health nurse
responder to take the lead in emergency events.
Ultimately, the key starting points for emergency preparedness rest with individual people,
often within households. People can contribute by reducing hazards in and around their homes,
preparing emergency supply kits and household emergency plans, and monitoring emergency
communications carefully. Community education regarding the contents of an emergency supply
kit is an important role of the PHN. In addition to changes in public policy, educating the
community regarding preparation is essential. Educating citizens on what to have in an
emergency kit for themselves and their pets can help alleviate the stress of mandatory
evacuations. (Box 20.3)
Geoff prepares an outline of disaster preparedness planning topics that will be included in
the certification program. What topics does he choose?
In addition, he plans an emergency exercise for the end of the program. What type of
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geographic and demographic characteristics might have an effect on program content?
20.3 Basic Emergencies Supplies
Recommended items to include in a basic emergency supply kit:
Water, 1 gallon of water per person per day for at least 3 days, for drinking and sanitation
Food, at least a 3-day supply of nonperishable food
Battery-powered or hand crank radio and a NOAA weather radio with tone alert and extra batteries for
both
Flashlight and extra batteries
First aid kit
Whistle to signal for help
Dust mask, to help filter contaminated air and plastic sheeting and duct tape to shelter-in-place
Moist towelettes, garbage bags, and plastic ties for personal sanitation
Wrench or pliers to turn off utilities
Can opener for food (if kit contains canned food)
Local map
Practice Point
An ongoing community assessment process contributes to the development and revision of
an effective disaster plan.
Mitigation
Mitigation is a prevention process with two components. First, mitigation is an effort to prevent
identified risks from causing a disaster. By focusing on implementation of preventive measures
for reducing and eliminating identified risks before the event occurs, mitigation becomes a cost-
effective primary prevention. Structural mitigation involves creation or removal of structures or
alteration of the environment to remove or modify risks. The upgrading of building codes after
Hurricane Andrew in Florida in 1992 resulted in decreased structural damage during Hurricane
Irma in 2017. Another example is the installation of a generator to be used during a power
failure. Nonstructural mitigation includes disaster training for healthcare personnel, the
establishment of emergency evacuation regulations, land use planning, legislation, and
insurance.
Second, mitigation involves efforts to lessen the impact of a disaster by initiating measures
to limit damage, disease, disability, and loss of life among the members of a community (tertiary
prevention). In this case, mitigation refers to a broad range of activities that are only
accomplished satisfactorily by planning prior to the event. An example is the trimming of trees
near power lines to prevent loss of power during an incident
Personal Protective Equipment
Personal protective equipment (PPE) has been used in healthcare for a century. PPE primarily
refers to the use of respiratory equipment as well as gloves, gown, and/or goggles. The purpose
of PPE is to prevent the transfer of the hazardous agent from the victim or the environment to
healthcare practitioners. The type of agent present determines the kind of PPE required. In
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general, biologic, chemical, and radiologic exposures occur by breathing contaminated air,
dermal contact, and/or by eating or drinking adulterated products. Nurses who have been
prepared as active response team members are often issued “Go Kits” that contain various useful
items, such as gloves, surgical masks, N95 masks, goggles, pencils and paper, and large trash
bags. A fit-tested respirator also may be included.
The Occupational Safety and Health Administration (OSHA) has outlined four levels of
personal protection and the types of equipment that should be worn in various emergency
situations (Table 20.1). The agent involved and the risk of exposure are the primary
determinants of the level of PPE required. If PPE is to be used, a PPE program should be
implemented that addresses the hazards present; the selection, maintenance, and use of PPE; the
training of employees; and monitoring of the program to ensure its ongoing effectiveness. Just-
in-time training (JITT) videos are available for PPE training purposes.
TABLE 20.1 Levels for Personal Protection in Disasters: A, B, C, and D
Level of Protection Equipment
Level A
Highest protection for respiratory tract, skin, eyes,
and mucous membrane protection
SCBA, fully encapsulated water- and vapor-proof suit with a
cooling system, boots, gloves, hard hat, and a two-way
communication device
Level B
Highest protection for respiratory tract; skin, and
eye-splash resistant protection
SCBA, liquid splash-resistant clothing, hood, gloves, hard hat,
boots, two-way communication device
Level C
Same level of protection for skin and eyes as level
B, air-purifying system for respiratory tract
Full face, air-purifying respirator rather than SCBA, liquid
splash-resistant clothing, hood, gloves, hard hat, boots, two-
way communication device
Level D
Standard work protection from splashes, minimal
skin protection, no respiratory protection
Cover suits, safety glasses, gloves, boots, and face shield
SCBA, self-contained breathing apparatus.
Occupational Safety and Health Administration Standards—29-CFR Standard number 1910.132 Personal Protective Equipment. Retrieved from
http://www.osha.gov.
Practice Point
To ensure your safety during an emergency event, learn where PPE is located in your facility
and how to use and dispose of it properly. Include your local or county HAZMAT unit at a
yearly in-service on proper use of equipment.
Practice Point
Disasters occur locally, but their impact can extend globally.
Response
All response begins at the local level, where the disaster management plan is implemented and
responders are deployed. This mobilization is multidisciplinary, and the first people on the scene
will more than likely be law enforcement, fire, and ambulance crews. Reaching the victims and
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http://www.osha.gov
beginning the triaging process is essential to prevent loss of life. Response also refers to
minimizing, improvising, and restoring transportation and communication systems, as well as
providing food, water, and shelter to those affected. The disaster plans that are most effective are
clear, easy to understand, use a structured incident command system (ICS), and are frequently
practiced and updated to ensure a coordinated, timely response.
Disaster response can involve fear of the unknown and the daunting prospect of serving
entire communities during a very difficult time. However, by their nature, all types of disasters
do not occur regularly. This is an opportunity for nurses to embrace the opportunity to test skills,
practice disaster plans, and assert themselves as key members of state, regional, county, and
local response organizations.
Incident Command System
When a disaster occurs, there is an immediate need for organization and management at the
scene of the incident. The ICS is an on-site, flexible, all-hazards system that provides a set of
personnel, policies, procedures, facilities, and equipment integrated into a common
organizational structure that is designed to improve emergency response operations of all types,
sizes, and complexities.
The ICS designates common titles and roles to be used in all organizations and agencies that
respond to disasters. It organizes emergency response in five major functional areas: command,
planning, operations, logistics, and finance and administration (Fig. 20.4). These temporary
management hierarchies control funds, personnel, facilities, equipment, and communications
until the requirement for management and operations no longer exists. Operations can be
expanded or contracted as required. Participants are trained and approved by legitimate
authorities before incidents occur so that personnel from a wide variety of agencies,
jurisdictions, and backgrounds can combine rapidly into a common management structure using
common terminology. The result is a unified, centrally authorized, legitimate, cost-effective
emergency organization that facilitates communication and coordination of response efforts.
Nurses and other healthcare professionals are encouraged to become a part of their local ICS.
Basic level courses (ICS 100–200) are available online at the FEMA website.
Most countries have national agencies that oversee response in that country. Western
Europe, India, Russia, the United Kingdom, Australia, and Canada refer to disaster phases as
outlined above. New Zealand uses different terminology; disaster phases are known as the four
Rs (reduction [mitigation], readiness [preparedness], response, and recovery).
Geoff decides that he wants to incorporate ICS into the practice sessions. How could he
do this?
Practice Point
Participate in your local multidisciplinary ICS network as a part of your disaster response
activities.
Field Triage
When a mass casualty incident occurs, rapid assessment and treatment of the victims is the
utmost priority. On a disaster site, the process of field triage identifies and assesses those people
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who need medical care and prioritizes their needs. Triaging soldiers on the battlefield has been
in practice for quite some time. In fact, field disaster response is based on evidence gained by
measuring successful outcomes during combat. Triage is used in mass casualty situations and in
any disaster event. The victims are assessed by their presenting condition and are then color
coded as to the severity of the case. A triage tag, colored tape, or ribbon is placed on each
injured person after being prioritized to indicate status (Fig. 20.3; Table 20.2).
FIGURE 20.3 FEMA response to Hurricane Harvey. Houston, Texas, September 6, 2017—Two
volunteers pitch cardboard boxes of donated goods as they stack food, clothing, and cleaning
supplies for distribution to Hurricane Harvey survivors. (Source: Retrieved October 23, 2017, from
https://www.fema.gov/media-library/assets/images/141121. Photo by Christopher Mardorf/FEMA.)
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https://www.fema.gov/media-library/assets/images/141121
FIGURE 20.4 Incident command structure. (Source: Adapted from: Federal Emergency
Management Agency. [2008]. National incident management system. Retrieved from
http://www.fema.gov/pdf/emergency/nims/NIMS_core .)
TABLE 20.2 Color Coding for Prehospital Triage
Red Critical Unstable, requiring immediate intervention
Yellow Urgent Stable, but may deteriorate
Green Delayed Injured or ill but stable and not likely to deteriorate (walking wounded)
Black Expectant Dead or nonsalvageable given available resources
Basic triage and rapid treatment (START) is a simple, prehospital triage system that was
developed in California to assist emergency responders for use in earthquakes. Evidence based
and field proven, the system separates injured people into four groups according to the severity
of their injuries or illnesses (Box 20.4).
During a mass casualty incident, wherever it may occur, many different local, national, and
international agencies work together in the initial rescue phase. These agencies must be able to
communicate information, especially critical information about the condition of victims,
effectively. With the increase of international disasters, naturally occurring and otherwise,
preparedness professionals have called for a global standardized triage system with well-defined
categories and instructions. This universal triage classification system includes a standardized
approach to chemical, biologic, and radiologic agents as well as injuries sustained from an
explosion that provides prompt information to medical providers, increasing their ability to care
for victims promptly and efficiently.
Field triage is an essential topic for the nurses in the disaster management training
program. What are the essential components of field triage? How does Geoff use this
information in planning specific hands-on experiences?
Practice Point
Identify yourself as a nurse during an event. This helps establish your credibility as a
competent responder and establishes you as part of the multidisciplinary emergency
response team.
20.4 Simple Triage and Rapid Triage: The START Model
0 Those who have died
1 Injured, requiring immediate transfer
2 Injured, who can wait to be transferred
3 Injured, with minor less urgent needs
Practice Point
Become familiar with the POD/EDS plan for your facility and for your community. Make sure
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http://www.fema.gov/pdf/emergency/nims/NIMS_core
POD/EDS location agreements are current.
Mental Health Issues
Mental health issues during the response phase can be serious and of a permanent nature. Those
especially vulnerable include the elderly and children. The Substance Abuse and Mental Health
Agency (SAMSA) 2017 provides guidelines for working with victims of disasters as well as
resources for those needing additional assistance. (Box 20.5)
Recovery
The recovery phase begins as the disaster ends. Many of the factors that may continue into the
recovery phase and create challenges for victims include:
Continuing death, chronic illness, and/or disability
Population shift if recovery is prolonged
Contamination of food and water supplies, with an increased risk of infectious diseases
Collapse of local and regional healthcare access
Increased need to provide mental health services: “psychological first aid” for disaster victims and
responders
20.5 Tips for Communicating With Survivors
1. Clearly identify yourself and your role.
2. Communicate calmly. Make eye contact and use an open posture (avoid crossing your arms or legs,
lean forward, and stand or sit directly facing the person or group).
3. Communicate warmth. Express empathy, use a soft tone and welcoming gestures, and listen
carefully.
4. Speak slowly. Repeat yourself, if necessary.
5. Do not use euphemisms. For example, state very clearly that their loved one has died or is missing.
6. Be factual and gentle and do not engage in speculation or make broad statements like “everything
will be ok.”
7. Acknowledge the emotions of those who are suffering. Speak to the person with respect.
8. Use concrete questions to help the person focus. Use closed-ended questions—questions the person
can answer with a yes or a no, or by providing specific information—and explain why you are
asking the question.
9. Listen and allow for emotional expressions or crying without interruption.
10. Do not answer questions outside of your expertise. Refer people to appropriate experts.
11. Avoid using examples from your own life, and keep the focus on those currently suffering (SAMSA,
2017).
12. Look for cues in body language, and ask if they would like to be left alone.
13. Suggest the survivor contact support resources, such as family members, medical professionals, or
religious leaders.
The timeline for recovery varies widely, depending upon the type and extent of the disaster.
The initiation of stress debriefing and mental health services is essential in most cases. However,
recovery may also involve rebuilding damaged buildings, transportation systems, and
communication systems, as well as the relocation of those affected by the disaster. Communities
that perform a hazard risk assessment to predict the effects of disasters on a community, and
have a targeted disaster plan in place, are better prepared to address recovery issues.
Although normal operations may return, critical incident stress debriefing for staff members
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is important. Responders may have been exposed to traumatic situations or worked for lengths
of time that left them exhausted. (Spenser & Spellman, 2013).
The impact of long term mental health issues after a disaster are just beginning to be
recognized. Several studies show rates of PTSD after Hurricane Katrina as high as 62.5% among
preschool children directly affected by the storm and a 50% occurrence among some groups of
adults, such as female caregivers and parents of affected children. (Lamberg, 2008; Schroeder,
2017). Persons with a history of mental illness are also more likely to suffer from mental health
issues after a disaster. Additional psychological health competencies have been developed due to
the recognition of the long-term effects of experiencing a disaster for victims and responders
(Box 20.6).
Documentation During a Disaster
During an emergency event, it is not possible or expected that normal documentation standards
and protocols will be maintained. When responding to an emergency, the time, place, general
assessment of the field, and the name of the Incident Commander should be noted. Events move
quickly, and documentation of observations is important. However, it is not possible to
document all the information that is normally required, such as victims’ names. Every event is
organized differently. For example, during a possible anthrax “white powder” site investigation,
there were enough nurses so that one could be assigned to be the site scribe. This nurse
circulated among responders and took notations as reported to her. She became the primary
contact for the medical care director, an absolute necessity to obtain an accurate clinical report
Geoff requires a plan for documentation of events during the hands-on practice sessions.
What does he include and how does he plan to implement documentation in the practice
sessions?
20.6 Nursing Psychological Care Competencies During a Disaster
1. Describes the phases of psychological response to disaster and expected behavioral responses
2. Understands the psychological impact of disasters on adults, children, vulnerable populations,
communities and themselves
3. Provides appropriate psychological support for survivors and responders, and an understanding of
how to look after themselves. Assess survivor’s psychological needs and identify psychological
interventions that can be applied in the short term before referral
4. Uses therapeutic relationships effectively in a disaster situation
5. Identifies an individual’s behavior response to the disaster and maladaptive responses
6. Differentiate between adaptive responses to the disaster and maladaptive responses
7. Understands the impact of disasters on children’s growth and development as well as on the overall
family unit. Conducts mental health assessments and interventions pending psychological consult
where applicable. Applies appropriate mental health interventions and initiates referrals as required
8. Identifies appropriate coping strategies for survivors, families, responders, and themselves
9. Identifies survivors and responders requiring additional mental health nursing support and refers to
appropriate resources
Adapted from Hutton, A. et al. (2016). Review of the ICN framework of disaster nursing competencies. Prehospital and Disaster Medicine, 31(6), 683.
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Practice Point
Time is a factor in a disaster. Note unusual incidents and appropriate essential observations
and report immediately.
Evaluation
Evaluation is the foundation for evidence-based disaster response. By analyzing specific aspects
of the plan and assessing the effectiveness of the plan in action, future planning efforts are
enhanced. All agencies, organizations, and personnel who were involved in the disaster response
should take part in the evaluation. An evaluation meeting takes place during the recovery phase
immediately after the incident, eliciting observations and suggestions from participants. This
provides valuable information for revisions of the Emergency Plan. Often referred to as a “hot
wash” session, it is conducted while everything is fresh in one’s mind, so as to not be forgotten.
The more formal report, referred to as an After Action Report (AAR) provides a detailed list of
strengths and weaknesses, successes and failures, and suggestions for improvement in future
responses.
ROLES OF NURSES IN DISASTER MANAGEMENT
The ability of nurses to be calm, creative, and responsive to emergency situations is an asset, and
it is imperative that roles be clearly articulated. PHNs are experts in providing health education
for the various populations in a community setting. They can be proactive in providing
information and developing educational materials for dissemination to an anxious public,
especially for disasters that can be anticipated, such as hurricanes or tornadoes.
For most nurses, disaster preparedness planning is usually associated with the workplace.
One of the first questions a nurse may ask is, “What is my role if an emergency occurs”? Nurses
should be familiar with the EOP in their workplace and understand how their practice may
change during an emergency or disaster. For example, a long-term care facility may become a
shelter, or nurses in home healthcare agencies may be expected to be first responders. In many
organizations, the nursing staff would be deployed by the operations officer. They may also take
part in planning, logistics, or finance and administration. A summary of nursing competencies
for disaster planning and management is outlined in Box 20.7. In addition, the Association of
Community Health Nursing Educators (ACHNE) (2008) has developed competencies for entry-
level nurses in response to mass casualty incidents; these competencies can be found online (See
Box 20.7).
Also, some normal workplace activities will likely continue. Knowing in advance exactly
what is expected of the healthcare facility during an emergency or disaster gives all staff
members the opportunity to acquire the pertinent knowledge and to practice necessary skills
beforehand. Today, the majority of healthcare facilities, health departments, and private industry
include emergency preparedness information as part of the orientation process for new
employees. They should know the communication structure inherent in the ICS that has been
established for the organization.
20.7 Responsibilities of Public Health Nurses in Disaster Management
Assess the needs of the community as the events unfold
Conduct surveillance for communicable disease and unmet needs
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Prevent and control the spread of disease
Maintain communication channels to ensure accurate dissemination of information to colleagues and the public
Organize and manage points of distribution centers and mass immunization sites as required
Provide on-site triage as needed
Manage behavioral responses to stress
Ensure the health and safety of self, colleagues, and the public
Document events and interventions
Public Health Nurses as First Responders
Public health nursing practice focuses on the provision of comprehensive public health services
to ensure that community members have access to preventive care, immunizations, safe food and
water, and assistance with services that may go beyond medical needs. An extensive knowledge
of the community is the foundation for these services. Therefore, the PHN’s expertise is
valuable in all phases of the disaster management continuum, whether anticipating potential
emergencies, developing appropriate plans, building system-wide partnerships, practicing
implementation of disaster management plans and skills on a regular basis, or evaluating
outcomes. By increasing clinical knowledge and skill sets associated with specific biologic,
chemical, radiologic and explosive agents, PHNs are better prepared to apply their upgraded
proficiencies in the field. The responsibilities of PHNs in disaster management are outlined in
see Box 20.2. Even though there will be clutter, clamor, and confusion during a disaster, PHNs
are not expected to function as critical care nurses in a disaster setting.
Evidence for Practice
Although public health nurses assume the lead in conducting disease surveillance activities
in daily practice, their roles during a disaster response have become clearer. Working
closely with members of multidisciplinary response and planning teams has secured the
public health nurse’s position on the disaster team. Clinical skills aside, general
management skills possessed by public health nurses are a value to the team.
“Well-prepared PHNs bring leadership and management expertise to each phase of disaster
cycle. As an integral part of the healthcare system infrastructure within their community and
jurisdictions, PHNs have established linkages to community health–related networks and
resources that are vital to developing disaster preparedness plans and policies at local, regional,
state, and national levels. These connections between PHNs and community partners must occur
in order to address complex issues such as providing mass care during the chaos of a disaster,
prioritizing scarce resources, supervising spontaneous volunteers and unlicensed healthcare
workers, identifying and planning for the care of populations with functional and access needs,
as well as developing and maintaining effective systems of volunteers prepared to assist prior to
the incident. PHNs also can use their networks across regional and state boundaries to achieve
consistency in the protocols, practice standards, and operational guidelines prior to the disaster
incident” (APHN, 2014, p. 11).
20.8 Selected Preparedness Goals from Healthy People 2020
PREP-1 (Developmental) Reduce the time necessary to issue official information to the public about a
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public health emergency
PREP-2 Reduce the time necessary to activate designated personnel in response to a public health
emergency
PREP-4 Reduce the time for state public health agencies to establish after action reports and
improvement plans following responses to public health emergencies and exercises
PREP-5 Increase the percentage of school districts that require schools to include specific topics in their
crisis preparedness, response, and recovery plans
PREP-6 (Developmental) Increase the proportion of parents and/or guardians aware of the emergency or
evacuation plan in their child(ren)’s school including the evacuation location and how to get
information about the child in the event of a disaster
PREP-7 Increase the proportion of adults residing with children attending school who have an
emergency plan and have household discussions of that emergency plan
PREP-8 (Developmental) Increase the proportion of adults who engage in preparedness activities for a
widespread outbreak of a contagious disease after recently receiving preparedness information on
outbreaks
PREP-16 Increase the percentage of Medical Reserve Corps units who participate in preparedness and
public health activities
PREP-18 (Developmental) Increase the membership and diversity of HPP-funded healthcare coalitions
that are engaged in collaborative emergency preparedness planning and response
PREP-20 Increase in measures to protect children during disasters
HP2020 (2017) Preparedness Goals. Retrieved on October 9, 2017, from https://www.healthypeople.gov/2020/topics-objectives/topic/preparedness/objectives.
Outcomes and data are identified in Healthy People 2020 related to Preparedness (Box 20.8).
Several of the activities and tools identified in the disaster management continuum examined are
identified, including MRCs.
20.9 What You Can Do Immediately to Be Prepared
1. Join your local MRC or CERT
2. Familiarize yourself with your community’s Emergency Response Plan
3. Take the ICS Training online
4. Prepare your personal emergency kit evacuation kit (https://www.ready.gov/build-a-kit
https://www.ready.gov/build-a-kit).
BIOTERRORISM
A bioterrorism event involves the intentional release of viruses, bacteria, fungi, or toxins from
living organisms into the environment for the purposes of causing illness or death. Although
agents may result in familiar diseases, someone intent on harming others can engineer agents to
make them more deadly or to extend their life on a variety of surfaces. Biologic agents are air-
or waterborne and are inhaled or ingested (Centers for Disease Control and Prevention, 2017a).
For terrorists, there are some distinct advantages to using biologic versus chemical agents. The
incubation periods of live agents afford the terrorist time to leave the scene of the crime before
detection, whereas releases of chemicals are evident almost immediately, regardless of the
circumstances. However, the use of these agents requires sophisticated expertise to weaponize
resulting in long and potentially dangerous preparation times. Box 20.10 presents the advantages
of biologic agents as weapons.
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https://www.healthypeople.gov/2020/topics-objectives/topic/preparedness/objectives
https://www.ready.gov/build-a-kit
https://www.ready.gov/build-a-kit
How do you defeat terrorism? Don’t be terrorized. Salman Rushdie
History of Bioterrorism
The world has become aware that bioterrorism is not a new tactic. History will reveal that as
early as 1346, the Tartar army hurled corpses of plague victims over the walls of Caffa, a seaport
on the Crimean coast, and 400 years later, Russians used the same tactic against Sweden. Using
infected people as “weapons” may have contributed to the spread of plague across Europe in the
14th century. People who became victims ultimately became weapons themselves; a smallpox or
plague victim approaching a village must have been a fearsome sight. Later, during the Pontiac
Rebellion in 1763, the British army provided the Delaware Indians with blankets and
handkerchiefs from a smallpox hospital (Barras & Greub, 2014).
20.10 Advantages of Biologics as Weapons
Infectious via aerosol
Organisms fairly stable in the environment
Civilian populations are susceptible
High morbidity and mortality rates
Person-to-person transmission (smallpox, plague, viral hemorrhagic fever)
Difficult to diagnose and/or treat
Easy to obtain
Inexpensive to produce
Potential for dissemination over large geographic area
Creates panic
Can overwhelm medical services
Perpetrators escape easily
Previous development of organisms for biologic weapons
The word terrorism was first used in 1795 during the French Revolution, when the “reign of
terror” was unfolding on the streets and hillsides of France. During World War I, Germany used
biologic agents to infect livestock hindering troop movement. In the United States, the
development of biologic warfare agents began in 1942, under President Franklin D. Roosevelt,
and was not discontinued until the late 1960s. The former Soviet Union began a massive
program to develop biologic weapons in the 1970s. In 1979, there was an accidental release of
anthrax at a Soviet military facility, resulting in 68 deaths, and it is believed that this ultimately
led to the end of the program.
Since the 1990s, worldwide there have been 19 reported bioterrorism attacks, killing
approximately 1,900 and injuring over 8,500. Civilians were the most common target, followed
by soldiers, prisoners of war, and government officials (Johnston, 2016). As more nations have
acquired, or are seeking to acquire, biologic weapons, there are concerns that individual
terrorists or terrorist groups may acquire the technologies and expertise to use these agents.
Weaponized forms of some agents have been used against civilian populations as was the case
when anthrax-contaminated mail was circulated in New Jersey, New York, and Washington,
DC. Biologic agents may be used for an isolated assassination or to cause the injury or death of
thousands of people. Environmental contamination could be a long-term threat.
An eye for an eye, and the whole world would be blind. Khalil Gibran
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Categories of Bioterrorism Agents
The CDC (2017a) has divided biologic agents into three categories (Box 20.12: A, B, and C).
The high-priority agents in category A include organisms that pose a risk to national security.
These agents: (1) can be easily disseminated or transmitted from person to person; (2) result in
high mortality; (3) have the potential for major public health impact; (4) might cause public
panic and social disruption; and (5) require special action for public health preparedness.
“Category A” agents are discussed in the following section.
Detection of a Bioterrorism Event
Early detection of a biologic event is often difficult. The first recognition of a bioterrorism event
may result from routine surveillance activities. However, a single case or a few cases of
bioterrorism-related disease may not be identified. Surveillance for infectious diseases is a
continual process, conducted on an everyday basis by clinicians and laboratory staff. All
personnel in any healthcare-related activity should be aware of the diseases that may be
associated with bioterrorism. In actuality, all people should be involved in reporting unusual
events or illnesses to the local public health department. PHNs are important resources in
collecting and analyzing symptoms before a diagnosis is made. By identifying unusual spikes in
disease, deliberate biologic attacks will be revealed in a timely manner. PHNs also use their
system-wide relationships with their communities to track illness. Box 20.11 presents
epidemiologic clues indicating that a deliberate biologic attack may have occurred.
20.11 Epidemiologic Clues of a Bioterrorism Attack
1. Single case of disease caused by an uncommon agent (e.g., glanders, smallpox, viral hemorrhagic
fever, inhalational, or cutaneous anthrax) without adequate epidemiologic explanation
2. Unusual, atypical, genetically engineered, or antiquated strain of an agent (or antibiotic-resistance
pattern)
3. Higher morbidity and mortality in association with a common disease or syndrome or failure of such
patients to respond to usual therapy
4. Unusual disease presentation (e.g., inhalational anthrax or pneumonic plague)
5. Disease with an unusual geographic or seasonal distribution (e.g., tularemia in a nonendemic area,
influenza in the summer)
6. Stable endemic disease with an unexplained increase in incidence (e.g., tularemia, plague)
7. Atypical disease transmission through aerosols, food, or water, in a mode suggesting deliberate
sabotage (i.e., no other possible physical explanation)
8. No illness in persons who are not exposed to common ventilation systems (have separate closed
ventilation systems) when illness is seen in persons in close proximity who have a common
ventilation system
9. Several unusual or unexplained diseases coexisting in the same patient without any other
explanation
10. Unusual illness that affects a large, disparate population (e.g., respiratory disease in a large
population may suggest exposure to an inhalational pathogen or chemical agent)
11. Illness that is unusual (or atypical) for a given population or age group (e.g., outbreak of measles-
like rash in adults)
12. Unusual pattern of death or illness among animals, (which may be unexplained or attributed to an
agent of bioterrorism) that precedes or accompanies illness or death in humans
13. Unusual pattern of death or illness among humans, (which may be unexplained or attributed to an
agent of bioterrorism) that precedes or accompanies illness or death in animals
14. Ill persons who seek treatment at about the same time (point source with compressed epidemic
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curve)
15. Similar genetic type among agents isolated from temporally or spatially distinct sources
16. Simultaneous clusters of similar illness in noncontiguous areas, domestic or foreign
17. Large numbers of cases of unexplained diseases or deaths
Source: Treadwell, T., Koo, D., Kuker, K., & Khan, A. S. (2003). Epidemiological clues to bioterrorism. Public Health Reports, 118(2), 92–98.
Practice Point
Report higher-than-normal cases of infectious disease, unusual occurrences, and clusters of
illnesses to the local department of public health.
Bioterrorism Agents
Anthrax
Anthrax results from infection with spore-forming bacillus bacteria (Bacillus anthracis) that
occur naturally in the soil. The resulting noncontagious acute infectious disease occurs primarily
in cattle and sheep. Contact with infected animals or contaminated animal products may lead to
infection in humans. In the past, anthrax, considered a wool sorter’s disease, was prevalent
among tanners. Cutaneous anthrax occurs from inoculation of spores under the skin,
gastrointestinal and oropharyngeal anthrax occurs from ingesting contaminated meat, and
inhalation anthrax occurs from spores entering the respiratory tract while breathing (Table 20.3).
Without swift diagnosis and treatment, inhalational anthrax is usually fatal in approximately
90% of the cases. In 2001, weaponized anthrax spores were sent through the U.S. postal system,
resulting in 22 cases and 5 deaths.
Once infection has been diagnosed, antibiotic treatment usually runs a 60-day course.
Researchers have developed a protective vaccine against anthrax. Military personnel and people
at high risk, such as workers in research laboratories who handle anthrax bacteria routinely or
those who work with imported animal hides or furs from areas where standards are insufficient
to prevent exposure, are most likely to receive the vaccine.
Postexposure prophylaxis, which combines 60 days of antibiotics plus three doses of
vaccine, is effective in preventing anthrax disease from occurring after an exposure. In an attack,
PHNs may set up PODs/EDSs in their communities to administer prophylactic medications.
20.12 Categories of Bioterrorism Agents
Category A Agents
Pose the greatest risk to the public because they:
Spread easily
Result in a high mortality rate
Cause public panic
May affect national security
Require special training and response and may be unfamiliar to the responding community
Easy to obtain and “weaponize”
Can overwhelm existing medical resources
High-priority agents include organisms that pose a risk to national security because they:
Can be easily disseminated or transmitted from person to person
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Result in high mortality rates and have the
potential for major public health impact
Might cause public panic and social disruption
Require special action for public health preparedness
Agents/diseases include the following:
Anthrax (Bacillus anthracis)
Botulism (Clostridium botulinum toxin)
Plague (Yersinia pestis)
Smallpox (variola major)
Tularemia (Francisella tularensis)
Viral hemorrhagic fevers (filoviruses [e.g., Ebola, Marburg] and arenaviruses [e.g., Lassa, Machupo]
Category B Agents
Pose less of a threat to the public. However, they are a danger because:
They are easily available
Can be reproduced and disseminated easily
Surveillance and tracking will still require an intense response
Mortality, though lower than classified “A” agents, still pose a serious public health threat
Agents/diseases include the following:
Brucellosis (Brucella species)
Epsilon toxin of Clostridium perfringens
Food safety threats (e.g., Salmonella species, Escherichia coli O157:H7, Shigella)
Glanders (Burkholderia mallei)
Melioidosis (Burkholderia pseudomallei)
Psittacosis (Chlamydia psittaci)
Q fever (Coxiella burnetii)
Ricin toxin from Ricinus communis (castor beans)
Staphylococcal enterotoxin B
Typhus fever (Rickettsia prowazekii)
Viral encephalitis (alphaviru ses [e.g., Venezuelan equine encephalitis, Eastern equine encephalitis, Western equine
encephalitis])
Water safety threats (e.g., Vibrio cholerae, Cryptosporidium parvum)
Category C Agents
Include emerging pathogens and share these attributes:
They are easily engineered for mass production and dissemination
Their potential for high morbidity and mortality rates is significant
Diseases include the following:
Emerging infectious diseases
Nipah virus
Hanta virus
Multiple drug–resistant infectious diseases
From National Center for Environmental Health (NCEH). Retrieved from http://www.cdc.gov/nceh/; Agency for Toxic Substances and Disease Registry
(ATSDR). Retrieved from http://www.atsdr.cdc.gov/; Coordinating Center for Environmental Health and Injury Prevention (CCEHIP). Retrieved from
http://www.cdc.gov/about/organization/ccehip.htm.
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http://www.cdc.gov/nceh/
http://www.atsdr.cdc.gov/
http://www.cdc.gov/about/organization/ccehip.htm
TABLE 20.3 Bioterrorism Agents
Anthrax
Agent Bacillus anthracis
Aerobic, spore-forming bacterium
Forms of disease/systems affected Cutaneous
Inhalational
Gastrointestinal
Oropharyngeal
Transmission Skin: direct contact with spores
Respiratory: inhalation of aerosolized spores
Gastrointestinal: ingestion of undercooked meat of infected
animals
No person-to-person spread
Reporting Report suspected cases to local/state health departments
Incubation 1–7 days
Signs and symptoms Fever, fatigue, body aches
Inhalational: cough, chest pain, dyspnea
Gastrointestinal: nausea, bloody diarrhea
Cutaneous: necrotic ulcer, edema
Laboratory Serology
Ulcer exudate
Treatment Ciprofloxacin or doxycycline
Additional antimicrobials for 60 days
Postexposure prophylaxis Ciprofloxacin or doxycycline
Mortality High (80–90%), inhalational form
Botulism
Agent Toxin produced by Clostridium botulinum
Spore-forming bacterium found in soil and contaminated food
Forms of disease/systems affected Neuroparalytic illness
Foodborne ingestion of preformed toxin
Infant ingestion of soil-producing toxin in gastrointestinal tract
Wound infection by toxin
Transmission Not spread from person to person
Reporting Report suspected case to local/state health department
Incubation 12–72 hours
Signs and symptoms Difficulty swallowing, speaking
Double or blurred vision, dilated pupils
Constipation (infant botulism)
Descending flaccid paralysis
Laboratory Stool, vomitus, suspect food samples
Treatment Prompt diagnosis
Antitoxin, ventilator support
Postexposure prophylaxis None
Mortality Low
Plague
Agent Bacterium Yersinia pestis
Found in rodents and their fleas; found throughout the world
Forms of disease/systems affected Pneumonic (lungs)
Bubonic (lymph glands)
Septicemic (blood)
Transmission Pneumonic: inhalation of aerosolized spores; spread person
to person
Bubonic: bite by an infected flea; not spread person to person
Septicemic: multiplication of bacteria in blood; not spread
person to person
Reporting Report suspected cases to local/state health department
Incubation 1–6 days
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Signs and symptoms Pneumonic: chest pain, dyspnea, hemoptysis, sepsis,
respiratory shock
Bubonic: tender, swollen lymph glands (buboes), bacteremia,
fever
Septicemic: fever, bacteremia, sepsis
Laboratory Blood, sputum, bubo culture
Treatment Streptomycin, gentamicin, tetracyclines
Postexposure prophylaxis Ciprofloxacin or doxycycline
Mortality High (pneumonic) if untreated within 24 hours
Smallpox
Agent Smallpox virus
Systems affected General viral infectious disease
Transmission Person to person, aerosolized spread
Contact with infected body fluids
Reporting Declared eliminated by World Health Organization in 1980;
one confirmed case constitutes an outbreak. Report case to
local/state health departments
Incubation 7–12 days (12-day average)
Signs and symptoms Influenza-like, high fever, body aches
Early rash, raised bumps (most contagious)
Pustular rash, raised firm bumps (contagious)
Pustules with scab formation (contagious)
Resolving scabs (contagious)
Scabs resolved (noncontagious)
Laboratory Pharyngeal or nasal swab
Scab examination
Serology
Treatment Supportive intravenous therapy
Antibiotics for secondary infections
Postexposure prophylaxis Smallpox vaccine within 4 days of exposure
Mortality Moderate (20–40%), unvaccinated
Tularemia
Agent Francisella tularensis
Found in rodents, rabbits, hares (also known as rabbit fever)
Pulmonary
Forms of disease/systems affected Cutaneous
Gastrointestinal
Transmission Not spread person to person
Cutaneous
Gastrointestinal
Inhalational
Reporting Report cases to local/state health departments
Incubation 3–4 days average (up to 14)
Signs and symptoms Fever, chills, body aches
Dry cough
Joint pain
Ulcers on skin and mouth
Laboratory Sputum, blood cultures
Treatment Streptomycin, gentamicin
Postexposure prophylaxis Ciprofloxacin or doxycycline
Mortality Low, 5–15%, untreated
Viral hemorrhagic fevers (VHFs)
Agent Highly contagious virus; Ebola, Marburg, Lassa fever, and
arenaviruses
Systems affected General viral infectious disease
Gastrointestinal
Cutaneous
Cardiovascular
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Transmission Field rodents, arthropod ticks
Vectors not known for Ebola, Marburg
Person-to-person spread greatest as disease progresses
Reporting Report suspected cases to local/state health departments
Incubation 2–21 days, agent dependent
Signs and symptoms High fever, headache, body ache
Bloody diarrhea, mucous membrane hemorrhage
Shock, circulatory collapse
Laboratory Serology
Treatment Ribavirin for Lassa fever
Supportive therapy for other VHFs
Postexposure prophylaxis None
Mortality High
80–90% Ebola-Zaire
50–60% Ebola-Sudan
Variable for other VHFs
The Strategic National Stockpile enables large amounts of these medications to be made
available on short notice. CDC’s Strategic National Stockpile is the nation’s largest supply of
potentially lifesaving pharmaceuticals and medical supplies for use in a public health emergency
severe enough to cause local supplies to run out. The stockpile ensures the right medicines and
supplies are available when and where needed to save lives.
When state, local, tribal, and territorial responders request federal assistance to support their
response efforts, the stockpile ensures that medicine and supplies get to those who need them
most during an emergency. Organized for scalable response to a variety of public health threats,
the repository contains enough supplies to respond to multiple large-scale emergencies,
simultaneously (CDC, 2017b).
FIGURE 20.5 Triage tag.
Nurses also have the responsibility to educate the public about anthrax by managing
“hotlines,” answering questions, providing factual information, and offering reassurance.
Botulism
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Botulism is a muscle-paralyzing disease caused by the bacterium Clostridium botulinum, which
is found in the soil worldwide. The toxin produced by the bacterium is the most potent lethal
substance known to humans. The disease is relatively uncommon; in the United States, there are
approximately 100 reported cases per year. Botulism is probably familiar to most consumers:
beware of canned food with “popped” tops. Botulism is not spread person to person in any of its
forms.
Foodborne botulism occurs when the preformed toxin is ingested and can affect people of
any age. As cases are identified and confirmed, health departments have environmental
inspectors, guided by epidemiologic data patterns, who work diligently to ensure that
contaminated foods are removed from stores to protect against further illness.
In botulism, muscle weakness begins and descends through the body. At the point where
breathing muscles are involved, ventilator assistance becomes necessary. Antitoxin must be
administered because a toxin produced by C. botulinum is the cause of the paralysis. A supply of
this antitoxin is maintained by the CDC (CDC, 2017a).
Plague
Plague, believed to have first emerged in Egypt about 540 ad, is an infectious disease caused by
the bacterium Yersinia pestis, found globally in rodents and their fleas. The World Health
Organization (WHO) reports the occurrence of 1,000 to 3,000 cases yearly throughout the world
(WHO, 2018). In the US, between 2 to 15 cases of plague are reported annually, primarily
occurring in the western states (CDC, 2018). Most cases are of the bubonic form, which is the
most common of the three forms of plague (see Table 20.3).
Pneumonic plague occurs when Y. pestis infects the lungs. Airborne transmission from
person to person makes this form of plague a possible agent of choice as a bioweapon. The
incubation period, 1 to 6 days, makes it possible for the bacteria to spread to others before
symptoms occur. Considering this incubation period and the mobile society of the developed
world, pneumonic plague can spread easily from state to state, country to country. The gap
between infection and diagnosis also makes early treatment more difficult. The bacterium occurs
naturally and, therefore, could be weaponized by an organization technologically savvy enough
to create an aerosol.
Without early treatment, pneumonic plague has a high mortality rate. Several types of
antibiotics are effective in the treatment of all forms of plague. Should there be a confirmed
bioterrorism attack, prophylactic distribution of antibiotics to the public will occur from
POD/EDS sites with medications supplied by the Strategic National Stockpile.
Smallpox
Smallpox is an acute, contagious, and possibly fatal disease caused by the variola virus. Humans
are the only known reservoirs. The virus is contagious and spreads from person to person by
contact or through inhalation of aerosols. In America, smallpox last occurred in 1949, and in the
world, it last occurred in Somalia in 1977. In 1980, the WHO declared the disease eradicated.
For further scientific research on the smallpox virus, the CDC has maintained stockpiles of the
virus at its laboratories. Before the dissolution of the former Soviet Union, stockpiles existed at
sites throughout that country. After the tragic events of September 11, 2001, officials in the
United States became concerned that smallpox could become a biologic weapon.
No treatment exists for smallpox, and the only prevention available is vaccination. The
vaccine is made from a virus called vaccinia, which is a “pox”-type virus related to smallpox.
Unlike many other vaccines, the smallpox vaccine contains live vaccinia virus. For that reason,
it is necessary to care for the vaccination site carefully to prevent the virus from spreading. In
2003, several states initiated a smallpox immunization campaign to protect citizens. For
example, in New Jersey, JITT training for smallpox immunization techniques began. PHNs
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operated PODs throughout the state to administer vaccination to first-line healthcare workers
and clinically oriented first responders. Currently, the United States has stockpiled enough
smallpox vaccine to vaccinate everyone in the United States in the event of a biologic event that
involves smallpox. The disease itself has been eliminated for more than three decades; therefore,
the report of just one confirmed case of smallpox would be declared an outbreak. See Table 20.3
gives more information about smallpox.
Tularemia
Tularemia is a potentially serious illness caused by the bacterium Francisella tularensis, which
occurs naturally in the Northern Hemisphere. Approximately 200 cases of tularemia are reported
yearly in rural and semirural areas of the United States, mostly in the southern, central, and
western states. Summer outbreaks also often occur on Martha’s Vineyard in Massachusetts. The
bacterium is not spread person to person, but a low infectious dose, 1 to 10 organisms, is spread
by aerosol or the intradermal route. People who are infected can die if not treated quickly with
the correct antibiotic. F. tularensis occurs naturally; thus, it could be harvested and reengineered
as a bioweapon (see Table 20.3). If the organism can be aerosolized, severe respiratory illness
would result.
Practice Point
Unusual, out-of-season spikes in infectious disease cases may indicate a bioterrorism attack.
Viral Hemorrhagic Fevers
Viral hemorrhagic fevers (VHFs) are a group of illnesses caused by several distinct RNA virus
families. The survival of these viruses is dependent on host vectors, usually rodents, mosquitoes,
and ticks. The viruses are found only in geographic areas where their host species live.
However, the hosts of two VHFs, Marburg fever and Ebola fever, are unknown. Humans are
infected when they accidentally come into contact with infected hosts. In some instances,
humans can transmit the virus to one another.
The diseases appear to be global; however, VHFs do not occur naturally in the United States.
Outbreaks are sporadic and cannot be easily predicted. In general, the term VHF is used to
describe a severe multisystem syndrome that damages the vascular system throughout the body,
and the body’s ability to regulate itself is impaired. Hemorrhaging occurs, but the bleeding itself
is rarely life-threatening. Although some types of hemorrhagic fever viruses can cause relatively
mild illnesses, many cause severe, life-threatening conditions, and mortality is high. For
example, Ebola hemorrhagic fever is a severe, often fatal viral disease in humans, and it is one
of the most virulent viral diseases known to humankind. No treatment or vaccine is available,
and death occurs in 50% to 90% of all cases of clinical illness. Prevention involves rodent and
insect control. The 2014–2016 Ebola epidemic in West Africa required a massive international
response. The arrival in a Dallas, Texas, hospital of a traveler from Liberia with Ebola and its
subsequent transmission to two nurses working there led to rapid changes in domestic
preparedness and response recommendations and practices in healthcare facilities nationwide.
(CDC, 2016)
20.13 Biosafety Levels for Infectious Agents
1. Not known to consistently cause disease in healthy adults
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2. Associated with human disease
3. Hazard from percutaneous injury, ingestion, mucous membrane exposure
4. Indigenous or exotic agents with potential for aerosol transmission
5. Disease may have serious or lethal consequences
6. Dangerous/exotic agents that pose high risk of life-threatening disease, aerosol-transmitted laboratory
infections; or related agents with unknown risk of transmission
From Centers for Disease Control and Prevention, Office of Health and Safety (Biosafety information page). Retrieved from
http://www.cdc.gov/od/ohs/biosfty/bmbl4/bmbl4s3t.htm.
Ebola Precautions
The CDC classifies VHF viruses as biosafety level four (BSL-4) pathogens (Box 20.13). Once
illness is confirmed, isolation is enforced along with strict infection control techniques (Fig.
20.6). The CDC, in partnership with the WHO, has developed guidelines for healthcare workers
(WHO, 2017). Researchers have developed an experimental vaccine that was tested in an
outbreak in Democratic Republic of the Congo in 2017 (Maxmen, 2017).
Practice Point
Maintain a library of biologic, chemical, and radiologic fact sheets from the CDC website to
provide clear, accurate information to the public and fellow clinicians.
FIGURE 20.6 CDC (2017) strategic national stockpile. (Retrieved October 17, 2017, from
https://www.cdc.gov/phpr/stockpile/index.htm.)
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http://www.cdc.gov/od/ohs/biosfty/bmbl4/bmbl4s3t.htm
https://www.cdc.gov/phpr/stockpile/index.htm
FIGURE 20.7 Ebola testing: While in the field, dressed in a full complement of personal protective
equipment (PPE), this epidemiologist was implementing a rapid diagnostic test, which was used
during the Ebola response to quickly test for the presence of Ebola virus. (Retrieved from:
https://www.phil.cdc.gov/phil/details.asp. Public Health Service Illustration Library.)
CHEMICAL DISASTERS
The intentional or accidental spill of chemical substances can have a devastating effect both on
the environment and on human health. In 1984, the release of toxic gases at Union Carbide’s
pesticide plant in Bhopal, India, resulted in approximately 8,000 deaths and 150,000 injuries.
Severe contamination with heavy metals and toxic cancer-producing chemicals occurred at the
factory site, on the surrounding land, and in the groundwater. This disaster brought the horror of
industrial development to people’s attention worldwide and stimulated development of
environmental policy and legislation throughout the world. In response, the U.S. Congress
passed the Emergency Planning and Community Right-to-Know Act (EPCRA) to address
concerns about storing and handling of toxic chemicals.
Multiple chemical environmental disasters have occurred, such as the spill of 11 million
gallons of crude oil into Prince William Sound by Exxon Valdez and the collapse of the BP oil
rig that spewed huge amounts of oil from the ocean floor, to contaminate the Gulf Coast of the
United States. Oil from this disaster entered the Gulf Stream and spread to the Atlantic Coast
and beyond. The toxic chemical waste landfill used by Hooker Chemical in Love Canal, Niagara
Falls, New York, affected hundreds of people who lived there before cleanup plans were
initiated. OSHA is now responsible for developing programs to prevent chemical incidents. The
Environmental Protection Agency requires all companies that use flammable and toxic
substance to develop a risk management program that includes hazard assessment, a prevention
program, and an emergency response program. The CDC categorization of hazardous chemicals
is outlined in Table 20.4, and the characteristics of individual chemical agents can be reviewed
in depth at the CDC website.
TABLE 20.4 Centers for Disease Control and Prevention Categorization of
Hazardous Chemicals
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https://www.phil.cdc.gov/phil/details.asp
Category Action Example
Biotoxins Poisons that come from plants or animals Ricin
Blister agents/vesicants Chemicals that severely blister the eyes, respiratory tract, and skin
on contact
Mustard gas
Blood agents Poisons that affect the body by being absorbed into the blood Cyanide
Caustics (acids) Chemicals that burn or corrode people’s skin, eyes, and mucus
membranes (lining of the nose, mouth, throat, and lungs) on
contact
Hydrogen
fluoride
Choking/lung/pulmonary
agents
Chemicals that cause severe irritation or swelling of the respiratory
tract (lining of the nose and throat, lungs)
Chlorine
Incapacitating agents Drugs that make people unable to think clearly or that cause an
altered state of consciousness (possibly unconsciousness)
Fentanyl
Long-acting anticoagulants Poisons that prevent blood from clotting properly, which can lead to
uncontrolled bleeding
Super warfarin
Metals Agents that consist of metallic poisons Mercury
Nerve agents Highly poisonous chemicals that work by preventing the nervous
system from working properly
Sarin
Organic solvents Agents that damage the tissues of living things by dissolving fats
and oils
Benzene
Riot control agents/tear
gas
Highly irritating agents normally used by law enforcement for crowd
control or by individuals for protection
Mace
Toxic alcohols Poisonous alcohols that can damage the heart, kidneys, and
nervous system
Ethylene glycol
Vomiting agents Chemicals that cause nausea and vomiting Adamsite
From National Center for Environmental Health (NCEH)/Agency for Toxic Substances and Disease Registry (ATSDR), Coordinating Center for Environmental
Health and Injury Prevention (CCEHIP).
A chemical’s persistence, the length of time a chemical remains potent after its
dissemination, is a factor that contributes to the classification of, and response to, a given agent.
Nonpersistent chemicals lose their effectiveness in a few minutes to a few hours. For example,
chlorine and other pungent gases are nonpersistent chemicals that might be used by terrorists
whose goal is to take control of a site of interest. In contrast, persistent chemicals remain in the
environment for weeks. For example, liquids such as blister agents and certain nerve agents are
oily, and decontamination procedures are difficult.
Geoff works with the public health department, hospitals, and other community
organizations in planning the disaster management exercise. It will be conducted in a
Texas city of 100,000 residents where a deliberate release of anhydrous ammonia via a
large explosive device has occurred.
Determine the characteristics of the chemical release and the type of cases that may
appear for triage.
Chemicals have been used as tools of war for centuries. However, the destructive qualities of
chemicals are not primarily the result of their explosive qualities. Modern chemical warfare
began in World War I. At that time, available gases such as chlorine and phosgene were in use.
Trench warfare was the main military formation, and soldiers were particularly vulnerable to
this form of attack. In effect, attackers simply opened canisters of the gas and let prevailing
winds disseminate the chemicals. During the 20th century, the development of chemical
munitions, such as artillery shells, projectiles, and bombs, increased a chemical’s capacity to kill
and maim (Organization for Prohibition of Chemical Weapons, 2016).
Although living organisms can be biologic warfare agents, nonliving toxins produced by
living organisms (e.g., botulinum and ricin) can be considered chemical agents according to the
Chemical Weapons Convention. Similar to bioterrorism agents, these chemical agents can affect
health through inhalation, ingestion, or skin absorption. Examples are nerve agents such as sarin
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and VX, gases such as the sulfur and nitrogen mustard agents, and choking agents such as
phosgene (CDC, 2015). The use of the herbicide Agent Orange during the Vietnam War for
defoliation became a crisis due to the genetic and cancer-causing side effects experienced by the
U.S. military as well as citizens of Vietnam. (ACS, 2017) In an attempt to reduce the amount of
chemical weapons, the Department of Defense began incinerating weapons at eight U.S. sites
beginning in 2005. In addition, industrial chemicals, poisonous chemicals found in nature, and
chemicals made from compounds in everyday use can be released intentionally. Unlike biologic
agents, which require an incubation period before symptoms appear, a chemical agent, when
released, makes its presence known immediately through observation (explosion), self-
admission (accidental), or the occurrence of rapidly emerging symptoms, such as burns,
difficulty breathing, or convulsions (Spenser & Spellman, 2013) (Fig. 20.8). People may be
exposed to a chemical in three ways: by breathing the chemical directly; by swallowing
contaminated food, water, or medication; or by touching the chemical or coming into contact
with contaminated clothing or objects.
FIGURE 20.8 Cleanup of the crash of a small airplane. This firefighter is trying to prevent the
highly volatile aviation fuel from exploding and causing a fire.
Practice Point
You may be exposed to chemicals, even though you may not be able to see or smell
anything unusual.
Fear is a defining element of chemical and biologic terrorism. In 1995, after the sarin attack
in the Tokyo subway system, the “worried well” descended on the Japanese healthcare system in
far greater numbers than those who were actually affected. In 2001 to 2002, the anthrax events
in a New Jersey postal facility resulted in a similar response by the community. The New Jersey
health department received approximately 100 calls daily, reporting “white powder” events in
schools, banks, gas stations, and even doughnut shops. Recognizing that perception is reality to
many people, authorities dispatched teams to investigate the reports. A nursing contingent
provided telephone support for concerned citizens. No retrieved samples turned out to be
anthrax, but for the 700 plus people who called in, the testing of the samples and the presence of
a public health nursing team to answer questions and allay fears was an important step toward
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restoring public confidence in the face of a real, or thought-to-be-real, anthrax attack. The
reaction by the public, fueled by fear, would seem to be a catalyst to encourage “copycat”
events. However, every report called in required a response that involved sampling, testing, and
community education. To do less would not meet the standards of public health practice and
disease investigation. This serves as another example of how the process itself is time-
consuming and costly but essential.
The only thing we have to fear is fear itself. Franklin D. Roosevelt
Role of Nurses in a Chemical Disaster
In the field, the PHN’s response to a chemical incident is summed up in two words: “act
quickly.” HAZMAT experts report to the hot zone on notification of the release of the chemical.
The nurse may be asked to report to a temporary evacuation site where people exposed to the
chemical are awaiting triage (Fig. 20.9). Donning PPE must be the first priority. Then
assessment of the victim’s ability to breathe is necessary. Maintaining adequate respiratory
function tops the list for effective client management in a chemical event. Keeping the victims in
a sitting position with constrictive clothing loosened or removed is necessary. If the client
cannot sit, the torso should be elevated.
In the citywide disaster management drill at the end of the program on emergency
preparedness that Geoff has designed, PPE is necessary. What PPE is required for
exposure to anhydrous ammonia?
FIGURE 20.9 Decontamination tent. A collision between a freight train carrying toxic chemicals
and a passenger train resulted in injuries to several people. Before they were transported to a
local hospital, emergency medical personnel carried out on-site decontamination in this temporary
facility.
Practice Point
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After donning PPE, the first action in a chemical incident is to maintain adequate ventilation
for the victims.
Field decontamination of the victim requires removal of as many outer layers of clothing as
possible and placing the victims at a good distance from unaffected population. Washing with
soap—or at least water—should follow. For more thorough decontamination, field tents may be
erected nearby. Victims who have been severely compromised by the chemical release will be
transported to the hospital; there, they will undergo decontamination on the facility grounds
before being admitted into the emergency department. The nurse leader is responsible for
maintaining communication, especially updating the receiving institutions on client transfer and
clinical status. The final activity is for all those working at the decontamination site to be fully
decontaminated.
DECONTAMINATION TENT
During the day of the disaster management scenario, 75 “victims” plus six high-fidelity
HST models are on site. Various levels of chemical injuries are represented, with the HST
models representing the most seriously injured. Arrangements are made for field triage
and victim transfer to four medical centers in the area. The nurse responders, the majority
of whom were participants in the certificate program, don PPE and assist in the prioritizing
of clients in the streets. As the triage activities begin, the nurses facilitate effective client
transfer to emergency departments. There are more than 1,000 response participants,
including county and local public health department personnel.
Stay or Go?
The decision to stay or go should be made quickly; as time passes, options are reduced. The
decision should be made by evaluating factors specific to the event:
The HAZMAT involved
The population threatened
The time span involved
The current and predicted weather conditions
The ability to communicate emergency information
The toxicity of the released factor influences the decision to move. Radio stations, social
media and the websites of local health departments will report information about the event.
Generally speaking, once toxicity has been determined, actions are taken according to the level
of toxicity and the duration of the event (Table 20.5).
TABLE 20.5 Suggested Actions Following Release of a Hazardous Chemical
Nature of Exposure Action
High toxicity and short duration Shelter in place
Low toxicity and long duration Evacuate
High toxicity and long duration Calculate indoor concentrations (done by
HAZMAT)
Evacuate, if necessary
HAZMAT, hazardous materials.
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Shelter in Place
Shelter in place is used for short-duration incidents, when moving would result in a greater
hazard, or it is impractical to evacuate. People should stay inside their home, place of business,
or nearest building available. It is a protective action that provides a suitable place to stay until
the threat from a hazardous agent has passed. Guidelines for sheltering in place are presented in
Box 20.14.
Practice Point
Ensure that your place of employment has an effective shelter in place and evacuation plan
and that it is included in orientation for new employees.
20.14 Guidelines for Sheltering in Place
Remain inside your home or office
Shut down heating, ventilation fan, and air conditioning systems
Close and lock all windows and exterior doors
Stuff a towel tightly under each door and tape (aluminum foil or waxed paper) around the sides and top of the door
Cover each window and vent in the room with a single piece of plastic sheeting, seal edge with duct tape, and fill any
cracks or holes with clay or similar material, such as those around pipes entering a bathroom
Close the fireplace damper
Go to an interior room without windows that is above ground level. Some chemicals are heavier than air and may
seep into basements
Get your disaster supplies kit
Listen to your radio or television until you are told all is safe or you are told to evacuate
If the shelter in place order is related to an infectious disease, there may also be an order for
social distancing. Social distancing is an action taken by Public Health officials to stop or slow
down the spread of a highly contagious disease. The action may be related to a naturally
occurring communicable disease event such as the H1N1 influenza pandemic of 2009 or by a
bioterrorism release of a highly infectious disease. The goal is to keep social interactions to a
minimum by having a minimal amount of social interactions. People are requested to stay at
home and public gatherings are cancelled. In the case of the need for a POD/EDS during a social
distancing event such as to provide medications or immunizations, families remain in their cars
and a “drive thru” clinic is provided.
Evacuation
Evacuation occurs when there is potential for massive explosions and fire as well as for long-
duration events. People must leave their homes and go to a safer area. In localized, internal
events, invacuation, where people in a hospital or residential facility may be moved to another
floor or area within the facility, may occur. Natural disasters and industrial accidents require
people to evacuate, sometimes on a large scale. Based on the characteristics of the emergency, a
combination of evacuation and in-place protection measures may be appropriate. People in areas
downwind and in proximity to a chemical release, where concentrations are likely to be higher
and less time is available for response, might be advised to shelter in place. At the same time,
areas that are upwind or farther from the release might be evacuated. Evacuating upwind areas
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makes sense as a precautionary measure because a wind shift could rapidly place these areas in
jeopardy. In fact, evacuation is most effective when it is used as a precautionary measure; thus,
it is necessary to practice evacuation plans. Guidelines for evacuation are presented in Box
20.15.
Evidence for Practice
Evacuation is considered an important strategy to limit victim exposure to hazardous
chemical release (HCR). However, because of the wide range of possible disaster
scenarios, there is little evidence-based research to guide evacuation or sheltering
decisions. A 1.5 mile area of evacuation of residents near a chemical plant in Texas after
Hurricane Harvey in 2017 was taken as a preventive measure after the refrigeration system
was destroyed during the hurricane and chemicals that required refrigeration were allowed
to heat up, thus causing explosions and a release of gases. There was a significant lead
time as temperatures were rising, thus allowing a safe, orderly evacuation.
In a study by Melnikova, Wu & Orr (2015), the most frequent public health response to
chemical incidents between 1999 and 2008 was restricting access to the area (26% of
incidents), public health actions (12%), evacuation (7%), decontamination (4%), and
shelter-in-place (1%). Ammonia and carbon monoxide were associated with adverse health
effects in the population and the most public health response actions.
20.15 Guidelines for Evacuation
Wear long-sleeved shirts, long pants, and sturdy shoes
Take your pets with you
Lock your home
Take your disaster supplies kit
Use travel routes specified by local authorities: do not use shortcuts because certain areas may be impassable or
dangerous
Stay away from downed power lines
Practice Point
Maintaining close contact with local HAZMAT teams guides the decision-making process for
evacuation/shelter-in-place activities.
RADIOLOGIC DISASTERS
Radiation is energy that moves in the form of particles or waves, such as heat, light, radio
waves, and microwaves. Ionizing radiation is a high-energy form of electromagnetic radiation.
People benefit from it daily through the warmth of the sun and the use of x-ray technology. In
fact, small amounts of radioactive materials are in the air, drinking water, food, and human
body. It is known that excessive radiation affects the body in many ways, and often those results
do not become evident for several years. The health outcome depends on: (1) the amount or dose
of radiation absorbed; (2) the type of radiation; (3) the route of exposure; and (4) the length of
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time exposed to the dose.
When large doses are released accidentally (e.g., from a nuclear power plant) or intentionally
(e.g., in a terrorist act), there is an increased risk that health effects will occur. The combined
disasters of an earthquake, a tsunami, and a radiologic release in the Iwate Prefecture in Japan in
2011 is an example of a multidimensional disaster that serves as an example of a local disaster
with global implications. Within days, the CDC activated their emergency operations center to
respond to the health issues related to the three different disasters recorded (FDA, 2015). Very
often, the terms exposure and contamination are used incorrectly or interchangeably. Internal
exposure occurs when the radioactive materials enter the body by eating or drinking, whereas
external exposure occurs when the radioactive source is outside the body. Contamination occurs
when particles of radioactive material are deposited where they are normally not found. The
Environmental Protection Agency provides additional information on radiologic risks on its
website (CDC, 2017c).
20.16 Radiologic Resources for Nurses
American College of Medical Toxicology Course on TICs and TIMs. American College of Medical
Toxicology, http://acmt.net/Chemical_Agents_of_Opportunity.html
Centers for Disease Control and Prevention (CDC) Radiation Emergencies. Training, and Tools,
http://emergency.cdc.gov/radiation/trainingguidance.asp
Nuclear Radiologic Incident Annex, https://www.fema.gov/media-library/assets/documents/25554
Radiation Decontamination Procedures, http://www.remm.nlm.gov/ext_contamination.htm/
Radiation Emergency Assistance Center/Training Site OR1SE provides expertise in the medical
management of radiation incidents through the operation of the Radiation Emergency
Assistance Center/Training Site (REAC/TS), a dedicated DOE facility located in Oak Ridge,
Tennessee, http://orise.orau.gov/reacts
Radiation Disasters: Preparedness and Response: American College of Radiology, (2012).
Radiation Disasters: Preparedness and Response for Radiology,
http://www.acr.org/membership/legal-business-practices/disaster-preparedness
Internal Contamination Clinical Reference, CDC, http://www.emergency.cdc.gov/radiation/iccr.asp
Radiologic Terrorism: Medical Response to Mass Casualties,
https://emergency.cdc.gov/radiation/masscasualties/training.asp
Radiologic Terrorism: Emergency Management Pocket Guide for Clinicians,
http://www.emergency.cdc.gov/radiation/pocket.asp
REAC/TS center at the Oak Ridge National Laboratory at, http://orise.orau.gov/reacts/
Public Health Planning for Radiologic and Nuclear Terrorism,
https://emergency.cdc.gov/radiation/masscasualties/publichealthplanning.asp
Virtual Community Reception Centers, CDC, http://www.emergency.cdc.gov/radiation/crc/vcrc.asp
DOE, Department of Education; ORISE, Oak Ridge Institute for Science and Education; TIC, toxic industrial chemical; TIM, toxic industrial materials.
Source: Veenema, T., & Thornton, C. (2015). Understanding nurse’s role in health systems response to large-scale radiologic disasters. Journal of Radiology
Nursing, 34(2), 64.
“Dirty” Bombs
Deliberate release of a radioactive agent, the use of “dirty” bombs, has become an increasing
concern. This is a radiologic dispersion device that uses explosives as well as radioactive
materials. The act of explosion disseminates the radioactive agent. The range of a “dirty” bomb
is relatively small. Exposure to a dirty bomb is via inhalation, skin, and gastrointestinal tract.
This exposure may lead to health impacts, including malignancies, genetic mutations, and
reproductive issues. In addition, the impact on the environment is of concern (Durakovic, 2017).
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http://acmt.net/Chemical_Agents_of_Opportunity.html
http://emergency.cdc.gov/radiation/trainingguidance.asp
https://www.fema.gov/media-library/assets/documents/25554
http://www.remm.nlm.gov/ext_contamination.htm/
http://orise.orau.gov/reacts
http://www.acr.org/membership/legal-business-practices/disaster-preparedness
http://www.emergency.cdc.gov/radiation/iccr.asp
https://emergency.cdc.gov/radiation/masscasualties/training.asp
http://www.emergency.cdc.gov/radiation/pocket.asp
http://orise.orau.gov/reacts/
https://emergency.cdc.gov/radiation/masscasualties/publichealthplanning.asp
http://www.emergency.cdc.gov/radiation/crc/vcrc.asp
With low-level radiation, the greatest risk to the population is the blast itself. The radiation
levels released are not likely to cause severe illness. For this reason, “dirty” bombs often are not
considered weapons of mass destruction. Dealing with the fear that such an event would instill
in the public could very well be the greatest challenge facing first responders. In addition, the
economic impact of a “dirty” bomb, involving cleanup efforts and decontamination of the site, is
significant.
Practice Point
In a radiologic emergency, it is necessary to decrease time spent near the source, increase
distance from the source, and increase shielding from the source.
The best way to solve any problem is to remove its cause. Martin Luther King
Role of Nurses in a Radiologic Disaster
In a radiologic event, people should leave the area quickly (distance, time); enter the nearest
building (shielding); cover their noses and mouths; remove their clothes and seal them in
double-thickness trash bags; shower as soon as possible (decontamination); clean and cover any
open wounds; and listen to the radio, watch the television, or access the state’s website.
Community-based nurses are not called to the actual location. However, nurses working in a
receiving station may observe dust on arrivals. It must be assumed that dust on victims is
radioactive. PPE should be worn, as well as a radiation badge to measure personal exposure.
People should remove their clothing and be referred for decontamination. Physical injuries are
more acute than radioactive contamination. Stable victims should be moved out of the area
quickly, and the people in surrounding facilities should be notified. Information should be
documented; it will be used to monitor long-term health consequences. Accurate information
regarding appropriate protective actions should be made available to the public.
Evidence for Practice
As noted by Veenema & Thornton (2015b), nurse involvement during a radiologic event
may potentially include site response; “the establishment of community reception centers for
population screening and monitoring; decontamination; shelter management; and the
psychosocial support of victims, families, coworkers, and the community impacted by the
event.” While nurses have historically reported lack of confidence in responding to a
radiologic disaster, an increased emphasis in nursing educational programs and the
mandate for healthcare institutions to have emergency plans and drills with employees has
begun to address this issue.
BLAST INJURIES
In the blink of an eye, an explosion and its subsequent blast can create chaos and lay waste to an
area previously untouched. Explosions can occur as a result of an industrial accident, such as the
fertilizer plant explosion and fire that happened in Texas, or when used as a weapon of choice
739
by a terrorist, as witnessed during the Boston Marathon bombings in April 2013. Construction
directions for makeshift devices are readily available on the internet. Such a mechanism can be
inexpensive to build while producing many casualties with injuries not normally seen after
naturally occurring disasters. Injuries sustained in an explosion are multisystem threatening and
“war-like” in their presentation: mutilation; shrapnel wounds to bone, soft tissue, and vascular
structures; and dismemberment. In the Boston attack, the limited loss of life, and saving of many
critically ill victims was unprecedented. It is believed that first responders were already on the
scene for the event, thus able to provide immediate first aide and transport to hospitals. In
addition, the presence of numerous level I trauma units in the metropolitan also contributed to
the minimal deaths among the victims. The improvisational use of tourniquets on bombing
victims on-site has been documented to be an effective intervention to stop bleeding and
ultimately save lives. Field stabilization of bombing victims can be incorporated into
professional and volunteer responder training to sustain the survival rate of victims as seen in
Boston. Also noted was the courage of fellow marathon runners and volunteers.
A concerted community effort to practice response to mass casualty events through
collaborative exercises among agencies supported this coordinated response. Prior preparation in
Boston included 71 MCI drills with numerous area agencies (Operation Urban Shield) to better
prepare local institutions and staff to respond (City of Boston, 2014).
During a field response in an explosion-based event, there are some considerations to weigh
(CDC, n.d.):
Explosions in confined spaces are associated with higher morbidity and mortality.
Communication with victims may be difficult due to sudden temporary deafness.
Many injuries are not life-threatening due to blunt force trauma from flying debris.
Open wounds have an increased chance to become infected.
Triage and lifesaving efforts should not be delayed because of the possibility of a dirty bomb detonation.
Detailed assessments and on-site evaluations are counterproductive to decreasing mortality.
Practice Point
The most important aspect of field response to an explosion victim in the field is stabilization
and rapid transfer to a hospital.
PUBLIC HEALTH DISASTER RESPONSE
Collaboration among federal, state and local agencies include use of BioWatch. BioWatch
monitors the air for biologic agents likely to be used in a bioterrorism attack. If a detection
occurs, public health and other local and state officials use the information to coordinate
emergency response, including prompt medical care and other actions to protect public health
and safety. This combination of early warning and rapid response may potentially reduce illness
and death from a bioterrorism attack. BioWatch is a cornerstone in the DHS’s comprehensive
strategy for countering terrorism. BioWatch jurisdictions and federal agencies work together to
ensure the overall resilience of the program. Effective working relationships between federal,
state, and local public health, laboratories, law enforcement, and environmental health agencies
are key to BioWatch’s success (DHS, 2016).
Every state department of health has established reporting requirements to ensure accurate
surveillance of infectious diseases. All disasters originate as local events, and historically, local
health departments respond accordingly, through stepped up surveillance activities or
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communication with their respective state health department. It is part of a larger emergency
response effort within the region. The Health Alert Network (HAN) is a nationwide integrated
information and communication system that links local and state health and safety departments.
This network broadcasts and receives health alerts, offers distance learning opportunities, and
provides electronic laboratory reporting and disease surveillance. In an emergency, the HAN
provides essential information for an appropriate response from public health officials. People
will be informed of the type of health hazard, area(s) affected, self-protection measures,
evacuation routes, shelter locations, the type and location of medical facilities, and telephone
numbers to call if extra help is needed.
Scope and Magnitude of Response
The scope of the disaster should become evident within the first hours of the emergency, and the
magnitude of a public health response can be assessed. An act of terrorism will involve large
numbers of innocent people, with a sudden increased demand for health-related services. Triage,
transport, medical care, and mental health services for victims, their families, responders, and
the community may be necessary. Also, recovery, transportation, and storage of human remains
may be required. It is necessary to know what other agencies are involved, if an incident
command post has been established and commander identified, and if state, local, or tribal
operations centers have been activated. A large-scale emergency response could involve dozens
of agencies at various levels of government, working together in accordance with mutual aid
agreements and written emergency plans.
The public health response should be implemented in accordance with existing EOPs and
procedures. As part of this joint effort, all participants should function within the incident
management system adopted by the community. Once the need for the participation of the health
department and PHNs has been established, key personnel should be notified. It will be
necessary to coordinate with area healthcare partners and document efforts to contact
participants, including unsuccessful attempts. A representative from the health department
should be assigned to establish communications and act as liaison to others in the emergency
operations center. The health department will take steps to ensure the safety of the response
team. This may include the use of PPE and ongoing safety reports throughout the day.
Throughout the event, documentation of activities should be maintained.
It is essential to constantly verify the status of the response effort. Asset and resource
allocation plans will be made in response to the disaster. The mutual agreements among
providers can be implemented, calling on partners to assist in the evacuation of residents, the
provision of temporary shelter and food, or the transfer of the injured to hospitals outside of the
affected community.
A response is always a dynamic process; therefore, an ongoing assessment of the situation
should be in place. Once the health department and the regional public health system have been
activated, health surveillance systems should be initiated. The needs of special populations
within the jurisdiction should be addressed. The state authorities are involved at this stage, and
local health authorities must confirm that the state laboratories are available so that the process
of specimen collection and analysis can begin. A contact person should be identified for updates.
Additional consideration should be given to the jurisdiction’s policy on using volunteers during
a disaster response. Often, the MRC/CERT is activated. If the incorporation of volunteers is
used, the MRC/CERT contact person should be included in the communication effort.
Depending on the scope of the disaster and its nature—natural or intentional—state and,
perhaps, federal representatives may be at the operations site. Specially trained response teams
may be brought into the region if required. The public health authorities have the responsibility
to request additional staff, supplies, and other resources as soon as the need is identified. This is
741
carried out through the ICS. Monitoring of health resources is essential to maintain a sustained
response.
As assessment and updates continue, the characteristics of the response may begin to change.
The support of response personnel must be a priority. Backup shift personnel should be
mobilized at the outset and deployment to the site arranged. After the acute phase of a disaster
passes, specific activities related to the nature of the event should be addressed. These may
include agent identification; laboratory collection and analysis; dissemination of educational
materials; evacuation plans; health status assessment of responders as well as the general public
affected by the event; infectious disease protocol implementation; and assessment of water
supply, food safety, and vector control. The importance of veterinary services during an
emergency event cannot be overlooked. Professionals in this field should be included in disaster
plan development. During Hurricane Katrina, it was found people would not evacuate as they
did not want to leave their pets. In response, congress passed the “Pets Evacuation and
Transportation Standards (PETS) Act” and the Post-Katrina Emergency Response Act
(PKEMRA) in response to public outcry about the safety and well-being of pet animals during
disasters. An example of this response has been the development in Massachusetts of the State
of Massachusetts Animal Response Team (SMART). The goals include:
Minimize the threats to the health and safety of animals and humans
Minimize the economic impact of animal emergencies
Decrease the spread of disease to animals and humans during any emergency
Understand the interface between human and animal health (USDA, 2017)
The difficult we do immediately. The impossible takes a little longer. The United States
Army–Air Force
Communication During a Disaster
Communication is one of the most important aspects of maintaining a detailed, dynamic, and
broad-based response to a disaster. “Risk communication” is defined as a science-based
discipline that provides an interactive exchange of information and opinions among individuals,
groups, and institutions in a disaster setting. Risk communication in emergencies is used to
inform the public about an event or issue to empower members of a community to protect
themselves. The risk communication plan is an important component of the disaster
preparedness plan; it involves identifying key decision-makers, a risk communication team,
representatives for talking to media contacts, a clinical spokesperson, and a venue for
conducting media updates. High-concern situations can change the rules of communication. The
rapid dissemination of health messages; the adaptation of health messages for diverse audiences,
locations, and circumstances; and the delivery of key risk messages at various points in time are
often challenges while communicating during a disaster (Sutton, League, Sellnow, & Sellnow,
2015). Similar to emergency preparedness planning, effective risk communication occurs during
all stages of the disaster cycle (Bradley, McFarland, & Clarke, 2014) (see Fig. 20.2).
The need for a strong knowledge base in emergency preparedness and the communication
sciences, as well as coordination across agencies is needed to design and convey messages that
meet the needs of the intended population (Marin & Witt, 2017; Miller et al., 2017)
Risk communication often involves multiple messages between multiple groups concerning
the nature of risk. The perception of the risk depends on the circumstances. For example,
although a voluntary evacuation may produce anxiety, it is more acceptable than one imposed on
citizens. Earning trust and credibility is essential for effective risk communication. It is
especially important when dealing with the fear factor associated with a deliberate attack.
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During this process, public health officials, nurses, and other representatives must provide clear,
accurate information while minimizing the fear that may be associated with the event.
With heightened emotion, there is potential for an already bad situation to get worse.
Rumors and unreliable information can create an unstable environment. Reassurance in times of
crisis is essential. It is essential to listen and not interrupt. Simple statements such as “the risk is
low” or “nurses are available to answer your questions at this toll-free number…” are very
effective. Depending on the situation, nurses can suggest actions to decrease risk of illness or
suggest that people call their primary care provider if they become ill. Trust and credibility will
be compromised if these emotions are not addressed effectively. It is important to remember that
feelings of fear, frustration, and anger in a crisis are to be expected, and the resulting behavior
should not be taken personally.
Nurses may become the targets of this fear and frustration particularly when there is a
shortage of needed materials. For example, in the initial phases of the immunization effort for
H1N1 in 2009 and 2010, the demand for vaccine far outweighed the supply. Nurses often had
the task of dealing with frustrated and angry people who were being told to obtain their
immunizations yet could not succeed in finding available vaccine. Another example is when the
shelters fill to overflowing during a MCI and people lack basic necessities. There should be
backup plans in this type of situation. Sometimes, important information is not available or
cannot be verified. In that case, the information should not be communicated to the public. “I
don’t know” is acceptable and may even increase a nurse’s credibility. Under no circumstances
should a nonclinical person convey or interpret clinical data. A field nurse should be identified,
who will receive client reports from another clinician in the receiving facility or surge site.
Medical terminology can be badly misinterpreted by someone who is unaccustomed to working
in the medical professions. Erroneous messages, even if innocently transmitted, derail efforts to
keep the public well informed. During a crisis, messages should be reiterated frequently. When
interacting with the media, a clinician should be present to answer any questions or clarify
information. Fact sheets regarding the crisis should be prepared for informing the public and
shared with public information officers. The biologic, chemical, and radiologic fact sheets from
the CDC should be distributed if needed.
During the disaster preparedness drill in Texas, nurses conduct triage activities and
communicate with receiving hospitals to facilitate swift transfer of victims. What underlying
principles are practiced when communicating with the receiving hospitals?
It takes me two weeks to prepare an impromptu speech. Mark Twain
Geoff creates an evaluation tool to use following the disaster management exercise. What
topics did Geoff include in the after-action analysis?
Results of Geoff’s evaluation indicate that the use of agent-specific simulation training
in the classroom enabled the nurses to increase their competency skills while raising their
confidence in a nonthreatening setting. These practice sessions enable them to perform
effectively in the field.
KEY CONCEPTS
Nurses play an important role in all phases of disaster response.
All practicing nurses should become familiar with disaster phases and their role during an event.
Public health nurses practice principles of disaster response on a daily basis.
Although disasters do not occur with frequency, planning with vulnerability assessment can reduce their
743
impact on the community.
Properly implemented triage models minimize the morbidity and mortality of people affected by the event.
Disaster phases and the nursing process are closely aligned.
Biologic agents have an incubation period, which delays the investigation of the use of such agents as
weapons.
Chemical agents cause illness and/or death shortly after release. Decontamination is required for most
chemical exposures.
Response during a radiologic event may potentially include site response; establishment of community
reception centers and monitoring; decontamination; shelter management; and psychosocial support. Fear
and intimidation are a terrorist’s strongest tools in orchestrating an attack.
During a biologic, chemical, or radiologic event, the “worried well,” in addition to the injured, can overwhelm
and immobilize the healthcare system.
Policies and procedures for mass immunization clinics should be in place to adapt to an emergency
POD/EDS operation.
Public health nurses’ clinical skills in agent identification, triage, and field activities may be greatly
enhanced through the use of simulation technology in repeated training experiences.
CRITICAL THINKING QUESTIONS
1. Identify a disaster scenario, outline the disaster preparedness steps that should be used, and relate them
to the nursing process.
2. Both your local and state health departments have confirmed reports of 16 cases of pneumonic plague
among students at a large suburban college campus.
a. Develop a just-in-time training (JITT) program on standard and droplet infection control practices for
health department staff members and college residents and staff. Use the boxes, tables, and figures
found in this chapter, and if necessary, consult other resources.
b. Prepare a postexposure antibiotic prophylaxis distribution plan for your community.
3. Identify several roles that a public health nurse can function in, within the framework of a multidisciplinary
planning committee. Consider how his or her assessment, implementation, and evaluation skills can be
utilized in a nonclinical role.
4. Conduct a risk assessment and all hazard vulnerability studies using a community of choice, or review a
disaster event taken from recent history, and identify weaknesses that contributed to the emergency.
Could the event have been minimized or even prevented with accurate assessment?
5. List the emergency plans that must be in place before, during, and after a hazardous chemical release to
provide essential care for clients and the community at large following the disaster.
COMMUNITY RESOURCES
Local, county, and state public health departments
Local Visiting Nurse Associations
Local town hall
Local fire department
Local police department
Regional Red Cross
Regional Medical Reserve Corps (MRC) or Community Emergency Response Team (CERT)
U.S. Homeland Security regional offices
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WEB RESOURCES
Please visit thePoint for up-to-date web resources on this topic.
For online training in Incident Command Structure: https://training.fema.gov/nims/
Medical Reserve Corps: https://mrc.hhs.gov/HomePage
Certified Emergency Response Team (CERT): https://www.ready.gov/community-emergency-response-
team
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https://www.aphis.usda.gov/aphis/ourfocus/animalwelfare/sa_ep/ct_ep_information
https://www.dhs.gov/about-dhs
https://www.dhs.gov/biowatch-program
http://www.who.int/topics/haemorrhagic_fevers_viral/en/
http://thepoint.lww.com/vitalsource/ebook/9781975111694
https://training.fema.gov/nims/
https://mrc.hhs.gov/HomePage
https://www.ready.gov/community-emergency-response-team
Part 5
Specialty Practice
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Chapter 21
Community Mental Health
Judith Shindul-Rothschild
For additional ancillary materials related to this chapter. please visit thePoint
ALONE
From childhood’s hour I have not been
As others were; I have not seen
As others saw; I could not bring
My passions from a common spring.
From the same source I have not taken
My sorrow; I could not awaken
My heart to joy at the same tone;
And all I loved, I loved alone.
Then—in my childhood, in the dawn
Of a most stormy life—was drawn
From every depth of good and ill
The mystery which binds me still:
From the torrent, or the fountain,
From the red cliff of the mountain,
From the sun that round me rolled
In its autumn tint of gold,
From the lightning in the sky
As it passed me flying by,
From the thunder and the storm,
And the cloud that took the form
(When the rest of Heaven was blue)
Of a demon in my view.
—Edgar Allan Poe
CHAPTER HIGHLIGHTS
Epidemiology of mental illness from a public health perspective
Early intervention in the treatment of schizophrenia
Strategies to enhance treatment adherence
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http://thepoint.lww.com/vitalsource/ebook/9781975111694
Public health implications for children with behavioral disorders
Evolution of community mental health
Policy development and legislation for mental health services
Role and responsibilities of the community mental health practitioner
OBJECTIVES
Interpret the meaning of mental illness in the context of societal and cultural norms about behavior.
Describe the scope of mental illness and the effects on morbidity and mortality worldwide.
Describe the side effects of antipsychotic medication and its implications for nursing assessment and
long-term treatment.
Analyze emerging models of treatment that offer promise in improving the quality of life for the chronic
mentally ill in communities.
Identify the social and biologic factors associated with the incidence of mood and anxiety disorders.
Describe public health programs to decrease the incidence of suicide, especially among youth.
Differentiate the key signs and symptoms of attention-deficit/hyperactivity disorder and bipolar disorder
in children as members of families in communities.
Identify the motor, language, and social characteristics of infants and toddlers that are early signs of
autism spectrum disorders as members of families in communities.
Describe the policy implications in the shift in locus of care to community mental health centers for the
chronic mentally ill.
Identify the key components of psychological first aid.
KEY TERMS
Autism spectrum disorders: Also known as pervasive developmental disorders; cause severe
and pervasive impairment in thinking, feeling, language, and the ability to relate to others.
“Black box” warning: Warning by the Food and Drug Administration (FDA) to advise clients and
caregivers of dangers related to the use of a drug or treatment alone or in combination.
Community mental health centers: Primary care centers and neighborhood-based centers in
communities with the goal of serving populations and aggregates in need of follow-up care
and counseling.
Culturally competent mental health services: Mental health services by professionals who
demonstrate knowledge in group values, traditions, and the cultural expression of mental
illness.
Deinstitutionalization: The phenomenon of allowing patients who leave care in large, complex
healthcare systems to receive care in neighborhoods and communities on an outpatient basis.
Diagnostic and Statistical Manual, 5th edition (DSM-5): The standard classification of mental
disorders, published by the American Psychiatric Association and used by mental health
professionals in the United States, it is intended to be applicable in a wide array of contexts
and used by clinicians and researchers of many different orientations.
Early intervention programs: Specialized teams of professionals whose primary goal is to
maintain the individual’s current level of educational and vocational functioning through early
treatment.
First-generation antipsychotics: Medications developed and used early in the science of
psychiatric therapeutics.
Nonadherence: The choice to not follow directions for care; can include medications, follow-up
healthcare appointments, or wellness checkups.
President’s New Freedom Commission on Mental Health: Expert panel created to advise
Congress and the President on how policymakers could improve mental health services for
both the chronic mentally ill and children with serious mental illnesses.
Prodromal stage: Earliest stage of beginning pathology.
Psychological first aid: An evidence-informed intervention in the immediate aftermath of a
750
disaster.
Second-generation antipsychotics: Medications developed more recently in the science of
psychiatric therapeutics.
Tardive dyskinesia: Twisting movements of tongue, limbs, and torso; irreversible; often a side
effect of psychotropic medication.
CASE STUDY
References to the case study are found throughout this chapter (look for the case study icon).
Readers should keep the case study in mind as they read the chapter.
Carmen, a 48-year-old immigrant from Peru, is brought to the emergency department by her
daughter after taking 10 mg of lorazepam (Ativan) in less than 4 hours. Her daughter describes her
mother as acting “crazy” and not making any sense. Carmen lives with her mother, her husband,
her two sons, her daughter, and her daughter’s child. Until 2 years ago, Carmen worked cleaning
houses when she sustained a back injury. She has been taking 5 mg of
hydrocodone/acetaminophen (Vicodin) prn every 6 hours, but her supply ran out, and she claims
that her nurse practitioner would not send in another prescription to the pharmacy. Carmen speaks
some English and explains to the psychiatric nurse that she was in such pain from her back that
she just wanted the pain to end. The psychiatric clinical nurse specialist contacted a primary care
provider in the community, who expressed concern that Carmen was suicidal and needed
additional medical evaluation for her back injury. After consulting with the primary care providers,
her family, and Carmen herself, the psychiatric mental health clinical specialist admitted Carmen to
a locked psychiatric unit for evaluation.
In the psychiatric unit, Carmen begins to wail loudly, slap her head with her hands, and throw
her head in a backward motion against a wall. She stands rigidly against a wall and appears
unresponsive to a nurse’s inquiries in English about what she is experiencing. Given her daughter’s
concern about her mother’s mental status on admission, and her current behavior and
unresponsiveness to the nurses’ inquiries, an order is requested for an prn dose of olanzapine
(Zyprexa) 5 mg. When a student nurse asks Carmen in Spanish what is wrong, she replies that her
pain is unbearable and she needs Vicodin; otherwise, she just wants to be dead.
CULTURAL CONTEXT OF MENTAL ILLNESS
Mental health and, conversely, mental illness are concepts bound by culture. Understanding of
what connotes mental health is shaped by social norms that evolve from generation to
generation. In Western cultures, medical science interprets any deviation from normative
function of the five senses as indicative of a psychotic disorder. Hearing a voice, claiming to see
an object, or having certain tactile sensations are viewed as pathologic states to be treated by
psychiatric professionals. In some parts of the world, spiritual possession or healers with special
powers and beliefs are culture-bound syndromes (Hwang, Myers, Abe-Kim, & Ting, 2008).
Whenever health professionals are tempted to label behavior as “abnormal,” it is important to
always be cognizant of the values of the health professional and how these values may be in
conflict with community norms. Differences in incidence by race, gender, and ethnicity are
evident in many mental illnesses. It is important to determine whether these differences are a
product of better surveillance and access to treatment or whether psychiatric professionals are
more apt to label a behavior deviant in a certain population. Because of the stigma associated
with mental disorders, many people and their families are reticent to speak publicly of their
experiences and need for services. It is crucial that advocates are cognizant of the epidemiologic
findings that describe the needs, trends, risk factors, and effectiveness of community mental
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health services. Sound epidemiologic research, both nationally and internationally, is the
foundation policymakers need to formulate, plan, and implement effective community-based
programs that address the needs of the mentally ill.
In Western cultures, emotional distress is most often expressed verbally, whereas in
Asian or Latino cultures, somatization, specifically, physical complaints of pain, headache,
or stomach aches can be a prominent symptom of depression and anxiety (Hwang et al.,
2008). For Carmen, both her emotional and physical pain warrants nursing intervention
and careful assessment. By alleviating her physical pain, nurses can more
comprehensively assess her mental status and what, if any, symptoms of mood or
psychosis would benefit from psychotropic medication.
DEFINITIONS OF MENTAL ILLNESS
Although there is no universally accepted definition of mental health, for practical purposes,
widely accepted parameters of the types of behaviors that connote psychopathology must be
used to measure the incidence, morbidity, and mortality of mental illness in a population. The
first challenge for epidemiologists who study the prevalence of mental illness is to develop valid
operational definitions and standardized measurement instruments. Since 1952, the American
Psychiatric Association (APA) has been refining the diagnostic criteria that describe mental
illness. This nomenclature is compiled in a text titled the Diagnostic and Statistical Manual of
Mental Disorders (DSM-5) (APA, 2013). The National Comorbidity Survey (NCS) is a
nationally representative survey that assesses the prevalence of major mental illnesses according
to the criteria in the DSM-5 (Kessler & Wang, 2008). Internationally, the World Mental Health
initiative replicated the NCS. This allowed researchers to examine cross-cultural prevalence of
major mental illnesses (Kessler & Wang, 2008).
“Normal” is just a setting on the dryer. Barbara Johnson, author
Practice Point
Epidemiologic studies describe the social costs of mental illness and are essential to target
programs to populations in greatest need. Healthy People 2020 identified the following key
objectives in measuring progress toward improving mental health: suicide, adolescent suicide
attempts, serious mental illness in homeless adults, employment of homeless adults, and the
employment of people with serious mental illness and eating disorder relapses. The Centers
for Disease Control and Prevention (CDC) tracks epidemiologic data to determine the extent
to which target objectives for mental health and mental disorders have been reached (Fig.
21.1).
SCOPE OF MENTAL ILLNESS
Psychiatric disorders are the leading cause of disability worldwide. Every year, approximately
one-third of the world’s population suffers from a major mental illness, yet almost two-thirds do
not receive any mental health treatment (Thornicroft, 2007). Countries that spend a larger
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portion of their gross domestic product on healthcare are also those countries where individuals
are most likely to receive treatment for mental illness (Wang et al., 2007). Despite the
prevalence of disability associated with major mental illness, these disorders are much more
likely to be untreated than physical illness at every income level (Ormel et al., 2008). Those
suffering from alcoholism and addictive disorders are most likely to go untreated (78%),
followed by anxiety disorders (57%), depression (56%), and bipolar disorder (50%)
(Thornicroft, 2007). Young African Americans and the elderly have the highest rates of unmet
psychiatric care (Neighbors et al., 2007).
The mind is like an iceberg, it floats with one-seventh of its bulk above water. Sigmund
Freud
FIGURE 21.1 National Center for Health Statistics (2016). (National Center for Health Statistics.
[2016]. Chapter 28: Mental Health and Mental Disorders. Healthy People 2020 [p. 28–7].
Midcourse Review. Hyattsville, MD: U.S. Department of Health and Human Services.)
Stigma, inequities in mental health benefits, and fragmentation in the delivery system have
prevented many people, especially the elderly, those in rural areas, and ethnic minorities, from
receiving appropriate mental health treatment. The failure to identify and treat young people for
mental illness can have profound social consequences, including truancy, incarceration,
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addiction, unplanned pregnancy, poverty, and suicide.
Evidence for Practice
A panel of experts used a narrative review methodology to identify best practices to
promote mental health in low and middle income countries (Petersen et al., 2016). The
study concluded that “best practice” population level interventions include laws and
regulations to control access to alcohol and lethal means of suicide. “Good practice”
population level interventions include child protection laws, control of parasitic infections
that cause neurologic disorders and public awareness campaigns. Community level
intervention “best practices” include education programs to promote mental health for
school age youth and parents of infants. Community level “good practices” include: training
community health workers to screen for mental illness in schools or neighborhoods and
assist with community-based support and recovery; integrating mental health promotion
programs in the workplace; and psychoeducation for parents of youth to increase
knowledge of mental disorders (Petersen et al., 2016). The authors emphasize that in low
and middle income countries these population- and community-based interventions are an
essential component to promoting mental health as well as early identification and referral
for treatment of mental disorders (Petersen et al., 2016).
SOME MAJOR MENTAL ILLNESSES
Worldwide there has been a global shift in disease burden from communicable diseases to
noncommunicable diseases, including mental and behavioral disorders (Murray et al., 2012).
Major mental illness may be broadly grouped into three categories: thought disorders, mood
disorders, and anxiety disorders. Often, the dysfunction that a person is experiencing in his or
her thinking or mood is further complicated by substance abuse, dementia, or a medical
condition. One of the top 10 causes of disability worldwide is schizophrenia, a thought disorder
characterized by psychotic thinking and profound social apathy or withdrawal.
Evidence for Practice
In 2008, the Mental Health Gap Action Programme (mhGAP) in the World Health
Organization (WHO) conducted a systematic review of evidence on the treatment of major
mental illness in resource-poor countries. On the basis of this scientific review, the WHO
released the “mhGAP Intervention Guide for mental, neurological, and substance use
disorders in nonspecialized health settings” (WHO, 2010). The intent of the intervention
guide is to provide nonspecialist healthcare providers’ evidence-based protocols to expand
mental healthcare in resource-poor settings (WHO, 2010).
Schizophrenia
Epidemiology
About 1% of the world’s population suffers from schizophrenia. Symptoms of schizophrenia
typically first appear in late adolescence or young adulthood and persist throughout a person’s
life, causing significant impairment in all aspects of a person’s psychosocial functioning. The
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exact etiology is unknown; however, genetic studies have found a high concordance of
schizophrenia (40% to 50%) among monozygotic twins (Clarke, Kelleher, Clancy, & Cannon,
2012). Complications in pregnancy, delivery, viral infections, early childhood stress, head
injuries, and cannabis abuse have all been implicated in increasing the risk of developing
schizophrenia. Although the onset of symptoms of the disease is similar across a range of
countries and cultures, there is debate among epidemiologists about cross-cultural comparisons,
suggesting that the functional status of people with schizophrenia is higher in developing rather
than developed countries.
TABLE 21.1 Prevalence of Common Mental Disorders Worldwide (% of
population), 2015
Practice Point
Nurses in Western cultures need to be mindful of the fact that there are societies and
cultures whose beliefs about what connotes abnormal behavior are very different from those
in the United States. All social indicators are culture bound, so when epidemiologists conduct
cross-cultural comparisons of mental illness and disability, they need to take these cultural
differences into account.
Carmen receives a prn dose of hydrocodone/acetaminophen (Vicodin) for pain and
olanzapine (Zyprexa) for agitation. Mary, a student nurse, stays with Carmen as she
rested in her room, and within an hour, her restlessness, agitation, and emotional distress
markedly diminished. Mary converses with Carmen in Spanish and asks her about how
she manages her pain at home. Carmen explains that she believes her son, who lives
with her and recently became unemployed, has been taking her Vicodin and selling it.
She tearfully shares with Mary that she has been running out of Vicodin before she can
refill the prescription, and her nurse practitioner has refused to prescribe additional pills.
Carmen says that she has repeatedly pleaded with her son to stop, to look and see what
he was doing to his mother, but he continues to take her pain medication. In desperation,
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Carmen admits to Mary that she took an overdose of lorazepam because she could no
longer stand the pain and could see no other way out of the situation.
Practice Point
All states have laws mandating that licensed healthcare professionals report elder abuse and
neglect. In Carmen’s case, the treatment team reported Carmen’s claims of drug diversion by
her son to the Department of Elder Protection. Prior to Carmen’s discharge, the Department
of Elder Protection conducted an investigation and prohibited Carmen’s son from living in the
home with his mother.
Early Intervention Programs for First-Episode Psychosis
One of the most promising advances in the treatment of schizophrenia has been the use of early
intervention programs for people at risk for psychosis. Early intervention programs for first-
episode psychosis began in Australia in the 1980s and quickly spread to the United Kingdom,
Europe, North American and Asia (McGorry, Killackey, & Yung, 2008). Detailed descriptions
of the mission, goals, and services of the early intervention programs worldwide are available on
the internet (Table 21.2). All these programs typically consist of specialized teams of nurses,
occupational and rehabilitative therapists, and physicians, whose primary goal is to maintain the
person’s current level of educational and vocational functioning.
The early intervention programs are based on the theory that repeated episodes of psychosis
are toxic to the brain, producing debilitating cognitive effects that may be minimized with early
treatment. The hope is that if the initial treatment occurs during the first episode of psychosis,
the less likely the person will be incapacitated by the disease during his or her life. The shorter
the duration of untreated psychosis, termed DUP, the more likely the individual will be achieve
and sustain a higher level of functioning. Researchers are also examining whether intervening
even prior to the onset of psychotic behavior will improve treatment responsiveness and
cognitive functioning. Early intervention programs attempt to identify at-risk people prior to the
onset of hallucinations, delusions, and other symptoms of disordered thinking. Early
identification is complicated by the fact that, on average, adolescents and their families delay
seeking psychiatric treatment until 1 to 5 years after the onset of psychotic symptoms.
Ideally, early intervention programs identify young adolescents at risk during the prodromal
stage and immediately begin treatment with a low dose of a second-generation antipsychotic.
Psychotropic medication treatment is also supplemented by psychoeducation, cognitive-
behavioral therapy, and family therapy. Studies suggest that both psychopharmacologic and
psychotherapy interventions are essential to minimize the social disruptions that characterize
schizophrenia, such as dropping out of school, withdrawal from friends and family, and loss of
employment.
The specialized teams of mental health practitioners intervene across the entire spectrum of
the illness, including outreach, early identification, treatment, and long-term follow-up.
Occupational and rehabilitation counselors work with clients to maintain role functioning at
work or school during the treatment phase. Psychotherapists provide family therapy, family self-
help groups, and peer support to help manage the symptoms of the illness and enhance treatment
adherence, especially with low-dose atypical antipsychotics. Community health nurses, too,
have an integral role to play in each facet of the early intervention treatment model. In the
predisease phase, primary care nurses who work in schools or pediatrician’s offices are well
positioned to identify youth who may be at risk. During the acute phase, nurses assess the
therapeutic efficacy of antipsychotic treatment and educate clients and their families about how
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antipsychotic medication can help alleviate symptoms of the illness and the importance of
treatment adherence. During the maintenance phase, nurses play a critical role in helping
families and clients adhere to treatment recommendations and manage some of the residual
symptoms of the disease.
TABLE 21.2 Early Intervention Programs for First Psychotic Episode
Country Program Internet Link
Australia Australian Early Intervention
Network for Mental Health in
Young People (AusEinet)
http://www.auseinet.flinders.edu.au
Melbourne—Early Psychosis
Prevention and Intervention
Centre (EPPIC)
www.eppic.org.au
Canada British Columbia—Early
Psychosis Initiative (EPI)
www.mheccu.ubc.ca/projects/EPI
Calgary—Early Psychosis
Program (EPP)
www.ucalgary.ca/cdss/epp
Vancouver—Helping Overcome
Psychosis Early (HOPE)
www.hope.vancouver.bc.ca
Finland Detection of Early Psychosis
(DEEP Project)
http://www.med.utu.fi/tutkimus/tutkimusprojektit/psykiatria3.html
France Paris—PREPSY http://prepsy.free.fr/
Germany Cologne—Early Recognition and
Intervention Center
http://www.kompetenznetz-schizophrenie.de/rdkns/index.htm
Ireland Dublin—Detection, Education and
Local Team Assessment
(DELTA)
http://www.deltaproject.ie/
Netherlands Amsterdam—People with
Increased Vulnerability to
Psychosis (PSILON)
http://www.ypsilon.org/hulp/advies/preventi/index.htm
New Zealand Takapuna—Early Intervention
National Training Program
http://www.werrycentre.org.nz/
Norway Program to Reduce the Duration
of Untreated Psychosis
(TIPPS)
www.tips-info.com
Singapore Early Psychosis Intervention
Program (EPIP)
http://www.epip.org.sg/
Switzerland Basil—FEPSY Project http://www.fepsy.ch/
United
Kingdom
NHS—Early Intervention in
Psychosis
http://www.iris-initiative.org.uk/
United States Albuquerque—Early Assessment
and Resource Linkage for
Youth (EARLY)
http://www.earlyprogram.org/
Boston—First-Episode and Early
Psychosis Program (FEPP)
www.massgeneral.org/allpsych/Schizophrenia/
Chicago—First-Episode
Psychosis Program
http://uillinoismedcenter.org/content.cfm/psychosis
Los Angeles—Center for the
Assessment and Prevention of
Prodromal States (CAPPS)
http://www.capps.ucla.edu/
Manhattan—Center of Prevention
and Evaluation (COPE)
http://cumc.columbia.edu/dept/pi/research/clinics/pc.html
New Haven—Prevention Through
Risk Identification and
Prevention (PRIME)
www.ynhh.org/ynhph/ynhph.html
Pittsburgh—Services for the
Treatment of Early Psychosis
(STEP)
http://www.upmc.com/services/behavioral-health/pages/early-
psychoses.aspx
Portland, Maine—Prevent Mental
Illness With Early Detection
http://www.preventmentalillness.org/pier_home.html
Salem, Oregon—Prevent Mental http://www.preventmentalillness.org/pier_home.html
757
http://www.auseinet.flinders.edu.au
http://www.eppic.org.au
http://www.mheccu.ubc.ca/projects/EPI
http://www.ucalgary.ca/cdss/epp
http://www.hope.vancouver.bc.ca
http://www.med.utu.fi/tutkimus/tutkimusprojektit/psykiatria3.html
http://prepsy.free.fr/
http://www.kompetenznetz-schizophrenie.de/rdkns/index.htm
http://www.deltaproject.ie/
http://www.ypsilon.org/hulp/advies/preventi/index.htm
http://www.werrycentre.org.nz/
http://www.tips-info.com
http://www.epip.org.sg/
http://www.fepsy.ch/
http://www.iris-initiative.org.uk/
http://www.earlyprogram.org/
http://www.massgeneral.org/allpsych/Schizophrenia/
http://uillinoismedcenter.org/content.cfm/psychosis
http://www.capps.ucla.edu/
http://cumc.columbia.edu/dept/pi/research/clinics/pc.html
http://www.ynhh.org/ynhph/ynhph.html
http://www.upmc.com/services/behavioral-health/pages/early-psychoses.aspx
http://www.preventmentalillness.org/pier_home.html
Illness With Early Detection
Schizophrenia.com. Retrieved on June 3, 2013, from http://www.schizophrenia.com/earlypsychosis.htm#ill; National Alliance for the Mentally Ill. Retrieved on
May 28, 2013, from http://www.nami.org/FirstEpisode/clinics_psychosis .
The prodromal signs and symptoms suggesting that a young adolescent is at risk for
developing psychosis are not unlike those behaviors exhibited during normal adolescent
development. Screening tools to identify adolescents at risk for developing schizophrenia have
been developed by practitioners in Germany, Australia, the United Kingdom, and the United
States. The Structured Interview for Prodromal Symptoms and the Scale of Prodromal
Symptoms are two widely used scales in the United States developed by researchers at Yale
University (Miller et al., 2002). Specific prodromal signs and symptoms manifested in
adolescence include sleep disturbance, anxiety, irritability, deterioration in role function,
depressed mood, social withdrawal, poor concentration, suspiciousness, loss of motivation, and
perceptual disturbances (Yung et al., 2007). Early identification of psychosis and administration
of low-dose antipsychotic medication may help mitigate the chronic, debilitating course of
schizophrenia and significantly improve long-term outcomes.
Evidence for Practice
A systematic review of early intervention programs in schizophrenia found that the
screening criteria for identifying prodromal symptoms were nonspecific and mental health
professionals were hesitant to identify patients at high-risk (Cheng & Schepp, 2016). Cheng
& Schepp (2016) emphasize that community mental health nurses need training and
screening tools to appropriately identify at-risk individuals who can benefit from early
intervention for psychosis.
Primary Prevention Programs
One of the challenges for researchers is to better understand the relationship between substance
abuse, the onset of psychotic symptoms, and relapse. Originally, it had been presumed that
adolescents who are susceptible to mental illness abuse cannabis or other illicit substances as a
means of self-medication. There is empirical evidence that cannabis use is a component cause of
schizophrenia and increases the risk two- to fourfold (Clarke, Kelleher, Clancy, & Cannon,
2012). Each episode of psychosis is an assault to the neural mechanisms in the brain. Extensive
studies have shown that cannabis use may increase risk of developing psychosis in at-risk
individuals.
The possibility that the amount, duration, and strength of cannabis may be a precursor to the
development of schizophrenia has significant implications for both drug education programs and
early intervention programs for psychosis. Public health education campaigns should continue to
educate adolescents about the potential adverse effects of cannabis use, especially on mental
health. Encouraging even modest declines in an individual’s dose and duration of cannabis use
may delay conversion to psychosis or attenuate psychotic symptoms. The more conversion to
psychosis can be delayed or avoided, the greater the likelihood that neurocognitive function
maybe preserved.
Legislating marijuana into legitimacy does not make it safe. Chittaranjan Andrade (2016,
e742)
There has been a significant downward trend in the use of cannabis by middle-school age
youth attributed to the success of drug educational programs (National Institute on Drug Abuse,
758
http://www.preventmentalillness.org/pier_home.html
http://Schizophrenia.com
http://www.schizophrenia.com/earlypsychosis.htm#ill
http://www.nami.org/FirstEpisode/clinics_psychosis
2016). Nationally, cannabis use among high school seniors has remained stable except in states
where cannabis is legal for medical or recreational use. Significantly more high school seniors in
states where cannabis is legal consume cannabis edibles or smoke cannabis than in states where
cannabis is not legal (National Institute on Drug Abuse, 2016). A future area for epidemiologic
research will be to examine whether the rise in the use of cannabis and synthetic cannabinoid
substances is correlated with an increase in the prevalence and morbidity of schizophrenia in the
United States.
Enhancing Treatment Adherence in Schizophrenia
Nonadherence with medication is the most common factor associated with relapse and
recurrence of psychotic symptoms. One of the largest studies of treatment efficacy for patients
diagnosed with schizophrenia, the Clinical Antipsychotic Trials of Intervention of Effectiveness
(CATIE) study, found that 74% of the patients discontinued their medication before 18 months
(Levine, Rabinowitz, Faries, Lawson, & Ascher-Svanum, 2012). The longer and more
frequently patients diagnosed with schizophrenia experience psychotic symptoms, the greater
the gray matter atrophy in the prefrontal cortex and greater the impairment of executive
cognitive function (Morton & Zubek, 2013). A common feature of all early intervention
programs is to educate the client and the family about how nonadherence to the medication
regime can lead to relapse. To be maximally effective, both the client and the family must be
educated about the morbidity associated with untreated psychotic symptoms, especially in light
of growing evidence that the more frequent the psychotic episodes, the greater and more lasting
the negative effects on cognitive function.
Nursing interventions to enhance medication adherence applicable to those with chronic
mental illness may include oral and written reminders, self-monitoring tools, cues, and positive
reinforcements by both the nurse and the family. Psychoeducation by community health nurses
should teach clients and families about the signs of impending relapse, how medication can help
remit the more debilitating negative symptoms of the disease, and the importance of lifestyle
changes, especially avoiding use of illicit substances. Psychosocial interventions for clients with
chronic mental illness also include employment or vocational training, social skills development,
and coaching, with an emphasis on problem solving and motivational interviewing. Family
support groups, training in cognitive-behavioral approaches, and basic communication strategies
are particularly helpful for families who are trying to manage medication administration in the
home.
In addition to psychosocial interventions, which can be prohibitively expensive and difficult
to implement in resource-poor countries, long-acting injectable antipsychotic (LAI) medications
are another strategy to promote recovery from psychosis. A long-acting injectable form of
antipsychotic should not be administered until it is clear how the client responds to oral forms of
the medication. The first-generation antipsychotics haloperidol decanoate and fluphenazine
decanoate, and the second-generation antipsychotics risperidone microsphere, olanzapine
pamoate, paliperidone palmitate, aripiprazole monohydrate, or lauroxil, are antipsychotics
available as long-acting preparations. LAI vary in duration from 1 to 4 months (Stevens,
Dawson, & Zummo, 2016).
Evidence for Practice
A comparison of treatment adherence with LAI versus oral antipsychotic medication for
individuals with schizophrenia found that over a 1-year period, individuals on LAI
antipsychotics were 20% less likely to discontinue their medication (Greene, Yan, Chang,
759
Hartry, Touya, & Broder, 2017). A systematic review also concluded there is sufficient
empiric evidence supporting a correlation between LAIs and treatment adherence for first-
episode psychosis or recent-onset schizophrenia (Kim, Lee, Yang, Park, & Chung, 2012).
Yet there are wide cross-cultural variations in prescribing LAIs with over half of the mental
health prescribers in the United Kingdom likely to prescribe LAIs in first-episode psychosis
compared to less than half of the prescribers in the United States (Kim et al., 2012).
Student Reflection
In the following conversation, two nursing students discuss the use of antipsychotic
medication.
Student 1: Obviously, all patients have the right to refuse treatment, especially injections
of antipsychotic medication, unless they pose an immediate danger to themselves or others.
But it seems inhumane not to offer chronic mentally ill patients the option of taking their
antipsychotic medication by injection, especially those who become so impaired they can’t
take care of themselves and put themselves at risk.
Student 2: I heard that some community outreach programs in England provide financial
incentives for patients to receive their injections (Claassen, 2007).
Student 1: Don’t you think that is unethical, to bribe a patient to take the medication by
offering money or gifts?
Student 2: Well, what is the alternative, the community has rights, too, and what if a
chronic mentally ill person is so psychotic that he or she is wandering the streets
intimidating people? If I worked in a mental health center and I was directed to give a gift to
entice a patient to take medication, I wouldn’t have any problem with doing that—the patient
can refuse both if he or she wants to.
Student 1: I think it would be better to go to court and seek a court order on the basis of
the medical evidence and the patient’s mental health history rather than to offer the patient
a bribe, especially since most of the patients receiving the injectable medication are
disproportionately incarcerated, uninsured, or poor people, who may belong to ethnic
minorities (Glazer, 2007).
Medication adherence is also complicated in clients with schizophrenia because all
antipsychotic medications have side effects that can interfere with normal daily functioning.
Some side effects, especially with first-generation antipsychotics (e.g., haloperidol and
fluphenazine), can be life-threatening and physically debilitating. Of particular concern with the
first-generation antipsychotics is the risk of developing tardive dyskinesia (TD). This
condition, which is irreversible, is characterized by twisting movements of tongue, limbs, and
torso. The longer the clients are on the first-generation antipsychotics, the greater the risk of
acquiring TD. Because TD is permanently disfiguring, nurses in the community should routinely
screen patients for subtle symptoms of TD using the Abnormal Involuntary Movement Scale
(Guy, 1976). Some of the other debilitating side effects of the first-generation antipsychotics
include akathisia (extreme restlessness in the limbs), dystonia (severe stiffness in muscles, most
prominently the neck), blurred vision, urinary retention, and neuroleptic malignant syndrome.
The second-generation antipsychotics have fewer extrapyramidal symptoms and are much
less likely to cause TD but have greater risks of metabolic syndrome. Metabolic syndrome is an
adverse effect of treatment with second-generation antipsychotics (such as clozapine,
olanzapine, quetiapine, risperidone, and ziprasidone) that develops as a result of pronounced
weight gain, dyslipidemia, and hyperglycemia. Clients may experience weight gain on all of the
antipsychotics; however, almost half of all patients on the second-generation antipsychotics
experience a 20% increase in weight. Evidence is mounting that the second-generation
antipsychotics, in particular clozapine and olanzapine, may increase the risk of developing new-
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onset type 2 diabetes.
At this time, regulations mandating regular monitoring of the client’s weight and other
symptoms associated with type 2 diabetes have not been promulgated by the FDA. In 2004, the
APA and the American Diabetes Association (ADA) developed consensus guidelines to screen
clients on second-generation antipsychotics for the development of cardiovascular diseases and
type 2 diabetes (Table 21.3). The ADA and the APA emphasize that given the significant risk
for developing hyperglycemia, the consensus guidelines should be considered a basic standard
of care for all schizophrenic patients prescribed the second-generation antipsychotics.
Studies have shown that neither class of antipsychotics is superior in treating the positive
and negative symptoms of schizophrenia and both have risks of adverse effects. One exception
is clozapine, which has been shown to be superior in treating both the positive and negative
symptoms of schizophrenia. It is important to note that clozapine has been associated with life-
threatening agranulocytosis. The FDA has established a national clozapine registry and
mandates white blood cell (WBC) counts within 24 hours of the initial dose, weekly for 6
months, and then every 2 weeks. Pharmacists may only dispense enough clozapine until the next
WBC count test and must receive notification of the laboratory results prior to dispensing any
additional medication. Like the other second-generation antipsychotics, clozapine causes weight
gain, which is one of the most common side effects of the drug that contributes to nonadherence.
The World Psychiatric Association has recommended that government funding agencies provide
coverage for a broad array of medication treatment options to allow individualized treatment
based on safety, tolerability, and efficacy of first- and second-generation antipsychotics (Tandon
et al., 2008).
Practice Point
All antipsychotics have untoward effects that can compromise treatment adherence and
physical health. Community health nurses must carefully monitor clients especially for TD,
agranulocytosis, and metabolic syndrome, which can be a precursor to type 2 diabetes.
Patients with schizophrenia have a two- to threefold increased risk of death mostly from
metabolic syndrome and it is a major public health concern for this population (Ventriglio,
Gentile, Stella, & Bellomi, 2015).
High-Risk Populations
The unemployed, the poor, and the homeless all report higher levels of depression, anxiety,
schizophrenia, and substance abuse than the general population (WHO, 2008). Whether these
social conditions trigger the symptoms of depression, anxiety, and psychosis or the debilitating
effects of these illnesses lead to loss of employment, housing, and subsequent poverty is a
source of debate within the field of epidemiology. The rising number of mentally ill clients who
are homeless has steadily increased in the United States as state governments embarked on a
systematic plan to “deinstitutionalize” the mentally ill. The goal of deinstitutionalization is to
replace state hospitals with smaller group homes, half-way houses, or other supported living
arrangements that integrate, rather than separate, the chronic mentally ill in the community.
Tragically, the services available in the community seldom have kept pace with the demand for
services. The gap in community-based services persists in all developed countries because of
fiscal and political constraints.
In the United States, local officials resist proposals to site-supported living arrangements in
their community. At the state level, mental health appropriations for community-based care are
rarely fully funded. At the federal level, both Congress and the White House have continued to
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tighten eligibility criteria for social security disability—the primary financial resource for the
chronic mentally ill who cannot work. Other federal programs in the Departments of Health and
Human Services, Labor, Education, and Veterans Affairs that target homeless people have been
“level funded.” Therefore, funding has not kept pace with inflation. As government resources
for the poor and disabled erode, shelters have been transformed from temporary to permanent
housing. On the streets of any urban area, the failure to integrate the chronic mentally ill is
glaringly apparent.
TABLE 21.3 Recommendations for Monitoring Patients Taking Second-
Generation Antipsychotics
Practice Point
Individuals who have chronic mental illness are eligible to receive supplemental security
income (SSI). However Martone (2014) notes that no where in the United States can the
chronic mentally-ill receiving SSI find affordable housing. Without additional federal or state
funding to support community-based housing for the chronic mentally ill, homelessness will
continue to be a significant public health issue.
Role of Community Mental Health Teams in the Treatment of
Schizophrenia
Prior to the community mental health movement and the deinstitutionalization of the mentally
ill, people with chronic mental illness would be “warehoused,” or confined to state hospitals for
prolonged periods, many for life. Deinstitutionalization began as a humane initiative to end this
“warehousing.” But tragically, insufficient housing and the lack of other social supports in the
community often results in homelessness for people with chronic mental illness. The burden of
providing supportive care for the severe and persistently mentally ill has increasingly fallen to
community agencies and families.
As a person with schizophrenia becomes less capable of managing social role
responsibilities, families are faced with the burden of assuming the locus of care and support.
Respite services, day-treatment facilities, and sheltered workshops are a few of the outpatient
services that help alleviate the daily burden of care for families. Within families, caregiver
burden is disproportionately shouldered by women, often the mother of the person with chronic
mental illness. Women at greatest risk for burnout from the burden of care are Caucasian
mothers caring for young adults with bipolar disorder in the home (Zauszniewski, Bekhet, &
Suresky, 2008).
Families of people with chronic mental illness assume many of the economic costs
associated with custodial care, but significant costs are also incurred by federal and local
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governments. People with schizophrenia are one of the largest beneficiaries of the federal and
state welfare system. Federal, state, and local funds support care for people with chronic mental
illness in homeless shelters, jails, long-term care facilities, and state mental hospitals. Too often,
clients with chronic mental illness slip into no-care zones, adrift between the social welfare and
healthcare sectors. The fragmentation of care among a myriad of institutions and professionals
makes collaboration and continuity of care a major challenge for providers.
To address these shortcomings in the delivery of care, the WHO (2013) Mental Health Gap
Action Program recommends training community health workers in underresourced countries to
provide evidence-based interventions for common mental health needs. Community health
workers may be referred to as promotorales, paraprofessionals, or lay counselors (Barnett,
Gonzalez, Miranda, Chavira, & Lau, 2017). Unlike standard treatment approaches, community
health workers provide supportive mental healthcare in the client’s home, school, or places of
worship instead of medical setting. Ideally, community mental health teams are composed of a
variety of mental health professionals including, nurses, physicians, social workers, and
occupational and rehabilitation therapists, who can care for the more complex mental health
needs of families and individuals. However in underresourced countries or regions, there is
compelling evidence that community health workers improve the mental health outcomes for
individuals and families (Barnett et al., 2017).
Internationally, several studies are evaluating the effectiveness of community mental health
teams and early intervention programs, including the EDIE study in the United Kingdom, the
LifeSPAN study in Australia, the OPUS study in Denmark, the PRIME study in the United
States, and the TIPS study in Norway (Marshall & Lockwood, 2005). ACT is an evidence-based
treatment for the chronically mentally ill that includes interdisciplinary teams, with a focus on
medication management, housing, and rehabilitation. Findings thus far indicate that the most
effective aspects of ACT are those that target psychosocial functioning, including vocational
skills and supported employment, activities of daily living, and social relationships (Mueser,
Deavers, Penn, & Cassisi, 2013).
Clients with schizophrenia often have a myriad of comorbid chronic health conditions.
Obesity, hypertension, and severe cardiac and metabolic complications all are prevalent to much
higher degrees in people with schizophrenia due to higher rates of smoking, poor nutrition, and
lack of exercise. The social apathy associated with the disease, limited access to healthcare
services, and social stigma make it difficult for clients with schizophrenia to advocate for their
healthcare needs. As client advocates, an important role of the community health nurse is to
ensure that the primary healthcare needs of the chronic mentally ill are met in a variety of
community-based agencies.
Practice Point
A promising research initiative from the National Institute of Mental Health (NIMH), Recovery
After an Initial Schizophrenia Episode (RAISE), is a network approach to integrate early
intervention models with ACT (Narayan, Mohwinckel, Pisano, Yang, & Manji, 2013). The goal
of RAISE is to integrate community-based biopsychosocial treatment in the early stages of
schizophrenia to minimize relapse, morbidity, and disability associated with chronic mental
illness.
Mood and Anxiety Disorders
Epidemiology
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SOCIAL FACTORS
Unlike schizophrenia, for which the incidence is stable across cultures worldwide, there is
substantial variation in the incidence of mood disorders and suicide. Noted sociologist Emile
Durkheim wrote in 1925, “Man is the more vulnerable to self-destruction the more he is
detached from any collectivity. The extent that familial society is more or less cohesive, tightly-
knit and strong—man is more or less strongly attached to life” (Durkheim, 1972), p. 13). By the
end of the century, epidemiologic studies empirically validated Durkheim’s theories that social
factors do play a prominent role in the incidence of mood and anxiety disorders.
Globally, suicide ranks as one of the top causes of preventable deaths. Public health
organizations in the United States and worldwide have targeted populations at-risk for harm
reduction initiatives and prevention programs. A population approach holds the greatest promise
for lowering the rate of suicide because predicting who will commit suicide is challenging. Past
self-harm behavior is the strongest predictor of risk for suicide but 60% of individuals who
commit suicide did not have a previous attempt (Christensen, Cuijpers, & Reynolds, 2016).
Populations at Risk for Suicide
One of the most pressing public health concerns for community mental health nurses is to
address the precipitous increase in the rate of suicide, especially among young adults (Box 21.1).
Worldwide, suicide among adolescents is the second leading cause of death (Centers for Disease
Control and Prevention, 2013a; World Health Organization, 2012). Youth suicide is highest in
developed countries and in South East Asia (Abraham & Sher, 2017). Suicide rates vary by
gender with males having higher rates in developed countries and females having higher rates in
rural communities in China and India (Abraham & Sher, 2017). In addition to a history of
trauma, mood or substance disorder, a significant social risk factor is social isolation especially
among immigrant or indigenous populations, homeless youth, or those in foster care (Abraham
& Sher, 2017). In areas of the world where there is civil violence, terrorism, war or natural
disasters, the impact of trauma to a community on the risk for suicide in youth is less certain
(Abraham & Sher, 2017). Societal protective factors include family and social cohesion with
strong adherence to cultural or religious beliefs that actively discourage suicide (Abraham &
Sher, 2017).
21.1 Evidence-Based Intervention to Promote Mental Health in Children
Cultural Adaptation of Cognitive Behavioral Therapy (CBT) for Puerto
Rican Youth
Cultural Adaptation of Cognitive Behavioral Therapy (CBT) for Puerto Rican Youth is a short-term
intervention for Puerto Rican adolescents aged 13–17 years who are primarily Spanish-speaking and
have severe symptoms of depression. The intervention was informed in consideration of culturally
sensitive criteria (i.e., language, developmental, and socioeconomic factors). Puerto Rican adolescents
identified as having symptoms of depression received the intervention after being referred by local
schools, clinics, and mental health professionals.
Areas of interest Mental health treatment
Outcomes Review date: December 2010
Symptoms of depression
Internalizing symptoms
Externalizing symptoms
Self-concept
Outcome categories Mental health
Social functioning
Ages 13–17 (Adolescent)
Genders Male
Female
Races/ethnicities Hispanic or Latino
Settings Outpatient
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Other community settings
Geographic locations Urban
Implementation history This intervention was first implemented in 1992 at the University of Puerto Rico, Río Piedras
Campus. Since then, 198 Puerto Rican adolescents have received this intervention.
NIH funding/CER studies Partially/fully funded by National Institutes of Health: Yes
Evaluated in comparative effectiveness research studies: Yes
Source: SAMHSA’s National Registry of Evidence-Based Programs and Practices. Retrieved May 28, 2013, from
http://www.nrepp.samhsa.gov/ViewIntervention.aspx?id=219.
The WHO recommends three evidenced-based population strategies to reduce suicide,
including:
1. Restrict access to means of self-harm/suicide
2. Develop policies to reduce harmful use of alcohol as a component of suicide prevention
3. Encourage the media to provide information about where to seek help and avoid
sensationalizing suicide (World Health Organization, 2012)
The most common lethal means of suicide varies by country and access. Globally, pesticide
poisonings are a major cause of fatalities in non-Western countries whereas in the United States,
firearms, opioids, and over the counter medications such as aspirin and acetaminophen are often
used in suicide (Abraham & Sher, 2017). Government prohibition of toxic pesticides was an
effective harm reduction intervention in both South Korea and Sri Lanka (Global Burden of
Disease Collaboration, 2016). In Sri Lanka, bans on toxic pesticides cut the suicide rate in half
(Patel et al., 2016).
In the United States, suicide now surpasses motor vehicle accidents as a leading cause of
death (Centers for Disease Control and Prevention, 2013b). In addition to age, gender
differences are significant, with rates of completed suicides more than twice as high for men
than for women, and retired, divorced, white men at highest risk (Fig. 21.2). In 2014 the suicide
rate for females aged 10 to 14 had the largest percent increase (200%) over the past decade than
all other age groups (Curtin, Warner, Hedegaard, 2016). Self-harm behaviors, such as cutting or
burning of the skin, has also increased significantly among adolescent girls (Mojtabai, Olfson, &
Han, 2016). Adolescents in lower socioeconomic groups and American Indian/Alaskan Native
youth have the highest rates of mortality from suicide (Shain, 2016). Almost half of adolescents
who committed suicide used a firearm (Shain, 2016) (Figs. 21.3 and 21.4).
In October of 2004, the U.S. FDA mandated the following warning to be added to the drug
information insert included in all antidepressant packaging:
Antidepressants increase the risk of suicidal thinking and behavior (suicidality) in children and
adolescents with major depressive disorder and other psychiatric disorders.
Anyone considering the use of an antidepressant in a child or adolescent for any clinical use must balance
the risk of increased suicidality with the clinical need.
Patients who are started on therapy should be observed closely for clinical worsening, suicidality, or
unusual changes in behavior.
Families and caregivers should be advised to closely observe the patient and to communicate with the
prescriber.
Up until the issuance of what is termed by the FDA as a “Black box” warning, there had
been a steady rise in the use of SSRIs by pediatric practitioners. In the wake of the FDA
warning, there are recent indications that the number of adolescents being prescribed
antidepressants is beginning to decline. Now the concern expressed by pediatric practitioners is
how to best weigh the risks and benefits of treatment with antidepressants so that the gains
achieved over the past decade in lowering the rates of suicide among youth are not reversed.
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FIGURE 21.2 Healthy People 2020 target to decrease suicide by gender. (National Vital Statistics
System—Mortality [NVSS-M], CDC/NCHS. Retrieved May 29, 2013, from
http://www.healthypeople.gov/2020/topicsobjectives2020/nationalsnapshot.aspx?topicId=28.)
FIGURE 21.3 Healthy People 2020 target to decrease suicide by ethnicity. (National Vital
Statistics System—Mortality [NVSS-M], CDC/NCHS. Retrieved May 29, 2013, from
http://www.healthypeople.gov/2020/topicsobjectives2020/nationalsnapshot.aspx?topicId=28.)
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http://www.healthypeople.gov/2020/topicsobjectives2020/nationalsnapshot.aspx?topicId=28
FIGURE 21.4 Trends in suicide rates by gender and means 1999 to 2010. (Centers for Disease
Control and Prevention. [2013]. Suicide among adults aged 35–64. Years—United States, 1999–
2010. Morbidity and Mortality Weekly Report, 62[17], 325.)
The National Strategy for Suicide Prevention (NSSP) is a public health initiative launched
by the federal government to prevent suicide through public health education and community-
wide interventions that restore cohesiveness among community members (National Strategy for
Suicide Prevention, 2012). A key feature of the NSSP is to disseminate public health programs
about suicide prevention widely, among a wide range of institutions in society, especially
schools. Community health nurses, who may practice in nontraditional settings (i.e., parish
nurses, senior or recreational centers, and people’s workplaces), are ideally positioned to
implement many of the proposed program initiatives.
A man who has not passed through the inferno of his passions has never overcome them.
Carl Jung
One of the objectives of NSSP is to limit access to lethal means of attempting suicide.
Firearm access is a risk factor for suicide in the United States (U.S. Department of Health and
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Human Services, 2012). Often, suicide is an impulsive act that may be prevented if the means of
completing the suicide was removed. The rate of completed suicides has been significantly
reduced in many countries by a public health strategy termed means restriction (U.S.
Department of Health and Human Services, 2012). A higher number of firearm laws in a state
are associated with a lower rate of suicides from firearms fatalities (Fleegler, Lee, Monuteaux,
Hemenway, & Mannix, 2013). Unfortunately, in American society, the power of the National
Rifle Association, the availability of firearms, and the cultural value of personal freedom have
thwarted enacting any meaningful restrictions on firearms.
Community health nurses can promote “means restriction,” especially in families where
there is a member at risk for suicide. Families who own firearms should be encouraged to secure
firearms using trigger locks and locking bullets in a separate location from the firearm. If a client
informs the nurse that he or she is having thoughts of taking an overdose, then prescription or
over-the-counter medications that may be fatal in overdose should be removed or secured in a
safe location. Although families might presume that removing the instrumental means of harm is
an ineffective gesture, the community health nurse must reassure the family that their actions are
sending a strong, unambiguous message to the potential victim that people care about them and
will take any necessary steps to ensure their safety.
Practice Point
One of the factors that may explain the marked increase in suicide among preteen girls is the
rise in cyberbullying. Middle school girls in particular report the highest rates of being
victimized by cyberbullying and victims are twice as likely to have attempted suicide
(Messias, Kindrick & Castro, 2014). The U.S. Department of Health and Human Services has
created a public health media campaign at: www.stopbullying.gov. The website describes
prevention strategies for parents and schools as well specific guidance to report
cyberbullying to online service providers, police, and schools.
Nursing Interventions for Mood and Anxiety Disorders
The symptoms of major depression or anxiety commonly seen in community settings are
fatigue, headache, backache, gastrointestinal complaints, anhedonia, and sleep and appetite
disturbance. Clients who are exhibiting these somatic signs as well as mood symptoms should be
asked directly if they have had any thoughts of harming themselves. If a client responds in the
affirmative, the nurse needs to ascertain if the client has a specific plan and the means to carry
out the plan.
Nonsuicidal self-injury is a growing public health problem especially among young adults.
Epidemiologic reports indicate those young adults at highest risk are the unemployed, women,
those with only a high school education, and those with a history of mood, anxiety, or
personality disorders (Olfson et al., 2017). Nonsuicidal self-injury should always be interpreted
as a cry for help. Community mental health nurses can play an important role in implementing
community-based initiatives to prevent suicide and suicide attempts, especially among youth.
Evidence for Practice
A study of homeless youth in Texas found that homeless youth had higher rates of
depression than the general population and were significantly more likely to abuse synthetic
marijuana and alcohol (Narendorf, Cross, Maria, Swank & Bordnick, 2017). The authors
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conclude that homeless youth with untreated depression are misusing alcohol or synthetic
marijuana to “self-medicate” their mood symptoms instead of seeking mental health
treatment from healthcare professionals due to stigma and barriers to accessing mental
health services. The Runaway and Homeless Youth Program funded by the U.S.
Department of Health and Human Services provides grants to community agencies to
provide mental and physical health services as well as individual and family counseling. For
more information on how to apply for grants to address the unmet needs of homeless youth
see: https://www.acf.hhs.gov/fysb/resource/rhy-fact-sheet.
Evidence for Practice
An integrative review of 11 large population studies found that lesbian, gay, bisexual, and
transgender (LGBT) populations had significantly higher rates of nonsuicidal self-injury than
non-LGBT populations (Jackman, Honig & Bockting, 2016). The HEEADSSS (an acronym
for Home, Education/Employment, Eating, Activities, Drugs and Alcohol, Sexuality,
Suicidality, and Safety) is an evidence-based assessment tool that incorporates screening
questions for sexuality and self-harm behaviors tailored to adolescents and young adults
(Smith & McGuinness, 2017). Additional resources for community health nurses caring for
LGBT youth and adults are available at the National LGBT Health Education Center at:
https://www.lgbthealtheducation.org/
Nursing Interventions for Hoarding Disorder
In the revision to the DSM-5 a new category of mental disorder was added under the category of
obsessive-compulsive disorder to address the serious personal and public health implications of
hoarding behavior. To be diagnosed with hoarding disorder, a person must accumulate, and not
discard, items to such a degree that it significantly impairs their ability to perform basic skills of
daily living. A residence may become so cluttered with waste that it is a health, fire, and safety
hazard. Left unchecked, hoarding behavior has severe public health and sanitation implications
for families, neighbors, and the community at large. The more longstanding the hoarding
behavior, the poorer the prognosis and more difficult it becomes to change hoarding behavior
(Burton, Arnold & Soreni, 2015).
Multimodal treatment for hoarding is similar to that of obsessive-compulsive disorder with
the use of antidepressants and cognitive behavioral therapy. An essential component to treatment
includes family support and involvement in treatment. The burden of hoarding behaviors on
families is equivalent to, or greater than, living with an individual who has dementia (Drury,
Ajmi, de la Cruz, Nordsletten, & Mataix-Cols, 2014). In most cases, the hoarding behavior first
appeared in childhood or adolescence. About 25% of children diagnosed with autism spectrum
disorder exhibit hoarding symptoms (Storch et al., 2016). The more parents accommodate to the
child’s hoarding behavior to avoid outbursts, the greater the likelihood treatment will be
ineffective. Parents should be encouraged to restrict the space for desired items and if the space
is full, then direct the child to discard items before others are added (Morris, Jaffee, Goodwin, &
Franklin, 2016).
Community health nurses play an important role in identifying adults suffering from
hoarding disorder because most do not seek treatment or acknowledge problematic hoarding
behaviors (Brakoulias & Milicevic, 2015). A home assessment to determine the extent of
hazards and if additional resources are necessary to clean and declutter the home, is the first
stage of intervention by community health nurses (Murphy, 2014). Often the hoarder has limited
insight about the adverse consequences of their behavior and contests the need to declutter. To
overcome such an impasse, Murphy (2014) advises inviting a group of concerned family
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members to describe, in a nonjudgmental way, the adverse effects of the person’s hoarding
behavior. If the person expresses a willingness to declutter, the community health nurse can
assist the person develop a timeline for achieving reasonable goals. Any behavior change is
difficult and for a person with hoarding disorder, strong emotional attachments to inanimate
objects or animals can make relinquishing these belongings all the more challenging. If the
community health nurse identifies immediate health, fire, or safety hazards then it is appropriate
to also enlist the assistance of the local fire department, board of health, and building inspection
services (Murphy, 2014). Hoarding is a chronic condition and periodic check-ins by the
community health nurse are essential components to sustaining a clean, safe, and de-cluttered
home (Raeburn, Hungerford, Escott, & Cleary, 2015).
Evidence for Practice
An intervention study for individuals with mild intellectual disability suffering from hoarding
behavior, reported a reduction of hoarding behaviors of 36% to 50% much higher than
previous reports of CBT interventions in persons who do not have intellectual disability
(Kellett, Matuozzo, & Kotecha, 2015). The authors attribute the higher rate of remission to
conducting all the CBT intervention in the person’s home where they were closely
supervised to remove clutter and organize items, rather than in individual or group CBT
sessions outside the home. Conducting all CBT interventions in the home also has the
added benefit of proactively heading off acquiring items. Another effective intervention is to
photograph the clutter at baseline and as treatment progresses to provide a visual record of
achieving treatment goals (Mataix-Cols, 2014)
Practice Point
Self-help groups based on the book The Buried Treasures provide specific activities to
address hoarding behaviors (Tolin, Frost, & Steketee, 2013). Groups maybe led in the
community by trained professionals or persons in recovery from hoarding behavior. The
facilitators guide for The Buried Treasures Workshop is available at no charge at
http://www.mutual-support.com/the_buried_in_treasures_workshop_and_facilitators_guide.
Attention-Deficit/Hyperactivity Disorders and Disruptive Behavior
Disorders in Children
Approximately 1 in 10 youths have severe emotional disturbance with substantial functional
impairment (Williams, Scott & Aarons, 2017). Disruptive behavior disorders, such as
oppositional defiant disorder and conduct disorder, are often diagnosed as co-occurring with
attention deficit hyperactivity disorder. Disruptive behavior disorders in childhood and
adolescence account for the majority of psychiatric hospitalizations for children and half of all
outpatient psychiatric treatment (Oruche et al., 2015).
The overlap in symptoms among ADHD, bipolar disorder, and disruptive behavior disorders
makes it difficult for the school nurse to correctly identify students at risk and make referrals for
appropriate treatment. Hyperactivity and impulsivity, hallmarks of ADHD, may also be
displayed by children with bipolar disorder. Because the pharmacologic treatment for both
conditions is vastly different—in ADHD, children are prescribed stimulants and in bipolar
disorder, children are prescribed second-generation antipsychotics and mood stabilizers—it is
important that clinicians recognize the subtle features that distinguish the two disorders.
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The main characteristics that help healthcare practitioners, including school nurses,
differentiate ADHD from bipolar disorder are the pervasiveness of the symptoms and the
predominant symptoms. In children with ADHD, hyperactivity and impulsivity are evident in all
spheres of the child’s life. There is a constancy and pervasiveness of the hyperactivity in school,
at home, and in activities. Distractibility and unrelenting motor behavior (e.g., always being in
motion, begin unable to sit still and attend to a task) are the symptoms that cause the most
distress for parents and teachers. Unlike bipolar disorder, mood and anxiety symptoms are not
predominant in ADHD; generally, teachers and parents do not characterize the child with
ADHD as angry, irritable, and moody.
Children diagnosed with bipolar disorder have a predominance of mood symptoms such as
irritability, sleep disturbances, and anxiety (Kowatch, 2016). For a child with bipolar disorder,
the slightest frustration can set off a flood of crying, screaming, or anxiety symptoms. Unlike
toddlers who have temper tantrums that are time limited, children with bipolar disorder can have
rage episodes that can last from 2 to 3 hours. In general, children who are angry and frustrated
can be comforted by adults. However, children with bipolar disorder appear inconsolable. Angry
or aggressive outbursts are unpredictable and episodic, varying from day to day and moment to
moment. Because these violent outbursts overlap with symptoms seen in disruptive behavior
disorders, oppositional defiant disorder is often diagnosed with bipolar disorder in children.
Family history may also alert the clinician to the possibility a child has bipolar disorder
rather than ADHD. Most children with bipolar disorder had a family history of mood disorder. If
parents or siblings report that they have experienced performance difficulties in school or work,
it is important for the diagnostician to determine whether the poor performance was due to mood
symptoms (such as depression) or motor behavior (such as impulsivity). If the social role
functioning of a family member was disrupted primarily by mood symptoms, this may suggest
that the child is more at risk for bipolar disorder than for ADHD.
Finally, clinicians, as well as school nurses, should carefully observe for improvement in
target symptoms with medication treatment. With ADHD, there should be some improvement in
symptoms after an adequate trial of psychostimulants. Similarly, with bipolar disorder, there
should be an improvement in symptoms after treatment with second-generation antipsychotics.
The danger in failing to make a proper diagnosis is that if children with bipolar disorder are
prescribed antidepressant or stimulant drugs, there can be an exacerbation of suicidality,
hostility, and agitation. Current estimates are that 20% to 40% of children initially diagnosed
with depression will develop bipolar disorder. It is crucial for school nurses to carefully monitor
any child on antidepressants for a worsening of symptoms, especially any indications of
disinhibition.
Multidisciplinary collaboration among teachers, therapists, and primary care providers is a
central feature of comprehensive treatment for the child with any behavioral disorder.
Psychotherapies, specifically cognitive-behavioral therapy and family therapy, have been
demonstrated to be effective in the management of depression but not as effective as
antidepressants alone. Self-help groups for families are of enormous benefit in helping families
cope with the child’s disruptive behaviors that can quickly lead to caregiver burnout.
The role of the school nurse is integral to helping the child or adolescent understand the
nature of the disorder; the purpose and side effects of medication; and the importance of
maintaining a healthy lifestyle, including good sleep hygiene, avoidance of caffeine, relaxation
techniques, and abstinence from illicit drugs. It may sound like a tall order for the school nurse,
but there is compelling evidence that young adults and children respond positively to primary
interventions, education, and support from caring adults. Often, a depressed child will come to
the health office with somatic complaints such as headache, gastrointestinal upset, or fatigue.
The school nurse’s office can be an oasis of calm and comfort in the midst of the daily demands
of school life. Empathy, active listening, and unconditional positive regard are the cornerstones
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to developing a therapeutic alliance—an alliance that can make a significant positive impact on
the quality of a child’s experience in school.
Practice Point
A study of 15 primary caretakers of adolescents’ with disruptive behavior disorders identified
major challenges in managing the adolescents’ aggressive and defiant behavior and the
resulting inactions with police, school, and mental health professionals (Oruche et al, 2015).
Based on their findings, the authors advise that in addition to assessing specific behaviors
that are challenging for caregivers, community health nurses should also inquire about
interactions with the school, police, and other child welfare agencies that also significantly
contribute to caregiver burden.
The Precipitous Rise in Autism—A Public Health Crisis
Throughout the world, there has been an increase in the prevalence rate of autism that is not
explained by improved screening or changes in diagnostic criteria. Epidemiologic surveys of
autism in America, Western Pacific, and Europe do not statistically differ with a global mean
prevalence of 1 child out of 160 having a pervasive developmental disorder (Elsabbagh et al.,
2012). Based on parent self-report, in 2013 the CDC estimates that 1 in 50 children in the United
States has autism, which represents a 2% increase in all age groups in 5 years (Blumberg et al.,
2013). Given the public health implications of the growing numbers of children worldwide
diagnosed with autism, the foundation, “Autism Speaks” has partnered with the WHO and the
CDC to enhance collaboration among researchers investigating the causes of pervasive
developmental disorders and improve healthcare services, especially in developing countries
(Elsabbagh et al., 2012).
Etiologic factors under investigation include genetic, biologic, developmental, and
environmental agents. The heritability of autism is high, with an increased recurrence risk of
12% to 20% in siblings of a child diagnosed with autism (Chase & Leboyer, 2012). A genetic
test for autism in a population of central European decent has been developed with a level of
diagnostic accuracy and offers promising insights in genetic testing research for other ethnic
populations (Skafidas et al., 2012). While specific alleles contribute to risk, there is growing
research evidence that environmental factors and the interaction between the environment and
genes also play an important role in the etiology of autism. For example, epidemiologic studies
of unaffected siblings find fewer prenatal and perinatal exposures and complications than with
the affected sibling (Chase & Leboyer, 2012).
Given the upsurge in autism cases, epidemiologists are investigating potential exposures that
effect entire populations. The list of causative environmental agents includes exposures in utero,
to the mother, and in infancy. Exposures during pregnancy associated with increased risk of
developing autism include medications such as antibiotics, valproic acid, SSRIs, and
misoprostol as well as substances such as ethanol, thalidomide, and the insecticide chlorpyrifos
(Atladóttir, Henriksen, Schendel, & Parner, 2012; Chase, & Leboyer, 2012; Croen, Grether,
Yoshida, Odouli, & Hendrick, 2011; Duchan & Patel, 2012).
Given the profound public health implications for the rising rate of autism among U.S.
children, in 2006 Congress created a federal advisory committee, the Interagency Autism
Coordinating Committee (IACC) to accelerate progress in autism research and services. In 2011,
Congress reauthorized the IACC, which is assisted by the Office of Autism Research
Coordination (OARC), to communicate directly to Congress, other government agencies, and
the public the latest information about federally supported autism research. The 2012 IACC
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Strategic Plan documents the magnitude of groundbreaking research and advances in treatment
with the explicit goal of improving the quality of life for autistic children and their families
(Interagency Autism Coordinating Committee, 2012).
Most research investigating the genetic and environmental risk factors for autism has been
conducted with populations in developed countries. Yet unlocking the clues about the role of
parental age, complications in pregnancy or medications taken in pregnancy can best be
elucidated with cross-cultural comparisons for these and other associated risk factors. Even in
the United States, prevalence rates of autism are higher in more affluent communities (Durkin et
al., 2010). The Global Autism Public Health Initiative has partnerships in 42 nations to expand
epidemiologic research globally in an effort to identify how genes and the environment may
interact to increase the risk for autism. Epidemiology research on environmental factors
associated with autism, both in the United States and abroad, is critical in providing public
health nurses specific targets for education and prevention with at-risk populations.
PUBLIC HEALTH INITIATIVES IN AUTISM
Public health organizations have an important role in promoting screening programs and
providing information about treatment resources. In the past, diagnosis of autism was often
delayed until preschool because clinicians would look for evidence of language impairments
before making a definitive diagnosis. More recently, the emphasis is on screening for prodromal
symptoms in infancy with the hope that some of the more debilitating features of the disorder
might be mitigated with early intervention and treatment. A goal of Healthy People 2020 is to
increase the proportion of young children with an autism spectrum disorder (ASD) and other
developmental delays who are screened, evaluated, and enrolled in early intervention programs.
The CDC’s “Learn the Signs—Act Early” is a health education campaign targeting parents,
educators, and healthcare providers promoting awareness of child development and information
about early intervention programs. In the United States, Hispanic and African American children
have been diagnosed later and enter treatment for autism later than Caucasian children. The
CDC’s “Learn the Signs—Act Early” education effort includes parent-friendly materials that are
customizable for populations with health disparities to improve case finding and referral. The
foundation “Autism Speaks” has partnered with the Ad Council to create Spanish language
educational ads for the media, church groups, and other community organizations to also
enhance outreach to Latino and black communities.
Practice Point
In 2013, the diagnostic criteria for autistic disorder in DSM-5 eliminated the diagnosis of
Asperger syndrome, and the category of pervasive developmental disorders was replaced
with ASD (APA, 2013). Public health and school nurses should be aware of parents’
heightened concerns that the more precise diagnostic criteria will be used to deny their child
special education services (Halfon & Kuo, 2013). When educating parents of newborns about
normal developmental milestones, it is important for community health nurses to encourage
parents to report any concerns they may have about their child’s social or language
development.
EVOLUTION OF COMMUNITY MENTAL HEALTH
In the United States, community-based treatment of the mentally ill gained momentum as World
War II veterans returned home exhibiting the symptoms of posttraumatic stress disorder (PTSD).
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There was a recognition that witnessing or experiencing a horrific traumatic event could have
debilitating effects on the mind. The stigma associated with mental illness also began to subside
in the wake of the tragic 1942 Cocoanut Grove fire in Boston, in which hundreds of trapped
victims died and scores of survivors and their families sought mental health services. Through
his pioneering work with people traumatized by the Cocoanut Grove fire, Dr. Erich Lindemann
developed the concept of crisis intervention and promoted the notion that those suffering from
mental illness can be best healed with their own communities among family and social
institutions who cared and supported them.
By the early 1960s, a scathing report by the Joint Commission on Mental Health and Illness
about conditions in state-supported psychiatric hospitals prompted the adoption of the
Community Mental Health Center (CMHC) Act and federal initiatives to revamp mental
healthcare delivery (Dixon & Goldman, 2004). Initially, the populations to be served by CMHCs
were those suffering from acute, not chronic, mental illnesses (Dixon & Goldman, 2004). In the
coming decades, more than 700 CMHCs funded by the federal government were created, and
through outreach services, many younger and less-debilitated individuals received mental health
services than ever before (Feldman, 2004). One of the distinctive features of these mental health
centers was that treatment was to be population based. Each community mental health center
was responsible for providing a range of mental health services to people who lived in a specific
geographic area that was not to exceed 200,000 people. The services mandated by the CMHC
Act included inpatient, outpatient, day treatment, and emergency treatment, as well as
consultation and education to the community (Feldman, 2004). It was a sweeping agenda, with
profound implications for the continued viability of state-run psychiatric hospitals.
Aided by advances in the development of pharmacologic treatment of the mentally ill, the
numbers of patients treated in state mental hospitals precipitously declined. Coupled with
changes in involuntary commitment regulations that made the confinement of patients against
their will unlawful except in extreme instances of a clear danger to themselves or others, more
and more mentally ill found themselves homeless. CMHCs had paved the way for mental health
services to be provided for those who were acutely ill. However, few resources were in place at
these centers to provide the range of supportive care needed by the overwhelming numbers of
mentally ill who were rapidly being discharged from state hospitals.
The deinstitutionalization trend began as a humane effort to reduce the stigma associated
with mental illness and reintegrate those suffering from mental illness into community-based
settings. Indeed, some of the patients with chronic mental illness who qualified for income
support through Social Security Disability were transferred to long-term care facilities, half-way
houses, and supportive housing. However, in all too many cases, vast numbers of those
discharged from state hospitals fell into a no-care zone—homeless, living on the streets or in
shelters.
In hindsight, as originally conceived, the CMHCs were ill prepared, financially or
organizationally, to meet the housing, income, employment, and rehabilitation needs of people
with chronic mental illness. By the 1980s, the President’s Commission for Mental Health
offered a new agenda to the CMHCs that shifted the funding to rehabilitation, affordable
housing, and vocational training (Geller, 2000). The shift to a more pragmatic treatment model
recognized that clients with severe mental illness would likely have a lifelong dependency on
services aimed at sustaining their independence and social functioning.
On the state level, community health nurses responsible for case management must negotiate
with separate agencies for mental health services, criminal justice, substance abuse, and housing
services. Coupled with the split at the federal level between the Social Security Administration,
Medicare, and Medicaid, it is easy to see how a family or provider would have difficulty
accessing or coordinating care. By reallocating federal expenditures to the state level, it is hoped
that the states will be able to provide a comprehensive model of care that encompasses the entire
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spectrum of services for the chronic mentally ill within one entity.
Since deinstitutionalization began, there has been an outcry of frustration from nurses in the
community about the lack of supportive services to meet the needs of people with chronic
mental illness. Community mental health nurses have been forceful advocates at the state,
national, and local level to ensure that policies and programs are in place to provide a safe haven
for those no longer confined to state-run psychiatric hospitals. These state hospitals remain the
provider of last resort for clients with intractable symptoms.
Over a decade ago, Geller (2000) warned that by solely focusing on the locus of care or
where the care is given, without regard to the humane character, appropriateness, or quality of
care, there is a risk that the very conditions deinstitutionalization sought to ameliorate will be
recreated. One of the future goals for community health nurses will be to find innovative ways to
partner with families in designing and implementing mental health programs that reflect the
values, traditions, and beliefs of their community.
Carmen’s treatment team begins planning for the psychiatric care she will need in the
community from the day she is admitted. The case manager contacts day programs near
Carmen’s home and negotiates with Medicare disability reviewers to approve outpatient
treatment for 2 weeks. At discharge, Carmen’s mood is much improved, and she is
reassured that a referral to a pain specialist is pending. Although the day-treatment
program is near her residence, she has to rely on family members for rides. She is
hesitant to ask her family for them, and at home, unexpected financial expenses mean
that she does not fill her prescriptions for both pain management and depression. Carmen
is readmitted to the hospital less than a month after her original discharge. She returns in
severe pain, saying that she is “too much of a burden” to her family and “what is the point
of living.” During the second hospitalization, the case manager is able to arrange for
transportation to and from day treatment and enroll Carmen in a low-cost medication
administration program offered by a pharmaceutical company to improve her adherence
with the treatment plan.
LEGISLATION FOR PARITY IN MENTAL HEALTH
INSURANCE BENEFITS
The United States maintains the unique distinction of having a private health insurance system
that allocates benefits based on where a person is employed. Because health insurance is a
substantial cost to employers, myriad strategies have been used to contain healthcare costs. One
of these strategies is that traditionally, in private health insurance, there have been different
benefits, copays, and insurance limits for mental health versus medical health conditions.
Beginning in 1993, Congress debated the merits of legislating equal benefits for all healthcare
conditions. Proponents of parity cite research evidence that many mental disorders are more
responsive to treatment than common medical conditions and that with early treatment, the more
chronic, residual effects of mental disorders maybe lessened. More than 365 organizations
representing a wide array of public interest groups, local governments, and healthcare providers,
including the American Psychiatric Nurses Association and the American Nurses Association,
support mental health parity.
After 3 years of debate, the Mental Health Parity Act (MHPA) was enacted, requiring that
lifetime and annual ceilings on expenditures for mental healthcare not be lower than those for
physical illness. In an important concession, MHPA only applied to employer-based insurance
that served 50 or more employees, exempting small businesses or people who were self-insured,
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and it excluded certain psychiatric conditions. As can be found with all public policies,
ingenious strategies were devised to thwart the spirit of the 1996 parity law. For example, some
private insurance plans set limits on inpatient days for psychiatric treatment or increased the
copays and deductible charges for mental healthcare.
In the original legislation, it was stipulated that the provisions of the MHPA would expire, or
“sunset,” in 6 years. After a 12-year battle on Capitol Hill and in the White House, in October of
2008, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act
(MHPAEA) of 2008 was passed by Congress and signed by President Bush. The MHPAEA of
2008 expands the MHPA of 1996 and mandates that by January 1, 2010, health insurance plans
covering 50 or more employees provide equal benefits for medical, surgical, mental health, and
substance use treatment. All health insurance coverages, including deductibles, co-payments,
coinsurance, and out-of-pocket expenses, and all treatment limitations, including frequency of
treatment, number of visits, days of coverage, or other similar limits, will be the same regardless
of health need or diagnosis. Those opposed to the MHPA argued that health insurance costs to
employers and individuals would increase significantly if benefits for mental and medical
conditions were equal. To date, mental health parity has not led to increased health insurance
costs (Mark, Vandivort-Warren, & Miller, 2012).
The passage of the Patient Protection and Affordable Care Act (PPACA) in 2010 assured
that behavioral health would be an essential benefit for all insurance plans. Starting in 2014, the
PPACA requires all individual and small group plans to comply with the provisions of the
MHPAEA. The goal of the PPACA coupled with the MHPAEA was to extend behavioral health
insurance benefits to more than 60 million Americans. Yet 2 years later, a quarter of insurance
plans were not adhering to these requirements. Instead these insurers instituted multiple barriers
to mental healthcare including prior authorization requirements, denials of claims, insufficient
numbers of approved behavioral health providers, and limits on coverage for psychiatric
medications (Medford-Davis & Beall, 2017).
A promising provision in the PPACA is incentives to integrate mental and medical
healthcare service through patient-centered medical homes. The model medical home provides
person-centered care through a team of providers that coordinate all primary healthcare
including mental healthcare. The aim of patient-centered medical homes is to improve outcomes
of care, especially for the chronic mentally ill, the majority of whom also have comorbid
medical conditions.
Evidence for Practice
A cluster randomized trial investigated if the Depression CAREPATH intervention would
decrease hospital readmissions for Medicare recipients with co-occurring depression and
medical conditions (Bruce, Lohman, Greenberg, Bao and Raue, 2016). The CAREPATH
intervention used by home health nurses included assessment of mood symptoms with the
PHQ-9, case management with specialist providers, patient education to promote
medication adherence, application of practice protocols for depression symptom
management and routine evaluation of behavioral health outcomes. Bruce and colleagues
(2016) reported that patients who were referred to CAREPATH prior to hospital discharge
had a 55% lower rate of readmission than those who received routine home healthcare. The
findings suggest that a patient-centered medical home model that integrates management
of depression with home health nursing care can significantly lower the rates of readmission
for depressed older adults.
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ROLES AND RESPONSIBILITIES OF THE COMMUNITY
MENTAL HEALTH PRACTITIONER
Throughout this chapter, the roles of the community health nurse as teacher, clinician, and
advocate have been described. Mental health is a leading health indicator in the U.S. Healthy
People 2020 program (see Fig. 21.1), and mental health promotion and disease prevention are an
integral part of nursing practice. Box 21.2 outlines selected primary, secondary, and tertiary
levels of prevention that help reduce risk, identify and limit disabilities, and reduce
complications of mental health problems.
Providing population-based care that addresses the cultural diversity of a community
remains one of the most pressing challenges facing all health providers. The WHO and the
PPACA have cited the application of culturally sensitive care for people suffering from mental
illness as one of the most pressing goals in the new millennium. There is not a single path to
achieve this objective, although there is unanimity on the importance of providing mental health
services that are sensitive to the cultural needs and expectations of clients and their families.
21.2 Levels of Prevention in Community Mental Health
Primary
Educate families and community groups about mental health issues, symptoms of stress, and barriers to seeking
help
Foster availability of support services for community groups, such as prenatal and parent education sessions,
bereavement sessions, and caregiver support
Secondary
Screen for mental health disorders
Refer high-risk people for diagnostic services
Provide mental health services following stressful community events
Tertiary
Promote support groups for people with mental health disorders
Initiate health promotion activities as a part of rehabilitation services.
Developing a therapeutic alliance is the cornerstone to culturally sensitive nursing care. The
Substance Abuse and Mental Health Services Administration (SAMHSA) has developed
cultural competence standards for mental healthcare services (see link
https://www.samhsa.gov/section-223/cultural-competency). For example, one of the
implementation guidelines is that bilingual mental health staff be certified in language
proficiency and cultural competence. The outcome benchmark recommended by SAMHSA is
that 90% of racial/ethnic consumers of mental health services be satisfied with the
communication styles of mental health specialists. In addition, culturally competent nursing care
plans must identify and involve a range of community resources, including native societies,
healers, spiritual leaders, and community organizations. Culturally competent community health
nurses must demonstrate knowledge in group values, traditions, and the cultural expression of
mental illness. In turn, therapeutic interventions described in the treatment plan should reflect
the client’s cultural values. Education and outreach programs must be designed to include
specific information that addresses the unique cultural needs of a community.
Almost a decade ago, the Surgeon General’s Report on Mental Health (U.S. Department of
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https://www.samhsa.gov/section-223/cultural-competency
Health and Human Services, 1999) urged researchers to investigate differences in access to care
and treatment response by culture, race, or ethnicity. More recently, the PPACA also highlighted
the importance of expanding access to culturally competent mental health services (Nardi,
Waite, & Killian, 2012). It is important to acknowledge that health insurance reform alone will
not be sufficient to erase racial and ethnic healthcare disparities. Disparities in access and
response to mental health treatment exist by age, gender, race, ethnic background,
socioeconomic status, and geographic location (Dougherty, 2004). Clinic hours, transportation,
stigma, and the availability of culturally competent mental health providers are some of the
roadblocks marginalized populations face when attempting to access mental health services
(Alegria et al., 2012). Community health nurses can play a critical role in advancing nursing
knowledge and understanding of how models of nursing care can be developed that account for
cultural differences in access to care, treatment responsiveness, and adherence. Mental health
parity will never be fully realized until systems of culturally sensitive care meet the needs for
treatment in every community (McCarty, 2013).
Practice Point
Community health nurses should seek certification in cultural competence and incorporate
the standards of cultural competence developed by SAMHSA into treatment plans and
programs that provide mental health services.
PSYCHOLOGICAL FIRST AID
Populations Traumatized by Disasters
Since 1970, the incidence of natural disasters throughout the world has been rising and
irrespective of the socioeconomic status of the country, lifetime exposure to natural disasters is
high, ranging from 4.4% to 7.5% (Kessler, McLaughlin, Koenen, Petukhova, Hill, & The WHO
World Mental Health Consortium, 2012). Globally, there were 168 natural disasters and 150
human-made disasters, resulting in 20 million fatalities, 50 million casualties, and 2000 million
homeless in 2012 (Sigma, 2013). Population’s hardest hit were in Asia where over 1,900 people
died or were missing from Typhoon Bopha and Africa where three million people were
displaced from floods. The same year, more than 45,000 people, the majority of whom were
civilians and children, were victims of terrorist attacks with 64% of all attacks occurring in
Afghanistan, Iraq, and Pakistan (U.S. Department of State, 2012).
In the United States, the incidence of natural disasters has been increasing since 1998
(FEMA, 2013). Back to back hurricanes causing historic flooding and record property damage in
Texas, Florida Puerto Rico and the Virgin Islands have tested the federal and volunteer disaster
relief efforts as never before. “Rampage shootings,” characterized by a male engaging in a
shooting spree within institutions familiar to him, but toward victims that may be unknown,
have also been increasing in the United States since the 1990s (Harris & Harris, 2012, p. 1054).
Four terrorist attacks, including the First World Trade Center bombing in 1993, the Oklahoma
City bombing in 1995, the 9/11 attacks in 2001, and the Boston Marathon bombing in 2013,
resulted in over 3,000 deaths and 2,000 injuries to U.S. civilians (National Consortium for the
Study of Terrorism and Responses to Terrorism, 2012).
Populations at Risk for Psychological Trauma
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Natural and human-made disasters inflict psychological impacts on populations that are 4 to 50
times greater than the number of physical injuries (McCabe, Barnett, Taylor, & Links, 2010).
Studies of the psychological effects of disasters find considerable variation in prevalence
rates among populations, ranging from 14% to 76% for prolonged grief reactions, to 5% to 68%
for PTSD, and to 10% to 45% for major depression (Kristensen, Weisaeth, & Heir, 2012).
Population risk factors for developing disaster-associated PTSD include female gender; older
adult age; Hispanic ethnicity; lower education level; personal injury; witnessing in injury or
death, especially among family or friends; and prior history of psychiatric illness, especially
PTSD, major depression, or panic disorder (North, Oliver, & Pandya, 2012). Psychological
harms are also greater when a community is victimized by a terrorist attack or a rampage
shooting rather than a natural disaster. The challenge for public health nurses is how best to
intervene to minimize psychological harms when an entire community or a population has been
traumatized.
In the 1950s, the federal government requested that the APA develop guidelines for
providing psychological support to communities affected by disasters. Building on the principles
of crisis intervention originated by Eric Lindeman, a brief therapeutic intervention was
developed termed psychological first aid (Forbes, 2011). Psychological first aid is designed to
be delivered by disaster relief workers, including nurses who are often on the front lines of a
disaster in a variety of community-based settings.
The core features of psychological first aid are to protect, connect, and direct (Fig. 21.5).
Nurses can protect victims of a disaster by, first and foremost, providing food, clothing, and
shelter. Psychological first aid is the fundamental principles of therapeutic communication such
as active listening, allowing silence, allowing the expression of emotions, and paraphrasing
these reactions to convey understanding and compassion. Similar to the nursing process, the first
steps of psychological first aid include assessment of physical and psychological well-being,
coping skills, and social supports. Victims should be assessed for severe psychological reactions
especially suicidal or homicidal ideation and directed to mental health disaster specialists.
The second stage of psychological first aid mirrors the intervention phase of the nursing
process. The most immediate concern for many survivors is their desire to be reunited with
friends, family, and social and spiritual supports. Connection with family and loved ones can be
challenging in the aftermath of a disaster. Relief workers have developed innovative strategies to
reunite families and friends as quickly as possible. Disaster mental health nurses may meet with
families to gather information for the identification process in the event of death. Nurses can
minimize retraumatization by limiting the number of individuals, victims and survivors, interact
with to “tell their story” and the number of individuals who witness the horror of aftermath.
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FIGURE 21.5 SAMSHA psychological first aid for first responders. (SAMHSA psychological first
aid for first responders: Tips for emergency and disaster workers. U.S. Department of Health and
Human Services. NMH05-0210. Washington, DC: U.S. Government Printing Office. Retrieved May
29, 2013, from http://store.samhsa.gov/shin/content/NMH05-0210/NMH05-0210 .)
TABLE 21.4 Evidence-Based Psychological Interventions for Mass
Casualties
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http://store.samhsa.gov/shin/content/NMH05-0210/NMH05-0210
In the third stage of psychological first aid, nurses act as advocates and direct survivors to
relief agencies. Nurses actively partner with survivors in practical problem-solving to address
specific, immediate concerns. It is critical that nurses not make promises or conjecture about the
availability of resources. Information to survivors must be credible, culturally and linguistically
appropriate, timely, and specific as to where and when resources may arrive, such as
transportation, assistance for dependents, medical care, or housing. During this stage, nurses
provide psychoeducation on bereavement for individuals, families, and communities who are
coping with multiple losses.
Families, survivors, and first responders benefit from education about expected behavioral
responses to avoid pathologizing normal grief reactions. Expected psychological reactions may
include guilt or shame, anger, frequent crying or blunting of emotions, difficulty concentrating,
uncharacteristic social isolation, and inability to forget sensory images of trauma. Expected
physical reactions may include headaches, fatigue, gastrointestinal disturbance, pain, disrupted
sleep, and disrupted eating (too much or too little). Deep breathing, yoga, prayer, and spiritual
reflection can help diminish anxiety for those exhibiting expected psychological responses. As
much as possible, encourage individuals to engage in group activities to facilitate social
cohesion, hope, and resilience.
Survivors or first responders experiencing moderate to severe psychological reactions,
including suicidal or homicidal ideation, should be directed to disaster mental health specialists.
Moderate psychological reactions include nightmares, intrusive daytime images, bodily
sensations related to traumatic experience, excessive physical startle reflex, extreme anxiety
alternating with numbing, and difficulty modulating anger. Cognitive behavioral therapies are
evidence-based interventions that can help individuals cope with the moderate symptoms of
emotional distress (Everly, Barnett, & Links, 2012). Symptoms of major mental illness such as
dissociation, panic attacks, agoraphobia, depression or substance abuse, in addition to the
inability to perform basic self-care, or threats of violence against others or self would warrant
immediate emergency treatment.
In disasters, ordinary people emerge as innovative problem solvers who are responsive to the
needs of others around them. This prosocial response has been documented by researchers over
several decades in countless disasters and highlights the resilience of communities even in the
face of horrific traumatic events (McCabe et al., 2012). Resilience is built on the self and
community perception of having the ability to cope and respond flexibly to the unexpected.
Faith-based organizations, social clubs, and local schools are a few of the indigenous community
supports that provide extraordinary services in disasters and are vital to long-term psychological
recovery (McCabe et al., 2011) (Table 21.4).
Evidence for Practice
In 2009, a scientific review by the Advisory Council to the American Red Cross determined
that psychological first aid was an evidenced-informed intervention that can be used
effectively by trained volunteers to address the basic needs of individuals in the immediate
aftermath of a disaster (Fox et al., 2012). The same year, the WHO Mental Health
Guidelines Development Group concluded that psychological first aid, and not psychological
debriefing, should be provided to populations affected by disaster (WHO, 2011) (Box 21.3).
The U.S. Medical Reserve Corps training manual on psychological first aid (Brymer et al.,
2006) and the WHO state there is insufficient evidence on the efficacy of debriefing and
caution there is a risk that the systematic ventilation of feelings maybe triggering and hinder,
rather than support, the recovery of survivors and first responders.
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21.3 WHO Psychological First Aid in Different Cultures
Consider the Following Questions as You Prepare to Offer PFA in Different Cultures:
Dress Do I need to dress a certain way to be respectful?
Will affected people be in need of certain clothing items to keep their dignity and customs?
Language What is the customary way of greeting people in this culture?
What language do they speak?
Gender, Age and Power Should affected women only be approached by women helpers?
Who may I approach? (In other words, the head of the family or community?)
Touching and Behavior What are the usual customs around touching people?
Is it all right to hold someone’s hand or touch their shoulder?
Are there special things to consider in terms of behavior around the elderly, children, women, or
others?
Beliefs and Religion Who are the different ethnic and religious groups among the affected people?
What beliefs of practices are important to the people affected?
How might they understand of explain what has happened?
World Health Organization. (2011). (Psychological first aid: Guide for field workers. Geneva: WHO, War Trauma Foundation and World Vision International.
Retrieved May 28, 2013, from http://whqlibdoc.who.int/publications/2011/9789241548205_eng .)
KEY CONCEPTS
Genetic, biologic, and environmental risk factors all influence the incidence of mental illness.
Early intervention can minimize the morbidity associated with mental illness.
Adherence to psychopharmacology and psychotherapy enhances recovery from mental illness.
The continuum of care for the chronic mentally ill includes community services, such as supportive housing
and employment.
Public health initiatives to educate communities about mental health can be effective in lowering the
incidence of high-risk behaviors such as suicide.
Psychological first aid is recommended to help support survivors and first responders to natural and
intentional disasters.
CRITICAL THINKING QUESTIONS
You are a school nurse in a middle school when Jamal comes to the nurse’s office requesting medication for a headache.
You notice that his eyes are red, and it appears as if he has been crying. You ask if he is hurt, but he denies it. The phone
rings in the office, and a teacher tells you that a female student has approached her concerned about Jamal. The teacher
tells you that Jamal sent her a text message saying that he flunked his biology examination and wished he was dead.
1. What is the most immediate nursing assessment that should be evaluated?
2. If Jamal is hesitant to share his thoughts with you, what could you say or do to develop a therapeutic
alliance?
3. What other collateral sources of information would you contact to evaluate the risk of suicide associated
with the text message? Would you leave Jamal alone to discuss the situation with other colleagues?
4. If Jamal shared with you a suicide plan that includes harming himself with a weapon, what would be your
first nursing intervention?
5. If you determined Jamal was at risk for self-harm, to whom would you refer Jamal?
6. How would you continue to assess Jamal’s mental health while he was a student in the middle school?
7. How might health insurance, transportation, and family circumstances influence Jamal’s ability to access
mental health services?
8. What educational program would you develop for the middle school to educate students about ways to
cope with stress and how to respond if a friend needs support?
HEALTHY PEOPLE 2020 EVIDENCE-BASED RESOURCE
RECOMMENDATIONS
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Mental Health and Mental Illness: Collaborative Care for the Management of Depressive Disorders (The
Community Guide, 2016)
Developed by: Community Preventive Services Task Force. Collaborative care for the management of
depressive disorders is an interdisciplinary model of person-centered medical home that uses nurse case
managers to link primary care providers, patients, and mental health specialists.
Healthy People 2020 topic area(s): Access to health services; mental health and mental disorders
Healthy People 2020 objectives: MHMD-11, MHMD-4, AHS-5
Strength of recommendation: 4 out of 4
Exercise for Students
Apply the core components of collaborative care in caring for a client in a community-based setting by:
1. Demonstrating evidence-based screening for depressive disorders by using the PHQ-9 for adults or the
HEADSSS for children and adolescents
2. Provide patient and family education to promote treatment adherence
3. Apply evidence-based protocols for the proactive management of diagnosed depressive disorders
4. Mobilize clinical and community support for active patient engagement in treatment goal setting and self-
management (Fig. 21.6)
FIGURE 21.6 Mental Health in My Community: Information Graphic. (SAMHSA. [2013]. Retrieved
on August 5, 2017, from https://store.samhsa.gov/product/Mental-Health-in-My-Community-
Information-Graphic/SMA13-4725. References available at:
https://store.samhsa.gov/shin/content/SMA13-4725/SMA13-4725_Reference .)
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Chapter 22
School Health
Pamela Pershing DiNapoli
For additional ancillary materials related to this chapter. please visit thePoint
Computers are useless. They can only give you answers.
Pablo Picasso
Education is what remains after one has forgotten what one has learned in school.
Albert Einstein
Home computers are being called upon to perform many new functions, including the
consumption of homework formerly eaten by the dog.
Doug Larson
CHAPTER HIGHLIGHTS
Historical perspectives of school health
Components and organization of school health programs
School health scope of services
Health assessment and screening of school-aged children
Development, implementation, and evaluation of preventive health programs
Common health concerns in schools
OBJECTIVES
Trace the history of school health practice.
Explain the scope of the school nurse’s role in the provision of healthcare.
Identify useful sources for tracking epidemiology of common health concerns.
Use best practice guidelines to address common preventable health concerns of the student population.
KEY TERMS
Americans with Disabilities Act (ADA): Wide-ranging federal legislation enacted in 1990 that is
intended to make American society more accessible to people with disabilities.
Coordinated school health: A systematic approach to school health recommended by the CDC
as a strategy for improving students’ health and learning in the nation’s schools.
Council on School Health: Coalition of a wide range of community stakeholders, including
family and student representatives, who contribute to the development of action plans
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designed to improve the health and safety of the students.
Early Periodic Screening, Diagnosis, and Treatment (EPSDT): Program mandated by a
federal law passed in 1969 that required that children and adolescents younger than 21 have
access to periodic screenings.
Electronic bullying: Any kind of repeated aggression perpetrated through information
technology, such as the internet, to intentionally harm or harass another individual.
Every Student Succeeds Act (ESSA): Replaced and updated the No Child Left Behind Act
(NCLB) and supersedes Individuals with Disabilities Education Act (IDEA) the federal law
enacted in 1990 and reauthorized in 1997 designed to protect the rights of students with
disabilities by ensuring that every individual receives a free appropriate public education,
regardless of ability. ESSA promotes equitable general education for all students, as well as
protects the supports and services necessary for individuals with disabilities.
Food Allergy and Anaphylaxis Management Act (FAAMA): Requires the U.S. Secretary of
Health and Human Services to develop and make available to schools a voluntary policy to
manage the risk of food allergy and anaphylaxis in schools and provide for school-based food
allergy management incentive grants to support implementation of food allergy management
guidelines in public schools.
Individual education plan (IEP): A plan developed by a multidisciplinary team to provide
education and services to any student that has an identified disability to correspond with
individual needs in the least restrictive environment.
Individuals with Disabilities Education Act (IDEA): Federal law designated in 1990,
reauthorized in 1997 and redesignated in 2015. As the Every Student Succeeds Act (ESSA)
was designed to protect the rights of students with disabilities by ensuring that everyone
receives a free appropriate public education, regardless of ability.
School Health Index: An online self-assessment and planning tool that schools can use to
improve their health and safety policies and programs.
School health nursing: Specialized practice of nursing that protects and promotes student
health, facilitates optimal development, and advances academic success. School nurses,
grounded in ethical and evidence-based practice, are the leaders who bridge healthcare and
education, provide care coordination, advocate for quality student-centered care, and
collaborate to design systems that allow individuals and communities to develop their full
potential.
Whole School, Whole Community, Whole Child (WSCC): Combines and builds on the
coordinated school health model and the Association for Supervision and Curriculum
Development’s (ASCD) Whole Child approach to education to promote improved health and
educational outcomes for children in schools.
Youth Risk Behavior Surveillance Survey (YRBSS): Biannual report of the common risk
behaviors that influence the health of youth in the United States.
CASE STUDY
References to the case study are found throughout this chapter (look for the case study icon).
Readers should keep the case study in mind as they read the chapter.
Susan is the school nurse in a rural elementary school for children in kindergarten through grade 5.
The school has approximately 300 students, who present Susan with many challenges. One child
with special health needs is in a wheelchair, is catheterized twice a day while at school, and
receives a tube feeding at lunch. Two children who have type 1 diabetes—one requires blood
sugar monitoring and insulin injections at a minimum of once daily, while the other has a
continuous insulin pump. Several children have allergies ranging from severe peanut allergies to
bee stings. In addition, Susan administers daily medications to 18 students at various times; these
medications include methylphenidate (Ritalin), gabapentin (Neurontin), carbamazepine (Carbatrol),
and Lactaid.
Susan uses a computerized database to track the visits of the children to her office, which
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average 30 per day. Reasons for visits include playground injuries and acute illnesses with
symptoms such as vomiting, fever, or headache.
INTRODUCTION
Many people outside of the school environment have little understanding of the scope of the
roles and responsibilities of the school nurse. Currently there are more than 55 million children
enrolled in nearly 125,000 U.S. schools. The association recommendation is a ratio of one nurse
for every 750 students. However, it is estimated that only 41% of schools have full-time RNs,
with school nurses frequently serving several schools. Findings from the National Association of
School Nurses (NASN) 2016 School Nurses Survey indicate that school nurses cover, on
average, three buildings and serve an average of 924 to 1,072 students (Mangena & Maughan,
2015). As such, schools represent one of the greatest opportunities to communicate important
health messages to America’s children and youth (AAP, 2016).
The role of the school nurse, first introduced in the early 1900s, has changed dramatically
over the years. These changes closely parallel the increasing number of complex health issues
being seen within the school system. Although the school nurse is often seen merely as someone
who applies adhesive bandages or who serves as a parent substitute for children having
difficulty adjusting to the school setting, the role of the school nurse has evolved to where it is
now recognized as a specialty area in nursing. The scope of the role in promoting wellness
includes administrative, educational, clerical, and supportive responsibilities, along with
encouragement of school wellness policies, such as physical activity in daily practice (Avery,
Johnson, Cousins, & Hamilton, 2013). This chapter describes school health nursing and
illustrates how the school nurse has become a cornerstone in providing healthcare and health
promotion to school-aged children and their families.
In 2017, the NASN revised their definition of school nursing to being, “a specialized
practice of nursing, protects and promotes student health, facilitates optimal development, and
advances academic success. School nurses, grounded in ethical and evidence-based practice, are
the leaders who bridge healthcare and education, provide care coordination, advocate for quality
student-centered care, and collaborate to design systems that allow individuals and communities
to develop their full potential” (NASN, 2017).
Therefore, school nurses:
Help encourage positive responses to normal development.
Help promote health and safety.
Help solve actual and potential problems.
Help promote academic success.
Provide case management services.
Work with others to develop student and family capacity for adaptation, self-management, and continued
growth.
HISTORICAL PERSPECTIVES
The history of school nursing can be traced back to 1902, when Lillian Wald, working in a New
York City public school, saw that school nursing services were a way to decrease excessive
absenteeism. At that time, the role of nurses in schools was limited to the treatment of minor
contagious diseases, the conduct of health education programs, and the use of home visits to
demonstrate recommended treatments to family. Historically, the scope of school health services
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was often the function of public health nurses contracted through municipal health departments.
However, soon the first city-wide school nursing program in the world was established. Lina
Rogers (Struthers) became the first school nurse in New York City and is credited with
providing evidence-based nursing care across the city (Rollins, 2011; Vessey & McGowan,
2006).
During the following decades, there was a dramatic increase in the number of school nurses
in the United States. The last Health Resources and Services Administration (HRSA) health
workforce survey done in 2008 estimated that 1.9% of licensed registered nurses worked in the
school environment in the United States (HRSA, 2010). As the number of school nurses
increased, the role of the school nurse became more focused on screening and referral. The
Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program provided for by
Section 1905(a) in Title XIX of the Social Security Act, which was passed in 1965, was an
influential factor promoting this key school nursing role in screening and referral. EPSDT
recognized that schools can be a focal point from which to identify children with problems, to
increase students’ access to both preventive and curative health services, and to ensure
appropriate use of healthcare resources for children and adolescents who received Medicaid and
were younger than 21 (http://www.cms.gov/Regulations-and-Guidance).
However, the strongest influence on school nursing practice came with the passage of the
Education for All Handicapped Children Act of 1975 (Public Law 94-142). Children who had
previously been unable to attend school because of chronic or complex medical issues were now
entitled to a public education, and they began attending public schools. School nurses were now
providing more complex care for conditions such as seizure disorders, asthma, cardiac
conditions, cystic fibrosis, quadriplegia, and life-threatening allergies (Robert Wood Johnson
Foundation, 2010). For example, peanut allergy, the most common cause of anaphylaxis, is a
medical emergency that requires immediate treatment with an epinephrine (adrenaline) injector
(EpiPen, Twinject) and a trip to the emergency department.
Today, given the wide range of health needs in the student population, it is not uncommon
for school nurses to record up to 100 visits in a single day. With the increase in these complex
conditions came the need to perform high-tech skills, such as tube feedings, catheterizations, and
suctioning. The inclusion of children with special needs led to a change in the EPSDT program.
The School Health-Related Services Plan Section 1905(r)(5) of the Social Security Act (the Act)
requires that any medically necessary healthcare service listed in Section 1905(a) of the Act be
provided to an EPSDT recipient even if the service is not available under that state’s Medicaid
plan. An amendment required identification of children who have a learning problem due to a
medical problem that requires special services. Once the child is identified, an Individual
Education Plan (IEP) or 504 plan, which lists services needed by the child, is completed by the
school. The schools employ people with special training to assist children with special needs.
The IEP is reviewed annually and eligibility is reviewed every three years. The school nurse is
an integral member of the IEP and should advocate for his or her role during all special
education meetings. Box 22.1 lists the direct medical services reimbursable by Medicaid when
performed by a school as part of the IEP and when consistent with state Medicaid regulations.
The Individuals with Disabilities Education Act (IDEA), originally the Education for all
Handicapped Children Act, has undergone several legislative amendments in recent years.
Lawmakers made these changes to accommodate the changing climate for disabled people in the
United States and to promote the belief that “improving educational results for children with
disabilities is an essential element of our national policy of ensuring equality of opportunity, full
participation, independent living, and economic self-sufficiency for individuals with disabilities”
(Individuals with Disabilities Education Improvement Act of 2004). The IDEA requires students
be evaluated based on academic achievement, functional performance, cognitive functioning,
communication status, health, hearing and vision, motor abilities, and social-emotional status
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(Department of Education, https://sites.ed.gov/idea/, n.d.). The most recent change came when
the IDEA was amended in December of 2015 through Public Law 114-95, the Every Student
Succeeds Act (ESSA), which attempts to ensure success by focusing on the best teaching and
learning strategies for all students, including gifted and talented students, and not just authorized
for children with disabilities. States are accountable for protecting the general education, as well
as the supports and services necessary for individuals with disabilities to succeed as provided
under the IDEA (Department of Education, https://sites.ed.gov/idea/, n.d.).
22.1 Direct Medical Services Reimbursable by Medicaid
1. Providing health/mental health services contained in an IEP.
2. Medical/health assessment and evaluation as part of the development of an IEP.
3. Conducting medical/health assessments/evaluations and diagnostic testing and preparing related
reports.
4. Providing personal aide services.
5. Providing speech, occupational, physical and other therapies.
6. Administering first aid, or prescribed injection or medication.
7. Providing direct clinical/treatment services.
8. Performing developmental assessments.
9. Providing counseling services to treat health, mental health, or substance abuse conditions.
10. Developing a treatment plan (medical plan of care) for a student if provided as a medical service.
11. Targeted case management (if provided or covered as a medical service under Medicaid).
12. Transportation (if covered as a medical service under Medicaid).
13. Activities that are services, or components of services, listed in the state’s Medicaid plan.
Source: https://www.cms.gov.
You have got to keep autistic children engaged with the world. You cannot let them tune
out. Temple Grandin
Danielle is a student with special health needs who attends the school where Susan
works as a nurse. Susan must catheterize her twice daily while at school, and while
Danielle’s aide can assist with her tube feedings, Susan has primary responsibility for
programming and attaching the pump to Danielle’s “MIC-KEY button.”
ROLE OF THE SCHOOL NURSE
The school nurse provides a critical link between the child, the family, and the education and
healthcare systems. Each of the 50 states has a state nurse practice act that regulate the
profession of nursing, including school nursing. The Scope and Standards of Professional
School Nursing Practice (American Nurses Association & National Association of School
Nurses, 2017) defines the practice of school health nurses.
Building on the evidence-based principles of the school nursing standards for competent
quality care, the NASN developed a Framework for 21st Century School Nursing Practice (the
Framework), which provides structure and focus for student-centered nursing care that occurs
within the context of the students’ family and school community. Surrounding the students,
family, and school community are the nonhierarchical, overlapping key principles of care
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https://sites.ed.gov/idea/
https://www.cms.gov
coordination, leadership, quality improvement, and community/public health (NASN,
http://www.nasn.org/nasn/nasn-resources/professional-topics/framework). It should be
acknowledged that many school health programs suffer as a result of inconsistency and
ambiguity in the practice of school nursing. In an effort to prioritize the learning and health
needs of students, the Whole School, Whole Community, Whole Child model (WSCC) was
developed by the Association for Supervision and Curriculum Development (ASCD) and the
Centers for Disease Control and Prevention (CDC). The WSCC model outlines the 10
recommended components of a comprehensive school health program, as summarized in Table
22.1.
Provision of health services by the school nurse is the anchor of the school health program.
To address the diverse needs of students, the school nurse must adopt the central management
position for all children and adolescents in the school. The role that emerges within the context
of this management position requires that the nurse have skills in health assessment, including
skills in the identification of common problems that impact a child’s learning, such as vision
impairment, attention-deficit/hyperactivity disorder (ADHD), and scoliosis. Screening is also a
valuable tool in identifying and treating problems that may result in a child being excluded from
school, such as infestation with lice, or other communicable diseases. Health promotion, health
education, and child health advocacy are key components of the school nurse’s role. Many
nurses take on the expanded role of certified health educator and function increasingly as
valuable classroom teachers. The nurse needs to collaborate with other members of the school
health services team to integrate comprehensive wellness policies and practices into school
action plans, as a provision of participating in federal programs such as WSCC, ESSA, and
Child Nutrition Programs (CDC, https://www.cdc.gov/healthyschools).
TABLE 22.1 Comprehensive School Health Programs
Recommended
Components
Description
Health education Curricula and instruction for students in pre-K through grade 12 that address a variety
of topics such as alcohol and other drug use and abuse, healthy eating/nutrition,
mental and emotional health, personal health and wellness, physical activity, safety
and injury prevention, sexual health, tobacco use, and violence prevention
Nutrition and environment
services
Provides students with opportunities to learn about and practice healthy eating
through available foods and beverages, nutrition education, and messages about
food in the cafeteria and throughout the school campus
Employee wellness A coordinated set of programs, policies, benefits, and environmental supports
designed to address multiple risk factors (e.g., lack of physical activity, tobacco use)
and health conditions (e.g., diabetes, depression) to meet the health and safety
needs of all employees
Social and emotional
school climate
A climate that promotes health, growth, and development by providing a safe and
supportive learning environment
Physical environment A physical environment that protect occupants from physical threats (e.g., crime,
violence, traffic, and injuries) and biologic and chemical agents in the air, water, or
soil
Health services Intervene with actual and potential health problems, in addition to wellness promotion,
preventive services and staff, student and parent education; complement the
provision of care coordination services
Counseling, psychological
and social services
Services include psychological, psychoeducational, and psychosocial assessments;
direct and indirect interventions to address psychological, academic, and social
barriers to learning
Community involvement Community groups, organizations, and local businesses create partnerships with
schools, share resources, and volunteer to support student learning, development,
and health-related activities
Family engagement Families and school staff work together to support and improve the learning,
development, and health of students
Physical education and
physical activity
Provides the opportunity for students to learn key concepts and practice critical skills
needed to establish and maintain physically active lifestyles throughout childhood,
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https://www.cdc.gov/healthyschools
adolescence and into adulthood
Source: Centers for Disease Control and Prevention. Components of the Whole School, Whole Community, Whole Child (WSCC). Retrieved from
https://www.cdc.gov/healthyschools/wscc/components.htm.
Hugs can do great amounts of good—especially for children. Diana, Princess of Wales
Practice Point
School nursing requires autonomous practice and independent decision-making.
Health Assessment
Typically, there are three types of school health service visits that require the nurse to use
assessment skills. The first type of visit is for acute illness (e.g., vomiting, fever, or headache)
and playground injury. The nurse can easily use physical assessment skills and knowledge of
first aid to address these issues. For example, peanut allergy, the most common cause of
anaphylaxis, is a medical emergency that requires immediate treatment with an epinephrine
(adrenaline) injector (EpiPen, Twinject) and a trip to the emergency department.
The second type is for typical screenings, often begun when the child enters school
(immunization status) and may be continued as the child grows and is at risk for problems that
may impact learning, such as vision impairment. Routine screening may require referral and
follow-up. The third type of visit is for counseling. Students may seek out the school nurse for
advice and support regarding daily stressors encountered in the social framework of the school,
such as being picked on or bullied by others. These visits require that the nurse assess the child
individually. In addition, there are visits that are part of population-based screening programs
that may include periodic vision and hearing tests, height and weight measurements (e.g., to
calculate body mass index [BMI]), or immunization checks; these may result in health teaching
activities.
Individual Health Assessment
The individual assessment of the child is specific to the need for the visit and may not occur in
the health office. In any case, health assessment should be the responsibility of a licensed
healthcare professional in the school setting. Within the school, a variety of data sources are
available to the nurse to use in completing a thorough assessment of the child’s chief complaint.
The nurse should begin by collecting subjective data gathered from the child, teacher, or parent,
or any other witness to the complaint. Data should include location, frequency, duration and
severity, quality, quantity, setting, associated symptoms, and precipitating factors that make the
symptom better or worse. Objective data provide information that makes the nurse’s job of
understanding the complaint easier. These data should include any information or signs pertinent
to the illness, such as fever.
Practice Point
The child’s chief complaint may only be the tip of the iceberg. Use all data sources available
to assess the problem.
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Collectively, this information guides the actions taken by the nurse. These actions might
include treatment, referral to a healthcare provider, and notification of a parent and/or sending
the child home. Individual school policy dictates the extent to which the nurse is able to treat the
presenting symptoms.
Danielle also receives occupational and physical therapy services while at school. Susan
must incorporate data gathered from the treatment notes, as well as from the special
medical services treatment providers who monitor Danielle’s medical care within her
home. It is important that Susan maintains frequent communication with this team to
ensure close monitoring of Danielle’s healthcare needs.
Population-Based Assessment
There are no federal laws requiring that periodic screening be provided by the schools, although
as a public health concern consistent with EPSDT, these screenings are often a major part of the
school health program. The screenings may be essential to the early detection of, and
intervention in, problems that may affect academic success.
In addition, people often ask a school nurse why he or she performs periodic screening and
how schools use this information. Screening programs typically begin when the child enters
school and may continue in different forms throughout the child’s education. Before
implementing a screening program, schools should address these questions. For example, it is
helpful if the health education curriculum addresses the conditions being assessed in the
screening process. That way everyone, including the school staff, students, and families, is fully
informed. It is necessary to develop clear procedures that evaluate the results of screening tests
and stipulate how the results will be reported. In addition, it is essential to establish what the
desired screening outcomes are and to emphasize those that fall outside of the targeted
benchmarks.
The school nurse should play a major role in planning these screenings and will need to
spend the required time to develop a successful program. For example, in response to the obesity
epidemic, many schools are implementing walking programs or similar exercise programs to
encourage the recommended 60 minutes a day of physical activity. Box 22.2 lists the school
health screenings that school nurses frequently coordinate.
Practice Point
The Screening, Brief Intervention, and Referral to Treatment (SBIRT) tool focuses on early
detection, risk assessment, brief counseling and referral intervention that can be utilized in
the school setting to reinforce healthy behaviors and address safety issues
(https://www.samhsa.gov/sbirt).
Health Promotion and Assessment of School Health Needs
Healthy People 2020 has acknowledged the need for targeted data collection and health
promotion efforts regarding the common health concerns of children and adolescents
(USDHHS, Healthy People 2020, 2018). One tool, the Youth Risk Behavior Surveillance
Survey (YRBSS), is a voluntary, biannual survey of the common risk behaviors influencing the
health of the nation’s youth. These risk behaviors are identified because of their potential impact
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on the long-term health and well-being of youth. Box 22.3 illustrates the six behavior categories
for which statistics are typically reported. The CDC’s YRBSS website
(https://www.cdc.gov/healthyyouth/data/yrbs/index.htm) is a source of additional information
about this data collection tool.
22.2 Typical School Health Screenings
Immunization Screening
Vision Screening
Hearing Screening
Postural Screening
Body Mass Index Screening
A second data collection tool is the School Health Index, which focuses on how schools can
promote physical activity, healthy eating, and adoption of a tobacco-free lifestyle, and a wide
range of safety-related behaviors in an attempt to counter common risk behaviors (CDC, 2014).
There are two versions of the index, one for elementary schools and the other for middle schools
and high schools. These can be obtained in print form or can be used online. The importance of
the School Health Index is its ability to help schools identify the strengths and weaknesses of a
particular school’s policies and programs for promoting health and safety. On the basis of this
assessment, school personnel can develop an action plan, which is then incorporated into a
school’s overall improvement plan to promote the health and safety of the students. The CDC
developed the School Health Index Self-Assessment and Planning Guide for the following
purposes (CDC, n.d.):
Enabling schools to identify the strengths and weaknesses of health and safety policies and programs
Enabling schools to develop an action plan for improving student health, which can be incorporated into
the school improvement plan
Engaging teachers, parents, students, and the community in promoting health-enhancing behaviors and
better health
22.3 Youth Risk Behavior Surveillance Survey Risk Behavior Categories
Behaviors that contribute to unintentional injuries and violence
Sexual behaviors related to unintended pregnancy and sexually transmitted diseases, including HIV infection
Alcohol and other drug use
Tobacco use
Unhealthy dietary behaviors
Inadequate physical activity
Evidence for Practice
Along with the School Health Index, the CDC has several standardized adolescent and
school health tools that assist in assessment, planning, implementing, and evaluating
school health programs.
The CDC’s Division of Adolescent and School Health and School Health Services websites
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provide more information (https://www.cdc.gov/healthyyouth/;
https://www.cdc.gov/healthyschools/). Tools are available to the school nurse and other
health professionals responsible for the provision of the continuum of healthcare services.
Health Education Curriculum Analysis Tool (HECAT), which helps schools, school districts,
and other school personnel responsible for curricular redesign and continuous quality
improvement to analyze health education programs on the basis of alignment with national
health education standards and characteristics of effective health education curricula.
Physical Education Curriculum Analysis Tool (PECAT), which enables users to analyze
written physical education curricula based on alignment with national standards, guidelines,
and best practices for quality physical education programs.
Healthy Students, Promising Futures which helps Local Education Agencies (LEA) link to
state and local agencies to improve school-based health. Opportunities include helping
families and students to enroll in health insurance and expanding services to at-risk
students (https://www2.ed.gov/admins/lead/safety/healthy-students/toolkit ).
School health advisory councils consisting of a wide range of community stakeholders hold
the greatest potential for addressing the health needs of students to support their physical,
cognitive, and emotional development. Based on past CDC recommendations, approximately
one-third of the nation’s schools had school health councils. Many states mandate by law that
schools have councils that develop and evaluate school health action plans. The development of
these councils has significantly improved the odds that schools have comprehensive policies and
programs that address common health concerns. The WSCC advocates for the integration and
alignment between health and education acknowledging the interrelatedness between learning
and health (Lewallen et al., 2015).
The establishment of school-based health centers (SBHCs) and services complement the
work of the school nurse as a model of primary healthcare in the schools. SBHCs are
specifically designed to fill gaps in health services, including those to prevent teen pregnancy.
The appearance of SBHCs began in the early 1980s. Today, more than 2,000 SBHCs exist in 49
of 50 states. The SBHCs do not take the place of existing nursing services, but they enhance
health services by decreasing barriers to needed healthcare. The National Association of
Pediatric Nurse Practitioners advocates SBHCs as a necessary component of comprehensive
healthcare for children. The SBHCs are located where the children are and can effectively treat
problems affecting children’s health.
The Affordable Care Act appropriated $200 million from 2010 through 2013 for the centers,
to build new facilities, purchase equipment, and expand services (Wall Street Journal, 2012).
This infusion of money enabled those SBHCs receiving funding to increase capacity by over
50%. Subsequently, the Department of Child, Adolescent and Family Health SBHCs have
established key performance measures to ensure continued quality, growth and sustainability of
SBHCs (School-Based Health Alliance, https://www.sbh4all.org/resources/quality-counts/five-
performance-measures/).
Practice Point
Collaboration across the community, school, and health sectors to meet the needs and
support the full potential of each child is the most important step that schools can take to
improve their comprehensive school health program.
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https://www.cdc.gov/healthyschools/
https://www2.ed.gov/admins/lead/safety/healthy-students/toolkit
https://www.sbh4all.org/resources/quality-counts/five-performance-measures/
Susan is the chair of the School District Wellness Committee. The Wellness Committee
was formed primarily to oversee the nutrition and physical activity needs of the school
community as part of an overall commitment to wellness. The committee has recently
implemented a before-school walking program to encourage children to engage in at least
60 minutes of physical activity per day.
The School Nurse as Health Educator
Schools, where children and adolescents spend one-third of their day, present an ideal setting for
providing health education. A health education curriculum is an important part of a
comprehensive kindergarten to grade 12 school health program. Consistent with the WSCC
program, evidence-based health education programs may vary in their approach but should be
age-appropriate and should focus on developing and enhancing social and emotional strengths
(ASCD & CDC, 2014).
Programs that serve to increase self-esteem, develop social skills, and increase understanding
of issues such as peer influence and decision-making should be considered. Some professionals
have recommended that the school nurse’s role in health education should be that of a resource
person or consultant and not necessarily that of a teacher. This opinion is contrary to that of the
NASN, which considers health education an important intervention to be implemented as a
primary responsibility of the school nurse.
Whether or not the school nurse is in the classroom, health education is a priority. The
school nurse must seek to accomplish health teaching in encounters with students and families,
in the classroom, in individual counseling sessions (e.g., teaching a child how and when to use
his or her EpiPen), and in group meetings. Despite the existence of National Health Education
Standards, the Society for Public Health Education reports that health education in schools is a
low priority (SOPHE, 2018). By adopting the eight National Health Education Standards,
schools increase the likelihood that children will adopt lifelong health-promoting behaviors. It is
recommended that the focus of health education be skill-based and address the health promotion
concerns identified in the National Health Objectives of Healthy People 2020. This includes
focusing on protective factors that support health-enhancing behaviors related to nutrition,
physical activity, and safe use of social media, and that promote the avoidance of drug, alcohol
and tobacco use, and the prevention of bullying and other forms of violence.
Emergency Preparedness
An essential role of the school nurse is to be prepared for emergencies, yet as few as 75% have
any specialized training in emergency care beyond basic life support. Emergency preparedness
does not address a specific hazard but addresses the planning, response, and recovery needs
within a local community, such as a school. An example of a training program offered to
provide nurses with knowledge and skills to respond to a mass casualty is the School Emergency
Triage Training (SETT) program offered by the NASN. It is the position of NASN that the
school nurse has the skills to provide leadership in all phases of emergency preparedness and
response. Doyle (2013) has identified four roles that by virtue of the school nurses’ specialized
education can be performed in an emergency situation: prevention, preparedness, response, and
recovery.
COMMON HEALTH CONCERNS
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It is easier to build strong children than to repair broken men. Frederick Douglass
Substance Use: Drugs and Alcohol
Epidemiology
The National Survey on Drug Use and Health (NSDUH) is sponsored by the Center for
Behavioral Health Statistics and Quality, a division of the Substance Abuse and Mental Health
Services Administration (SAMHSA). SAMHSA is the primary source of data on drug and
alcohol use in the civilian population. NSDUH tracks indicators of substance use and mental
health among people aged 12 years or older, and further aggregates data by age group, including
youths ages 12 to 17 and young adults ages 18 to 25. The most current estimate of illicit drug
use among youths ages 12 to 17 years is 8.8%, whereas among young adults ages 18 to 25, the
estimate is 23.2%. The most commonly reported illicit drug used in these age groups is
marijuana. From 2002 to 2015, the prevalence of marijuana use has declined in youths ages 12
to 17 (8.2% to 7.0%), but has increased steadily in young adults. In 2015, about one in five
young adults ages 18 to 25 (19.8%) were current users of marijuana. A recent addition to the
survey was related to prescription drug (psychotherapeutics) misuse, defined as use in any way
not directed by a prescriber of any drug in the following categories: pain relievers, tranquilizers,
stimulants, and sedatives. About 2% of adolescents (one in 50) and 5.1% of young adults were
current misusers of psychotherapeutic drugs. Pain relievers were the substance most often
misused.
NSDUH also collects data on current alcohol use, including binge drinking and heavy use.
Although the estimated alcohol use among adolescents decreased between 2002 and 2015, about
one in 10 adolescents aged 12 to 17 years were current alcohol users in 2015. About 5.8% of
these current drinkers were binge drinkers, defined as having five or more drinks on the same
occasion on at least one day in the past 30 days, and about one in 100 were heavy drinkers,
defined as having five or more drinks on the same occasion on five or more days in the past 30
days (SAMHSA, 2017).
Best Practices: Drug and Alcohol Prevention
Based on the trends in drug and alcohol use, the school nurse should consider introducing
prevention during the three periods when the interventions are most likely to produce results: (1)
the primary prevention or inoculation phase, which is designed to introduce knowledge; (2) the
secondary prevention or early relevance phase, when information is likely to have meaning and
applicability to students; and (3) the tertiary prevention or later relevance phase, when young
people are actually being exposed to new situations involving experimentation. Programs and
booster sessions should be implemented throughout these periods (National Registry of
Evidence-Based Programs and Practices [NREPP], n.d.). There is an extensive body of research
related to the effectiveness of school-based substance abuse programs. The SAMHSA has
collated a series of evidence-based programs with the potential to produce sustained behavior
change (NREPP). The NREPP website (www.nrepp.samhsa.gov) is a searchable database of
interventions that have been evaluated in comparative effectiveness research. It is important to
assess the needs and interests of the group carefully prior to the selection of any program.
Providing school drug education programs that are meaningful and motivating to the participants
should also be considered. Integrating the goals of the child’s grade in school with
developmentally appropriate prevention programs is essential. For example, is the goal of the
program nonuse, delayed use, or harm minimization? In addition, the school nurse should design
programs that are behavior-focused and use teaching and learning principles and interactive
techniques that give students an opportunity to practice new skills, rather than relying on
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knowledge-based programs.
Practice Point
Classroom-based drug education should be made routinely available in schools as a cost-
effective method for the prevention of drug abuse.
It is clear that a substantial number of adolescents will experiment with substances and that
given the limited funding available in many schools for prevention programming evidence-based
prevention strategies must be initiated as early as elementary school to prevent initiation (Singh,
Jimerson, & Renshaw, 2011).
Substance Use: Smoking
Epidemiology
Tobacco use, including smokeless tobacco products continue to be the leading cause of
preventable disease in the United States. Among adolescents who reported current tobacco use,
30.3% used tobacco products other than cigarettes, but did not smoke cigarettes. During the late
1990s, the overall downward trend in current cigarette smoking among high school students
began to slow, as observed by the National Youth Tobacco Survey (NYTS) and other national
surveys. However, some of this decline may reflect the use of electronic vaporizing devices for
delivering nicotine, such as e-cigarettes. For example, data from the most recent NYTS indicates
that more than a quarter-million middle school and high school students in 2013 (263,000) never
smoked a conventional cigarette, but used e-cigarettes (Bunnell et al., 2015). A recent surgeon
general’s report on this trend indicates there has been a 900% increase since 2011 (U.S.
Department of Health and Human Services, Office of the Surgeon General, 2016). Findings
from 2015 indicated that 2.4 million high school students and 620,000 middle school students
reported having used an e-cigarette at least one time in the past 30 days. E-cigarettes are tobacco
products that deliver nicotine and are associated with the initiation of the use of other tobacco
products. Serious unintended consequence of this trend is the increase in accidental poisoning
due to exposure to liquid nicotine and passive exposure to nicotine.
The Healthy People 2020 objectives also specifically target adolescent tobacco use. Specific
objectives include reducing the reported use of tobacco products in the previous 12 months from
7.7% to 5.7%. Also included are objectives to decrease the initiation of smokeless tobacco and
cigars among children and adolescents, aged 12 to 17 years. Healthy People 2020 suggests that
effective prevention approaches for improving health behaviors in adolescents must include
school-based prevention programs, as well as community-wide strategies that address the overall
social context of health risk behaviors.
Best Practices: Prevention of Tobacco Use
In the early 1990s and to the extent that tobacco use was linked to increases in smoking-related
illnesses, the tobacco industry made a legal agreement, following a lawsuit co-sponsored by the
states of Texas, Florida, Mississippi and Minnesota, to put an end to all marketing efforts that
primarily target cigarette use by minors. In 1998, the Attorneys General of the 46 remaining
states signed the Multistate Settlement Agreement (MSA) with the four largest tobacco
companies in the United States to settle state suits that were initiated to recover costs associated
with treating smoking-related illnesses. Conditions of the agreement included restrictions on
tobacco advertising and marketing. As youth spend up to 25% of their waking hours in school
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and are thus a captive audience for tobacco prevention programming, programming should start
with tobacco prevention education before students begin to smoke. The CDC supports school-
based tobacco prevention and control programs that include targeted, evidence-based
interventions combined with comprehensive policies and practice. CDC guidelines for school-
based tobacco prevention can be found in Box 22.4.
Prohibit tobacco use at all school facilities and events at all times.
Encourage and help students and staff to quit using tobacco.
Provide developmentally appropriate instruction in grades K–12 that addresses the social and
psychological causes of tobacco use.
Are part of a coordinated school health program through which teachers, students, families,
administrators, and community leaders deliver consistent messages about tobacco use.
Are implemented within the context of and reinforced by communitywide efforts to prevent tobacco use
and addiction.
There is sufficient evidence that school-based tobacco prevention can produce at least short-
term effects and reduce the prevalence of tobacco use among school-aged youth.
22.4 Recommendations for School-Based Tobacco Prevention Programs
1. Develop and enforce a school policy on tobacco use.
2. Provide instruction about the short- and long-term negative physiologic and social consequences of
tobacco use, social influences on tobacco use, peer norms regarding tobacco use, and refusal skills.
3. Provide tobacco-use prevention education in kindergarten through 12th grade; this instruction should
be especially intensive in junior high or middle school and should be reinforced in high school.
4. Provide program-specific training for teachers.
5. Involve parents or families in support of school-based programs to prevent tobacco use.
6. Support cessation efforts among students and all school staff who use tobacco.
7. Assess the tobacco-use prevention program at regular intervals.
Source: From Centers for Disease Control and Prevention. Tobacco use prevention in schools: Guidelines and strategies. Retrieved on September 9, 2017, from
https://www.cdc.gov/healthyschools/tobacco/strategies.htm.
Practice Point
Strategies to prevent tobacco use, including e-cigarettes, in schools should begin with
specific training of both the school personnel, who interact with the adolescents on a daily
basis, and the student peer leaders involved with the program.
Sexual Behavior and Teenage Pregnancy
On average, 70% of adolescents have a preventive health visit only every four years. Despite
recommendations for annual screening, particularly for adolescents engaging in high-risk
behavior, such as sexual activity, there are many barriers to this type of preventive healthcare in
primary care. These barriers include limited evidence that behavior counseling is effective,
limited confidence in primary care providers to provide counseling, and perceived lack of
interest by adolescents to receive counseling (Ham & Allen, 2012). This clearly represents
missed opportunities for important dialogues that may prevent detrimental outcomes of sexual
behavior, including unintended pregnancy and sexually transmitted infections. Students
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https://www.cdc.gov/healthyschools/tobacco/strategies.htm
attending school should have the opportunity to receive knowledgeable and accessible sexual
behavior education and counseling. Evidence supports the effectiveness of high-intensity school-
based education and counseling in group settings as a way to reduce rates of consequences of
high-risk sexual behavior (Manlove, Fish, & Moore, 2015; SIECUS, n.d.).
Epidemiology
Childbearing among teenagers has continued to decrease since 1991. Most recent birth rates
have been reported as 22.3 births for every 1,000 adolescent females ages 15 to 19. Most
adolescents who give birth are aged 18 to 19 years. Although also declining in number, birth
rates continue to be higher among Hispanic and black adolescents (CDC, 2016a). While reasons
for the declines are not clear, teens seem to be delaying onset of sexual activity, and more of
those who are sexually active seem to be using birth control than in previous years. Long-acting
reversible birth control can be a good option for a teenaged woman. Implants and intrauterine
devices (IUDs) are two types. These do not require her to do anything on a regular basis, such as
take a pill each day. For the past 10 years, the prevalence of adolescent pregnancy has been
declining, but the ramifications for those teenagers who do become mothers are long-lasting,
keeping adolescent pregnancy on the list of major public health problems. There is a strong
association between teenage pregnancy and child well-being. Morbidity associated with children
of teenage pregnancy includes higher rates of preterm birth and low birth weight (CDC, 2012).
Best Practices: Pregnancy Prevention
Evidence-based teen pregnancy prevention programs are those that have demonstrated, in at
least one program evaluation, a positive effect on preventing teen pregnancies, sexually
transmitted infections, or sexual risk behaviors. The Adolescent Family Life (AFL) program,
created in 1981 (Title XX of the Public Health Service Act), was the first federal program to
focus on adolescents. From 1998 to 2009, the program relied heavily on abstinence-only
education. In 2010, a new Teen Pregnancy Prevention program was funded to provide
“medically accurate and age-appropriate programs that reduce pregnancy.” The Patient
Protection and Affordable Care Act (ACA) enables states to operate a new Personal
Responsibility Education Program (PREP), which is a comprehensive approach to teen
pregnancy prevention that educates adolescents on both abstinence and contraception to prevent
pregnancy and STDs. Finally, the Title V Abstinence Education Block Grant is available to
states specifically for abstinence-only education. State Abstinence Education Grant Programs
continue to provide funds for programs offering mentoring, counseling, or adult supervision
programs to promote abstinence.
Since 2009, the U.S. Department of Health and Human Services (USDHHS) has sponsored
an independent systematic review of the teen pregnancy prevention literature to identify
programs with evidence of effectiveness in reducing teen pregnancy, sexually transmitted
infections, and associated sexual risk behaviors. The American Academy of Pediatricians, the
American Academy of Family Physicians, and the American Medical Association all endorse
sex and contraceptive counseling performed by healthcare professionals as the model to be used
to promote responsible sexual behavior and reduce teen pregnancy. The most recent YRBSS
reports that the prevalence of sexual intercourse among high school students nationwide is
41.2% of students; 30.1% of students are currently sexually active. The prevalence of having
ever had sexual intercourse was higher among males (43.2%) than females (39.2%); of these,
3.9% had had sexual intercourse for the first time before age 13. The prevalence of not having
used any method of birth control to prevent pregnancy ranged from 7.2% to 20.0% (USDHHS,
2016). In previous surveys, the reasons that female students gave for not using contraceptives
consistently included the belief that pregnancy will not affect them, the desire to become
pregnant, “cultural” beliefs, and fear.
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Despite evidence that supports SBHC and the school nurse as a pivotal access point to
contraceptive counseling, barriers continue to exist. The ACA of 2010 that provided significant
funding for SBHCs, particularly those that serve Medicaid-eligible populations, expired in 2013.
Funding for SBHCs remains an issue. Most available on-site services include abstinence
counseling (84%), pregnancy testing (81%), and counseling for birth control (70%); however,
about 60% are prohibited from dispensing contraception, thus limiting access (Ethier et al.,
2011).
Practice Point
A multidisciplinary team consisting of nurse practitioners, educators, school nurses, social
service workers, and other professionals should collaborate to meet the needs of children
and adolescents.
Student Reflection
My community health clinical experience was in a city high school in Massachusetts. During
my time there, I became acutely aware of the student issues regarding STIs, teen
pregnancy, and the lack of sexual health information. The statistics of STI rates are
frightening: one in four of American girls have had an STI, and in one year in
Massachusetts, syphilis increased by 20%, gonorrhea by 12%, and chlamydia infections by
8.3%. An annual questionnaire given in high schools around the state found that in 2015,
64% of teens have had intercourse by the time they graduate from high school, and many
more engage in a range of other sexual activities. Only 50% of the students said that their
parents had talked to them about sex!
There also were a high number of teenage pregnancies in the high school. Along with
my teacher, I became involved in presenting seminars for students who were currently
pregnant or had recently had a child. The groups were small to create an intimate
nonjudgmental or nonthreatening atmosphere. The teen mothers-to-be learned what to
expect in pregnancy and the changes that their bodies would be going through. They
learned how to stay healthy—about the right things to eat, things to avoid eating, when to
see a doctor, how to know when to go to the hospital, and seeking father and family
support. We also discussed the labor process and postpartum issues, in particular
postpartum depression and shaken baby syndrome. Then the group learned about lifestyle
changes when the baby arrives. This included feeding and sleeping patterns, along with
crying issues. We demonstrated changing a diaper and washing the baby and practiced
using dolls. At all times, the students had the opportunity to ask questions and clear up any
misconceptions or concerns. We also supplied information about STIs, contraception, and
safe sex. Pamphlets, magazines, posters, fact sheets, contact information, and other
resources were available.
I believe that a nurse has a responsibility to be proactive by encouraging clients to make
healthy decisions and live a healthy lifestyle without pressuring them. By providing students
with information, we empowered students and gave them the opportunity to make their own
informed decisions. In the evaluations completed by the students, they found the
interventions “catchy, current, and something that they could relate to.”
Sexually Transmitted Infections
Epidemiology
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Sexually transmitted infections are among the most common infectious diseases nationwide.
Young people (aged 13 to 24) account for half of the 20 million new sexually transmitted
infections in the United States. Among young people (aged 13 to 24) diagnosed with HIV in
2015, 81% were gay and bisexual males (USDHHS/CDC, 2016). Accurate measures of STIs in
this population are difficult to obtain because many affected people have few, if any, identifiable
symptoms and others delay seeking treatment. Provisions in the Affordable Care Act of 2010
extended the coverage for dependent children, allowing dependent children to remain on their
parents’ insurance plans until the child reached 26 years of age (CDC, 2017a). Additional
provisions in the Act promote clinical preventative services by requiring that insurance plans
cover key preventative services, which include some screening and testing services for STDs,
without charging a deductible or co-pay (Fox & Shaw, 2015). One aim of these provisions was
to assure access to preventative and treatment STD services for adolescents and young adults,
however the CDC (2017a) reported that 22.6% of survey respondents aged 15 to 17 and 8.2%
aged 20 to 22 who were on their parents’ private insurance would not access these services due
to questions about confidentiality and the possibility of their parents finding out about their
sexual health. Additional information can be found in Chapter 3.
Practice Point
Making HIV testing a routine part of healthcare for adolescents and adults 13 to 64 years of
age is one of the most important strategies recommended by the CDC for reducing the
spread of HIV (CDC, 2017b).
School Relevance
The school nurse’s role as a case finder is extremely important because the nurse is in a good
position to provide the necessary counseling and referral for STI treatment. However, school
health personnel should know that symptomatic adolescents who are suspected of having an STI
cannot be excluded from school. In addition, health personnel should also be aware that federal
law stipulates that adolescents can go directly to a health department–operated STI clinic for
diagnosis and treatment of their disease without parental consent. In some cases where
communication with parents does not occur, the student may choose not to seek treatment for
what could ultimately result in long-term consequences of the infection. If this is the case,
school health personnel should preserve the student’s privacy while assisting the student with
contacting the health department and arranging for necessary diagnosis and treatment. Finally,
health professionals should assist in the identification of all sexual contacts involved so they can
be warned and treated. In many cases, it may be easier to locate and speak with these students at
school (Borawski, Tufts, Trapl, Hayman,Yoder, & Lovegreen, 2015).
Practice Point
It is rare for a person to contract an STI without some form of sexual contact. Although as
many as 50% of teens are sexually active by the end of high school, not all are engaging in
heterosexual contact. Students should be aware that sexual contact may involve mouth-to-
genital contact, either homosexual or heterosexual.
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Nutrition
Epidemiology
Obesity in children and adolescents is a serious health concern. From 1999 to 2015, there was a
significant increase in the prevalence of obesity (with rates ranging from 10.6% to 13.9%).
Trends indicate that an estimated one in five children and adolescents aged 2 to 19 are obese
(Ogden et al., 2016). Children and adolescents (2 to 19 years) are considered overweight with a
BMI) between ≥85th and <95th percentile, and obese with a BMI ≥95th percentile. This is
largely a result of overeating and insufficient exercise, which lead to an energy imbalance.
Obese children and adolescents are at risk for many of the health problems currently seen in
adults. They are more likely to have conditions such as high blood pressure, high cholesterol,
and type 2 diabetes that are risk factors for cardiovascular disease (CDC, 2016b). In addition,
children and adolescents who are obese are more likely to remain obese as adults. Although in
recent years the obesity epidemic in children and adolescents appears to be stabilizing, it
remains at an unacceptably high level.
Continued obesity in children may result in an epidemic of cardiovascular disease and type 2
diabetes in the adolescent population. Cardiovascular disease is already the fifth leading cause of
preventable death among adolescents, and there has been a marked increase in insulin resistance
and type 2 diabetes. The National Health Objectives of Healthy People 2020 address
cardiovascular disease prevention in adolescents by focusing on physical inactivity and obesity.
The 2015 YRBSS report indicates that 48.6% of children in the United States engage in exercise
that results in sweating or hard breathing for the recommended 60 minutes per day, five or more
days per week and 27.1% on all seven days (CDC, 2016b). Exercise can be linked to both
physical and emotional well-being by decreasing cardiovascular risk factors, reducing feelings
of depression and anxiety, and stimulating an overall improvement in psychological health and
academic functioning.
This might be the first generation where kids are dying at a younger age than their parents
and it’s related primarily to the obesity problem. Judy Davis, Australian actress
Adolescents, both in school and out, have wide access to foods with low nutritional value
and high levels of fat and calories through vending machines, à la carte lunches, and snack bars.
Although the USDA school-based nutrition programs have played a key role in contributing to
improvement in overall health indicators in adolescents, there is no legislation banning foods
sold outside of the cafeteria. The food environment in schools often serves to reinforce poor
eating habits. Schools are the primary setting for engaging children in the establishment of
lifelong positive behaviors. However, the matter of food choices should also be addressed using
broad-based environmental and public health policy approaches.
Best Practices: Nutrition
In the Child Nutrition and WIC Reauthorization Act of 2004, the U.S. Congress established a
requirement that all school districts with a federally funded school meals program develop and
implement wellness policies that address nutrition and physical activity by the start of the 2006
to 2007 school year (Section 204). The CDC has established a self-assessment and planning tool
(School Health Index) and guidelines that can be used in school health programs in an effort to
improve the food environments of school-aged children and adolescents. These current CDC
guidelines focus on changing the social norms and environments of adolescents. In addition to
school-based prevention, the guidelines recommend policy and regulatory strategies, community
participation, establishment of public and private partnerships, strategic use of media,
development of local programs, coordination of statewide and local activities, linkage of school-
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based activities to community activities, and use of data collection and evaluation techniques,
such as the School Health Index (described previously) to monitor program impact.
Practice Point
An extension of the CDC website gives access to the School Health Index at no cost to the
school. Based on the results of the assessment, a school can strengthen existing school
health programs. For example, a school may choose to implement CDC Guidelines to
Promote Lifelong Healthy Eating, which identify strategies most likely to be effective in
promoting lifelong healthy eating among young people. Alternatively, it may choose to
implement CDC Guidelines to Promote Lifelong Physical Activity, which identify strategies
most likely to be effective in helping young people adopt and maintain a physically active
lifestyle.
Joe, who is 10 years old, is in the fifth grade in the school where Susan works. When he
was 8, he was diagnosed with ADHD. Joe also has a severe peanut allergy and must
avoid any contact with peanuts and peanut-containing products. Using yearly height and
weight screenings, Susan has found that Joe’s body mass index is in the 99th percentile,
which indicates obesity. Using the nine CDC guidelines, synthesized research, and best
practices related to promoting healthy eating and physical activity in schools, identify
Joe’s needs and plan interventions to address each of these nutritional issues
(https://www.cdc.gov/healthyschools/npao/pdf/mmwr-school-health-guidelines .).
Student Reflection
During my clinical rotation in community health, I encountered several high school students
struggling with eating disorders, a common problem in this age group. One particular case
that I found interesting involved a senior boy on the wrestling team who came to the health
office because he was not feeling well. He complained of being tired and feeling worn out;
he said that he just felt like he needed to go home and rest. After calling his mother, he
transferred the call to the nurse. The nurse explained to his mother that her son was not
feeling well and asked whether he could be dismissed. The mother stated, “I know what is
wrong with him. The wrestling coach told him to only drink water for the past two days
because of the match tomorrow. That’s why he is not feeling well.” The mother said that she
was very concerned about this practice. However, she did not want to make a big deal out
of the situation because she did not want the coach to bully her son, who loves wrestling.
She agreed to let her son come home. However, I couldn’t help but think of this boy, who
was putting wrestling ahead of eating; he was at risk for an eating disorder.
This is a disturbing situation. However, no matter how much education is provided to
students, I do not think the situation will change unless the teachers and coaches are
involved and see the necessity of promoting healthy eating.
Violence
I have a theory because I was being beaten up a lot by people outside of school; it was
almost like if I could make myself sick enough they’d take sympathy on me. Daniel Johns,
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https://www.cdc.gov/healthyschools/npao/pdf/mmwr-school-health-guidelines
Australian musician
Violence was declared a public health emergency in 1985, and since then, violence prevention
has been a national health promotion objective. However, the incidence of youth violence
remains higher in the United States than in most developed countries. The YRBSS
(USDHHS/CDC, 2016) measures a number of behaviors that contribute to violence including
carrying a weapon (e.g., gun, knife, or club) (16.2%), carrying a gun (5.3%), physical fighting
(22.6.8%), and carrying a weapon on school property (4.1%). YRBSS also measures intimate
partner violence including dating violence. Of students who reported dating, 10.6% had been
forced to do unwanted sexual things. Another type of violence among children and adolescents
is bullying; 20.1% of students had been bullied on school property, and 15.5% reported
experiencing electronic bullying, defined as bullying through e-mail, chat rooms, instant
messaging, websites, or texting. These numbers have remained relatively stable over time.
Although the news media has recently devoted much attention to the potential dangers of
technology, face-to-face verbal and physical aggression is more common than electronic
bullying. The most dramatic result of bullying is suicide; 8.6% of adolescents have attempted
suicide.
The tongue like a sharp knife…kills without drawing blood. Buddha
In response to an increased awareness to bullying—specifically defined as unwanted,
aggressive behavior among school-aged children that involves a real or perceived power
imbalance—numerous prevention and intervention programs have been implemented that have
now made children and adolescents safer in school than anywhere else. The school nurse should
be aware that students who are bullied at school are likely to feel disconnected or dislike school.
They have lower academic success and school attendance records. Box 22.5 lists elements of
successful bullying prevention efforts.
22.5 Bullying Prevention
Assess bullying.
Engage parents and youth.
Set policies and rules.
Build a safe environment.
Educate about bullying.
Source: https://www.stopbullying.gov/prevention/at-school/index.html.
The many new technologies available have positively impacted students’ education;
however, concerns have been raised by educators and parents about the potential dangers that
also exist through inappropriate use of the technologies. In an attempt to prevent unsafe and
inappropriate use of these technologies, an increasing number of school systems are developing
policies that address these concerns, specifically limiting the use of cell phones by students
while in school, and controlling access to websites on school computers (Hertz & David-Ferdon,
2008). The CDC has published a brief for educators and caregivers to address the issue of
electronic media and youth violence. Suggestions for educators, policymakers, caregivers, and
parents to address electronic bullying are summarized in Boxes 22.6 and 22.7.
Evidence for Practice
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https://www.stopbullying.gov/prevention/at-school/index.html
A recent study by Foshee and colleagues (2013), examined the negative consequences of
dating violence among adolescents. The study measured the consequences of both
physical (including hitting, slapping or being hit) and psychological victimization (hurting
feelings, saying insulting things, controlling behaviors). The researchers found that the
consequences varied by type of violence and by gender. Victims of physical violence were
more likely to smoke cigarettes, girls were more likely to use marijuana, and boys were
more likely to have close friends. Victims of psychological violence increase the probability
of alcohol use and internalizing the symptoms of this violence. The results of the study
confirm that dating violence has detrimental consequences and that identification of both
physical and psychological violence is important to implement evidence-based prevention
strategies.
22.6 Electronic Media and Youth Violence
Explore current bullying prevention policies and work collaboratively to develop new policies. States, school
districts, and boards of education must work in conjunction with attorneys to develop policies that protect the rights
of all students and also meet the needs of the state or district and those it serves. In addition, it is also helpful to
involve representatives from the student body, students, families, and community members in the development of
the policy. The policy should also be based upon evidence from research and on best practices.
Explore current programs to prevent bullying and youth violence. Many of the programs developed to prevent
face-to-face aggression address topics such as school climate and peer influences that are likely to be important for
prevention of electronic aggression.
Offer training on electronic aggression for educators and administrators. The training should include the
definition of electronic aggression, characteristics of victims and perpetrators, related school or district policies,
information about recent incidents of electronic violence in the district, and resources available to educators and
caregivers if they have concerns.
Talk to adolescents. Providing young people opportunities to discuss their concerns through, for example, creative
writing assignments is an excellent way to begin a classroom dialogue about using electronic media safely and
about the impact and consequences of inappropriate use. Technology safety could easily be integrated into the
standard health education curricula. Educators and researchers should explore with adolescents how electronic
media can be used as tools to prevent electronic aggression and other adolescent health problems.
Work with information technology (IT) personnel and support staff. Administrators must create the
infrastructure and support necessary for classroom teachers to work with IT staff to keep abreast of issues affecting
young people and develop strategies to minimize risk.
Create a positive school atmosphere. Research indicates that students who feel connected to their school, who
think their teachers care about them and are fair, and who think the school rules are clear and fair are less likely to
perpetrate any type of violence or aggression, including electronic aggression.
Have an action plan in place to address incidents. Be proactive in developing a thoughtful plan to address
problems and concerns. Having a plan in place may make young people more likely to come forward with concerns
and may support the appropriate handling of a situation when it arises. Create an atmosphere that encourages a
dialogue between educators and young people and between families and young people about their electronic
experiences.
Source: Hertz, M. F., & David-Ferdon, C. (2008). Electronic media and youth violence: A CDC issue brief for educators and caregivers. Atlanta, GA: Centers
for Disease Control and Prevention.
22.7 Cyberbullying: Suggestions for Parents and Caregivers
1. Talk to your child. Just as you would ask children where they are going and whom they are going to
be with whenever they leave the house, ask where they are going and whom they are with when they
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are on the internet. Talk with teens to come up with a solution to prevent or address victimization that
does not punish the teen.
2. Develop rules. Together with your child, develop rules about acceptable and safe behavior for all the
electronic media they use and what they should do if they become a victim of electronic aggression
or they witness or know about another teen being victimized.
3. Explore the internet. Visit the websites your child frequents. Remember that young people can learn
new information on the internet, interact with and learn about people from diverse backgrounds, and
express themselves to others who may have similar thoughts and experiences. Technology is not
going away, so forbidding young people to access electronic media may not be a good long-term
solution. Together, parents and youth can come up with ways to maximize the benefits of technology
and decrease its risks.
4. Talk with other parents and/or caregivers. Discuss strategies that are effective as well as those that
do not work.
5. Encourage your school or school district to conduct a class for caregivers about electronic
aggression. Review school or district policies on the topic, recent incidents in the community, and
resources available to caregivers who have concerns.
6. Keep current. Keep current on what new devices and features your child is using. You need to know
“where they are going” and explore these websites yourself. Ask your teenager to educate you. This
may help strengthen parent–child communication and bonding, which is important for other
adolescent health issues as well.
Source: Hertz, M. F., & David-Ferdon, C. (2008). Electronic media and youth violence: A CDC issue brief for educators and caregivers. Atlanta, GA: Centers
for Disease Control and Prevention.
Practice Point
Ineffective programs are characterized by assumptions about the cause-and-effect
relationships that result in violence in schools. For example, there is an assumption that
exposure to media violence causes violence. In fact, the problem of youth violence extends
beyond the exposure to media into the social context of youth. School health programs must
work instead to construct a culture of nonviolence.
Susan has become aware that some of the children have been making fun of Joe
because of his daily visits to the nurse’s office. Joe confides in her that children
sometimes pick on him because he takes medicine and cannot eat peanuts. Today, a
student pushed a peanut butter sandwich into his face and laughed when he got upset.
Identify specific interventions that should be taken to stop this bullying.
Student Reflection
During my clinical rotation in community health, I assisted a school nurse at an elementary
school. I worked with many emotionally distressed students in need of emotional support.
Often, they were homesick, frustrated with an assignment, or just needed time away from
the stress of the classroom. I listened to the children’s worries, offered advice on how to
cope with their sadness, and called their parents if necessary. However, everything I had
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been taught and all the experience I had could not have prepared me for a visit I received.
A teacher entered the nurse’s office, looking rather disturbed, and asked to speak to
myself and my teacher (the school nurse) in a separate room. The teacher said that a
student, very upset, had told the teacher that her father hits her and that she is too scared to
go home because he might hit her again. The teacher calmed the student down, telling her
that she would be protected. The nurse called the social worker, and everyone met to
decide the best action to take to protect this child.
First, the nurse called the Department of Children and Families (DCF) so it could file a
report. The DCF said that because its staff believed that the current situation could be one
where it was unsafe for the student to return home, a representative was going to come to
the school. The DCF requested that the nurse call the student to the office and that the child
was to be inspected for any signs of physical abuse.
It was very difficult for the teacher/nurse to have to ask the child, who trusts the nurse
and had developed a relationship with the nurse, to take off her clothes so that we could
observe for signs of abuse. During the examination, the student was tearful; however, it
appeared that she trusted us and she provided more information about the potential abuse.
She said “he hits me but I hate when I see the blood coming from there (her bottom).” This
made me very concerned, since it was unclear whether she was talking about blood from
where she got hit on the bottom, or if there was some kind of sexual abuse involved. We did
not see any signs of physical abuse.
The DCF wanted information about both her and her brother, including their friends, their
demeanor in the nurse’s office, medical record information, and the nurses’ interactions with
the parents of the children. I was not able to be very helpful, since I had not had a lot of
interactions with the children, but my teacher had a wealth of information. She was able to
look back at her electronic log and see that the boy had visited the nurse’s office on five
occasions, tearfully seeking emotional support. The nurse also said that the father was
“difficult to deal with,” and on one occasion left a message threatening to call the nurse’s
boss because the nurse was requesting records that the children had received a physical
examination.
During the next 10-day period, the DCF investigators visited the children’s home, talked
with both the children and parents, and decided not to open the case. I had a lot of different
feelings and mixed emotions during this time, and this case helped shape my philosophy
and value system regarding community and public health nursing. First, I was horrified. I
wanted the father to be locked up immediately and the children to be protected. However,
soon I realized there were DCF procedures and nursing procedures that had to be followed.
Having to check the child for hit marks really upset me. I thought that it was unfair that the
nurse had to break this child’s trust, which might affect the student’s willingness to come to
the nurse’s office in the future. However, we worked hard to make the examination as
painless as possible.
THE SCHOOL NURSE AS A CHILD ADVOCATE
Advocacy plays a central role in school health personnel’s responsibility for the overall physical
and emotional well-being of the children and adolescents they serve. Advocacy involves both
teaching children and empowering others who care for the children to ensure quality care. Key
components of the advocacy role include collaboration and policy-making. School nurses often
spend more time with specific students than any other adult during the school day
(Alexandropoulou, 2013). The advocacy role emerges from this caregiving process.
As an advocate, the school nurse needs to find a balance between empowering parents and
others external to the school to pursue healthcare for the child. The child with a chronic health
condition presents a unique challenge for nurses as advocates. The nurse must often mediate
between educators, parents, and physicians to ensure children with chronic health conditions can
function to their maximum potential. As many as 10% to 15% of children in schools are affected
with chronic conditions, such as asthma, diabetes, and seizure disorders, that require daily
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treatment (USDHHS, National Heart, Lung, and Blood Institute, 2013). The nurse as advocate
has two important roles: spreading knowledge and networking. Spreading knowledge does not
ensure health, but a person’s sense of being able to control his or her own healthcare does
promote healthy behaviors. This sense of control comes from the provision of adequate
resources. Networking is also important. Working together, the school nurse, parents, teachers,
and healthcare providers can ensure that the child with special healthcare needs has access to all
educational resources and opportunities. Knowledge of federal laws, including the Americans
with Disabilities Act (ADA), IDEA, Section 504, Family Educational Rights and Privacy Act
of 1974 (FERPA), and Food Allergy and Anaphylaxis Management Act (FAAMA) is
essential (see definitions at the beginning of the chapter). The school nurse who has identified a
pupil in the school who has special healthcare needs, working within the constructs of the
Framework for 21st Century School Nursing Practice (NASN, 2016), plays an important role by
coordinating the interests of families, education, healthcare systems, public health, insurance,
and community agencies. A meeting arranged to provide health accommodations—a 504 plan,
IEP, or other school plan—has the potential to improve the long-term outcomes for the child.
Children may represent themselves in these meetings if appropriate, but at a minimum should
have representation by the family, school health staff, special education coordinator, and any
person trained to assist the student or who has primary responsibility for the student. As an
advocate, the school health staff should (USDHHS, National Heart, Lung, and Blood Institute,
2013) do the following:
Provide education and communication necessary to ensure that the student’s health and educational needs
are met.
Implement strategies to reduce disruptions in the student’s school activities.
Communicate with families and healthcare providers as authorized.
Ensure the student receives prescribed medications and treatments and that staff who interact with the
student on a regular basis are knowledgeable about these needs.
Provide a safe and healthy school environment to promote learning.
Today, in addition to her routine activities, Susan is participating in a transition planning
meeting about Joe. He will be going to middle school next year, and his parents have
asked for a transition planning meeting. For his ADHD, he currently takes 20 mg of Ritalin
in the morning before school and 10 mg at lunch time. His severe peanut allergy requires
that an EpiPen be kept in the nurse’s office. His 504 plan, which was developed when he
was diagnosed, allows Joe to take his medication midday, provides for a peanut-free
lunch environment, and suggests that Joe’s desk be positioned in such a way that
distractions are limited.
Who should be included in the planning meeting?
What topics should be discussed? Prepare an anaphylaxis algorithm for Joe.
What are Susan’s responsibilities regarding this transition meeting?
Joe’s parents are hoping that he can stop taking his medication. Lately, Susan has had to
send a messenger to remind him to take it. She knows that Joe’s transition into middle
school will be important in the development of his self-esteem. A strong sense of self-
esteem will be a protective factor against engaging in health risk behaviors in middle
school. What recommendations can Susan make that would help resolve this situation?
Practice Point
812
With the attention and scrutiny given to personal health information in all settings, and as a
result of federal legislation, it is imperative for school nurses to revisit policies and
procedures for protecting the privacy of student and family health information.
THE FUTURE OF SCHOOL HEALTH: WHOLE
SCHOOL, WHOLE COMMUNITY, WHOLE CHILD
(WSCC) MODEL
For each of the common health problems discussed in this chapter, it should be made clear that a
single focused approach to prevention based only on education, that is, one that is approached
only by teaching, has a minimal effect. The National Association of School Nurses has endorsed
the provision of comprehensive school health services, called the Whole School, Whole
Community, Whole Child model, as one possible solution
(https://www.cdc.gov/healthyyouth/wscc/index.htm). This model serves as a blueprint for policy
and practice for the 21st century school nurse. The collaborative design uses the resources of a
community (including health educators, counseling, psychological services, nutrition, the
environment, and the family) to provide support services and to promote changes throughout the
school environment to improve the health and well-being of students. Nurses have long been
aware of the importance of practicing within context to implement and sustain change. As a
result of the groundbreaking findings from the National Longitudinal Study of Adolescent
Health, school connectedness has become a key focus point in the provision of primary
healthcare (CDC, 2009). Research has identified the importance of the link between schools and
community within a prevention framework. Community-driven programs that encourage key
stakeholders, including students, to set the agenda and create solutions are more likely to create
a supportive environment for engaging in health-promoting behaviors.
In the political sphere of the provision of quality public education, schools have been
challenged to rethink and redesign efforts to educate children. These reforms will undoubtedly
continue to challenge the school nurse. The success of any education program must be linked to
the social environment. School nurses have the expertise in assessment, education, and advocacy
necessary to play a major role in meeting the needs of children and adolescents to ensure
academic success.
KEY CONCEPTS
Since the passage of PL 94-142 in 1975, school nurses provide more complex care for conditions such as
seizure disorders, asthma, cardiac conditions, cystic fibrosis, quadriplegia, and life-threatening allergies
while facing new and emerging trends in the management of behavioral health issues.
The role that emerges within the context of this management position requires the nurse to have skills in
health assessment, health promotion, skills as a health educator, and the ability to work as a child health
advocate.
Data from the Youth Risk Behavior Surveillance Survey (YRBSS), a biannual report of the common risk
behaviors influencing the health of our nation’s youth, can be used by the school nurse as a tool for
monitoring trends both locally and nationally.
There are online clearinghouses of school-based, evidence-based programs for the prevention of common
health risk behaviors.
School nurses play a key advocacy role that includes collaboration and policy-making, often participating in
school district wellness committees.
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The future of school nursing is providing a prevention framework that links the community and the school.
CRITICAL THINKING QUESTIONS
The school nurse has a unique role in the provision of school health services for children with special
health needs, including children with chronic illnesses and disabilities with various degrees of severity.
This case describes the role of the school nurse caring for a child with type 1 diabetes.
Susan has two students with type 1 diabetes in her school, one requires blood glucose monitoring and daily
insulin injections, while the other has a continuous insulin infusion pump. The incidence of type 1 diabetes
presents a complex challenge to school healthcare providers. Type 1 diabetes ranks as the second most
common chronic illness in childhood, second only to asthma. The American Diabetes Association (ADA,
2015) reports that about 193,000 Americans under age 20 live with diabetes and 17,900 are diagnosed with
type 1 diabetes annually, and another 5,300 with type 2 diabetes. Children with diabetes are considered
disabled and as such are protected under federal laws that prohibit discrimination against children with
disabilities. Studies show that the majority of school personnel have an inadequate understanding of
effective diabetes management. It is best for the student to monitor blood glucose and respond to the results
as quickly as possible to avoid possible complications.
What are the essential elements of a diabetes medical management plan for each student with diabetes in
the school?
When the school nurse is unavailable, who is legally responsible for providing care to a child with diabetes?
What expectations should the school nurse have of the students in diabetes care?
COMMUNITY RESOURCES
Local and county public health departments
State and local police departments
Local community centers
Town parks and recreation departments
Primary care physicians
Advanced nurse practitioners
YMCA and YWCA programs
Local amusement centers
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WEB RESOURCES
Please visit thePoint for up-to-date web resources on this topic.
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https://www.sophe.org/focus-areas/school-health/
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http://online.wsj.com/article/SB10000872396390444358804578016221407143166.html
http://thepoint.lww.com/vitalsource/ebook/9781975111694
Chapter 23
Faith-Oriented
Communities and Health
Ministries in Faith
Communities
Susan K. Chase
For additional ancillary materials related to this chapter. please visit thePoint
Faith is taking the first step even when you don’t see the whole staircase.
Martin Luther King Jr.
Fear knocked at the door. Faith answered. No one was there.
Author unknown
CIRCLES
We are circles, in circles
Brushing and touching
Reaching and breaching
Our narrow confines
Giving and needing
Following, leading
Calling and heeding
Reciting our lines
—Anonymous
CHAPTER HIGHLIGHTS
Faith communities as centers for community health
Cultural and developmental features of faith community work
Integration of body, mind, and spirit in whole-person health
Health promotion in faith communities
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OBJECTIVES
Differentiate faith community nursing from community health nursing.
Describe various models of faith community nursing practice.
Explain scope and standards of faith community nursing practice.
Give examples of community assessments and interventions used by faith community nurses.
KEY TERMS
Congregation: An organized group of people who share religious beliefs, customs, or practices.
The congregation has an internal governance structure and may be independent or affiliated
to local or national denominations. It is a community within the larger community.
Congregation-based model: A faith community nurse serving a particular faith community by
virtue of a contract or job description; supports the concept of a faith community nurse who
can be paid or serve as a volunteer.
Faith community nursing: A specialty practice of nursing having registered nurses contribute to
the health and wholeness of people in the context of a faith community. The faith community
nurse is part of the ministry staff of the congregation and serves the illness needs of individual
people, families, and the entire faith community. This broader term is the preferred term, and
is used in settings in which the word “parish” may have no meaning or association, but many
original documents used “parish nursing” as the title for the role.
Institution-based model: The faith community nurse serves a health system with assignment to
particular congregational settings. In this model, the parish or faith community nurse serves as
liaison and helps plan and coordinate care, particularly at times of transition.
Parish nursing: Equivalent to faith community nursing; it was the original term describing the
practice.
Spiritual care: Care of the human spirit that may include dealing with the meaning of health,
illness or loss, relationships with God and others, and which has the goal of peace.
CASE STUDY
References to the case study are found throughout this chapter (look for the case study icon).
Readers should keep the case study in mind as they read the chapter.
Mary is the faith community nurse in a medium-sized suburban congregation. She conducted a
monthly blood pressure screening session between the two services on Sunday morning. Matilda
Swenson, a 76-year-old Swedish immigrant, who is active in the church despite the fact that she
does not drive, has Mary check her blood pressure every month. The readings and notes for the
past several months are shown below:
Medications: Advil for arthritis; no known drug allergies
Primary MD: Dexter Smith
June: 154/92 mm Hg; instructed patient to call her physician and notify him of the reading; gave pt
a copy of her readings
July: 148/88 mm Hg; asked whether pt had called her physician and she had not. Repeated
importance of contacting MD. Pt reported that she only went to rheumatologist for arthritis and
they never checked her BP. Instructed pt to reconnect with primary care MD and report BP
readings
September 2 (Labor Day weekend): 184/98 mm Hg; asked whether Mary could contact MD with pt
present. Pt agreed. Drove pt home and called on-call service for advice. Learned that primary
care physician had left the service but that the covering MD was available. Discussed with MD
whether to go to the ER, but MD tells Mary to have pt call first thing Tuesday am for an
appointment. Called a friend of pt who was a member of the congregation who agreed to drive
pt to MD Tuesday am. Reported plan to clergy to support follow-up
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September 4: Called to follow up on appointment. Learned that MD had switched pt from Advil to
Tylenol for her arthritis pain and started her on atenolol for BP management. Planned to call in
3 days to check on pain level and medication compliance
October: 134/78 mm Hg. Reviewed mild exercise and low-salt diet; reinforced following medication
plan. Pain control acceptable
Mrs. Swenson had been most bothered by her arthritis pain and had not found a new primary
care physician when her previous physician left the practice. Her hypertension was causing her no
symptoms, and arranging appointments was difficult. By assisting her in activating appropriate
care, Mary helped Mrs. Swenson control her hypertension. Medications (nonsteroidal
antiinflammatory drugs), smoking, or alcohol consumption sometimes exacerbates elevated blood
pressure. At least in part, because of Mary’s efforts, Mrs. Swenson has felt better cared for by her
new healthcare team, and her new treatment plan helps to increase her comfort and function and to
reduce her health risks.
Mary records the number of home and hospital visits that she makes and keeps track of
services used for referrals. She also keeps track of how many seniors in the congregation are able
to maintain independent living with her support. She compiles an annual report showing who had
access to health ministry in the year, including the numbers of people who belong, and who do not
belong, to the congregation. Some health-related programs are open to the community, which is
seen as an outreach for the congregation. Documenting participation by both members and
nonmembers of the congregation is important in sustaining support for faith community nursing
programs.
NURSING IN FAITH COMMUNITIES
Faith community nursing is a specialty practice of nursing that sees the faith community as a
source of health, healing, and wholeness, and that sees the entire community as the recipient of
care. Faith community or parish nurses have specialized education in spiritual care and health
promotion in working in the faith community setting. They see the faith community as the focus
and context of care, and their work has a goal of providing health promotion, health screening,
and health teaching as well as caring for individuals, families, and groups associated with the
congregation. The faith community nurse does not replace activities that a community health or
visiting nurse service would provide. There are no direct care activities such as dressing changes
or injections regularly performed. The faith community nurse considers the needs of
congregation members and makes referrals and advocates for quality care for congregation
members. Additionally, the faith community provides a context that promotes the values,
beliefs, and cultural practices of a community to support and enhance the experience of health as
well as faith. In addition to providing health promotion activities, the faith community nurse
provides guidance to members of the faith community as they act out their faith and provide care
to other members of the community. In this way, the faith community nurse supports the
ministry of the faith community itself. Nursing in faith communities combines the worlds of
ministry and community nursing. The faith community nurse meets the needs of a particular
community—the faith community. This chapter will focus on the activities of faith community
nurses as providers and supporters of health in the particular community organized around a
faith stance.
Faith consists in believing when it is beyond the power of reason to believe. Voltaire
For community nurses, health is not the mere absence of disease. The faith community nurse
“focuses on the intentional care of the spirit, as well as on the promotion of holistic health, and
prevention or minimization of illness within the context of a faith community” (American
Nurses Association [ANA], 2012, p. 5). Faith community nurses also establish programs that
819
support health promotion for individual people and groups in the congregation.
Practice Point
When a faith community member is diagnosed with a new chronic illness such as diabetes,
consider the mental and spiritual issues that might be raised as the entire family deals with
the new diagnosis. Assess the family for signs of stress and help them work through what the
diagnosis means to them spiritually.
HISTORY OF FAITH COMMUNITY NURSING
Faith community nursing is a fairly recent concept; however, in ancient times, families and
religious communities served as a primary source of health and illness care. Religious groups
and monasteries established the first hospitals that were designed to provide “hospitality.”
Religious orders of both men and women delivered healthcare to the poor as they acted out their
faith. For the individual person, the faith tradition provides the basis for many health beliefs and
practices. Understanding a person’s religious and spiritual background is important in
establishing healthcare priorities. Linking to the history of the congregation provides access to
resources such as denominational materials.
Diseases of the soul are more dangerous and more numerous than those of the body.
Cicero
Granger Westberg, a Lutheran minister and hospital chaplain, began “parish nursing” in the
1980s. He had been involved in grant-funded holistic health programming, hospital chaplaincy,
and community outreach by the healthcare system. Pastor Westberg consistently used the term
“wholistic” to emphasize the wholeness of person which faith community nursing exemplifies.
He made the observation that all churches had a number of nurses as members and that these
nurses formed an informal network of advice and support because congregation members looked
to them as sources of advice and information.
The Lutheran General Hospital established an interfaith outreach program where nurses from
several Chicago area congregations were paid in part by their congregations and in part by a
grant to provide services in their congregations and to come together for regular training and
support. This holistic care model was linked to the hospital through the chaplaincy program. The
hospital saw the parish nursing program as a kind of outreach to the community. The role was
new, so no organized curriculum existed. As part of a grant-funded program, the nurses met
regularly and asked for help on issues that arose during their care, such as health counseling,
grief and loss, health promotion, spiritual care, and leading prayer. The parish nurses were
already competent nurses, but they needed additional training in community health concepts and
principles. In addition, they needed more knowledge and skill in spiritual care because this was
part of their role. Over the years, the congregations assumed more responsibility for the financial
support of the nurses, who eventually received full support from the congregation.
MODELS OF FAITH COMMUNITY PRACTICE
Currently, faith community nurses work either on a volunteer basis or in paid positions. Some
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work in an individual congregation, and others are based in a healthcare system which has links
to several congregations. In any case, the principles of parish or faith community nursing apply.
Table 23.1 shows the variety of faith community nurse models (Solari-Twadell & McDermott,
1999).
In a paid congregation-based model, the nurse is hired by the faith community to provide
faith community nursing services. There is a job description, a clear list of resources or advisors,
and a plan for evaluation. The advantage of this model is that the congregation clearly commits
to supporting the program, and the nurse is a named member of the congregational staff.
Potential problems can exist if the congregation staff members do not understand the role of the
nurse. The role of the faith community nurse is different from that of (1) a chaplain who
conducts hospital and home visits, in that the faith community nurse can help interpret and
advocate for healthcare services, or (2) a visiting nurse service, in that the faith community nurse
knows the members of the congregation over time and sees them in states of illness and health
and in that the faith community nurse is not employed to do specific technical skills requiring
medical orders that congregation members might need. Overall, the strength of this model is that
the faith community nurse is committed for a set number of hours to develop the faith-based
nursing program for the entire faith community.
TABLE 23.1 Models of Faith Community Nursing Practice
Paid Unpaid
Based in congregation Paid and based in congregation Volunteer and based in congregation
Based in health system Paid and affiliated with health system Volunteer and affiliated with health
system
The parish pays Mary to work 20 hours a week for the parish, and she has an office on
the church property. She can conduct individual assessments and teaching in this space
or use larger meeting rooms for educational programs.
In an unpaid congregation-based model, a faith community nurse volunteers his or her
services in a congregational setting. Even though unpaid, this faith community nurse provides
the same standard of care in the services as those provided by a paid nurse. Just as with the paid
model, the congregation should have an advisory committee, with a job description and an
evaluation method, so that the program can develop. The faith community nurse might need to
ask for these things or develop them for the congregation. Even unpaid faith community nurses
require a budget for supplies, resources, and continuing education. One disadvantage to having
an unpaid faith community nurse is that this person may not be recognized as a member of the
ministry team, and will probably have fewer hours to offer in service. One advantage is that the
faith community nurse can limit how much time he or she offers, and can maintain other
employment. This allows nurses who work in clinical or educational settings to offer their
services to the congregation as both a professional volunteer activity and as a lay ministry. It
also allows a congregation that cannot financially support a faith community nursing program to
receive some of its benefits.
Often, new programs are started using an unpaid, congregation-based model. After the
benefit of the program is demonstrated, a paid model can be supported. Both paid and unpaid
congregation-based models share a disadvantage. The nurse usually operates independently,
with little assistance from other nurses, and there is little support for developing new approaches
to care. Faith community nurses often form informal networks to offer such encouragement to
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independent faith community nurses and attend regional and national conferences for faith
community nurses to learn and share ideas.
Practice Point
In an unpaid congregation-based model, the faith community nurse must be creative in
securing resources to support the program. Obtaining small-grant funding can help, and
making a case for an item in the parish budget can help obtain blood pressure equipment,
including large-sized cuffs, health reference books, and teaching handouts for specific
conditions.
In a paid institution-based model, a faith community nurse is employed by a health system,
hospital, or community agency. The benefit to the agency is that the faith community nurse can
serve as an ambassador and referral agent for the institution. For example, a religiously affiliated
hospital can support the services of faith community nurses in key feeder congregations, so that
clients discharged from the hospital have coordinated transition to the home congregation
setting. Discharge coordination or “transitional care” can result in smoother transitions for
patients and can reduce costs for the hospital system. The faith community nurse does not
provide direct nursing care services, but supports the patient and family members in assuming
self-care and in engaging the healthcare system appropriately. One advantage of this model is
that the faith community nurse is connected to other healthcare providers for clinical and
personal support. Reports and accountability for practice lie with the healthcare system. The
faith community nurse who works within this model may not be considered by members of the
congregation to be “one of their own” as much as with the congregation-based community
model.
In an unpaid institution-based model, which is the least often used, some hospitals or care
systems may support their nursing staff by allowing time off, sometimes with pay, as these
nurses volunteer their time in congregation settings. This can be an advantage for the nurse who
wants to have time to offer services to his or her own congregation, but also wants to maintain
primary identification with a healthcare institution. This can be an advantage for the institution,
since community nursing activities are consistent with its mission and it receives referrals, and
patients discharged from the institution benefit from coordinated transitional care. Evidence
indicates that there is need for follow-up care for older persons with diabetes. Transition care
provided by a faith community nurse might have reduced the hospital readmission rates. Further
research is needed to test such models.
Evidence for Practice
A research study followed 96 patients who were over the age of 65 after discharge from at
least a 48-hour stay in a community hospital and who were diabetic but for whom diabetes
was not the reason for the admission. Patients were in good glucose control when entering
the hospital. Phone calls were made at 1 week and 1 month following discharge to assess
transitional care issues. Both quantitative and qualitative data were collected. Multimorbidity
was found in 75% of patients, most commonly from coronary artery disease, diabetic
neuropathy, and chronic kidney disease. Diabetes-related complications were evident in
46% of respondents. Unplanned care events occurred for 41% of participants, most
requiring unplanned provider visit and 21% requiring hospital readmission. “Results of this
study suggest that home recovery transition of an older person with diabetes is dynamic,
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and transition outcomes are influenced by multiple persona and community transition
conditions” (LaManna, Bushy, Norris, & Chase, 2016, p. 81).
Whatever the practice setting or the organizational structure of the faith community nurse,
having a theoretic model for driving practice can help to organize both activities and reports. A
model is useful when explaining a new practice to audiences such as congregation councils and
members themselves. One model was developed by conducting a grounded theory analysis of
case reports of faith community nurse network in a southern U.S. state. The analysis revealed a
multistep model of practice: “(1) entering the private world, (2) connecting to faith, (3) mutually
transforming experience, and (4) sustaining health” (Dyess & Chase, 2012, p. 224). Nurses
reported that, at times, a task such as taking a blood pressure established a relationship of caring,
and doing this simple task opened the door to deeper conversations. The encounter almost
always had a faith component which included reflection or prayer. The experience transformed
both patient and nurse in sharing their human experience in a faith context, and finally, health
was supported through comfort as well as active intervention.
THE UNIQUENESS OF FAITH COMMUNITIES
Regardless of the model chosen, the prospective faith community nurse must consider certain
factors when setting up a faith community nursing program. A congregation is a group of
people with its own structure, and the faith community nurse must work within this structure.
Where the program will fit into the congregation in organizational terms is one of the first things
to consider. Even if the faith community nurse is in a paid model, most of the congregation
members that the nurse will be working with are volunteers. Assumptions about communication
or accountability that work in healthcare agencies will not necessarily apply in this setting. The
faith community nurse must discover whether there is already a committee or commission which
focuses on health concerns. Perhaps there is a social ministry group or an outreach group in the
congregation. Understanding the structure of the congregation as a whole is important to support
coordination with ongoing ministry activities in the congregation. Otherwise, long-time
volunteers or leaders might be offended. This is part of the assessment process that will be
discussed in more detail later in this chapter.
The pastor, rabbi, or other congregational leader can be a great source of information about
structure. If no suitable group exists, the faith community nurse needs to assemble an advisory
board (King, 2011). The advisory board offers leadership, establishes policy, and helps develop
guidelines. Having the support of an advisory board is essential for solving problems and
avoiding pitfalls. Membership of the board can vary but might include the pastor, a spiritual
director, designated health professionals, and interested lay people. The advisory board can help
develop support for a budget for the program. When new members join the advisory board, they
will need orientation about the faith community nursing program. By providing new members of
the board with articles about faith community nursing, past annual reports of the congregation,
and written job descriptions and evaluation forms, the faith community nurse assists the new
member in becoming an active participant in the program. Meetings can take place as often as
once a month. Meeting less than six times a year means that members will not have as much
participation as they might like, and support for the faith community nurse might be diminished.
Relationship With the Clergy
Supportive relationships with the spiritual head of the congregation are important for the success
of a faith community nursing program. Unless the pastor has worked with a faith community
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nurse before, repeated explanations will most likely be necessary. One common misconception
is that the faith community nurse is a private visiting nurse for the congregation. Faith
community nurses do not provide direct hands-on nursing care. Rather, they provide confidential
professional nursing that includes assessment, teaching, referral, and counseling. An important
resource on activities that faith community nurses offer can be found in the ANA’s Faith
Community Nursing: Scope and Standards of Practice (2012) which can be shared with clergy
or others for guidance. If a member of the congregation is in need of visiting nurse services, the
faith community nurse provides an appropriate referral.
Evidence for Practice
One interview study explored the experiences of chronically ill seniors who were members
of an established faith community nurse’s practice in a large suburban congregation.
Despite the fact that individuals had from two to nine different diseases and were taking two
to 19 different medications, the seniors reported that their lives were connected to others,
and that they felt they were living well. They were connected to the goodness of God in their
lives, and most were caregivers for others, which gave their lives meaning (Dyess & Chase,
2010).
In another study, researchers developed a survey that explored clergy members’
commitment to health-related programming, and their experience with “congregational
health ministers,” a term used to include faith community nurses and other health
professionals such as social workers, therapists, or pharmacists who were working in the
congregational setting. Nearly 350 pastors from 80 different denominations returned the
survey. The pastors fell into five main categories: mainline Protestant, conservative
Protestant, African American Protestant, Roman Catholic, and other (Catanzaro, Meador,
Koenig, Kuchibhatla, & Clipp, 2006). The groups with the most experience with
congregational health ministers were mainline Protestant and Catholic, and congregations
that were large, suburban, and financially well off. Pastors with congregational health
ministries in place in their settings reported more frequent health promotion programming in
their setting. The most common reported reason for starting a health program in the church
was that a nurse who was a member proposed it (Catanzaro et al., 2006). This study shows
that individual nurses can influence health programming in their own faith communities.
In the case study, the morning that Mary detects the highest blood pressure reading, she
communicates her concern about Mrs. Swenson’s health issue to the pastor, Mr. Dryden.
She wants him to be fully informed about his parishioner. Being new in her position, Mary
wants him to develop trust in how the program is operating. This way, if Mrs. Swenson
needed to be admitted to hospital, he would not be surprised. He would also be able to
set up a clergy visit.
Faith Community as Community
Faith community nursing is focused on the entire community of faith, not just on individual
people who happen to be members of the community. This is consistent with most models of
community healthcare. To assess the health of the faith community, principles of epidemiology,
which were discussed earlier in this book, can be applied. The faith community group may be
smaller than some other aggregate groups, but the same principles are appropriate. Although
epidemiology began with tracing the patterns of infectious disease in the community at large,
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within the faith community, goals such as reducing disease risk factors, reducing the burden of
chronic illness, and promoting health become more prominent than infectious disease.
Nevertheless, principles of epidemiology can be used as a method to determine patterns of
illness for the faith community, and risk factor assessment helps the nurse decide what programs
to provide.
One of the major tools of epidemiology is statistics. Florence Nightingale was an early user
of statistics to gather support for the changes she wanted to make in the British healthcare
system. Similarly, faith community nurses can use statistics in two ways. First, the nurse should
gather general demographic data about the faith community, including age, family structure, and
proximity of residence to a healthcare facility and other health resources. These data can be
summarized with descriptive statistics that can be used to generate reports and to assist planning.
Second, the nurse should use data about various diseases from comparison groups, such as
public health prevalence data. Is swine flu (H1N1) or methicillin-resistant Staphylococcus
aureus infection becoming more prevalent in the area? County health departments publish data
on certain reportable diseases which can be useful in planning screening or educational
programs. It helps to compare the rate of cardiac events or strokes in a faith community which
has wellness programs with rates for the same conditions in the region or nation. Using these
data, the faith community nurse can demonstrate both the need for programming and the
effectiveness of the programs conducted. See Community Resources for further information.
Evidence for Practice
A research review of faith community health promotion for African Americans pointed out
that using practice sites away from traditional healthcare systems can increase access to
effective diabetes health education programs. Fourteen studies were reviewed. Overall,
these studies showed the effectiveness of using culturally appropriate messages with the
faith community as the recruitment source and the place for delivering the material. The
studies used a collaborative approach in designing and carrying out their activities. Patient
outcomes included increased vegetable usage, weight loss, and lowered HbA1c levels
(Newlin, Dyess, Allard, Chase, & Melkus, 2011).
Practice Point
Developing a needs-and-skills inventory is a good way to determine what kinds of programs
a congregation might value. Do people want information regarding specific high-impact
conditions such as diabetes or heart disease risk, or do they care more about learning how to
support the functioning of their aging parents? Sometimes, people are reluctant to admit to
having weaknesses, but they want to help the health ministry. For example, a homebound
person could have the “job” of writing cards to people who are in the hospital or who are
having birthdays.
Another way to consider a congregation’s social patterns is to explore the various ways
members relate to one another, both individually and in groups. Faith communities often
develop around ethnic groups. Roman Catholic parishes might be predominantly Irish, Italian,
Polish, or Hispanic. Lutheran congregations might be German, Swedish, Finnish, or
Norwegian. Congregations in areas with high immigration rates will likely be oriented around
specific groups. Jewish congregations share ethnic as well as religious commonalities. Are
gatherings planned around major life events such as weddings, funerals, baptisms, or other
entry rituals? (Are regular feast or holy days important to the group?) Understanding ethnic
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roots can help the parish nurse understand preferences and traditions that might affect health
issues (Breisch, Hurley, & Moore, 2013). In all cases, the faith community nurse needs to be
careful to avoid stereotyping, and to assess each individual person’s perspective. However,
celebrating ethnic background is a wonderful way to build community and make all people
feel welcome.
The secret of health for both mind and body is not to mourn for the past, nor to worry
about the future, but to live the present moment wisely and earnestly. Buddha
Faith community nurses engage in primary, secondary, and tertiary prevention activities in
their congregations. Primary prevention activities include programs on walking or other forms of
exercise to maintain health, smoking cessation programs, and heart-healthy eating programs.
Secondary prevention includes screening for hypertension or hyperglycemia, and setting up
screenings such as mammogram vans or other tests to diagnose problems early. Tertiary
prevention is another important focus where faith community nurses work to minimize the effect
of health problems and maximize function for people with conditions such as diabetes, stroke, or
injury.
Faith communities are also part of a larger geographic or public community. Federal support
for faith initiatives has increased in recent years. The congregation can be a site for health-
related programming for entire communities. For some people in these communities, this may be
the only health resource. One such program in central Texas organized a coalition that included
state health departments, healthcare organizations, faith communities, county and city health
departments, and local colleges and universities (Patillo, Chesley, Castles, & Sutter, 2002).
Working together over 3 years, the coalition offered workshops to more than 1,000 nurses and
prepared 54 nurses with the full parish nurse educational programs. The work of this coalition
allowed the number of active congregational programs to increase from five to 53, established
web links to state health department resources, and offered services to Hispanic migrant families
without health insurance. Students from local colleges and universities gained experience in
conducting events such as health fairs.
ROLES OF THE FAITH COMMUNITY NURSE
Faith community nurses perform several roles which are similar to nurses’ roles in many
settings, but which often have a different emphasis. For example, as many community health
nurses do, faith community nurses maintain lists of community and healthcare referrals. On the
other hand, the faith community nurse’s role as patient advocate may be unique because the faith
community nurse has an ongoing relationship with the congregation member, may know family
members, and can directly follow up on recommendations and additional referrals. Faith
community nurses do health teaching in a variety of settings. These may include group settings
for topical areas such as general health promotion, end-of-life planning, or healthy lifestyle
activities. Faith community nurses may also do individual teaching for congregation members
with specific health conditions. The ministry to the congregation as a whole often leads the faith
community nurse to organize and support volunteer groups, such as home visitors, drivers to
appointments, or volunteers to provide meals to families who have members just home from the
hospital. Faith community nurses can also lead or convene groups with specialty leaders such as
bereavement or family caregiver groups. Perhaps more importantly, faith community nurses
provide spiritual care based in the belief structures of the congregation. This may include
assisting the congregation member to discern God’s presence in a difficult time or to use
spiritual resources as a support. The roles and activities of faith community nurses are varied.
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One of the functions of the health cabinet or other congregational group is to assist the faith
community nurse in planning and evaluating activities.
Mary has several roles as a faith community nurse. Her primary responsibility is to
empower Mrs. Swenson to make healthcare choices that promote better long-term health.
Describe four roles that Mary assumes as a faith community nurse.
Evidence for Practice
One study reported on the activities and roles of parish nurses. A statewide survey was
completed by 72 parish nurses, most of whom were volunteers who worked less than 10
hours a week. The largest denominations represented were Catholic (25) and Methodist
(23) (King & Tessaro, 2009). Activities reported by the parish nurses were blood pressure
screening (70%), physical health counseling (45%), health education relating to exercise
(31%), and nutrition (29%). The nurses also provided counseling on spiritual health (28%)
and bereavement (21%), and they offered support to clients engaged in weight control
(25%) and stress reduction (25%). The range of services and support provided by parish
nurses in this study reflects a balance of body, mind, and spiritual concerns. In the parish
setting, nurses can truly provide holistic care.
An additional survey of nurses in a large Catholic healthcare system (McGinnis & Zoske,
2008, p. 179) revealed that parish nurses, in addition to health promotion, “provide chronic
disease management that is often lacking in our current healthcare systems.” These
activities included case management, advocacy, collaborating with other health
professionals, and assisting clients in adapting to functional limitations.
HEALTHY PEOPLE 2020 PRIORITIES
Where do faith community nurses obtain guidance for planning, programming, and prioritizing
their activities? Some of the best sources are national guidelines to support health such as
Healthy People 2020 (U.S. Department of Health and Human Services, n.d.). Healthy People
2020 is the program sponsored by the federal government to help set health goals for the United
States as a whole. The Healthy People 2020 framework can guide faith community nurse
programming. Introducing the model to the congregation starting with the health cabinet or
advisory group can support program development. Leading health indicators are listed in Box
23.1.
Most of these health indicators are issues that can be addressed in congregation-wide health
promotion programs. The midcourse report indicates that outcomes are actually worsening for
mental and oral health, with little or no improvement in diabetes outcomes. Physical activity for
all age groups in the congregation can be supported through hiking clubs, senior exercise
programs, or by sponsoring an aerobics group in one of the church rooms. Denominationally
related weight management programs are available which a church could sponsor. Smoking
cessation materials can be prominently displayed. Alcohol and substance abuse problems can be
addressed individually, or by having the church be the site of a 12-step program. Parental groups
can develop and support the teaching of healthy sexuality. In any congregation, the parish nurse
must be alert to signs of domestic violence which can include child abuse or neglect, elder abuse
or neglect, or partner violence. Individual referrals and support can be important. Mental health
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is often a hidden health problem. Knowledge of risk, and insight into high-risk situations, can
assist the faith community nurse in appropriate assessment and response, specifically for
referrals. To ensure that each member of the congregation obtains appropriate care, the nurse
can counsel members individually about access to care, or offer resources in a reading area or
library at the faith community.
23.1 Healthy People 2020 Leading Health Indicators
Physical activity
Overweight and obesity
Tobacco use
Substance abuse
Responsible sexual behavior
Mental health
Injury and violence
Environmental quality
Immunization
Access to healthcare
Source: Office of Disease Prevention and Health Promotion, United States Department of Health and Human Services. Retrieved from
http://www.healthypeople.gov.
Practice Point
Periodically review the Healthy People 2020 or other such initiatives and reflect on what
health programming suggested by these groups would benefit the congregation. Would
adding a senior exercise group both help maintain socialization and improve function? Would
a youth group focused on safety reduce the risk of traumatic injury or death for the younger
members of the congregation?
Student Reflection
In community health, we try to think of ways of reaching people with health programs before
they get sick and need acute care. When I was placed with a faith community for my
experience, I realized that this is real community care. This is where people come together
regularly, and there is always a chance for a health program, either with new mothers or
with senior citizens. At my site, we sponsored a new mothers group, and used the church
nursery for child care for the toddlers, so that the mothers could focus on the classes on
nutrition. They shared a lot of wisdom with each other, too.
SCOPE AND STANDARDS OF PRACTICE
Faith community nurses function by virtue of their license to practice nursing. The vast majority
of nurses in the United States are employees of hospitals, long-term care facilities, or home care
agencies. In contrast, the faith community nurse functions more independently. The resources of
the nursing profession as a whole, including the ANA’s Faith Community Nursing: Scope and
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http://www.healthypeople.gov
Standards of Practice (2012) are important guides to the faith community nurse. In terms of
well-developed policies or procedures, the faith community nurse may not have the same level
of structure as the nurse who works in a complex healthcare system. The ANA Standards of
Care for Faith Community Nursing Practice are organized around the steps of the nursing
process (Table 23.2).
How do faith community nurses actually spend their time? Using focus groups, researchers
have conducted studies of parish nurses themselves. This method brings together people who
have shared an experience to discuss and share their impressions of that experience with a
researcher. The researcher then analyzes the discussion and presents the findings. One study
involved 17 faith community nurses from a hospital-sponsored program of volunteer nurses.
These nurses discussed the attributes of the care that they delivered in their parish settings.
Investigators used a focus group and telephone interviews (Chase-Ziolek & Iris, 2002). The faith
community nurses reported that their most important contributions to their congregation were
health promotion and prevention of disease, advocacy, health education, health counseling,
psychosocial support, and spiritual care. They stated that the congregational setting provided a
personal relationship which extended over time, and which integrated faith and health in a way
that was rewarding to them and their patients. The nurses also reported that having the time to
meet such a wide range of needs, and contend with differences in beliefs, even in the
congregational setting, presented a challenge.
TABLE 23.2 Standards of Care for Parish Nursing Practice
Standard Sample Criteria
Assessment Collects comprehensive, appropriate data
Collaborates with others in selecting and collecting data
Data may include the following:
Demographics, including living arrangements
Health and illness incidence
Functional status
Spiritual issues
Psychological issues
Social issues in the community
Community services and resources
Assessment is an ongoing process
Assessment data are used to form diagnoses
Diagnosis Identifies actual and high-risk diagnoses and potential areas for growth, with
attention to strengths
Makes holistic diagnoses that include body–mind–spirit issues
Uses accepted standardized nomenclature in documentation
Diagnoses are recorded and communicated to support health and healing
Outcome identification Expected outcomes are determined for each diagnosis, preferably with the
client’s participation
Outcomes are measurable
Outcomes are adapted to the particularities of the client, including cultural
aspects and are achievable
Planning Plans for health promotion are developed at every opportunity
Plans specify activities and who should perform them
Plans include evidence-based approaches
Particular strengths and weaknesses of each client/family/group are considered
Plans include a consideration of the client’s values/beliefs/customs
Plans include follow-up activities
Implementation Interventions are mutually developed with the people involved
Interventions are within the legal, professional, and contractual scope of
practice
Activities include the use of appropriate technology
Interventions are recorded in standardized language to provide for continuity of
care
Evaluation Evaluation includes care of individuals, families, and groups using outcome
criteria
Evaluation of the major programs of the parish nurse is ongoing
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Revisions of plans and programs are based on evaluation data
Source: Adapted from American Nurses Association. (2012). Faith community nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: American
Nurses Association.
To determine the perceptions of members of the congregation about parish nursing,
researchers conducted an ethnographic study of faith community nursing in two congregations,
one predominantly African American and one predominantly white (Tuck & Wallace, 2000;
Wallace, Tuck, Boland, & Witucki, 2002). Ethnographic studies consider the language and
culture of a particular group of people. This study showed that congregants were grateful for the
easy access to health information that the faith community nurse provided. They also reported
that the parish nurse was able to combine health and spirituality issues, and helped people more
actively promote their own health. Specifically, many congregants described a successful, faith
community approach to weight loss.
THE NURSING PROCESS IN FAITH COMMUNITY
NURSING
In all interactions, the faith community nurse should keep in mind that the nursing process is the
basis of the caring relationship (ANA, 2012). Individual assessments may include blood
pressure, gait stability, home assessment for safety, assessing for distress related to grieving for
the recently widowed, and assessment of knowledge regarding self-management of medical
diagnoses and chronic illness. Family assessments might include stress assessment for the family
with a new baby, support of the wife who is transporting her husband for chemotherapy, or
strategizing with parents of teenagers whose behavior has been troubling. Community
assessments can include assessing whether healthcare is accessible to members of the
congregation, and determining whether a recent industry closing will create personal or financial
stress for members of the congregation.
Assessment and Diagnosis
Epidemiologic principles are useful in planning faith community nurse programming. When
assessing the health of a faith community, the community as a whole is the target of concern.
Several key questions need to be addressed:
What are the common health problems experienced by members of this community? The faith
community nurse visits members in the hospital, and in counseling individual members, he or she begins
to see patterns that affect the congregation as a whole.
What are the chief demographic groups in the congregation? A large number of elderly people means that
health programs need to be planned with an understanding of major health problems of the elderly, and
should include support for maximizing functional status. A large number of young families means that
programs need to include parenting support. Young mothers groups can provide socialization and
encouragement to an important segment of the congregation. An active youth group means that health
programs can be woven into activities in which the youth group participates.
What are the health assets of the faith community? Churches and synagogues have a rich group of
volunteers who can assist their communities by providing meals after hospitalization, transportation to
physician visits or treatments, hospital visits by specially trained visitors, and support groups for a variety
of conditions. Assessing for strength is the key focus of community health assessment.
What environmental health concerns exist in the congregation? The congregation is rooted in a local
community. Members include people who have lived in the community for generations, as well as
newcomers. By being active in the particular community, members become active in environmental
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health concerns. For example, the first meeting to address an observation of a cluster of cases of
childhood leukemia was in a church in the community. A successful book and movie, A Civil Action
(Harr, 1995), tells how a toxic waste dump endangered the health of a Massachusetts community. The
book shows how members of the community came together in a faith community setting to begin to
address their concerns about the safety of their local environment.
The purpose of an assessment is to provide baseline data and support reporting and planning.
A health assessment can be thought of as a needs assessment for developing congregational
programming. Faith community nursing is often misunderstood because concepts of community
health are frequently not understood by the general public, who see healthcare as physician-
dominated and disease-focused. Fortunately, the importance of self-care and active participation
in maintaining a person’s own health has become widely accepted today. Faith community
assessment can lead to important health programming in a rich community setting. North
American Nursing Diagnosis Association-International (NANDA-I) regularly updates the list
and organization of nursing diagnoses (NANDA-I, 2017). Many of these are applicable to the
community as a whole. Domains of nursing diagnoses include health promotion, nutrition,
activity/rest, role-relationships, coping/stress tolerance, and life principles. Diagnoses under the
domain of life principles include decisional conflict, readiness for enhanced spiritual well-being,
and spiritual distress. These domains are clearly aligned with the practice of faith community
nurses.
TABLE 23.3 Nursing Diagnoses Appropriate to the Faith Community Setting
Individual Family Community
Ineffective health maintenance Impaired home maintenance Lack of health-seeking behaviors
Impaired swallowing Risk for imbalanced nutrition:
more than body requirements
Imbalanced nutrition: more than body
requirements
Impaired physical mobility Risk for activity intolerance Deficient diversional activity
Impaired memory Deficient knowledge: asthma
management
Deficient knowledge: resources for
Alzheimer’s caregivers
Chronic low self-esteem Caregiver role strain Powerlessness
Death anxiety Chronic sorrow Diminished readiness for enhanced
community coping
Risk-prone health behavior Compromised family coping Ineffective protection
Risk for loneliness Decisional conflict Risk of other-directed violence
Source: Adapted from North American Nursing Diagnosis Association-International. (2012). Nursing diagnoses: Definitions and classification 2012–2014 (H.
Herdman, ed.). Philadelphia, PA: Author.
Mary maintains records of blood pressure trends and current medications for all church
members who come for blood pressure screening. This assists her in detecting patterns
of concern. What other assessment data would Mary gather that would be helpful,
particularly for the senior citizens in the congregation? A monthly senior luncheon held at
the church hall allows for socializing among the senior members of the congregation as
well as those in the surrounding community. A program is associated with the luncheon,
and every year Mary presents a talk about a health-related topic related to her activities.
Suggest three possible topics for Mary to consider for her presentation.
Practice Point
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Ask a faith community nurse to share his or her best practices. Find out what documentation
system the local health department uses. Does this nurse use a similar type? Perhaps if all
nurses used a common format, they could combine reports and better evaluate the health of
the community.
Diagnoses for faith community nurses should include nursing diagnoses as identified by
organizations such as the NANDA (Herdman & Kamitsuru, 2017), the Omaha System
(Martin, 2005), or some other recognizable nomenclature system. Diagnoses can be made
for individual people, families, or the entire faith community. Table 23.3 lists diagnoses that
would be appropriate for each of these three levels.
Mary identifies that Mrs. Swenson has several diagnoses that need intervention. Based
on what you know about Mrs. Swenson from this case study, name three of these nursing
diagnoses.
Interventions and Outcomes
Outcomes may seem to be the end point in the nursing process, but before choosing
interventions, it is necessary to determine which outcomes are desirable and achievable
(Bulechek, Butcher, & Dochterman, 2008). This choice must include preferences of the client,
family, and community and must include consideration of people’s values and beliefs and
resources as well as best available evidence for what actions are likely to have positive benefits
for the patient. Nurses should individualize outcomes for diagnoses based on these factors. For
example, for the diagnosis of ineffective therapeutic regimen management, the outcome for one
person might involve independent management of diabetic testing and medication management.
The outcome for another person might involve following the advice of a visiting nurse and
taking medications as prescribed. Outcomes for the community as a whole might include
acceptance of health status, caregiver emotional health, pain level control, decision-making, or
self-care (Moorhead, Johnson, Maas, & Swanson, 2008). When nurses have determined
outcomes, they can select interventions that support attainment of those specific outcomes.
Planning in the context of the faith community includes care of individual people, as well as
care of the entire faith community. For example, the faith community nurse might assess the
health risk factors of members of the community as high risk for cardiovascular illness and plan
programs for heart health, including (1) nutrition programs using the church kitchen to plan and
prepare healthy, tasty food; (2) hypertension screening; and (3) an exercise program in the
church basement.
Faith and prayer are the vitamins of the soul; man cannot live in health without them.
Mahalia Jackson
Evidence for Practice
Ann Solari-Twadell, one of the key leaders in parish nursing, has conducted research on the
interventions that active faith community nurses most often use. This study used a detailed
survey based on the current version of the Nursing Intervention Classification (NIC) (Solari-
Twadell, 2002; Solari-Twadell & Hackbarth, 2010), including interventions from the
behavioral domain such as coping assistance, patient education, communication
enhancement, and cognitive therapy. Physiologic interventions reported by nurses included
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activity management and nutrition education. One intervention not included in the NIC which
faith community nurses reported as essential was “prayer.” Prayer was listed as an activity
in the NIC under the intervention labeled spiritual growth facilitation. One intervention listed
under community was program development. This groundbreaking research is the most
extensive report to date of the specific interventions that faith community nurses actually
use, and it can be the basis for documentation systems, as well as for faith community
nurse educational program development.
Weis, Schank, Coenen, and Matheus (2002) conducted a research study to examine the
most frequent diagnoses and interventions reported by faith community nurses when
working with groups of parishioners. They collected data from 22 faith communities over a
5-month period. The groups represented a variety of ages and included both men and
women. In addition to quantitative data recorded by the faith community nurses, 10
participated in a focus group interview about what it is like working with groups of
congregation members and whether documentation labels fit. The majority of group
activities (56%) were for disease prevention, such as smoking cessation. Of group
sessions, 18% were for illness management concerns, such as asthma or arthritis.
Although this study did not use as extensive a data collection instrument as the Solari-
Twadell study, it showed that the nursing diagnoses selected for the group activities include
health-seeking behavior, potential for spiritual well-being, knowledge deficit, anxiety, social
isolation, and altered family processes. The interventions selected included active listening,
health screening, support system enhancement, and presence. Other interventions for the
groups included spiritual and emotional support. The nurses in the focus groups validated
that these labels were a good description of their activities with congregation groups (Weis
et al., 2002).
Community-Level Interventions
Of particular concern in community health is the disparity that some groups experience in
gaining access to appropriate care. Faith community settings can be a unique and powerful
approach to filling gaps in care. Recent immigrants and people without English language skill
are particularly vulnerable to health risks. One faith community nursing intervention project
focused on 100 Mexican American women with gestational diabetes (Mendelson, McNeese-
Smith, Koniak-Griffin, Nyamathi, & Lu, 2008). Participants in the study completed the Health
Promoting Lifestyle Profile (HPLP-II), which was used to measure the effect of a randomized
trial of a parish nurse intervention program. This program consisted of a 9-hour educational
program regarding nutrition, with a spiritual message related to health and wholeness consistent
with the belief system of the participant. Participants not selected for the intervention received
the usual care. Outcomes were scores of the HPLP-II 3 weeks after the session, maternal glucose
(hemoglobin A1C [Hgb A1C]) on admission for delivery, and birth weight of the infant to detect
macrosomia, a common result of gestational diabetes. The study showed that scores on the
HPLP-II for the parish nurse intervention group were significantly higher in stress management,
health responsibility, physical activity, and spirituality. The study did not show differences in
Hgb A1C or macrosomia. The sample size may have been too low to show an effect, and the
intervention may need to be designed for more of a nurse “dose,” that is, more engagement to
show lasting effect.
Implementation requires carrying out interventions in ways that are well supported by
nursing textbooks, clinical evidence, or national guidelines. Interventions classified by the NIC
(Bulechek et al., 2008) or the Omaha System (Topaz, Golfenshtein, & Bowles, 2014) can target
individual people, families, and communities. The internet provides access to guidelines for
screening and managing many health concerns.
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Student Reflection
At first, when I began assisting a faith community nurse, I was uncomfortable talking with
patients about faith issues because I did not feel prepared by my college courses in how to
do this. Once I realized that I did not have to have all the answers about religious issues, I
relaxed about listening to how people’s faith gave their lives meaning. I finally got up the
courage to ask whether the patient wanted to share a prayer at the end of a visit, and I
found she was praying for me, too. That was a beautiful moment, and it did not matter what
denomination we belonged to, which was different. I now feel comfortable including spiritual
care in my interventions with patients.
Community-Level Outcomes and Documentation of Practice
Nurses need to evaluate outcomes for individual people, families, and communities. Did
individuals, families, and groups meet the outcomes that were set for them? Did they maximize
their rehabilitation following surgery? Did families successfully bond with their new babies?
Did the shut-ins in the congregation feel the warmth of the holiday season through visits, calls,
or cards? Documentation systems which report health status of clients or communities before
and after faith community nursing interventions are able to show the difference nursing makes in
this setting.
Faith community nurses have begun to document the outcomes of their practice, including
its effect on costs of care (Brown, 2006; Miller & Carson, 2010; Rydholm, 2006; Rydholm et
al., 2008). Rydholm reports on the work of faith community nurses in supporting community
resources, and as informal caregivers who provide many of the services needed by elders and
those with chronic illnesses. By gathering the stories of parish nurses, this researcher has
documented “an interruption of downward-spiraling illnesses through rapid access to care”
(Rydholm, 2006, p. 10). Some of the issues addressed were unsteadiness in movement, syncope,
medication confusion, hypertensive crises, and shortness of breath. By coordinating care at an
early stage, faith community nurses reduced more expensive hospitalizations. Brown (2006)
reviewed parish nurse documentation and showed that healthcare costs were reduced by parish
nurses who reduced emergency department visits through advocacy and referral.
Rydholm and colleagues (2008) reported a study of 1,061 notes by 75 faith community
nurses who worked in Minnesota which were made during the care of 713 older adults.
Researchers uncovered the needs of elders which were met by the faith community nurses,
including end-of-life care, access and referral, guidance, providing adaptive equipment, and
offering calm and motivating support. These elements are consistent with the case study at the
beginning of the chapter. Without access to a faith community nurse, elders and people with
chronic illness may develop serious complications, lose their ability to live independently, or
enter the healthcare system through the emergency department, which is unnecessarily
expensive.
Evidence for Practice
In addition to health promotion, parish nurses provide for the sick and dying. O’Brien (2006)
conducted a qualitative research study of parish nursing for elders near the end of life.
Using a theory of spiritual well-being in illness that she had developed, she observed a
parish nurse care for 15 elders at the end of life. The nurse used the Spiritual Well-Being
Interview Guide and continued to visit the elders, two to four times over 8 months. The
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elders exhibited five identifiable nursing diagnoses: spiritual alienation, spiritual anxiety,
spiritual anger, spiritual loss, and spiritual peace. Interventions offered included sharing
prayer and scripture, spiritual presence, and pastoral counseling. By dealing with the
meaning of their health and illness, the parish nurse was able to assist some of the elders
who were in distress in achieving some peace in their lives.
It is important to document faith community nursing, which allows people to see how this
new specialty is actually practiced. One study (Burkhart & Androwich, 2004) reported that
an existing documentation system, the NIC, was used to code free-form charts from 170
health records from 13 parish nurses at seven sites, including urban, suburban, and rural
settings. The investigators conducted this research to determine whether the system could
capture the actions of parish nurses in 1,607 separate interactions. Experts coded notes
separately and checked their accuracy by comparing their coding choices. Overall, 93% of
interactions fit existing categories, with 117 different interventions identified. The study
made several recommendations for new or modified interventions to fit the community
practice of parish nursing.
In the Burkhart and Androwich (2004) study, the most frequently used interventions were
surveillance, spiritual support, admission care, medication management, emotional support,
referral, and vital sign monitoring. The interventions in NIC are organized into domains. The
most frequently used domains were safety, behavioral, and health system activities. The
NIC labels describing spiritual care worked well in this setting. The new interventions that
were proposed included scheduling appointments, communication with patient, case
closure, community transport, supply management (community), and dying care
(community). Faith community nursing extends such care to the community, so
recommendations were made to adjust the interventions as published by the research
group which developed the NIC classification. This research showed that one published and
accessible system was able to capture most of the faith community nurse activities recorded
in parish nurse notes.
In a state of the science paper, Dyess, Chase, and Newlin (2010) reported that four
main areas of evidence exist related to faith community nursing (1) the development of new
faith community nursing practices, (2) actions and roles that were reported by faith
community nurses, (3) the evaluation and documentation of faith community nursing
practices, and (4) perceptions of faith community nursing by congregation members. The
authors point out that further research is needed in the area of demonstrating the outcomes
of faith community practices.
ETHICAL CONSIDERATIONS
All the ethical principles that guide nursing practice in general apply to nursing in faith
communities. On the surface, it might seem that ethics would not be a problem where practice is
independent, and where the community might be expected to share common values because of a
common faith. In most cases, this is true. The parish nurse works to empower members of the
congregation to take charge of their health. This can enhance their autonomy. The faith
community nurse is also guided by beneficence, the act of doing good. This is an even more
stringent requirement than nonmaleficence: the need to do no harm.
However, ethics do play a role in faith community nursing. One area where parish nurses can
commit an ethical breach comes up often in the family context of a congregation. This area is
the need to protect confidentiality. One member of the congregation might ask how another
member, who is in the hospital, is doing. Because of the professional code requiring
confidentiality, the parish nurse has more restrictions that the average person might have on
what can be shared in everyday conversations in the congregation. The parish nurse is bound by
professional confidentiality not to reveal information about the health of patients, even if they
are known to members of the congregation. Refusing to share information in a way that does not
seem cold is a delicate art. One way to avoid this conflict is to explain to congregants early in
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the program, and often thereafter, that confidentiality for each member will be maintained.
Often, the nurse can simply say, “I am sure that she would appreciate a call or a card;” this
relieves pressure to share much information. In annual reviews, and in meetings with the
advisory committee, issues of confidentiality or other general ethical issues can be discussed,
and annual reports use group or aggregate data only, so they are unlikely to betray a confidence.
Whoever seeks to set one religion against another seeks to destroy all religion. Franklin
D. Roosevelt
EDUCATION FOR FAITH COMMUNITY NURSING
Continuing education programs are often used to educate faith community nurses for their role.
The Westberg Institute, formerly the International Parish Nurse Resource Center and renamed to
honor the founder of faith community nurse, Lutheran Pastor Granger Westberg, has developed
a curriculum which can be delivered in a continuing education format, or through a more formal
academic program for college credit. The curriculum for all participants is developed at the
baccalaureate nurse level, even though many faith community nurses have diploma or associate
degree preparation. Others may have master’s degrees in community health, theology, or in
advanced practice roles, such as nurse practitioner or clinical nurse specialist. The second
edition of Faith Community Nursing: Scope and Standards of Practice (ANA, 2012) includes
guides for advanced practice nurses as well as registered nurses. The scope of practice and
breadth of faith community programs is in part determined by the educational preparation of the
faith community nurse. A study designed to compare activities of faith community nurses who
had, and had not, completed the endorsed education program from the Westberg Institute
(Mosack, Medvene, & Wescott, 2006) found that for 265 nurses in a statewide network, those
who had completed a particular educational program (53%) worked more hours per month and
were more likely to provide health screening, health education, and referrals, especially referrals
to those services which were nonmedical sources, such as social services and mental health
services. The Westberg Institute is now a part of the Church Health Center based in Memphis,
TN (https://westberginstitute.org/give//). Among the roles of the Church Health Center are
developing the curriculum for the preparation of faith community nurses, and identifying the
seven specific functions that parish nurses perform in faith community work. These functions
are derived from activities that all nurses may engage in, but some of these activities differ in
faith community nursing (Table 23.4). Additionally, the Health Ministries Association offers a
membership organization for nurses and others in health ministry, as well as training programs
for prospective faith community nurses (https://hmassoc.org/).
Certification for Faith Community Nursing is now available through the America Nurses
Credentialing Association (ANCC). It uses a portfolio process which is well-described on the
AACN Website (http://www.nursecredentialing.org/FaithCommunityNursing).
In response to the need for community health experiences and in conjunction with faith
community and other community initiatives, student nurses in academic programs can have
clinical practice experiences in faith community settings (King, 2011). Students are not actually
asked to function fully as faith community nurses. The role of the parish nurse includes spiritual
care consistent with the faith and values of the congregation, which may be beyond appropriate
expectations for the student, but many of the health screening and promotion activities can be
performed by students with supervision.
TABLE 23.4 Functions of the Faith Community Nurse
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Function Examples
Integrator of faith and health Spiritual care
Spiritual assessment
Sharing scripture
Therapeutic listening
Personal health counselor Therapeutic communication
Assessing for emotional distress
Assessing for suicide risk
Health educator Individual health teaching
Group health teaching
Provider of health resources
Health advocate Empowerment of members of the congregation
Empowerment of the congregation to improve the health of the
community
Referral agent Maintaining lists of local providers/agencies
Communicating with referrals
Coordinator of volunteers Assessing for needs for volunteer services
Recruiting and training volunteers
Scheduling and supporting volunteers
Commissioning and recognizing volunteers
Accessing and developing support groups Referring congregation members to existing support groups
Developing support groups for congregation members
KEY CONCEPTS
Faith community nursing provides health promotion, health screening, and health teaching as well as care
for individual people and groups associated with the congregation.
A variety of faith community nursing models exist. In the congregation-based model, the nurse is hired by
the faith community to provide faith community nursing services.
The steps of the nursing process are applied to the faith community.
Values, cultural practices, and faith are a part of health.
The body, mind, and spirit of community members are the primary focus of nursing in faith communities.
CRITICAL THINKING QUESTIONS
1. The congregation is happy to hear that a nurse wishes to establish a faith community nursing ministry in
their setting. They are concerned about liability and require that the nurse not “write anything down”
because they believe that any written documentation would provide the basis for legal suits. How should
the parish nurse respond?
2. What sources of information are best for planning educational programs for parishioners? How does the
parish nurse select materials?
3. An 86-year-old male parishioner is on hospice care at home, and his daughter, a nurse, has been trying to
meet all his physical needs around the clock. The pastor, who had made a home visit, calls the faith
community nurse to express his concern that the daughter is becoming “burned out.” How can the faith
community nurse engage the faith community as a whole to provide volunteer support to this family?
4. The faith community nurse decides to increase health awareness by holding a health fair. What types of
exhibitors would be good to include? Would the health fair be any different when held in the
congregational setting than in another community setting? In what ways?
COMMUNITY RESOURCES
Start with the Westberg Institute (https://westberginstitute.org/), formerly the International Parish Nurse
Resource Center. They have directories of active programs.
In your area, contact church offices to determine whether the individual congregations have health-related
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programs.
Visit the website for the Health Ministry Association (https://hmassoc.org/). They have general health
information and access to a membership organization. If your college has a chaplain or ministry center, ask
the staff there whether they know of programs in your area.
Hospitals, particularly those with religious affiliations, may have an active faith community link.
Check out Community Commons (https://www.communitycommons.org/). It offers maps and surveys that
can be searched by zip codes to determine health concerns and resources available in specific
communities. Individual accounts can be opened and searches and reports saved for future use.
REFERENCES
American Nurses Association. (2012). Faith community nursing: Scope and standards of practice (2nd
ed.). Silver Spring, MD: Author.
Breisch, A. J., Hurley, P. S., & Moore, L. (2013). Faith community nursing: Innovative practice in faith-
based settings. Tar Heel Nurse, 75(3), 12, 16.
Brown, A. (2006). Documenting the value of faith community nursing: 2. Faith nursing online. Creative
Nursing, 12(2), 13.
Bulechek, G. A., Butcher, H., & Dochterman, J. M. (Eds). (2008). Nursing interventions classification
(NIC) (5th ed.). St. Louis, MO: Elsevier.
Burkhart, L., & Androwich, I. (2004). Measuring the domain completeness of the nursing interventions
classification in parish nurse documentation. Computers, Informatics, Nursing, 22(2), 72–82.
Catanzaro, A. M., Meador, K. G., Koenig, H. G., Kurchibhatla, M., & Clipp, E. C. (2006). Congregational
health ministries: A national study of pastors’ views. Public Health Nursing, 24(1), 6–17.
Chase-Ziolek, M., & Iris, M. (2002). Nurses’ perspectives on the distinctive aspects of providing nursing
care in a congregational setting. Journal of Community Health Nursing, 19(3), 173–186.
Dyess, S. M., & Chase, S. K. (2010). Caring for adults living with a chronic illness through communities of
faith. International Journal for Human Caring, 14(4), 38–44.
Dyess, S. M., & Chase, S. K. (2012). Sustaining health in faith community nursing practice: Emerging
processes that support the development of a middle-range theory. Holistic Nursing Practice, 26(4), 221–
227.
Dyess, S. M., Chase, S. K., & Newlin, K. (2010). State of research for faith community nursing 2009.
Journal of Religion and Health, 49(2), 188–199.
Harr, J. (1995). A civil action. New York: Random House.
Herdman, T. H., & Kamitsuru, S. (Eds.). (2017). NANDA International, Inc. Nursing Diagnoses:
Definitions and Classification 2018–2020, Eleventh Edition © 2017 NANDA International, ISBN 978-1-
62623-929-6. Oxford, Wiley Blackwell.
King, M. A. (2011). Parish nursing: Holistic care in faith communities. Holistic Nursing Practice, 25(6),
309–315.
King, M. A., & Tessaro, I. (2009). Parish nursing: Promoting healthy lifestyles in the church. Journal of
Christian Nursing, 26(1), 22–24.
LaManna, J. B., Bushy, A., Norris, A. E., Chase, S. K. (2016). Early and intermediate hospital-to-home
transition outcomes of older adults diagnosed with diabetes. The Diabetes Educator, 42(1), 72–86.
Martin, K. (2005). The Omaha System: A Key to Practice, Documentation, and Information Management
(Reprinted 2nd ed). Omaha, NE: Health Connections Press. ISBN no. 978-0-9825727-1-9.
McGinnis, S. L., & Zoske, F. M. (2008). The emerging role of faith community nurses in prevention and
management of chronic disease. Policy, Politics & Nursing, 9(3), 173–180.
Mendelson, S. G., McNeese-Smith, D., Koniak-Griffin, D., Nyamathi, A., & Lu, M. C. (2008). A
community-based parish nurse intervention program for Mexican American women with gestational
diabetes. Journal of Obstetric, Gynecologic and Neonatal Nursing, 37, 415–425.
Miller, S., & Carson, S. (2010). A documentation approach for faith community nursing. Creative Nursing,
16(3), 122–131.
Moorhead, S., Johnson, M., Maas, M. L., & Swanson, E. (Eds.). (2008). Nursing outcomes classification
(NOC) (4th ed.). St. Louis, MO: Elsevier.
Mosack, V., Medvene, L. J., & Wescott, J. (2006). Differences between parish nurses and parish nurse
associates: Results of a statewide survey of an ecumenical network. Public Health Nursing, 23(4), 347–
353.
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https://hmassoc.org/
https://www.communitycommons.org/
Newlin, K., Dyess, S. M., Allard, E., Chase, S., & Melkus, G. (2011). A methodological review of faith-
based health promotion literature: Advancing the science to expand delivery of diabetes education to
Black Americans. Journal of Religion and Health, 51(4), 1075–1097.
O’Brien, M. E. (2006). Parish nursing: Meeting spiritual needs of elders near the end of life. Journal of
Christian Nursing, 23(1), 28–33.
Patillo, M. M., Chesley, D., Castles, P., & Sutter, R. (2002). Faith community nursing: Parish
nursing/health ministry collaboration model in central Texas. Family & Community Health, 25(3), 41–
51.
Rydholm, L. (2006). Documenting the value of faith community nursing: 1. Saving hundreds, making
cents: A study of current realities. Creative Nursing, 12(2), 10–12.
Rydholm, L., Moone, R., Thornquist, L., Alexander, W., Gustafson, V., & Speece B. (2008). Care of
community-dwelling older adults by Faith Community Nurses. Journal of Gerontological Nursing,
34(4), 18–29.
Solari-Twadell, P. A. (2002). The differentiation of the ministry of parish nursing practice within
congregations (Unpublished dissertation). Loyola University of Chicago.
Solari-Twadell, P. A., & Hackbarth, D. P. (2010). Evidence for a new paradigm of the ministry of parish
nursing practice using the nursing intervention classification system. Nursing Outlook, 58, 69–75.
Solari-Twadell, P. A., & McDermott, M. (Eds). (1999). Parish nursing: Promoting whole person health
within faith communities. Thousand Oaks, CA: Sage Publishing.
Topaz, M., Golfenshtein, N., & Bowles, K.H. (2014). The Omaha system: A systematic review of the
recent literature. Journal of the American Informatics Association, 21(1), 163–170.
Tuck, I., & Wallace, D. C. (2000). Exploring parish nursing from an ethnographic perspective. Journal of
Transcultural Nursing, 11(4), 290–299.
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from http://www.healthypeople.gov/
Wallace, D. C., Tuck, I., Boland, C. S., & Witucki, J. M. (2002). Client perceptions of parish nursing.
Public Health Nursing, 19(2), 128–135.
Weis, D. M., Schank, M. J., Coenen, A., & Matheus, R. (2002). Parish nurse practice with client
aggregates. Journal of Community Health Nursing, 19(2), 105–113.
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Chapter 24
Palliative and End-of-Life
Care
Patricia Tabloski
For additional ancillary materials related to this chapter. please visit thePoint
DYING
The sun kept setting, setting still;
No hue of afternoon
Upon the village I perceived,—
From house to house ‘t was noon.
The dusk kept dropping, dropping still;
No dew upon the grass,
But only on my forehead stopped,
And wandered in my face.
My feet kept drowsing, drowsing still
My fingers were awake;
Yet why so little sound myself
Unto my seeming make?
How well I knew the light before!
I could not see it now.
‘T is dying, I am doing; but
I’m not afraid to know.
—Emily Dickinson
CHAPTER HIGHLIGHTS
Social trends in aging and dying
Palliative and hospice care for persons across the lifespan
Caring for a person at the end of life
Strategies for managing pain and common symptoms
OBJECTIVES
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Describe the role of the community health nurse in providing quality end-of-life care for seriously ill
persons and their families.
Recognize changes in demographics, economics, and service delivery that require improved nursing
interventions at the end of life.
Identify the diverse settings for end-of-life care and the role of the nurse in each setting.
Describe how pain and presence of troublesome symptoms affect the dying person.
Explore pharmacologic and alternative methods of treating pain.
Identify the signs of approaching death.
Describe appropriate nursing interventions when caring for the dying.
Describe postmortem care.
Discuss family support during the grief and bereavement period.
KEY TERMS
Adjuvant drugs: Medications used along with analgesics to increase the effectiveness of the
drugs to treat pain and associated symptoms.
Advance directives: Documents signed by a person indicating his or her choice or wishes for
medical treatment or naming of another to make choices if the person is unable to do so.
Bereavement: A period of time or state of mind where feelings of loss, grief, or mourning are
experienced by the survivor after the death of a loved one.
Breakthrough pain: Pain that is experienced despite the fact that a person is receiving
scheduled pain relief medication.
Comfort measures only (CMO): A plan of care that specifies nursing interventions designed not
to treat disease but to improve pain, function, or quality of life.
Grief: Feelings of despair, sadness, and remorse in response to the loss of a loved one.
Healthcare proxy: A person designated to make healthcare decisions for another in the event
that he or she is unable to make such decisions because of illness or disability.
Hospice care: Care of persons and families who have 6 months or less to live in what they
consider their home.
Mourning: The outward social expressions of loss often dictated by cultural norms, customs,
rituals, and tradition.
Palliative care: Interdisciplinary team-based care for persons and family members experiencing
life-threatening illness or injury that addresses their physical, emotional, social, and spiritual
needs.
Postmortem care: Care provided by nurses to the body after death.
CASE STUDY
References to the case study are found throughout this chapter (look for the case study icon).
Readers should keep the case study in mind as they read the chapter.
Louise Clark is an 86-year-old woman who has just been discharged from a long-term care facility
to her home. She spent 3 weeks at the facility after a 6-day acute care hospitalization for
pneumonia and weight loss. Mrs. Clark, whose husband died 10 years ago, now lives alone with
the help of her daughter, Mary, who lives nearby. Mary helps with cooking, shopping, and cleaning
but is feeling overwhelmed; she is concerned that her mother may need more day-to-day
assistance but does not want to consider permanent nursing home placement at this time.
Mrs. Clark has been diagnosed with several chronic conditions common to older persons,
including macular degeneration, heart failure, and atrial fibrillation. The drugs and all the care
related to these conditions were prescribed by primary care and emergency department physicians
from whom she has received care over the last several years.
It is apparent to Mrs. Clark’s family that she is failing and seems to be on a downhill trajectory,
841
but her physician continues to state that “she is doing just fine for a woman her age.” Mrs. Clark
has named her daughter Mary as her healthcare proxy but has never given her specific information
about the kind of care she would like as she gets older, other than to say she does not want to
suffer needless pain and medical intervention near the end of her life as her husband did the year
before he died.
Mrs. Clark received home care visits to assess and monitor her cardiovascular status. Her
functional status has varied and at times she has been unable to leave her home without much
effort. A home care nurse came to visit her for 2 months and then referred her to the local elder
care services to acquire homemaker and home health aide assistance with bathing, meals, and
light housekeeping. Mrs. Clark has had two emergency department visits and three admissions to
the acute care hospital in the last year. These visits were related to falls, exacerbation of heart
failure, and pneumonia. After each hospitalization, Mrs. Clark improved but never returned to her
prehospitalization function.
Mary is concerned that it is now less safe for her mom to live at home alone despite the help of
her family and professional services and feels that more services are required to ensure her mom’s
safety. She was told that in order to qualify for more services she would need to become Medicaid
eligible by “spending down” to $2,000 in order to receive the additional care she needed. Mrs. Clark
is hesitant to spend down as she wanted to leave a small inheritance to her daughter.
NURSING AND PERSONS WITH CHRONIC DISEASE
Something began me
And it had no beginning
Something will end me
And it has no end. Carl Sandburg
The number of adults of all ages in the United States with chronic progressive illness is growing
dramatically. Approximately one half of adults (about 117 million people) have one or more
chronic health conditions. Additionally, one in four adults have two or more chronic conditions,
many of which are considered disabling (Ward, Schiller, & Goodman, 2014). Greater numbers
of vulnerable adults and children with multiple chronic conditions are residing in the
community, resulting in such problems as strained caregiver systems, shortages of homecare
workers and supportive services, increasing numbers of frail older adults with limited decision-
making capacity, and dwindling financial resources (Ringer, Hazzan, Agarwal, Mutsaers, &
Papaioannou, 2017). Community- and home-based end-of-life palliative care and hospice
services are necessary because of an increase in the aging population, an increase in the number
of people who wish to receive advanced care and die in their own homes, and a decrease in the
number of family caregivers available for care (Ringer, et al., 2017). Strained family caregivers
are documented to be at increased risk of depression, financial strain, and diminished quality of
life.
In its publication Dying in America: Improving Quality and Honoring Individual
Preferences Near the End of Life (2015), the Institute of Medicine (IOM) summarized key issues
facing seriously ill and dying persons receiving care at the end of life. The report warned of the
dangers associated with current end-of-life care including increasing medicalization of natural
death, depersonalization of the dying, and rising costs and patient burden resulting from overly
aggressive and/or futile care. Many medical centers currently provide palliative care services to
their seriously ill patients but community-based palliative care programs are often not part of the
integrated health system and a gap in care exists for many persons after discharge to the
community. This is especially true if the person does not meet hospice admission criteria. To
qualify for hospice care, the person must be expected to live for 6 months or less and agree to
forgo aggressive disease treatment. However, palliative care is applicable early in the course of
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illness and can be delivered in conjunction with other therapies that are intended to prolong life,
such as chemotherapy or radiation therapy, and includes testing needed to better understand and
manage distressing clinical complications (World Health Organization [WHO], 2017). Key
concepts of both hospice and palliative care include compassionate care delivered by a highly
functional expert interprofessional team, holistic focus, emphasis on pain management and
symptom control, and focus on improvement of quality of life.
In 2015, 94% of hospice patients were 65 years of age or older and more than 47% were 85
years of age or older. The median length of care in hospice was 23 days. Pediatric patients
(younger than 24 years of age) and younger adults (25 to 64 years of age) accounted for
approximately 5% of hospice admissions (National Hospice and Palliative Care Organization
[NHPCO], 2016). Cancer was the most common principle diagnosis accounting for more than
27% of the persons receiving care. It is thought that younger adults and children with life-
threatening or life-limiting conditions are often not referred for hospice care for a variety of
reasons, including patient, family, and caregiver’s fear of acknowledging the seriousness of the
underlying condition, lack of knowledge regarding the services and benefits offered by a
pediatric hospice, scarcity of hospices offering pediatric services, and lack of reimbursement by
many insurance companies (Center to Advance Palliative Care [CAPC], 2017). However, with
the passage of the Patient Protection and Affordable Care Act of 2010, hospice care for children
was expanded and children who are enrolled in the Medicaid or Children’s Health Insurance
Program (CHIP) hospice benefit may continue to receive care for their terminal condition. This
change in pediatric hospice eligibility signaled a potential increase in demand for pediatric
hospice services, however currently only 28% of hospices provide community-based services to
children and the average number of pediatric patients cared for ranged from 0 to 10 patients per
year (NHPCO, 2015). See Table 24.1 for core components of pediatric palliative and hospice
care.
Because of nursing’s holistic focus, nurses in all settings, including community health
nurses, are uniquely qualified to provide comprehensive, effective, compassionate, and cost-
effective care to persons at the end of life. The Hospice and Palliative Nurses Association
(HPNA, 2015) has issued a position statement declaring that professional nursing care is critical
to achieving goals of care at the end of life, and that support of hospice and palliative care
research and education is necessary to ensure delivery of such care.
Among the members of the healthcare team, nurses spend the most time and have the most
frequent and continuous contact with patients and families at the end of life (American Nurses
Association [ANA], 2016; HPNA, 2015). Patients of all ages and their families look to their
nurse to educate, support, and guide them throughout serious illness and, if need be, the dying
process. This intimate position allows the nurse to advocate for improved quality of life for the
person with serious illness. According to HPNA (2015), “when faced with serious illness,
people turn to professional nurses for education, support, and guidance” (p. 2). Informed
understanding of the person’s values, wishes, and goals allows the nurse to attend to each
person’s physical, emotional, psychosocial, and spiritual needs.
TABLE 24.1 Core Components of Pediatric Palliative and Hospice Care
Patient- and family-centered care
Respecting and partnering with patients and families
Pursuing care that is high quality, readily accessible, and equitable
Providing care across the age span and life span, integrated into the continuum of care
Ensuring that all clinicians can provide basic palliative care and consult specialists in a timely manner
Improving care through research and quality improvement efforts
Source: American Academy of Pediatrics, 2013.
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Evidence for Practice
A systematic literature review surveying the unmet needs of persons receiving palliative
care and their caregivers who received home-based palliative care services was conducted
to identify ways care can be improved. The most frequently reported unmet need was
effective communication with and between healthcare professionals. The researchers found
that lack of communication negatively impacted the psychosocial care received by seriously
ill persons and their caregivers. Physical care needs were met, indicating that the palliative
home care services were delivering satisfactory care in this domain, but could improve
communication to prevent or reduce suffering in areas such as psychosocial domains
(Ventura, Burney, Brooker, Fletcher, & Ricciardelli, 2013). Quality of life issues that are
crucial to address include self-esteem, adaptation to illness, social functioning,
relationships, and spirituality.
Failure to acknowledge the presence and nature of distress experienced by seriously ill
persons and their families may result in fragmentation of care, anxiety, and discomfort.
Aggressive treatment of one condition may exacerbate the optimal functioning of other health
problems. Through specialized end-of-life education with emphasis on therapeutic
communication and pain and symptom management, the community health nurse can foster
comfort and dignity for seriously ill persons, as well as for those with life-threatening illness;
clarify goals of care; decrease unnecessary hospitalization; and prevent the administration of
futile, aggressive end-of-life care.
Seriously ill persons and their families look to nurses to educate, support, and guide them
throughout the illness trajectory. This intimate position allows nurses to advocate for improved
quality of life for people with serious illness. According to HPNA (2015), “achieving quality of
life, especially at the end of life, is contingent upon competent, ‘state of the art’ professional
nursing care.” Informed understanding of the individual’s values, wishes, and goals allows
nurses to attend to the physical, emotional, psychosocial, and spiritual needs of each person.
Let us live so that when we come to die even the undertaker will be sorry. Mark Twain
Student Reflection
I was assigned to visit Mrs. Clark during my community health rotation with my preceptor,
Julie, an experienced home care nurse. At first I was frightened. I thought such a frail older
person should be in the hospital, where she could be safe and nurses could look after her
24 hours a day. Julie explained to me that caring for older persons at the end of their lives is
complicated; nurses can provide physical care and manage pain and symptoms in the home
while attending to the psychological, social, and spiritual needs of the older adult and the
family. Hospice and palliative care services can offer a number of benefits to frail persons
living at home, including access to a multidisciplinary team skilled in the management of
pain and symptoms that often accompany advanced disease. After Julie discussed the
possibility of a hospice referral with Mrs. Clark and her daughter, everyone (including me)
felt a lot better.
Hospice and palliative care nurses acknowledge and accept death as a natural process and
realize that they can be instrumental in helping people achieve the kind of death they desire.
Obtaining the services needed to promote safety can help alleviate the fears of professional and
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lay caregivers, and persons residing in their homes in need of skilled nursing services will
benefit from appropriate referrals and visiting nurse services. In addition, chronically ill persons
may benefit from friendly visitor programs, home-delivered meals, community-based van or
transportation services, and homemaker services. A person receiving hospice care has access to
additional services. Typically, hospice provides for home health aide five times a week for
people with Medicare or who have private insurance with a hospice benefit in place. In 1982, the
Medicare Hospice Benefit was enacted and authorized care in the person’s home, and in 2015
Medicare spending per person receiving benefits was $11,510 (NHPCO, 2016). In 2015, close to
25% of Medicare hospice spending was for persons with the principle diagnosis of dementia.
Close to 45% of deaths of persons in hospice care occurred in the home, 32% in nursing
facilities, 15% in inpatient hospices, and 8% in acute care hospitals. The Centers for Medicare &
Medicaid Services’ definition of hospice is presented in Box 24.1. Seriously ill persons can
access Medicare hospice benefits if they meet all of the conditions listed in Box 24.2.
Generally, hospice care includes services that are reasonable and necessary for the comfort
and management of a terminal illness. According to the NHPCO (2017), the 10 components of
quality in hospice care include the following:
Patient- and-Family-Centered Care
Providing care and services that are responsive to the needs and exceed the expectations of those served.
Ethical Behavior and Consumer Rights
Upholding high standards of ethical conduct and advocating for the rights of patients and their family
caregivers.
Clinical Excellence and Safety
Ensuring clinical excellence and promoting safety through standards of practice.
Inclusion and Access
Promoting inclusiveness in the community by ensuring that all people—regardless of race, ethnicity,
color, religion, gender, disability, sexual orientation, age, or other characteristics—have access to
programs and services.
Organizational Excellence
Building a culture of quality and accountability within our organization that values collaboration and
communication and ensures ethical business practices.
Workforce Excellence
Fostering a collaborative, interdisciplinary environment that promotes inclusion, individual
accountability, and workforce excellence through professional development, training, and support to all
staff and volunteers.
Standards
Adopting the NHPCO Standards of Practice for Hospice Programs and/or the National Consensus
Project’s Clinical Practice Guidelines for Quality Palliative Care as the foundation for an organization.
Compliance With Laws and Regulations
Ensuring compliance with all applicable laws, regulations, and professional standards of practice, and
implementing systems and processes that prevent fraud and abuse.
Stewardship and Accountability
Developing a qualified and diverse governance structure and senior leadership who share the
responsibilities of fiscal and managerial oversight.
Performance Measurement
Collecting, analyzing, and actively using performance measurement data to foster quality assessment and
performance improvement in all areas of care and services (NHPCO, 2017).
24.1 Definition of Hospice
Hospice provides comfort and support services to people who are terminally ill. It helps them live out the time they
845
have remaining to the fullest extent possible.
Hospice care is provided by a specially trained team that cares for the “whole person,” including his or her
physical, emotional, social, and spiritual needs.
Hospice provides support to family members caring for a terminally ill person.
Hospice is generally given in the home.
Hospice services may include drugs, physical care, counseling, equipment, and supplies for the terminal and related
condition(s).
Hospice is not only for people with cancer.
Hospice does not shorten or prolong life.
Hospice focuses on comfort, not on curing an illness.
Source: National Hospice and Palliative Care Organization. (2013). NHPCO facts and figures: Hospice care in America. Alexandria, VA: NHCPO.
24.2 Conditions That Must Be Met to Obtain Medicare Hospice Benefits
The patient is eligible for Medicare Part A (Hospital Insurance).
A physician and the hospice medical director certify that the patient is terminally ill and has 6 months or less to live
if the illness runs its normal course.
The patient signs a statement choosing hospice care instead of other Medicare-covered benefits to treat the terminal
illness. Medicare will still pay for covered benefits and treatment of any other health problems not related to the
terminal illness.
The patient receives care from a Medicare-approved hospice program.
Source: Center for Medicare and Medicaid Services (2018). Medicare Hospice Benefits. Retrieved from https://www.medicare.gov/Pubs/pdf/02154-Medicare-
Hospice-Benefits .
Hospice does not speed up or slow down the dying process. It does not prolong life and it
does not hasten death. National Hospice Foundation
Healthcare reform and benefits covered by Medicare are currently under debate in the U.S.
Congress; therefore, it is wise to visit the Medicare website (http://www.medicare.gov) and/or
consult with a knowledgeable social worker to obtain the most current and accurate information
regarding services covered. The healthcare reform act has expanded services covered under the
hospice benefit in an effort to improve care of the person nearing the end of life. At present, a
person can get Medicare hospice benefits when they meet all of the following conditions:
They are eligible for Medicare Part A (Hospital Insurance).
The physician or nurse practitioner and the hospice medical director certify that the person is terminally
ill and has 6 months or less to live if the illness runs its normal course.
The person accepts comfort care rather than curative care.
The person signs a statement choosing hospice care instead of other Medicare-covered treatments for
terminal illness or other related conditions.
Medicare covers the following hospice services when they are needed to care for the person
with terminal illness and related condition(s):
Doctor services
Nursing care
Medical equipment (such as wheelchairs or walkers)
Medical supplies (such as bandages and catheters)
Drugs for symptom control or pain relief (may require a small co-payment)
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https://www.medicare.gov/Pubs/pdf/02154-Medicare-Hospice-Benefits
http://www.medicare.gov
Hospice aide and homemaker services
Physical and occupational therapy
Speech–language pathology services
Social worker services
Dietary counseling
Grief and loss counseling for the ill person and family
Short-term inpatient care (for pain and symptom management)
Short-term respite care (may require a small co-payment)
Any other Medicare-covered services needed to manage pain and other symptoms related to the terminal
illness, as recommended by the hospice team (Medicare.gov, 2017)
Palliative care for children can reduce a child’s pain, help manage other distressing
symptoms, and provide important emotional support to the child and family throughout the
course of an illness. Research has shown that pediatric palliative care services may also increase
overall satisfaction with care for patients and their families. Yet, many healthcare providers
continue to hesitate to recommend palliative care for the youngest patients, and parents and
caregivers are often unaware of its benefits (National Institutes of Health, 2014). See Box 24.3
for Pediatric Palliative Care Referral Criteria.
Viewing death as a natural process, not a medical failure, is of utmost importance. Some
caregivers consider that death is not normal and when it occurs, someone is at fault. Of course,
nurses know that this is not true; in many serious progressive illnesses, death is an expected
outcome. Nurses who help patients die comfortably and with dignity provide the following
principles of quality person-centered care (National Consensus Project [NCP] for Quality
Palliative Care, 2013):
Providing care and services that are responsive to the needs and exceed the expectations of those we
serve.
The ill person and family compose the unit of care.
The hospice interdisciplinary team, in collaboration with the patient, family, and caregiver, develops and
maintains a person-, family-, and caregiver-directed, individualized, safe, and coordinated plan of
palliative care.
Addressing loss, grief, and bereavement needs begins with the initial assessment at the time of admission
to the hospice and continues throughout the course of care.
Anticipatory mourning services are provided to help patients, families, and caregivers cope with the
multitude of losses that occur during the illness and eventual death of the patient. Bereavement services
are provided after death and are based on a number of factors, including a bereavement risk assessment
which assesses intensity of grief, coping and adapting abilities of the survivors and their individual needs,
and the benefits and burdens of treatment.
24.3 Pediatric Palliative Care Referral Criteria
Perinatal/neonatal: Life-threatening diagnoses made months to hours before birth of the neonate in the few days,
weeks, or months of life
Neurologic conditions: Hypoxic injury, birth trauma, structural malformation of the CNS, metabolic diseases,
genetic or congenital syndromes
Congenital heart defects: Ventricle malformation, pulmonary vein stenosis, cardiomyopathy, pulmonary
hypertension, coarctation of the aorta, posttransplant care
Other diagnoses: Cystic fibrosis, solid organ transplant, oncology, primary immunodeficiency disorders, acquired
immunodeficiency disorder, acute leukemia
Source: Adapted from Stroupe, L. M. (2013). Process improvement for pediatric supportive care. Journal of Hospice and Palliative Nursing, 15(8), 479–484.
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http://Medicare.gov
To supply this care, nurses must be well educated, have appropriate supports in the clinical
setting, and develop a close collaborative partnership with palliative care service providers and
hospice programs.
Student Reflection
I was amazed at how quickly my home health nurse preceptor mobilized community-based
resources. After making several phone calls to her professional colleagues (all of whom she
knew by their first names!), she was quickly able to get the needed services in place. It
really illustrated the importance of communication and teamwork.
Nurses must be confident in their clinical skills when caring for the dying—awareness of the
ethical, spiritual, and legal issues they may confront while providing end-of-life care is essential.
Many nurses believe that the first step in the process is confronting their own personal fears
about death and dying. By addressing their own fears, nurses are better able to help seriously ill
persons and families when they are confronted with impending death. The nurse may then more
objectively recognize and respect the person’s and family’s values and choices which guide their
decisions at the end of life. Table 24.2 identifies common problems that interfere with quality
end-of-life nursing care.
DEATH IN THE UNITED STATES
Stages in the Dying Process
Elisabeth Kübler-Ross, a psychiatrist at the University of Chicago, was also a pioneer for end-
of-life care; the early hospice movement was supported by her research. Kübler-Ross (1969)
interviewed hundreds of dying persons and published her findings in On Death and Dying: What
the Dying Have to Teach Doctors, Nurses, Clergy, and Their Own Families. It was through her
efforts that healthcare providers began to understand the needs of dying persons. Her work also
emphasized the need for pain relief in terminally ill persons. The outcome of this research was
the development of the “stages of dying.” These stages include denial, anger, bargaining, and
acceptance. It must be remembered that a dying person may not exhibit all of these stages, or
may move quickly through a stage, only to return to it at a later time.
TABLE 24.2 Problems That Interfere With Quality End-of-Life Community-
Based Nursing Care
Problem Potential Outcomes
The community health nurse may hesitate to
discuss a hospice referral.
Hospice services are not initiated in a timely manner; may come too
late to initiate advanced care planning and to support end-of-life
choices.
The patient has not discussed his or her
end-of-life preferences for care.
Professional caregivers and families may not have the appropriate
information to institute a plan of care that meets the patient’s
expectations, including provision of appropriate interventions.
Financial matters and insurance approvals
have not been obtained.
Needed services may be denied or delayed by a lengthy appeal
process.
Funeral wishes, organ donation, and
establishment of a will have not been
specified.
Same-sex partners may be excluded from involvement, valuable
organs are not available to others in need, and families may
argue over inheritance and disposition of property.
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Evidence for Practice
Although Kübler-Ross’ framework stimulated research and changed practice in the field of
end-of-life care, the concept may not be as simple as described. Today, not all researchers
agree with Kübler-Ross, and some claim that her research cannot be replicated
(Konigsberg, 2011). Today, there are over 25 instruments widely used to measure grief, and
each one differs from the other. It is difficult to categorize and synthesize all of the current
research, most of which tends to describe complex and unique emotional responses to
grief. Nurses will often find they need to think beyond the basic five stages.
Specialized Care at the End of Life
During the mid-1900s, technologic advances dictated that sick people should go to hospitals
where they could safely receive “high-tech” care. Surgery, antibiotics, and advanced testing
techniques became the focus of healthcare, shifting away from the provision of care to the
pursuit of cure. Table 24.3 illustrates the changing demographic and social trends surrounding
the cause of death in the years 1900 and 2015. In 2014, the 10 leading causes of death,
accounting for 80% of all death in the United States, include heart disease, malignant neoplasms,
chronic lower respiratory disease, accidents, stroke, Alzheimer disease, diabetes mellitus,
influenza and pneumonia, renal disease, and suicide (Centers for Disease Control and Prevention
[CDC], 2017a). Often, the exact cause of death is difficult to determine in seriously ill adults.
The person with Alzheimer disease may fall, fracture a hip, and die shortly after the injury.
However, the actual cause of the fall may have been a myocardial infarction that was not
detected. The death certificate may indicate a fall or Alzheimer disease as the cause of death,
whereas the true cause was the myocardial infarction. Some people think that these difficult-to-
categorize deaths may be deemed “natural deaths” or deaths that occur because of numerous
unspecified causes, including advanced age, organ failure, and impact of comorbidities.
TABLE 24.3 Cause of Death and Demographic/Social Trends
1900 2015
Focus of care Comfort Cure
Primary cause of death Infectious diseases—e.g., pneumonia,
influenza
Chronic illnesses—e.g., heart disease,
cancer
Average life expectancy 50 years 78.8 years
Number of older persons (>65) 3.1 million 467.8 million
Place of death Home Institutions
Caregivers Family Professional healthcare providers
Disease trajectory Short, downward trend Prolonged, variable, peaks and valleys
Functional decline at the end of
life
Short-term—expected and surprise Lingering expected—frailty
Source: Centers for Disease Control and Prevention. (2017). FastStats: Death and mortality. Retrieved from http://www.cdc.gov/nchs/fastats.death.htm.
In children in 2014, the main causes of death for those aged 1 to 4 years were accidents,
congenital malformations, and assault due to homicide, and for those aged 5 to 14 years causes
of death included accidents, cancer, and suicide (CDC, 2017b). Infant mortality rates have
declined from 2005 to 2014 by 15%. The poisoning death rate among teens aged 15 to 19 years
nearly doubled, from 1.7 to 4.2 per 100,000, in part because of an increase in prescription drug
overdoses (e.g., opioid pain relievers). Childhood motor vehicle traffic-related death rates
declined 41%; however, these deaths remain the leading cause of death by unintentional injury.
849
http://www.cdc.gov/nchs/fastats.death.htm
Malignant neoplasms, heart disease, congenital anomalies, sudden infant death syndrome,
homicide, and suicide remain significant threats to the health of children and adolescents. It is
thought that 25% of all childhood deaths are preventable (NHPCO, 2015).
In the past century, social changes and technologic advancements had shifted the goals of
modern healthcare from care to cure. Over the decades, the experience of serious illness, death,
and dying in the United States has evolved. What was once a short, rapid decline, which often
occurred in the relative comfort of one’s own home, now encompasses a trajectory of chronic
illness with steady decline, periodic crises, the need for ongoing aggressive treatment, and
finally death. Adults with chronic and progressive illnesses often lack coordinated care, with
multiple episodic and unplanned emergency department visits which focus on single systems,
quick diagnosis, and cure. As a result, seriously ill adults are at risk for polypharmacy, falls,
functional decline, and institutionalization (NHPCO, 2017).
Mrs. Clark has stated that she feels as if she is on a merry-go-round because she is in
and out of the hospital so often. She says “I never want to go back to the cold, noisy
hospital again. Please help me stay here in my home with my TV, my cats, and my
memories.”
NURSING CARE WHEN DEATH IS IMMINENT
Hospice care can be provided in many settings, including the person’s home, hospital, nursing
home, assisted-living facility, and inpatient hospice facility. When surveyed, most Americans
express a preference to die in their own homes; however, many still die in institutional settings
(NHPCO, 2017). However, the past 20 years have seen a shift in the trends in place of death,
with increasing numbers of people dying in their homes and long-term care settings, and
decreasing numbers of people dying in the hospital.
Not only are fewer people dying in the hospital, older adults are spending less time in the
hospital at the end of life. A recent report of the Dartmouth Atlas Project revealed that the
average number of days older adults spend in the hospital before death, as well as the percentage
of deaths associated with an intensive care stay, has declined in recent years (The Dartmouth
Institute for Health Policy and Clinical Practice, 2013). The report also demonstrated that
increasing numbers of older adults are choosing hospice care at the end of life.
Data from numerous studies demonstrate high degrees of symptom distress in persons in
hospitals and nursing homes; high use of burdensome technologies in seriously ill persons;
caregiver burden on families; and communication problems among ill persons, families, and
caregivers about the goals of care and medical decisions that should follow (Last Acts, 2002;
NHPCO, 2017; Quill, 2000; SUPPORT Principal Investigators, 1995). Seriously ill persons who
die at home avoid some of these problems. However, the reality of dying at home is often more
complicated. Family caregivers are often stressed or may not be ever present; the home
environment may be small, chaotic, or even unsafe; symptom control may be more difficult; and
the provision of basic nursing care such as bathing and grooming may be difficult for ill persons
and caregivers. Additionally, some caregivers and seriously ill persons may prefer more
supportive inpatient care at the end of life (Lysaght & Ersek, 2013).
It requires more courage to suffer than to die. Napoleon Bonaparte
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Evidence for Practice
Research at the Dartmouth Atlas for Healthcare has provided evidence that populations
living in regions with lower intensity of care in the last 6 months of life did not have higher
mortality rates than those living in regions with higher care intensity. More than 80% of ill
persons say that they wish to avoid hospitalization and intensive care during the terminal
phase of illness, but those wishes are often overridden by other factors. If more intense
intervention does not improve life expectancy, and if most ill persons prefer less care when
more intensive care is likely to be futile, the fundamental question is whether the quality of
care in regions with fewer resources and more conservative practice styles is more
appropriate than in regions where more aggressive treatment is the norm (The Dartmouth
Institute for Health Policy and Clinical Practice, 2013). All healthcare providers, including
nurses, must work together and advocate for improvement in the quality of care provided at
the end of life.
Decisions About Level of Care
Wherever seriously ill persons spend their last days, these persons and their families face
difficult decisions about end-of-life care. Uncertain prognoses may affect decision making on
the part of these persons, their families, and their healthcare providers, which perhaps leads to
unnecessary interventions and treatments. Older people, especially, are at risk for overly
aggressive care because they have high comorbidity rates and an increased likelihood of
dementia (Ward et al., 2014). For some older persons, medical treatments offer little or no
benefit, and at the same time may be painful or increase the burden of living; such care may be
futile. Nurses, physicians, social workers, clergy, and others are responsible for counseling ill
persons and families about making decisions regarding the type and level of care the person
wishes to receive for the remainder of his/her life. After the decision has been reached, it is
usually noted in the person’s chart by the nurse or any other member of the healthcare team, so
that the entire healthcare team is aware of the person’s wishes. Of course, the ill person is
always able to reverse these decisions.
Comfort Measures Only
A dying person may decide to receive comfort measures only (CMO)—that is, allow death to
occur naturally while maximizing comfort. CMO is the preferred choice when the person
confronts his or her mortality and considers less aggressive treatment. A nurse should review the
use of life-sustaining technologies with the seriously ill person. Those persons who wish to have
CMO may receive traditional hospice care, with healthcare professionals focused on quality of
life rather than on the length of life.
The physician or advanced practice nurse usually orders CMO when the ill person, family,
and staff are in agreement that the best care for the person is not to prolong the dying process,
but to keep the dying person comfortable. Comfort becomes the focus of care when cure is no
longer an attainable goal, expected quality of life is unacceptable, and comfort is a priority for
the dying person and family (Moneymaker, 2005). This does not mean that nursing care or
treatments stop. Assessment and management of any physical conditions, activities of daily
living, and behaviors, as well as pain, continue on a daily basis. Provision of excellent nursing
care at the end of life can be a challenge, especially when the family has been told by the
physician that “nothing more can be done.” The designation of a person as CMO does not signal
the end of care, but rather shifts the focus of care from aggressive treatment of the disease to
active nursing interventions to improve function, comfort, and quality of life.
851
Advance Directives
Many Americans are fearful of death and hesitate to discuss end-of-life preferences with their
families and significant others. This can be problematic when the person becomes very ill or
incapacitated, and the healthcare professionals consult for assistance in medical decision
making. People of all ages should begin to discuss these issues with others who may be called
on to make decisions in the case of serious illness or injury. This should occur in a noncrisis
situation when the person has time to discuss the issue in depth, ask questions, and think about
the risks and benefits of various interventions. Personal values, past experiences, cultural beliefs,
religious preferences, medical knowledge, family orientation, and life experiences all help
determine the end-of-life preferences. Each person and his or her family should provide input
into treatment decisions which are then based on goals of care, assessment of risk and benefit,
best evidence, and personal preferences.
Advance directives are legal documents that allow people to convey their wishes for end-of-
life care and include living wills, durable powers of attorney for healthcare, and healthcare
proxies. Legal requirements for advance directives vary from state to state; some state laws
mandate the use of living wills, and others require designation of a healthcare proxy or durable
power of attorney for healthcare. All of these documents go into effect when the person is no
longer able to communicate his or her wishes. Living wills are documents in which persons
describe their wishes regarding treatment intended to sustain life. This may include acceptance
or limitation of life-sustaining treatment in the face of a life-threatening illness. It is necessary to
copy a living will and share it with others; the physician, nurse, family members, and significant
others should have copies and should indicate their willingness to comply with the terms stated
therein. Many people place the living will in a safety deposit box so that others, who may not
wish to honor it, cannot gain access to it. A healthcare proxy or durable power of attorney for
healthcare is a person (and an alternate if the primary proxy is not available) designated to make
decisions for the person if he or she is unable to do so. The person should then discuss his or her
wishes with the proxy to ensure appropriate end-of-life care. The healthcare proxy is responsible
for medical decisions only if the ill person is unable to do this, and does not have legitimate
input into any other areas of the person’s affairs (e.g., financial). It is necessary to make multiple
copies of the proxy form, and healthcare providers and family members (including proxies)
should keep them readily accessible.
Decision making around the time of death raises many legal and ethical questions. Public
debate and scrutiny help shape the ethical outcome of medical dilemmas. Healthcare
professionals must work within the limits of the law and their professional standards of practice.
Established ethical principles and moral norms play a vital role in determining healthcare issues.
In 1976, the Karen Ann Quinlan case brought life-sustaining medical treatment to the
forefront of the U.S. legal system. A medical intervention, procedure, or administration of
medicine to prevent the moment of death is seen as life sustaining. This includes
cardiopulmonary resuscitation (CPR), renal dialysis, use of ventilators, insertion of feeding
tubes, total parenteral nutrition, chemotherapies, and other life-prolonging interventions. When
questions regarding the initiation, ongoing use, and removal of life-sustaining technologies arise,
and there are no advance directives in place, ethical and emotional issues arise. Many healthcare
institutions have formed ethics committees to address these issues and to provide guidance and
advice to the clinician, ill person, and family. If the ill person lacks a responsible family
member, the courts may appoint a legal guardian. This is a cumbersome and difficult process,
and naming a healthcare proxy or completing a living will prevents this process.
In 1990, the U.S. Supreme Court declared that all Americans have a right to make healthcare
decisions. Even if a person is deemed currently incompetent or unable to make his or her own
decisions, the person’s previous wishes become the determining factor concerning care. The
Patient Self-Determination Act became a federal law in 1991. This act states that the person
852
must understand that he or she may refuse medical treatment, care, procedures, medicines, and
other similar procedures. It also states that all persons must receive information about their right
to prepare advance directives.
Most healthcare institutions have developed policies concerning self-determination which
comply with specific state laws. In order to provide proper care as determined by the state
statutes, it is necessary for the interdisciplinary team to form a collaborative relationship with
the ill person and family. When the ill person is unable to make decisions, the healthcare team
must consider the person’s diagnosis, the benefit or burden of treatment, the effect on the
prognosis, and expressed verbal patient preference. Family members, other concerned people, or
surrogates may take part in the decision-making process. Reevaluation must be ongoing because
the person’s situation changes throughout the course of illness and treatment. Although a
person’s decision-making capacity may be fluctuating or limited, the individual may sometimes
be able to understand some aspects of the medical situation, and even express preferences
through nonverbal communication.
ARTIFICIAL NUTRITION AND HYDRATION
The decision to institute artificial nutrition and hydration should take into account possible
benefits and risks. It has traditionally been assumed that artificial nutrition and hydration meet
several therapeutic goals: prolonging life, preventing aspiration pneumonia and “starvation,”
maintaining independence and physical function, improving nutritional status, assisting in
healing of pressure ulcers, and decreasing suffering and discomfort at the end of life (ANA,
2017; HPNA, 2015). However, the literature does not support this. Studies have shown that
nursing home residents living with feeding tubes have similar survival rates to those living
without these tubes, and that aspiration rates are higher in persons with feeding tubes (Lacey,
2005). Furthermore, artificial nutrition and nutritional supplements do not enhance the strength
and physical function of frail elderly people and can also cause harm due to decreased caloric
needs at the end of life (ANA, 2017; HPNA, 2011). Also, contrary to expectations, most actively
dying persons do not experience hunger, even if they have inadequate caloric intake. In fact,
risks such as increased infection, sensory deprivation, and restraint use have led researchers and
palliative care experts to discourage the use of feeding tubes in dying persons and those with
advanced dementia. To explore alternatives to artificial nutrition techniques, collaboration with
other healthcare professionals (nutritionists and speech therapists) is indicated.
Dying persons, who feel strongly that they do not want feeding tubes inserted, should inform
their healthcare proxies, and specify this in their living wills. Administration of artificial
nutrition and hydration is a medical treatment, and thus a person can accept or reject it. This
right reflects respect for patient autonomy.
CARDIOPULMONARY RESUSCITATION
CPR is the process of restarting the heart and/or lungs after one or both have stopped working.
Traditionally, CPR is for people who are experiencing cardiac or respiratory arrest; simply put,
CPR is most successful when it occurs in the hospital, specifically in the intensive care unit.
However, when the seriously ill adult is frail, has multiple chronic conditions, and is nearing the
end of life, CPR is significantly less effective. Current federal law mandates that long-term care
facilities must ask residents (or their surrogates) whether they wish to receive CPR in the event
of a cardiac or respiratory arrest. Research on CPR performed on elderly nursing home residents
consistently shows very poor outcomes. Survival following CPR is less than 5% in this
population, with most studies showing 0% survival. In such persons, the poor outcome of CPR
in nursing home residents and those nearing the end of life is more likely a result of the
irreversibility of the underlying diseases that end in cardiopulmonary arrest (American Medical
Directors Association, 2013). Deciding to put a do-not-resuscitate (DNR) order in place usually
involves the ill person, his or her family, the nurse, physician, and others on the healthcare team.
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In most healthcare facilities, the physician or primary healthcare provider must write the DNR
order in the chart for it to be legal using a standardized form such as POLST (provider order for
life-sustaining treatment); if no order is written, CPR is administered by default if the need
arises. It can be very upsetting for the nurse to provide CPR to a dying person, and the person
may suffer injury from anoxia, broken ribs, and aspiration.
When the nurse approaches the seriously ill person and the family for clarification of the
person’s “code” status, it is best to discuss the issue as fully and objectively as possible. It is
necessary to present the facts with empathy, and express the idea that clinicians will support
whatever reasonable decision is made. This conversation should be part of an ongoing
discussion of the person’s wishes and goals for end-of-life care. According to the ANA, “the
efficacy and desirability of CPR attempts, a balancing of benefits and burdens to the ill person,
and therapeutic goals should be considered” (ANA, 2012, p. 2). The nurse should emphasize
that the decision not to resuscitate is not condemning that person to death. Rather, the nurse is
helping the person decide whether medical intervention might reverse the death process and
even prohibit a peaceful death. The process of letting go may be painful for both the dying
person and the family.
Euthanasia and Physician-Assisted Suicide
Death is not the greatest of evils; it is worse to want to die, and not be able to. Sophocles
Active euthanasia, or mercy killing, is the practice of ending the life of a terminally ill person, at
the request of the person, for the purpose of limiting suffering. Active euthanasia is illegal
throughout most of the United States, but legislators continue to sponsor bills in support of this
action, and much public debate is ongoing concerning this issue. Rarely, a medication given for
pain relief may have the unintended consequence of shortening the dying person’s life; however,
because the intent of the medication is relief of pain and not the hastening of death, this is not
considered euthanasia.
In 1994, Oregon voters approved physician-assisted suicide, which refers to a physician
acting to aid a person in ending his or her life. Terminally ill residents of Oregon may receive
prescriptions for lethal medications from their physician for self-administration. Currently
(2018), it is legal in the states of Washington, Vermont, Oregon, California, Colorado,
Washington, DC, Montana, and Hawaii (ProCon, 2018). The ANA (2013) does not endorse the
concept of participation of nurses in the process of euthanasia, mercy killing, or assisted suicide.
Cultural and Religious Issues
People of many cultural backgrounds reside in the United States. Culture encompasses
dimensions such as race, ethnicity, gender, age, abilities/disabilities, sexual orientation, religion
and spirituality, and socioeconomic status (Cain, Surbone, Elk, and Kagawa-Singer, 2018). An
ever-changing system, culture is shaped over time as beliefs, values, and lifestyle patterns are
passed from generation to generation. Sensitivity and empathy are essential when caring for a
dying person from a different culture. Each person is a unique individual with cultural
preferences that influence the specialized needs of the person, the family, and their caregivers.
Evidence for Practice
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Despite efforts to improve access to palliative care to all seriously ill persons, improvements
are not reaching minority populations (Spruill, Mayer, & Hamilton, 2013). In a classic study,
the SUPPORT Principal Investigators (1995) reported that the healthcare system expended
fewer resources on African Americans than on others with similar disease processes.
Despite a higher incidence rate of cancer, shorter survival time after diagnosis, and higher
cancer death rates, African Americans made up only 8.2% of the population who used
hospice in 2015, and they were less likely to use hospice services compared with other
racial groups (Spruill et al., 2013). In general, some minority persons often have an
underlying mistrust of the healthcare system, and the literature has frequently described
cases in which African Americans desire aggressive life-sustaining interventions in the face
of terminal disease. These persons may choose feeding tubes and CPR because of fears of
being denied healthcare similar in scope to that of Caucasians.
Religion and spirituality play an important role in the forming of beliefs and practices which
are paramount when death is imminent. Feelings of guilt, remorse, comfort, or peacefulness may
all relate to religious beliefs. Religious customs are extremely important to many dying persons,
and as death nears, concerns or fears may intensify. It is helpful to know a person’s religious
preference; the nurse should remember that each person’s spiritual reactions are highly
individualized. Requests by family or ill persons to seek spiritual counseling should be met with
respect. Many healthcare facilities have chaplains, clergy, social workers, and others to assist
staff. The nurse should ensure that spiritual care is made available to a person at the end of life.
At times, a religious belief may help the person determine the type of end-of-life care to
request. The nurse must be aware of concerns the ill person may have, and respond
therapeutically. The age-old question of why this is happening may take on religious tones or
thoughts. The ill person may discuss or allude to punishment, atonement, God’s will, or hope for
a miracle. The nurse should follow the person’s lead in determining spiritual needs and beliefs.
Serious illnesses frequently initiate a search for life’s meaning, and questions may arise
regarding the person’s purpose in life. Religious or spiritual beliefs may even influence the
emotional response to pain.
When discussing religion or spirituality with the ill person, it is important to assist the person
in seeking meaning. Nurses who believe they are unable to assist ill persons in discussions of
spirituality should make referrals to others on the team who have skills and knowledge in this
area.
Specific rituals and practices are found in different faiths and religions. It is common for a
person of the Roman Catholic faith to wish to receive the sacrament of the anointing of the sick
to give spiritual strength and prepare for death. A religious item such as a rosary or medal may
bring comfort. A person who is Jewish may want to see a rabbi and participate in prayers. Burial
takes place as soon as possible after death and before the Sabbath. A person who is Muslim may
prefer that a family member be notified as soon as death occurs. It is best to wait for this person,
since special washing and shrouding procedures should take place after death. Placement in a
position that faces Mecca is sometimes preferred. If there is no family member to prepare the
body, the staff may do so provided that they wear gloves. The burial of the body should occur as
soon as possible, and cremation is not acceptable. Table 24.4 summarizes some religious beliefs
and rituals practiced at the end of life.
PALLIATIVE CARE
Palliative care is interdisciplinary team-based care that is focused on the relief of suffering for
persons with serious illness. It attempts to achieve the best possible quality of life, not only for
seriously ill persons but also for their families (NHPCO, 2016). Nursing interventions which
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help enhance the quality of persons’ lives, reduce pain and suffering, optimize functionality, and
promote appropriate goal setting and decision making are integral to the provision of excellent
palliative care (HPNA, 2011).
Regardless of the stage of the disease or the need for curative therapies, palliative care is
appropriate for persons with life-limiting, serious illness. It may be concurrent with life-
prolonging care, or may be the main focus of care (NHPCO, 2016). Although ill persons may be
of any age, even children, palliative care is especially appropriate when provided to older people
who have the following:
Acute, serious, life-threatening illness (e.g., stroke, trauma, major myocardial infarction, and cancer,
where cure or reversibility may or may not be a realistic goal, but the burden of treatment is high)
Progressive chronic illness (e.g., end-stage dementia, congestive heart failure, renal or liver failure, and
frailty)
TABLE 24.4 Religion and End-of-Life Care
Religion Belief Ritual
Christian Christians believe in an afterlife and
the resurrection of Jesus Christ.
Catholic
Anointing the sick by a priest
Reconciliation and communion
Funeral held 2–3 days after death
Protestant
No last rites
Anointing of the sick by some
Others
Mormons will administer a sacrament
Jehovah’s Witnesses will not receive blood
transfusions
Some sects have hands-on healing techniques
Judaism Death confers meaning to life. Euthanasia is prohibited. Burial usually takes place
within 24 hours. The funeral or shiva is held after the
burial. Autopsy, organ donation, and cremation are not
allowed. A rabbi is usually called when death is near.
Muslim Muslims believe in an afterlife. The
purpose of worldly life is to prepare
for eternal life.
As death approaches, the patient is positioned supine
facing Mecca. The room is perfumed, and anyone who
is unclean leaves the room. Prayer occurs five times a
day. Discussion of death and grief counseling are
discouraged. Euthanasia is not allowed by law. Organ
donation is allowed. Autopsy is discouraged.
Buddhist Belief in the afterlife through the
pursuit of perfection in worldly life.
End-of-life decisions are made with much family
consultation. Families often do not want the patient to
know the diagnosis to hide bad news. The elderly do
not talk about funeral arrangements and often defer to
physicians to make treatment decisions for them.
Source: Data from Cheng, B. (1997). Cultural clash between providers of majority culture and patients of Chinese culture. Journal of Long-Term Health Care,
16, 39—43.; Kirkwood, N. (1993). A hospital handbook on multiculturalism and religion. Sydney, Australia: Millennium Books.; Ross, H. (2000). Islamic
tradition at the end of life. Unpublished manuscript.
Palliative care may occur in all settings, including hospitals, outpatient clinics, long-term
care facilities, or the home. The person and family are supported during the dying and
bereavement, when they may experience feelings of loss after the death of a loved one. The
care provided emphasizes quality of life and living as fully as possible up until the moment of
death.
The future and growth of palliative care will be largely determined by its acceptance within
the medical model, and by reimbursement for palliative care services. The focus of palliative
care includes the following:
Controlling symptoms
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Coordinating care
Reducing unnecessary tests and futile interventions
Ongoing conversations with the ill person and family (NHPCO, 2017)
I am not afraid of death, I just don’t want to be there when it happens. Woody Allen
HOSPICE CARE
Through expert medical care, pain and symptom management, and emotional and spiritual
support, hospice care provides support for people in the last phase of life-limiting illness, so that
they may live as fully and comfortably as possible (NHPCO, 2017). In 2014, an estimated 1.651
million persons received services from hospice. This estimate includes the following:
83.3% of persons died while in hospice care
6.3% revoked hospice care (changed their minds and opted to return to aggressive care)
6.9% were discharged and deemed no longer terminally ill (known as “live” discharges) (NHPCO, 2017)
The work of nurse leaders such as Florence Wald, Dame Cicely Saunders (also a physician),
and Jeanne Quint Benoliel highlighted the need for “competent, expert, evidence-based care
provided in a way that embodies compassion, respect for dignity, and an appreciation for the
whole person and the family” (NHPCO, 2017). Another nurse leader, Harriet Goetz, published
an approach to care for the dying in 1962, emphasizing therapeutic communication and
symptom management techniques to provide comfort. Current standards of comprehensive and
compassionate hospice and palliative nursing care are built upon the foundation of the work of
these nurse leaders.
When two physicians determine that a seriously ill person has 6 months or less to live, and
the dying person and family agree to provide care and comfort as opposed to aggressive medical
intervention, loved ones often seek hospice. Hospice care focuses on the whole person by caring
for the body, mind, and spirit. The goal is for the person to live his or her last days as fully and
comfortably as possible. To achieve this goal, a multidisciplinary team of physicians, nurses,
therapists, home health aides, pharmacists, pastoral counselors, social workers, and trained lay
volunteers assist the family and caregivers in providing care (Fig. 24.1). The hospice nurse
assumes the role of specialist in the management of pain and control of symptoms, and assesses
the ill person’s and family’s coping mechanisms, available resources for the provision of care,
the ill person’s wishes, and the support systems in place.
Hospice personnel may work with caregivers and ill persons in the home, nursing homes,
other long-term care settings, and hospitals. Hospitals may have affiliated hospices, and some
home health agencies promote their own home care hospices. Freestanding hospices that provide
a homelike atmosphere in which care is provided by trained staff at the facility are also
available, and these hospices may be a good option for persons who prefer a home death but do
not have the necessary resources and support to safely remain in their homes. All hospices
encourage family involvement and promote death with dignity. Because the experience of the
dying and death of a loved one deeply affects the family, supportive care is provided to family
and caregivers throughout the illness trajectory and for a period after the death has occurred.
CARING FOR PERSONS AT THE END OF LIFE
The nurse providing quality end-of-life care to a seriously ill person and his or her family
assumes the role of expert clinician. As an expert clinician, the community health nurse acts
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autonomously and completes physical, psychological, social, and spiritual assessments, and this
nurse designs and implements plans of care (in collaboration with the ill person, family, and
interdisciplinary team) to meet the ill person’s needs. Many validated instruments are available
for use for healthcare professionals, including instruments for the assessment of pain and
symptoms, mental health and mood, meaning in life and spirituality, functional assessment,
quality of life, and caregiver strain. See the Toolkit of Instruments to Measure End-of-Life Care
website (http://www.chcr.brown.edu/pcoc/resourceguide/resourceguide ) for online copies
and instructions for use of these various instruments.
Nurses who regularly assist seriously ill persons and families to understand changes in their
health status and the implications of these changes can alleviate many commonly held fears.
Common fears and concerns of the dying include the following:
Death itself
Thoughts of a long or painful death
Facing death alone
Dying in a nursing home, hospital, or rest home
Loss of body control, such as bowel or bladder incontinence
Not being able to make decisions concerning care
Loss of consciousness
Financial costs and becoming a burden on others
Dying before having a chance to put personal affairs in order
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http://www.chcr.brown.edu/pcoc/resourceguide/resourceguide
FIGURE 24.1 Interdisciplinary hospice team.
The community health nurse can assist the ill person to address some of these fears by
ensuring comfort and support. Often, the nurse is present for the patient and family and can
communicate compassion through caring acts. For instance, the small act of adjusting the ill
person’s position so he or she can see the television a little better can be greatly appreciated by
the patient and family. When a person is diagnosed with a serious illness, life continues for an
indefinite period; many persons live much longer than their prognosis predicts. The timing of a
natural death is unpredictable, and it is difficult to predict exactly when death will occur. It is
essential that each person have the opportunity to live life fully each day until the moment of
death rather than engaging in a long, tedious dying trajectory. Therefore, accurate and timely
deliverance of nursing care and addressing potential problem areas are of prime importance. The
nurse’s assessment guides the interdisciplinary team in providing individualized care with
respect for the person’s wishes. The goal of the nurse is to help the seriously ill person achieve
the best possible quality of life through relief of suffering, control of symptoms, and restoration
of functional capacity while remaining sensitive to personal values, cultural practices, and
religious beliefs (NHPCO, 2017).
Pain Management
Merciful relief of pain is essential for quality end-of-life care in dying persons, and nurses,
including community health nurses, have a primary role in the assessment and management of
pain at the end of life (ANA, 2016). According to the ANA, nurses are responsible for assessing
pain and administering medications and providing other measures of comfort to alleviate
troublesome symptoms. Many patients and families fear pain during the dying process.
However, through ongoing assessment of levels of pain, administration of pain medication, and
evaluation of the effectiveness of the pain management plan, nurses may help alleviate the
distress associated with untreated pain in dying persons.
Pain is associated with many negative outcomes in dying persons. It has the potential to
hasten death and is associated with needless suffering at the end of life. People in pain do not eat
or drink well, do not move around, cannot engage in meaningful conversations with others, and
often become isolated to save energy and cope with the pain. Untreated pain is related to
sleeplessness, psychological distress, fatigue, and restlessness, and nurses have a moral
obligation to advocate on behalf of ill persons so that pain is appropriately managed (ANA,
2016).
Evidence for Practice
Although efforts are under way to improve pain treatment at the end of life, there is growing
evidence that improvements are not reaching all persons. Groups at particular risk for
undertreatment of pain include older adults, minorities, and women (IOM, 2015). Inadequate
pain relief may stem from the person’s inability to communicate pain; for example, some
older persons may be unable to report their pain because of delirium, dementia, aphasia,
motor weakness, language barriers, and other factors. Furthermore, minority persons are at
high risk for inadequate pain relief at the end of life. Possible barriers for these persons
include disparities in access to many treatment options at the end of life, insensitivity to
cultural differences in attitudes toward death and end-of-life care, and mistrust of the
healthcare system (Spruill et al., 2013). The provision of culturally sensitive care is a
necessary component of effective and comprehensive end-of-life care. Cultural preferences
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dictate how nurses assess and treat pain, provide for privacy, interact with the family, and
deliver postmortem care after death.
Practice Point
At the end of life, assessing and managing pain, as well as relieving symptoms, is a primary
responsibility of the hospice nurse. Untreated pain near the end of life is a nursing
emergency and requires aggressive nursing intervention to ensure a comfortable and
dignified death.
Pain Assessment
Pain assessment, including a thorough history, guides the development of a comprehensive pain
management plan. Pain is a subjective experience, with self-report being the gold standard by
which pain is measured. Accurate pain assessment is the basis of pain treatment, and physicians
or nurses should perform it in a systematic and ongoing manner. Helpful questions may include
the following:
How bad is the pain? (It may help to use the facility pain indicator such as smiley face or rate the pain on
a scale of 1 to 10.)
How would you describe the pain (e.g., sharp, shooting, or dull)?
Is the pain accompanied by other troublesome symptoms such as nausea or diarrhea?
What makes the pain go away?
Where does it hurt the most?
Does the pain interfere with your ability to eat and sleep?
What do you think is causing your pain?
What have you done to alleviate the pain in the past? (ELNEC, 2006)
The nurse should carefully observe the dying person for the following signs:
Moaning or groaning at rest or with movement
Failure to eat, drink, or respond to the presence of others
Grimacing or strained facial expression
Guarding or not moving parts of the body
Resisting care or noncooperation with therapeutic interventions
Rapid heartbeat, diaphoresis, or change in vital signs
If an ill person has a potential reason for pain at the end of life, the nurse should assume that
pain is present until proven otherwise. For instance, even in the absence of a complaint, if a bed-
bound person has excoriated skin secondary to urinary incontinence, the nurse should
aggressively treat the area with a moisture barrier and a soothing cream to alleviate pain and
discomfort even though the patient has not complained of pain.
After conducting a complete pain assessment, the nurse shares the information with other
members of the healthcare team, including the physician, advanced practice nurse, pharmacist,
and others. This collaboration is essential to achieve adequate pain control.
Types of Pain in Dying Persons
Pain at the end of life is complex and multifactorial, and prevalence varies according to
diagnosis and other factors. Pain in the terminally ill may be both nociceptive and neuropathic
(Markman & Narasimhan, 2016). It is important to differentiate between these types of pain for
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the pain to be appropriately managed. Nociceptive pain is the signal the brain imparts when
there is tissue inflammation or damage. Cardiac ischemia and arthritis are examples of
nociceptive pain. Nociceptive pain can be divided into two categories: somatic pain, which is
characterized by aching, throbbing, or stabbing due to skin, muscle, or bone injury, and visceral
pain, which is characterized by gnawing, cramping, or aching due to injury of the internal
organs. Nociceptive pain usually resolves when the injury heals, and initial treatment involves
nonopioid pain relievers. Acetaminophen is usually the first choice, followed by nonsteroidal
anti-inflammatory drugs (NSAIDs); if no relief, then physicians and advanced practice nurses
may choose opioids. Neuropathic pain, which occurs when nerves have been damaged,
commonly affects older adults and takes the form of diabetic neuropathy, postherpetic neuralgia,
or poststroke syndrome. The pain associated with these conditions is often described as burning,
electrical, or tingling. Difficult to relieve with routine pain medications, neuropathic pain may
be deep and severe. At times, anticonvulsants, antidepressants, and opioids are used for pain
relief.
Mrs. Clark continues to become weaker and frailer at home, and she has developed
severe pain in her left hip. You consult with the hospice physician, who recommends
morphine. Mary fears that giving her mother morphine will hasten her death. What is your
response?
Many healthcare providers, patients, and families believe that pain management with opioids
shortens life; conversely, significant evidence exists to the contrary (ANA, 2016). Inadequate
pain relief hastens death by increasing physiologic stress, potentially diminishing
immunocompetency, decreasing mobility, worsening risk of pneumonia and thromboembolism,
and increasing the work of breathing and myocardial oxygen requirements (Fine & MacLow,
2006). Unrelieved pain at the end of life can cause psychological distress and spiritual death and
is often associated with negative outcomes, such as decreased quality of life (Markman &
Narasimhan, 2016). Nurses can play a key role by teaching dying persons and families that
aggressive pain control and relief of pain is an indicator of quality nursing care.
Pain Relief During the Dying Process
Various nonpharmacologic and pharmacologic methods of pain control may be implemented to
control pain in the dying person. Some nonpharmacologic approaches to reducing pain may
include providing a glass of warm milk to promote sleep, a back rub, a change of position, a
favorite peaceful musical selection, spending time listening to the person, and/or visits from a
priest, minister, or rabbi to meet spiritual needs. Nonpharmacologic methods can be used with
pharmacologic therapy, and often augment the therapeutic effects of the drugs, resulting in the
use of smaller doses.
Pharmacologic methods require close collaboration between the nurse, the physician, and the
pharmacist to ensure the use of the correct medication, dosing regimen, and route of
administration. These experts still use the model of pain relief developed by the WHO (1990) as
the basis for the pharmacologic approach to pain management. It advocates a stepwise approach
for pain treatment on the basis of the presence of mild, moderate, and severe or unrelenting pain.
If the person has neuropathic pain, mild pain (1–3 on the 0–10 scale) requires the use of
adjuvant drugs (nonopioid medications such as antidepressants and muscle relaxants).
Moderate pain (4–6 on the pain scale) necessitates the use of low doses of opioids; the use of
nonopioids and adjuvants may continue. Severe pain (7–10 on the pain scale) requires the use of
higher opioid doses. Persons presenting with severe pain should receive higher doses initially,
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rather than risking prolonged periods of uncontrolled pain while medications are titrated up from
lower doses. It is necessary to titrate medications on the basis of the person’s goals,
requirements for supplemental analgesics, pain intensity, severity of undesirable or adverse drug
effects, measures of functionality, sleep, emotional state, and person’s or caregiver’s report of
the impact of pain on quality of life (ANA, 2016).
Whatever drugs are chosen, it is important to administer them routinely, and not on an as-
needed (prn) basis, to prevent the unpleasant experience of the person perceiving pain and then
waiting for pain relief. Long-acting drugs (sustained-release formulations) are ideal because they
provide consistent pain relief. Short-acting or immediate-release agents are excellent prn
medications, and their only use should be for control of breakthrough pain. Breakthrough pain
is defined as “intermittent episodes of moderate to severe pain that occur in spite of control of
baseline continuous pain” (Markman & Narasimhan, 2016). Common in persons with advanced
disease, breakthrough pain may occur with specific activities (physical therapy, activities of
daily living) and end-of-dose failure (pain that occurs near the end of the usual dosing interval of
regularly scheduled medications), and it may also be spontaneous. Breakthrough pain requires
prompt treatment to avoid the fear or memory of pain and to prevent decreased functional
ability. Dying persons who consistently experience breakthrough pain should have their
healthcare provider increase the dosage of their regularly scheduled, long-acting pain
medications.
Types of Drugs Used to Control Pain
NONOPIOID ANALGESICS
Common types of drugs in this category include acetaminophen and NSAIDs, which may be
used alone or in combination with adjuvant drugs to enhance their effect. These drugs are very
effective for the treatment of mild to moderate pain. Persons with normal liver function should
take 4 g or less daily to avoid liver damage. It is essential to use these drugs with caution in
individuals with liver disease or who have a history of significant alcohol use and a dose of less
than 3 g daily is recommended for these persons. NSAIDs can cause gastric irritation by
inhibiting prostaglandin formation. Decreased prostaglandin synthesis results in thinning of the
mucous lining that protects the stomach; this may result in gastrointestinal bleeding, especially
in older adults. Other common side effects of NSAIDS are renal dysfunction and impaired
platelet aggregation.
A newer class of NSAIDs selectively blocks the cyclooxygenase-2 (COX-2) enzyme, and
there appears to be less risk of gastrointestinal bleeding with these drugs. However, studies have
suggested that this benefit may not extend beyond 6 to 12 months (Reuben et al., 2017).
Furthermore, these drugs have been linked to increased risk of heart attack and stroke when used
for prolonged periods. The U.S. Food and Drug Administration (FDA) has withdrawn several of
these drugs, but others continue to be used cautiously.
OPIOIDS
Many experts consider opioids to be the most useful agents for pain management in persons with
advanced illness (IOM, 2015). These medications block receptors in the central nervous system
and prevent the release of chemicals involved in pain transmission. Examples are codeine,
morphine, hydromorphone, fentanyl, methadone, and oxycodone. The WHO considers morphine
to be the gold standard for the relief of cancer pain. Adverse effects are rare, and the only
absolute contraindication for use is a history of a hypersensitivity reaction (rash, wheeze, or
edema). Respiratory depression may occur with titration of opioid analgesics; however, this
rarely occurs at the end of life (Reuben et al., 2017). Most often, the respiratory rate becomes
slower as the result of the dying process, not opioids. Constipation and sedation are two
troublesome symptoms that are often associated with opioid use. Meperidine and propoxyphene
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are not recommended for use in older people because of their ineffectiveness in treating pain and
their association with serious side effects. As disease progresses and organ function deteriorates,
the potential for accumulation of the toxic metabolites of these drugs can lead to seizures,
delirium, and tremors.
Some people with pain need higher levels of opioids than others and may fear reporting their
pain is a sign of weakness. Others may fear addiction to opioid medications and refuse
medication, resulting in needless suffering. When used as prescribed in seriously ill or dying
persons, opioid medications improve activity levels and quality of life and ease suffering.
Patients should be urged to use these medications without fear of addiction or feelings of guilt
by interpreting their use as a sign of weakness.
Opioids often involve side effects such as nausea and feeling of lethargy that usually
gradually resolve within 1 to 3 days. Other side effects, such as constipation, do not resolve
without treatment. Over time, persons in pain will become opioid tolerant, meaning their bodies
have adjusted to the medication and higher doses will be needed to relieve their pain. This is to
be anticipated by the nurse, and the ill person should be reassured that this does not mean they
are addicted but rather their body has become adjusted to the medication and the same dose does
not work as well as it once did.
ADJUVANT ANALGESICS
A wide array of nonopioid medications from several pharmacologic classes has been shown to
improve pain relief when used concomitantly with pain medications. Such adjuvant medications
include muscle relaxants, corticosteroids, anticonvulsants, antidepressants, and topical
medications. Their use may enhance the effectiveness of other types of drugs, allowing
improved treatment of pain at lower doses with decreased risk of side effects. Clinicians may
prescribe them at any step of the “analgesic ladder” developed by the WHO (1990).
Routes of Administration
Usually, physicians prefer the oral route of administration because it is the easiest and most
comfortable for the ill person. However, many routes of administration are available at the end
of life when the person can no longer swallow. Pain medication may be administered by the
following routes.
ORAL
Tablets, liquids, and capsules are administered orally to control pain. Long-acting or sustained-
release tablets can control pain for up to 24 hours. Persons who are able to swallow can use this
method until very close to the time of death. It is possible to mix liquid medications in juice and
to open capsules and mix the contents in applesauce. For an oral medication, a higher dose of
medication is usually necessary because of the first-pass effect (deactivation that occurs when
medication passes through the liver).
ORAL MUCOSA
Even when the person can no longer swallow, it is possible to deliver medication to the oral or
buccal mucosa, from which it is absorbed. Placement of highly concentrated liquids such as
morphine onto the mucosa involves using a dropper. Liquid morphine has a short half-life and
duration of action; thus, more frequent administration may be necessary.
RECTAL
Some medications are available in suppository form, and the rectal route may be useful when the
person can no longer swallow or has problems with nausea and vomiting. The rectal route is
invasive, and it may be difficult for family members to deliver medication using this route. In
addition, if the ill person cannot move easily, the positioning required for suppository insertion
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may be problematic.
TRANSDERMAL
Medications such as the fentanyl patch require placement on the skin of the upper body every 72
hours for relief of pain. However, because of changes in blood flow, metabolism, and fat
distribution, some persons do not achieve or maintain stable drug levels and adequate pain relief.
Peak onset may be delayed up to 24 hours, necessitating coverage with short-acting agents
during the initial day of treatment.
TOPICAL
Topical capsaicin and local anesthetics (EMLA) can be useful for pain associated with
postherpetic neuralgia and arthritis, and prior to invasive procedures such as insertion of IV lines
or injections. When applied in small amounts to confined areas, as is recommended, topical
medications usually result in little systemic absorption.
PARENTERAL
The IV and subcutaneous routes are useful when the person is unable to swallow (intramuscular
administration is inappropriate in the palliative care setting) (Paice & Fine, 2006). Pain may be
associated with these methods of delivery. The IV route provides rapid drug delivery and pain
relief, although risks of infection increase because of the need for vascular access. If the IV
route is used, it is important to use the appropriate fluid delivery system and the smallest amount
of fluid possible. This minimizes the risk of volume overload, which may lead to excess
secretions and difficulty breathing. Subcutaneous administration is slower to take effect, with
infusion of 2 to 3 mL/h the easiest to absorb.
INTRASPINAL
The administration of drugs into or around the spinal cord via the epidural or intrathecal route is
reserved for those persons who cannot achieve pain control in any other manner. The complexity
of equipment used to deliver medications in this way leads to increased costs, and caregiver
burden is a potential risk. Furthermore, risk of infection is a significant concern.
Tolerance
Persons who are managed with opioid analgesics over a period of time invariably develop
tolerance or a “state of adaptation in which exposure to a drug induces changes that result in a
diminution of one or more of the drug’s effects over time” (Paice & Fine, 2006, p. 135).
Medication dosages that were once therapeutic are no longer effective, especially as disease
worsens. According to the ANA (2016), when pain and other distressing symptoms are present,
the person should have appropriate and sufficient medication by appropriate routes to control
symptoms, in whatever dosage, and by whatever route is needed to relieve pain and increase
comfort. It is imperative not to undertreat pain. As pain increases, it is essential to explore
underlying causes, medicate the person promptly, monitor the response to medication, and
inform other team members about the effectiveness of the pain relief plan. The goal is to
eliminate pain and help dying persons to improve the quality of their life through relief of
suffering. Dying persons may need more pain medication than the normal range for the
prescribed drug. Organic changes are occurring rapidly and systems are closing down; thus,
absorption levels of drugs are also diminishing.
Preventing and Managing Adverse Effects
CONSTIPATION
Most opioid analgesics slow the movement of material in the intestinal tract and result in poor
bowel elimination. Constipation may contribute to increased pain in dying persons, and it is
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extremely important that the nurse monitor the bowels carefully. It is necessary to initiate a
prophylactic bowel regimen when using opioid analgesics. This includes the use of stool
softeners (e.g., docusate sodium) and bowel stimulants (e.g., senna). Senna tea and fruits may
also be helpful, and nurses should encourage patients to increase their fluid intake, if possible. Ill
persons should avoid using bulking agents (e.g., psyllium) to prevent fecal impaction.
SEDATION
Many persons experience sedation when opioid analgesics are initiated; however, this effect
should subside within 24 to 48 hours. If this condition continues after 24 to 48 hours, and
clinicians have checked and managed other correctable causes the opioid dose should be reduced
and the person observed for improvement in level of consciousness. Although sedation is
commonly cited as a reason for avoiding opioids in older adults, evidence to support this claim
is lacking (Bishop & Morrison, 2007).
RESPIRATORY DEPRESSION
As previously discussed, respiratory depression is often a concern for healthcare providers when
using opioids for pain management; however, it is rarely a clinically significant problem for
opioid-tolerant persons (Reuben et al., 2017). Most people develop a tolerance to respiratory
depression within 5 to 7 days. If respiratory depression (respiratory rate <8 breaths/min or O2
saturation <90%) occurs, it usually has a multifactorial etiology.
NAUSEA AND VOMITING
Nausea and vomiting are common with the use of opioids in opioid-naive persons (those who
have never used an opioid drug before) due to the activation of the chemoreceptor trigger zone
in the medulla, vestibular sensitivity, and delayed gastric emptying (McPherson & Uritsky,
2011). Antiemetics that the person has used successfully in the past may be scheduled for 2 to 3
days with a gradual tapering of the dose. Symptoms should subside within a few days if the
underlying cause is the opioid analgesic (McPherson & Uritsky, 2011).
MYOCLONUS
Myoclonic jerking movements may be associated with high-dose opioid therapy (especially
morphine). If this occurs, an alternate opioid should be used.
PRURITUS
Pruritus is most commonly associated with the use of morphine and is related in part to a release
of histamine caused by the drug. Treatment with antihistamines (e.g., diphenhydramine) is
effective but is very likely to cause sedation in older adults.
Practice Point
Control of pain and any related adverse effects of the pain medication is crucial to the
delivery of quality end-of-life care. Fear of addiction should not be a factor when treating pain
in the dying person.
Management of Distressing Symptoms at the End of Life
Secretions
At the end of life, it may not be easy to manage secretions. Painful xerostomia (dry mouth) can
contribute to difficulty swallowing and impede clear speech; this is often exacerbated by the use
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of supplemental oxygen and reliance on open-mouthed breathing. Frequent mouth care at this
time is crucial for making the person comfortable. It is necessary to provide oral care using soft
swabs several times a day, and whenever the mouth has a foul odor or appears to be causing
problems for the ill person. The nurse may instruct family members about the use of oral swabs
or moistened cloths, allowing them to participate actively in their loved one’s care. Alcohol-
based products or those that contain perfume, lemon, or glycerin can be irritating and drying,
and their use is discouraged. A salt–soda solution (1 teaspoon salt, 1 teaspoon baking soda, 1
quart tepid water) or artificial saliva used every 30 minutes may minimize dry mouth and the
associated sensation of thirst (Emanuel, Ferris, von Gunten, Hauser, & Von Roenn, 2009). It is
acceptable to offer ice chips to relieve the feeling of dryness as long as the swallowing reflex is
present. To prevent aspiration, the nurse should remind caregivers not to give oral fluids when
the person can no longer swallow. Soothing ointments or petroleum jelly may be applied to the
lips to prevent painful cracking or drying. With increasing debility, oral thrush may appear, and
clinicians should prescribe oral antifungal medications (e.g., nystatin swish and swallow).
As death approaches and the person becomes increasingly sedated, the blink reflex
decreases, resulting in dry eyes. Opened or half-opened eyelids become dry and irritated. When
this occurs, the nurse or other caregiver provides frequent eye care to promote comfort.
Artificial tears or ophthalmic saline solutions may be used to prevent drying of the eyes. The
appearance of a loved one with half-open eyes, redness, or puffiness may be disturbing to family
members and should be avoided if possible.
Anorexia and Dehydration
Most dying persons stop eating and drinking, and anorexia and dehydration are common and
normal at the end of life. If the ill person chooses to refuse food and drink, the nurse should
consider this a rational decision and offer emotional and psychological support. Most experts
believe that dehydration at the end of life does not cause distress and may actually initiate
release of endorphins, resulting in a sense of well-being (ANA, 2016). Another benefit of
dehydration is the decreased risk of lung congestion due to pulmonary edema, which leads to
noisy, labored respirations, a sensation of breathlessness, and cough. By eliminating noisy
respirations, the dying person seems more comfortable, and quiet breath sounds decrease anxiety
for family members. Oliguria (production of less than 15 cc of urine per hour) is another
favorable outcome because the person does not need to be positioned to use the bedpan or urinal
frequently. When the dying person stops eating, the nurse can reassure the family that anorexia
may result in ketosis, leading to a peaceful state of mind and decreased pain. Furthermore,
research has shown that initiation of parenteral or enteral nutrition at this time neither improves
symptom control nor lengthens life (Emanuel et al., 2009).
Mrs. Clark has stopped eating, and her daughter is concerned that she is hungry. Mary
asks you if a feeding tube would help her mother get stronger and live longer. How would
you answer her?
Skin Integrity
It is necessary to monitor skin integrity carefully at the end of life because increased fatigue may
result in decreased movement, resulting in pressure over bony prominences. Edema, bruising,
dryness, and venous pooling may occur. Repositioning of the dying person is essential, using lift
or draw sheets, being careful to avoid shearing forces. Pressure-reducing surfaces, such as air
mattresses or air beds, may help in alleviating pressure without needing to reposition the dying
person frequently. To promote comfort and reduce the risk of skin breakdown, the nurse or
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caregivers may provide gentle massage. Family members may feel comfortable applying lotion
to the back or hands of the dying person, again allowing participation in the care of their loved
one. The nurse should tell them not to massage areas of nonblanching erythema and actual
breakdown; this exacerbates ongoing tissue damage.
Incontinence
Bowel and bladder incontinence are frequent occurrences at the end of life. Seepage from body
orifices may become uncontrolled, and it becomes necessary to have protective pads or briefs. It
is extremely important to prevent decubitus ulcers from forming at this time because further
breakdown is common due to contact with urine and feces. Barrier creams and change of
position may also help maintain skin integrity. The nurse should discourage the use of
indwelling urinary catheters if at all possible because they are often associated with distressing
and painful urinary tract infections.
Practice Point
Confusion, restlessness, and agitation are common but distressing symptoms of terminal
delirium.
Terminal Delirium
Terminal delirium can be a distressing phenomenon for families and caregivers. Typically,
terminal delirium presents as “the abrupt onset of fluctuating confusion, inattention, and reduced
awareness of the environment…and may include hallucinations and disturbances in sleep-wake
cycles” (Hosker & Bennett, 2016, p. 1). Visual, auditory, and olfactory hallucinations may
occur. It is important for the nurse to understand that this condition is often irreversible and that
the dying person’s experience of the delirium may be very different from what is witnessed by
caregivers (Hosker & Bennett, 2016). In older adults, delirium is often a presenting aspect of
acute illness or exacerbation of chronic illness. Further complicating the issue, delirium may
exist concomitantly with dementia in older adults (Koll et al., 2016).
Management of delirium includes identification and treatment of underlying causes
(infection, electrolyte imbalances), reduction of environmental stimuli, provision of a safe
environment, and reduction of anxiety. It is necessary to discontinue all nonessential
medications (those not needed for comfort) when goals of care so dictate, and to continue pain
medications and other agents used for comfort, such as benzodiazepines (lorazepam) and
neuroleptics (haloperidol).
Eventually, neurologic changes occur in dying persons, and they slip from a lethargic state
into an unconscious state (which may include periods of lucidness), then coma, and finally
death. Family members frequently ask how much longer their loved one will live. The anxiety
and distress of family and friends at this time may be great. Waiting for death is not an easy task,
and time may pass slowly. This may be frustrating to those who are at the bedside. Extra support
and encouragement at the crucial hours before death occurs are often necessary.
It is impossible to know exactly what unconscious persons at the end of life can hear;
however, data from operating rooms and “near-death” experiences suggest that persons near the
end of life may be more aware of their environment than they are able to show (Emanuel et al.,
2009). Although obtunded and comatose persons may not be able to communicate, it is believed
that their sense of hearing is intact. People present at the bedside must not say or discuss
anything they would not want the dying person to hear. Nursing interventions at this time
include encouraging family members to “let go” and give the terminal patient permission to die.
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Family members can assure their loved one that he or she will be “okay” and thank the person
for loving them. The nurse should allow display of appropriate gestures of affection and provide
privacy. Table 24.5 outlines suggested strategies for the management of common symptoms in
dying persons.
Practice Point
Pleasant conversation or music at the bedside of the comatose person may be therapeutic
and reassuring to the dying person.
NURSING CARE OF PERSONS WHO ARE CLOSE TO
DEATH
Preparing for Death
The knowledge or presumption that death is imminent may cause anxiety for the staff, family,
and the dying person. Watching the body shut down life processes can bring feelings of
helplessness and anxiety. Questions of an afterlife, unresolved emotional or social issues,
concerns centered around family members and their acceptance of death, and financial matters
are common issues generated at the end of life. It is part of the nursing role to attempt to allay
the fears of ill persons and families at this time. Nurses must also remember to support
themselves through this difficult period, recognizing and accepting an array of personal feelings.
They may need individual support, as well as team support from outside the healthcare facility,
to express and accept their true feelings. By doing this, it may be possible to prevent burnout.
In the context of terminal illness, hope is an ever-changing phenomenon. Healthcare
professionals should never deny hope for the dying person and family. Hope for a cure is not
unusual for both the ill person and family throughout the illness trajectory. As the disease
progresses, the seriously ill person may hope for small things to make the present situation more
tolerable, such as a favorite meal or a visit from a family member. Hope for a dying person may
focus on living to see a grandchild graduate from college or the birth of a great-grandchild. Near
the end of life, hopes may include such things as a comfortable death or death in the home. It is
not unusual for dying persons to hope to speak with loved ones before they die.
Nurses should realize that the will to live is extremely strong in many persons confronting
death, especially when there is a sense of unfinished business. Dying persons sometimes need
reassurance from their families and caregivers that all is well and it is “OK” to let go.
Mary is able to obtain Visiting Nurse Association (VNA) care and grant her mother’s wish
to remain in her own home until the end of her life. As Mrs. Clark approaches the final
moments of her life, Mary sits quietly at her mother’s bedside. Mary notices that her
mother is becoming dusky in color and that she seems to be having trouble breathing.
Mary turns to you for advice and reassurance that her mother is not suffering. How would
you respond?
TABLE 24.5 Suggested Strategies for the Management of Common
Symptoms in Dying Patients
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Problem Suggested Nursing Intervention
Constipation Stimulants such as prune juice, senna, or lactulose. Avoid bulking agents (psyllium) in
patients with inadequate fluid intake to avoid impaction. Monitor bowel function. Do not
allow the patient to go longer than 3 days without a bowel movement. A mineral oil
enema may be necessary to prevent impaction.
Delirium Treat underlying cause if possible (fever, urinary tract infection, pain). Avoid use of physical
restraints, sleep disruption, excessive medications. Urge family to remain with the patient,
and have staff frequently visit and speak to and touch the patient. Use alternative
interventions such as massage and music.
Dyspnea Treat underlying cause if known (bronchospasm, hypoxia). Administer opioids to slow
respiratory rate. Maintain the patient in a sitting position if possible. Minimize exertion by
spreading out interventions and treatments. Provide humidified oxygen for comfort. Use
alternative interventions such as massage and music.
Decubitus ulcers Use appropriate positioning techniques, changing position every 2 hours. Keep the patient’s
skin clean and dry. Use special mattress pads to relieve pressure.
Cough Assess and treat underlying cause such as postnasal drip or obstruction. Use chest
physical therapy, cool humidified air, elevate head of the bed, and suction secretions as
necessary. Cough suppressants may be used for comfort.
Anorexia and
cachexia
The etiology of cachexia is rarely reversible in advanced disease, and aggressive nutritional
treatment does not improve survival or quality of life and may create discomfort for the
dying patient whose body is shutting down. Provide excellent mouth care. Treat oral
problems such as candidiasis (thrush). Treat constipation, nausea, and vomiting, if
present, as underlying causes. Assess the room for problem odors and try to minimize as
much as possible. Generally, parenteral or enteral nutrition is useful only for patients with
an appetite who cannot swallow. Offer the patient’s favorite food and fluids as tolerated.
Nausea and
vomiting
This occurs in up to 70% of patients at the end of life. Causes include metabolic
disturbances, visceral disturbances, vestibular problems, medication side effects,
emotional upset, and radiation. Assess cause and treat if possible (i.e., remove offending
medication). Treatment medications include anticholinergics, steroids, benzodiazepines,
and antiemetics (ondansetron and granisetron). Anticipate this and administer
medications, if needed, before symptoms occur. Position the patient to prevent
aspiration. Use complementary therapies such as music, relaxation, hypnosis, and
acupuncture.
Fatigue Fatigue is a subjective sense of tiredness or lack of energy that interferes with usual
functioning. It may be disease related, treatment related, or psychological. If tolerated,
exercise can improve function and sleep. Frequent rest periods and transfusions for very
anemic patients may improve quality of life.
Anxiety Anxiety may be a side effect of many medications such as stimulants and corticosteroids, or
a paradoxical reaction to analgesics. Antidepressants and benzodiazepines may be
beneficial.
Source: Data from Emanuel, L. L., Ferris, F. D., von Gunten, C. F., Hauser, J. M., & Von Roenn, J. H. (2009). The last hours of living: Practical advice for
clinicians. Retrieved from www.medscape.com; End-of-Life Nursing Education Consortium. (2006). Promoting advanced practice nursing in palliative care.
Duarte, CA: City of Hope National Medical Center and Washington, DC: American Association of Colleges of Nursing.
The Dying Process
Under the wide and starry sky,
Dig the grave and let me lie. (from Requiem) Robert Louis Stevenson, while dying from
tuberculosis
Before death, the nurse must explain many physiologic processes to patients (if possible) and
their families and caregivers. An expected set of physiologic changes typically occurs when
death is imminent and is related to gradual hypoxia, respiratory acidosis, and renal failure. The
nurse plays an integral role in assisting the family members who witness these changes to plan
for the actual death. Expected changes include the following:
Buildup of saliva and oropharyngeal secretions due to loss of the ability to swallow may lead to gurgling,
crackling, or rattling sounds with breathing. This is sometimes referred to as the “death rattle,” although
this terminology should be avoided because it is often distressing to family members.
Changes in respiratory patterns (shallow breaths with periods of apnea) may indicate significant
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http://www.medscape.com
neurologic declines, with Cheyne–Stokes respirations often heralding the impending death.
Skin may appear dusky or gray and feel cold or clammy. Mottling of the lower extremities may take
place days or hours before the actual death.
Eyes may appear discolored, deeper set, or bruised.
Observing these body changes can be disturbing to family members. Although it is
extremely difficult to assure the dying person or family that death will happen within a certain
time frame, the nurse’s approach and explanations of the death process are reassuring to those
present. Some family members may want to be present when death occurs, and others may want
to be nearby but not physically present; it is important that the nurse support whatever decision
is comfortable for the family and ill person. Furthermore, patients may wish to be alone and die
quietly with no one present because it may be difficult for the dying person to have loved ones
near. Others find comfort in having family or professional caregivers in attendance. The dying
process is as individual as living.
When respirations cease and a stethoscope does not detect breath sounds or heart sounds, the
nurse should check the person’s carotid pulses with the stethoscope or fingers. Next, the nurse
should check the eyes for pupillary light reflex. If the pupils are fixed and dilated and the heart
has stopped beating, the clinician can pronounce that the person is dead. Other signs of death
include pale and waxen skin; lower body temperature; and relaxed muscles and sphincters, with
released urine and stool (Emanuel et al., 2009). The nurse should note the time death occurred
and put it on the person’s chart, notify the attending physician of the death, and make careful
notes in the person’s chart to document the time the physician has been notified, and any
directions received regarding postmortem care. There are certain settings where a nurse may
make the death pronouncement, including long-term care. It is necessary to notify members of
the interdisciplinary healthcare team of the death and express your condolences to the family.
Even if the family is expecting the death, the actual occurrence of death comes as a shock and
requires gentleness and empathy. If family members are present, the nurse should give them
sufficient time to spend with the deceased before the body is removed.
Student Reflection
Today, Mrs. Clark died quietly in her home. Even though her daughter, Mary, was there with
her through every step of the process, she seemed shocked and sad when her mother took
her last breath. She cried for a few minutes and then took my hand and smiled saying,
“Thank you for helping me through this. I never could have done this for Mom without you.” I
cried a little bit also—tears of sadness, because I would miss Mrs. Clark, as well as tears of
joy, because I knew I had helped her achieve the kind of death she wanted. I felt I had been
a “good nurse.”
Nursing Care After Death
One of the most difficult but essential parts of nursing is providing postmortem care. It is
essential that the nurse does this promptly, quietly, efficiently, and with dignity, thereby
communicating to the family that the deceased person was valued and respected. To promote
comfort and ease anxiety at a time of stress, the nurse should honor the family’s wishes about
performing any religious or cultural rituals and practices. The nurse may also invite the family
members to talk about their loved one and encourage the family members to touch and hold the
person’s body as they feel comfortable. If possible, before death occurs, the nurse should
straighten the limbs and place the head on a pillow. If the death is suspicious or occurs outside
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of a healthcare facility, the coroner may request that the body be left undisturbed until an
autopsy can be performed. However, the coroner does not investigate most deaths of seriously ill
persons who die in their own homes.
After the pronouncement, the nurse should glove, remove all tubes, replace soiled dressings,
pad the anal area in case of drainage, and gently wash the body to remove any discharges. The
body should lie on its back, with head and shoulders elevated on a pillow. The nurse should
grasp the eyelashes and gently pull the lids down. Insertion of dentures is necessary. It is
important not to tie or secure any body parts because this may cause skin indentations. The nurse
should place a clean gown on the body and pull a clean sheet up to the shoulders. When the
body is moved or the extremities repositioned, the body may produce respiratory-type sounds or
the chest may appear to rise and fall. Although this can be alarming, it is only the sound of air
leaving the lungs. The nurse may want to check for respiration sounds again to be certain that
the person is dead. The nurse should prepare necessary paperwork for the removal of the body
from the facility; call the funeral home, morgue, or other personnel for the removal of the body;
and note the time in the chart, as well as who was called, and again chart when the body was
released and to whom. It is advisable to also note whether eyeglasses, dentures, or any personal
artifacts were released with the body and to whom they were given. If the facility requires that
the body be identified with a tag, it is necessary to secure it properly.
Grief
The bitterest tears shed over graves are for words left unsaid and deeds left undone.
Harriet Beecher Stowe
Although the death may be expected, it may be met with shock by people who are left behind.
Rationalizations (e.g., he lived a long life) may help ease the initial numbness of the actual
death. Statements of relief, such as “he or she is no longer in pain,” may help the bereaved cope
with the immediate loss. The grieving process is considered difficult work that may last for
years, and it is hard to endure at times. Past death experiences, emotional health, religious
beliefs, and support of friends and family all are factors which may help ease the grief process.
Bereavement is the process one undergoes after a loss. Grief is the emotion felt after the loss.
The period of mourning is the recovery from the loss.
Several studies have shown that the accumulation of losses compounds the effects of grief
and bereavement associated with death in older adults (Konigsberg, 2011). The widow or
widower may experience grief for many years. Phases of grief may include some of the
following:
Numb shock: The widow or widower cannot believe the spouse’s death occurred. This phase is
marked by shock, emotional dullness, and restless behavior that may include stupor and
withdrawal. It may include physical characteristics such as nausea or insomnia. One wants to
protect oneself from the feeling of loss.
Emotional turmoil or depression: Alarm or panic-type reactions occur. Emotional expression
may include crying, low mood, sleep disturbance, and anorexia. Anger, guilt, or longing for
the deceased may take place. The widow or widower may also become preoccupied with the
meaning of the loss.
Reorganization or resolution: Reorganization eventually takes place, and coping strategies and
positive outlooks emerge. A final resolution phase leads to acceptance of the loss. The
widow or widower may return to prior levels of functioning.
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When the full effects of death and its associated consequences set in, so do regret, self-
doubt, and at times, despair. Life’s purpose becomes confusing, and mood swings are prevalent.
Being alone in the house may be a major problem. Research has shown that an active listener for
reminiscence is helpful to the older adult during grief work. The nurse may also encourage the
surviving spouse to focus on activities such as volunteer work. While actively participating in
such activities, older adults often find the affection and companionship they need at this time.
Caring for the Caregiver
Most community health nurses not only care for the seriously ill person but also support and
guide family caregivers. To prevent feelings of stress and burnout, those people who care for the
dying need support and an opportunity to express emotional responses and grief. A periodic
assessment might be beneficial for the caregivers who provide end-of-life care. Some questions
may include the following:
What have you done to meet your own needs today?
Have you laughed today?
Did you eat properly, rest enough, exercise, and play today?
What have you felt today?
Do you have something to look forward to?
Caregivers need to care for themselves to prevent anger, frustration, and anxiety. This makes
it possible for the caregivers to continue to be sensitive to the needs of the dying person.
I didn’t attend the funeral, but I sent a nice letter saying I approved of it. Mark Twain
COMPLEMENTARY AND ALTERNATIVE THERAPIES
Seriously ill persons and families may request complementary and alternative medicine (CAM)
concomitantly with hospice and palliative care. Use of CAM has great potential when integrated
with traditional medical practices in end-of-life care. Traditional medicine may share the
spotlight with such therapies as acupuncture, massage therapy, Reiki therapy, chiropractic care,
and herbal medicine. In 1998, the National Institutes of Health initiated the National Center for
Complementary and Alternative Medicine (NCCAM) now renamed National Center for
Complementary and Integrative Health (NCCIH). NCCIH is dedicated to exploring
complementary and alternative healing practices in the context of rigorous science, training
researchers, and disseminating authoritative information to the public and professionals.
Although for many complementary therapies rigorous evidence of effectiveness is lacking, many
persons who have used integrative health therapies at the end of life have reported that these
therapies have physical, psychosocial, and spiritual benefits.
The CDC reports that in 2007, 41.8% of hospice care providers offered CAM services, had a
CAM provider on staff or under contract, or both. Among hospice care providers offering CAM,
over one half offered massage (71.7%), supportive group therapy (69.0%), music therapy
(62.2%), pet therapy (58.6%), or guided imagery or relaxation (52.7%) (Berkovitz, Sengupta,
Jones, & Harris-Kojetin, 2011). Massage and mind–body interventions are cited as successful
strategies for easing anxiety, emotional distress, nausea, and pain while improving overall
comfort levels (HPNA, 2015).
Within the context of quality end-of-life care, the nurse must respect the unique needs of
each seriously ill person and his or her family. Several factors may cause people with serious
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illness to seek complementary therapies: they may hope that these alternative methods will
succeed where traditional medicine has failed, they may be attempting to regain control over
life-threatening disease, or they may hope to achieve relief of suffering and improved quality of
life. HPNA (2015) has developed a position statement regarding the use of complementary
therapies in end-of-life care. According to this position statement, nurses working in end-of-life
care need to learn about the many types of complementary therapies because the goals of CAM
to reduce suffering and enhance comfort are consistent with the goals of palliative care and
hospice nurses. Nurses should also be aware of the increasing use of complementary therapies,
recognize the role of CAM in symptom relief, and support the appropriate practice of
complementary therapies to promote holistic end-of-life care (HPNA, 2015).
KEY CONCEPTS
Studies have documented that the American healthcare system has substantial shortcomings in the care of
seriously ill persons and their families.
Many persons die in pain or suffering from adverse symptoms.
Aggressive care that carries a high burden of treatment is often delivered inappropriately to seriously ill
persons because of communication barriers and lack of planning.
The community health nurse can play a key role on the interdisciplinary team and serve as advocate,
educator, care provider, and planner of quality end-of-life care.
Pain and symptom control are crucial to the delivery of quality end-of-life care.
Cultural and ethnic variations are key factors to be considered when providing end-of-life care.
Palliative care and hospice programs can assist the nurse in the delivery of quality end-of-life care to
seriously ill persons and their families.
Families often rely on the nurse for support and assistance during the dying process and afterward in the
mourning and grieving period.
CRITICAL THINKING QUESTIONS
1. Speak to nurses and nursing assistants who work in one of your clinical rotations about the assessment of
pain in the dying person. What factors do they identify as important?
2. Explain possible reasons why caring for dying persons at the end of life may be difficult. Tell a story in a
small group of fellow students and observe their reactions.
3. Keep a clinical journal of your feelings and experiences as you begin to become proficient in providing
end-of-life care to seriously ill persons and their families.
4. Identify a few key people in your life who can help you as you struggle to become proficient in the
provision of end-of-life care.
5. Identify key people in your life who helped you to come to terms with and understand death.
6. Establish your own advance directive and name a healthcare proxy.
COMMUNITY RESOURCES
Local hospitals that have hospital-based palliative care or hospice home care programs
Local palliative care specialists
Visiting nurse associations
Volunteer church groups and friendly visitors
Elder affairs
Local and state health departments
State and Federal offices of Medicare and Medicaid
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Specialty disease organizations such as the American Cancer Society, The Alzheimer’s Association, The
American Heart Association, and others as needed
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http://www.who.int/cancer/palliative/definition/en/
Chapter 25
Occupational Health
Nursing
Christine Pontus and Patricia Goyette
For additional ancillary materials related to this chapter. please visit thePoint
Everything that is really great and inspiring is created by the individual who can labor in
freedom.
Albert Einstein
If you cannot work with love but only with distaste, it is better that you should leave your work.
Khalil Gibran
Oh, you hate your job? Why didn’t you say so? There’s a support group for that. It’s called
everybody, and they meet at the bar.
Drew Carey
CHAPTER HIGHLIGHTS
Characteristics of the worker and workplace
Roles and responsibilities of occupational health nurses
Models for occupational health practice
Worker and workplace assessment
Health promotion in workplace settings
Use of epidemiologic techniques in occupational health
Emergency preparedness and disaster management
Emerging issues in occupational health nursing practice
OBJECTIVES
Explain the role of nursing in occupational health.
State current trends in the U.S. workforce.
Describe the four types of exposures and hazards in the workplace.
Provide examples of common work-related injuries and illnesses.
Explain the interaction of agent, host, and environment as applied to the workplace.
Outline the steps involved in both worker and workplace assessment.
Describe potential benefits to both workers and businesses in offering health promotion programs.
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Explain how principles of epidemiology are applied to occupational health.
Assess specific components within an emergency preparedness plan that will vary from industry to
industry based on risk.
Describe how emerging technology, such as nanotechnology may impact occupational health practice.
KEY TERMS
American Association of Occupational Health Nurses (AAOHN): Professional association for
nurses working in a business setting, dedicated to the health and safety of workers, worker
populations, and community groups.
Biologic hazards: Hazards resulting from living organisms that cause adverse effects on people.
Chemical hazards: Generated from liquids, solids, dusts, fumes, vapors, and gases.
Ergonomics: Study of the relationship between people and their working environments.
Nanotechnology: Manipulation of matter on a near-atomic scale to produce new structures,
materials, and devices; generally defined as engineered structures, devices, and systems.
Nanomaterials: Things that have a length scale between 1 and 100 nm.
National Institute of Occupational Safety and Health (NIOSH): The federal agency
established to help ensure safe and healthy working conditions by conducting scientific
research, gathering information, and providing education and training in occupational safety
and health.
Occupational health history: An assessment of the characteristics of the workers’ present jobs,
a chronologic record of all past work and potential exposures, an occupational exposure
inventory, and a list of other exposures in the home or community.
Occupational Safety and Health Administration (OSHA): The federal agency that sets
exposure standards and is responsible for enforcement of safety and health legislation.
Physical hazards: Hazards that result from the transfer of physical energy to workers.
Psychosocial hazards: All organizational factors and interpersonal relationships in the
workplace that may affect the health of the workers.
Root cause analysis: A process for understanding and solving a problem, with the goal of
determining what happened, why it happened, and what can be done to prevent its
reoccurrence.
Workplace walk-through: A complete survey of the workplace, inside and outside, compiling
information as to the presence of hazards, the location of entries and exits, the availability of
emergency equipment, and potential trouble spots.
CASE STUDIES
References to the case studies are found throughout this chapter (look for the case study icon).
Readers should keep the case studies in mind as they read the chapter.
CASE 1
A 32-year-old female bank employee suddenly stops breathing while at work. A coworker calls
rescue (911), and emergency medical technicians rush her to the hospital. Later, physicians
determine that she suffered respiratory arrest related to an anaphylactic reaction. An occupational
health nurse (OHN) investigates both the hospitalization and the workers’ compensation claim
because the incident occurred at the place of employment. This investigation clarifies the incident
and identifies its underlying cause, so that measures can be taken to prevent it from happening to
other workers.
On receiving the case briefing from both the loss prevention and the claims management
departments, the OHN reviews the file and speaks to the worker and her supervisor. The worker
said that she had an anaphylactic reaction and that her supervisor told her not to return to work
until physicians discovered and medically confirmed the cause of her reaction. She has an
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appointment with an allergist about a possible allergy.
CASE 2
At the opening of business on a Friday morning, four people enter the occupational health clinic at
a factory. The employees complain of nausea, vomiting, diarrhea, fatigue, and headache. The
OHN, concerned that a common exposure caused these workers to become ill, discovers that all
four attended the company picnic the day before. A phone call to human resources reveals that
more employees who attended the picnic have called in sick with complaints of nausea, vomiting,
and diarrhea. At the picnic, the food included hamburgers; sausage and pepper sandwiches;
potato, chicken, and tossed salad; and beverages such as chocolate milk, soda, and water. The
OHN talks to the kitchen manager. Apparently, there have been recent problems with heat
regulators, a refrigeration unit, newly hired help, and the training of cafeteria workers. The nurse
immediately calls the Department of Public Health.
INTRODUCTION
Occupational health nurses (OHNs) can be found in as many diverse settings as there are types
of employment for workers. They observe and care for the community, group, business, or
organization as a whole. This chapter presents an overview of the discipline, work, regulations,
and conditions associated with the healthcare of the workforce, both nationally and
internationally. It is hoped that this information will heighten an awareness of the kinds of care
provided in the community workplace environment.
THE WORKER AND THE WORKPLACE
Work is an integral part of life for most people, providing challenging and worthwhile
experiences that evolve and change over time. On average, employed adults spend about one
third of their time at work. Health risks are inherent in every industry, and as the workplace
changes, the risk that workers will experience adverse health effects related to employment also
changes. Although the potential for serious adverse health effects from exposure to dangerous
substances or less-than-optimal conditions is associated with every occupation, the majority of
workers do not experience hazards in the workplace. The common workplace exposures and
hazards listed in Table 25.1 indicate that there are a wide variety of potential threats to health.
The specialty of occupational health focuses on the identification and control of risks to health
which occur as a result of physical, chemical, and other workplace hazards. The goal is to
establish and maintain a safe and healthy environment for workers. Occupational health is
closely allied to the specialty of environmental health, a field of public health science that
focuses on how the environment influences human health (see Chapter 19). Ergonomics, the
study of the relationship between people and their working environment, emerged during the
20th century. Also called biotechnology and human engineering, ergonomics is the applied
science of equipment design, intended to maximize productivity by reducing operator fatigue
and discomfort.
Designing your product for monetization first and people second will probably leave you
with neither. Tara Hunt, marketing consultant
In July 2017, there were approximately 160 million people in the workforce in the United
States, an increase from 2015 workforce of 157 million (U.S. Department of Labor, Bureau of
Labor Statistics [BLS], 2017). The U.S. Bureau of Labor Statistics also indicates that 3.3 of 100
workers in all industries, including state and local governments, have a reportable injury or
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illness. In contrast, in 2015, when state and local governments, which are responsible for
protection of the public, were removed from the calculations, there were 3.0 cases per 100
workers in private industry. The trends illustrated in Figure 25.1 show that small companies
have a lower rate of injury and illness over time, and companies with between 50 and 249
employees have consistently had the highest rates. The trends shown in Figure 25.2 indicate the
private industries that had at least 50,000 nonfatal occupational injuries and illnesses in 2015,
and showed that general medical and surgical hospitals were at the top of the list.
Table 25.2 shows the incidence rates of occupational injuries and illnesses by industry and
case types in 2015. The case rate reflects the total number of reportable events that occurred, the
majority of which are mild, such as strains and sprains. The case rate for days away from work
indicates that a more serious injury or illness occurred that required time away from work. The
resulting costs amount to billions of dollars each year. The injuries and illnesses occur at places
of business; therefore, this spreads the costs to consumers in the form of higher prices, to
workers in the form of lower wages, and to taxpayers.
Injuries were the most common result of workplace hazards. The majority of the 2.9 million
nonfatal workplace injuries and illnesses reported in 2015 were injuries. Seventy-five percent of
these injuries occurred in service-providing industries such as healthcare, professional, and
technical businesses (U.S. Department of Labor, BLS, 2016a). Table 25.3 indicates that the
highest incidence rate of injuries resulting in days away from work occurred from sprains,
strains, and tears, followed by cuts and bruises. Workplace illnesses, most of which are
associated with repetitive strain (i.e., carpal tunnel), accounted for only 0.5% of the total injury
and illness cases in 2015 contributing to the most days away from work (U.S. Department of
Labor, BLS, 2016b).
TABLE 25.1 Common Workplace Hazards and Exposures
Biologic Hazards Chemical Exposures Physical Hazards Psychosocial Factors
Infectious agents Hazardous drug and toxin
exposures
Electric and magnetic
fields
Sexual harassment
Contaminated body fluids Diesel exhaust Ultraviolet radiation Psychological stress
Poisonous plants Aerosols Cold stress Interpersonal problems
Insects, scorpions, spiders Respirable particulate
matter and fumes
Heat stress Assaults and violent acts
Venomous snakes Take-home toxins
(reached workers’ home
and families)
Noise
Vibration
Lighting
Bodily reaction and
exertion
Substances in cleaning
solutions, for example,
floor strippers,
disinfection, and
sterilization products
Falls
Fires and vibration
Particulate inhalation
Unsafe machinery and
equipment
Abrasive blasting
Inadequate workstations
Transportation accidents
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FIGURE 25.1 Total recordable nonfatal occupational injury and illness incidence rates by
employment size class, private industry, 2011 to 2015. (From Bureau of Labor Statistics, U.S.
Department of Labor. [2017]. Workplace Injuries and Illnesses—2016. Retrieved from
http://www.bls.gov/news.release/pdf/osh .)
Unfortunately, deaths do occur in the workplace. In 2015, a total of 4,836 workers in the
United States died as a result of injuries sustained at work. Figure 25.3 shows the number and
rate of fatal occupational injuries by industry sector in 2015. Note that Figure 25.3 depicts that
the number of fatal injuries related to transportation is the highest. Figure 25.4 shows the manner
in which these occupational fatalities occurred. More work-related fatalities resulted from
transportation incidents than from any other event. In 2015, 3.4% of all workers had an injury or
illness related to the workplace; these statistics reflect a slight decrease from 2011 (U.S.
Department of Labor, BLS, 2016c).
FIGURE 25.2 Industries with at least 50,000 nonfatal occupational injuries and illnesses, private
industry, 2015. (From U.S. Bureau of Labor Statistics, U.S. Department of Labor. [2016]. Number
of nonfatal occupational injuries and illnesses by industry and case type 2015. Retrieved from
https://www.bls.gov/news.release/pdf/osh .)
TABLE 25.2 Incidence Rates of Nonfatal Occupational Injuries and Illnesses
by Industry and Case Types, 2015
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Industry Case Rate (%) Case Rate for
Days away from
Work (%)
Natural resources and mining 3.7 2.2
Construction 3.5 2.0
Manufacturing 3.8 2.2
Service providing 2.9 1.5
Trade, transportation, and utilities 3.6 2.2
Information 1.3 0.8
Financial activities 1.1 0.6
Professional and business services 1.4 0.7
Education and health services 4.0 1.9
Leisure and hospitality 3.5 1.5
Other services 2.3 1.2
Public administration 4.0 2.0
Total for all industries, including state and local government 3.3 1.0
Source: U.S. Bureau of Labor Statistics, U.S. Department of Labor Statistics. (2016). Incidence rates of nonfatal occupational injuries and illnesses by industry
and case types, 2015. Retrieved from http://www.bls.gov/news.release/osh.htm.
TABLE 25.3 Statistics on Occupational Injuries and Illnesses, Involving
Days Away From Work in Private Industry, State Government, and Local
Government, 2015
Characteristics Incidence Rate
Per 10,000 Full-
Time Workers
Median Days
Away From Work
Sprains, strains, tears 38.0 10
Cuts, lacerations, punctures 8.1 4
Bruises, contusions 9.1 3
Fractures 8.9 31
Multiple traumatic injuries 2.8 10
Heat (thermal) burns 1.6 5
Carpal tunnel syndrome 0.5 28
Amputations 0.5 22
Chemical burns 0.3 3
Tendonitis 0.2 14
Source: U.S. Bureau of Labor Statistics, Survey of Occupational Injuries and Illnesses, in cooperation with participating state agencies.
https://www.bls.gov/news.release/osh2.htm.
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https://www.bls.gov/news.release/osh2.htm
FIGURE 25.3 Number and rate of fatal occupational injuries, by industry sector, 2015. Note: Fatal
injury rates exclude workers under the age of 16 years, volunteers, and resident military. The
number of fatal work injuries represents total published fatal injuries before the exclusions. For
additional information on the fatal work injury rate methodology, please see
https://www.bls.gov/news.release/archives/cfoi_12162016 . (Source: U.S. Bureau of Labor
Statistics, Current Population Survey, Census of Fatal Occupational Injuries, 2016.)
FIGURE 25.4 Fatal occupational injuries in 2015 (National Census Preliminary Report). (Bureau of
Labor Statistics, U.S. Department of Labor. [2017]. National census of fatal occupational injuries in
2015. Retrieved from https://www.bls.gov/iif/oshwc/cfoi/cfch0014 .)
Occupational health is a responsibility assumed by nurses worldwide. The World Health
Organization (WHO) (2001) published a document describing the role of the OHN in workplace
health management. This document reflects WHO’s global plan to protect and promote workers’
health in the workplace, enabling people to increase control over their health and avoid
workplace hazards to their health.
OCCUPATIONAL HEALTH NURSING
Occupational health nursing and environmental health nursing are intertwined (see Chapter 19).
The American Association of Occupational Health Nurses (AAOHN) represents both
specialties. Occupational/environmental health nursing is defined as a specialty practice which
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https://www.bls.gov/iif/oshwc/cfoi/cfch0014
provides for and delivers health and safety programs and services to workers, worker
populations, and community groups. Practice focuses on promotion and restoration of health,
prevention of injury and illness, and protection from occupational and environmental hazards.
Practitioners combine their knowledge of public health and business with their healthcare
expertise to provide a safe and healthy work and community environment. The clients may be
individual workers, the work community, or the organization as a whole. This nursing specialty
is multidisciplinary, practiced through the integration of knowledge from a variety of
disciplines, including nursing, medicine, social and behavioral sciences, management, public
health, and occupational health specialties such as toxicology, industrial hygiene, and
ergonomics.
History
The earliest record of occupational health nursing, originally called industrial nursing, began a
few years after Florence Nightingale opened the “Nightingale Training School for Nurses” in
1860. In 1867, J. & J. Colman, a mustard company, hired Phillipa Flowerday in Norwich, Great
Britain. Many consider her employment at this company the earliest recorded evidence of a
company specifically hiring an industrial nurse to work in the dispensary and provide home care
services to workers and their families.
In 1885, the Vermont Marble Company hired Ada Mayo Stewart to care for employees and
their families, and she may have been one of the first “industrial nurses.” Often arriving by
bicycle, Ada conducted home visits providing care for ill workers and focused on teaching
healthy living habits to families. In 1888, a group of coal mining companies hired Betty
Moulder, a graduate of what is now Philadelphia General Hospital, to provide nursing care for
injured and ill workers and their families. Unfortunately, not much information is available
about her duties, background, or accomplishments.
Industrial nursing grew rapidly along with the growth of industry in the early 20th century.
People recognized that the provision of health services in the workplace led to more worker
productivity. Factories employed nurses to combat the spread of infectious diseases such as
tuberculosis, and to address health-related problems resulting from labor shortages during World
War I. There were several thousand industrial nurses by World War II, and the establishment of
educational programs along with professional organizations followed. The AAOHN formed in
1942, with 16 states represented by 300 nurses, and some member nurses created the American
Association of Industrial Nurses (AAIN). The intent of AAOHN was to improve occupational
health program services while enhancing career opportunities for occupational and
environmental health nurses (AAOHN, n.d.a).
In the United States, Congress passed several laws in the 1960s and 1970s to protect the
safety and health of workers, leading to an increased need for OHNs. The 1968 Mine Safety and
Health Act required the first prevention programs for workers. In 1970 came the Occupational
Safety and Health Act, which established two government agencies, the Occupational Safety
and Health Administration (OSHA), and the National Institute of Occupational Safety and
Health (NIOSH). The mission of OSHA is to prevent work-related injuries, illnesses, and
fatalities by setting federal standards regulating workers’ exposures to potentially toxic
substances. Regulations, data, and information regarding compliance assistance, training
programs, and consultation are available at the OSHA website. The purpose of NIOSH is to help
ensure safe and healthy working conditions by conducting scientific research, gathering
information, and providing education and training in occupational safety and health. The
organization provides leadership worldwide by fostering the translation of new knowledge into
products and services. The NIOSH website contains more information about its activities.
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Standards of Practice
OHNs can be found in almost every industry, from manufacturing and construction to public
administration and leisure and hospitality businesses. They collaborate with employees,
employers, members of the occupational health and safety team, and other professionals to (1)
identify health and safety needs, (2) prioritize interventions, (3) develop and implement
interventions and programs, and (4) evaluate care and service delivery (AAOHN, 2012a). Their
scope of practice encompasses a broad range of activities that are discussed later in this chapter.
As the professional association for occupational and environmental health nurses, the
AAOHN establishes and promulgates standards to define and advance the practice within a
framework for evaluation. These statements describe the accountability of the practitioner and
reflect the values and priorities of the profession. AAOHN has identified 11 professional
practice standards that describe a competent level of performance with regard to the nursing
process and professional roles of the occupational and environmental health nurse. Criteria
developed for each standard are key indicators of competent practice and permit occupational
and environmental health nurses to evaluate their practice relative to the standards (AAOHN,
2012b). These standards can be accessed online.
The AAOHN identifies nine categories of competency in occupational and environmental
health nursing. OHN competencies are associated with specific guidelines as they relate to all
OHNs who function in various workplace settings. Different settings require different levels of
competency and specific skill sets. Benner (1984) identified five stages of competency in
clinical nursing practice: novice, advanced beginner, competent, proficient, and expert. Within
each stage are levels of achievement that are expressed in measurable behavioral objectives.
AAOHN has cross-referenced and stated behavioral objectives for the OHN in three of these
stages: competent, proficient, and expert. This establishes criteria for individual nurses and those
in management positions to use in their own professional development. AAOHN (2007)
competency levels in occupational and environmental health nursing are listed in Box 25.1.
The nicest thing about standards is that there are so many of them to choose from. Ken
Olsen, founder, Digital Equipment Corporation
Environmental issues, conditions, and activities unique to OHN practice are addressed in the
AAOHN Delivery of Occupational and Environmental Health Services position statement
(AAOHN, 2012a). AAOHN makes the assertion that based on training, education, and
experience, the licensed OHNs are in the best position to deliver comprehensive occupational
and environmental health services and workplace programs. Today, the scope of practice is
broad, including disease management, environmental health, emergency preparedness, and
disaster planning in response to natural, technologic, and human hazards in the work and
community environment (AAOHN, n.d.a).
25.1 AAOHN Competency Levels in Occupational and Environmental Health
Nursing
Competent—A nurse who is confident and a master with an ability to cope with specific situations.
There is less of a need to rely on the judgment of peers and other professionals (Benner, 1984).
Example: A competent occupational and environmental health nurse recognizes a range of practice
issues and functions comfortably in roles as clinician, coordinator, and case manager following
company procedures, utilizing assessment checklists and clinical protocols to provide treatment.
Proficient—A nurse with the ability to perceive client situations based on past experiences, with focus
on relevant aspects of the situation. The nurse is able to predict expected events in certain situations
and recognize that protocols must be altered at times to meet the needs of the client (Benner, 1984).
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Example: A proficient occupational and environmental health nurse quickly obtains the information
needed for accurate assessment and moves quickly to the critical aspects of a problem, within priority
setting and structural goals, in response to a client’s situation. The nurse usually possesses
sophisticated clinical or managerial skills in the work and/or community environment.
Expert—A nurse having extensive experience with a broad knowledge base that enables one to grasp a
situation quickly and initiate action. The nurse has a sense of salience grounded in practice guiding
actions and priorities (Benner, 1984). Example: An expert occupational and environmental health
nurse provides leadership in developing occupational safety and health policy within the
organization, functions in upper executive or management roles, serves as a consultant to business
and government, and designs and conducts significant research.
Source: Used with permission from American Association of Occupational Health Nurses. (2007). Competencies in occupational and environmental health
nursing. American Association of Occupational Health Nurses, 55(11), 442–447.
The OHN must also adhere to a code of ethics that is based on the belief that the goal of
occupational and environmental health nurses is to promote workers’ health and safety. The
purpose of the AAOHN Code of Ethics is to serve as a guide for registered professional nurses
to maintain and pursue professionally recognized ethical behavior when providing occupational
health services (AAOHN, 2012a).
Founded in 1972, the American Board of Occupational Health Nurses (ABOHN) is an
independent nursing specialty certification board. ABOHN is the sole certifying body for OHNs
in the United States. Standards of nursing practice are used to validate an individual registered
nurse’s qualifications, knowledge, and practice in specific areas of occupational health nursing
(ABOHN, 2012a). ABOHN awards four credentials: Certified Occupational Health Nurse
(COHN), Certified Occupational Health Nurse–Specialist (COHN–S), Case Management (CM),
and Safety Management (SM). More information can be obtained from the ABOHN website
(ABOHN, 2012b).
CONCEPTUAL FRAMEWORKS
The Epidemiologic Triad
The epidemiologic triad, discussed in detail in Chapter 6, is very helpful in occupational health
nursing practice as a means to understand the complex relationships among the workers, hazards
in the workplace, and hazards in the environment (Fig. 25.5).
Practice Point
Applying the epidemiologic triad model to the specific workplace helps OHNs understand the
interaction between hazards, workers, and the environment.
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FIGURE 25.5 The epidemiologic triad for the workplace.
Host
In the epidemiologic triad, each worker is a host within the work population. Each person (host)
has his or her own innate, nonmodifiable characteristics, some of which put him or her at risk for
workplace injury or illness. For example, age, gender, and ethnicity are nonmodifiable
characteristics, whereas lifestyle, work practice, and to some degree, health status are modifiable
characteristics. New workers with less than one year of experience are the most susceptible to
injury. In contrast, older workers, who may have chronic illness, hearing loss, vision difficulties,
or delayed reaction times, may adversely react to workplace hazards more frequently. Some
workers are hypersusceptible, developing reactions, even though their exposure levels are below
those determined to be safe.
Agent
The agents in the epidemiologic triad are workplace hazards classified as biologic, chemical,
physical, or psychosocial hazards (see Table 25.1).
BIOLOGIC AGENTS
Biologic agents include hazards from living organisms that have adverse effects. Although
human illness often occurs from exposure to microorganisms, toxins released from
microorganisms, insects, or animals are also biologic agents. Healthcare settings are particularly
vulnerable to biologic hazards, and transmission of resistant infectious organisms is a major
concern (see Chapter 14). Healthcare personnel are cognizant of potential exposures, but many
workers such as maintenance workers, security personnel, and cleaners may be inadvertently
exposed by trash, soiled linens, and contaminated equipment, which may result in illness.
CHEMICAL AGENTS
As industry grows, there is increasing general chemical contamination at work, at home, and in
the community. Less than one percent of the two million chemicals used in industry have been
studied for their effects on humans. Through ingestion, respiration, and injury, these
environmental chemicals enter the body, and although exposure may be less than the maximal
exposure standards (if they exist), the chemicals often accumulate, leading to a potentially
chronic or life-threatening condition. There are many examples of illnesses resulting from
chemical exposures. It has been known for decades that miners exposed to coal dust can suffer
from pneumoconiosis, or black lung disease. Inhalation of asbestos may cause mesothelioma, a
rare form of cancer found in the lining of the heart, lungs, abdomen, or the internal reproductive
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organs. Radiation exposure during pregnancy can result in congenital malformations, as can
exposure to heavy metals and antineoplastic drugs. Interaction between the various chemicals
entering the body also occurs, making it very difficult to predict the effects on health.
PHYSICAL AGENTS
Physical agents are sources of energy that may lead to injury or illness. Vibration produced
through use of power tools may contribute to Raynaud phenomenon, which is vasoconstriction
of the small arteries in fingers or toes, triggered by cold or emotional upset. Vibrations
associated with some power tools and trucks may adversely affect internal organs. Other
common physical agents are radiation, temperature extremes, noise, lighting, falls, and unsafe
equipment. Monitoring exposure to such agents and use of personal protective equipment such
as preventive clothes, eye guards, and hearing protection are common practice in industry.
Evidence for Practice
Initial recognition of latex allergy occurred in the late 1970s. Healthcare workers are at risk
through exposure to latex gloves or medical products containing latex. It is estimated that
8% to 12% of healthcare workers are latex-sensitive (OSHA, n.d.f). Hundreds of everyday
products contain latex. Repeated exposure to the protein in natural latex can make a person
more likely to develop a latex allergy. It usually begins within minutes of exposure but can
sometimes occur hours later. It produces varied symptoms, which commonly include runny
nose, sneezing, itchy eyes, scratchy throat, hives, and itchy burning sensations. However, it
can involve more severe symptoms including asthma marked by difficult breathing,
coughing spells, and wheezing; cardiovascular and gastrointestinal ailments; and in rare
cases, anaphylaxis and death (CDC, 2013). Healthcare workers with suspected latex
allergy may use nonlatex nitrile, synthetic rubber, or vinyl gloves.
PSYCHOSOCIAL AGENTS
Psychosocial agents include all organizational factors and interpersonal relationships in the
workplace that may affect the health of the workers. Psychosocial hazards are as real as physical
hazards, and if not recognized and controlled, they potentially can have a very negative impact.
Studies have found that workers who have a high expectation for productivity, yet little or no
control over their workplace and little reward for their efforts, are at risk for psychosocial
distress. Stress, anger, and frustration can result in aggressive behavior, harassment, sabotage of
the work or the work of others, poor physical and mental health, and disregard of safety
measures. These feelings are enhanced if there is a perception of employer unfairness. Multiple
studies have indicated that nurses have a wide range of occupational factors linked to stress such
as work overload, time pressure, exposure to infectious diseases, needlestick injuries, and
understaffing (NIOSH, 2008). Linked to psychosocial hazards are issues such as workplace
violence. There are several risk factors related to workplace violence in healthcare (Box 25.2).
Employers have increasingly developed strategies to manage the risks associated with
psychosocial hazards. Examples include identifying the psychosocial hazards at the workplace,
assessing ways to decentralize control, addressing workers’ concerns about the workplace, and
implementing systems to enable workers to report unacceptable behavior.
25.2 Workplace Violence Risk Factors in Health Care
Patient, Client, and Setting-Related Risk Factors
Working directly with people who have a history of violence, abuse drugs or alcohol, gang members, and
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relatives of patients or clients
Transporting patients and clients
Working alone in a facility or in patients’ homes
Poor environmental design of the workplace that may block employees’ vision or interfere with their
escape from a violent incident
Poorly lit corridors, rooms, parking lots, and other areas
Lack of means of emergency communication
Prevalence of rearms, knives and other weapons among patients and their families and friends
Working in neighborhoods with high crime rates
Organizational Risk Factors
Lack of facility policies and staff training for recognizing and managing escalating hostile and assaultive
behaviors from patients, clients, visitors, or staff
Working when understaffed—especially during mealtimes and visiting hours
High worker turnover
Inadequate security and mental health personnel on site
Long waits for patients or clients and overcrowded, uncomfortable waiting rooms
Unrestricted movement of the public in clinics and hospitals
Perception that violence is tolerated and victims will not be able to report the incident to police and/or
press charges
Source: U.S. Department of Labor Occupational Safety and Health Administration. (2016). Guidelines for Preventing Workplace Violence for Healthcare and
Social Service Workers. Retrieved on September 13, 2017, from https://www.osha.gov/Publications/osha3148 .
Of all man’s miseries the bitterest is this, to know so much and to have control over
nothing. Herodotus
Evidence for Practice
The National Institute of Occupational Safety and Health (2008) defines occupational stress
as “the harmful physical and emotional responses that occur when the requirements of the
job do not match the capabilities, resources, or needs of the worker.” Strategies
recommended by NIOSH to reduce workers’ stress include distribution of workloads that are
matched with workers’ capabilities and resources, clearly defined workers’ roles and
responsibilities, as well as methods to improve communication within the organization.
NIOSH also suggests that workers be offered opportunities to participate in decisions and
actions affecting their jobs. This process reduces uncertainty about career development and
future employment prospects. OHNs should be cognizant of stress in the workplace and
incorporate the strategies recommended by NIOSH in planning interventions.
Environment
The workplace exists within an external environment with specific geologic and atmospheric
characteristics, air and water quality, and presence or absence of environmental pollution.
Sometimes unanticipated results come from a difficult mix of agent, host, and environment
characteristics. For example, patients in the intensive care unit of a major Chicago hospital were
negatively affected by automobile exhaust from a highway a few hundred feet away. Replacing
the air conditioning system solved the problem. Economic and political decisions can affect the
public health infrastructure and, therefore, the health of a society. Factors such as adequate
housing, literacy, crowding, culture, customs, and availability and accessibility of healthcare
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https://www.osha.gov/Publications/osha3148
services are issues to be addressed. Social problems occurring from alcohol and substance abuse,
infectious diseases, and poverty can have an impact on workforce productivity.
Practice Point
There is a level of acceptable risk in any work setting. The primary goal is to lower the
accepted level of risk of injury and illness associated with employment.
Practice Models
Figure 25.6 illustrates the Hanasaari model. This framework takes into account all the factors
affecting people at work, a total environment concept. A group of OHNs developed this model
at a workshop in Hanasaari, Finland, in 1989. Endorsed by the Federation of Occupational
Health Nurses within the European Union (FOHNEU), it is now the basis for practice,
education, and research throughout the European Union. The model presents an outer circle that
represents the total global concept, covering all aspects of health and safety affecting the worker
population in the general environment. Extending out from the center (occupational health
nursing) are the social, political, ecologic, organizational, and economic factors that influence
the global environment. The man-work-health triangle indicates that the total environment can
have a significant effect on workplace health. Political and social policies, for example, either
expand or contract the development of occupational health.
FIGURE 25.6 The Hanasaari conceptual model for occupational health nursing (OHN). OHN is
presented in the center of the model. The curving circle of arrows represents flexibility, influence,
and eventual improvement in the health of people at work and in the total community environment.
(From Alston, R. M., et al. [1989]. Workshop for Occupational Health Nurses, Hanasaari, Finland
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[Unpublished manuscript]. Retrieved from
http://www.fohneu.org/hanasaari_conceptual_model_for_o.htm.)
A more recent model proposed by Thomason and Lagowski (2008) is one of collaboration
and reciprocation while using the nursing process. Earlier models have not focused on the key
concept of engaging clients in reciprocal relationships. This approach suggests that the OHN
should use leadership and interpersonal relationship skills which foster communication and
respect through continuous feedback from workers and community. The model provides a
means of engaging and collaborating with clients in restoring and maintaining health, well-
being, and workplace safety. Figure 25.7 illustrates the five steps of collaboration between the
nurse and the client.
One of the tests of leadership is the ability to recognize a problem before it becomes an
emergency. Arnold Glasgow, psychologist
The OHN must deal with individual, family, and community issues that often involve
medical, legal, and regulatory factors. Forces may contradict and hinder health and safety
priorities unless the OHN can communicate and act to resolve the issues. For example, a
system’s approach can be very effective within a single department or division. However, the
same system may fail when interfacing with other activities of the workplace within a
community. It is often the workers who take the responsibility to correct an unplanned problem,
and they may choose to put themselves at risk. Without recognition, support, and ongoing
communication with workers, the risk may not be apparent. It is through reciprocation during
these crucial moments of a worker’s life that an OHN can help sustain and maintain worker and
community health.
FIGURE 25.7 Reciprocation model. (From Thomason, D. A., & Lagowski, L. R. [2008]. Sustaining
a healthy work force in the 21st century—A model for collaborating through reciprocation. Journal
of American Association of Occupational Health Nursing, 56[12], 503–513.)
A large number of OHNs find employment in the field as individual, privately contracted
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http://www.fohneu.org/hanasaari_conceptual_model_for_o.htm
professionals. It is common for many occupational and environmental health nurses to work in
more than one designated role concurrently while employed by the same company (Zichello &
Sheridan, 2008). One particular practice model includes corporate OHNs who often have a
master’s degree. They can be responsible for managing the implementation of occupational
health goals and objectives for other nurses in various facilities.
The ABOHN (2012b) conducted a 2011 Occupational Health Nursing Practice Analysis.
Respondents revealed the majority of nurses are female (95.1%; male, 4.9%), and most do not
have global responsibility. Nurses spend the greatest amount of time in two practice areas:
health and wellness activities, and case management (ABOHN, 2012b). Midsize to larger
companies may have more than one occupational and/or environmental health nurse on site. In
large companies, there can be nurses and physicians, including advanced practice nurses, in
nurse practitioner roles.
There are various ways nurses enter and function in OHN positions. Most employers
conduct a job search for an OHN, OHN manager, or a nurse practitioner and are specific about
the education and experience required. Many employers look for a board-certified (ABOHN)
nurse who has at least a bachelor of science in nursing, with three to five years’ nursing
experience. Some employers search for an advanced practice nurse or nurse practitioner who is
prepared at the master’s level. In recent years, licensed practical nurses (LPNs) and licensed
vocational nurses (LVNs) are found to work in specific roles and function as team members with
other OHNs who may delegate and manage activity as necessary (AAOHN, 2012a).
OCCUPATIONAL HEALTH NURSING: PRACTICE
Following their job analysis study, the ABOHN determined and designated functional roles and
responsibilities for the occupational and environmental health nurse. Occupational health
nursing practice requires a wide variety of roles and functions, and specific responsibilities vary.
Roles include clinician, case manager, counselor, health promotion specialist,
manager/administrator, educator, and researcher (ABOHN, 2012a).
Clinician
The OHN acts as a clinician whose primary responsibilities are to prevent work and non–work-
related health problems, and to restore as well as maintain the health of workers. Assessments of
hazards, surveillance of the workers and workplace, investigation of illness, and monitoring
events that lead to an injury are fundamental to achieving this goal.
As in the case of an outbreak of illness following the company picnic, frequent
communication from employees brings a problem to a nurse’s attention. What
assessments should be performed as soon as the workers arrive at the clinic?
Worker Assessment
Along with the traditional history and physical assessment, an occupational health history of
every worker is an essential component of OHN practice. Components include characteristics of
the worker’s present jobs, a chronologic record of all past work and potential exposures, an
occupational exposure inventory, and a list of other exposures in the home or community.
Particular emphasis should include any individual characteristics that may predispose the worker
to increased risk in a particular job. This information provides an understanding of a worker’s
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current health status and the potential impact of exposures on health and future job performance.
Nurses have an opportunity to teach about workplace hazards and prevention measures when
performing worker assessments. Assessments may take place before the worker begins the job,
on a periodic basis, when the worker is being transferred to a different job with different
exposures, and when an exposure, illness, or injury occurs. The goal of assessments is to identify
the agent, host, and environmental characteristics which could place the worker at risk, and to
take preventive steps to eliminate or reduce adverse exposures.
Following a work-related illness or injury, an initial physical assessment, including
documentation and medical case record initiation, is required. Direct care and treatment of
injuries is provided, often using established medical protocols. Referrals are then made for
further evaluation as required. However, illnesses and injuries are often symptoms of problems
in the workplace. The concept of root cause analysis (RCA), discussed shortly, can be applied
when performing an accident investigation after an injury.
In Case 2, the OHN conducts a telephone interview with the employee who had an
anaphylactic reaction. What type of information should the OHN obtain?
The OHN discovers that the employee had been a nurse who left hospital employment
four years earlier and began working in the bank. At the hospital, she had a good
attendance record. She left the hospital because she was having difficulty doing her work;
she had a rash on her hands and a general low energy level. Her hands would begin to
heal and she felt better on long weekends and vacations. She was not asthmatic, had
never experienced any respiratory problems, and had never received a diagnosis of an
allergy. However, on further questioning and investigation, the OHN learns that the
woman’s mother was a nurse who could not work in a hospital setting because of a latex
allergy. (She was also allergic to bananas and avocados.) This information confirms the
possibility of an inherited type of sensitivity that a physician would need to further explore.
Practice Point
OHNs are more likely to notice the influence of work–health interactions if the worker
assessment data are complete. The assessment involves continuous monitoring and
surveillance of workers and their environment.
Workplace Assessment
A workplace walk-through is a technique for an assessment of the workplace. This process
leads to an understanding of the work process, the requirements for the various jobs, the
materials involved, the presence of actual or potential hazards, and the work practices of the
employees (Peek-Asa et al., 2009). It is a complete survey of the workplace, inside and outside,
compiling information as to the presence of hazards, the location of entries and exits, the
availability of emergency equipment, and potential trouble spots (Box 25.3). If the organization
employs a health and safety officer or risk manager, the workplace walk-through analysis will be
a shared responsibility.
It is helpful to use a team approach during this process, soliciting the help of employees in
gathering the information. OSHA strongly encourages maximum employee participation in the
walk-through. Better-informed and more alert employees can assist in identifying and correcting
potential injury and illness hazards in one’s workplace. Talking with employees during the
walk-through helps identify the nature and extent of specific hazards. The assessment should be
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comprehensive, thorough, and take place frequently because conditions may change daily. A
system for corrective action should be in place when improvement is needed.
25.3 Workplace Walk-Through—Evaluation of Workplace Hazards
Alarms and detection devices
Occupancy, building diagrams
Exits
Fire prevention plans
Procedures for processing, receiving, shipping, and storage
Condition of buildings and grounds
Housekeeping program for fall prevention
Heating, ventilation, air-conditioning systems
Electricity
Lighting
Presence of guards for machine use
Worker training procedures
Hand and power tools
Hazardous materials
Maintenance and servicing of machines and equipment (control of hazardous energy)
Personal protective equipment use
Emergency action plans
In Case 1, the OHN also finds that renovation and construction was occurring on the
floors above the employee’s office and in adjacent offices when the worker became ill.
Fellow employees state that they noticed an odor on the day their coworker was rushed to
the hospital. Five employees detected the odor, and two of them experienced headaches,
with symptoms such as light-headedness and itchy, watering eyes. They became alarmed
when their coworker started to have serious difficulty breathing.
The construction supervisor states that walls in the adjacent office space were being
painted, carpets installed, seams glued, and general cleaning done in nearby areas the
day of the incident. Immediately, the nurse asks the supervisor what type of paint was
used the day of the incident. The OHN also wants to know what material the carpet was
made of, and the types of glue and cleaning products used. A combination of
environmental factors such as chemicals, fumes, vapor, dust, heat, or moisture may
create an adverse condition for some people.
Case Manager
Case manager responsibilities include coordination and management of services for ill or injured
workers, including various aspects related to group health, workers’ compensation, and
regulations pertaining to the Family Medical Leave Act (FMLA) (AAOHN, n.d.a). Case
managers are as concerned with prevention as they are with healthcare after an accident. The
overall goal is to do everything that can be done to prevent accidents and minimize illness.
The case manager tracks each incident that relates to employees’ health and safety,
beginning immediately after the onset of an illness or injury, and continuing through
rehabilitation and return to work. Following the initial event, case managers gather case
characteristics that provide detailed information about the circumstances of workplace injuries
and illness that required one or more days away from work. There are four basic case
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characteristics: nature of the workplace incident, the part of the body involved, the source of the
illness or injury and the circumstances that resulted in the exposure or event. After case
managers record this information for ongoing monitoring of the workplace, they perform an
RCA.
Root Cause Analysis
Root cause analysis (RCA) is a process for understanding and solving a problem with the goal
of determining what happened, why it happened, and what can be done to prevent its recurrence.
Sometimes, determination of the problem is easy; however, the process can be more
complicated.
There are usually three basic types of causes: (1) tangible physical causes in which materials
or machines have failed; (2) human causes when people did something wrong, either by
commission or omission; or (3) organizational causes in which the policies or procedures used to
make decisions were faulty. RCA incorporates all three types of causes, and it is possible to
apply this method in almost any situation. It involves investigating the patterns of negative
effects, finding hidden flaws in the system, and discovering specific actions that contributed to
the problem. This often means that RCA reveals more than one root cause. By tracing actions
back to their origins, the person using RCA can determine where the problem started and how it
contributed to the illness or injury that occurred. RCA is the application of the scientific method
to a specific workplace problem when applied to occupational health settings. The steps of RCA
are outlined in Box 25.4.
In Case 2, explain the steps that the OHN would take in initiating an RCA of the outbreak
of illness following the company picnic. (Refer to Chapter 14 to review the steps in
investigating an outbreak.)
Counselor/Consultant
The OHN acts as an advisor in selecting, developing, implementing, and evaluating occupational
health and safety services within both organizations and communities. As a clinician and nurse
consultant, it is the role of the OHN to investigate all possible material and chemical exposures
that could lead to an adverse reaction in workers. By law, workers and their advocates have a
right to know the substances to which they may be exposed, and therefore, they may request the
requisite information. A material safety data sheet (MSDS) provides information to employers
from the manufacturer or producer of substances.
25.4 Root Cause Analysis Process in Occupational Health
Define the Problem
Define the characteristics of the case.
Determine the circumstances under which it occurred.
Collect Data
Determine whether similar illnesses or injuries occurred in the past.
Compare similarities and differences.
Create a timeline related to the problem.
Determine the impact of the problem.
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Identify Possible Causal Factors
Convene people involved in the situation to discuss cause.
Determine the sequence of events that led to the illness or injury.
Identify the conditions that allowed the problem to occur.
Identify other problems that could be related to the problem.
Create a chart of possible causal factors.
Identify causal factors and possible interrelationships.
Identify the Root Cause(s)
Identify the true causes of the illness or injury.
Determine why the causal factor(s) exist.
Determine the real reason the problem occurred.
Recommend and Implement Solutions
Identify ways to prevent the problem from happening again.
Plan for implementation of solutions.
Identify who will be responsible.
Determine the risks of implementing the solution.
Evaluate the Outcome
Develop and implement an evaluation plan.
In addition to counseling people about work-related illnesses and injuries, OHNs also
counsel groups regarding issues such as substance abuse, psychosocial needs, wellness/health
promotion concerns, and work-related issues. The OHN may also assume primary responsibility
for managing a variety of employee assistance programs. Often, an off-site provider or group is
contracted to offer workers and their families counseling and other crisis intervention services.
The nurse may also handle referrals to community resources while coordinating follow-up care
for workers (AAOHN, n.d.a).
When we turn to one another for counsel we reduce the number of our enemies. Khalil
Gibran
In Case 1, after learning about the renovation, the OHN asks for a list of materials and the
MSDSs for the substances used that day. The construction supervisor supplies names of
the materials, a phone number to obtain a list of materials, as well as the MSDSs that
addressed all the elements of the substances used during the renovation project.
Review of the MSDSs reveals that latex paint was used the day of the episode, along
with cleaners and glues containing volatile organic compounds (VOCs). VOCs consist of
a variety of chemicals that may have short- and long-term adverse health effects.
Thousands of products emit VOCs, including paints, lacquers, paint strippers, adhesives,
glues, cleaning supplies, pesticides, building materials, and furnishings. Concentrations of
VOCs are consistently greater indoors than outdoors (U.S. Environmental Protection
Agency [EPA], 2012a).
Health Promotion Specialist
As a health promotion specialist, the OHN participates in the development and management of a
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multidimensional, broad-range health promotion program that supports the business objectives
of the organization. Health promotion and illness and injury prevention is a function that the
OHN performs along a continuum for the worker population. The objective is to create an
environment for the worker that provides a sense of balance among work, family, personal,
health, and psychosocial concerns (AAOHN, n.d.a). Healthy People 2020 Occupational Health
and Safety Objectives for the United States are presented in Box 25.5.
25.5 Healthy People 2020 Occupational Health and Safety Objectives
OSH-1 Reduce deaths from work-related injuries.
OSH-2 Reduce nonfatal work-related injuries.
OSH-3 Reduce the rate of injury and illness cases involving days away from work due to overexertion or
repetitive motion.
OSH-4 Reduce pneumoconiosis deaths.
OSH-5 Reduce deaths from work-related homicides.
OSH-6 Reduce deaths from work-related assaults.
OSH-7 Reduce the proportion of persons who have elevated blood lead concentrations from work
exposures.
OSH-8 Reduce occupational skin diseases or disorders among full-time workers.
OSH-9 (Developmental) Increase the proportion of employees who have access to programs that prevent
or reduce employee stress.
OSH-10 Reduce new cases of work-related, noise-induced hearing loss.
Source: From Healthypeople.gov. (2013). Healthy People 2020: Occupational safety and health. Retrieved from
http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=30.
Educating all employees and administrative staff regarding the exposures and hazards
associated with the workplace is the foundation of health promotion efforts. Corporate nurse
educators often design programs that are used to educate workers in multiple settings, with state,
regional, national, or international audiences (Dirksen, 2006). Programs are conducted through
webcasts, satellite broadcasts, webinars, or established websites.
The health promotion frameworks discussed in Chapter 5 have a particular application in
occupational health and safety. For example, the OHN has a unique opportunity to contribute to
the current Healthy People prevention agenda. He or she can use leading health indicators and
national occupational health and safety objectives to assess the status of the workplace. This
information is useful for identifying prevention objectives for the workplace, and
implementation of specific interventions and action plans. The actual prevention activities
performed at any given time are a result of many changing variables in the organization, and a
balance among primary, secondary, and tertiary prevention efforts is essential. For example, the
nurse who is concentrating on developing strategies to prevent work site injuries and disease
(primary prevention) may have little time or resources for testing individual employees for risk
factors that increase the potential for illness or injury (secondary prevention).
Historically, the OHN has been involved with workers in a supportive role to maintain health
at the work site. In the 1989 work by Michael O’Donnell, the seminal definition of health
promotion gave OHNs interested in the pursuit of wellness a relevant rationale to pursue this
approach. According to O’Donnell (Fig. 25.8), optimal health includes a balance of physical,
emotional, social, spiritual, and intellectual health. The nurse can contribute toward this end by
creating an environment that develops awareness and encourages behavior change (O’Donnell,
2009).
A common health and safety promotion program in occupational settings involves
preservation of sight and hearing. Within a company eye protection program, the OHN often
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http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=30
works collaboratively with the safety director and/or human resources personnel in the oversight
of these programs. The OHN has a role in coordinating administration of eye examinations for
those employees who need prescription safety eyeglasses. There are several approaches that a
company can take when establishing and maintaining a hearing protection program. The OHN
may become a certified hearing conservationist and carry out the required monitoring of noise
levels within specific facilities, work areas, and departments. He or she may oversee or manage
the distribution of hearing protection to workers, conduct education as needed, administer
audiometric testing at the work site, manage the feedback of hearing tests results to employees,
and ensure follow-up with a physician when needed.
FIGURE 25.8 O’Donnell health promotion model. (O’Donnell, M. P. [2009] Definition of health
promotion 2.0: Embracing passion, enhancing motivation, recognizing dynamic balance, and
creating opportunities. American Journal of Health Promotion, 24[1], iv–iv.)
Manager/Administrator
The responsibilities of the OHN frequently include participation in the development,
management, and evaluation of the entire health and safety program of the organization in
conjunction with both the medical and safety directors. Written policies and procedures
consistent with organizational goals and objectives are required to ensure compliance with legal,
regulatory, and ethical standards. Often, a company may ask the OHN to prepare a business plan
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that justifies the cost for establishing health promotion programs. This plan, by necessity,
justifies how the program will be implemented within the organizational culture by using key
approaches such as working with teams and choosing relevant and sensitive interventions.
Constant surveillance, monitoring, and auditing of the safety conditions of the workplace is
essential. This includes monitoring individual employees in their immediate work environment.
A health record can be kept on employees separate from their other employment records. This
process often starts with an initial physical examination appropriate to the type of work that is
going to be done. The physical examination helps ensure fitness for the job and provides a
baseline for future comparison. Often, an employee’s health and safety orientation and training
follows, with issuance of proper personal safety protection. The OHN schedules routine safety
meetings stressing health-related issues, such as safety gear and proper lifting techniques, on a
proactive basis and conducts them thereafter on a need-to-know basis. An example of this is the
introduction of a hazardous substance into the work area requiring more detailed information to
ensure job safety. When injured employees do not return to work, the OHN may initiate or
oversee a workers’ compensation claim on behalf of the employee to ensure that the worker
receives workers’ compensation benefits.
OSHA Compliance
The need to comply with OSHA standards is often the starting point for initiation of safety
measures. The U.S. Department of Labor collects data from employers about occupational
injuries and illness across the country. The OSHA designs and distributes record-keeping forms
called the OSHA log. The OHN is usually responsible for filling out the OSHA log. This injury
log is a record of accidents and illness that occur within a given year at every workplace facility
employing 10 or more people. It is used to report total injuries and illness annually to OSHA and
must be posted at the work site.
Other Legal Responsibilities
In addition, the OHN works with employers on compliance with regulations and laws affecting
workers and the workplace. These regulations and laws include state and federal regulations
dictated by FMLA and the Health Insurance Portability and Accountability Act (HIPAA)
(AAOHN, n.d.a). The OHN may be responsible for record-keeping and tracking employees who
need to utilize FMLA, including securing the privacy of these records. According to FMLA, an
employee is eligible to exercise his or her right after working a minimum of 12 months and at
least 1,250 hours. In the case of serious illness affecting themselves or family members, when
all conditions are met under this act, employees can leave work for up to 12 weeks and return to
work without penalty. The OHN involved with managing FMLA for an organization sends out
communication to all employees who apply. The nurse helps ensure that the worker(s) or
physician(s) is in compliance with the regulation by submitting the proper paperwork to the
employer.
The OHN is also responsible for the privacy and record-keeping of occupational health and
safety information as it relates to individuals at the workplace. The HIPAA mandates that all
medical information be held in confidence. One way to ensure privacy is to keep all health-
related information in a separate, secured file and storage area other than the business or human
resource files.
Researcher
As researchers, OHNs contribute to the future of the profession by identifying, analyzing,
monitoring, measuring, and evaluating the effects of workplace exposures and hazards for
workers and members of the community. They gather and use health and hazard data to select
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and implement preventive and control measures in a continual process. Examples include
analysis of the effects of toxic chemical exposure, development of plans to prevent work-related
accidents, and an analysis of groups, not just individual people, to detect patterns, trends,
changes, and commonalities, as in pandemic situations (AAOHN, n.d.a; Dirksen, 2006).
The National Occupational Research Agenda (NORA) is a partnership program to stimulate
innovative research and improved practices for safer, healthier workplaces. The program is
directed toward the study of disease and injury, the work environment and the workforce, and
the various research methods which are used to study occupational health. Released in 1996,
NORA has become a research framework for NIOSH and the nation. Diverse parties collaborate
to identify the most critical issues in workplace safety and health. NORA is composed of
councils which focus on specific sectors of industry, such as construction, agriculture, or
healthcare. The councils develop goals and strategies for the nation, and encourage partnerships
to address the goals and promote improved workplace practices, all using open processes. The
partners then work together to develop goals and objectives addressing these needs. All
interested people have an opportunity to participate in this process through the CDC website.
Practice Point
The recognition of conditions that may harm the individual worker or members of the
community is a crucial responsibility of the OHN.
IMPLEMENTING HEALTH PROMOTION IN THE
WORKPLACE
It is imperative that management be involved in all stages of the health promotion effort. The
company may give the OHN complete responsibility to create the initial vision and implement
the plan, but constant communication with management is necessary to ensure that the plan is
meeting the organization’s expectations.
Balance theory is a systems approach that can be used by OHNs to help them organize a
prevention model. The balance theory states that one element in the system influences other
elements, having the potential to be positive or negative depending on the effect one part plays
on another (Brunette, 2006). When using the balance theory, each workplace system is
examined and categorized into five areas:
1. Organization
2. Tasks
3. Tools and technologies
4. Physical environment
5. People
The scenario in Case 2 illustrates the dynamic of the balance theory. The systems
breakdown in this case involves operational and SM policy and procedure, machinery,
and training of personnel. Identify several check-and-balance procedures that need to be
in place to ensure a decreased health and safety risk for worker populations.
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Developing a Team Approach
In creating a wellness team, it is essential to include key people, such as health professionals and
interested parties in the workplace, who can help to identify company or organizational needs.
Team members can contribute to the development of a plan of action based on national and local
trends. They can also help with the distribution of surveys and answer questions.
Collecting data for presentation to management, such as projected healthcare costs based on
current utilization trends, is one way to initiate a program. Insurance companies can provide
reports of medical usage (utilization reviews) on the basis of diagnosis and/or categories of visits
made to providers. The OHN may have the team review health insurance data; research national
leading health indicators; or conduct interviews, workplace assessments, or on-site surveys to
help determine the findings and outcome of the data.
Choosing Interventions
Interventions that are appropriate for a company or work site(s) through assessment of health
promotion programs depend on the findings of an employee-needs assessment which is
conducted by and for the organization. It is important that the team members who are involved
know the purpose of the needs assessment prior to the actual method chosen, and the need for
follow-up and future planning.
A good start for a small to midsize company is to conduct a needs assessment with a general
health promotion questionnaire. The questionnaire or survey can ask employees basic lifestyle
questions, such as number of hours worked each week. Consumption of alcohol, diet, and
smoking, exercise activity level, hours of sleep, and existing medical coverage is an excellent
place to begin collecting data. The OHN should also watch for workers who take a second job to
earn extra money, which may lead to fatigue and injury on and off the job.
It is important for a team to know what percentage of the working population has access to
medical care because health promotion efforts depend on available resources. Some employees
have medical coverage provided by a spouse or significant other working at another company.
Others simply cannot afford medical insurance, and they are often referred to as the working
poor (Luhby, 2012; Shipler, 2004).
The passing of the Massachusetts healthcare reform act made the Commonwealth the first
state in the United States to address the problem of inadequate health insurance for all citizens. It
is mandated by law that healthcare coverage be offered by all employers to workers. The state
requires submission of proof of purchase or coverage for health insurance for both employer and
employees to avoid a fine. Employers need to show they offered healthcare insurance, and if an
employee declines, the employer must have the worker submit proof of healthcare insurance to
be ready to present to the state if necessary. Workers must be ready to pay a fine on their state
income tax return if they do not show proof of healthcare insurance (MassResources, 2013).
Practice Point
A proactive prevention approach in occupational health incorporates the belief that there are
no accidents but only events that were not noticed or managed correctly with proper
intervention.
IMPLEMENTING A PROGRAM: EXAMPLE, SMOKING
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CESSATION
Step I
The OHN makes a presentation to management to support offering a smoking cessation
program. It is important to state the method that will be used to obtain the data (e.g., using a
survey, questionnaire, or by direct interview). The OHN and/or the team could present the
number of employees (by percentage) who smoke and the number of employees who say they
would participate in a smoking cessation program if offered.
Step II
To initiate the program, the OHN sends out a memo calling appointed team members to attend a
meeting. The team conducts an information-gathering meeting to point out why a smoking
cessation program is needed, based on current smoking behaviors in the company. This includes
statistics shared about smoking behaviors and risk at the local, state, and national levels. It is
best if the OHN is prepared with a meeting agenda and educational information to hand out to
attendees for review.
Step III
The OHN and/or the team presents the following information to justify the cost involved with
conducting a smoking cessation program. Statement of fact: It is documented that workplace
smoking, and especially the secondhand smoke associated with it, causes death and long-term
illness. Direct medical costs for employers and schools include the following:
Increased absenteeism
Higher cleaning costs
Decreased productivity
Higher insurance premiums (health, fire)
Increased property damage resulting from tobacco use by smokers
Step IV
The OHN and/or the team should provide take-home information, such as a copy of U.S.
Morbidity and Mortality Figures Related to Tobacco Use from the CDC Fact Sheet. It is also
necessary to review handout material with the group for discussion.
Step V
The OHN and/or the team should review the economics of smoking. For example, each year, the
United States spends nearly $170 billion on medical care to treat smoking-related disease in
adults, according to the CDC (CDC, 2017). Together with absenteeism and regular smoke
breaks, the annual cost is estimated to be $3,077 per worker. The OHN can present the number
of smokers currently working in the company and multiply that number by the projected cost of
$3,077 per worker a year. An estimated dollar figure would show that the cost to initiate a
smoking cessation program justifies the investment.
The following is an example of the initiation of a smoking cessation program and how it
might progress once it is approved by management. A realistic goal would be to reach and help
4% of the smoking population become nonsmokers by the end of year 1 of the program. With
more education and incentives for employees, the program could similarly affect an additional
1% after 2 more years.
Items such as cost of a program and incentives may be part of the program for those who
need more support to quit smoking. The program is best offered when most workers are
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interested and can attend it. Time of day is important. Ideally, program times are set up during
lunch time or directly after work, with experts who know how to work with people who may
wish to discontinue smoking.
The OHN and/or team may send follow-up letters to participants periodically to offer
continued support and information, and to provide tips about diet and activities that support the
employee’s new nonsmoking behavior. Invitations to join activities, such as baseball, rowing, or
bowling leagues to help people replace old behaviors may help. Finally, program planners
should anticipate that there will be those who relapse, and they should provide reassurance for
continuing with the program. It is necessary to establish a plan of action to support these
workers who want to begin the process again.
Much of what the OHN does in health promotion is to support employees in their choice of
behaviors that are more life-enhancing. In 2012, Truth Initiative (formerly Legacy) and AAOHN
developed a partnership with two primary goals. First, Truth Initiative and AAOHN would
develop a survey together that would assess such topics as the smoking behavior of its members,
the availability of tobacco cessation resources to offer workers, and tobacco cessation training,
among other smoking related topics. Second, Truth Initiative would offer BecomeAnEX.org, a
free quit smoking program that helps adult smokers relearn life without cigarettes, to AAOHN
members as a resource for themselves and for their workers (AAOHN, n.d.b). Creating an
opportunity to affect people and the quality of their lives at the work site is a logical place to
begin.
Student Reflection
After working several years in the hospital, I realized that many patients were there because
of needless accidents and diseases that could be prevented. Knowing how devastating the
consequences of acute and chronic diseases can be, I decided to focus on health promotion
and prevention of disabilities in the community when I returned to the university. I really
enjoyed my experience in a health promotion program in the workplace. It allowed me to
apply both my nursing and previously acquired knowledge while learning something new.
The project required tracking, quantifying, and systematically measuring the outcome of
a simple nursing intervention, monitoring the employees’ blood pressure (BP). The key to
the success of this program had to do with consistent follow-up, continued monitoring, and
referral for medical treatment as needed.
The first step was to conduct a facility-wide volunteer BP screening. All employees who
were being screened received a questionnaire that contained general history questions
such as the following:
Have you had high BP in the past?
Are you currently under a doctor’s care?
Are you being treated for high BP?
Are you taking medication?
Are you overweight?
Do you exercise?
Advertisements for the program appeared in the company newsletter. Employees who
participated for 5 consecutive weeks of BP monitoring received stipends for use in the
company cafeteria. Individuals who were interested signed up and had their BP taken
systematically, department by department, in the building where they worked. Workers with
extremely elevated BP received an immediate referral to a healthcare provider for follow-up
care. Nurses asked workers with no known history of elevated BP, but who showed two out
of three moderately elevated readings at week 3, to return periodically to continue their
screenings. With the workers’ consent, nurses also gathered weight information and further
investigated diet and medical history. At this point, the nurses recommended that workers
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who continued to show consistent moderate elevations see their physician.
The process continued with workers who showed slight elevations while working on
goals involving exercise and diet. This experience showed me that most workers respond
well when given the education and the support associated with the BP screening and
monitoring program. Throughout this project, I was able to track progress and demonstrate
the potential to increase quality of life, reduce medical costs, and prevent further disease
such as stroke, heart attack, and kidney disease. The workplace does indeed have a
captive audience; when approached in the right manner, these workers are very interested
in maintaining and pursuing their health.
EPIDEMIOLOGY AND OCCUPATIONAL HEALTH
The use of epidemiology as a tool for assessing the hazards of workers has a long and productive
history. Ancient Egyptian documents told about the difficult life of workers, and other early
historical publications addressed the hazards of working with heavy metals and mining. In the
17th century, the Italian physician Ramazzini outlined the health hazards of chemicals, dust,
metals, repetitive or violent motions, odd postures, and other disease-causative agents
encountered by workers in 52 occupations. The first physician to clearly recognize the
relationship between healthy workers and economic productivity, Ramazzini is now considered
the father of occupational medicine.
Occupational epidemiology today deals specifically with the study of distribution and
determinants of states of health related to hazardous exposures and conditions found in the
workplace. In other words, epidemiologic methods are applied to populations of workers. The
nurse needs to explain trends and potential or real hazards, based on epidemiologic reports, to
workers, managers, and community representatives (Lukes, 2007). The epidemiologic data, plus
the documented need in the workplace, are the rationale for recommending health promotion
programs.
Epidemiologic Surveillance
Health surveillance is an essential concept in occupational health. The need to carefully monitor
both the employee and the work environment to detect any health risk and thereby be able to
initiate health protective behaviors is critical. “A strong health surveillance program,
implemented by the OHN or nurse manager, is an essential component of an employer’s effort
to promote workers’ optimal health and safety, thus preserving the company’s valuable human
and financial resources” (AAOHN, 2015). Workplace health surveillance includes physical
examinations and the tracking of injuries, illness, hazards, and exposures both in individual
people and for groups of workers. Every industry should have monitoring procedures in place
that are specific to the setting. For example, biomonitoring assesses the total body burden of a
hazardous chemical in a worker through laboratory tests of body fluid specimens. The best
practice is to use noninvasive procedures as much as possible.
Evidence for Practice
According to the CDC (2015a), occupational exposure to bloodborne pathogens from
needlesticks and other sharps injuries is a serious problem, resulting in approximately
385,000 needlesticks and other sharps-related injuries to hospital-based healthcare
personnel each year. Similar injuries occur in other healthcare settings, such as nursing
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homes, clinics, emergency care services, and private homes. Sharps injuries are primarily
associated with occupational transmission of hepatitis B virus (HBV), hepatitis C virus
(HCV), and human immunodeficiency virus (HIV), but they have also been implicated in the
transmission of more than 20 other pathogens. In 2011, the CDC released surveillance data
from 1981 to 2010 documenting 24 cases of acquired HIV among nurses. Table 25.4 shows
2015 Hepatitis C outbreaks in the United States, by setting.
The National Institute for Occupational Safety and Health (NIOSH) released two new
modules that allow for the tracking of sharps incidents and blood and body fluid exposures
among healthcare workers using a system uniquely available for U.S. healthcare facilities
on a free, voluntary basis. The system, Occupational Health Safety Network (OHSN),
collects existing injury data (e.g., date of injury or illness, location of incident, description of
illness, days away from work, and other data collected in OSHA logs) among healthcare
personnel to (1) help identify job titles at highest risk for injury in their own facility, (2)
develop interventions for the safety and health of hospital staff, and (3) objectively measure
impact over time (NIOSH, 2017).
TABLE 25.4 Hepatitis C Outbreaks by Setting—United States, 2015
Setting State Outbreak-Associated
Infections
Outpatient
Prolotherapy clinic California 5
Insulin infusion clinic California 9
Pain management clinic Michigan 2
Cardiology clinic West Virginia 5
Hospital
Hospital Utah >7
Hemodialysis
Outpatient hemodialysis facility
Outpatient hemodialysis facility New Jersey 2
Outpatient hemodialysis facility New Jersey 2
Outpatient hemodialysis facility New Jersey 2
Outpatient hemodialysis facility Pennsylvania 3
Outpatient hemodialysis facility Pennsylvania 3
Outpatient hemodialysis facility Pennsylvania 2
Outpatient hemodialysis facility California 3
Source: Center for Disease Control (CDC). (2017). Viral hepatitis. Retrieved on September 16, 2017, from
https://www.cdc.gov/hepatitis/statistics/2015surveillance/Table1.1.htm.
Incidence
Workers often come to an OHN with symptoms. If there happens to be more than one worker
from the same department with consistent symptoms and objective findings, the OHN may
immediately begin to suspect that a cluster or cohort is forming. Clusters are aggregations of
disease diagnoses collected from a specific population within a distinct period of time or space.
Documenting the number of cases of an injury or disease is an important responsibility of the
OHN (Eisen, Wegman, & O’Neill, 2006).
The calculation of incidence rates is a helpful tool in understanding the severity of a
workplace problem. For example, the nurse can tally the number of workers whose scores on a
hearing test change when compared with the previous year’s results. The yearly occurrence rate
of hearing loss among workers is determined by dividing the number of workers who have
changes in their recorded hearing test(s) by the number of workers at risk during that year. If 56
of 1,000 employees have more difficulty hearing at certain frequencies this year than last, then
the yearly incidence rate for hearing loss is 56 divided by 1,000, or 0.056%. It is 5.6% for the
current year (see Chapter 7).
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The OHN should calculate specific rates for population subgroups, often by age, sex, or
exposure. For example, it may be beneficial to calculate an injury rate during several different
activities. The OHN might find it helpful to calculate a rate for hearing loss among workers who
perform a work-related activity such as operating loud machines in a specific department at the
workplace (Lukes, 2007).
Prevalence
Prevalence reflects the total burden of the injury or illness that exists in the population—in this
case, the workplace. It includes both new cases and existing cases. Using the example of hearing
loss, the prevalence rate indicates the extent of hearing loss in the workplace. When hearing loss
has occurred, it is imperative that people be protected through a hearing conservation program.
In most cases, once the damage begins, the person without protective equipment or a transfer to
a quieter environment is at greater risk for more hearing loss at an increasing rate. Prevalence
rises over time if working conditions are not corrected (Lukes, 2007).
Ratios
Ratios can compare and involve groups of workers in settings. Hearing tests may be given to
workers from different departments within the same facility, or to workers who do the same type
of work in another facility or building in another state or country. This approach adds clarity
when comparing the number of affected workers in an organization that employs workers
located in various geographic locations. The ratio of workers who incurred the greatest hearing
loss from the previous year may be compared by facility, department, or task. This can provide
information about different groups and how noise, injury, or disease affects them over a specific
period of time (Lukes, 2007).
Epidemiologic Studies
Two types of epidemiologic studies are common in investigating occupational health issues in
the workplace: cohort and case-control studies. First, prospective, cohort epidemiologic studies
investigate workers who have been exposed to a variety of chemical, biologic, or physical agents
(see Table 25.1). The purpose of these follow-up studies is to determine whether the risk of
adverse health outcomes is increased after the event. Second, epidemiologic studies may involve
the evaluation of workers who have already experienced a common adverse health outcome. In
this case, the outcome has already occurred, so the purpose of these case-control studies is to
investigate, retrospectively, what agent or set of agents may explain their condition. Chapter 8
discusses these methods in more detail.
Ecologic studies are types of epidemiologic studies that compare the rates of exposures and
diseases in different populations. Aggregate data on exposure and disease are gathered, rather
than data pertaining to individuals. This could be data from a group of workers within an
organization, facility, community, state, or nation. Average exposures and disease rates are
compared between two groups in different locations during the same time (Eisen et al., 2006).
Ecologic studies are the fastest and easiest of epidemiologic studies related to the OHN practice.
These approaches study the relationships between variables when research or funds are limited.
Case 2 demonstrates that actions lead to an outcome and that actions further unfold in a
sequence of related events. The OHN learns that at the time of the outbreak, one of the
refrigerator units was about to be replaced because of higher-than-normal holding
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temperatures. Also, there had been a turnover of kitchen staff in the last few weeks.
Apparently, the department was short on kitchen help on the day of the picnic, and there
was no record of the daily temperatures required that morning.
Holding food at correct temperatures is essential to avoid food-borne illness. “Cooked
food is safe only after it’s been heated to a high enough temperature to kill harmful
bacteria. Color and texture alone won’t tell you whether your food is done” (U.S.
Department of Health & Human Services [HHS], n.d.a). For hot food, this temperature
must be 140°F (60°C). For cold food, this temperature must be 40°F (4°C) or colder.
Keeping food within the recommended temperatures is necessary to prevent microbial
growth (U.S. Department of Agriculture, 2013).
By calculating attack (incidence) rates associated with the various foods, the OHN
determines that the sausage was contaminated. Most of the people who ate the sausage
manifested symptoms of food poisoning, establishing the relationship between ingestion
and sickness (Aschengrau & Seage, 2003; Lukes, 2007).
EMERGENCY PREPAREDNESS PLANNING AND
DISASTER MANAGEMENT
As a member of the emergency planning committee in the workplace, the OHN contributes to
the design and implementation of the emergency preparedness plan. The plan ensures a line of
communication with emergency management teams. Having an emergency planning committee
composed of representatives from all departments is the best way to establish emergency
planning in business environments. Committee members meet on a regular basis and have
access to all relevant health and safety information, so that they can make responsible, informed
decisions. The committees annually review documentation and update the existing emergency
plans. This includes all state and federal laws that apply to the facility and type of business
operation (OSHA, 2010).
Components of an Emergency Preparedness Plan
The goals of an emergency plan are to anticipate emergencies and to establish clear reporting
instructions for employees. The plan names key personnel who will assume necessary tasks. It
establishes emergency escape routes, and procedures to identify workers and visitors with and
without disabilities. The plan ensures that predesignated areas have been arranged and
employees have participated in actual drills (OSHA, n.d.b).
The committee is responsible for conducting a vulnerability analysis best utilizing an all-
hazards approach. Committee members review the types of emergencies that are likely to occur
at the facility and what resources will be needed to respond. Major natural emergencies are fires,
floods, hurricanes, tornadoes, earthquakes, and winter storms. Human-made or technologic
events include fires, violence, bomb threats, transportation accidents, industrial accidents, civil
disturbance, radiation, and unintentional or intentional release of chemicals or infectious
organisms (bioterrorism) (Federal Emergency Management Agency [FEMA], 2013).
Next, the committee reviews existing internal resources such as personnel, security systems,
sprinkler and alarm systems, transportation and heavy equipment, shelters (for providing shelter
in place), and firefighting apparatus (OSHA, n.d.d, n.d.e). If a facility is located near a river or
body of water, it is necessary to have a plan to deal with flooding, one of the most common
hazards in the United States (FEMA 2014).
Key components of the emergency plan involve alarms, reporting, communication,
evacuation, a system for counting the occupants, procedures for staff who do not immediately
evacuate, and rescue and medical services. (A list of key personnel, training for all staff, drills,
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with an approach to conduct an assessment following an emergency evacuation plan, must
identify escape routes that are clearly marked and meet the criteria within the key components.)
It is essential that the plan discuss how workers and visitors with and without disabilities will be
assisted through the evacuation routes and where they will reassemble for verification of safe
evacuation (OSHA, n.d.c, n.d.d).
Critical Functions of the Plan
The OHN helps ensure that procedures are established for people who attend to critical functions
in the facility and who do not leave the building immediately. Floor captains are responsible for
making sure everyone gets out of the building. This includes people who administer first aid and
those trained to use fire extinguishers (OSHA, n.d.c).
Internal rescue and medical services depend highly on the location of the facility and its
proximity to police, fire, and external rescue services. According to the hazard communication
standard (OSHA, n.d.a), employers must have personal protective equipment available for those
who work with and around hazardous material and chemicals (Fig. 25.9). They also must have
procedures to decontaminate workers who work with and around hazardous material and
chemicals. Another important aspect of every plan is shelter in place. A shelter-in-place policy
and procedure must be established for emergencies such as hurricanes, tornadoes, high winds, or
chemical releases in buildings such as healthcare and correctional facilities. Having drills on a
regular basis helps ensure that workers know what they are to do in an emergency. When alarms
go off, evacuation needs to occur quickly and in an orderly manner. The intent of the drill is to
reduce confusion and panic (OSHA, n.d.b, n.d.c). Chapter 20 discusses emergency preparedness
in further detail.
FIGURE 25.9 Personal protective equipment: personal fit testing for emergency preparedness.
A plan for resuming operations following an emergency is necessary. The OHN may
conduct a needs assessment that identifies the immediate and ongoing needs of the staff and the
organization following an emergency. It is essential that counseling services are available for
employees who may suffer from symptoms of posttraumatic stress. The committee periodically
evaluates and modifies the plan to update key personnel lists, emergency contacts, and telephone
numbers. Floor plans, changes of department location, and ongoing work in the building should
908
be kept current (OSHA, 2010, n.d.b).
NANOTECHNOLOGY AND OCCUPATIONAL SAFETY
AND HEALTH
Nanotechnology is among the emerging technologies impacting healthcare today. The National
Institute for Occupational Safety and Health (NIOSH) defines nanotechnology as the
manipulation of matter on a near-atomic scale to produce new structures, materials, and devices,
and is generally defined as engineered structures, devices, and systems. Nanomaterials (Fig.
25.10) are defined as those things that have a length scale between 1 and 100 nm. At this size,
materials begin to exhibit unique properties that affect physical, chemical, and biologic behavior
(NIOSH, n.d.)
Nanotechnology offers the promise of vast improvements in many sectors such as consumer
products, energy, materials, manufacturing, and medicine. Figure 25.10 shows a novel
nanomaterial, a bamboo-like structure of nitrogen-doped carbon nanotubes, that can be utilized
in diagnosing and treating previously inaccessible tumors. Despite the promising offers, there
are also concerns about potential health hazards to workers, the environment, and consumers.
For example, “nano-sized particles may be more likely to reach the bloodstream and pass
through the blood-brain barrier than larger particles of the same composition and thus may
represent a unique health hazard” (Centers for Diseases Control and Prevention [CDC], 2015b).
Furthermore, products containing nanoparticles such as antibacterial products utilizing
nanoparticles of titanium dioxide (TiO2) or silver, for example, are already being used and
possibly affecting individuals handling them. “Some toxicological studies show that animals
exposed to titanium dioxide (TiO2) and carbon nanotubes (CNTs) have displayed pulmonary
inflammation, and perhaps the most troubling nding is that CNTs can cause asbestos-like
pathology in mice” (NIOSH, 2013). Workers within nanotechnology-related industries have the
potential to be exposed to uniquely engineered materials with novel sizes, shapes, and physical
and chemical properties. Occupational health risks associated with manufacturing and using
nanomaterials are not yet clearly understood.
FIGURE 25.10 Diagnosing and treating previously inaccessible tumors with novel hybrid
nanomaterials. This image shows the bamboo-like structure of nitrogen-doped carbon nanotubes,
50 nm in diameter and 500 to 1000 nm in length, to which 10-nm spherical gold particles have
909
been linked. This novel material can be traced in the body by using x-ray and heat from exposure
to laser energy. This combination may allow surgeons to identify and treat tumors that are
inaccessible to current surgical techniques. (Source: National Cancer Institute [2016]. Creator:
Julia Chifman, PhD., and Ravi Nandan Singh, PhD. https://visualsonline.cancer.gov/details.cfm?
imageid=10865.)
NIOSH is the federal agency that conducts research and makes recommendations to prevent
work-related injuries, illnesses, and deaths. It is conducting an extensive and multi-faceted
research program with partners to better understand the occupational health and safety
implications of nanotechnology. NIOSH has issued recommendations for controlling worker
exposures to engineered nanomaterials during the manufacture and industrial use of those
materials. These recommendations are based on technologies now applied in the various
industries that use nanomaterials, and on control methods that have been shown to be effective
in reducing occupational exposures in other industries.
Healthy People 2020 addresses the benefits and potential environmental and health impact
of nanotechnology. Although improvements in occupational safety and health surveillance are
ongoing, there are several emerging areas in which national data systems are not yet available or
merit further research. For example, there are recognized data gaps in understanding the safety
and health effects of exposure to nanoparticles—the ultrafine, manipulated particles used in
many industries (U.S. Department of Health & Human Services [HHS], n.d.b).
With over 1,000 nanomaterial-containing products ranging from cosmetics to medical
products already on the market, it is essential that occupational safety and health implications
are explored to ensure a safe and healthy work environment. OHNs may find themselves at the
forefront of managing workers’ exposures and illness related to nanomaterials. “Occupational
health nurses should maintain a heightened sense of awareness regarding the presence of
nanomaterials in the workplace, current safety strategies being used, as well as developments of
nanoscience, about emerging safety issues and methods in order to properly advocate for safe
working environments” (Goyette & Journaey, 2014).
KEY CONCEPTS
The primary responsibility of the OHN is that of injury prevention and health promotion, including
recognition of conditions that may harm the individual worker or the community.
The occupational health nursing process begins with assessment of both the worker and the workplace.
Disciplines that guide the occupational nurse in understanding the agent, host, and environment
relationship are epidemiology, toxicology, industrial hygiene, and safety principles.
Advocating for patients, clients, or groups is a continual process in occupational health nursing.
The knowledge base generated through epidemiologic studies is used to identify and prevent injury and
disease.
The recognition of adverse conditions, and the initiation of proven practice interventions, supports
individuals and groups in both their work and community environments.
With good occupational health surveillance programs in place, it is possible to proactively identify
employees at risk by tracking incidence and prevalence of injuries and illness and their causes.
The nurse must have the autonomy and skills to take action and reduce possible exposure or harm to
workers.
An understanding of regulatory, legal, and economic functions and their relationship to business production,
workers, and the community environment is an essential component of occupational health nursing
practice.
Occupational health nurses must be abreast of emerging technologies with the potential to impact nursing
practice.
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https://visualsonline.cancer.gov/details.cfm?imageid=10865
CRITICAL THINKING QUESTIONS
1. When the population’s rate is unknown, the OHN may want to use a national or state rate to compare
information that is being obtained at the work site. For example, if 10% of those who participate in a
company’s health screening indicate they are smokers, what generalizations, if any, can be made by the
OHN about the smoking rate of the company’s population if a smoking assessment has not been done?
Does 10% represent the true percentage of smokers? Does the company have the same or higher
smoking rate as the rest of the state (e.g., approximately 25%). What percentages of workers who smoke
avoid health screening?
2. Choose an occupational setting and describe the process of risk assessment you would initiate in that
setting.
3. Review Figures 25.1 to 25.3, as well as Table 25.3. What are some of the factors that contributed to the
decline in rates of injury and illness at the workplace? What confounding factors might be present?
4. In Case 1, the OHN deduced possible substances (agents) to which workers could be exposed. The next
steps are to determine how the substances are delivered to the workers (host) and to investigate the
characteristics of the workplace which lead to transmission of the substances (environment). The OHN
inquires about the heating, ventilation, and air conditioning (HVAC) system at the bank. One of the
questions asked concerned the position of the air vents which deliver air into the office space, and its
relationship with the renovation work. The OHN learns that neither an extra exhaust system was provided
for the project nor was any provision made to deal with particulates of construction materials which may
have been in the air. Use this information to develop an epidemiologic triangle that identifies the
interactions between the harmful substances (agent), the workers (host), and the workplace
(environment).
HEALTHY PEOPLE 2020 LEARNING ACTIVITY
Occupational Safety and Health
Healthy People 2020 provides a blueprint to identify nationwide health improvement priorities. This national
consensus plan includes 42 topics, with a subset of 12 leading health indicators (LHIs) and over 1,200
objectives. It offers a framework for strategic planning to promote health improvement and achieve health
equity through measurable objectives and deliberate actions. The Healthy People 2020 website is dense with
important information on the development, implementation, and progress of this national plan. Learning to
navigate the website, to access the rich materials offered is vital to gain a deep understanding of the national
health improvement priorities, specific objectives, and initiatives seeking to achieve the national goals and
objectives.
Occupational Safety and Health is a topical area identified as a priority in Healthy People 2020. To learn more
about this topic go to https://www.healthypeople.gov. Topics are listed alphabetically; scroll down to “O” and
click on Occupational Safety and Health to read about the topic. Then, click on the link for “Overview” to find
the answers to the following questions:
1. What is the goal for this topic?
2. What are the 10 sectors focused by National Occupational Research Agenda (NORA)?
3. What are emerging issues in occupational safety and health?
Once you’ve answered those questions, click on the link for “Objectives” and then select one of the
objectives. Analyze the data, looking specifically at any disparities, progress made, and thinking about
continued barriers to achievement. Then, click on the link for “Resources and Interventions” and select
Occupational Safety and Health Resources. Review the resources and interventions to explore evidence-
based resources and consumer information related to occupational safety and health to address and prevent
occupational injuries and/or illnesses.
911
https://www.healthypeople.gov
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WEB RESOURCES
Please visit thePoint for up-to-date web resources on this topic.
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http://thepoint.lww.com/vitalsource/ebook/9781975111694
Index
Note: Page numbers followed by b, f, or t indicate text in boxes, figures, or tables, respectively.
A
AA (Alcoholics Anonymous), 411, 421
AAIN (American Association of Industrial Nurses), 620
AAOHN (American Association of Occupational Health Nurses), 615, 620, 621b
AAR (after action report), 486, 499
abandoned properties, 472t
ABOHN (American Board of Occupational Health Nurses), 622
abstinence, 394
abuse, 260
child, 384
of disabled people, 384–385
elder, 383–384
mandatory reporting of, 383, 383b
and neglect, 260–261
ACA (Affordable Care Act), 51, 68–70, 121, 560, 563
acamprosate, 419
accessible services, 255
accidental disasters, 490
accountability, in grant funding, 205
accountable care organizations (ACOs), 66, 263–264
ACHI (Association for Community Health Improvement), 206
ACHNE (Association of Community Health Nurse Educators), 10, 500
ACIP (Advisory Committee on Immunization Practices), 106, 317
ACOs (accountable care organizations), 66, 263–264
acquired immunodeficiency syndrome (AIDS), 32, 36, 46, 81, 102, 107, 108, 114, 116, 117,
297. See also human immunodeficiency virus (HIV) infection
active immunity, 106
activities of daily living (ADLs), 144, 277, 598
ADA (Americans with Disabilities Act), 553, 569
addiction, 394, 395
Addiction Equity Act, 542
ADHD (attention deficit hyperactivity disorder), 237–238, 539
adjusted rates, 151, 155
adjuvant analgesics, for pain management, 606
915
ADLs (activities of daily living), 144, 277, 598
Adolescent Family Life (AFL) program, 563
advance directives, 590, 598–600
artificial nutrition and hydration, 599
cardiopulmonary resuscitation, 599–600
Advisory Committee on Immunization Practices (ACIP), 106, 317
advocacy, 68
Affordable Care Act (ACA), 51, 68–70, 121, 560, 563
African Development Bank, 45
After action report (AAR), 486, 499
age-adjusted rates, 155, 156f
Agency for Healthcare Research and Quality (AHRQ), 7, 33, 63, 123, 255, 315
Agency for Toxic Substances and Disease Registry (ATSDR), 458
Land Reuse Program, 478
agent, 296
in epidemiologic triad, 141, 141b
Agent Orange, 509
aggregate, 3, 10b
AHRQ (Agency for Healthcare Research and Quality), 7, 33, 63, 123, 255, 315
AIDS (acquired immunodeficiency syndrome), 32, 36, 46, 81, 102, 107, 108, 114, 116, 117,
297. See also human immunodeficiency virus (HIV) infection
airborne transmission, 302
air quality, 482
alcohol abuse, 395, 398
AUDIT-C and CAGE screening instruments for, 414, 414b
nursing assessment and implications for, 417–418t
Alcoholics Anonymous (AA), 411, 421
Alcohol Use Disorders Identification Test (AUDIT), 409
Allegheny County Immunization Coalition, 2017, 232
all-hazards vulnerability study, 486
The Allies Against Asthma initiative, 190
ambient air, 472t
American Academy of Family Physicians, 563
American Academy of Pediatricians, 563
American Association of Industrial Nurses (AAIN), 620
American Association of Occupational Health Nurses (AAOHN), 615, 620, 621b
American Board of Occupational Health Nurses (ABOHN), 622
American Chemical Society, 456
American College of Obstetricians and Gynecologists, 377–378
American Diabetes Association, 35
American Journal of Nursing, 284
American Journal of Preventive Medicine, 200
American Medical Association, 377
916
American Nurses Advocacy Institute (ANAI), 62
American Nurses Association (ANA), 62, 377, 388, 542, 575
Code of Ethics, 67
Nursing’s Agenda for HealthCare Reform by, 62
Scope and Standards of Home Health Nursing Practice, 254
American Psychiatric Association (APA), 525
American Public Health Association (APHA), 10
American Recovery and Reinvestment Act (ARRA), 65
Americans with Disabilities Act (ADA), 553, 569
America Nurses Credentialing Association (ANCC), 586
AmeriCorps, 35
ANA. See American Nurses Association (ANA)
ANAI (American Nurses Advocacy Institute), 62
analytical studies, 169, 172, 175
case–control studies, 176–177
cohort studies, 175–176
ANCC (America Nurses Credentialing Association), 586
Anglo-American culture, 221
anorexia, at end of life, 608
anthrax, 503, 506
antibiotic-resistant microorganisms, 364–365
antibiotic stewardship, 330, 365
antigenic drift, 330, 331
antigenic shift, 330, 331
antimicrobial-resistant threats, in United States, 364
AOEC (Association of Occupational and Environmental Clinics), 470
APA (American Psychiatric Association), 525
APHA (American Public Health Association), 10
armed conflict, health effects of, 45
ARRA (American Recovery and Reinvestment Act), 65
artificial nutrition and hydration, 599. See also advance directives
ASCD (Association for Supervision and Curriculum Development), 554, 556
ASD (autism spectrum disorders), 524, 540
Ask Me 3 Good Questions for Good Health (tool), 123
Aspergillus fumigatus meningitis, 306
assessment
asset-based, 227, 241–242
community, 145 (See also community assessment)
family, 267–288
of health needs and assets, 142–145
individual, 143–145
assisted living, 245, 256–257
association, 169
917
Association for Community Health Improvement (ACHI), 206
Association for Supervision and Curriculum Development (ASCD), 554, 556
Association of Community Health Nurse Educators (ACHNE), 10, 500
Association of Occupational and Environmental Clinics (AOEC), 470
and American College of Medical Toxicologists, 470b
Association of State and Territorial Directors of Nursing (ASTDN), 10
Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN), 378
assurance, 36
ATSDR (Agency for Toxic Substances and Disease Registry), 458, 478
attack rate, 155–156
attention deficit hyperactivity disorder (ADHD), 237–238, 539
attributable risk, 151, 165
autism, precipitous rise in, 540–541
autism spectrum disorders (ASD), 524, 540
avian influenza, 339–341
influenza A (H5N1), 299, 339–340
influenza A (H7N9), 299
AWHONN (Association of Women’s Health, Obstetric, and Neonatal Nurses), 378
B
Balanced Budget Act, 245, 249
balance theory, 631
Barton, Clara, 18
Behavioral Risk Factor Surveillance System (BRFSS), 146, 174, 187, 188
behavior change models, 99, 110
ecologic model, 114–117, 114f
health belief model, 111
learning model, 110–111
relapse prevention model, 113–114
social learning theory, 112
theories of social support, 113
theory of reasoned action, 112
transtheoretical model, 111–112
bereavement, 590
and palliative care, 602
β-blockers, 256
bilateral agencies, 29, 46
Bill and Melissa Gates Foundation, 46
Bills of Mortality, 137
binge drinking, 398, 407
bioavailability, 454, 468
biologic hazards, 615
biomonitoring, 454, 469
918
bioterrorism
agent, 503, 504t–506t, 506–508
attack, epidemiologic clues of, 502b
biosafety levels for infectious agents, 508b
categories of, 502, 503b
detection of, 502
history of, 501–502, 501b
Black box warning, 524
SSRI and pediatric practitioners, 535, 537
blast injuries, 514
blended families, 273
block grants, 31
BLS (Bureau of Labor Statistics), 617
Bon Secours Care-A-Van, 206b
Borrelia burgdorferi, 297, 335, 345
Boston Marathon bombing, 514, 544
botulism, 506
bovine spongiform encephalopathy (BSE), 298
breakthrough pain, 591, 605
breast-feeding education, 87
Breckinridge, Mary, 19, 19f
BRFSS (Behavioral Risk Factor Surveillance System), 146, 174, 187, 188
Broad Street pump, 139–140
BSE (bovine spongiform encephalopathy), 298
bubonic plague, 332
built environment, 194
bullying, prevention of, 566b
buprenorphine, 420
Bureau of Labor Statistics (BLS), 617
C
CAGE questionnaire, 409
CAIBL (Community Assessment Instrument for Baccalaureate Learners), 242
Calgary Family Assessment Model (CFAM), 267, 269, 275–277
developmental assessment, 277
functional assessment, 277
structural assessment, 275, 276f
Calgary Family Intervention Model (CFIM), 267–268, 269, 277–278, 279t
affective domain, 277, 279t
behavioral domain, 277–278, 279t
cognitive domain, 277, 279t
CAM (complementary and alternative therapies), 612
Campbell, Jacquelyn, 377
919
Campylobacter infection, 308
CA-MRSA (community-acquired methicillin-resistant Staphylococcus aureus), 301–302
Canada, healthcare system in, 38–39
cannabis use, 398
CAPC (Center to Advance Palliative Care), 592
CAPTA (Child Abuse Prevention and Treatment Act), 384, 404
CARA (Comprehensive Addiction and Recovery Act), 413
Carbapenem-resistant Enterobacteriaceae (CRE), 364
cardiac illness, prevention of progression of, 36
cardiopulmonary resuscitation (CPR), 599–600
care delivery value chains (CDVCs), 90
Caregiver Advise, Record, and Enable (CARE) Act, 283
caregiver burden, 268, 283
care management, 245, 247
caring community, 256
carrier, 296, 301
CAS (Chemical Abstracts Service), 456
case–control studies, 169, 176–177
case fatality rate, 151, 163
case management, 245, 247–248
case manager, 248
responsibilities of, 248b
case series, 172
case studies, 169, 172
catheter-associated urinary tract infections (CAUTIs), 305
Catholic Relief Services, 46
CATIE (Clinical Antipsychotic Trials of Intervention of Effectiveness), 530
causality, 170, 176
criteria for, 176b
cause-specific mortality rate, 151, 163
CAUTIs (catheter-associated urinary tract infections), 305
CBPHI (community-based public health initiative), 241
CBPR (community-based participatory research), 196
CCPHN (Core Competencies for Public Health Nursing), 11
CDC. See Centers for Disease Control and Prevention (CDC)
CDVCs (care delivery value chains), 90
census tract maps, 235
Center for Medicare and Medicaid Services (CMS), 51, 66, 69, 187, 490
Centers for Disease Control and Prevention (CDC), 33, 172, 488, 556
categorization of hazardous chemicals, 509t
on chlamydia screening, 314
health planning by, 187
surveillance system, 306
920
TB infection control guidelines for healthcare settings, 356
Ten Great Public Health Achievements by, 5, 5b
Yellow Book, 335
Center to Advance Palliative Care (CAPC), 592
central line-associated bloodstream infections (CLABSIs), 305
CERT (Certified Emergency Response Teams), 488, 494–500, 494b
CERT (Community Emergency Response Team), 487
Certified Emergency Response Teams (CERT), 488, 494–500, 494b
Certified Emergency Response Teams (CERT), 494–500
Certified Occupational Health Nurse (COHN), 622
CFAM. See Calgary Family Assessment Model (CFAM)
CFIM. See Calgary Family Intervention Model (CFIM)
change theory, 197
Lewin’s model of change, 197
changing, 197
force field analysis, 198, 199f
refreezing, 197–198
unfreezing, 197
CHAs (community health assessments), 186
Chemical Abstracts Service (CAS), 456
chemical and contaminant exposure, 482
chemical disasters, 508–510
nurses in, role of, 510–511
chemical hazards, 616
Chemical Weapons Convention, 509
Child Abuse Prevention and Treatment Act (CAPTA), 384, 404
child maltreatment, 384
Child Nutrition and WIC Reauthorization Act, 565
children
attention-deficit/hyperactivity disorders in, 539
intimate partner violence, impact of, 380–381
obesity in, 564–565
palliative care for, 595
promote mental health in, 534b
Children’s Defense Fund (CDF), 441
Children’s Health Insurance Program (CHIP), 34, 69, 189, 592
chlamydia, 313–314
Chlamydia trachomatis, 313
chloroquine-resistant malaria, 303
cholesterol and cardiovascular disease, relationship between, 236, 237t
CHWs (community health workers), 202–203
Citizens for Global Solutions, 35
CIWA-Ar (Clinical Institute Withdrawal Assessment of Alcohol Scale, revised), 415, 416f
921
CLABSIs (central line-associated bloodstream infections), 305
Clean Air Act (CAA), 455b
Clean Water Act, 455b
clean water and sanitation, 481–482
climate
change, 482–483
influence on health, 473t
Clinical Antipsychotic Trials of Intervention of Effectiveness (CATIE), 530
Clinical Institute Withdrawal Assessment of Alcohol Scale, revised (CIWA-Ar), 415, 416f
clinical trials, 170, 179
Clostridium difficile, 364
Clostridium tetani, 300
CMO (comfort measures only), 591, 598
CMS (Center for Medicare and Medicaid Services), 51, 66, 69, 187, 490
CNPE (Congress on Nursing Practice and Economics), 10
coalitions, 186
to improve community health status, 190, 191, 191b
Cocoanut Grove fire, 541
Code of Ethics for Nurses, 67
COGS (Collaborative Oncological Gene-environment Study), 432
COHN (Certified Occupational Health Nurse), 622
cohort study, 170
coinsurance, 51
collaborative models, 227, 242
Collaborative Oncological Gene-environment Study (COGS), 432
College AIM, 407
colonization, 296, 301
comfort measures only (CMO), 591, 598
Commission on Social Determinants of Health (CSDH), 187
common source outbreak, 296, 305
communicable disease, 75. See also infectious disease
foodborne diseases, 307–309
and infectious disease, difference between, 300
surveillance for, 306–307
waterborne diseases, 309–312
communities of solution, 230
Communities Putting Prevention to Work (CPPW), 148
community, 190, 227, 229
assessment (See community assessment)
as interdependent systems, 239f
as partner, 190, 227, 238
safety and crime in, 473t
systems theory, 190
922
working with, 190–191
coalition, 190, 191, 191b
population of interest, defining of, 190–191
stakeholders and opinion leaders, 191, 191b
community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA), 301–302
Community and District Empowerment for Scale-Up (CODES) project, 196
community assessment, 145, 189, 228–229
by community health nurses, 232–233
defining community and boundaries in, 229–233
geopolitical communities, 229–230
phenomenologic communities, 230–231
societal, national, international communities, 231
frameworks for, 233
assets-based approach, 241–242
collaborative model, 242
community as partner framework, 238
epidemiologic approach, 233–236
functional health status approach, 238–241
geographic information systems, 237
process, overview of, 229b
resources for, 235b
school setting, assessment in, 232
Community Assessment Instrument for Baccalaureate Learners (CAIBL), 242
community-based health insurance, 90
community-based participatory research (CBPR), 196
community-based public health initiative (CBPHI), 241
community benefit programs, 206
in action, 206b
community change, planning for, 23, 185
change theory, 197
community readiness for change, 198
levers of change, 198
Lewin’s model of change, 197–198
collaboration and teamwork, 202
community health workers, 202–203
community assessment, 189
community-level interventions, 199
evaluation of, 203–204
funding for programs, 204–206
guide to community preventive services, 199–200, 200b
logic model, 200
SMART objectives, 202
sources of evidence for, 200b
923
health impact pyramid, 192–193, 193f
health planning, 186–189
multilevel interventions, 193–194
nurse-managed health centers, 208
social determinants of health, 194
health disparities, health equity, and social justice, 195–196
health impact assessment, 195
neighborhoods and communities empowerment, 196–197
obesogenic and salutogenic environments, 194
social ecologic model, 192
social marketing, 207
systems theory, 190
working with community, 190–191
Community Emergency Response Team (CERT), 487
community empowerment, 186–187
definition of, 196
model, 196–197
Ottawa Charter on, 187
World Health Organization on, 186–187
community environment, 456. See also environmental health
and effects on health, 471t–473t
Community Guide, 200
community health advocates. See community health workers (CHWs)
Community Health Assessment and Group Evaluation (CHANGE), 189b
community health assessments (CHAs), 186
community health centers, 66
Community health improvement planning, 189
models and tools for, 189b
community health nurse, 190
community health workers (CHWs), 202–203
community-level interventions, 192
community mental health
centers, 524
and services, 541
evolution of, 541–542
levels of prevention in, 543b
practitioner role, 543–544
teams, in schizophrenia treatment, 533
Community Mental Health Center (CMHC) Act, 541
community readiness model (CRM), 198–199
community report card, 233–234
indicators, 234t
community stakeholders, 191, 191b
924
Community Toolbox, 189b
Community Transformation Grant (CTG), 65, 205
competencies, 3, 11
cultural (See cultural competency)
for public health nursing practice, 11
complementary and alternative therapies (CAM), 612
Complete Streets, 194–195
Comprehensive Addiction and Recovery Act (CARA), 413
comprehensive care, 255
computerized screening surveys, 407
concentrated animal feeding operations (CAFOs), 472t
congregation, 573, 577
based model, 573
paid, 575–576
unpaid, 576
Congress on Nursing Practice and Economics (CNPE), 10
contagious disease, 296, 300
controls, 170, 176
convergence model, 330, 331, 333f
coordinated care, 255
coordinated school health, 553
co-pay, 51
Core Competencies for Public Health Nurses (CCPHN), 11
cost–benefit approach, 51, 56
cost sharing, 51
council on school health, 553
county health department, 34
CPPW (Communities Putting Prevention to Work), 148
CPR (cardiopulmonary resuscitation), 599–600
CRAFFT drug screening questionnaire, for adolescents, 404, 404b
craving, 394, 419
CRE (Carbapenem-resistant Enterobacteriaceae), 364
Creating Community Connections project, 230
Crimean War, 488
critical health literacy, 126–127
CRM (community readiness model), 198–199
cross-cultural nursing, 213, 215
cross-sectional studies, 170, 174
crude mortality rates, 163
crude rates, 151, 155
CSDH (Commission on Social Determinants of Health), 187
CTG (Community Transformation Grant), 65, 205
cultural brokerage, 220
925
cultural competency, 22–23, 51, 58, 59, 213, 215–216
institutional, 216
principles of, 216
Cultural Competency Curriculum for Disaster Preparedness and Crisis Response, 491
cultural health assessment
healthcare organizations, 224
individual clinicians, 224
cultural humility, 217
culturally competent mental health services, 524
cultural safety, 213, 217–218
cultural sharing, 215
culture, 213, 214
communication, impact on
nonverbal communication, 220
style of communication, 220
verbal communication, 219–220
definition of, 214
and diet, 219, 220f
dynamic nature, 214–215
ethnocentrism, 217–218
family members, role of, 221
folk medicine, use of, 223–224, 224b
and health, 219–224
healthcare and, 219–224
illness, attribution of, 219
learning of, 215
macroreligious, 219
as nursing concern, 214
properties of, 214–215
race, 218
religion and, 221–223, 222f
sharing, 215
sick person, decision of, 221
subculture, 218
time orientation, 221
Western biomedicine, 218–219
cyberbullying, 567b
D
DALYs (disability-adjusted life years), 82, 83b
Dartmouth Atlas Project, 597
DCPP (Disease Control Priorities Project), 79
death
926
close to, nursing care
after death, 611
caring for caregiver, 612
dying process, 610–611
grief, 611–612
preparing for death, 609
leading causes of, in United States, 137t
death rates. See mortality rates
decontamination, 487
and blister agents, 509
tent, 511
deductibles, 51
dehydration, at end of life, 608
deinstitutionalization, 524
and schizophrenia treatment, 532
demographic and health survey (DHS), 78
demographic data, 151, 158
demographic transitions, 75, 78
demographic variables, 170
Department of Defense (DoD), 306
Department of Health and Human Services, 29, 31, 37
Department of Homeland Security (DHS), 21, 493
dependent variable, 170
DES (diethylstilbestrol), 176–177
descriptive studies, 170, 171, 172
case studies, 172
cross-sectional studies, 174
survey research, 172–173
designated drivers, 197
determinants of health, 75, 78
developmental model, 227
DHS (Department of Homeland Security), 21, 493
Diagnostic and Statistical Manual, 5th edition (DSM-5), 524
diethylstilbestrol (DES), 176–177
directly observed therapy (DOT), 330, 352
dirty bombs, 513
disability-adjusted life years (DALYs), 82, 83b
disaster
accidental, 490
chemical, 508–511
documentation, 499
emergencies supplies, 495b
evaluation, 499–500
927
levels for personal protection in, 496t
management, 492–494, 492f
nurses role in, 500–501
point of distribution plans, 494
preparedness, 492–494
public health nurses in, 500b
natural, 489–490
nursing psychological care competencies, 499b
populations traumatized by, 544
preparedness
in culturally diverse society, 491
and management competencies, 494b
plans, 24–25
radiologic, 512–513
recovery phase of, 498–500
terrorism, 490
tips for communicating with survivors, 498b
types of, 489
disease, 102, 105
contagious, 296, 300
infectious (See infectious disease)
management, 247
natural history of, 142, 143f, 144
Disease Control Priorities Project (DCPP), 79
disruptive behavior disorders, in children, 539
district nurses, 3, 15, 16b
disulfiram, 419
diverse workforce, 58
divorce, effects of, 272
Dix, Dorothea, 17
DNR (do-not-resuscitate) order, 599
DoD (Department of Defense), 306
domestic terrorism, defined, 490
Domestic Violence Enhanced Home Visitation (DOVE) Program, 385
do-not-resuscitate (DNR) order, 599
DOT (directly observed therapy), 330, 352
drinking water–associated outbreaks, 309–310
droplet transmission, 303
drugs and alcohol, 561. See also school health
DSM-5 (Diagnostic and Statistical Manual, 5th edition), 524
DUP (duration of untreated psychosis), 528
duration of untreated psychosis (DUP), 528
Dying in America: Improving Quality and Honoring Individual Preferences Near the End of
928
Life, 592
E
early intervention programs, 524
for psychosis, 528
Early Periodic Screening, Diagnosis, and Treatment (EPSDT), 553, 555
Ebola
fever, 298, 507
precautions, 508, 508f
testing, 508f
Ebola virus disease (EVD), 356–360
outbreaks of, 356–358
prevention and control of, 358–360
signs, symptoms, and diagnosis of, 358
ecologic model, 99, 114–117, 114f
exosystem, 116
macroculture, 116–117
microsystem, 115–116
ontogenic system, 115
use of, 114
ecomaps, 268, 275, 276f
Economic Research Service (ERS), 433
economics, 51, 55
ecosystem, 330, 334
EDS (emergency dispensing site), 487, 494
Education for All Handicapped Children Act, 555
education, for public health nursing practice, 12
EHRs (electronic health records), 3, 8, 65
elderly people
physical functioning of, decline in, 144–145
in rural area, 438–439
elder mistreatment, 383–384
electronic bullying, 553–554
electronic health records (EHRs), 3, 8, 65
electronic visit verification, 258
ELISA (enzyme-linked immunosorbent assay), 108
emergencies, disasters, and terrorism, 489–491
emergency dispensing site (EDS), 487, 494
emergency operations plan (EOP), 494
Emergency Planning and Community Right-to-Know Act (EPCRA), 508
emerging infectious diseases, 329–365, 330, 332f
antibiotic-resistant microorganisms, 364–365
definition of, 331
929
factors influencing, 331, 332b
changing ecosystems, 333–335
climate and weather, 333–335
human susceptibility to infection, 333
lack of political will, 336
microbial adaptation and change, 331–333
public health infrastructures, breakdown of, 336
travel, technology, and industry, 335–336
IOM on, 331, 332b, 333f
recent reemerging and
avian influenza, 339–341
Ebola virus disease, 356–360
Escherichia coli O157:H7, 348–349
H1N1 influenza (swine flu) pandemic, 341–342
Lyme disease, 345–348
Middle East respiratory syndrome coronavirus, 337–339
novel avian influenza A (H7N9) virus, 343–344
severe acute respiratory syndrome, 336–337
tuberculosis, 349–356
West Nile virus, 344–345
Zika virus disease, 360–362
vaccine-preventable diseases, reemergence of, 362
elimination of, 363–364
measles, 362–363
mumps, 363
pertussis, 363
rubella, 363
emotional turmoil or depression, 612
empathy, 262
endemic, 296, 303
end-of-life care, 596t
chronic disease, nursing and persons, 591–595
complementary and alternative therapies, 612
cultural and religious issues, 600–601
nursing care, 597–601
for persons, 602–603
management of distressing symptoms, 608–609
pain management, 603–607
religion and, 601t
endowment funds, 31
entitlement programs, 31
environment
effects of, on health, 24
930
in epidemiologic triad, 141, 141b
environmental contaminants, exposure pathways for, 460–467t
environmental epidemiology, 454
benefits of, 477–478
environmental health, 454
assessment
assessment of individuals, 474
community, 471–474
contaminants, assessing, 457–459, 468
health impact, determining, 468–470
children’s health and
healthy schools and early care and education, 480
vulnerability to environment, 479
environmental epidemiology, 477–478
environmental justice, 480–481
evaluation, 476
global environmental health challenges
air quality, 482
chemical and contaminant exposure, 482
clean water and sanitation, 481–482
climate change, 482–483
healthy environments
healthy communities, 478
healthy homes, 478–479
history of, 455–456
human health and, 454–457
community environment, 456
genetic and behavioral factors, 457
nursing and environmental health, 457
interventions, 474–476
environmental health nurses, 24
environmental justice, 454, 480–481
Environmental Protection Agency (EPA), 310, 323, 455, 508
enzyme-linked immunosorbent assay (ELISA), 108
EOP (emergency operations plan), 494
EPA (Environmental Protection Agency), 310, 323, 455, 508
EPCRA (Emergency Planning and Community Right-to-Know Act), 508
epidemic, 134, 296, 303
epidemic curve, 151
epidemiologic descriptive studies, 151–152, 167
epidemiologic models, 140–142, 227, 233
epidemiologic triad, 140–141, 141b
natural history of disease, 142, 143f
931
web of causation, 141, 142f
wheel of causation, 141
epidemiologic research
cycle, 171, 171f
definition of, 170
intervention studies, 177–179
observational studies, 171–177
purposes of, 171
epidemiologic transitions, 75, 78
epidemiologic triad, 134, 140–141, 141b
epidemiology, 3–4, 22, 134
definition of, 136, 171
development of, as science, 137–140
goals of, 136
milestones in, 138–139t
models, 140–142
principles in practice, application of, 142–149
health needs and assets, assessment of, 142–145
health services, evaluation of, 149
healthy lifestyles, promotion of, 146
outbreaks, prevention and control of, 148
planning and implementing interventions, 146
safe and healthy environment, contribution to, 148–149
EPSDT (Early Periodic Screening, Diagnosis, and Treatment), 553, 555
equity, 51
definition of, 65
in healthcare access and quality, 65
ergonomics, 616, 617
ERS (Economic Research Service), 433
Escherichia coli O157:H7, 298, 309, 348–349
ESSA (Every Student Succeeds Act), 554, 556
ethics education, 68
ethnocentrism, 213, 217–218
euthanasia, 600
active, 600
evacuation, 487
during disaster, 512
guidelines for, 512b
EVD. See Ebola virus disease (EVD)
Every Student Succeeds Act (ESSA), 554, 556
evidence-based nursing, 4, 21–22, 170
evidence-based public health, 4, 22
exposure, 454
932
environmental contaminant and people, 454
estimate, 454
health effects determination, 468
history, 454, 475t
of contaminants, 474
pathway, 454
of contaminant, 458
environmental media and transport mechanisms, 458
point of exposure, 458–459
receptor population, 468
route of exposure, 459
source of contamination, 458
extended family, 271
external validity, 178
threats to, 178b
extraneous variables, 170
Exxon Valdez, 508
eye contact, 220
F
FAAMA (Food Allergy and Anaphylaxis Management Act), 554, 569
faith community
nursing, 573–575
education for, 586, 587t
ethical considerations, 586
functions of, 587t
history of, 575
home visits, 258
nursing process in, 582–585
roles of, 579
scope and standards, 581–582, 581t
practice
models of, 575–577, 576t
relationship with clergy, 577–578
uniqueness of, 578–579
falls, in home care, 259–260, 260t
family, 268, 269, 270
assessment
Calgary Family Assessment Model, 275–277, 278t
15-minute family assessment, 280, 280b
blended, 273
changes in family life cycle, 271–272
cohabiting couples and, 273
933
community health nurses’ responsibility to, 287
definitions of, 270
gay and lesbian, 273
health teams, 257
homeless, 273–274
interventions
Calgary Family Intervention Model, 277–278, 279t
interview, 280, 280b
single-parent, 272–273
support by community health nurses, 281–287
theoretical perspective of, 270–271
family developmental theory, 271
family structural-functional theory, 270–271
family systems theory, 270
family caregiver, 246, 263, 283–287
caregiver burden, 283
characteristics and needs, 283–284
home health nurses and, 284–287
resources for, 285b
Family Educational Rights and Privacy Act of 1974 (FERPA), 569
family-focused home visiting, 281–283
Family Medical Leave Act (FMLA), 627
family–nurse relationship, 282–283
family nursing practice, 269
competencies, 269b
Family Spirit, 403b
Family Systems Nursing (FSN), 268, 274–275
Farr, William, 137, 140
FAS (fetal alcohol syndrome), 400, 402b
Federal Emergency Management Agency (FEMA), 21, 53, 635
federally qualified health centers, 66
Federation of Occupational Health Nurses within the European Union (FOHNEU), 624
FEMA (Federal Emergency Management Agency), 21, 53, 635
femicide, 373, 377
Ferguson v. the City of Charleston (South Carolina), 403, 404
FERPA (Family Educational Rights and Privacy Act of 1974), 569
fetal alcohol syndrome (FAS), 400, 402b
FHPs (functional health patterns), 228, 238, 240b–241b
field triage, 497–498, 498t
firearms, 374–375, 374b, 375f
first-generation antipsychotics, 524, 531
first-psychotic episode, intervention programs for, 529t
Fliedner, Theodore, 15
934
FMLA (Family Medical Leave Act), 627
focus groups, 242
Food Allergy and Anaphylaxis Management Act (FAAMA), 554, 569
foodborne diseases, 307–309
prevention of, 323
force field analysis, 198, 199f
forensic nursing, 388
framework, 228, 233, 268. See also community assessment
Framingham Heart Study, 175
France, healthcare system in, 39–41
Francisella tularensis, 507
FSN (Family Systems Nursing), 268, 274–275
functional health patterns (FHPs), 228, 238, 240b–241b
funding, for community health programs, 204–205
accountability, 205
community benefit programs, 206
government agencies, 205–206
local resources, 206
private foundations, 206
program replication, 205
project funding, 205–206
sustainability, 205
TheFuture of Public Health (IOM report), 20
G
gastroenteritis, 307–308
gay and lesbian families, 273
GBD. See global burden of disease (GBD)
GDP (gross domestic product), 51, 56
gender-based violence, 373, 376
genital herpes, 322
genograms, 268, 275, 276f
genomics, 430
and underserved populations, 432–433
geofences, 258
geographic information systems (GISs), 237
geographic positioning systems (GPS), 493
geopolitical community, 228, 229–230
geriatric scholar program (GSP), 437
Germany, healthcare system in, 41–42
GISP (Gonococcal Isolate Surveillance Project), 314
GISs (geographic information systems), 237
Global Autism Public Health Initiative, 540
935
global burden of disease (GBD), 25–26, 75, 78–82
impact of disease burden, 79–82, 80f
noncommunicable diseases, 79, 81b
risk factors and, 82
role of nurses, 82
global health, 75–76, 78
definition of, 77
demographic and epidemiologic transitions, 78
determinants of health, 78
factors affecting
economics and politics, 89–90
healthcare systems, 90–92
global burden of disease, 78–82
health indicators, 82–84, 83b
poverty and risk factors, 84
role of nurses, 92
Sustainable Development Goals, 85–89
women, poverty, and health, 84–85
Global Initiative on Primary Prevention of Substance Abuse, 397
Global War on Terror (GWOT), 446
Gonococcal Isolate Surveillance Project (GISP), 314
gonorrhea, 314–315
GPS (geographic positioning systems), 493
Graunt, John, 137
Grey Sisters, 15
grief, 591, 611–612
grocery stores, access to, 472t
gross domestic product (GDP), 51, 56
GSP (geriatric scholar program), 437
Guideline and Template for Community Health Improvement Planning, 189b
GWOT (Global War on Terror), 446
H
HAIs (healthcare-associated infections), 296, 305–306
HALE (health-adjusted life expectancy), 82, 83b
HAN (Health Alert Network), 514
hantavirus pulmonary syndrome (HPS), 297, 302
Harvard Nurses’ Health Study, 176
HBV (hepatitis B virus), 301
HCBS (home and community-based services), 66
HCV (hepatitis C virus), 173–174
health, 76, 99–100, 102
counseling, 193
936
definitions of, 77
determinants of, 78
disparities, 4, 5, 37
social determinants of, 431–432
equity, 195
finance, 55–56
grid, 77, 77f
insurance, 68
models, 77
personal responsibility for, 9–10
social determinants of, 4
women, poverty and, 84–85
health-adjusted life expectancy (HALE), 82, 83b
Health Alert Network (HAN), 514
health assessment, cultural, 224
health belief model, 100, 111
healthcare
access to, 56–57, 473t
changes in, 4–10
costs in United States, 246–247
in developed nations, 37–38
Canada, 38–39
France, 39–41
Germany, 41–42
Netherlands, 42–43
United Kingdom, 43
funding for, 34–35
government in, role of, 4–6
measures of, in developed countries, 35t
organization of, 31
patient/client-centered care, 6–7
personal responsibility for health in, 9–10
proxy, 591, 598
quality, 63
technology and, 7–8
health information technology, 8
telehealth, 8–9
in twenty-first century, 4–10
in United States, 5–6, 31–35
vulnerable populations and, 37
workforce diversity, 57–59
World Health Organization on, 4–5
healthcare-associated infections (HAIs), 296, 305–306
937
healthcare reform
community-based services associated with, 65–66
health advocacy and, 68
healthcare systems
financial support, need of, 90–91
value-based delivery system, 90
healthcare workers, shortages of, 91–92, 92t
health disparities, 4, 5, 37, 195, 268, 431–432
health education materials, 124
health impact assessment (HIA), 195
health impact pyramid, 192–193, 193f
health indicators, 76, 82–84, 83b
health information technology (HIT), 4, 8, 65
Health Insurance Portability and Accountability Act (HIPAA), 262, 630
health literacy, 100, 118, 187
basic level of, 118–119
at community level, 127
critical, 126–127
definition of, 118, 126
expanding responsibility for, 121
functional, 119
and health education, 122–126
health outcomes linked to, 121
and health promotion, 126–128
Healthy People 2020 and, 125
increasing interest in, 119
knowledge and skills related to, 119–120, 120t
low, populations at risk for, 119b
origins of, 118
practices, 122, 122b
universal precautions, 100, 123, 124t
health maintenance organization (HMO), 250
Health People 2020, 208b
health personnel issues, in rural area, 434–435
health planning, 186
community health improvement planning process, 189
definition of, 186
at global level, 186–187
Ottawa Charter, 186–187
Shanghai Declaration, 187
Sustainability Development Goals, 187
WHO model, 186–187
at national and state levels, 187–189
938
Healthy People 2020, 187–188
National Prevention Strategy, 188
state departments of public health, 188–189
health policy, 51
components of, 53
definition of, 53
and nursing political involvement, 62–63
nursing’s role in shaping of, 59–61
policy-making process, 54, 54f
government in, 53–54
policy adoption, 54
policy assessment, 54–55
policy formulation, 54
policy implementation, 54
policy modification, 55
setting agenda, 54
in the United States, 55
and political process, 52–55
health professional shortage area (HPSA), 430, 434–435, 435b
and MUA/MUP, 435t
Health Promoting Lifestyle Profile (HPLP-II), 584
health promotion, 100, 102, 103
epidemiologic model and prevention, 103–104
health literacy and, 126–128
levels of prevention, 105
primary prevention, 105–106, 105b
secondary prevention, 107–108
tertiary prevention, 108–109
and social determinants of health, 127
health report card, 197
Health Resources and Services Administration (HRSA), 57–58, 434, 555
health services research, 70–71
healthy communities, 454, 478
design, 194
Healthy Dollar project, 206b
healthy environments, creation of, 194
healthy homes, 478–479
Healthy People 2020, 10, 20, 34, 102–103, 146, 233
goals of, 10b, 153, 187
health communication objectives, 125b
healthier food access in schools, 148
and health literacy, 125
leading health indicators, 233b
939
new areas of interest in, 103b
objectives, 174, 187–188
for environmental health and water quality, 310b
for food safety, 307b
for immunization and infectious diseases, 298b
for sexually transmitted diseases, 313b
occupational health and safety in, 628b, 637
preparedness goals from, 501b
priorities, 580, 580b
rural health priorities, ranking, 438b
target to decrease suicide by ethnicity, 536f
target to decrease suicide by gender, 535f
Healthy People coordinator, 189
Healthy People initiatives, 102–103. See also Healthy People 2020
Heffernan, Claire, 333
hepatitis B virus (HBV), 301
hepatitis C virus (HCV), 173–174
herbal medications, and adverse interactions, 260b
herd immunity, 106, 330, 333
herpes simplex virus (HSV), 322
HIA (health impact assessment), 195
High-Level Political Forum (HLPF), 86–87
Hildebrandt, Eugenie, 196
HIPAA (Health Insurance Portability and Accountability Act), 262, 630
Hippocrates, 136
HIT (health information technology), 4, 8, 65
HIV infection. See human immunodeficiency virus (HIV) infection
HLPF (High-Level Political Forum), 86–87
HMO (health maintenance organization), 250
H1N1 influenza, 299
pandemic, 341–342
hoarding disorder, nursing interventions for, 538
home and community-based services (HCBS), 66
homebound, 246, 251
home care computerized records, 262
home care models. See also home visit
assisted living, 256–257
home visits to homeless, 257–258
parish/faith community nursing, 258
home care nurses, 248. See also home healthcare
safety tips for, 258–259, 259b
home healthcare, 246, 248–249
chronic conditions and quality improvement in, 262–263
940
and current healthcare reform, 263–264
financing and regulation of, 250–254
history of, 249, 249b
interprofessional care, 255
nurse–family interactions in, 261
confidentiality, 262
contracts, 261–262
culture, 261
role and scope of, 254
telehealth, 255–256
types of agencies, 249
hospital-based, 250
official, 250
private/voluntary, 249–250
proprietary, 250
Home Health Care Department of Boston General Hospital, 250
homeless families, 273–274
homeless populations, 449
home visit, 258
actual visit, 259–261
to homeless, 257–258
home safety risks, assessment for
abuse and neglect, 260–261
falls, 259–260, 260t
medication errors, 259, 259b, 260b
initiating visit, 258
post visit planning, 261
preparation for, 258–259
directions and visit verification systems, 258
paperwork, 258
personal safety, 258–259, 259b
supplies and equipment, 258
termination of visit, 261
hospice
benefits, medicare, 594b
care, 602
clinical excellence and safety, 594
compliance with laws and regulations, 594
ethical behavior and consumer rights, 593
inclusion and access, 594
organizational excellence, 594
patient- and-family-centered care, 593
performance measurement, 594
941
standards, 594
stewardship and accountability, 594
workforce excellence, 594
definition of, 594b
home care, 258
Hospice and Palliative Nurses Association (HPNA), 592
hospital-based agencies, 246, 250
host, in epidemiologic triad, 141, 141b
hot wash session, 499
HPNA (Hospice and Palliative Nurses Association), 592
HPS (hantavirus pulmonary syndrome), 297, 302
HPSA (health professional shortage area), 430, 434–435, 435b
and MUA/MUP, 435t
HPV Champion Toolkit, 317
HPV (human papillomavirus) infection, 316–318
HRSA (Health Resources and Services Administration), 57–58, 434, 555
HRSA Data Warehouse (HDW), 435
HST (human simulation training), 487, 494
HSV (herpes simplex virus), 322
human health and environmental health, 454–457
community environment, 456
genetic and behavioral factors, 457
nursing and environmental health, 457
human immunodeficiency virus (HIV) infection, 302, 318–321
and AIDS, 318
diagnosis of, 320–321
guidelines for prevention of, 320, 320b
Healthy People 2020 objectives for, 320, 321b
incidence and prevalence of, 318f, 319f
mortality and morbidity rates, 36
screening for, 108
human papillomavirus (HPV) infection, 316–318
human rights, 373, 376
human simulation training (HST), 487, 494
human trafficking, 386–387, 430, 448–449
hurricane
Andrew, 495
of Fall, 2017, 488
Irma, 495
Katrina, 491
Hurricane Harvey, 215
hypothesis, 170
hypothesis-generating research, 172
942
hypothesis-testing studies, 172
I
IACC (Interagency Autism Coordinating Committee), 540
IADLs (instrumental activities of daily living), 277
IAFN (International Association of Forensic Nurses), 388
ICN (International Council of Nurses), 29, 46, 62
ICS (incident command system), 487, 496–497, 497f
IDEA (Individuals with Disabilities Education Act), 555
IEP (Individual Education Plan), 554, 555
IGRA (interferon-g release assay), 353–355
IHR (International Health Regulations), 44
illicit drugs use, 399–400, 417–418t
immunity, active, 106
incidence, 373
incidence density, 152, 163, 165
incidence rates, 152, 155–156
and indexes of health, 157t
types of
attributable risk, 165
incidence density, 163, 165
mortality rates, 163
relative risk ratio, 165
variations in, 160
incident command system (ICS), 487, 496–497, 497f
incontinence, at end of life, 608
incubation period, 296
independent variable, 170
individual assessment, 143–145
Individual Education Plan (IEP), 554, 555
Individuals with Disabilities Education Act (IDEA), 555
indoor air, 472t
infectious agents, 300
characteristics of, 301b
infectivity of, 300
pathogenicity of, 300
portals of entry and exit, 301
reservoirs of, 302
transmission of, 302–303
infectious disease, 296, 297, 300. See also emerging infectious diseases
chain of infection, 300, 300f
agents, 300, 301b
environment, 302
943
host, 301–302
transmission, 302–303
and communicable disease, difference between, 300
Healthy People 2020 objectives for, 298b
incubation period, 301
new and reemerging, examples of, 297–299
outbreak investigation, 303–305
establishing existence of outbreak, 304
person, place, and time in, 304–305
steps in, 303b
prevention and control of, 322–324
sexually transmitted infections, 312–322
surveillance for, 306
inferred causality, 176
influenza A (H7N9) virus, 343–344
Influenza Risk Assessment Tool (IRAT), 341
information management, 64–65
injection drug users, 411–413
in-kind support, for community health programs, 206
inmate, 430
in jails and prison, 441
insecticide-treated bed nets (ITNs), 82
Institute of Medicine (IOM), 20, 37, 331, 592
convergence model, 331, 333f
on emergence/reemergence of infectious diseases, 331, 332b
on global health, 77
quality of care, definition of, 63
institution-based model, 574
paid, 576
unpaid, 576–577
instrumental activities of daily living (IADLs), 277
intentional crime victims, model of care for, 387
Interagency Autism Coordinating Committee (IACC), 540
interdisciplinary team, 257
interferon-g release assay (IGRA), 353–355
intermittent care, 246, 253
internally displaced persons, 45
internal validity, 175
threats to, 176b
International Association of Forensic Nurses (IAFN), 388
International Committee of the Red Cross, 46
International Council of Nurses (ICN), 29, 46, 62
international health organizations, 45–46
944
International Health Regulations (IHR), 44
International Monetary Fund, 45
International Parish Nurse Resource Center, 586
International Refugee Organization, 45
interprofessional collaboration, 246, 255
intervention studies, 170, 177–179
preventive trials, 178–179
therapeutic trials, 179
intimate partner violence (IPV), 23–24, 373, 376–383
clinic-based advocacy for, 386
extent of, 377–380
Healthy People 2020 on prevention of, 380
impact on children, 380–381
in pregnancy, 379
and principles of trauma-sensitive care, 382, 382b
risk factors for, 378t
safety assessment and planning in, 383
screening and assessment guidelines for, 378
screening for, 381–382, 382b
intoxication, 394, 405
intrafamily strain, 268, 283
intrauterine devices (IUD), 563
invacuation, 487
during disaster, 512
IOM. See Institute of Medicine (IOM)
IPV. See intimate partner violence (IPV)
IRAT (Influenza Risk Assessment Tool), 341
ITNs (insecticide-treated bed nets), 82
IUD (intrauterine devices), 563
Iwate Prefecture, 512
J
Jackson, Richard, 194
jails and prisons, underserved populations in, 441–444
JITT (just-in-time training), 496
The Joint Commission (TJC)
on health literacy, 121
on mental health and illness, 541
Journal of Forensic Nursing, 388
just-in-time training (JITT), 496
K
945
Kellogg Foundation, 31
key informant, 186
Kübler-Ross, Elisabeth, 595
L
LAI (long-acting injectable antipsychotic), 531
lay health advisors. See community health workers (CHWs)
lay workers, 196
leading health indicators (LHI), 637
learning environment, 123
learning model, 100, 110–111
Learn the Signs—Act Early, 540
Legionnaires disease, 297, 311
LEP (limited English proficiency), 491
lesbian, gay, bisexual, transgender and queer (LGBTQ) community, 431, 444–446, 447b
lethality assessment, 373, 377
Lewin, Karl, 197
LGBTQ (lesbian, gay, bisexual, transgender and queer) community, 431, 444–446, 447b
LHI (leading health indicators), 637
LifeSkills Training program, 405, 406b
lifestyle management, to lower blood pressure, 173t
Lifestyle Medicine Institute, 189b
limited English proficiency (LEP), 491
Listeria monocytogenes, 308
listeriosis, 308
Living Proof Project, 46
local health departments, 34
logic model, 186
for community health program, 200
for influenza immunization program, 201f
long-acting injectable antipsychotic (LAI), 531
long-term changes, 152, 163
lung cancer and smoking, link between, 136
Lyme disease, 297, 302, 345–348
epidemiology of, 345–346
exposure to, 346
prevention of, 347–348, 348b
symptoms and signs of, 346–347
two-tier testing for, 346f
M
mad cow disease, 298
946
managed care, 246, 249
managed care organizations (MCO), 440
MAP-IT, 189b
Marburg fever, 507
Massachusetts HealthCare Reform Act, 631
mass casualties, psychological interventions for, 546t
mass casualty events, 488
mass casualty incident (MCI), 487, 488
material safety data sheet (MSDS), 627–628
maternal mortality rate, 25
MCI (mass casualty incident), 487, 488
McIver, Pearl, 20
MCO (managed care organizations), 440
MDGs. See Millennium Development Goals (MDGs)
MDGs (Millennium Development Goals), 30, 44–45, 187
Meaningful Use (MU) initiative, 66
means restriction, 537
measles, 362–363
Medicaid, 20, 31, 34, 69, 250, 556b
medical home, 246
Medical Home model, 255
medically underserved area (MUA), 430, 435
medically underserved population (MUP), 430, 435
medical necessity, 246, 254
Medical Reserve Corps (MRC), 487, 488, 494–500, 494b
medical village, 203
Medicare, 20, 31, 34, 69, 250
Medicare Modernization and Improvement Act, 249
medication safety, at home, 259, 259b
memoranda of understanding (MOU), 492
meningitis, Aspergillus fumigatus, 306
mental disorders worldwide, prevalence of, 527t
Mental Health Gap Action Program, 533
mental health insurance benefits, 542–543
mental health issues, 498
Mental Health Parity Act (MHPA), 542
mental illness
cultural context of, 525
definitions of, 525
major, 527–541
scope of, 525–526
men who have sex with men (MSM), 314, 316
MERS-CoV (Middle East respiratory syndrome coronavirus), 299, 337–339
947
methadone, 420
methamphetamine use, 413
methicillin-resistant Staphylococcus aureus (MRSA), 301, 336
metropolitan divisions, 433
MHPA (Mental Health Parity Act), 542
MI (motivational interviewing), 100, 109–110, 109b, 262, 406, 409, 422b
Michigan Alcoholism Screening Test—Geriatric Version (MAST-G), 409, 410
microbes, 331–333
microbial adaptation, 330, 332
microorganisms, antibiotic-resistant, 364–365
Middle East respiratory syndrome coronavirus (MERS-CoV), 299, 337–339
middle range theory, of community empowerment, 196
Millennium Development Goals (MDGs), 30, 44–45, 187
Mine Safety and Health Act, 621
mitigation, 495–496
Mobilizing for Action through Planning and Partnerships (MAPP), 189b
models of health, 77
adaptive model, 77
clinical model, 77
eudaimonistic model, 77
role-performance model, 77
modifiable risk, 100, 104
mood and anxiety disorders
epidemiology, 534
nursing interventions for, 537
populations at risk for suicide, 534–537
morbidity, 152, 156
Morbidity and Mortality Weekly Report (MMWR), 36, 104, 200
mortality rate, 152, 163
cause-specific, 163
crude, 163
motivational interviewing (MI), 100, 109–110, 109b, 262, 406, 409, 422b
MOU (memoranda of understanding), 492
mourning, 591, 612
MRC (Medical Reserve Corps), 487, 488, 494–500, 494b
MRSA (methicillin-resistant Staphylococcus aureus), 301, 336
MSA (Multistate Settlement Agreement), 562
MSA (Multistate Settlement Agreement), 562
MSDS (material safety data sheet), 627–628
MSM (men who have sex with men), 314, 316
MUA (medically underserved area), 430, 435
multilateral agencies, 30, 45–46
Multistate Settlement Agreement (MSA), 562
948
mumps, 363
MUP (medically underserved population), 430, 435
Mycobacterium tuberculosis, 349
myoclonus, 607
N
NA (Narcotics Anonymous), 411
NAAL (National Assessment of Adult Literacy), 118
naloxone, 420
NALS (National Adult Literacy Survey), 118
naltrexone, 419
NANDA-I (North American Nursing Diagnosis Association International), 582
nanomaterials, 616, 634
nanotechnology, 616, 636–637
NARA (National Association of Regulatory Administrators), 480
Narcotics Anonymous (NA), 411
NAS (neonatal abstinence syndrome), 400–401
NASN (National Associate of School Nurses), 554
National Action Plan to improve health literacy, 121, 122b
National Adult Literacy Survey (NALS), 118
National Assessment of Adult Literacy (NAAL), 118
National Associate of School Nurses (NASN), 554
National Association of Pediatric Nurse Practitioners, 560
National Association of Regulatory Administrators (NARA), 480
National Center for Complementary and Alternative Medicine (NCCAM), 612
National Center for Complementary and Integrative Health (NCCIH), 612
National Center on Elder Abuse (NCEA), 383
National Center on Health Statistics (NCHS), 187
National Comorbidity Survey (NCS), 525
National Consensus Project (NCP), 595
National Council of State Board of Nursing (NCSBN), 57–58
National Guideline Clearinghouse, 409
National Health and Nutrition Examination Survey (NHANES), 188, 469
National Healthcare Quality and Disparities Report (NHQDR), 5, 63
National Healthcare Safety Network (NHSN), 305
National Health Education Standards, 560
national health expenditure, 52, 56
National Health Expenditure Accounts (NHEAs), 30, 37
National Health Interview Survey (NHIS), 187
National High Blood Pressure Education Program, 172–173
National Hospice and Palliative Care Organization (NHPCO), 592
National Incident Management System (NIMS), 487, 493–494
National Institute for Occupational Safety and Health (NIOSH), 149, 616, 621, 636
949
National Institute on Alcohol Abuse and Alcoholism (NIAAA), 398, 407, 408t
National Institutes of Health (NIH), 33, 431
National League for Nursing (NLN), 62
National Library of Medicine, 431
2015 National Nursing Workforce Survey, 9
National Occupational Research Agenda (NORA), 630
National Patient Safety Foundation, 123
National Prevention and Health Promotion Council, 188
National Prevention Council, 188
National Prevention Strategy (NPS), 31, 188
National Registry of Evidence-Based Programs and Practices (NREPP), 561
National Response Framework (NRF), 487, 493
National Rifle Association, 537
National Strategy for Suicide Prevention (NSSP), 537
National Survey on Drug Use and Health (NSDUH), 561
National Youth Tobacco Survey (NYTS), 561
Nationwide Health Information Network (NwHIN), 8
conceptual model, 8, 8f
natural disasters, 489–490
natural history, 134
of disease, 142, 143f, 144
naturally occurring retirement communities (NORCs), 257
NCCAM (National Center for Complementary and Alternative Medicine), 612
NCCIH (National Center for Complementary and Integrative Health), 612
NCEA (National Center on Elder Abuse), 383
NCHS (National Center on Health Statistics), 187
NCP (National Consensus Project), 595
NCS (National Comorbidity Survey), 525
NCSBN (National Council of State Board of Nursing), 57–58
necrotizing fasciitis, 298
neglect, 260–261
Neisseria gonorrhoeae, 314, 364
neonatal abstinence syndrome (NAS), 400–401
Netherlands, healthcare system in, 42–43
neuropathic pain, 604
NFP (Nurse–Family Partnership) program, 282
NGOs (nongovernmental organizations), 30, 31, 35, 46, 493
NHANES (National Health and Nutrition Examination Survey), 188, 469
NHEAs (National Health Expenditure Accounts), 30, 37
NHIS (National Health Interview Survey), 187
NHPCO (National Hospice and Palliative Care Organization), 592
NHQDR (National Healthcare Quality and Disparities Report), 5, 63
NHSN (National Healthcare Safety Network), 305
950
NIAAA (National Institute on Alcohol Abuse and Alcoholism), 398, 407, 408t
Nightingale, Florence, 15–16, 17f, 140, 488
NIH (National Institutes of Health), 33, 431
NIMS (National Incident Management System), 487, 493–494
NIOSH (National Institute for Occupational Safety and Health), 149, 616, 621, 636
NLN (National League for Nursing), 62
NMHCs (nurse-managed health centers), 208
nociceptive pain, 604
nonadherence, 524
with medication in schizophrenia, 530
noncommunicable disease, 76
nongovernmental organizations (NGOs), 30, 31, 35, 46, 493
nonopioid analgesics, for pain management, 605–606
nontyphoid Salmonella, 308
NORA (National Occupational Research Agenda), 630
NORCs (naturally occurring retirement communities), 257
noroviruses, 307–308
North American Nursing Diagnosis Association International (NANDA-I), 582
NPS (National Prevention Strategy), 31, 188
NREPP (National Registry of Evidence-Based Programs and Practices), 561
NRF (National Response Framework), 487, 493
NSDUH (National Survey on Drug Use and Health), 561
NSSP (National Strategy for Suicide Prevention), 537
nuclear family, 271
null hypothesis, 170
numb shock, 612
Nurse–Family Partnership (NFP) program, 282, 385, 402, 402b
nurse-managed health centers (NMHCs), 208
nurses
as advocates, 61–62
in chemical disasters, role of, 510–511, 510f
in disaster management, role of, 500–501
as educators, 63
ethical obligation, 66–68
global health issues, role in, 92
in radiologic disaster, role of, 513
radiologic resources for, 513b
nursing and environmental health, 457
nursing process, epidemiologic process and, 142, 144t
NwHIN (Nationwide Health Information Network), 8
conceptual model, 8, 8f
NYTS (National Youth Tobacco Survey), 561
951
O
OARC (Office of Autism Research Coordination), 540
OASIS (Outcome and Assessment Information Set), 251
Obama, Barack, 68
Obamacare, 35. See also Affordable Care Act (ACA)
obesity, 146, 147f
in children, 564–565
prevention program, 148
obesogenic environment, 194
observational studies, 170, 171–177
analytical studies, 175
case–control studies, 176–177
cohort studies, 175–176
descriptive studies, 172
case studies, 172
cross-sectional studies, 174
survey research, 172–173
occupational and environmental health problems, in rural area, 439–441
occupational health history, 616, 626
occupational health nurses (OHN), 616
nonfatal occupational injuries, 619t
worker and workplace, 617–620
occupational health nursing
biologic agents, 622
chemical agents, 622
emergency preparedness planning, 635–636
environment, 624
epidemiologic triad, 622, 622f
epidemiology and occupational health, 633–635
Hanasaari conceptual model for, 624f
health promotion in workplace, 631
Healthy People 2020, 637
history, 620–621
host, 622
implementing a program, 632
nanotechnology and, 636–637
physical agents, 623
practice, 625–626
case manager, 627
clinician, 626
counselor/consultant, 627–628
health promotion specialist, 628–630
manager/administrator, 630
952
models, 624–625
researcher, 630–631
psychosocial agents, 623
standards of practice, 621–622
workplace violence risk factors, 623b
Occupational Safety and Health Administration (OSHA), 495, 616, 621
odds ratio (OR), 170, 177
O’Donnell health promotion model, 629f
OECD (Organization for Economic Cooperation and Development), 30
Office of Autism Research Coordination (OARC), 540
Office of Management and Budget (OMB), 433
Office of Minority Health, 491
Office of the National Coordinator for Health Information Technology (ONC), 8
funding of NwHIN by, 8
SAFER guides for EHRs, 8
official agencies, 246, 250
OHN (occupational health nurses), 616
nonfatal occupational injuries, 619t
worker and workplace, 617–620
Oklahoma City bombing, 544
olanzapine pamoate, in schizophrenia treatment, 531
Omaha System, 251–252, 252b–253b
On Air, Waters and Places (Hippocrates), 136
On Death and Dying: What the Dying Have to Teach Doctors, Nurses, Clergy, and Their Own
Families, 595–596
opinion leaders, 191
opioid substitution treatment, 397
opioid use, 399–400
OR (odds ratio), 170, 177
Oregon Healthy Teens Survey, 157
Organization for Economic Cooperation and Development (OECD), 30
OSHA (Occupational Safety and Health Administration), 495, 616, 621
Ottawa Charter, 127, 186–187
outbreaks, 134
investigations in, 148b
prevention and control of, 148
Outcome and Assessment Information Set (OASIS), 251
out-of-pocket costs, 51
outreach workers. See community health workers (CHWs)
Oxfam International, 46
P
pain management, end-of-life care and, 603–607
953
constipation, 607
drugs in, 605–606
myoclonus, 607
nausea and vomiting, 607
pain assessment, 604
pain relief, 605
pruritus, 607
respiratory depression, 607
routes of administration, 606–607
sedation, 607
tolerance, 607
types of pain, 604–605
palliative care, 591, 601–602
pandemic, 303, 330, 340
Pandemic Severity Assessment Framework (PSAF), 341
parish nursing, 246, 258, 574, 575
practice, standards of care for, 581t
passive immunity, 106
pathogenicity, 296, 300
patient advocacy, 51
patient-centered care, 255
patient-centered medical home (PCMH), 66, 203, 257
patient/client-centered care, 6–7
patient navigators. See community health workers (CHWs)
patient outcomes, 245, 251
Patient Protection and Affordable Care Act (PPACA), 5, 90, 188, 542, 592. See also
Affordable Care Act (ACA)
Patient Self-Determination Act, 599
Patriot Act, section 802 of, 490
PCMH (patient-centered medical home), 66, 203, 257
Pediatric Environmental Health Specialty Units (PEHSU), 470
pediatric palliative and hospice care, 592t
pediatric palliative care referral criteria, 595b
peer educators. See community health workers (CHWs)
PEHSU (Pediatric Environmental Health Specialty Units), 470
periodic change, 152, 162
period prevalence, 152, 156
perpetrate, 373
Persily, Cynthia, 196
personal protective equipment (PPE), 487, 495–496
personal responsibility, 9–10
Personal Responsibility Education Program (PREP), 563
personal space, 220
954
pertussis, 363
Pete Domenici Mental Health Parity, 542
Pets Evacuation and Transportation Standards (PETS) Act, 515
Pew Research Center, 273
phenomenologic community, 228, 230–231
philanthropic organizations, 30, 31, 46
physical activity, access to, 472t
physical hazards, 616
physician-assisted suicide, 600
PIAAC (Program for the International Assessment of Adult Competencies), 118
PKEMRA (Post-Katrina Emergency Response Act), 515
Plague, 507
plan of care, 246, 251
PMR (proportional mortality ratio), 152, 163
pneumonic plague, 332
POD (point of distribution), 487, 494
point of distribution (POD), 487, 494
point prevalence, 152, 156
policy, 51
definition of, 52
health, 53 (See also health policy)
public, 52–53
polio cases, 335
political advocacy, 51
politics, 51, 53
and policy-making process, 53–55
POLST (provider order for life-sustaining treatment), 599
Pontiac Rebellion, 501
population aggregate, 186
population health, 246
management, 255
population of interest, 190–191
populations at risk, 152, 153
positive reinforcement, 110–111
Post-Katrina Emergency Response Act (PKEMRA), 515
postmortem care, 591, 611
posttraumatic stress disorder (PTSD), 431
PPACA (Patient Protection and Affordable Care Act), 5, 90, 188, 542, 592
PPD (purified protein derivative) skin test, 302
PPE (personal protective equipment), 487, 495–496
precautionary principle, 454
and community environment, 456
Precede–Proceed Model, 189b
955
PREP (Personal Responsibility Education Program), 563
President’s New Freedom Commission on Mental Health, 524
presumptive viremic blood donors (PVDs), 345
prevalence, 373, 377
prevalence rates, 152, 156–157
calculation of, 155b, 156
factors influencing, 156
importance of, 156–157
period prevalence, 156
point prevalence, 156
variations in, 160
Prevention and Public Health Fund, 205–206
preventive trials, 170, 178–179
primary healthcare, 76
primary prevention, 100, 105–106, 105b, 142, 143f
private foundations, 206
Prize Incentives Contingency Management for Substance Abuse, 422b
prodromal stage, 524
and psychosis, 528
program evaluation, resources for, 202b
Program for the International Assessment of Adult Competencies (PIAAC), 118
program model. See logic model
Project ASSERT, 421b
promotores(as) de salud. See community health workers (CHWs)
propagated (continuous) outbreak, 296, 305
proportion, 152, 154
proportional mortality ratio (PMR), 152, 163
proprietary agencies, 246, 250
prospective studies, 170, 175
provider order for life-sustaining treatment (POLST), 599
pruritus, 607
PSAF (Pandemic Severity Assessment Framework), 341
psychological first aid, 524, 544–547
defined, 544
in different cultures, 547b
psychosis, early intervention programs for, 528
psychosocial hazards, 616
PTSD (posttraumatic stress disorder), 431
public health, 4, 10, 31, 76. See also healthcare
central goal of, 31
commitment, 44–46
International Council of Nurses, 46
international health organizations, 45–46
956
refugee and disaster-relief assistance, 45
World Health Organization, 44–45
definition of, 77
functions of, 34–35
government agencies and, 31–32
initiatives in twentieth century, 18–21
milestones in, 14t–15t
principles of, 10, 10b
trends in, 35–37
expenditures and health, 37
health status and its determinants, 35–36
utilization of healthcare resources, 36
vulnerable populations, 37
public health delivery system, in United States, 31–34
public health disaster response
communication during disaster, 515–516
scope and magnitude, 514–515
public health initiatives, in autism, 540–541
public health intervention wheel, 11, 12f
public health nurses (PHN), 488
in disaster management, 500b
public health nursing, 4, 10. See also public health
challenges for, 21
community change, planning for, 23
cultural competence, 22–23
eliminating health disparities, 22
emergencies, disasters, and terrorism, response to, 24–25
evidence-based practice, 21–22
global environment, 25–26
safe and healthy environment, 24
competencies for, 11
current state, 10–12
interventions, 4, 11–12, 12f, 13t
principles of, 10, 11b
roots of, 13–21, 14t–15t
scope and standards of practice, 11
Public Health Nursing: Scope and Standards of Practice, 11, 12, 18
public health policy, 51
public health surveillance, 306–307
functions of, 105b
public policy levers, 198
purified protein derivative (PPD) skin test, 302
p value, 170
957
PVDs (presumptive viremic blood donors), 345
Q
Quad Council of Public Health Nursing Organizations, 10
quality and safety, 255
quality improvement efforts, 63
quality of care, 51–52, 53, 63–64
QuantiFERON-Gold (QFT-G) test, 353
quasi-experimental study, 170
designs, 178
R
race, 218
radiologic disasters, 512–513
dirty bombs, 513
nurses role in, 513
rate, 154
adjusted, 155
calculation of, 137
crude, 155
definition of, 135, 152
incidence, 155–156, 163–165
prevalence, 156–157
rules for calculation of, 155b
specific, 158–163
use of, in descriptive research studies, 167
Rathbone, William, 15
ratio, 152, 154
Raynaud phenomenon, 623
RCA (root cause analysis), 616, 626, 627, 628b
RE-AIM framework, for health behavior research evaluation, 204
real time, 487
real-time technology, 256
reciprocation model, 625f
recovery, 498–499
recreational waters, 472t
Red Cross, 492
reemerging infectious disease, 330
reforms, 52, 68
refreezing, 197–198
refugee, 30, 45
registered nurses (RNs), 57–59, 68
958
reimbursement, 246, 249
reinforcement learning, 110
relapse prevention model, 100, 113–114
relationship, 170
relative risk (RR), 170, 175–176
calculation of, 175
definition of, 175
relative risk ratio, 152, 165
religion, and culture, 221–223, 222f
remarriage, 272
remission, 394
research design continuum, 175, 175f
reservoirs, 296, 302
respiratory depression, 607
retrospective studies, 170. See also case-control studies
right to health, 76
risk, 135, 144
risk assessment, 454
and environmental contaminant, 458
risk communication, defined, 515
risk factors, 76, 82, 135, 144
risk reduction, 100
risperidone microsphere, in schizophrenia treatment, 531
RNs (registered nurses), 57–59, 68
Robert Wood Johnson Foundation, 31
Robinson, Mary, 15
Roll Back Malaria project, 82
roll with resistance, 262
root cause analysis (RCA), 616, 626, 627
in occupational health, 628b
Rosaldo, Renato, 214
RR (relative risk), 170, 175–176
calculation of, 175
definition of, 175
rubella, 363
rural area, underserved populations in, 433
elderly people, 438–439
health personnel issues, 434–435
morbidity and mortality issues, 436–437, 437b
occupational and environmental health problems, 439–441
Ryan White Program funds networks of care, 32
S
959
Safe Drinking Water Act (SDWA), 323
Salmonella enteritidis, 308
salmonella outbreak, 160–161
Salmonella typhimurium, 160
salutogenic environment, 194
same-sex couples, 273
SAMHSA (Substance Abuse and Mental Health Services Administration), 410–411, 420, 543
sample, 170
sarin attack, 510
SARS (severe acute respiratory syndrome), 298–299, 331, 336–337
SBHC (school-based health centers), 560
SBIRT (screening and brief intervention with referral to treatment), 396, 406
scenario, 487
disaster, 492
schizophrenia
community mental health teams, 533
enhancing treatment adherence, 530–532
epidemiology, 527–528
high-risk populations, 532–533
intervention programs, 528, 530
prevention programs, 530
school-based health centers (SBHC), 560
School Emergency Triage Training (SETT), 560
school health, 554–555
child advocate, 568–569
future of, 569–570
health concerns
drugs and alcohol, 561
nutrition, 563–565
sexual behavior and teenage pregnancy, 562–563
sexually transmitted infections, 563
smoking, 561–562
violence, 566
historical perspectives, 555–556
index, 554, 558
nursing, 554, 555
programs, 557t
school nurse, 556–557
health assessment, 557–558, 559b
health promotion and assessment, 558–560, 559b
school health nurses, 232
School Health Related Services Plan Section, 555
school violence, 375–376, 376f
960
screening and brief intervention with referral to treatment (SBIRT), 396, 406
screening procedures, types and examples of, 107b
SDGs. See Sustainable Development Goals (SDGs)
SDH. See social determinants of health (SDH)
secondary infections, 296, 305
secondary prevention, 100, 107–108, 142, 143f
second-generation antipsychotics, 524
and schizophrenia, 531, 532t
self-awareness, 224
self-efficacy, 262
theory, 112
self-help programs, 411
self-neglect, 261
sensitivity, 107, 107b, 152, 165–166
calculation of, 166b
SETT (School Emergency Triage Training), 560
severe acute respiratory syndrome (SARS), 298–299, 331, 336–337
Sexual Assault Nurse Examiner (SANE) programs, 387
sexually transmitted diseases (STDs), 312
chlamydia, 313–314
gonorrhea, 314–315
Healthy People 2020 objectives for, 313b
hepatitis B, 322
herpes simplex virus, 322
high-risk person, 312
HIV infection, 318–321
HPV infection, 316–318
prevention of, 312, 324
syphilis, 315–316
untreated, consequences of, 312
sexually transmitted infections (STIs), 441, 563. See also sexually transmitted diseases (STDs)
Shanghai Declaration, 187
SHARE Approach, 7
Shattuck, Lemuel, 17
Shattuck Report, 17
shelter in place, 487, 511–512, 511b
shingles, 106
short-term change, 152
silencing the self, concept of, 117
Simple Triage and Rapid Triage (START) model, 498b
simulation, 487
in drills, 495
single-parent families, 272–273
961
skilled care, 246, 253
and nonskilled nursing care, 253t
skilled needs, 246, 252, 253
skin integrity, at end of life, 608
smallpox, 507
SMART (State of Massachusetts Animal Response Team), 515
SMART format, for program objectives, 201b, 202
smart surveillance, 365
smoking, 561–562, 562b. See also school health
Snow, John, 139–140
social determinants of health (SDH), 4, 86, 194
health disparities, health equity, and social justice, 195–196
health impact assessment, 195
neighborhoods and communities empowerment, 196–197
obesogenic and salutogenic environments, 194
social distancing, 487
social ecologic model, 192, 194
social facts, 193
social justice, 195–196
social learning, 100, 112
social marketing, 207
Social Security Act, 20, 555
social support, 100, 113
Society for Public Health Education, 560
somatic pain, 604
Special Supplemental Food Program, for Women, Infants, and Children (WIC), 31
specificity, 107, 107b, 152, 166
calculation of, 166b
specific rates, 152, 158–163
person in, 158–160
place in, 160–161
time in, 161–163
spiritual care, 574, 575
SSIs (surgical-site infections), 305
SSPs (Syringe Service Programs), 411, 412f
stakeholder, 186
Staphylococcus aureus, 297
State and Federal Response Networks, 493
state department of health and human services, 34
state departments of public health, role of, in health planning, 188–189
State Emergency Management Agency, 494
state health department, 33–34
State of Massachusetts Animal Response Team (SMART), 515
962
STDs. See sexually transmitted diseases (STDs)
Stoklosa, Hanni, 387
strategic national stockpile, 487, 506
Streptococcal TSS, 297
Streptococcus pyogenes, 298
subculture, 213, 218
Substance Abuse and Mental Health Services Administration (SAMHSA), 410–411, 543, 561
substance use, 394–395
alcohol, 398
cannabis, 398
college students and binge drinking, 407–409
at early age, 404–407
global policies to minimize harms from, 395–396, 395b
illicit drugs, 399–400
impact on community, 413–414
injection drug users, 411–413
methamphetamine users, 413
national scope of, 396–397
older adults, 409–411
pregnant women and, 400–404
public health models for populations at risk, 414–419
scope of, 395
tobacco, 398–399
substance use disorders (SUD), 394, 396
in adolescents, 404–405
evidence-based psychosocial treatments in, 420–423
goals of Healthy People 2020, 423
medication-assisted treatments for, 419
alcohol-dependent disorders, 419
opioid use disorders, 419–420
suicide, mood/anxiety disorders, 534–537
superfund, 455b
surgical-site infections (SSIs), 305
surveillance, 296, 306, 487, 488
of healthy populations, 105
surveys, 5
survey research, 170, 172–173
sustainability, 186
in grant making, 205
Sustainable Development Goals (SDGs), 45, 85–89, 86f, 187, 195
evaluation of, 86–87
17 goals in, 85–86
implementation of, nurses in, 87
963
progress at meeting of, 88–89t
syphilis, 315–316
Syringe Service Programs (SSPs), 411, 412f
system, 268, 270
systems theory, 190
T
Table Top Exercise (TTX), 494
tardive dyskinesia (TD), 524
and schizophrenia, 531
Task Force on Community Preventive Services (TFCPS), 199–200
TB. See tuberculosis (TB)
TD (tardive dyskinesia), 524
and schizophrenia, 531
teach-back method, 124
technology, and healthcare, 7–8
teenage pregnancy, 562–563
telecardiology, 256
telehealth, 4, 8–9, 246, 255–256
terminal delirium and end of life, 609, 610t
terrorism, 487, 490
tertiary prevention, 100, 108–109, 142, 143f
TFCPS (Task Force on Community Preventive Services), 199–200
theory, 268
of action (See logic model)
of change (See logic model)
of reasoned action, 100, 112
therapeutic trials, 170, 179
time, variations in, 161–163
long-term changes, 163, 164f
periodic changes, 162–163
short-term changes, 161–162
tobacco industry, and related policies, 55
tobacco use, 398–399
tolerance, 394, 411
toxicology, 454
defined, 468
toxic shock syndrome (TSS), 297
transcultural nursing, 58, 213, 215
transmission, of infectious agent, 296, 302
airborne transmission, 302
direct contact, 302–303
droplet transmission, 303
964
indirect contact, 303
transtheoretical model, 100, 111–112
Trench warfare, 509
Treponema pallidum, 315
triangulation, 231
TRICARE (federal funds for military personnel and their dependents), 34, 250
trimorbidity, 430
and homeless population, 449
TSS (toxic shock syndrome), 297
TST (tuberculin skin test), 350, 353–355, 354f
TTX (Table Top Exercise), 494
tuberculin skin test (TST), 350, 353–355, 354f
tuberculosis (TB), 302, 349–356
active TB infection, 350, 351
contact investigation, 352, 353f
diagnostic tests, 353–355
epidemiology of, 349
infection control guidelines for healthcare settings, 356
latent TB infection, 350, 350t, 351
to active TB disease, 351b
and HIV infection, 350–351
multidrug-resistant TB, 349, 355–356
prevention and control of, 351–355
reporting of, 352
rifampicin-resistant TB, 349
symptoms and signs of, 350
tuberculin skin test, 350, 353–355, 354f
as urgent global health priority, 84
tularemia, 507
type I error, 170
type II error, 170
U
UHC (universal health coverage), 86
ultraviolet (UV) radiation, 473t
underserved population, 430
health risks
genomics, 432–433
health and health disparities, 431–432
vulnerability, 431
homeless populations, 449
human trafficking, 448–449
in jails and prisons, 441–444
965
LGBTQ community, 444–446
rural populations, 433
elderly people, 438–439
health personnel issues, 434–435
morbidity and mortality issues, 436–437
occupational and environmental health problems, 439–441
themes of, 450b
veterans and health, 446–448
underserved populations, 230
unfreezing, 197
UNHCR (United Nations High Commissioner for Refugees), 45
United Kingdom, healthcare system in, 43
United Nations, 44
United Nations Educational, Scientific, and Cultural Organization (UNESCO) Sustainable
Development Goals, 30, 45
United Nations High Commissioner for Refugees (UNHCR), 45
United Nations Security Council, 490
United States
Census Bureau, 187, 433
death in, 595–597, 596t
healthcare system, 56–57, 63
hepatitis C outbreak in, 634t
urbanized area and rural population (2010, 2000) in, 433t
United States Department of Agriculture (USDA), 481
United States Preventive Services Task Force (USPSTF), 314, 315, 380
on chlamydia screening, 314
universal health coverage (UHC), 86
URAC (Utilization Review Accreditation Commission), 247
urban/rural areas, definitions of, 434b
urinary tract infections (UTIs), 305
U.S. Agency for International Development (USAID), 46
USDA (United States Department of Agriculture), 481
U.S. Department of Agriculture (USDA), 433
U.S. Department of Health and Human Services (USDHHS), 32–33, 33f, 63, 306, 563
health planning by, 187
USDHHS (U.S. Department of Health and Human Services), 32–33, 33f, 63, 306, 563
health planning by, 187
U.S. Food and Drug Administration, 7
U.S. Fund for UNICEF, 35
USPHS (U.S. Public Health Service), 20
U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), 297
USPSTF (United States Preventive Services Task Force), 314, 315, 380, 556, 569
on chlamydia screening, 314
966
U.S. Public Health Service (USPHS), 20
Utilization Review Accreditation Commission (URAC), 247
UTIs (urinary tract infections), 305
UV (ultraviolet) radiation, 473t
V
vacant lots, 472t
vaccination
hepatitis B, 322
HPV, 317
MMR, 363
pertussis, 363
vaccine-derived polioviruses (cVDPVs), 335
vaccine-preventable diseases, 106, 106b, 330, 362
vaccinia, 507
variables, 170
variola virus, 507
vector-borne transmission, 303
vectors, 473t
vehicles, 303
Venezuelan hemorrhagic fever, 302
Veteran’s health, 430
Veterans Health Administration, 34, 446
VHF (viral hemorrhagic fevers), 507–508
violence, 373–374, 566
electronic media and youth, 567b
gun, 374–375, 374b
impact of, 374
intervention for prevention of, 385–386
intimate partner, 376–383
prevalence of, factors for, 374
school violence, 375–376, 376f
viral hemorrhagic fevers (VHF), 507–508
visceral pain, 604
visiting nurse associations (VNAs), 249, 250
VNAs (visiting nurse associations), 249, 250
VNRs (voluntary national reviews), 87
voluntary agencies, 246, 249–250
voluntary national reviews (VNRs), 87
vulnerable populations, 431. See also underserved populations
W
967
Wald, Lillian, 18, 18f
walking school bus program, 205
war-induced displacement, 45
Washington Heights-Inwood, 203
water-associated disease outbreak, 309–312
waterborne diseases, prevention of, 323
water, sanitation, and hygiene (WASH) interventions, 87
weaponize, 487
forms of bioterrorism, 502
web of causation, 135, 141, 142f, 194
well-being, 100, 102
Westberg Institute, 586
West Nile virus (WNV), 344–345
prevention of infection, 345
symptoms of, 344
transmission of, 344
wheel of causation, 135
WHO. See World Health Organization (WHO)
Whole School, Whole Community, Whole Child (WSCC), 554, 556, 569
wild poliovirus (WPV), 335
windshield survey, 228, 232–233
withdrawal, 394, 410
WNV. See West Nile virus (WNV)
women
and health, 84–85
with HIV/AIDS, 114, 117–118 (See also ecologic model)
workforce
crisis, 91
diversity, 52
migration, 91–92
workplace
hazards and exposures, 617t
walk-through, 616, 626, 627b
World Bank, 30, 45, 46
World Health Organization (WHO), 4–5, 30, 44–45, 149
Commission on Social Determinants of Health, 70, 187
on community empowerment, 186–187
Health Statistics Report highlights, 82, 83b
social determinants of health, 431
top 10 causes of death, 296
World Mental Health, 525
World Trade Center, 488
bombing, 544
968
WPV (wild poliovirus), 335
WSCC (Whole School, Whole Community, Whole Child), 554, 556, 569
X
xerostomia, 608
Y
Yersinia pestis, 507
Youth Risk Behavior Surveillance Survey (YRBSS), 188, 554, 558
youth, solution pyramid for, 442–443b
YRBSS (Youth Risk Behavior Surveillance Survey), 188
Z
Zika virus disease, 299, 359–361
during pregnancy, 361, 362
prevention and control of, 361
signs, symptoms, and diagnosis of, 361
zinc supplementation, 87
zoonoses, 302
969
Table of Contents
Cover 1
Title Page 2
Copyright 3
Contributors 4
Reviewers 8
Preface 10
Acknowledgments 15
Contents 17
PART ONE: The Context of Community and Public Health Nursing 23
Chapter 1: Public Health Nursing: Present, Past, and Future 24
Chapter 2: Public Health Systems 62
Chapter 3: Health Policy, Politics, and Reform 92
Chapter 4: Global Health: A Community Perspective 129
PART TWO: Evidence-Based Practice and Population Health 159
Chapter 5: Frameworks for Health Promotion, Disease Prevention, and
Risk Reduction
160
Chapter 6: Epidemiology: The Science of Prevention 211
Chapter 7: Describing Health Conditions: Understanding and Using Rates 235
Chapter 8: Gathering Evidence for Public Health Practice 260
PART THREE: Implementing Nursing Practice in Community Settings 279
Chapter 9: Planning for Community Change 280
Chapter 10: Cultural Competence: Awareness, Sensitivity, and Respect 321
Chapter 11: Community Assessment 341
Chapter 12: Care Management, Case Management, and Home Healthcare 367
Chapter 13: Family Assessment 400
PART FOUR: Challenges in Community and Public Health Nursing 434
Chapter 14: Risk of Infectious and Communicable Diseases 435
Chapter 15: Emerging Infectious Diseases 483
Chapter 16: Violence and Abuse 543
Chapter 17: Substance Use 575
Chapter 18: Underserved Populations 625
Chapter 19: Environmental Health 660
Chapter 20: Community Preparedness: Disaster and Terrorism 697
PART FIVE: Specialty Practice 748
Chapter 21: Community Mental Health 749
Chapter 22: School Health 789
970
Chapter 23: Faith-Oriented Communities and Health Ministries in Faith
Communities
817
Chapter 24: Palliative and End-of-Life Care 840
Chapter 25: Occupational Health Nursing 877
Occupational Safety and Health 915
971
Cover
Title Page
Copyright
Contributors
Reviewers
Preface
Acknowledgments
Contents
PART ONE: The Context of Community and Public Health Nursing
Chapter 1: Public Health Nursing: Present, Past, and Future
Chapter 2: Public Health Systems
Chapter 3: Health Policy, Politics, and Reform
Chapter 4: Global Health: A Community Perspective
PART TWO: Evidence-Based Practice and Population Health
Chapter 5: Frameworks for Health Promotion, Disease Prevention, and Risk Reduction
Chapter 6: Epidemiology: The Science of Prevention
Chapter 7: Describing Health Conditions: Understanding and Using Rates
Chapter 8: Gathering Evidence for Public Health Practice
PART THREE: Implementing Nursing Practice in Community Settings
Chapter 9: Planning for Community Change
Chapter 10: Cultural Competence: Awareness, Sensitivity, and Respect
Chapter 11: Community Assessment
Chapter 12: Care Management, Case Management, and Home Healthcare
Chapter 13: Family Assessment
PART FOUR: Challenges in Community and Public Health Nursing
Chapter 14: Risk of Infectious and Communicable Diseases
Chapter 15: Emerging Infectious Diseases
Chapter 16: Violence and Abuse
Chapter 17: Substance Use
Chapter 18: Underserved Populations
Chapter 19: Environmental Health
Chapter 20: Community Preparedness: Disaster and Terrorism
PART FIVE: Specialty Practice
Chapter 21: Community Mental Health
Chapter 22: School Health
Chapter 23: Faith-Oriented Communities and Health Ministries in Faith Communities
Chapter 24: Palliative and End-of-Life Care
Chapter 25: Occupational Health Nursing
Occupational Safety and Health