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1) Explain the role of the community health nurse in partnership with community stakeholders for population health promotion.

2)Explain why it is important to appraise community resources (nonprofit, spiritual/religious, etc.) as part of a community assessment and why these resources are important in population health promotion.

CHAPTER 1
Populations as Clients
By Sue Z. Green
“We often think of nursing as giving meds on time, checking
an X-ray to see if the doctor needs to be called, or taking an
admission at 2:00 a.m. with a smile on our faces. Too often,
we forget all the other things that make our job what it truly
is: caring and having a desire to make a difference.”—Erin
Pettengill (National CPR Association, n.d.)
Essential Questions
● How does expanding knowledge of population, community, and public health nursing
improve the nurse’s practice?
● What are expected competencies for the nurse practicing within population groups?
● How does the nurse apply the nursing process and collaborate with others to conduct a
population’s health assessment?
● Which community resources are useful during planning and interventions for a
population’s health?
Introduction
Nursing care of populations involves working with larger groups of people and their
corresponding multiple health care needs. Community and public health nurses consider the
effect of ethnicity, culture, spiritual values, and geographic and socioeconomic conditions on the
wellness of the population. Diverse populations have various health disparities and health
inequities that affect their ability to maintain health and meet health care needs. A greater
understanding of historical and theoretical concepts provides a foundation for the nurse’s
approach to care of populations. The role of the public health nurse and the essential function of
public health services are explored in this chapter. The nursing process is applied as an

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approach to assess a community or specific population. Impediments to effective practice are
discussed to aid the nurse’s awareness of barriers to overcome.
Population Health
●
Population health is defined as “the health outcomes of a group of individuals, including the
distribution of such outcomes within the group” (Kindig & Stoddart, 2003, p. 381). Population
health has a goal of measuring, intervening, and improving health disparities among groups, as
well as the distribution of health, all of which is driven by assessment and statistical data. Public
health, a subcomponent of population health, is the practice of protecting and promoting quality
of life and holistic health of persons and communities through the use of science, research, and
direct care. The American Public Health Association (APHA) defines public health nursing as
“the practice of promoting and protecting the health of populations using knowledge from
nursing, social, and public health sciences” (American Public Health Association [APHA], 2013,
p. 2). Interdisciplinary public health practices aim to prevent disease outbreaks, injuries, and
poor health while promoting cost-effective measures that improve quality of life and health as
well as reduce environmental hazards (APHA, n.d.; Centers for Disease Control and Prevention
Foundation, 2017).
Development of the Public
Health Nursing Role
●

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The historical path leading to the discipline of public/community health nursing began more than
a century ago. Several nursing pioneers fashioned programs that led to the development of
organized public health delivery.
● Florence Nightingale initiated “health visitors” in 1892, a group composed of lay female
missionaries with specialized training for instruction of health (Buhler-Wilkinson, 1985).
Much of the focus was teaching women about caring for themselves and their children.
This was the foundation of England’s district nursing today.
● Lillian Wald established the term public health nurse with a focus on treating social and
economic problems along with illness. In 1893, Wald and Mary Brewster put this belief
into practice on the Lower East Side tenements of New York. Two years later, this led to
the establishment of the Henry Street Settlement and, later, the development of the
Visiting Nurses Association (VNA) (Fee & Bu, 2010).
● Mary Breckinridge introduced nurse midwifery to the United States in 1925. She traveled
on horseback to deliver modern health care to the most inaccessible and poorest areas
of Appalachia in Kentucky (Frontier Nursing Service, 2015). This lead to the subsequent
development of the Frontier Nursing Service (FNS) and the expansion of public health
nursing into remote rural areas (Frontier Nursing University, n.d.).
Policy Reform
The public health profession continues to evolve. Various policy reforms in the United States
have shaped public health nursing to become what it is today. Public health needs drive
development of programs to improve public health. Sanitation reforms occurred as public health
nursing emerged. Public health education, improved waste disposal methods, and clean-water
policies reinforced the importance of the environment to the nation’s health. In 2004, a
presidential order, signed by President George W. Bush, established the Office of National
Coordinator for Health Information Technology, which included incentives for providers using
health information technology (HIT), motivating them to utilize electronic medical records (Bush,
2004; DeSalvo, Dinkler, & Stevens, 2015). Timely and efficient access to patient-related
information ushered in a new era of health informatics and population health. The 2010
Affordable Care Act (ACA) reinforced the importance of the use of HIT. Gradual transition of
services to outpatient or community settings further reinforce the nurse’s role in population
health management and health information technology.
From public health nursing, subspecialties have emerged, including school nursing, industrial
and occupational health nursing, child health nursing, tuberculosis nursing, rural nursing, and
the American Red Cross. Born from the rise of nursing specialty interest groups, the National
Organization of Public Health Nursing (NOPHN) emerged with Lillian Wald as the first president.
Many groups have since formed to address the varying needs of nurses across settings and
clinical specialties, including the American Nurses Association (ANA). The ANA, the largest
nursing organization, represents nurses across the United States, reinforcing the role of public
health nursing. The ANA recognizes and promotes the Quad Council Coalition of Public Health
Nursing Organizations (QCC or Quad Council) and public health nursing’s scope and standards
of practice. The ANA also supports nursing involvement in public health advocacy, education,
and policy, along with evolving health issues (American Nurses Association [ANA], n.d.).

Quad Council Coalition
The QCC comprises four nursing organizations serving public health nursing. Current
members include the Alliance of Nurses for Healthy Environments (ANHE), Public
Health Nursing Section of the American Public Health Association (PHN Section of
APHA), the Association of Community Health Nurse Educators (ACHNE), and the
Association of Public Health Nurses (APHN) (Quad Council Coalition of Public Health
Nursing Organizations [QCC], n.d.).
The QCC is the vehicle for guiding and developing current critical components and
competencies. Beginning in 2011, the QCC competencies were aligned to the Core
Competencies for Public Health Professions, a guiding document the QCC developed to
bridge academic and public health practice (Public Health Foundation, n.d.; QCC, n.d.;
Swider, Krothe, Reyes, & Cavetz, 2013). This alignment provided a mechanism to
promote nursing evidence-based competencies congruent with other public health
professions and academic practices. The nursing competencies span three tiers of
practice over various skill domains with competencies. The three tiers categorize
practice as:
● Tier 1-basic or generalist
● Tier 2-specialist or midlevel
● Tier 3-executive and/or multi-systems level (Swider et al., 2013).
Those at the Tier 1 level work directly with the diverse populations to promote health
and prevent disease, collect and analyze data, plan programs, and conduct outreach
activities to reduce health disparities (QCC, n.d.). Tier 2 public health nurses are in
management or supervisory roles and assist in implementation of public health

programs (QCC, n.d.). Tier 3 competencies are for senior management or nurse
executive roles. Tier 3 public health nurses are responsible for administration,
organization, and operation of public health programs (QCC, n.d.).
Today’s Community and Public
Health Nurses
●
Health promotion and care for the community and population at large reflect public/community
health nurses’ mission, vision, and commitments. Community health nursing and public
health nursing are terms synonymous for the role of the nurse outside institutional settings;
however, the terms are distinct from each other. Community health nursing has traditionally
focused on nursing care for acute and chronic conditions outside the traditional hospital setting,
primarily involving restorative care. Now, community health nursing involves health promotion of
individuals and families, providing care in settings such as occupational or educational systems.
Public health nursing addresses health promotion beyond an individual’s or family’s needs,
incorporating community aspects and global or environmental concerns. Public health nursing
focuses on groups, populations, or the health of an entire geographical sector (Canales &
Drevdahl, 2014; Kulbok, Thatcher, Park, & Meszaros, 2012; Reifsnider & Garcia, 2015).
Public health nursing is a population-focused practice. This practice concentrates on the
defined population’s needs for prevention of illness and health improvement (Association of
Public Health Nurses [APHN], n.d.; ANA, n.d.; APHA, 2013). A public health nurse (PHN)
incorporates dynamics extending to small groups, or aggregates, and beyond for improvement
of a population’s overall health. In turn, this improves the health of individuals and families’
living, employment, and recreational environments (Swider & Kulbok, 2015). Aggregates are
persons who are grouped together because of common characteristics or location. The PHN’s
educational background is traditionally a baccalaureate or advanced practice level (Reifsnider &
Garcia, 2015). To a nurse providing inpatient or primary care, a population means the patients
who are within that setting, but for a PHN, the population is inclusive of the entire aggregate
living in the community or a larger geographic sector. The PHN’s population shares
commonalities of disease and risk and, unlike patients in an inpatient setting, the population

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comprises all persons irrespective of whether they request services (Reifsnider & Garcia, 2015).
Most nurses practice at individual and interpersonal levels of a community, but PHNs practice at
the organizational, community, and public policy levels as well. The PHN collaborates with other
disciplines and key community stakeholders. These stakeholders are persons who are both
involved and directly affected by the plans, actions, and outcomes of population health care. For
example, stakeholders may be local government officials, community groups, faith-based
organizations, or local business owners.
The PHN’s practice involves the use of epidemiology. Epidemiology is the health science that
studies the incidence and prevalence of disease in large populations. Incidence rates denote
the emergence of a new illness. Prevalence rates reflect, in a given timeframe, the presence or
pervasiveness of disease in a population compared to the overall health of the population at
large. Epidemiologists aim to detect the source and cause of epidemics resulting from the
pervasive presence of infectious diseases.. These scientists seek to understand patterns
associated with the spread of communicable diseases and identify methods to minimize
incidence or prevent outbreak. Programs in public health originate from data obtained through
epidemiological research and focus on addressing infective agents, safeguarding biological or
human hosts, and controlling the environment to prevent the spread of disease.
Aspects of the Public Health Nursing Role
● Advocates for the health of populations.
● Establishes credibility with the community.
● Concentrates on an aggregate or groups to improve the health of all.
● Seeks prevention of illness.
● Acts as a role model for leadership in provisions of health.
● Fosters community organization.
● Applies the ethical theory of utilitarianism—making choices for “the greater
good.”
● Incorporates epidemiologic knowledge and methods.
● Conducts health assessment for entire populations for prevalence of disease,
risk factors, self-perceived health status, functional ability, and psychological
stressors.
● Demonstrates versatility in dynamic collaborative environments.
● Exhibits cultural competence with diverse populations.
● Designs interventions for specific populations.
● Evaluates outcomes of interventions (Harkness & DeMarco, 2015; Joyce,
O’Brien, Belew-LaDue, Dorjee, & Smith, 2014; Kulbok, Thatcher, Park, &
Meszaros, 2012).

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The 10 Essential Public Health
Services
The Centers for Disease Control and Prevention (CDC) (n.d.) identifies three functions and 10
essential public health services (see Figure 1.1). Note the cyclical nature of Figure 1.1,
indicating that assessment, policy development, and assurance are ongoing. System
management features all the functions and essentials and incorporates the essential service of
research. The discipline of nursing has the ability to be involved in every aspect of the wheel.
Figure 1.1
The 10 Essential Public Health Services

Note. Adapted from “The Public Health System & the 10 Essential Public Health Services,” by the
Centers for Disease Control and Prevention, 2017.

Assessment
The assessment function incorporates the essential services of monitoring health status and
diagnosis and investigation of community health problems and hazards (see Figure 1.1). PHNs
are involved in data collection, community health assessment, and maintenance of data banks
on population health statistics. The PHNs use the information to identify health risks and
disparities, determine health service needs, and locate health care assets and resources to
support health and quality of life improvements (Centers for Disease Control and Prevention
[CDC], 2014). This health monitoring and identification process includes using technology, such
as geographic informational systems (GIS) to map the population for groups at higher risk
than the overall population (CDC, 2014). The monitoring and diagnosis essential service of the
assessment function involves timely identification and investigation of health threats; use of
diagnostic resources, such as state public health laboratories; and development of plans to
reduce health threats (CDC, 2014). The PHN is involved in epidemiologic investigations of
disease outbreaks, patterns of infections, environmental hazards, chronic diseases, injuries, and
any additional threat to the population, as well as developing plans for health care interventions
(see Table 1.1).
Policy Development
The development of public health policies address essential services and work to inform,
educate, and empower the public about health concerns while mobilizing the community in
support of key initiatives. (CDC, 2017b) (see Figure 1.1). The PHN builds knowledge and
shapes attitudes about health through health education initiatives, informing the public of
choices in health decision making, skills, and behaviors that contribute to a healthy quality of
life. Health promotion and education is often supported through partnerships with employers,
faith-based organizations, schools, and health care providers for implementation of initiatives
and reinforcement of health information (CDC, 2014). Public service announcements are one
mechanism in which media and marketing campaigns work to disseminate health information
(see Table 1.1). Mobilization of community partnerships also aid in the identification of health
problems and provide a source of both human and material resources. As public awareness
increases, partnerships, coalitions, and alliances develop to support prevention, screening, and
rehabilitation projects (CDC, 2014). The mobilization of partnerships serves as a foundation
toward effective local public health governance. Policies and plans develop to support both
individual and community efforts to protect health, further improve health, and prepare for
emergency response to health threats (CDC, 2014). The PHN may be involved in the
development of health policies, codes, regulations, and legislation that guide public health
protections. PHN planning for health improvement occurs at both the local and state levels,
including systematic alignment of resources for health improvement strategic planning.
Assurance

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●
The assurance function encompasses enforcing laws, linking people to care providers, assuring
a competent workforce, and evaluating program effectiveness (CDC, 2014). The enforcement of
laws and regulations are for the protection of health and safety. The PHN is involved in public
health emergencies requiring reinforcement, such as a quarantine, use of best practices to
achieve compliance with health regulations, and education of the public regarding laws and
regulations. Linking people in need of care to service providers involves the PHN’s identification
of barriers to care for various population aggregates and coordination of appropriate services to
address, intervene, and overcome the barriers, including cultural, transportation, and language
barriers.
PHNs participate as members of the competent workforce by maintaining active licensure; using
public health competencies, such as those from the QCC; and applying the concept of lifelong
learning. PHNs assess, educate, and train other public health participants, such as students,
volunteers, or lay community health workers. Measures for continuous quality improvements are
adopted by PHNs while maintaining standards of care. PHNs seek opportunities for ongoing
leadership development, cultural competence, and improvement of health disparities. PHNs
evaluate the effectiveness, accessibility, and quality of individual and population-based public
health services. This ongoing evaluation and review of effectiveness analyzes health status and
service utilization data (CDC, 2014). This management of performance provides information
toward allocation of resources and program revisions (CDC, 2014). The information should
show how the needs of the population are met, which approaches are working, and what
requires improvement.
System Management
Research is an essential service contained throughout all three functions (CDC, 2014). This
involves surveillance of the outcomes of research and development of links between public
health practice and academic or research settings (CDC, 2014). Common research areas of
focus include epidemiological studies, health policy analyses, and public health systems
research (CDC, 2014). The PHN is involved in research activities, including initiation of
research, participation of research by other entities, reporting results, and implementation of
resulting evidence-based policies (see Table 1.1).
Table 1.1
Nursing Public Health Interventions
Intervention Definitions Examples

Assessment
● Surveillance
● Screening
● Case finding
● Investigation of disease
and health events
The continuous, systematic
collection, analysis and
interpretation of
health-related data needed
for the planning,
implementation, and
evaluation of public health
practice (World Health
Organization [WHO], n.d.)

Screening used to detect risk
factors for diseases or
undiagnosed diseases

The systematic search for at
risk persons

Track statistical data and
clusters of health events for
risk to the community and
compliance with infection
prevention/control measures
Tracking progress and
spread of the Zika virus

Testing for tuberculosis in
persons living with HIV

MRSA reported among
several high school athletes
Policy Development
● Outreach
● Inform, educate,
empower
● Mobilize community
partnerships
● Develop policies
Providing information about
health issues to the at risk
groups, special interest
populations, or the
community at large
Public service announcement
regarding influenza season
and an upcoming flu
immunization clinic

Check for Understanding
1. What aspects of national and global public health require enlarging the nurse’s perspective beyond the care
of the individual and family?
2. How have nurses been instrumental in the creation of the current services in public health?
3. How do public health nurses meet the public’s need for services?
Theories to Inform Public Health
Nursing Practice
●
Assurance
● Referral and follow up
● Enforce laws
● Link to and/or provide
care
● Ensure competent
workforce
● Evaluate
Assistance to identify and
access necessary resources
to resolve health issues
Referral for counseling to
victim of intimate partner
violence and encouragement
for follow-up appointments

Childhood immunization
monitoring
System Management
● Incorporated within all
of the above
● The research aspects of
all of the above
Provides intersection of
health, information and
communication
technologies, and research
to employ new perspectives
and innovative solutions to
care for health problems
Epidemiological studies

Methods of data input and
quality monitoring

The nursing profession adopts theories and conceptual frameworks from other disciplines, such
as behavioral change models, systems theories including family systems theories, concepts of
distributive or social justice, and community organization models (see Table 1.2). When
applying these concepts, the nurse seeks to discover the factors that influence the public to
exchange unhealthy behaviors for healthier ones and seeks to determine how programs and
revisions in community activities can promote and maintain health. Ethical care and general
systems theory are discussed next to demonstrate further applications to nursing.
Table 1.2
Psychosocial Theoretical Approaches for Community Health Care
Ethical Care
Ethical concepts relating to population health focus on the interdependence of people and what
is of benefit to the population, while maintaining respect for the individual (Barrett et al., 2016).
This social justice concept aligns well with the utilitarian ethical concept of doing the greatest
good for the greatest number. The concept of distributive justice, a component of social justice,
emphasizes the need to equalize access to resources, assets, and services for all within a
community (Devia et al., 2017). Social justice is at the foreground for combating health care
Concepts from Other Disciplines Application to Community/Public Health
Nursing
Ethics, Distributive Justice, Social Justice First aid, food, and water distribution after a
regional disaster
General Systems Theory, Family Systems
Model
Assessment of the community
Behavioral Change Models:
● Transtheoretical Health Model
● Health Belief Model
Smoking cessation campaign and support
groups
Community Organization Models:
● Mobilizing for Action Through Planning
and Partnerships (MAPP)
● PRECEDE-PROCEED Model
● Community-Based Collaborative Action
Research (CBCAR)
Community and health care professionals
collaborate to improve health through
participatory decision making toward
identification of key issues and strategies to
develop and mobilize programs to achieve
health goals

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inequities and health disparities. Every human has a fundamental right to health and well-being
(WHO, 2017). Health inequities and disparities promote disease transmission, poverty, illiteracy,
contaminated air and water, inadequate nutrition, and other aspects affecting a person’s health.
Nurses have knowledge, skills, and the duty to care in order to rebalance inequities and
decrease health disparities. Nurses have access to numerous resources pertaining to nursing
ethics and public health, including
● ANA’s Code of Ethics for Nurses with Interpretive Statements (2015)
● ANA’s The Nurse’s Role in Ethics and Human Rights (2016)
● ANA’s Public Health Nursing: Scope and Standards of Practice (2015)
● ANA’s Nursing’s Social Policy Statement (2010)
● The ICN Position Statement on Nurses and Human Rights (2006)
● The ICN Code of Ethics for Nurses (2012)
● CDC’s Public Health Ethics website
● Principle of the Ethical Practice of Public Health (2002)
● WHO Guidelines on Ethical Issues in Public Health Surveillance (2017)
● Public Health Ethics: Cases Spanning the Globe (2016)
The Public Health Leadership Society’s Principle of the Ethical Practice of Public Health (2002)
contains 12 principles of ethical practice of public health, often referred to as the public health
code of ethics (National Association of County and City Health Officials, n.d.). These principles
are also used by the CDC, the APHA, and the National Association of County and City Health
Officials.
Table 1.3
A Comparison of Clinical vs. Public Health Ethics Focus
Clinical Ethics Focus Public Health Ethics Focus
Individual autonomy is central;
focus is on consent and privacy
Interdependence is central; autonomy can be restricted to
protect the public
Treatment of individual disease Prevention of disease in population
Fiduciary relation to patient Public stewardship
Individual informed consent Community engagement
Individual patient benefit and
harm
Populations and communities

Note. Adapted from Good Decision Making in Real Time: Public Health Ethics Training for Local
Health Departments. Student Manual, by the Centers for Disease Control and Prevention, 2017.
General Systems Theory
General systems theory is one approach to develop a broader understanding of population
health. Ludwig von Bertalanffy proposed a way of studying components of systems by applying
Aristotle’s view that a whole is greater than the sum of its parts. Suprasystems, or wholes,
comprise a system, the environment around the system, and energy flowing from the system
(see Figure 1.2). Multiple systems may be contained within a suprasystem. Assessing all of the
components and the flow of energy exchanges provides a greater perspective of the
suprasystem (Von Bertalanffy, 1972; Drack, 2009). The flow of energy and system components
works to resist stressors to the system and keep equilibrium, which is a state of balance or
stability (Eshlemann & Davidhizar, 2000). Changes in the suprasystem influence systems and
subsystems. The change may be small but can yield a large impact on a subsystem. In reverse,
small changes in one part of a subsystem or system can alter the other aspects of the system
and result in larger changes in the system or suprasystem. Sometimes this is known as the
“butterfly effect,” which refers to the analogy that a butterfly fluttering its wings in one country
moves and stirs the air until subsequently there is a change in weather in another country, such
as a hurricane or tornado (Andrews, 2010).
Nurses use the assessment components of the nursing process to gain a perspective of the
larger whole, the individual, or family. Within the context of public health, nurses influence
individuals, families, and communities to make measurable changes toward established health
goals. Nurses observe external influences on persons, the interactions within persons and
families, and the influences from persons and families on the surrounding environment. Through
these observations, nurses gain a greater perspective of the persons’ or families’ health and life,
Individual benefit and harm Greatest net social good
Clinicians making medical
interventions
Array of interventions and professionals
Authority based on doctor or
profession
Authority based on police powers
Law more of an adversary than
an ally
Law/Policy a key tool of the profession
Justice focus limited to access
to care
Social justice and health equity central

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stressors on the life, and resources to maintain or restore equilibrium. Through the assessment
of needs, strengths, and barriers, nurses initiate steps to empower change across multiple
levels: person, family, and the community.
Figure 1.2
General Systems Theory and Energy Flow

General Systems Theory

Premises of general systems theory include the following:
● A system consists of an overall whole called a susprasystem.
● Inside the susprasystem are three components:
○ A system with internal energy exchanges, known as throughput,
○ Input or environment energy influences around the system, and
○ Output or energy exchanges coming from the system.
● Studying the input, throughput, and output of the parts of the susprasystem
creates a greater perspective of the whole susprasystem (Von Bertalanffy, 1972;
Drack, 2009).
Nursing Theoretical Approaches
The theoretical and conceptual foundations of nursing practice incorporate the concepts of
humans, environment, health, and nursing. The relationship of these concepts to one another
reflect the exchange between members of the locus of care. The nurse interacts with individual
clients, who in turn engage with environmental influences, socioeconomic and cultural factors,
and unique attributes that inform health and well-being. Prominent nursing theoretical
approaches and general premises pertaining to health and wellness have application in
population health care (see Table 1.4).
Table 1.4
Nursing Theoretical Approaches for Population Health Practice
Nursing Concepts Premise Application to Population
Health Practice
Anderson’s Client As Partner Community populations are
those directly affected;
known as stakeholders; are
partners in health care
● Community involvement
as a partner,
stakeholder, and
collaborator in the
assessment of healthy
after-school activities
for local teens
● Grant writing to increase
availability of resources

King’s Theory of Goal
Attainment
Purposeful, quality
interactions between people,
groups, and community for
community functioning,
development, and health
maintenance
Community nurses use
resources such as
pamphlets, to educate the
public of the dangers of
carbon monoxide poisoning
with generator use, helping to
significantly reduce the
number of deaths the
following winter
Leininger’s Transcultural
Nursing
Understanding diverse
cultural health beliefs aids in
support of human health
choices and care
Respect and support of
alternative health practices
Neuman’s System Theory Continuous interaction of
humans with each other and
with environmental stimuli;
expanded awareness and
competence to function and
maintain balance and
harmony in presence of
stressors and defend against
threats
● Presence of stressors
associated with aging
noted, such as isolation
from others
● Community network is
established for reducing
isolation of the elderly
through friendly visitors
and community yoga
exercise groups
Orem’s Self Care Deficit
Theory
Concept of empowerment;
clients have deficits in ability
to provide health care for
themselves; nurses assist
client with
restoration/rehabilitation of
health
The nurse provides
education, advocacy, and
skilled interventions that
assist the community to
obtain healthy lives and
empowers the community to
take charge of its health

Check for Understanding
Orlando’s Nursing Process Assessment, planning,
implementation, and
evaluation as an organized
approach to nursing care
delivery
● Community assessment
of high suicide rates
among local teenagers
● Planning and
implementing suicide
prevention education for
a local school district
● Evaluation of
subsequent suicide
rates among local teens
of the school district
Pender’s Health Promotion
Model
Factors and relationships
contribute to
health-promoting behavior,
health enhancement, and
quality of life
Interpersonal influences of
community health helps
smokers commit to
smoking-cessation program
Roy’s Adaptation Model Process of adaptation to the
environment/external stimuli
● Advocacy for increasing
physical accessibility to
public places
● Advocacy for changing
school lunch menus and
vending machines to
healthy nutritional
choices
Watson’s Caring Healthy community is
holistic integration of social,
spiritual, and personal
resources to attain or
maintain health for
members’ body, mind, and
spirit
Caring and compassion
shown in aiding the homeless
population

1. Which nursing theoretical foundation that applies to individuals can be expanded to apply to population
health?
2. How do nursing theoretical concepts enhance the nurse’s approach to population health care?
Community Assessment and the
Nursing Process
●
Communities have three components: the population, a location, and a social system; therefore,
nurses assessing the communities consider the people within, the boundaries of the location,
and the general environment where the community exists. Narrowing the focus begins by
establishing boundaries or parameters in which to examine members of a community and the
environment. Professionals can also narrow the focus by defining sets of factors, or variables,
and analyzing population sets in various databases.
Population of Focus
Defining and describing characteristics of the population of focus is the first step in
population-focused assessment. The population may reside in a large metropolis, a small rural
community, or in a particular geographical region in which members of the population are
influenced by unique social, economic, and political circumstances. Certain health care
conditions and disparities are more prevalent in locations with larger population size, density,
and composition of characteristics. Over time, populations can grow or decline, and population
characteristics can change. Demographic characteristics, including culture, gender, educational
level, marital status, occupation, and income, form the basis for assessing population needs and
gaps in health.
Geopolitical Place
Environmental factors relevant to the geographic location affect the health of the community.
One means of examining the environmental conditions influencing the quantity and quality of life
for a given population is to evaluate the geopolitical location of a population. A geopolitical place
consists of community boundaries, transportation infrastructure, geographic features, climate,
vegetation, animals, and human-made homes and facilities. The nurse may begin by defining
the place in terms of natural geographic boundaries. Various mountain ranges may surround the

community. A river or rivers may dissect the area, or border the region. Injury and natural
disasters that occur are also associated with geographic location. This can include animal
influences on health (e.g., kicking, bites, or attack), poisonous vegetation, outdoor recreational
activities common in the area, geological activity, temperature extremes, and other adverse
weather activity.
Constructed geopolitical boundaries include ZIP codes, census tracts, voting districts, suburb
dimensions, school districts, health districts, and other legal or political boundaries. Man-made
structural boundaries, such as streets, bridges, airports, and transportation tracks, complete the
picture. Epidemiologic studies use data from specified geopolitical places to determine
population demographics, diversity, health services, and resources, including structural
facilities.
GIS tracking can assist health professionals in defining geographical or population boundaries.
Additionally, GIS can be used as a framework to organize health patterns, disparities, and
behaviors related to geographic overlay. In other words, GIS helps to determine where there are
disparities, health behaviors, or health deficits in an environment related to the geography of the
area. The organizing system of GIS can help professionals in population health informatics to
track and analyze data, define problem areas, and assess populations, so intervention can be
determined and implemented.
Phenomenological Place
Phenomenological place is a relational or psychological location rather than a geographical
location. A phenomenological place centers on history, culture, economics, education, spiritual
beliefs, values, common characteristics, or similar goals. These independent and
interdependent relationships create a context in which members of the community experience
belonging. An individual may belong within various phenomenological places. For example, one
person may belong to a church organization, cultural heritage group, library-reading group, and
a political activism group. Another person may belong to an animal shelter volunteer group,
online graphic novel interest group, and a veterans’ group. Social interactions, common
interests, goals, and various other characteristics assessment and analysis aids determination
of health status and health needs.
The community components discussed in this chapter are foundational to understanding
community assessment. Demographic characteristics of the population of focus determine the
size of population for assessment and the characteristics of the population. Geopolitical and
phenomenological place aid in the development of geographical, political, and psychosocial
context that guides population assessment.
Assessment Approach
A community assessment involves researching the safety and quality aspects of a community to
understand the interactions among the population, environment, and resources. Pertinent
informatics and community data retrieval from various resources measure behaviors and health
status of the population. Much like conducting a health assessment, the nurse undertakes a

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sequence of steps to discover subjective and objective information and then analyzes the
findings. Based on the findings, the nurse identifies needs, priority outcomes, a plan,
intervention, and a means to evaluate the intervention outcomes. Much like an individual health
assessment, the community or population assessment happens in an organized manner to
avoid overlooking subtle positive and negative findings. The process may take weeks or months
and may halt the prioritization of needs while funding and resources, such as people, assemble.
The first step in a community assessment is refining the focus to a particular targeted population
group or location. Although an extensive community assessment is possible, usually an initial
assessment occurs on a smaller scale. When conducting a community assessment, the nurse
determines what population and location will be assessed and if assistance of others or key
stakeholders are needed for the assessment. The assessment process includes the gathering
of data and observing the given group of people and their location for physical, psychological,
sociological, economic, spiritual, and lifestyles that reveal the current health status, problems, or
barriers to priority needs. Quantitative (numerical) and qualitative (explanatory or descriptive)
data are utilized as resources for a community assessment. Both are collected from both
primary and secondary sources of information.
Primary Sources of Data
Primary sources of data include the critical assessment resources of the defined community.
The people conducting the assessment directly collect the information. The components
include, but are not limited to, the people/population, geopolitical or phenomenological place,
health information systems, and the observable social interactions. These sources provide
information that the nurse and other group members obtain directly through means such as
observation and surveys. A population has parameters of variables or factors that define the
assessment or analysis.
The nurse can inspect the location of and listen to the population by conducting a walking or
windshield survey. A windshield survey occurs when someone drives through a defined
community’s geographical location, making observations of the locale. The person seeks
impressions of what life is like for the population in the neighborhood(s) and what those in the
heart of the area need. Housing age and general condition, availability of public transportation,
noise levels, general condition of motor vehicles, street or road conditions, traffic flow, types of
businesses, sources of recreation, education, police, fire department, and health care
accessibility are noted, along with natural boundaries, terrain, and climate. Observations provide
evidence of spiritual beliefs, architecture style, decay or renewal, and open spaces, such as
parks or vacant lots, to help form a picture of the life there. Signs of life may include notices and
posters (Mengistu & Misganaw, 2006). If walking through the area, the person assessing the
area may engage in conversations with people on the street, asking questions about the area.
An imprint or mental snapshot forms about what the population encounters day to day. A sense
of the area or people’s history, demographics, ethnicity, values, and beliefs forms. Walking and
windshield surveys provide firsthand impressions of the physical environment, economy,
political and governmental activity, recreation, availability of transportation, education, safety,
health, social services, and communication venues (Anderson & McFarlane, 2015). Because
walking or windshield surveys are not always feasible, the nurse is likely to use a secondary

resource, such as data from databases or health warehouses, to analyze the extent and
significance of health status or disparities.
Secondary Sources of Data
The nurse gleans pertinent data from secondary sources including research conducted by
others at a previous time. Websites and public documents are resources for gathering this
information. Data warehouses of epidemiological information can reveal current issues and help
with trending. GIS surveys can use computer information systems to overlay information such
as health variables, access to health care, transportation systems, neighborhoods, food
availability, or other available data to get a clear picture of how variables interact to increase or
decrease health outcomes. Further assessment continues through research of additional
primary and secondary sources of data and use of technology. The results of public forums and
focus groups provide additional material. These forums and focus groups are a venue for
people to answer some predetermined questions about a particular topic, permitting those who
would not ordinarily express an opinion an opportunity to provide input (Rotary International,
n.d.).
The assessment uses a holistic approach and identifies sources of spiritual support in the
community. The aim is to uncover the biological, spiritual, and psychosocial factors that
compose the population studied (CDC, 2010). The nurse can detect the effect humanitarian and
spiritual mission-based groups have on the community. For example, Habitat for Humanity
creates safe, affordable shelters with long-lasting, life-changing effects. Support groups and
counseling services may have a spiritual-based background, such as local Alcoholic
Anonymous groups, bereavement groups, equine or pet therapy programs, and divorce or
single parent support groups. Food banks, homeless shelters, and clothing centers operate as
mission-based services. Interfaith organizations join to form larger programing, such as
Interfaith Hospitality Network’s mission to provide food and temporary shelter for families. The
nurse assesses the organizations’ impact on the reduction of health inequities and disparities. If
an organization is not available to provide a service or discontinues a service, the nurse
assesses for gaps and other possible interventions. Likewise, spiritual resources can aid
nursing interventions that reduce health inequities and disparities.
The desired outcome of studying both primary and secondary sources is to form an
understanding of the populations, creating a complete picture of the defined population in the
community, their health status, and their health behaviors. The understanding includes
awareness of community history, organizations or groups among the population, and social,
political, and economic changes for the population. Comparisons to other like populations
provide further understanding through the compare/contrast processes (YMCA, 2012). Health
problems become more prominent. During this process, the nurse may align with community
leaders who are stakeholders in the outcome or persons who become partners in the pursuit of
health improvement. The terminology, partner in care, indicates that an individual or a group
within the population or community becomes a partner and collaborator in the public health
arena, with a voice in determining the approach to care.

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●
Table 1.5
Primary and Secondary Sources of Data
Primary Sources of Assessment Data Examples
People ● Structured interviews of key individuals
or stakeholders who have knowledge of
particular alterations or situations
○ People in the situation
○ Volunteers
○ Workers with knowledge
○ Spiritual groups
Environment ● Feedback from the environment of the
communities functioning physically and
socially
● Determination of assets and resources
Boundaries Statistics or description of the population’s
parameters
Demographics ● Observations
● Key interviews
Observation ● Walking or windshield survey
● Group dynamics
Secondary Sources of Assessment Data Examples

National Sources ● U.S. Census Bureau
● Government publications of data
State Sources ● Birth, deaths, and disease statistics
● Climate statistics
● Air quality
● Health department
Local Sources Public school finances, school enrollment,
levels of education, day care facilities, tax
records, housing starts, government housing,
shelters, employment rates, occupations, fire
and police protection, publication of local
history media (radio, television, newspapers,
city website), waste disposal and sanitation,
water sources and treatment, hospitals and
clinics, health department, counseling
services, religious groups and facilities,
sources for food and clothing, food pantry,
welfare services
Survey ● Random or sample selection of
members from particular groups within
the population
● Responses may provide a picture of the
larger population
Interviews and Presentations ● Testimonies from key community
members or experts
● Presentations to/from groups

Check for Understanding
1. What nursing perceptions of the client expand when applied to a population?
2. How do primary sources enlighten the nurse’s perspective of a population?
3. How does use of secondary sources enhance the assessment of the community?
Analysis, Diagnosis, and
Planning
Community Groups ● Results of forums and/or focus groups
by market researchers
● Random selection or participants
chosen to represent different groups of
the population to discuss a topic and aid
in determining the community interest in
or significance of an issue
Geographical Information Systems (GIS) ● U.S. Geological Survey’s GIS showing:
○ Climate areas
○ Where people and disease cluster
○ Traffic
○ Buying patterns
○ Utility lines
○ Pollution spread
● GIS overlay of health variables and
factors to enable analysis of health
status
Health Information Systems Databases or data warehouses that contain
pertinent population health information

●
Using a SWOT analysis, the nurse categorizes the assessment findings for the population’s
strengths, assets, and resources; notes weaknesses, challenges, limitations, restrictions, and
overall threats to the group, and identifies both actual and potential diagnoses (see Table 1.6).
The use of SWOT analysis promotes broader critical thinking about the population and
environment (Community Tool Box, n.d.). Consideration of stakeholders and spiritual resources
are included in this process.
Table 1.6
SWOT Analysis Example
Strengths
● Housing in adequate condition
● Family shelter for those in need
● Immunization clinics rotate though
shopping areas that are within walking
distance for most
● Multiple areas of housing for elderly
with low incomes
● Discount food warehouses on outskirts
of area
● Decreasing adolescent pregnancy rate
● City water fluoridation system
Weaknesses
● Lack of transportation (e.g., taxi or bus
service)
● High rate of unemployment among
young adult population
● Lack of low-income health clinics
● Multiple downtown retailers have closed
or gone out of business, leaving
buildings empty with “For Rent” or “For
Sale” signage and boarded windows
Opportunities
● Faith-based initiative forming free lunch
program and gathering with those with
health care needs
● New YMCA slated for spring
construction with room for community
events
● Interdisciplinary collaboration in place
through the local health
department—currently planning
Threats
● Flooding from river every spring and fall
● Increasing incidence of rabies
● Power outages during summer heat
waves leave elderly without air
conditioning
● Increasing incidence of opioid overdose
● Increasing incidence of adolescent
suicide rate

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Steps in the assessment of a population are similar to the logic model commonly used by health
professionals known as the PRECEDE-PROCEED model (Van Gelderen, Krumwiede,
Krumwiede, & Fesnke, 2018). The PRECEDE-PROCEED model is a comprehensive method of
assessing community needs for social and ecological areas for health promotion, then
identifying desired outcomes and the process for health promotion program implementation.
The nurse can use this model to organize the assessment of a population, including
epidemiological data, environmental diagnosis, and organizational and policy data as a basis for
program planning. The nurse formulates nursing diagnoses for the community based on the
findings and problems determined from the community assessment. The diagnoses can
incorporate all aspects of health. Prioritization of the diagnoses can narrow the focus and guide
care when a broad range of health care needs exist.
Prioritization Example
If the water supply is found to have unsafe levels of lead and elevated serum lead levels are
found in some children and adults, then the contaminated water supply would be a higher
priority than the development of a program for scoliosis screening. An appropriate nursing
diagnosis based on the relevant assessment data could be:
Contamination related to chemical contamination of water AEB venous blood lead levels of
above 10mg/dL in 25% of the adult and pediatric population and lead contamination of drinking
water of 100 parts per billion in 90% of samples (CDC, 2015; CDC, 2017a).
Selection of nursing diagnoses leads to determining outcome identification. Prioritization may be
in terms of what outcome will reach the largest segment of the population and have the highest
impact. Alternatively, perhaps a smaller segment has highly critical or life-threatening need and
will become the target of care. In either event, the nursing diagnoses are rank ordered.
Outcomes fashioned specifically for the targeted population are measureable, relevant, and
achievable (within the capacity of resources) and hold an explicit time requirement for
completion. Plans, derived from the identified outcomes, often include primary, secondary, and
tertiary prevention components. Primary prevention components aim to strengthen the
population’s resistance to stressors and illness. Secondary prevention targets areas that have
stressed the population or causes illness or weaknesses. Secondary prevention provides
support to lessen or overcome the stressors. Tertiary prevention intends to halt further system
imbalances of the system or population (Eshlemann & Davidhizar, 2000). Planning should
contemplate what the population would be like if the area of concern is resolved, then consider
what interventions would grow toward making that outcome a reality. Use of available
community resources provides support of the plan. Predetermining measurement of the
adolescent suicide intervention program
for local schools and media campaign
regarding opioid overdoses

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outcomes will help determine if success is evident through population behavior changes and
numerical and/or percentage statistical information.
Sample Nursing Community Diagnoses
● Contamination
● Deficient community health
● Ineffective community coping
● Readiness for enhanced health maintenance
● Risk for complicated immigration transition
● Risk for injection
● Risk for injury
● Social isolation (Herdman & Kamtisuru, 2018).
Intervention and Evaluation
●
The nurse has direction toward the population’s primary needs for nursing care by analyzing
data, prioritizing nursing diagnoses, and determining outcomes. Then, evidence-based and best
practice research regarding successful approaches by others occurs, including how to sustain
success effectively. Again, the PHN may use a logic model for organization. The PROCEED
portion of the PRECEDE-PROCEED model is congruent with the intervention and evaluation
process. The nurse chooses achievable strategies to fit the target population, determinates
resources, and seeks assistance and/or funding as needed. Perhaps, the priority is outreach to
local groups regarding the importance of influenza vaccination or preparation for weather
disasters. Another priority may be outreach regarding diabetic education classes at a local
public health setting. Whatever the priority, by setting outcomes and determining a plan of
action, the nursing process is applied to the broader population. Evaluation of results occurs
upon completion of the preplanned interventions. Input into statistical programs is encouraged
to provide systemic support and the discovery of trends. Statistical results support evidence of
change or areas that are lagging. Future programming or improvements have more strength

toward funding and persuasion of others when backed with data reflecting improvement in
health and financial implications.
Impediments to Effective
Practice
●
Apathy
Apathy is a barrier that can impede change in population health when the population and/or
health professionals believe that change is not possible or probable. “Knowing is not
enough; we must apply. Willing is not enough; we must do.”—Goethe
(Institute of Medicine, 2003, iii)Resignation to poverty, illiteracy, and other health
disparities creates a vacuum for motivation to change. Beliefs that the world must have the
underserved, underinsured, uninsured, and lack of funds or resources can be difficult to sway.
Stigma can impede health of populations. Sexual orientation disparities, migrant status, cultural
and language barriers, poverty, and illiteracy bear stigmas. Embarrassment, refusal to accept
charity, fear of deportation, pride, fear of separation/removal of family members become brick
walls at times, hindering access into health services.
Costs
Barriers such as cost, transportation, age, and geographic location impede community access
to health care programs and services. Among the ongoing barriers associated with cost for
communities include lack of funds to develop physical infrastructure, hire human resources
(employees) to provide services, and lobby efforts toward public policies. The insufficient
number of BSN-prepared nurses creates gaps in services. In this century, policy support has
grown for the preparation of those with BSN and advanced nursing practice. Fortunately,
awareness is growing that the cost of illness is greater than the cost of primary and secondary
preventative services, including a competent workforce. The Institute of Medicine (IOM) report,
The Future of Public Health (IOM, 1988), revealed disarray in the public health infrastructure.
Since the report’s publication, efforts have transpired to strengthen public health agencies,
develop the workforce, and envision Healthy People 2010, then Healthy People 2020 initiatives

(IOM, 2003; IOM, 2011). In addition, the ACA promoted health system reform with provisions
that pursued improved quality and effect, stronger workforce and health care infrastructure, and
greater focus on public health and prevention (APHA, 2012). The ACA’s emphasis on wellness
care supports access to and quality of care, including public health services (Berg & Dickow,
2014).
Resistance to Change
Resistance to change impedes healthy behaviors. Individuals show resistance to behaviors
necessary for health. Change has the connotation of losing control or choice, sacrificing
pleasures, such as favorite foods, increased cost, loss of personal time, or increased work, in
the form of dedicated physical exercise. Socially constructed norms, such as cultural beliefs,
some spiritual practices, medical mistrust, or mistrust of government services delay progress for
positive health behavior changes. Family or social support systems that do not discuss
health-related information or ridicule change reduce perceptions that change is needed. A
perception of lack of risk reduces the public’s preventative behaviors (You, Chen, & Liao, 2018).
The health care structure and personnel affect motivation to change. Difficulty in accessing
support services, such as nutritional information, diagnostic monitoring of progress, exercise
facilities, or drug therapies, slows progress. The health care professional’s demeanor can
impact motivation to change. Lack of health care professionals’ emphasis on the need for
lifestyle change, the impression that such change does not have a high value for that
professional, or the impression that the health care professional did not have confidence the
person could make lifestyle changes affect the person’s motivation (Hardcastle, Maxwell-Smith,
Hagger, O’Connor, & Platell, 2018). Those not motivated to make healthy behavioral changes
are often those who are at the most risk (Hardcastle et al., 2015). Conflicting information, a
patient’s lack of desire to arrange support, and lack of simple messages and strategies to stay
healthy contribute to delay or reinforcement of change (Hardcastle et al., 2018). Research is
ongoing in methods to impact these barriers to change. The nurse should conduct a
self-examination of how healthy behaviors are valued and role modeled, accurate information is
provided, nonjudgmental demeanors are conveyed, barriers to health care are reduced or
removed, and methods of simple messages and support are within that nurse’s practice.
Reflective Summary
Public/community health nursing has historical roots. The nursing role has evolved with
expected competencies for public health nursing and information technology. Nursing practice
targets groups of people in addition to individuals and families. An understanding of the interplay
of systems is foundational to nursing care of populations. The community becomes the nurse’s
client—not a singular patient, but a group of people who interact and participate in the health
and wellness of the community at large. Social justice is a concept to guide ethical care within
society. Disruption of health inequities and disparities are within the realm of nursing population
health practice. Nurses can conduct an assessment of the community by using the nursing
process, and thereby identifying and analyzing the problem areas, health disparities, and

resources for a population. This provides insight into the conditions in which the population
lives, works, and plays. By working with community stakeholders, which includes spiritual
groups, the nurse can make a difference in the health of larger groups.
Key Terms
Aggregate: Grouping of persons because of common characteristics or location.
Commitment: Dedication or sense of duty toward someone or something.
Community: A group of people within an open social system who share similar goals and live
within a similar area.
Community-Based Collaborative Action Research (CBCAR): A research approach to
understanding patterns of health problems and inequities from a social justice/ecological
perspective facilitated by key community stakeholders to promote human rights and health.
Community Health Nursing: Nursing care for acute and chronic conditions outside the
traditional hospital setting with a focus of restorative care.
Demographics: Statistical information regarding groups of persons.
Distributive Justice: Fair allocation of resources and services.
Empowerment: Promotion of power and authority to make decisions and changes.
Epidemiology: The study of disease appearance, course, spread, and eradication.
Equilibrium: A state of balance between stressors and energies for resistance to stressors. The
state of stability.
General Systems Theory: A structure with a network of interrelated, interacting, and
exchanging features that form a complex, balanced whole that can withstand external influences
and disruptions. Mathematical study of change by Dr. Ludwig von Bertalanffy.
Geographic Information Systems (GIS): Digital mapping system showing grouping of multiple
variables, such as climate areas, clusters of people and disease, traffic, buying patterns, utility
lines, and pollution spread. Capable of overlaying health variables and factors to enable
analysis of health status.
Group: Persons placed together.
Health Disparities: Variables that contribute to inequities or an unequal distribution of
resources for various populations; preventable differences in the burden of disease, injury,
violence, or opportunities to achieve optimal health that are experienced by disadvantaged
populations; specifically relatable to social, economic, and/or environmental disadvantages.
Incidence: Numerical rate of newly diagnosed occurrences of a disease in a population;
numerical value used as part of rate or frequency determination.

Mobilizing for Action Through Planning and Partnerships (MAPP): Method of
community-wide strategic planning, facilitated by public health leaders using the essential
services of public health to help communities make health and quality of life improvements.
Partner in Care: An individual or group within the population or community who becomes a
partner and collaborator in the public health arena, with a voice in determining the approach to
care.
Population: Inhabitants of an area.
Population-Focused: Attention particular to a given population.
Population Health: Defined as the health outcomes of a group of individuals, including the
distribution of such outcomes within the group.
Prevalence: Numerical fraction or ratio of disease diagnosis (incidence) in comparison with the
total population group; term used as part of rate or frequency determination.
Public Health: The practice of protecting and promoting quality of life of persons and
communities through the use of science, research, and direct care to prevent disease
outbreaks, environmental hazards, injuries, and poor health.
Public Health Nursing: “The practice of promoting and protecting the health of populations
using knowledge from nursing, social, and public health sciences” (APHA, 2013, p. 2).
PRECEDE-PROCEED Model: Logic model, developed by Lawrence Green, used as a tool by
health professionals to design, implement, and evaluate programs for health promotion and
health behavior changes.
Social Justice: Treating all fairly no matter what socioeconomic background, ethnicity, age,
citizenship, disability, or sexual orientation.
Stakeholder: Person or persons both involved and directly affected by plans, actions, and
outcomes. Person with a vested interest or personal stake in the outcome.
SWOT Analysis: An assessment and analysis technique used to determine internal strengths,
internal weaknesses, broader opportunities or external resources, and external threats for a
population or an organization. Method to develop a more in-depth perspective of an issue.
Suprasystem: Large structure or system with smaller components or subsystems.
Vision: An aspiration or a plan for the future.
References
American Nurses Association. (n.d.). Public health nursing. Retrieved from
http://nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/PublicHealt
hNursing
American Public Health Association. (n.d.). What is public health? Retrieved from
https://www.apha.org/what-is-public-health

American Public Health Association. (2012). Affordable Care Act overview. Retrieved from
https://apha.org/~/media/files/pdf/topics/aca/aca_overview_aug2012.ashx
American Public Health Association. (2013). The definition and practice of public health nursing.
Retrieved from
https://www.apha.org/~/media/files/pdf/membergroups/phn/nursingdefinition.ashx
Anderson, E. T., & McFarlane, J. M. (2015). Community as partner: Theory and practice in
nursing. (7th ed.). Philadelphia, PA: Wolters Kluwer Health—Lippincott, Williams, & Wilkins.
Andrews, A. (2010). The butterfly effect: How your life matters. Naperville, IL: Simple Truths,
LLC.
Association of Public Health Nurses. (n.d.). What is a PHN? Retrieved from
http://phnurse.org/What-is-Public-Health
Barrett, D. H., Ortmann, L. W., Dawson, A., Saenz, C., Reis, A., & Bolan, G. (Eds.). (2016).
Public health ethics: Cases spanning the globe. Springer Open. Retrieved from
https://link.springer.com/content/pdf/10.1007%2F978-3-319-23847-0
Berg, J. G., & Dickow, M. (2014). Nurse role exploration project: The Affordable Care Act and
new nursing roles. Nurse Leader, 12(5), 40-44. doi: 10.1016/j.mnl.2014.07.001
Buhler-Wilkerson K. (1985). Public health nursing: In sickness or in health? American Journal of
Public Health, 75, 1155-1161. doi: 10.2105/AJPH.75.10.1155
Bush, G. W. (2004). Incentives for the use of health information technology and establishing the
position of the national health information technology coordinator. Federal Register, 69(84),
24059-24061. Retrieved from
https://www.federalregister.gov/documents/2004/04/30/04-10024/incentives-for-the-use-of-h
ealth-information-technology-and-establishing-the-position-of-the
Canales, M., & Drevdahl, D. (2014). Community/public health nursing: Is there a future for the
specialty? Nursing Outlook, 62, 448-458. doi: 10.1016/j.outlook.2014.06.007
Centers for Disease Control and Prevention Foundation. (2017). What is public health?
Retrieved from https://www.cdcfoundation.org/what-public-health
Centers for Disease Control and Prevention. (n.d.). Ten essential public health services and
how they include addressing social determinants of health inequities. Retrieved from
https://www.cdc.gov/socialdeterminants/tools/index.htm
Centers for Disease Control and Prevention. (2010). Community health assessment and group
evaluation (CHANGE) action guide: Building a foundation of knowledge to prioritize
community needs. Atlanta, GA: U.S. Department of Health and Human Services.
Centers for Disease Control and Prevention. (2014). The 10 essential public health services: An
overview. Retrieved from
https://www.cdc.gov/stltpublichealth/publichealthservices/pdf/essential-phs.ppt
Centers for Disease Control and Prevention. (2015). Lead in drinking water. Retrieved from
https://www.cdc.gov/nceh/lead/leadinwater
Centers for Disease Control and Prevention. (2017a). Lead. Retrieved from
https://www.cdc.gov/nceh/lead
Centers for Disease Control and Prevention. (2017b). The public health system & the 10
essential public health services. Retrieved from
https://www.cdc.gov/stltpublichealth/publichealthservices/essentialhealthservices.html

Community Tool Box. (n.d.). Chapter 3, Section 14. SWOT analysis: Strengths, weaknesses,
opportunities, and threats. Retrieved from
http://ctb.ku.edu/en/table-of-contents/assessment/assessing-community-needs-and-resourc
es/swot-analysis/main
DeSalvo, K. B., Dinkler, A. N., & Stevens, L. (2015). The US Office of the National Coordinator
for Health Information Technology: Progress and promise for the future at the 10-year mark.
Annals of Emergency Medicine, 66(5), 507-510.
Devia, C., Baker, E. A., Sanchez-Youngman, S., Barnidge, E., Golub, M., Motton, F., . . .
Wallerstein, N. (2017). Advancing system and policy changes for social and racial justice:
Comparing a rural and urban community-based participatory research partnership in the
U.S. International Journal for Equity in Health, 16, 1-14. doi: 10.1186/s12939-016-0509-3
Drack, M. (2009). Ludwig von Bertalanffy’s early system approach. Systems Research &
Behavioral Science, 26, 563-572. doi: 10.1002/sres.992
Eshlemann, J., & Davidhizar, R. (2000). Community assessment: An RN-BSN partnership with
community. ABNF Journal, 11(2), 28-31.
Fee, E. & Bu, L. (2010). The origins of public health nursing: the Henry Street Visiting Nurse
Service. American Journal of Public Health, 100, 1206-1207. doi:
10.2105/AJPH.2009.186049
Frontier Nursing Service. (2015). Introduction to Frontier Nursing University. Frontier Nursing
Service Quarterly Bulletin, 90(2), 1.
Frontier Nursing University. (n.d.). History of FNU. Retrieved from
https://frontier.edu/about-frontier/history-of-fnu
Hardcastle, S. J., Hancox, J., Hattar, A., Maxwell-Smith, C., Thøgersen-Ntoumani, C., &
Hagger, M. S. (2015). Motivating the unmotivated: How can health behavior be changed in
those unwilling to change? Frontiers in Psychology, 6, 835, 1-4. doi:
10.3389/fpsyg.2015.00835
Hardcastle, S. J., Maxwell-Smith, C., Hagger, M. S., O’Connor, M., & Platell, C. (2018).
Exploration of information and support needs in relation to health concerns, diet and
physical activity in colorectal cancer survivors. European Journal of Cancer Care, 27(1),
1-9. doi: 10.1111/ecc.12679
Harkness, G. A., & DeMarco, R. F. (2015). Community and public health nursing. (2nd ed.).
Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.
Herdman, T. H., & Kamtisuru, S. (Eds.). (2018). NANDA International nursing: Diagnoses and
classification 2018-2020. (11th ed.). New York: Thieme.
Institute of Medicine. (1988). The future of public health. Washington, DC: The National
Academies Press.
Institute of Medicine. (2003). The future of the public’s health in the 21st century. Washington,
DC: The National Academies Press.
Institute of Medicine. (2011). The future of nursing: Leading change, advancing health.
Washington, DC: The National Academies Press.
Joyce, B. L., O’Brien, K., Belew-LaDue, B., Dorjee, T. K., Smith, C. M. (2014). Revealing the
voices of public health nurses by exploring their lived experience. Public Health Nursing, 32,
151-160. doi: 10.1111/phn.12113

Kindig, D., & Stoddart, G. (2003). What is population health? American Journal of Public Health,
9, 380–383. doi: 10.2105/ajph.93.3.380
Kulbok, P. A., Thatcher, E., Park, E., & Meszaros, P. S. (2012). Evolving public health nursing
roles: focus on community participatory health promotion and prevention. Online Journal of
Issues in Nursing, 17(2), 1. doi: 10.3912/OJIN.Vol17No02Man01
Mengistu, D., & Misganaw, E. (2006). Community health nursing. Ethiopia: The Carter Center.
Retrieved from
https://www.cartercenter.org/resources/pdfs/health/ephti/library/lecture_notes/nursing_stude
nts/comm_hlth_nsg_final
National Association of County and City Health Officials. (n.d.). Public health ethics. Retrieved
from https://www.naccho.org/programs/public-health-infrastructure/ethics
National CPR Association. (n.d.). 20 nursing quotes selected to give you strength and
inspiration. Retrieved from
https://www.nationalcprassociation.com/20-nursing-quotes-selected-to-give-you-strength-an
d-inspiration
Public Health Foundation. (n.d.). Quad Council public health nursing competencies. Retrieved
from http://www.phf.org/resourcestools/Pages/Public_Health_Nursing_Competencies.aspx
Quad Council Coalition of Public Health Nursing Organizations. (n.d.). Quad Council
competencies for public health nurses. Retrieved from
http://www.quadcouncilphn.org/documents-3
Reifsnider, E., & Gracia, A. A. (2015). What’s in a name? Does population health have the same
meaning for all stakeholders? Public Health Nursing, 32(3), 189-190. doi:
10.1111/phn.12202
Rotary International. (n.d.) Community assessment tools: A resource for Rotary projects.
Retrieved from https://my.rotary.org/en/document/community-assessment-tools
Swider, S. M., Krothe, J., Reyes, D., & Cravetz, M. (2013). The Quad Council practice
competencies for public health nursing. Public Health Nursing, 30(6), 519-536. doi:
10.1111/phn.12202
Swider, S. M., & Kulbok, P. A. (2015). Creating the future of public health nursing: A call to
action. Public Health Nursing, 32(2), 91-93. doi: 10.1111/phn.12193
Van Gelderen, S. A., Krumwiede, K. A., Krumwiede, N. K., & Fenske, C. (2018). Trialing the
community-based Collaborative Action Research Framework: Supporting rural health
through a community health needs assessment. Health Promotion Practice, 19. doi:
10.1177/1524839917754043
Von Bertalanffy, L. (1972). The history and status of general systems theory. Academy of
Management Journal, 15, 407-426. doi: 10.2307/255139
World Health Organization. (n.d.). Public health surveillance. Retrieved from
http://www.who.int/topics/public_health_surveillance/en
World Health Organization. (2017). Human rights and health. Retrieved from
http://www.who.int/mediacentre/factsheets/fs323/en
YMCA. (2012). Community audit tools: Three examples of assessments used to address
community health and equity. Retrieved from
https://activelivingresearch.org/sites/default/files/2012_CommunityAssessments_Hohman-P
arker-Rufo-Morales

You, S. H., Chen, S. C., & Liao, C. M. (2018). Health-seeking behavior and transmission
dynamics in the control of influenza infection among different age groups. Infection and
Drug Resistance, 11, 331-343. doi: 10.2147/IDR.S153797

CHAPTER 2
Epidemiology and Global Health
By Sue Z. Green
“In a world facing considerable uncertainty, international
health development is a unifying – and uplifting – force for
the good of humanity” —Dr. Margaret Chan,
Director-General, World Health Organization (2017f).
Essential Questions
● How do epidemiology and communicable disease affect local, community, state,
national, and global health care?
● How do global health issues shape the provision of health care?
● What socioeconomic variables could be modified to impede or halt disease
development?
● Which Sustainable Developmental Goals apply to direct improvement of global health?
● How does societal unrest disrupt global health goals?
Introduction
National and global threats to health are monitored by local, state, national, and international
agencies and organizations. Researchers seek to identify and control these threats or eliminate
them entirely. The principles used to examine and achieve prevention or control of disease are

foundational to public health care. Nurses gain knowledge and skill by learning research
approaches that use statistical data to predict the potential for disease and identify the
probabilities associated with disease prevention. In this chapter, initiatives to reduce threats to
population health are discussed on both the national and global scale. The process used to
investigate diseases that threaten a community or a larger population is also explored, in
addition to methods nurses can employ to avert or reduce disease impact.
Global Perspective of Health
Centers for Disease Control and Prevention
●
The Centers for Disease Control and Prevention (CDC), an agency of the U.S. federal
government, has multiple responsibilities to protect national and global health. T CDC is the
foremost public health agency of the U.S. government. The CDC’s mission is to protect the
nation’s health, safety, and security from threats within and from outside the United States
(CDC, 2014). This agency operates 24 hours a day 7 days a week to uncover and react to local,
national, and global health threats while using evidence-based methods and technology to
prevent, contain, or eliminate disease, disability, and death in the United States (CDC, 2017).
This includes the development of a public health workforce that promotes health and safety for
individuals, communities, and the environment (CDC, 2014). The United States participates
directly or indirectly in global programs that affect the nation’s health, such as activities lead by
the World Health Organization (WHO).
The World Health Organization (WHO)
The WHO, an agency of the United Nations, is considered the “global guardian of public health”
(World Health Organization [WHO], 2016, p. 1) and has the overall role of global health
security. Global health security is defined as proactive and reactive activities that reduce
vulnerability of populations to health threats regionally and internationally. The health care
system spans all countries of the globe and, while each country organizes the delivery of care
differently, there are health concerns that all countries face. The health threats include disease
outbreaks, malnutrition, bioterrorism, harmful environment or climate, and any emerging
disease, epidemic, endemic, or pandemic. The frequency of world travel increases the
likelihood of a health issue being transported from one country to another. The guardians of
global and national health security implement policy and preventative measures to control and

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eradicate the national, regional, and international threats. According to the WHO’s
Director-General, Dr. Margret Chen, “countries with strong health systems are better prepared
to cope with the added demands on health services and staff that outbreaks and other health
emergencies inevitably bring” (WHO, 2017f, p. 27). Thus, monitoring global health threats and
assisting other countries with health issues is pertinent to the CDC and national health security.
Epidemiology and
Epidemiological Research
Concepts
●
Epidemiology is the study of disease appearance, course, spread, and eradication. The
science, research, and technology associated with epidemiology aids the development of strong
health systems. Applied epidemiology is the application of epidemiologic studies for control
and prevention of diseases and other health problems. Epidemiological principles, including
public health assessment, policy development, and public assurance, are applied throughout
the essential functions and services of public health delivery. With various subspecialties, this
science involves the interplay of human, animal, and insect populations and the environment.
Epidemiologists aim to discover the factors affecting disease occurrence, determine who has
the greatest risk from these factors, and evaluate the effectiveness of health services to reduce
risks and improve population health. Disease detectives is a name that applies to the scientists,
physicians, nurses, veterinarians, and other health professionals who work as Epidemic
Intelligence Service (EIS) officers (CDC, 2018). These detectives conduct field investigations
to identify causes of outbreaks or sudden eruptions related to diseases and health problems.
Table 2.1 provides a list of public health problems and events that EIS officers investigate.
Table 2.1
Public Health Problems and Events
Environmental Exposures Lead and heavy metals

Air pollutants and other asthma triggers

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Note. Adapted from “Teacher Roadmap: What is Epidemiology?” by the Centers for Disease Control
and Prevention, 2016. Copyright 2016 by the Centers for Disease Control and Prevention.
Epidemiological Approach
Specific functions of public health departments, including the CDC and the WHO include public
health surveillance; field investigation; analytic study; evaluation of public health services’
effectiveness, accessibility, and quality; and policy development (CDC, 2012). Public health
surveillance is the uninterrupted systematic collection, analysis, and interpretation of health data
to guide decision making, planning, implementation, and evaluation of public health practices
(CDC, 2012; WHO, n.d.b). The surveillance provides information for action and becomes an
early warning system for public health emergencies. The process utilized in public health
surveillance also fosters documentation of the impact of health interventions, including tracking
progress toward goals and monitors health problems to determine priorities. This information is
used to inform the development of public health policies and strategies (WHO, n.d.b). The
process of surveillance is not limited to communicable disease, but may include chronic
disease, genetic and birth defects, maternal health, nutrition, health behaviors, and potentially
health problems related to environment or occupation (CDC, 2012). Field investigators study
Infectious Diseases Foodborne illness

Influenza and pneumonia
Injuries Increased homicides in a community

National surge in domestic violence
Noninfectious Diseases Localized or widespread rise in a particular type of cancer

Increase in a major birth defect
Natural Disasters Hurricanes Katrina and Rita (2005)

Haiti earthquake (2010)
Terrorism World Trade Center (2001)

Anthrax release (2001)

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outbreaks of infectious and noninfectious diseases and health problems to identify cases and
causes. A case is what meets the standardized criteria of person, place, time, and clinical
features specific to the outbreak or incident under investigation. The investigators also
recommend and implement strategies for prevention and control of disease, disabilities, injuries,
and death (CDC, 2018).
Descriptive and Analytic Epidemiology
Epidemiologic researchers study the distribution of health events and health conditions to
determine the potential causes of disease and identify approaches to control the spread of
disease. In conjunction with surveillance and field investigations, descriptive epidemiology
and analytic epidemiology research methods are employed when precision is required.
Descriptive studies characterize outbreaks according to person, place, and time (CDC, 2012,
2014). Descriptive studies can generate hypotheses related to the people, time, and place
associated with the outbreak. Analytic epidemiology examines the cause and effect relationship
between variables through a comparison of groups. Hypothesis testing is conducted to explain
the “how” and “why” of a health problem. The studies seek quantifiable data to determine the
root causes of disease and to provide evidence for prevention and control measures.
Seminal Case
In 1854, approximately 600 people died within three weeks from an outbreak of cholera
in London (HavardX, 2017; Shiode, Shiode, Rod-Thatcher, Rana, & Vinten-Johansen,
2015). John Snow, a physician, suspected that cholera was spread by way of
contaminated water. Snow canvassed the neighborhood to determine who became ill
and where they obtained their water. At that time, human waste was commonly tossed
into the streets, and bodily fluids drained into the ground, contaminating the water
below. By conducting a field investigation and plotting the data on a map, Snow
determined that the concentration of people, place, and time coincided with incidence of
disease. He concluded that the individuals who were drinking water from a central water
pump became ill as a result of contaminated water. (HarvardX, 2017; Papini &
Santosuosso, 2017; Shiode et al., 2015). Snow’s hypothesis was supported when he
determined that workers at the local brewery and workhouse did not drink from the
Broad Street pump and did not contract cholera (HarvardX, 2017). Access to the pump

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was removed, and cases of cholera began to decline shortly thereafter (Public
Broadcasting System, 2010).
Types of Analytic Epidemiological Studies
Analytical epidemiological studies fall into one of two categories: experimental and
observational. An experimental study involves a controlled process of exposure in which
individuals or communities are exposed to specific environmental elements. Immediately
following exposure, the researchers track the subjects for effects from the exposure.
Comparisons may be drawn against a control group that is not exposed to the specific
elements. (CDC, 2012, 2014). An observational study is more descriptive by nature. The
researcher draws inferences from observations of study participants, such as their behaviors,
exposure to elements, and related activities. Systematic collection of observable data forms the
basis of the conclusions of the research. An observational study may be subcategorized as a
cohort, case-control, or cross-sectional study (CDC, 2012, 2014). For a cohort study, each
person within a subgroup of a larger population falls into categories according to his or her
exposure to one or more risk factors for a disease or condition. In a case-control study,
researchers compare one group of individuals with a disease or condition to a control group of
individuals not affected by the disease or condition. In contrast, a cross-sectional study
examines a target population at a particular point in time without regard to exposure or disease
status. This approach provides information regarding the relative prevalence of disease at a
particular point of time (CDC, 2012). Cross-sectional studies are the weakest of the analytic
methods and are primarily intended to provide a snapshot or description of the population’s
exposure and disease status rather than to determine causation.
Concepts of Disease Occurrence
A fundamental approach to disease occurrence is represented in the epidemiologic triangle,
also known as the epidemiologic triad or agent-host-environment model (see Figure 2.1).
Originally used to study the infectious disease process, applications of the triangle are now used
to aid in the explanation and study of other health conditions’ occurrences. The triangle’s agent
component, also known as the “what,” of the triangle is the organism, genetic, chemical, or
physical cause of disease. The host, or “who,” of the triangle is the person or animal who can
acquire the disease or condition. Risk factors can influence the host’s susceptibility and
response to the agent. Risk aspects include degree and duration of exposure to the agent,
immunologic status, psychological wellness, anatomic structure—such as skin integrity—and
overall health status, including nutrition, genetic makeup, presence of other diseases or
conditions, medication use, and health practices. A carrier is a host that is infected or holding a
genetic trait of the disease or condition. A host usually displays no symptoms, but the agent
lives within the person, animal, or plant. The epidemiologic triangle’s environment component,
or “where,” represents the factors within the host’s environment that contribute to the chance of
exposure.
Figure 2.1

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Agent-Host-Environment Model

Socioeconomic environmental factors contributing to disease occurrence include crowding,
sanitization, availability of uncontaminated foods and water, and access to health care. Florence
Nightingale focused on the environment in order to reduce the chances of exposure and
increase the survival rate of soldiers in her care during the Crimean War. The aspects of clean
living conditions, rest and sleep, healthy food and water, and clean air in the environment have
been hallmarks of Nightingale’s legacy. Biologic environmental factors contributing to the risk of
exposure are the living organisms that can transmit diseases, such as insects, rodents, or dogs.
When an agent is transferred to a person through contact or bite, the animal becomes known as
a vector. Mosquitoes and ticks are common vectors in the United States that transmit disease
to and from humans and animals through their bite. Vector-borne diseases are commonly under
CDC and WHO surveillance. Physical environmental factors encompass climate and geology
including dust particles that can carry viruses.

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While the epidemiologic triangle depicts the components required for a disease occurrence, the
chain of infection depicts the process for disease transmission (see Figure 2.2). The infection
will not happen if a break in the chain or barrier interrupts any point of the process. The agent
lives in a reservoir or setting compatible for continued live existence. The reservoir may be
human, animal, or the general environmental constituents, such as water, soil, plants, or a
building’s composition and equipment features. The agent moves out of the reservoir though a
portal of exit. The portal of exit is the agent’s pathway of escape from the reservoir, which
happens through blood, feces, or mucus leaving a skin opening from splatters of body fluids, or
from aerosol into the air via coughing or sneezing. The mode of transmission is the means of
the agent’s travel from the portal of exit to the host. This vehicle for travel to the host is through
direct or indirect contact, ingestion, or inhalation. On arrival to the host, the agent requires an
entry into the host called the portal of entry. Skin openings, mucous membranes, or body
orifices, such as the nose, mouth, or urethra, provide access into the host. A vector can create a
portal of entry though its bite. The last link of the chain is the host. For the infection to occur, the
host must be susceptible to the agent’s pathogenicity. If the host’s immune system is strong
enough, it may halt the agent’s progress. Susceptible hosts often feature those who are very
young or very old, inadequately nourished, chronically ill, currently ill, or otherwise
immunocompromised. In addition to open wounds, the presence of invasive medical devices,
lines, or airways strain the immune system.
Figure 2.2
Chain of Infection

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Emerging diseases, endemics, epidemics, and pandemics can occur. An emerging
transmissible disease occurs when a previously undetected or unknown organism becomes an
infectious causative agent. Alternatively, emergence results from the evolution of an existing
organism, the spread of infections to new populations, or the reemergence of old infections as a
result of antibiotic resistance or the breakdown of public health measures. More recently,
noncommunicable diseases (NCDs) have raised concerns as emerging health conditions
have grown in endemic and epidemic proportions. NCDs are noninfectious, nontransmissible
disease or chronic disease, such as type 2 diabetes, arising from a combination of factors
including genetic disposition, as well as environmental, physiological, and behavioral factors. A
disease or health condition becomes endemic when it begins affecting a particular region or
population and is present at all times. For example, African sleeping sickness is endemically
present in sub-Saharan Africa, but is not endemic in the United States (WHO, 2017g). Malaria is

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endemic in Africa, Southeast Asia, the Eastern Mediterranean, and the Western Pacific, but not
the United States (WHO, 2017c). In contrast, an epidemic is a disease outbreak affecting a
community or many communities at the same time, but is not present all the time. Examples of
epidemics occurring in this century are severe acute respiratory syndrome (SARS) and the
Ebola virus. Pandemics occur on a global scale. The death toll in a pandemic is generally higher
than in an epidemic. The prevalence of HIV/AIDS across continents is pandemic in scale.
Use of Statistical Data with Disease Occurrence
The WHO has task forces and programs aimed to eradicate endemic communicable diseases.
The Malaria Threats Map is an interactive map that shows data reported to the WHO in an effort
to notify epidemiologists and other health professionals for the purposes of prevention,
diagnosis, and treatment (WHO, 2017d). Ending Cholera—A Global Roadmap to 2030 is a new
strategy for cholera control in 20 countries where the disease is endemic (Global Task Force on
Cholera Control, 2017). Outbreaks are of concern because the sudden occurrence of new
cases may indicate formation of an epidemic, endangering that region, country, and the world.
Yellow fever is of current concern as an endemic disease that has a resurgence of epidemic
outbreaks. In response to this emergency, the WHO supports a global strategy to eliminate
yellow fever epidemics by 2026 through vaccination programs (WHO, 2018). Both the CDC and
WHO monitor reports of disease and condition outbreaks and emergences for epidemic
emergencies. Both organizations post information on a weekly basis regarding surveillance
efforts and outbreaks. Epidemiologic research and reports from health professionals are crucial
to anticipating communicable disease emergencies and aiding in the development of a
response. Data warehouses, which are interactive tools such as the Malaria Threats Map,
direct observations and work to converge data as well as warn of issues to prevent epidemic
and pandemics. In recent years, surveillance, prevention, and control measures were set in
place in response to the epidemic effects of Ebola and the Zika viruses, and the H1N1 virus
pandemic of 2009. Other national and global health concerns include influenza, bacterial
meningitis, and antimicrobial resistance.
Statistical data is of great importance when evaluating aspects of incidence, prevalence,
morbidity, and mortality. These rates, ratios, and proportion calculations can indicate the
degree of risk a population experiences and the frequency of occurrence. The incidence rates
denote the emergence of a new illness. Prevalence rates reflect the amount of disease in a
population, compared to the overall health of the population. Ultimately, the objective data
predicts the further course and spread of the disease. Multiple sources of data collection serve
to form the basis of epidemiological data. The retrieval sources include questionnaires; surveys;
environmental samples from the air, water, and soil prior notifications to health departments;
financial records; human samples from biological testing; and government records. Access to
this information is aided by electronic storage systems.
Health information systems (HIS) provide electronic data for vital statistics and health
indicators. Vital statistics are measureable data regarding population groups, including births
and deaths. Health indicators, developed from the compilation of data and their statistical
analysis, depict the current state of health for a population, including morbidity and mortality
rates. Increases in a mortality rate can trigger surveillance of a population for signs, symptoms,

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and causes of illness outbreaks. Data warehouses electronically maintain important
epidemiologic information, contributing to the real-time availability of data for use by
epidemiologists, nurses, and other health professionals. Data warehouses are of increasing
importance to public health care. The Institute of Medicine’s (2001) report, Crossing the Quality
Chasm: A New Health System for the 21st Century, emphasizes the importance of data
collection, the movement toward electronic storage, and the sharing of vital information.
Public Health Surveillance and Cluster/Outbreak
Investigation
Continuous population surveillance aids in detection of emerging health problems in order to
intervene before a major outbreak occurs. The ongoing monitoring determines what problems
are currently taking place and organizes the data by health problem, time, place, and population
or cohort. Indicators of chronic disease are under surveillance. Data is retrievable regarding a
metropolitan area or state for chronic risk factors and number of those affected by chronic
disease (CDC, 2015). The CDC and WHO both periodically review diseases and conditions,
and then form the determination of which illnesses become reportable to health authorities
based on rate of occurrence, such as an emerging communicable disease. For example, a case
of sexually transmitted disease (STD) is reportable to the local health department on diagnosis.
Ebola and the Zika virus are also reportable communicable diseases. Once reported to the local
health department, persons who have STDs, Ebola, or other reportable conditions are
monitored, following the prescribed process of investigation.
The systematic process for outbreak investigation includes examining data as a cluster.
Outbreak investigation proceeds in an orderly fashion to reduce the possibilities of overlooking
important information (see Figure 2.3). Clusters occur when a small number of disease or health
conditions occur. Local and state public health departments monitor, investigate, and intervene
in these cases, as needed. Public health departments, the CDC, or WHO initiate an
investigation when sudden or higher than normal cases of a disease or health condition occur.
Field investigators for the state, CDC, and/or WHO begin by researching the outbreak,
gathering equipment and supplies, and making arrangements for travel to the outbreak location.
On site, the investigators speak with patients, review symptoms, and review the outcomes of
diagnostic testing to verify the health problem. A case definition is developed by the
investigators based on qualitative and quantitative data to categorize the results by the
problem’s clinical information, characteristics of those who have the illness, location information,
and illness onset and duration features. In other words, descriptive epidemiologic research
ensues to define the what, who, where, when, why, and how of the disease (CDC, 2012, 2014).
Once a definition is established, local health professionals are able to provide any matching
cases of the illness. Investigators study the additional dates, times, places, and persons from
the match to determine patterns. Research proceeds with analytic study, hypothesis
developments, and testing. Lastly, investigators work to control the disease through the best
evidence-based methods available for the specific illness to prevent further occurrence or
spread. The investigators then communicate the successful findings of prevention to local health

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professionals, the public, and other leaders so that they are informed and can participate in
prevention and control measures.
Figure 2.3
Outbreak Investigation

Note. Adapted from “Introduction to Epidemiology: Slide Presentation” by the Centers for Disease
Control and Prevention, 2014.
Check for Understanding
1. Which aspects of global travel increase the risk of epidemics?
2. What steps would the local health department nurse take if a local hospital reported cases of microcephaly
associated with the Zika virus?
3. How does a local health nurse use epidemiological data to promote population health?
Social Determinants of Health
Social determinants of health (SDOH) are conditions contributing or hindering a person’s
well-being (see Figure 2.4). These conditions include where people are born, grow, live, play,
learn, worship, work, and age (HealthyPeople.gov, 2018a; WHO, n.d.a). “Health is a
human right that requires “access to timely, acceptable, and affordable
health care of appropriate quality as well as to providing for the underlying

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determinants of health, such as safe and potable water, sanitation, food,
housing, health-related information and education, and gender equality”
(WHO, 2017b, para. 1).These intertwined elements are some of the biologic,
environmental, social, and economic variables that affect a person’s ability to have and maintain
good health. Health disparities are the impairments specifically related to social, economic,
and/or environmental disadvantages. Poverty, poor housing, social exclusion, bad sanitation,
contaminated water, insufficient healthy food sources, poor health care access, and inadequate
health systems are among the numerous conditions or social determinants that contribute to
risks of illness.
Health equity is the attainment of high-level health care for all individuals regardless of race,
ethnicity, social inequalities, location, or historical and contemporary injustices (U.S. Department
of Health and Human Services [HHS], 2008). The concept of equitable health relates to social
justice. More than a decade has passed since the WHO spearheaded a focus on social justice
and the SDOH (WHO, 2007). The WHO’s social justice focus underscores the idea that health is
a human right that requires “access to timely, acceptable, and affordable health care of
appropriate quality as well as to providing for the underlying determinants of health, such as
safe and potable water, sanitation, food, housing, health-related information and education, and
gender equality” (WHO, 2017b, para. 1). The core components to health require quality and
quantity health care information, services, programs, and facilities for every person despite age,
sex, location, and socioeconomic status (WHO, 2017b). Safe, effective, people-centered, timely,
equitable, integrated, and efficient services are hallmarks of quality health services (WHO,
2017b). Policies and programs to achieve health equity reduce health disparities (HHS, 2008).
Figure 2.4
Social Determinants of Health

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Note. Adapted from “Social Determinants of Health,” by the Office of Disease Prevention and Health
Promotion, 2018. Copyright 2018 by the Office of Disease Prevention and Health Promotion.
One of the overall goals of Healthy People 2020 is to achieve health equity, seek elimination of
disparities, and promote health improvements (HealthyPeople.gov, n.d.). Healthy People 2020
initiatives address the key SDOH areas of economic stability, education, social and community
conditions, health and health care, and the physical environment, known as the neighborhood
environment (see Figure 2.4) (HealthyPeople.gov, 2018a). Healthy People 2020 goals consist of
more than 42 topics for improving health in the United States (HealthyPeople.gov, 2018b).
Leading Health Indicators represent the 12 topics with high-priority issues and correspond with
advancing SDOH to promote health equity and reduction of health disparities.
The 10 Essential Public Health Services have been a means for the CDC to address the SDOH
(CDC, n.d.). Addressing individual health issues does not increase overall health equity and
reduce disparities (Davis & Chapa, 2015). Recently, the CDC launched an initiative, Health

Impact in 5 Years (HI-5), for innovative clinical and community-wide prevention approaches that
have proven, positive results, including key SDOH issues (CDC, 2016a). Community partners
work with public health sectors to improve early childhood education for improved cognitive
development and reduction of obesity, child abuse and neglect, youth violence, and emergency
department visits (CDC, 2016b). Among others, water fluoridation, use of clean diesel public
transportation, home improvement funds, and earned income tax credits are advocated. These
improvements reduce tooth decay, air pollution, cardiovascular and respiratory conditions, traffic
injuries, infant mortality, and maternal mental health (CDC, 2016b). These community-wide
efforts are anticipated to improve health equity and reduce health disparities within a 5-year
period.
Global Health Initiatives
Health equity is possible—not only here in the United States, but worldwide. Polio was once a
public health emergency, but the disease is nearly eradicated as a “When we try to pick
out anything by itself, we find it hitched to everything else in the universe.”
—John Muir (Discover John Muir, n.d.)result of global prevention efforts (Aylward,
2014). Common public health measures to improve a community’s health include sanitation,
adequate housing, clean air, and safe drinking water. Two leading population health indicators
are the reduction of health disparities and increased health equity. The 1978 Declaration of
Alma-Ata (WHO, 1978), from an international conference on primary care, marks a turning point
in global health and cooperation among governments for the right of complete physical, mental,
and social well-being for all humans. Subsequently, the United Nations declared eight
Millennium Development Goals (MDGs) for completion by 2015 to reduce poverty, hunger,
disease, illiteracy, environmental degradations, and discrimination against women (WHO,
2015). Monitoring corresponding health indicators reveals progress in various areas, such as
reduction of extreme poverty and hunger, the child mortality rate, and the maternal mortality
ratio (Shrivastava, Shrivastava, & Ramasamy, 2016; WHO, 2015). The MDGs promoted global
improvements by 2015, but did not end the need for global collaboration to promote human
health rights. In 2016, new WHO goals launched with a target for completion by 2030. Known as
the Sustainable Development Goals (SDGs) or Global Goals, they were designed not only to
continue the previous progress, but also to expand the mission of human health rights and
health promotion.
Challenges to the SDGs are factors that weaken global health security, such as war or
emerging disease. Challenges that weaken health security can differ from country to country,
but the localized issue can become a global concern. Epidemics, such as SARS, H1N1, Ebola,
and the Zika virus result in the WHO declaring emergencies to global health and shifting from
infrastructure building to shoring up against a new vulnerability (Rao, 2017). Intra- and
intercountry conflicts increase poverty and malnutrition while displacing millions of people
(d’Harcourt, Ratnayake, & Kim, 2017). Health facilities are shut down or may no longer be
structurally sound in war-torn regions or sites of natural disasters, such as earthquakes,

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hurricanes, or wildfires. Supplies are interrupted or inadequate because of the strains of
infectious disease, epidemic, or war as aid workers are evacuated. Mental health suffers with
the stress of weakened health security, further contributing to the risk factors for illness. Other
countries attempt to mitigate the damage by sending supplies, rebuilding the infrastructure,
caring for migrants, and setting up quarantines. The assistance of the other countries helps
reduce the vulnerability of the population to illness and works to halt spread of health risks
across international borders. The CDC partners with other U.S. agencies and international
organizations to prevent, detect, and respond to any threats regarding global health security
(CDC, 2016b). Ongoing threats include HIV, tuberculosis, malaria, antimicrobial resistance, and
the threat of pandemic influenza (National Academies of Sciences, Engineering, and Medicine,
2017).
Check for Understanding
1. How do health initiatives by the WHO, CDC, and Healthy People 2020 reduce the incidence of illness?
2. How can nurses use advocacy skills to reduce health disparities?
Leading Causes of Death
Many of the top 10 causes of deaths occurring in the United States coincide with the top 10
causes of death that occur globally (see Figures 2.5 and 2.6). Heart disease is the leading
cause of mortality for both the U.S. and the world. While holding differing ranks, other shared
causes include chronic lower respiratory disorders, cerebrovascular diseases, Alzheimer’s
disease, pneumonia, and diabetes (National Center for Health Statistics, 2017; WHO, 2017g).
These illnesses are among those that are modifiable or preventable, increasing the burden of
disease. The burden of disease reflects the morbidity, mortality, financial costs, and health
disparities resulting from disease, affecting human longevity and the well-being of countries’
social and economic bottom lines. The nurse’s role in health promotion and disease prevention
is key in both national and global goals to reduce the current leading causes of death. One
means of reduction is through educating patients and the public, targeting modifiable risk
factors.
Figure 2.5
Top 10 Causes of Death Globally, 2015

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Note. Adapted from “The Top 10 Causes of Death,” by the World Health Organization, 2017.
Copyright 2017 by the World Health Organization.
Figure 2.6
Leading Causes of Death in the U.S., 2015

Note. Adapted from Health, United States, 2016: With Chartbook on Long-Term Trends in Health, by
the National Center for Health Statistics, 2017. Copyright 2017 by the National Center for Health
Statistics.
“NCDs disproportionally affect people in low- and middle-income countries where more than
three quarters of NCD deaths-31 million-occur” (WHO, 2017e, para. 3). Modifiable risk factors of
unhealthy diet, physical inactivity, excess weight and obesity, diabetes, high blood pressure,
high cholesterol, and cigarette smoking all contribute to heart disease and strokes. Fardet and
Boirie’s (2013) analysis of more than 60 years of quantitative nutritional research revealed that
diabetes and obesity are key diseases that lead to other diet-related chronic diseases, including
cardiovascular disease. Excessive body weight and physical inactivity are risk factors for
development of type 2 diabetes, which is rapidly rising in low- and middle-income countries
(WHO, 2017a). National and global health initiatives now target obesity and physical inactivity in
attempts to reduce NCDs (HealthyPeople.gov, 2018c; WHO, n.d.a; WHO, 2017e).
As researchers learn more about genomic processes, human mobility, nutrition, and the
environment, more methods become known to halt or intervene in NCDs. For example,
malnutrition is certainly detrimental to health and well-being. Malnutrition develops from the

quality as well as the quantity of a diet. Diets associated with deaths have findings for high
intake of sodium, processed meats, and sugar-sweetened beverages (SSB), along with findings
for low intake of nuts, seeds, omega-3 fats from seafood, fruits, vegetables, and whole grains
(Micha et al., 2017). A diet leading to malnutrition is known as a suboptimal diet. More
recently, it has been found that a sizable portion of deaths because of heart disease, stroke, or
type 2 diabetes in the United States correlate with suboptimal diets (Micha et al., 2017).
Suboptimal diets are the target of studies for potential benefits of policy changes regarding fruit,
vegetable, and SSB consumption in order to reduce the burden of disease (Pearson-Stuttard et
al., 2017).
Nursing Roles in Prevention
Nurses are involved in all levels of prevention (Institute for Work and Health, 2015). The public
benefits from guidance and education from nurses at each level. Interventions targeting nutrition
prevent and reduce the effects of multiple health conditions.
Primary Prevention
Primary prevention measures include personal hygiene, diet, physical activity, safe food and
drinking water, sanitation, and immunizations (Fardet & Rock, 2016). Nurses work at this level to
educate the public in health promotion measures to prevent the occurrence of disease. For
example, nurses promote immunizations against disease, sanitization measures, and good
handwashing regimes for primary prevention of communicable disease. Nurses promote health
education regarding nutrition and exercise, knowing the interrelatedness of these health
measures to avoiding the development of NCDs. Nutrition education centers on diets of
reasonably sized portions high in whole grain, nuts, seeds, omega-3 fatty acids from seafood,
fruits, and vegetables that are low in SSBs, processed meats, and sodium. This includes
advocacy for healthy school lunch programs and education for all ages regarding portion sizes.
Health promotion and education measures for exercise can use reliable sources, such as the
American Heart Association (AHA), for details regarding the amount of physical activity needed
to maintain health. For example, the AHA recommends 150 minutes per week of moderate
exercise, 75 minutes per week of vigorous exercise, or a combination of both (American Heart
Association [AHA], 2014). Children and adolescents should have 60 minutes of moderate
exercise, preferably daily (AHA, 2018).
Secondary Prevention
Nurses conduct screenings for early detection and treatment of health problems. Nurses again
use education to promote health, but the education is directed at measures deterring the further
complications of current health problems and reducing the duration of the disease. Reduction of
barriers to adequate care are part of the nursing roles in secondary prevention. Promoting
measures to increase the number of people seeking and maintaining treatment regimens
reduces barriers, which facilitates reduction in costs, comorbidities, and mortalities (National
Academies of Sciences, Engineering, and Medicine, 2017). Nursing advocacy for funding of
specific NCDs screening and care promotes strengthening of systems. Screening for detection
of health conditions, such as hypertension, diabetes, and high cholesterol, serves to halt or slow
disease processes through subsequent treatment. Health education can prevent further injuries

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or reoccurrence. For example, nutrition and physical activity programs benefit overweight adults,
teens, and children. Population health puts nurses on the frontlines for returning people to
health and well-being, preferably without long-term health conditions.
Tertiary Prevention
Nurses continue health education and undertake measures to avoid chronic disability and to
delay further deterioration from health issues. Tertiary preventions use rehabilitation measures,
support groups, and health education to target complex and/or management of long-term health
problems. Nursing care fosters quality of life. Advocacy for disability services is within the
possibilities. The nurse seeks to return the person to healthy, everyday life, living with the
condition and still preventing further harm or death.
Examples of Nutrition and the Levels of Prevention
● Primary preventive nutrition—Measures for the public to reach an optimal level of
healthy nutrition from birth through aging, using nutrition programs such as Women,
Infants, and Children (WIC); school lunch programs; and nutrition educational resources,
such as food pyramids and pictures of portions for a healthy diet.
● Secondary preventive nutrition—Measures to maintain optimal healthy nutrition levels
as long as possible for people at risk because of health conditions, such as Meals on
Wheels and dietitian consultations.
● Tertiary preventive nutrition—Measures to influence rehabilitation or delay further
deterioration, such as condition-specific restrictions as in end-stage renal disease or
food supplements to increase intake of healthy nutrients (Fardet & Rock, 2016).
Reflective Summary
The CDC, WHO, and other epidemiological researchers seek to prevent, reduce, or eliminate
health conditions threatening the public’s health. Understanding epidemiological research
approaches involves applying the concepts of disease occurrence, methods of research, and
the importance of statistical data collection, storage, and analysis. Public health surveillance is
an ongoing process with teams ready to investigate and intervene for clusters of disease
occurrence along with the larger endemic, epidemic, and pandemic disease outbreaks. National
and international cooperation creates progress to reaching substantive goals for the reduction of
health disparities and disease, enhancing health for all. Nurses maintain an active role in all
aspects of health promotion and advocacy. One way nurses accomplish this is through
application of the levels of prevention to educate populations and to avert or impede the acute
and chronic impact of communicable and noncommunicable diseases.
Key Terms
Agent: The organism, chemical, or physical cause that is to blame for a disease or health
condition.

Analytic Epidemiology: The method of epidemiological studies or research that searches for
cause and effect; comparison of groups to provide a baseline and test hypotheses for
quantifiable association of exposures and outcomes; seeks information on the quality and
influences that determinants have on a disease occurrence.
Applied Epidemiology: The application of epidemiologic studies for control and prevention of
diseases and other health problems.
Burden of Disease: Estimates of the health problems’ impact on the world in terms of
indicators such as financial cost, mortality, and morbidity; estimates include statistical analyses
of disability-adjusted life year (DALYs), years of life lost (YLL), and years lost due to disability
(YLD).
Carrier: Person, animal, or plant infected or holding a genetic trait of the disease or condition,
but displays no symptoms of the agent within.
Case: A disease, injury, event, or situation that meets standardized criteria of person, place,
time, and clinical features specific to the outbreak or incident under investigation.
Case-Control Study: Researchers compare one group that has a disease or condition to a
control group that does not have the disease or condition.
Chain of Infection: The components and process required for transmission of disease.
Cohort Study: Researchers study a selected population in which each person falls into
categories of exposure to one or more risk factors for a disease or condition.
Communicable Disease: Disease that is transmissible via the chain of infection; also known as
infectious or contagious disease.
Cross-Sectional Study: Researchers observe a target population at a particular point in time
without regard to exposure to disease or disease status.
Cluster: A group of disease occurrences for time and place that is more than expected.
Data Warehouses: Large amounts of electronically stored data accumulated from a wide
variety of sources that is useful for statistical analysis.
Descriptive Epidemiology: The method of epidemiologic studies or research that
characterizes outbreaks according to person, place, and time to identify the problem and form
hypotheses.
Emerging Disease: An infection or health condition that is recently occurring in a population
whose incidence in humans is rapidly increasing over the past two decades or threatens to
increase in the near future.
Endemic: A disease or health condition present at all times that affects a particular region or
population.
Epidemic: A disease outbreak affecting many people or communities at the same time;
excessive disease occurrence for a particular time and place, but is not present all the time.

Epidemic Intelligence Service: Training program for disease detectives who practice applied
epidemiology and serve public health frontlines as ready responders to investigate public health
threats in the United States and the world.
Epidemiologic Triangle: The epidemiologic triad of agent, host, and environment as a model of
disease causation; another name for the Agent-Host-Environment Model.
Epidemiology: The study of disease appearance, course, spread, and eradication.
Experimental Study: A controlled process of exposure of an individual (clinical trial) or a
community (community trial).
Field Investigation: Scientific investigation of outbreaks of infectious and noninfectious
diseases and health problems, such as illness related to injuries, nutrition, environmental and
occupational health.
Health Disparities: Variables that contribute to inequities or an unequal distribution of
resources for various populations; preventable differences in the burden of disease, injury,
violence, or opportunities to achieve optimal health that are experienced by disadvantaged
populations; specifically relatable to social, economic, and/or environmental disadvantages.
Health Equity: Provision of resources necessary to live well to all individuals regardless of
varying social determinants of health (SDOH).
Health Indicators: Compilation of data that portrays the current state of health for a population
from a variety of sources, including morbidity and mortality rates.
Health Information System: A confidential computerized system that records, stores, and
conveys health-related data.
Health Security: Proactive and reactive activities that reduce vulnerability of populations to
health threats regionally and internationally.
Host: Person or animal who can acquire an infectious disease or health condition.
Hypothesis: A testable statement of a relationship; an epidemiologic hypothesis is the
relationship is between the exposure (person, time, and/or place) and the occurrence of a
disease or condition.
Incidence: Numerical rate of newly diagnosed occurrences of a disease in a population;
numerical value used as part of rate or frequency determination.
Levels of Prevention: Primary, secondary, and tertiary; these levels have a collective goal of
preventing or improving health by promoting positive health promotion behavioral changes.
Millennium Development Goals (MDGs): Eight global goals for improving lives of the world’s
poorest populations agreed upon by 189 countries and with a deadline of 2015.
Mode of Transmission: The agent’s travel from the portal of exit to the host through direct or
indirect contact, ingestion, or inhalation.
Morbidity: Illness or the incidence of ill health; the state of being unhealthy or diseased.

Mortality: Death; the number of those who died within a population.
Noncommunicable Disease (NCD): Noninfectious, nontransmissible, or chronic disease
arising from a combination of factors, including genetics, environmental, physiological, and
behavioral aspects.
Observational Study: Study in which the researcher, without control of the determinants of a
disease, draws inferences from observations of and systematic data collection from a group; an
observational study may be subcategorized as a cohort, case-control, or cross-sectional study.
Outbreak: Sudden breaking out, eruption, or occurrence of a disease or condition.
Pathogenicity: The ability of an agent to cause a disease or health condition.
Pandemic: Widespread or worldwide epidemic.
Portal of Entry: Point where the agent enters the host.
Portal of Exit: The pathway for an agent’s means of escape from the reservoir through blood,
feces, or mucus leaving an orifice or skin openings.
Prevalence: Numerical fraction or ratio of disease diagnosis (incidence) in comparison with the
total population group; term used as part of rate or frequency determination.
Public Health Surveillance: The uninterrupted systematic collection, analysis, and
interpretation of health data to guide decision making, planning, implementation, and evaluation
of public health practices.
Rate: Number of cases, diseases, or health conditions occurring at a particular time, depending
on the size of the population during that time.
Reservoir: The environment housing an agent that is compatible for continued live existence.
Social Determinants of Health (SDOH): Conditions of living, such as housing,
socioeconomics, transportation needs, quality of education, that directly impact health and
access to health care needs.
Social Justice: Treating all fairly no matter what socioeconomic background, ethnicity, age,
citizenship, disability, or sexual orientation.
Suboptimal Diet: A diet leading to malnutrition.
Sustainable Development Goals (SDGs): Seventeen global goals of the United Nation to end
poverty, protect the environment, and promote peace and prosperity by 2030; also known as
Global Goals.
Vector: Mode or agent of disease transmission.
Vital Statistics: Measurable data regarding population groups including births and deaths.
References

American Public Health Association. (2012). Affordable Care Act overview. Retrieved from
https://apha.org/~/media/files/pdf/topics/aca/aca_overview_aug2012.ashx
American Heart Association. (2014). American Heart Association recommendations for physical
activity in adults. Retrieved from
http://www.heart.org/HEARTORG/HealthyLiving/PhysicalActivity/FitnessBasics/American-H
eart-Association-Recommendations-for-Physical-Activity-in-Adults_UCM_307976_Article.js
p#.Wnj_cq6nFpg
American Heart Association. (2018). Preventing childhood obesity: Tips for parents and
caretakers. Retrieved from
http://www.heart.org/HEARTORG/HealthyLiving/HealthyKids/ChildhoodObesity/Preventing-
Childhood-Obesity-Tips-for-Parents-and-Caretakers_UCM_456118_Article.jsp#.WnkAw66n
Fpg
Aylward, R. B. (2014). Making history: From a public health emergency to a polio-free world.
Bulletin of the World Health Organization, 92(7), 466. doi: 10.2471/BLT.14.142273
Centers for Disease Control and Prevention. (n.d.). Ten essential public health services and
how they can include addressing social determinants of health inequities. Retrieved from
https://www.cdc.gov/stltpublichealth/publichealthservices/pdf/ten_essential_services_and_s
doh
Centers for Disease Control and Prevention. (2012). Principles of epidemiology in public health
practice: An introduction to applied epidemiology and biostatistics. (3rd ed.). Atlanta, GA:
Author. Retrieved from https://www.cdc.gov/ophss/csels/dsepd/ss1978/SS1978
Centers for Disease Control and Prevention. (2014). About CDC 24-7: Mission, role and pledge.
Retrieved from https://www.cdc.gov/about/organization/mission.htm
Centers for Disease Control and Prevention. (2015). Chronic disease indicators. Retrieved from
https://www.cdc.gov/cdi/index.html
Centers for Disease Control and Prevention. (2016a). Office of the associate director for policy:
Health impact in 5 years. Retrieved from https://www.cdc.gov/policy/hst/hi5/index.html
Centers for Disease Control and Prevention. (2016b). Global health – CDC and the Global
health security agenda: The global health security agenda. Retrieved from
https://www.cdc.gov/globalhealth/security/ghsagenda.htm
Centers for Disease Control and Prevention. (2017). 2017 CDC: Saving Lives. Protecting
People. [Brochure]. Retrieved from
https://www.cdc.gov/about/report/docs/2017healthsecurityreport
Centers for Disease Control and Prevention. (2018). Epidemic Intelligence Service: What EIS
officers do. Retrieved from https://www.cdc.gov/eis/what-eis-officers-do/index.html
Davis, S. L., & Chapa, D. W. (2015). Social determinants of health: Knowledge to effective
action for change. The Journal for Nurse Practitioners, 11(4), 424-429. doi:
10.1016/j.nurpra.2015.01.029
Discover John Muir. (n.d.). Main page. Retrieved from https://discoverjohnmuir.com
d’Harcourt, E., Ratnayake, R., & Kim, A. (2017). How can the sustainable development goals
improve the lives of people affected by conflict? Bulletin of the World Health Organization,
95(2), 157-158. doi: 10.2471/BLT.16.179622

Fardet, A., & Boirie, Y. (2013). Associations between diet-related diseases and impaired
physiological mechanisms: A holistic approach based on meta-analyses to identify targets
for preventive nutrition. Nutrition Reviews, 71(10), 643-656. doi: 10.1111/nure.12052
Fardet, A., & Rock, E. (2016). The healthy core metabolism: A new paradigm for primary
preventive nutrition. Journal of Nutrition, Health & Aging, 20(3), 239-247. doi:
10.1007/s12603-015-0560-6
Global Task Force on Cholera Control. (2017). Ending cholera—A global roadmap to 2030.
Retrieved from http://www.who.int/cholera/publications/global-roadmap/en
HarvardX. (2017, April 19). John Snow and the 1854 Broad Street cholera outbreak [Video file].
Retrieved from https://www.youtube.com/watch?v=lNjrAXGRda4
HealthyPeople.gov. (n.d.). About healthy people. Retrieved from
https://www.healthypeople.gov/node/5840
HealthyPeople.gov. (2018a). Social determinants of health. Retrieved from
https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health
HealthyPeople.gov. (2018b). Leading health indicators. Retrieved from
https://www.healthypeople.gov/2020/Leading-Health-Indicators
HealthyPeople.gov. (2018c). Heart disease and stroke. Retrieved from
https://www.healthypeople.gov/2020/topics-objectives/topic/heart-disease-and-stroke
Institute for Work and Health. (2015, Spring). What researchers mean by…primary, secondary
and tertiary prevention. At Work, 80, 2. Retrieved from https://www.iwh.on.ca/at-work/80
Institute of Medicine. (2001). Crossing the quality chasm: A new health for system for the 21st
century. Washington, DC: National Academy Press.
Micha, R., Peñalvo, J. L., Cudhea, F., Imamura, F., Rehm, C. D., & Mozaffarian, D. (2017).
Association between dietary factors and mortality from heart disease, stroke, and type 2
diabetes in the United States. JAMA, 317(9), 912-924. doi: 10.1001/jama.2017.0947
National Academies of Sciences, Engineering, and Medicine. (2017). Global health and the
future role of the United States. Washington, DC: The National Academies Press.
National Center for Health Statistics. (2017). Health, United States, 2016. Hyattsville, MD.
Retrieved from https://www.cdc.gov/nchs/data/hus/hus16
Papini, A., & Santosuosso, U. (2017). Snow’s case revisited: New tool in geographic profiling of
epidemiology. The Brazilian Journal of Infectious Diseases, 21(1), 112-115. doi:
10.1016/j.bjid.2016.09.010
Pearson-Stuttard, J., Bandosz, P., Rehm, C. D., Penalvo, J., Whitsel, L., Gaziano, T., …&
Capewell, S. (2017). Reducing U.S. cardiovascular disease burden and disparities through
national and targeted dietary policies: A modelling study. PLoS Med 14(6). doi:
10.1371/journal.pmed.1002311
Public Broadcasting System. (2010). John Snow: Pioneer of epidemiology. Retrieved from
https://az.pbslearningmedia.org/resource/envh10.sci.life.nathis.johnsnow/john-snow-pionee
r-of-epidemiology/#.WnERdq6nFpg
Rao, K. S. (2017). Challenging times for public health towards attaining Sustainable
Development Goals. Indian Journal of Community Medicine, 42(2), 65-68.
doi:10.4103/0970-0218.205210

Shiode, N., Shiode, S., Rod-Thatcher, E., Rana, S., & Vinten-Johansen, P. (2015). The mortality
rates and the space-time patterns of John Snow’s cholera epidemic map. International
Journal of Health Geographics, 14(1), 1-15. doi: 10.1186/s12942-015-0011-y
Shrivastava, S. R., Shrivastava, P. S., & Ramasamy, J. (2016). Assessing the status of United
Nations Millennium Development Goals. Annals of Tropical Medicine and Public Health,
9(2), 87-89. doi:10.4103/1755-6783.177373
U.S. Department of Health and Human Services. (2008). The secretary’s advisory committee on
national health promotion and disease prevention objectives for 2020. Phase I report:
Recommendations for the framework and format of Healthy People 2020. Section IV.
Advisory committee findings and recommendations. Retrieved from
https://www.healthypeople.gov/sites/default/files/PhaseI_0
World Health Organization. (n.d.a). Social determinants of health: About the social determinants
of health. Retrieved from http://www.who.int/social_determinants/sdh_definition/en
World Health Organization. (n.d.b). Health topics: Public health surveillance. Retrieved from
http://www.who.int/topics/public_health_surveillance/en
World Health Organization. (1978). Declaration of Alma-Ata: International conference on
primary health care, Alma-Ata, USSR, 6–12 September 1978. Retrieved from
http://www.who.int/publications/almaata_declaration_en ?ua=1&ua=1
World Health Organization. (2007). Closing the gap in a generation: health equity through action
on the social determinants of health. Geneva: Switzerland: Author. Retrieved from
http://apps.who.int/iris/bitstream/10665/43943/1/9789241563703_eng
World Health Organization. (2015). Millennium development goals (MDGs). Retrieved
http://www.who.int/mediacentre/factsheets/fs290/en
World Health Organization. (2016). The global guardian of public health. Retrieved from
http://www.who.int/about/what-we-do/global-guardian-of-public-health ?ua=1
World Health Organization. (2017a). Diabetes. Retrieved from
http://www.who.int/mediacentre/factsheets/fs312/en
World Health Organization. (2017b). Human rights and health. Retrieved from
http://www.who.int/mediacentre/factsheets/fs323/en
World Health Organization. (2017c). Malaria. Retrieved from
http://www.who.int/mediacentre/factsheets/fs094/en
World Health Organization. (2017d). Malaria: New interactive mapping tool. Retrieved from
http://www.who.int/malaria/news/2017/malaria-threats-map/en
World Health Organization. (2017e). Noncommunicable disease. Retrieved from
http://www.who.int/mediacentre/factsheets/fs355/en
World Health Organization. (2017f). Ten years in public health 2007-2017. Retrieved from
http://www.who.int/publications/10-year-review/en
World Health Organization. (2017g). Trypanosomiasis, human African (sleeping sickness).
Retrieved from http://www.who.int/mediacentre/factsheets/fs259/en
World Health Organization. (2018). Emergencies preparedness, response: Eliminating yellow
fever epidemics (EYE) strategy: Meeting demand for yellow fever vaccines. Retrieved from
http://www.who.int/csr/disease/yellowfev/meeting-demand-for-vaccines/en

CHAPTER 3
Community as Client
By Angel Falkner
Essential Questions
● Why is cultural competence so important in providing care for patients within the
community?
● What role does the public health nurse play in providing education to individuals and
communities?
● How does the nurse use evidence-based practice to identify disparities of health in
varying populations?
● How does the public health nurse address the varying learning needs of different patient
groups?
● What models are appropriate for community or population health improvement?
Introduction
Health promotion is a key element of public health. Public health nurses (PHNs) utilize tools and
nursing models that help them to promote health. PHNs also need to understand the importance
of cultural competence when working with emerging and vulnerable population groups. In
addition, the PHN’s role as patient advocate and educator is crucial to providing optimal care for
patients in diverse communities. The PHN also utilizes the nursing process to help improve
community health and move toward the goal of achieving health equity.
Culture, Race, and Ethnicity
Public health requires an understanding of the concepts of culture and cultural values as well
as the importance of cultural competence in caring for diverse populations. Cultural pluralism
can be described simply as the coexistence of multiple cultures within a population, which is a
common occurrence in many places throughout the world. The United States has long been
called a melting pot where varying cultures existing together. With each culture comes different
values that guide the daily behaviors and thought processes of individuals. Values heavily
influence an individual’s outlook on health care, illness, wellness, and treatment. Phrases such
as “He has very conservative values,” or “She has Christian values,” are examples of common
statements used to describe an individual’s belief system. The PHN must become familiar with
how these ascribed values directly impact health.

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Cultural competence is the ability to interact effectively with people of different cultures, belief
systems, and preferences. In so doing, PHNs demonstrate respect and responsiveness to
health beliefs and practices. Other terms associated with cultural competence include cultural
preservation, cultural repatterning, cultural brokering, and cultural dissonance (Bronheim,
2011; Huber, 2009)
Example of Cultural Dissonance
The family of a female patient requests a female nurse to replace the male nurse originally
assigned to care for the patient. The male nurse may be upset or think that he did something
wrong, but really, the request was based on the family’s cultural beliefs. The male nurse’s
feelings are based on a misunderstanding of the patient’s cultural values. This is something that
all nurses may face in their career and needs to be met head on in order to provide care to all
patients regardless of differences.
Culture and Subculture
Culture is defined in many different ways. The general consensus explains culture as a group of
people who share similar beliefs related to values, communications, dietary preferences, and
socialization patterns. Because culture impacts most aspects of life, it has a significant role in
health care choices, treatment, and compliance. A subculture is a group that falls under the
larger culture group umbrella, but constitutes its own set of values and beliefs
(Campinha-Bacote, 2011). An example of this would be the larger Hispanic culture having a
subculture of persons from Cuba. Though Cubans might be part of the larger Hispanic culture,
they have their own set of values, beliefs, and customs that are different from other groups
within the Hispanic culture, which makes them distinct. Nurses will undoubtedly work with
individuals from multiple cultures and subcultures, providing them with culturally appropriate
resources and education. It is essential for the nurse to be aware of and sensitive to the
differences between a culture and its subcultures in order to provide truly culturally competent,
holistic nursing care.
Stereotypes and Biases
The PHN will need to be aware of issues that may arise when working with diverse populations
within different communities. There are a number of stereotypes and biases associated with
different people depending on gender, race, and age. A stereotype is a preconceived
assumption regarding a certain group of people. A bias is personal feeling or attitude toward a
person or group based upon the stereotype associated with the individual or group of people.
Bias is widely described as “the negative evaluation of one group and its members relative to
another,” (FitzGerald & Hurst, 2017, p. 2). Implicit bias, a term used within the health care
community, is the unconscious attitude displayed based on stereotypes that directly affect
understanding, decisions, and actions that may impact patient care. This type of bias has been
found in a large number of health care workers (The Joint Commission, 2016; FitzGerald &
Hurst, 2017). The nurse should be well informed regarding stereotypes and biases in order to
be sensitive to these issues and provide the most unbiased care possible. Discrimination based

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on these stereotypes and biases is an unfortunate yet common occurrence in health care. The
nurse should be aware of these issues and be a strong advocate for those who have
experienced this kind of discrimination. Once again, this highlights the importance of cultural
competence as an imperative nursing skill, as ensuring that all people receive adequate health
care regardless of gender, race, age, or other socioeconomic disadvantage is the goal of health
equity (FitzGerald & Hurst, 2017).
Cultural Frameworks and
Assessment Tools
To complete a thorough assessment, it is crucial to address the individual’s cultural needs when
formulating a plan of care. The PHN receives information through a thorough question and
answer session with the patient. Incorporating cultural assessment is a requirement for all
assessments in order to provide culturally competent care. To assess the patient’s cultural
needs, the PHN may ask questions such as:
1. What are your or your family’s beliefs about health, life, nature and relationships?
2. What language and dialect is spoken within the home? How well do you speak and
understand English?
3. Do you and your family affiliate with a certain religion? Do you and your family attend
church regularly?
4. What health care providers do you or your family use? How do you and your family
perceive health care providers?
5. When do you or your family seek treatment for illness or injury?
6. Do you and your family practice any health promotion strategies in daily life? (Andrews &
Boyle, 2016)
The LEARN Model
The LEARN communication model (see Figure 3.1) has been used as an effective way to move
through feelings of apprehension triggered by cultural dissonance. The five steps of this model
include:
1. Listen
2. Explain
3. Acknowledge
4. Recommend
5. Negotiate
The PHN can use this tool to communicate effectively and provide culturally competent care.
Figure 3.1
LEARN Model

Example of Culturally Competent Care
The PHN may assess a patient who is of Mexican heritage and professes to be a
practicing Catholic. The patient ascribes to the values of Christianity and the teachings
of the Catholic faith in particular. She has five children and does not want to become
pregnant again, but she expresses concern about seeking birth control. She

understands that the use of birth control does not align with the social teachings of the
Catholic church. The PHN must take the patient’s concern into consideration when
forming a plan of care that respects her client’s values. The PHN elects to teach her
client to track her menstrual cycle and ovulation to avoid conception (American
Pregnancy Association, 2016).
Another way the PHN could provide culturally competent care for this patient would be
to apply the LEARN model to communicate with the patient.
● Listen: “Would you like to discuss options for pregnancy prevention that are
natural and not permanent?”
● Explain: “You are concerned because you do not wish to have more children at
this time, but you do not want to use typical birth control methods. Let me discuss
some options with you.”
● Acknowledge: “Though there are many safe and effective medical options for
pregnancy prevention, there are also ways to prevent pregnancy that are natural
and effective. Let’s talk about those.”
● Recommend: “I will review the natural family planning method with you now.”
● Negotiate: The PHN answers questions and addresses any concerns the patient
may have about the natural family planning method, and the patient decides
whether it is the correct plan of action for her.
Campinha Bacote Cultural Framework Model
The Campinha Bacote cultural framework model (see Figure 3.2) outlines five elements that
may occur in the process of becoming culturally competent. This model is regarded as a
prominent guide for cultural competence in nursing. The five elements of the Camphina Bacote
Model include:
● Cultural Awareness—the process of self-reflection that must occur in order for the
health care provider (in this case, the RN) to take care of multicultural populations
● Cultural Knowledge—the RN seeking information and education regarding different
cultures
● Cultural Skill—the process of utilizing assessment techniques, such as open-ended
questioning in order to obtain valuable cultural data

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● Cultural Encounters—the interactions between the RN and culturally diverse patients
that occur daily when providing care at the bedside or within the community
● Cultural Desire—the RN’s inner motivation to become culturally competent
(Transcultural C.A.R.E Associates, n.d.)
Motivation to become culturally competent is not something that can be taught, but is an
element of self-discovery, much like cultural awareness. Campinha-Bacote (Transcultural
C.A.R.E Associates,” n.d.) stated, “Cultural competence is a process of becoming culturally
competent, not being culturally competent,” (para. 2).
Figure 3.2
Campinha-Bacote Culture Model

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Note. Adapted from “Delivering patient-centered care in the midst of a cultural conflict: The role of
cultural competence,” by J. Campinha-Bacote, 2011, OJIN: The Online Journal of Issues in Nursing,
16. Copyright 2011 by OJIN: The Online Journal of Issues in Nursing.
Cultural Care Theory
Another prominent theorist is Madeleine Leininger. Leininger is often considered to be the
founder of transcultural nursing care. Leininger developed the cultural care theory (CCT), which
is based on the many interconnecting facets of an individual’s life that contribute to overall
health. CCT incorporates culture as well as religion, education, and economic and social
factors, all of which contribute to the individual’s well-being and influence the individual’s
decisions to seek medical treatment, when to seek treatment, and from whom to seek care. The
sunrise model for cultural competence is often utilized as a visual representation of the CCT
when educating nurses and health care providers on cultural competence. The sunrise model
(see Figure 3.3) illustrates how the elements involved in cultural care affect one another as well
as the nurse’s actions and care, all of which contribute to the individual’s health. At the center of
the model is the healthy, balanced patient. The patient’s health is directly influenced by a variety
of factors, including social, religious, economic, and cultural; collectively these are referred to as
the patient’s cultural care worldview. The nurse considers all elements within the patient’s
worldview and understands that they each play an important role in affecting the patient’s
health. Below the healthy, balanced patient, the model shows the different ways in which the
patient may seek to restore health, including folk care, nursing care, and professional systems.
Below this are the elements of cultural care that the nurse utilizes in order to provide culturally
congruent nursing care to the patient.
Figure 3.3
Leininger’s Sunrise Model

Note. Adapted from “The Sunrise Model: A Contribution to the Teaching of Nursing Consultation in
Collective Health,” by L. Pereira de Melo, 2013, in American Journal of Nursing Research, 1(1),
20-23. Copyright 2013 by the Science and Education Publishing.
Cultural and Linguistic Needs
As communities grow and become more diverse, the PHN’s ability to deliver culturally
competent care becomes more imperative. A major component within cultural care is
addressing the linguistic needs of these populations. The PHN must evaluate individual’s ability
to understand and comprehend English and provide resources in the appropriate language if

necessary, which may involve providing qualified interpretive services (Agency for Healthcare
Research and Quality [AHRQ], 2013).
A widely utilized and effective tool for provision of cultural care is the culturally and linguistically
appropriate services standards (CLAS). This tool (see Table 3.1) is used as a guide to provide
appropriate cultural care within various health care settings. The tool addresses common
concerns when providing culturally congruent care, such as respect of cultural or spiritual
practices, providing care in the patient’s preferred language, and health literacy concerns.
Table 3.1
CLAS Standards
National Enhanced Culturally and Linguistically Appropriate Service Standards
Principal Standard
Standard 1: Provide effective, equitable, understandable, and respectful quality care and
services that are responsive to diverse cultural health beliefs and practices, preferred
languages, health literacy, and other communication needs.
Governance, Leadership and Workforce
Standard 2: Advance and sustain organizational governance and leadership that promotes
CLAS and health equity through policy, practices, and allocated resources.

Standard 3: Recruit, promote, and support a culturally and linguistically diverse governance,
leadership, and workforce that are responsive to the population in the service area.

Standard 4: Educate and train governance, leadership, and workforce in culturally and
linguistically appropriate policies and practices on an ongoing basis.
Communication and Language Assistance

Standard 5: Offer language assistance to individuals who have limited English proficiency
and/or other communication needs, at no cost to them, to facilitate timely access to all health
care and services.

Standard 6: Inform all individuals of the availability of language assistance services clearly and
in their preferred language, verbally and in writing.

Standard 7: Ensure the competence of individuals providing language assistance, recognizing
that the use of untrained individuals and/or minors as interpreters should be avoided.

Standard 8: Provide easy-to-understand print and multimedia materials and signage in the
languages commonly used by the populations in the service area.
Engagement, Continuous Improvement and Accountability
Standard 9: Establish culturally and linguistically appropriate goals, policies, and management
accountability, and infuse them throughout the organization’s planning and operations.

Standard 10: Conduct ongoing assessments of the organization’s CLAS-related activities and
integrate CLAS-related measures into assessment measurement and continuous quality
improvement activities.

Standard 11: Collect and maintain accurate and reliable demographic data to monitor and
evaluate the impact of CLAS on health equity and outcomes and to inform service delivery.

Standard 12: Conduct regular assessments of community health assets and needs, and use
the results to plan and implement services that respond to the cultural and linguistic diversity
of populations in the service area.

Standard 13: Partner with the community to design, implement, and evaluate policies,
practices, and services to ensure cultural and linguistic appropriateness.

Standard 14: Create conflict- and grievance-resolution processes that are culturally and
linguistically appropriate to identify, prevent, and resolve conflicts or complaints.

Note. Adapted from “Enhanced Cultural and Linguistic Services Standards: Not Just Language
Anymore,” by V. Sanders-Thompson, 2016, Washington University in St. Louis Institute for Public
Health. Copyright 2016 by the Washington University in St. Louis.
Models of Health
The PHN needs a basic understanding of models that will help them to assess their patients and
formulate a tailored plan of care. There are a variety of conceptual models that outline patterns
of behavior related to health. These models are utilized as the basis for many health promotion
models seen in public health. Six major models will be overviewed followed by a chart for
comparison.
Health Belief Model
The health belief model (HBM) (see Figure 3.4), created in the 1950s by psychologists
Hochbaum, Rosenstock, and Kegels, is a way to determine an individual’s motivation for
seeking health care (LaMorte, 2016b). The six primary components within this model include:
1. Perceived susceptibility (“That will never happen to me, will it?”)
2. Perceived severity (“It is not that bad; I will be fine.”)
3. Perceived benefits (“Even if I go to the doctor, it won’t help.”)
4. Perceived barriers (“It will hurt. It costs too much. I don’t have time.”)
5. Cues to action (motivators to act and seek treatment, such as pain, disability, familial
pressure)
6. Self-efficacy (“Can I comply with treatment?”)
These elements are helpful to consider when evaluating whether an individual is ready to
receive education. The nurse can utilize this model by having meaningful and honest discussion
with clients to understand reasons for seeking or avoiding treatment and what motivates or
deters them in successful compliance.
Figure 3.4
Health Belief Model
Standard 15: Communicate the organization’s progress in implementing and sustaining CLAS
to all stakeholders, constituents, and the general public.

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Note. Adapted from “A Population-Based Study into Knowledge, Attitudes and Beliefs (KAB) about
HIV/AIDS,” by M. Dadgarmoghaddam, M. Khajedaluee, & M. Khadem-Rezaiyan, in Razavi
International Journal of Medicine, 2016, 4(1). Copyright 2016 by Razavi International Journal of
Medicine.
Health Promotion Model
Nola Pender and associates created the health promotion model (HPM) (see Figure 3.5), which
focuses on behaviors to improve health and achieve wellness (Khodaveisi, Omidi, Farokhi, &
Soltanian, 2017). The HPM states that health promotion behaviors are determined by:
● Personal experiences and characteristics,
● Perceived benefits and barriers, and
● Observed outcomes of intervention.

Figure 3.5
Health Promotion Model

Note. Adapted from Health Promotion in Nursing Practice (2nd ed.), by N. J. Pender, 1987.
Copyright Pearson Education.
Health Promotion Model Example
Josie, a 35-year-old mother of three has gained a significant amount of weight since the birth of
her first child 8 years ago. She attempted to take the weight off unsuccessfully a year ago.
Discouraged by her lack of progress, she says, “Everyone in my family is overweight. I am just
going to have to get used to it.” Her motivation to lose weight stems from her desire to keep up
with the kids and not be so tired all the time. Her barriers, or behavior specific cognitions,
include not having much free time, not having much energy, no access to a gym, and her sister
always telling her to “get used to being fat.” Her husband and her mom are motivating and

supportive of her desire to make changes. Her plan of action is to begin a food diary, eliminate
all fried foods, and start increasing her physical activity by hiking on weekends with the family
and walking the kids to school in the mornings instead of driving. Once she begins the plan and
sticks with it for a period of time, the hope is to see results, such as increased energy
(behavioral outcome). The PHN supports and encourages her throughout this process and sets
attainable goals that both Josie and the PHN agree upon together.
Primary Health Care Model
Another model is the primary health care model (PHCM) developed by Shoultz and Hatcher.
The primary health care model is closely tied to community health in that it embodies the idea of
health care for all people within a community. The focus is on community participation and
prevention measures based on six factors:
● Environment
● Economics
● Politics
● Education
● Health services
● Nutrition
The idea is that each of the six elements interact with one another and affect community health
overall. This model is not specific to individual patients but focuses more on the community as a
whole (Shoultz, Kooker, Sloat, & Hatcher, 2003). The PHN understands that these elements
interact and affect one another, and instead of focusing solely on improvement of health
services, they focus on helping to create change in all six of these areas in order to improve
community outcomes. The PHN may do this by assessing and identifying issues within the
community’s environment, such as a lack of walking paths available in the neighborhoods. The
PHN understands that ease and accessibility to walking paths will most likely increase the
probability that community members will increase their physical activity levels. The PHN takes
this information and makes recommendations to the local government officials to increase the
number of walking paths within neighborhoods.
Change Model
Kurt Lewin developed the change model (see Table 3.2), which can be used in community
health as well. This theory defines three phases of unfreezing, change, and refreezing.
Unfreezing is the preparation stage, which many find to be the most difficult. Once the individual
moves into the change stage, it becomes easier but requires support and motivation. During the
refreeze stage, the individual might have met set goals, but they will still require support and
reassurance and may set new goals at this point (Cummings, Bridgman, & Brown, 2015).
Table 3.2
Change Model

Note. Adapted from “Unfreezing Change as Three Steps: Rethinking Kurt Lewin’s Legacy for
Change Management,” by S. Cummings, T. Bridgman, & K. G. Brown, 2015 in Human Relations,
69(1), 33-60. Copyright 2015 by Human Relations.
Change Model Example
Phil is a 41-year-old man who is overweight and has been diagnosed with high blood pressure.
He used to work out when he was in his 20s but hasn’t in a very long time. In the unfreeze
stage, Phil recognizes that he has to change his diet and increase his activity to improve his
health, but he says, “I am afraid of change and I am comfortable with my lifestyle as it is.” His
friends, family, and medical team all encourage him to come up with a plan that incorporates
changes slowly and when he is ready. Phil enters the change stage when he decides to take
evening walks with his kids three nights a week. After a month of doing this routinely, he is
excited but anxious to see real changes. His medical team encourages him and praises him for
his dedication and hard work. During the refreeze phase, Phil continues to make more changes
and improvements in his lifestyle, but tries to set realistic goals with the help and support of the
medical team, PHN, and his family and friends.
Transtheoretical Model
The transtheoretical model (TTM) (see Table 3.3), developed by Prochaska and DiClemente,
highlights motivational factors related to readiness for change (Pro-Change Behavior Systems,
Inc., n.d.). The TTM has five distinctive phases that can be observed by the nurse. The nurse
may be most actively involved in the preparation and action phases, when behavior change
requires planning and initiation.
Unfreeze Change Refreeze
Preparation stage; explains
why the change is needed
Action phase; requires time
and communication; huge
learning curve
Support during change
process; evaluation of
barriers; allow for feedback
Most stressful stage; people
are most resistant and
question reasons for
suggested changes
Hands-on support by
caregiver is necessary to
engage audience (e.g.,
patient or community
members)
Clearly defined expectations;
constant communication
Time for motivating; get
others to be excited for
change
Make benefits of change as
clear as possible
Consistent support, praise,
reassurance

Table 3.3
Transtheoretical Model
Change Phase Behavior Example Comment Intervention
Precontemplati
on
No desire to make
changes
“I like eating whatever I
want.”
Education regarding
proper nutrition,
healthy lifestyle, risks
associated with poor
diet choices
Contemplation Consideration of
change
“I might be eating too
much fried foods, I do
feel very groggy and
run down when I eat
that way, I might cut
back to 2 times per
week”
Encourage patient to
make better choices,
acknowledge
willingness to make
small changes, ongoing
support
Preparation Planning to make
change
“I will eliminate fast
food from my diet and
eat vegetables 2 times
per day to help me feel
more energized and
less run down”
Help patient set goals,
reiterate importance of
adherence to plan, help
make environmental
changes that will
support meeting goal
Action Plan initiation “I stocked my house
with healthy food and
intend on taking a new
route to work so I can
avoid passing the fast
food place all the time”
Support of plan,
encourage
self-evaluation, reward
compliance to plan
Maintenance Initiation and
maintenance for 6
months or more
“I eat vegetables with
every meal and haven’t
eaten at the fast food
place since January, I
Set new goals, prepare
for setbacks, ongoing
support

Social Cognitive Theory
Bandura’s social cognitive theory (SCT) focuses on the learning process and the relationship
between person, environment, and behavior that is needed for learning to occur. This theory
focuses heavily on the individual’s environment and suggests that changes in the environment
changes will lead to behavior change (LaMorte, 2016a). Bandura also describes self-efficacy in
the process of behavior change. Self-efficacy, which goes beyond the individual’s capability to
manage his or her health care needs, involves the individual’s ability to believe he or she is fully
capable of self-management and behavioral modifications. The nurse plays an integral role in
nurturing feelings of self-efficacy in order to support the individual in making long-term changes
that promote health. This is done mainly through positive reinforcement and consistent
encouragement. The nurse should speak openly with patients, ensuring them that they are
capable of creating and sustaining desired changes.
Social Ecological Model
The social ecological model (SEM) can be seen in use for a number of preventative plans of
care within community health, such as the encouragement and education regarding
colonoscopies as a preventative measure for screening and detection of colon cancer. The
model, founded by Urie Bronfenbrenner, considers the relationship between the person,
community, relationships, and society in relation to promoting change behaviors or prevention
(Sincero, 2012). Each piece has elements for the PHN to consider that influence the patient’s
ability to make changes that promote health and prevent disease. The inner most ring of the
model (see Figure 3.6) is the individual level, which involves the individual’s attitudes and
perceptions of his or her health care needs, such as the need for colorectal cancer screening.
The next level is the interpersonal level, which indicates the individual receiving gentle coaching
or encouragement to participate in prevention activities, such as colonoscopies or biannual
dental cleanings. The third level, organizational, is the health care clinic or institution that
performs the screening or administers the preventative treatment. The fourth level, community,
involves working within communities to institute education regarding the importance of
prevention screenings. The last level, policy, involves work on a legislative level, such as
working to mandate that insurance companies provide well-woman exams or colonoscopies at
no cost to patients as part of health promotion and prevention measures (Centers for Disease
Control and Prevention [CDC], 2015a).
Figure 3.6
Social Ecological Model
feel much better and
less groggy all the
time”

Note. Adapted from “Colorectal Cancer Control Program (CRCCP): Social Ecological Model,” by the
Centers for Disease Control and Prevention.
Ecological Systems Theory
Urie Brofenbrenner also describes different environments that are influential throughout an
individual’s lifespan. They include the microsystem, mesosystem, exosystem, macrosystem,
and chronosystem (Sincero, 2012) (see Figure 3.7 and Table 3.4). Originally, the ecological
systems theory was developed for application in children, and highlighted the relevance of the
relationships within each system and their effect on the individual. The nurse understands and
values the importance of the impact and effect of each system, and works to support and
advocate for the needs of the patients depending upon their specific situation.
Figure 3.7
Ecological Systems Theory

Note. Adapted from “What is Bronfenbrenner’s Ecological Systems Theory?” by Psychology Notes
HQ, 2013. Copyright 2013 by Psychology Notes HQ
Table 3.4
Ecological Systems Theory
System Explanation
Microsystem Direct environment

Example: friends, teachers, or neighbors
Mesosystem Interaction between microsystem relationships

Example: parental involvement may lead to excelling in school
Exosystem How the elements in each individual’s life directly impact one another

Example: mom’s work schedule impacting the child’s ability to play sports
Macrosystem Cultural facets of the individuals environment, including socioeconomics

Note. Adapted from “Ecological Systems Theory,” by S. M. Sincero, 2012.
Ecological Systems Theory Example
Mark, a 22-year-old paraplegic, relies on his mother and full-time caregiver to meet his basic
daily needs. His mother and his home environment are his microsystem. Mark travels to his
doctor’s office two times a month and also goes to church on a weekly basis; his physician’s
office and church are part of his mesosystem. Mark’s father works full time and is not at home
much; however he just had a change in his medical benefits that will directly impact which
physician Mark can go see now; this is an example of Mark’s exosystem. Mark and his family
are very excited because he will soon receive his associate’s degree in generalist studies from
the local community college; this is an example of Mark’s chronosystem. The nurse understands
that each of these systems and their elements are a crucial balance in Mark’s overall health and
wellness. If one of these systems is disrupted in some way, it can negatively or positively impact
Mark’s health. When the nurse conducts an assessment, he or she can discover more details
about each of these systems and, if needed, help to restore balance or recommend resources
to help restore balance for Mark. In this example, the nurse could help find a list of physician’s
within the area that accept Mark’s new medical insurance and are familiar with treating patients
who are paraplegics.
Population Considerations
Vulnerability Versus At Risk
When discussing the terms vulnerability and at risk, it is important to recognize their similarities
and differences. A population or individual who is at risk may have predisposing factors that
cause an increased susceptibility to acquiring a disease or disorder, but might not necessarily
be part of a vulnerable population group. Vulnerable populations require special attention and
advocacy based on factors such as age, mental or physical disability, poverty, or ethnicity
(Stanhope & Lancaster, 2014).
At Risk vs. Vulnerable Example
Example: religious influences, poverty levels
Chronosystem Transition periods in life

Example: marriage, divorce, births, transitioning from high school to
college

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Jane is a 45-year-old Caucasian female with a familial history of breast cancer and heart
disease, putting her at risk for development of getting either of these diseases. She does not fall
into a vulnerable population group because she has stable employment, has medical insurance
benefits, and lives in a middle-class neighborhood.
Gene is a 51-year-old African American male with a family history of heart disease. Gene lives
in a neighborhood that falls well below the poverty line and works two jobs but still cannot afford
to pay for medical insurance. His social determinants of health (SDOH), along with his ethnicity,
make him part of a vulnerable population group; his ethnicity and family history also place him in
the at risk category.
Vulnerable Populations
Vulnerable populations are groups of people who require special attention related to well-being
and safety, including persons who cannot advocate for their own needs such as children,
prisoners, and the cognitively, emotionally, and physically impaired. Persons who fall into the
vulnerable category often have SDOH that contribute to such vulnerability such as poverty,
ethnic minorities, sexual preference, and insurance status (Waisel, 2013). The PHN will work
with a wide range of populations, including those who fall under this description. PHNs must
exhibit excellent cultural competency skills in working within these population groups as well as
take into consideration the various barriers to health promotion these persons will face. There
are many populations that continue to grow due to global factors. It is essential that the PHN
become familiar with such populations in order to provide individualized care.
Refugee and Immigrant Population
In recent years, there has been an increase in the refugee and immigrant population seen in
America and other countries worldwide (World Health Organization, n.d.). Refugees and
immigrants can be defined as vulnerable populations because they are often in an unknown
environment with little understanding of the new culture, resources, or language and will likely
require a host of support in order to acclimate to their new environments. PHNs must address
their needs with compassion and patience and advocate for their needs to the best of their
ability. This includes accounting for language barriers, lack of insurance, and provision of
resources such as clothing, food and water, and possibly housing needs.
Impoverished Population
A portion of the population within the United States continues to live below the poverty line.
Statistics indicate that 12.7% of the population, or approximately 40.6 million people, live in
poverty (Semega, Fontenot, & Kollar, 2017). The impoverished are those who cannot financially
provide the basic necessities of life such as food, clothing, and shelter; as such, they are
considered a vulnerable population (CDC, 2018c). The PHN must assist these individuals in
accessing health care and treatment, as well as resources to provide basics such as food,
water, and clothing. The PHN does so by collaborating with case management and social work
within all health care settings. Once these immediate needs are met, the nurse can focus
attention on health promotion education, but must also consider barriers to learning, such as
health literacy, reading level, motivation, and inability to participate in follow-up care.

Lesbian/Gay/Bisexual/Transgender/Questioning Population
The lesbian/gay/bisexual/transgender/questioning (LGBTQ) population requires the support and
attention of the health care community. Their vulnerability stems from the adversity and
discrimination they may face when seeking necessary medical services, as well as certain
disease processes that may be more prominent in the LGBTQ population group. The LGBTQ
may have a higher rate of diseases such as human immunodeficiency virus (HIV) and
autoimmune immunodeficiency syndrome (AIDS) which require special medical attention and
lifelong treatment (HIV.gov, 2017). Screenings, education regarding safe sex practices, access
to safe-sex methods, and prompt treatment in the event of a diagnosis should be key in caring
for members of this population. The PHN has a duty to support and fully advocate for the needs
of persons within this community and provide resources whenever necessary.
Uninsured and Underinsured
With the changes in the economy and the fluctuating unemployment rate, the number of
Americans without health insurance remains a huge concern. After the Affordable Care Act
(ACA) was enacted, many Americans were able to obtain health insurance. In fact, rates of
uninsured persons in the United States fell from 44 million in 2013 to 28 million by the end of
2016 (Henry J. Kaiser Family Foundation, 2017).
Individuals who do not have insurance are vulnerable because they often do not advocate for
their health care needs because of fear of cost or no access to resources. The PHN can help
provide information regarding low cost or free health clinics as well as free health screenings.
The PHN can also work with the health care team to help find resources to for the individual to
obtain health insurance or additional insurance coverage if possible.
Free care clinics are available in most cities and towns across the country. Some are run by
local or county governments and others are nonprofit organizations that offer low cost or free
services to the underserved, underinsured, or uninsured populations of their communities.
These facilities offer free medical, dental, and mental health care to patients free of charge. The
PHN can help locate clinics and coordinate care for patients who are in need of care from these
facilities. In addition, many PHNs may work at such facilities, either in a leadership or clinical
role providing nursing care and education to patients and mentoring and supporting colleagues
(Kamimura, Christensen, Tabler, Ashby, & Olson, 2013).
Barriers to Health Promotion
Intervention Programs
Strategies must be developed to help reduce and eliminate the various barriers to health
promotion amongst vulnerable populations to ensure patients from these groups achieve
optimal health. As patient advocates, the primary goal for the PHN is to help discover the
patients’ or communities’ needs and work to meet those needs and provide necessary
resources with the interdisciplinary team. A number of programs exist to aid in reducing risks
associated with vulnerable population groups. These include Medicaid, affordable housing,

welfare, and food stamps, now known as Supplemental Nutrition Assistance Program (SNAP).
Often, providing the basic living necessities is required before incorporation of health promotion
education or information can be provided.
The primary objective for the PHN is to help develop and incorporate health promotion
programs that foster healthy living choices. These programs are largely based upon clinical
practice guidelines (CPGs), which are statements based on evidence-based practice (EBP) to
help guide health care providers in making educated patient care decisions (Politi, Wolin &
Légaré, 2013). With regard to health promotion, many CPGs are being incorporated with the
use of shared decision making (SDM) in which the patient is included in the discussion and is
able to make an informed and educated decision about his or her own health. Following this
discussion, the provider is able to recommend choices based on the latest CPGs to optimize the
patient’s health care outcomes.
SDM Example
The PHN is assessing the needs of a new client who was recently diagnosed with high
cholesterol. The client expresses concerns about the complications of high cholesterol and
wants to know the best course of action to take but is nervous about medication therapy. The
PHN takes these concerns into consideration when discussing the client’s options with him and
allows the client to determine the best course of action that fits his needs and his life.
Health Promotion and Health
Protection Education Programs
Community Programs
There are many programs throughout varying communities aimed at health promotion. The PHN
is involved in development and implementation of such programs after assessment occurs. The
following overview illustrates several types of programs that might be seen within communities.
Family Programs
Family programs involve providing health promotion information and guidance regarding daily
life. Subjects of importance may include infant care, breastfeeding support, weight management
tips, healthy eating classes, and support groups, including coping with a new diagnoses or grief
support. Often, these types of classes are offered by local hospitals (Banner Health, n.d.). There
are also many programs that emphasize the importance of increasing physical activity and offer
low-cost sports and recreational activities. Community centers offer a wide variety of fitness
classes for all ages and levels, including group sports teams and family sports events (City of
Phoenix, n.d.).

School Programs
School-based programs are perhaps the most widely known of and acknowledged community
health programs. They have a dramatic effect on promoting healthy lifestyle choices from an
early age and target hot-button topics such as drugs and alcohol, bullying, nutrition and
exercise, and sex education. The role of school nurses in providing such education is
invaluable, and the PHN can be instrumental in providing education to school workers about
how to promote health in children (National Association of School Nurses, 2018). Since the
1980s, the Centers for Disease Control and Prevention (CDC) has helped coordinate improved
school programs using the Whole School, Whole Community, Whole Child (WSCC) model. This
model focuses on four important elements for school safety: social and emotional climate,
physical environment, community involvement, and family engagement (CDC, 2015c). One
program called “Bam! Body and Mind” is a collection of virtual information accessed on the CDC
website that offers advice on food and nutrition, physical activity, and safety. The website also
offers educational games and information that helps teachers to incorporate the program into
their curriculum (CDC, 2018a).
Workplace Programs
Workplace health promotion programs have gained more momentum in recent years. This has
occurred as a result of the shift in the focus of health care from treating disease to health
promotion. Both the employer and employee have many benefits associated with participation in
such programs. Benefits noted have been fewer missed days from work, decreased use of
medical insurance and disability benefits, increased productivity, and a decrease in turnover
rates (Black, 2017).
Workplace Health Promotion Example
L.L. Bean, Inc. developed a wellness program for their employees, called The Healthy Bean,
that integrates wellness benefits, such as free onsite fitness centers and discounts to offsite
fitness centers, instituting tobacco-free workplaces, and offering incentives for employee
participation in health risk appraisals (L.L. Bean, n.d.). Many employers have followed suit with
this growing trend, offering similar wellness programs that promote healthy lifestyles and habits.
Faith-Based Programs
Faith-based community programs are essential to promoting the spiritual aspect of health, which
is an important component to many populations who value spirituality and religion. In addition to
focusing attention on the physiological, faith-based nursing drives attention to the spiritual needs
of the individual, which is an important aspect in providing holistic nursing care to the individual
and community. Perhaps the most widely recognized faith-based programs may be hospital
facilities that were founded by denominations of the Christian faith such as Catholic, Lutheran,
Baptist, and Methodist. Medical care provided at a secular versus faith-based facility is largely
the same. Both offer spiritual care and chaplain services to patients and provide holistic medical
and nursing care. Faith-based institutions are based on the concepts of religious leaders, such

as Jesus Christ and his teachings of service to others and compassion and caring for all people
(Levin, 2016). Also of note is the White House Office of Faith Based Community Initiatives
(OFBCI), which developed an initiative during the Obama administration to assist with the
President’s Emergency Plan for AIDS Relief (PEPFAR) (Levin, 2014).
Hospital Programs
Hospitals are partners with various establishments within the community. They work together
with businesses, schools, senior centers, and organizations to provide health promotion
programs and resources to individuals within the community. Nonprofit hospitals are required to
provide community benefits, such as free or low-cost classes and seminars on common issues
including household safety, first-aid training, infant care, breastfeeding support, and car seat
safety. Many hospitals also provide online resources and education through their websites.
Nonprofit hospitals also perform a community health needs assessment every few years in
order to maintain their nonprofit status (CDC, 2015b).
Military Programs
Members of the military and their families require special attention and care as they often face
multiple stressors related to frequent life changes. The United Service Organizations (USO)
partnered with the White House under the Obama administration to form Joining Forces, which
aims to provide support for members of the military and their families (The White House:
President Barack Obama, n.d.). Joining Forces offered programs that provide education for
expectant mothers regarding healthy pregnancy and infant care, couples seminars, children’s
comfort group, employment resources, and access to health and wellness services (The White
House: President Barack Obama, n.d.). The USO is a nonprofit organization that has supported
members or the military for nearly 80 years (United Service Organization [USO], n.d.). The USO
offers a number of support programs including those for families of loved ones who are currently
serving, those who have lost loved ones in the military, and couples (USO, n.d.). These
programs require careful evaluation for their effectiveness once they have been instituted. It is
essential for the PHN to understand that these types of resources are available to patients who
may require such services.
Community/Public Health
Assessment
Just as the community as a whole requires assessments and needs planning, so to do the
families and individuals within the communities that PHNs work. Social, environmental, and
cultural needs must be addressed within this process as well. The process in community health
demands a focus on health risks. There are many assessment tools utilized to assist in this
process, such as the health risk appraisal, lifestyle assessment, and stress risk assessment.

Health Risk Appraisal
The PHN utilizes the health risk appraisal (HRA) to determine an individual’s health threats
based on demographic, behavioral, and personal characteristics. The HRA is a questionnaire
that gathers data on basics such as age, gender, ethnic background, history of disease, and
current lifestyle practices. Physical measurements such as height, weight, blood pressure, and
heart rate are taken. An individual’s personal results are then compared against national
averages of persons with similar characteristics in order to determine the level of risk for certain
diseases. The goal is to provide this information to the individual and assist the person in
developing a plan of action to help decrease these risks through lifestyle modification (Goetzel,
et al., 2011).
Lifestyle Assessment
Lifestyle assessment (LA) focuses on controllable lifestyle behaviors that are contributing to
overall health status. This may include diet, exercise level, smoking, illicit drug use, drinking
alcohol, or any other risk-taking behavior. During the assessment process, which involves
asking lifestyle questions, the PHN provides information regarding recommended lifestyle
changes and choices, immunization schedules, screening tests for common diseases, proper
nutrition, and increasing physical activity.
Stress Risk Assessment
The stress risk assessment (SRA) is utilized to evaluate the effect of major life stressors on an
individual’s overall health. The Social Readjustment Rating Scale (SRRS) is used to help
determine these effects with a series of questions related to stressful events such as a death in
the family, marriage or divorce, or changes in career. Each item receives an associated point
value and they are then tallied. The higher the number, the higher the risk for developing an
illness (see Table 3.5). The PHN assists in developing a plan and provides resources for the
individual to cope with these stressors and address physiologic symptoms associated with
stress.
Table 3.5
Social Readjustment Rating Scale
Life Event Change Units
Death of a Spouse 100
Divorce 73
Marital Separation 65

Note. A total of more than 150 points indicates an increased probability of an illness. Adapted from
“Social Readjustment Rating Scale (SRRS),” by S. McLeod, 2010, Simply Psychology. Copyright
2010 by Simply Psychology.
Health Teaching in Community
Health
Baccalaureate-prepared nurses are inundated with critical-thinking skills that broaden their
capabilities to care for their patients in more in-depth ways. Learning details of patient
education is one element that is crucial to this process. Patients’ education needs will vary
based on multiple factors, and education level, language barriers, socioeconomic status,
Death of a Close Family Member 63
Personal Injury or Illness 53
Marriage 50
Fired at Work 47
Marital Reconciliation 45
Retirement 45
Pregnancy 40
Death of a Close Friend 37
Change in Line of Work 36
Foreclosure 30
Change in Responsibilities at Work 29

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disability, and interest all affect the patient’s capability to receive information provided. This
chapter focuses on health teaching and its role in health promotion and disease prevention in
the community setting rather than the details of patient education in the acute care setting. The
assessment process and tools discussed for these purposes are applicable to the individual
patient as well as the community when dealing with groups of learners as an audience.
Patient education often occurs during an acute hospital stay or upon discharge. For instance,
the RN may educate the newly diagnosed diabetic patient on how to properly monitor his or her
blood sugars at home when the patient is discharged; however, health teaching begins long
before the acute event occurs. For example, the nurse provides health teaching regarding the
importance and preventative benefits that regular cardiovascular exercise has on heart health
on a long-term basis. The purpose of health teaching is health promotion and disease
prevention. The intent is to help individuals make healthy choices in their everyday lives to
prevent an acute hospitalization related to disease.
The Adult Learner
In order to maximize the learner’s comprehension of delivered content, it is essential that the
PHN become familiar with the concept of adult learning styles or andragogy. In 1980, Malcolm
Knowles, a prominent educator, developed the theory of andragogy, which encompasses the
idea that adults have their own individualized needs as learners (Pappas, 2013). There are four
prominent principles that embody the generalized needs of adult learners:
1. Adults desire involvement in their education plan.
2. Adults base their current learning process on past learning experiences.
3. Adults relate given teaching concepts to things that are relevant to their lives.
4. Adults base their learning on finding a solution to a current problem.
Collaboration with the educator and the need to be respected are critical to the learning process
for adults. Adults desire validation of knowledge they have already gained from past
experiences in order to be open to accepting new information. In addition to the individual’s
learning needs, the nurse instructor must also be aware of the collective community’s learning
needs.
Learner Assessment
The learner must have a certain degree of emotional readiness in order to be open to any kind
of instruction. This means the learner must have a motivation or willingness to learn new
concepts or skills. Experiential readiness is based on the learners’ background, skill, and
ability to learn (Ohio State University, 2007). This also includes cultural needs and barriers the
learner may possess. Assessment of each of these involves the nurse instructor asking a series
of open-ended questions to evaluate the learner’s attitudes and readiness toward the education
process (see Table 3.6).
Table 3.6
Learner Assessment

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Note. Adapted from Nurse as Educator: Principles of Teaching and Learning for Nursing Practice,
3rd edition, by S. Bastable, 2014. Copyright 2014 by Jones and Bartlett Publishers.
Health Literacy
Health literacy is the level at which an individual can accept, process, and comprehend basic
health information. As nurses identify needs and create health promotion programs or plans of
care, they must take into consideration the identified audience’s capability to understand the
information being provided to them (Johnson, 2015). Programs and plans of care must be
catered to the specific health literacy needs of the given population. The nurse must not assume
the audience or individual will understand the concepts presented and must provide time for the
audience to ask questions and have all inquiries thoroughly addressed.
Every learner has barriers they must overcome in order to comprehend information being
taught. The nurse instructor must also learn to assess for such barriers. Obvious physical
Readiness Level Example Questions Rationale
Emotional Readiness ● What do you do in your
everyday life to keep
healthy?
● What makes being
healthy difficult for you?
● What would you like to
learn more about?
● Assess attitudes about
health promotion
● Assess barriers or
stressors
● Assess for promotion
priorities
Experiential Readiness
● Background
● Skills
● Ability
Background
● Tell me about yourself,
your family, your
culture.
Skills
● How would you
describe your ability to
learn a new skill?
Ability
● How does outside
influence, such as
sound or people, affect
your ability to
concentrate?
Background
● Obtain information
regarding familial and
cultural influence on
health
Skill
● Assess learners
self-perception of
capability to learn
Ability
● Assess for educational
environment needs

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barriers such as poor vision may require the use of a larger font on learning materials or audio
or video media. Emotional barriers may be more difficult to address and may require a great
amount of patience to allow the learner to feel comfortable with the instructor. Cultural or
language barriers may require the nurse instructor to utilize official interpretive services or, in
some instances, only speak to the patriarch or matriarch of the learner’s family.
Nurse instructors must be aware of health literacy barriers and modify the way in which they
educate their patients to accommodate their needs (AHRQ, 2016). The “teach back” method is
a widely used and trusted way to ensure comprehension. In addition to health literacy, low
literacy is also a barrier that must be assessed and addressed. Several assessment tools are
available to gather information regarding patients’ literacy levels, which helps determine
appropriate learning materials for patients. Tests such as the Rapid Estimate of Adult Literacy in
Medicine Short Form (REALM-SF) and the SMOG readability test are commonly utilized for
evaluation of literacy levels (AHRQ, 2016). The SMOG readability test is a way to assess the
learning materials for grade-level reading and comprehension (see Table 3.7). The prospective
reading materials are reviewed by counting off 10 sentences in the beginning, middle, and end
of the text. The words are then given a number value depending on the number of syllables in
each word. The numbers are then added together to determine the approximate grade level of
the written material. The higher the number, the higher the reading level of the material (see
Table 3.7). Once the readability of the material is determined, nurse educators can evaluate
whether to use it or find alternatives that are more appropriate to the patient’s needs
(Readability Formulas, n.d.). If the patient is unable to read, there are other options to provide
education, such as pictures and video. As always, the nurse instructor must remain sensitive
when addressing these needs, as they may spark feelings of embarrassment and shame for the
patient. Once assessment is complete and the barriers are identified, the teaching process can
begin.
Table 3.7
SMOG Readability
Score Reading Level by Grade
≤ 6 Sixth Grade
7 Seventh Grade
8 Eighth Grade
9 High School Freshman

Note. Adapted from “Readability Tests,” by G. Gústafsdóttir, 2018. Copyright 2018 by Siteimprove.
Principles of Teaching
Teaching Techniques
Before teaching and learning can take place, aspects of physical environment, which includes
temperature of the room, ease of accessibility for the intended audience, lighting, and
appropriate seating, should be considered. The nurse instructor should also be aware of the
educational environment, which includes body language, eye contact, and participation of the
learner, to help learning occur. In order to teach effectively, it is important to become familiar
with different teaching methods. The nurse may have some notion of teaching basic topics, but
addressing large groups may require new ideas and recommendations (see Table 3.8). The
methods for which education can be provided are truly limitless and can be elaborated upon by
the instructor’s individual creativity. The key is to retain the learners’ attention and incorporate
their input and address questions when they arise.
Table 3.8
Teaching Methods
10 High School Sophomore
11 High School Junior
12 High School Senior
13 College Freshman
14 + College Sophomore
Method Advantages Disadvantages Examples
Audiovisual Visually stimulating;
highlights key
concepts
May require
equipment that is
inaccessible
Flip charts, DVDs,
PowerPoint
presentations,
projectors

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Note. Adapted from “Is the effectiveness of lecture related to teaching approach or content type?” by
J. Danielson, V. Preast, H. Bender, & L. Hassall, 2014, Computers and Education, 72, 121-131;
“What Is Your Teaching Style? 5 Effective Teaching Methods for Your Classroom,” by E. Gill, 2013;
“Teaching Strategies,” by George Mason University, n.d.
Objectives and Content Selection
Also crucial to the education process is the creation of applicable learning objectives that
guide the learner in understanding the take-away message. These objectives should guide the
nurse instructor as well, reminding the instructor of what the content’s focus should be.
Objectives should be direct and state what the learner should gain as a result of the education.
An example would be “The learner will describe the importance of practicing safe sex methods.”
Objectives also include the domains of learning: cognitive, affective, and psychomotor. This
means the objectives should encompass learning the new skill, acquiring the tools to apply the
skill in daily life, and finally incorporation of attitudes and feelings surrounding the new
knowledge and skill application. Evaluation and revision are essential to ensuring that optimum
benefits are achieved from instituted health teaching programs (Clark, 2015).
Evaluation
When evaluating the effectiveness of a new health education program, the program’s objectives
should be reviewed to see if the learners met them. When evaluating short-term outcomes, the
cognitive domain is assessed to determine whether learners understood the presented material.
Long-term evaluation is a bit more difficult because the nurse instructor often does not have
long-term access to the learner. Only the learner truly knows if, over time, he or she has
benefited from a health teaching program. The nurse instructor can observe for changes in the
community after a community outreach education program by gathering statistical data related
to the topic. For example, a lower rate of teenage pregnancy one year after presenting a
safe-sex practices program to the community.
In order for nurse instructors to improve their teaching style and related outcomes, it is
imperative that he or she is evaluated as well. The evaluation should be of the instructor, the
content being taught, and ways in which the content was provided. Feedback from the learners
as well as peers are good ways for nurse instructors to gain valuable insight into their
effectiveness on the intended audience.
Lecture Inexpensive;
instructor can
customize; appeals
to all learners
Passivity of learners;
lack of attention
Traditional lecture,
recorded lecture,
blogs
Group Discussion Learner/Instructor
interaction; learner
feedback
Not effective in very
large groups; some
learners may not
participate
Question and answer
sessions, discussion
following lecture

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Community Planning and
Intervention
A community can have many definitions; generally it is considered a group of people within an
open social system who share similar goals and live within a similar area. There are several
models used in community health that are used for community assessment. The process for
planning and intervening for communities varies from the process for individuals. PHNs are
instrumental in the process of planning for and intervening in communities in a number of ways.
Becoming familiarized with the steps of the process and various tools utilized in the process is
essential for the baccalaureate student.
Community Health Organizational Structure Models
PRECEDE/PROCEED Model
The PRECEDE/PROCEED model (see Figure 3.8), is used for community health assessments
and needs planning. The PRECEDE part of this model stands for:
● Predisposing,
● Reinforcing, and
● Enabling
● Causes in
● Educational
● Diagnosis and
● Evaluation.
The PRECEDE portion of this model is divided into phases. During the first phase, the
community health assessment is performed to determine the specific needs of the community.
During the second phase, the priority need is identified and achievable goals are developed that
aim to resolve or improve the identified problem. Factors are then examined that may be
contributing to the source of the problem, such as insufficient knowledge (predisposing factor) or
insufficient resources (enabling factor). The final phase of the PRECEDE portion of this model
involves determining best practice methods to help improve the problem and working with local
organizations to help determine any roadblocks to integrating the suggested changes
(Community Tool Box, n.d.b).
Once the need has been identified, the PROCEED part of this model helps to define the
implementation process. PROCEED stands for:
● Policy
● Regulatory and
● Organizational
● Constructs in
● Educational and
● Environmental

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● Development.
During this part of the process, the plan is implemented and then evaluated. Widely used within
public health, this model has been heavily relied upon as the best method for assessing,
identifying, and creating applicable plans of action that create change within the given
community (Tapley & Patel, 2016).
Figure 3.8
PRECEDE/PROCEED Model

Note. Adapted from Health Promotion Planning: An Education and Ecological Approach (4th ed.), by
L. Green & M. Kreuter, 2005. Copyright 2005 by Mayfield Publishers.
Community Partnership Model
Sometimes called the community as partner model, the community partnership model (CPM)
was founded at the University of Texas School of Nursing. This model is loosely based on
Neuman’s systems theory and focuses on the community as partner and the nursing process.
The model describes the community and its relation to eight subsystems that all affect and
relate to one another (see Figure 3.9). The PHN works within the community to help plan,
implement, and evaluate ways to reduce stressors and restore balance (McNicoll, 2017). For
example, if the patient has issues with safety and transportation, the nurse would work with the
interdisciplinary team and the patient to attain reliable transportation resources, such as a bus
pass. The nurse takes into consideration all elements that can affect the patient’s overall
wellness.
Figure 3.9
Community Partnership Model

Note. Adapted from Community as Partner: Theory and Practice in Nursing (5th ed.), by E. T.
Anderson & J. M. McFarlane, 2008. Copyright 2008 by Lippincott Williams & Wilkins.
Helvie Energy Framework Model
The Helvie model was developed by Carl Helvie after his many years working in public health as
an RN. Helvie defined the community itself as a constantly changing energy field that is
continually influenced by other energies within the community environment such as education
and economics (Sines, Fanning, & Potter, 2013). This framework is mainly used by advanced
practice nurses in community health. The PHN working in the advanced practice role uses this
model to develop and implement a plan to help bring a balance between all elements and
restore harmony within the community.

Epidemiology Framework Models: GENESIS and MAPP
There are two primary epidemiology framework models: general ethnographic and nursing
evaluation studies (GENESIS) and mobilization for action through planning and partnerships
(MAPP). GENESIS blends epidemiologic and ethnographic data in order to determine a
community’s health needs. The model assesses areas in the community such as economy,
education, employment, and environment.
MAPP is a tool used to develop plans to improve health and public health systems (National
Association of County & City Health Officials, n.d.). MAPP is largely considered a cyclical
process, as efforts to make improvements within communities will always continue (see Figure
3.10). MAPP begins much like other models with assessment of needs within a given
community, progressing to identification of the priority problem, formulation of goals, creation of
strategies to integrate change, implementation, and evaluation. The six steps of the MAPP
model include:
● Development—A committee is formed, and the process is planned.
● Visioning—The community and committee work together to form a cohesive vision of
community health.
● Assessment—Four in-depth community assessments are collected.
○ Community themes and strengths
○ Local public health systems assessment
○ Community health status assessment
○ Forces of change assessment
● Strategic Issues—Data is examined and key issues are determined.
● Goals/Strategies—A plan of action to address key issue or issues is formed
● Action Cycle—Planning, implementation, and evaluation of action plan is planned,
implemented, and evaluated (Community Tool Box, n.d.d)
Figure 3.10
MAPP

Note. Adapted from “Section 13. MAPP: Mobilizing for action through planning and partnerships” by
Community Tool Box. Copyright 2018 Community Tool Box.
Examples of Planning Initiatives
Partnerships to Improve Community Health (PICH)
Partnerships to Improve Community Health (PICH) is a 3-year initiative developed by the CDC
that aims to implement best practice methods to reduce the prevalence of chronic illnesses
within various communities across the United States (CDC, 2018b). In 2014, 39 communities,
including large cities and Native American tribes, were awarded sums of money to be disbursed
over a 3-year period to assist with the coordination of programs that targeted specific problems
such as tobacco use, poor nutrition, physical inactivity, and health promotion. PHNs within these

communities assist with the development and incorporation of programs that target these topics
in order to create improvements in the given population’s health overall (CDC, 2018b)
Community Health Improvement Plans (CHIP)
Community health improvement plan (CHIP) was developed by the Institute of Medicine (IOM)
as a framework for guiding the process of community improvements. This planning and
implementation occurs after the community health assessment has been performed. Similar to
other models described, a CHIP begins with identification of the problem, followed by the
formulation of a feasible plan of action that will create change, implementation of the plan, and
evaluation for efficacy; this process may start over again if necessary (see Figure 3.11). The
CHIP model necessitates the involvement of all key stakeholders, including the community
members who are directly affected by the identified problem. For instance, victims of domestic
abuse should be involved in the planning process to develop a plan to advocate for and support
abused women. As with many other models described, the priority issue is identified, community
members are identified for collaboration, the team and community members analyze the issue,
a plan of action is formulated and implemented, and the outcomes are monitored (Community
Tool Box, n.d.c).
Figure 3.11
CHIP Model

Note. Adapted from Improving Health in the Community , by J. S. Durch, L. A. Bailey, and M. A. Stoto
(Eds.), 1997. Copyright 1997 by the National Academy Press.
Racial and Ethnic Approaches to Community Health (REACH)

Racial and Ethnic Approaches to Community Health (REACH) is a national program
administered by the CDC that specifically aims to reduce health disparities among racial and
ethnic minorities. Much like PICH, communities are awarded funding to support health concerns
of tobacco use, physical inactivity, poor nutrition, and health promotion; however, the REACH
program awards funding to ethnic and racial minority populations. Funding is intended to create
evidence-based programs that directly target these primary health concerns within these
communities. PHNs participate in this process by helping to incorporate programs that target
these specific health concerns once funding is allocated to these communities (CDC, 2017).
Community Health Toolbox (CHT)
The Community Health Toolbox (CHT) is a free online resource developed by the University of
Kansas. This resource, utilized both locally and globally by professionals as well as the public,
offers hundreds of modules and various tools related to public health in three languages. The
online resource offers tools on assessing, planning, and implementing community action plans
and 46 chapters related to community building skills. PHNs, students, and other members of the
interdisciplinary and public health team can use this resource to locate tools and learn details of
how to apply assessment plans to communities (Community Tool Box, n.d.a).
Role of PHNs in Community Health Planning
While each model for assessment planning will present itself with different steps, the process is
similar to the nursing process because it requires careful assessment, diagnosis of the problem,
planning, implementation of the plan, and evaluation. Typically, the community assessment
process involves some more detailed steps such as collection and analyzation of data specific
to the presenting issue. For instance, data related to teen drug use in a given community would
be collected over a period of time. This process is often conducted by PHNs who are familiar
with the community and its residents. Once data is collected and presented, the problem can be
clearly identified and goals can be set that focus on improving the problem. Once again, PHNs
assist with this process as they often have a clear picture of the community’s issues and work
directly with the population. Effective strategies can be developed utilizing the PHNs advice and
other key stakeholders input. Finally, once the plan is instituted, it must be monitored for
progress and success or failure rates, which can be a task allocated to PHNs as well (Catholic
Health Association of the United States, 2013).
Scope and Standards for Public Health Nurses
The American Nurses Association (ANA) Scope and Standards for Public Health Nurses
specifies the roles and obligations of the public health nurse (see Table 3.9). The American
Public Health Association (APHA) defines public health nursing as, “the practice of promoting
and protecting the health of populations using knowledge from nursing, social and public health
sciences,” (American Public Health Association, 2013, p. 2). The process for public health
nurses contains similar steps to the standard nursing process with some particular differences
such as diagnosis. Typically, nurses do not diagnose; however, in public health nursing, this is a
crucial step in creating necessary change within communities (American Nurses Association
[ANA], 2013). In addition, the Quad Council Coalition of Public Health Nursing Organizations

(QCC) also developed a series of competencies that are specific to the PHN and the varying
roles. The QCC competencies are divided into three tiers, with the first being for the majority of
public health nurses who work hands on with members of the community (see Table 3.10).
Table 3.9
ANA Standards of Practice for Public Health Nursing
Note. Adapted from Public Health Nursing: Scope and Standards of Practice (2nd ed.), by the
American Nurses Association, 2013. Copyright 2013 by the American Nurses Association.
Table 3.10
PHN Tiered Competencies
Standard 1 Assessment The public health nurse collects data related to the health
of the given population.
Standard 2 Population
Diagnosis
The public health nurse analyzes collected data to
determine health priorities
Standard 3 Outcome
Identification
The public health nurse determines expected outcomes
based on priorities
Standard 4 Planning The public health nurse assists with development of plan
of action that will achieve expected outcomes
Standard 5 Implementation 1. Coordination: coordinating the implementation of
the plan.
2. Health Education and Promotion: involvement in the
education process
3. Consultation: community groups consulted to
facilitate the incorporation of the plan.
4. Regulatory Activities: assists in making public health
regulation changes as needed.
Standard 6 Evaluation The public health nurse evaluates the population for
effectiveness of implemented plan
Tier Competencies

Note. Adapted from “Quad Council Competencies for Public Health Nurses,” by Association of
Community Health Nursing Educators, 2011. Copyright 2011 by the Association of Community
Health Nursing Educators.
Reflective Summary
The public health nurse’s role continues to be of great importance in addressing the varying
needs of communities as well as individuals across the United States. Cultural competence and
obtaining the skills and tools necessary to provide such care is essential to all nurses no matter
their area of expertise. Health promotion will continue to be the primary focus in providing
optimal care for patients, with nurses being the primary proponent in developing and providing
programs and individual education on varying topics. As emerging populations change and
grow, it is vital to remain aware of their ever changing needs and advocate for individualized
care whenever possible. Education and community base programs will continue to improve
when they are based on EBP and the latest research.
Key Terms
Affective Domain: Feelings and emotions associated with the learning process.
Andragogy: Theory encompassing the idea that adults have their own individualized needs as
learners.
Bias: External and internal influences within a study that can affect the validity and reliability of
the outcomes.
Cognitive Domain: The acquisition and dissemination of knowledge.
Community Health: Health care focused on improving the health of individuals within a given
community.
Tier 1 Competencies apply to the day to day functioning of the generalist nurse
in the public health setting.
Tier 2 Competencies apply to the PHN that is in a management or supervisory
role, assists in implementation of public health programs.
Tier 3 Competencies apply to the PHN in executive or senior management roles.
These PHNs are responsible for administration, organization and
operation of public health programs.

Community: A group of people within an open social system who share similar goals and live
within a similar area.
Cultural Awareness: Being knowledgeable about one’s own thoughts, feelings, and
sensations, as well as the ability to reflect on how these can affect interactions with others.
Cultural Brokering: Using cultural and health science knowledge to help formulate a culturally
sensitive plan of care.
Cultural Competence: To be respectful and responsive to the health beliefs and practices as
well as cultural and linguistic needs of diverse population groups.
Cultural Desire: Inner motivation to become culturally competent.
Cultural Dissonance: Sense of discomfort caregivers may experience when an individual or
population has cultural differences that may be considered difficult to accept.
Cultural Encounters: Interactions between RN and culturally diverse patients.
Cultural Knowledge: Seeking out information and education regarding different cultures.
Cultural Pluralism: The coexistence of multiple cultures within a population.
Cultural Preservation: The ability of the nurse to uphold and respect cultural values and
practices.
Cultural Repatterning: The sensitive education regarding a practice that may cause harm.
Cultural Skill: The process of utilizing assessment techniques to obtain valuable cultural data.
Culture: Traditional beliefs and values shared among a common group of people.
Emotional Readiness: Motivation or willingness to learn new concepts or skills.
Experiential Readiness: The learners’ background, skill, and ability to learn.
Health Literacy: The level at which an individual can accept, process, and comprehend basic
health information.
Health Promotion: Educating people about healthy lifestyles, reduction of risk, developmental
needs, activities of daily living and preventive self-care that enables them to improve their health
by making positive decisions.
Health Teaching: Begins before the onset of disease; the purpose of which is health promotion
and disease prevention.
Implicit Bias: The unconscious attitude displayed based on stereotypes that directly affect
understanding, decisions, and actions that may impact patient care.
Learning Objectives: Goals explaining what the learner is expected to understand and take
away from the learning experience.
Learning Styles: Individualized way of learning based on different personality characteristics.

Patient Education: Individualized and structured process to provide pertinent information to
patients regarding their specific plan of care.
Psychomotor Domain: Application of the learned skill.
Public Health: The practice of protecting and promoting quality of life of persons and
communities through the use of science, research, and direct care to prevent disease
outbreaks, environmental hazards, injuries, and poor health.
Stereotype: A preconceived notion of who a person is based on factors such as race, gender,
weight, and socioeconomic status.
Subculture: Group that falls under the umbrella of a larger culture group, but has its own set of
values and beliefs.
Teaching Methods: Ways of providing educational information to the intended audience
(visual, audio visual, lecture).
Values: The beliefs that serve as standards that ultimately influence behavior and thought
processes within the cultural group.
Vulnerable Populations: People who require special attention related to well-being and safety,
including persons who cannot advocate for their own needs such as children, prisoners, and
cognitively impaired.
References
Agency for Healthcare Research and Quality. (2013). Planning culturally and linguistically
appropriate services. Retrieved from
https://www.ahrq.gov/professionals/systems/primary-care/cultural-competence-mco/plancla
s.html
Agency for Healthcare Research and Quality. (2016). Health literacy measurement tools
(revised). Retrieved from
http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy/inde
x.html
American Nurses Association. (2013). Public health nursing: Scope and standards of practice
(2nd ed.). Retrieved from
https://www.nursingworld.org/~4adc06/globalassets/catalog/book-toc/public-health-nursing-
scp–stds-2e_toc
American Pregnancy Association. (2016). Fertility awareness: Natural family planning (NFP).
Retrieved from http://americanpregnancy.org/preventing-pregnancy/natural-family-planning/
American Public Health Association. (2013). The definition and practice of public health nursing:
A statement of the public health nursing section. Washington, DC: American Public Health
Association. Retrieved from
https://www.apha.org/~/media/files/pdf/membergroups/phn/nursingdefinition.ashx
Andrews, M. M., & Boyle, J. S. (2016). Transcultural concepts in nursing care (pp. B1-B3).
Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.

Banner Health. (n.d.) Classes, support groups and events. Retrieved from
https://www.bannerhealth.com/calendar
Black, A. (2017). Five reasons employee wellness is worth the investment. Retrieved from
https://health.gov/news/blog-bayw/2017/05/five-reasons-employee-wellness-is-worth-the-in
vestment/
Bronheim, S. (2011). Promising practices: Cultural brokers help families and providers bridge
the cultural gap. Retrieved from
https://nccc.georgetown.edu/documents/NCCC_PP_Cultural%20Brokers
Campinha-Bacote, J. (2011). Delivering patient-centered care in the midst of a cultural conflict:
the role of cultural competence. OJIN: The Online Journal of Issues in Nursing, 16(2). doi:
10.3912/OJIN.Vol16No02Man05
Catholic Health Association of the United States. (2013). Assessing and addressing community
health needs. Retrieved from
https://www.chausa.org/docs/default-source/general-files/cb_assessingaddressing-pdf ?
sfvrsn=4
Centers for Disease Control and Prevention. (2015a). Colorectal cancer control program
(CRCCP): Social ecological model. Retrieved from
https://www.cdc.gov/cancer/crccp/sem.htm
Centers for Disease Control and Prevention. (2015b). Community health assessments and
health improvement plans. Retrieved from
https://www.cdc.gov/stltpublichealth/cha/plan.html
Centers for Disease Control and Prevention. (2015c). Expanding the coordinated school health
approach. Retrieved from https://www.cdc.gov/healthyschools/wscc/approach.htm
Centers for Disease Control and Prevention. (2017). Racial and ethnic approaches to
community health. Retrieved from
https://www.cdc.gov/nccdphp/dnpao/state-local-programs/reach/index.htm
Centers for Disease Control and Prevention. (2018a) Bam! Body and mind. Retrieved from
https://www.cdc.gov/bam/index.html
Centers for Disease Control and Prevention. (2018b). Partnerships to improve community
health. Retrieved from
https://www.cdc.gov/nccdphp/dch/programs/partnershipstoimprovecommunityhealth/index.h
tml
Centers for Disease Control and Prevention. (2018c). Social determinants of health: Know what
affects health. Retrieved from https://www.cdc.gov/socialdeterminants/
City of Phoenix. (n.d.). Classes and programs. Retrieved from
https://www.phoenix.gov/parks/classes-and-programs
Clark, D. R. (2015).Bloom’s taxonomy of learning domains. Retrieved from
http://www.nwlink.com/~donclark/hrd/bloom.html
Community Tool Box. (n.d.a). Home. Retrieved from https://ctb.ku.edu/en
Community Tool Box. (n.d.b) Section 2: PRECEDE/PROCEED. Retrieved from
http://ctb.ku.edu/en/table-contents/overview/other-models-promoting-community-health-and
-development/preceder-proceder/main
Community Tool Box. (n.d.c). Section 6. The Institute of Medicine’s community health
improvement process (CHIP). Retrieved from

https://ctb.ku.edu/en/table-of-contents/overview/models-for-community-health-and-develop
ment/chip/main
Community Tool Box. (n.d.d). Section 13. MAPP: Mobilizing for action through planning and
partnerships. Retrieved from
https://ctb.ku.edu/en/table-of-contents/overview/models-for-community-health-and-develop
ment/mapp/examples
Cummings, S., Bridgman, T., & Brown, K. G. (2015). Unfreezing change as three steps:
Rethinking Kurt Lewin’s legacy for change management. Human Relations, 69(1), 33-60.
doi:10.1177/0018726715577707
FitzGerald, C., & Hurst, S. (2017). Implicit bias in healthcare professionals: a systematic review.
BMC Medical Ethics, 18(19). doi: 10.1186/s12910-017-0179-8.
Goetzel, R. Z.; Staley, P.; Ogden, L.; Stange, P.; Fox, J.; Spangler, J.; Tabrizi, M.; Beckowski,
M. …Taylor, M. V. (2011). A framework for patient-centered health risk
assessments-providing health promotion and disease prevention services to Medicare
beneficiaries. Atlanta, GA: U.S. Department of Health and Human Services, Centers for
Disease Control and Prevention. Retrieved from
https://www.cdc.gov/policy/hst/HRA/FrameworkForHRA
Henry J. Kaiser Family Foundation. (2017). Key facts about the uninsured population. Retrieved
from https://www.kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population/
HIV.gov. (2017). What are HIV and AIDS? Retrieved from
https://www.hiv.gov/hiv-basics/overview/about-hiv-and-aids/what-are-hiv-and-aids
Huber, L. M. (2009). Making community health care culturally correct. American Nurse Today
4(5). Retrieved from
https://www.americannursetoday.com/making-community-health-care-culturally-correct/
Johnson, A. (2015). Health literacy: how nurses can make a difference. Australian Journal of
Advanced Nursing, 33(2), 20-27.
Kamimura, A., Christensen, N., Tabler, J., Ashby, J., & Olson, L. (2013). Patients utilizing a free
clinic: physical and mental health, health literacy, and social support. Journal of Community
Health, 38(4), 716-723. doi:10.1007/s10900-013-9669-x.
Khodaveisi, M., Omidi, A., Farokhi, S., & Soltanian, A. R. (2017). The effect of Pender’s health
promotion model in improving the nutritional behavior of overweight and obese women.
International Journal of Community Based Nursing and Midwifery, 5(2), 165–174.
L.L. Bean. (n.d.). Winning programs: L.L. Bean, Inc. (2012). Retrieved from

L.L. Bean, Inc. (2012)

LaMorte, W. W. (2016a). The social cognitive theory. Retrieved from
http://sphweb.bumc.bu.edu/otlt/MPH-Modules/SB/BehavioralChangeTheories/BehavioralCh
angeTheories5.html
LaMorte, W. W. (2016b). The health belief model. Retrieved from
http://sphweb.bumc.bu.edu/otlt/MPH-Modules/SB/BehavioralChangeTheories/BehavioralCh
angeTheories2.html
Levin, J. (2014). Faith-based partnerships for population health: Challenges, initiatives, and
prospects. Public Health Reports, 129(2), 127–131.

Levin, J. (2016). Partnerships between the faith-based and medical sectors: Implications for
preventive medicine and public health. Preventive Medicine Reports, 4, 344–350. doi:
10.1016/j.pmedr.2016.07.009
McNicoll, L. (2017). Geriatric co-management as a service line: Spreading co-management
within an institution. Innovation in Aging, 1(1), 612. doi: 10.1093/geroni/igx004.2147
National Association of County & City Health Officials. (n.d.). Mobilizing for action through
planning and partnerships (MAPP). Retrieved from
https://www.naccho.org/programs/public-health-infrastructure/performance-improvement/co
mmunity-health-assessment/mapp
National Association of School Nurses. (2018). Healthy communities – The role of the school
nurse. Retrieved from
https://www.nasn.org/advocacy/professional-practice-documents/position-statements/ps-he
althy-communities
Ohio State University. (2007). Getting your message across: Clear and effective health
communication. Retrieved from
https://medicine.osu.edu/sitetool/sites/pdfs/ahecpublic/HL_Get_the_Message
Pappas, C. (2013). The adult learning theory-andragogy of Malcolm Knowles. Retrieved from
https://elearningindustry.com/the-adult-learning-theory-andragogy-of-malcolm-knowles
Politi, M., Wolin, K., & Légaré, F. (2013). Implementing clinical practice guidelines about health
promotion and disease prevention through shared decision making. Journal of General
Internal Medicine, 28(6), 838-844.
Pro-Change Behavior Systems, Inc. (n.d.). The transtheoretical model. Retrieved from

Transtheoretical Model of Behavior Change

Readability Formulas. (n.d.). The SMOG readability formula, a simple measure of
gobbledygook. Retrieved from
http://www.readabilityformulas.com/smog-readability-formula.php
Semega, J. L., Fontenot, K. R., & Kollar, M. A. (2017). Income and poverty in the United States:
2016. Washington, DC: U.S. Census Bureau. Retrieved from
https://www.census.gov/library/publications/2017/demo/p60-259.html.
Shoultz, J., Kooker, B. M., Sloat, A. R., & Hatcher, P. A. (2003). Four ways to teach phc in a
changing world. International Nursing Review, 45(6), 187–191.
doi:10.1046/j.1466-7657.45.no.6issue342.8.x
Sincero, S. M. (2012). Ecological systems theory. Retrieved from
https://explorable.com/ecological-systems-theory
Sines, D., Fanning, A., & Potter, K. (Eds.). (2013). Community and public health nursing (5th
ed.). Sussex, UK: John Wiley & Sons, Ltd.
Stanhope, M., & Lancaster, J. (2014). Foundations of nursing in the community:
Community-oriented practice (4th ed.). St. Louis, MO: Elsevier.
Tapley, H., & Patel, R. (2016). Using the PRECEDE-PROCEED model and service-learning to
teach health promotion and wellness: An innovative approach for physical therapist
professional education. Journal of Physical Therapy Education, 30(1), 47-59.
The Joint Commission. (2016). Implicit bias in health care. Quick Safety, (23). Retrieved from
https://www.jointcommission.org/assets/1/23/Quick_Safety_Issue_23_Apr_2016

The White House: President Barack Obama. (n.d.). Joining forces. (n.d.). Retrieved from
https://obamawhitehouse.archives.gov/joiningforces.
Transcultural C.A.R.E Associates. (n.d.). Our model of service. Retrieved from

Home

United Service Organizations. (n.d.). The organization: Our mission. Retrieved from
https://www.uso.org/about
Waisel, D. (2013). Vulnerable populations in healthcare. Current Opinion in Anesthesiology,
26(2), 186-192. doi: 10.1097/ACO.0b013e32835e8c17
World Health Organization. (n.d.). Refugee and migrant health. Retrieved from
http://www.who.int/migrants/en/

CHAPTER 4
The Environment, Policy, and Health
Effectiveness
By Sue Z. Green
‘Saving our planet, lifting people out of poverty, advancing
economic growth … these are one and the same fight. We must
connect the dots between climate change, water scarcity,
energy shortages, global health, food security, and women’s
empowerment. Solutions to one problem must be solutions for

all.” —Ban Ki-moon, former United Nations
Secretary-General (2011, paras. 23-24).
Essential Questions
● What are the environmental influences on populations?
● How do environmental influences affect nursing practice?
● What oversight organizations guide regulations and policies?
● What are the interrelationships among health policy, social justice, and nursing practice?
Introduction
Health care’s rapid transformation during this century centers on the environment, health care
policies, and effectiveness of the health care system. When entering nursing, the focus is often
on bedside skills, an individual’s immediate needs, and the closest health care setting.
Advancement in nursing practice now demands that nurses look beyond the proximate and
seek to understand the larger world that encompasses health care. Health disparities, inequities
of care, and the need to advocate for social justice become integral to new nursing roles for this
century. An understanding of environmental health and the components of the U.S. health care
system provide a foundation for care of populations.
Environmental Health
●
Environmental health is the broad science focused on how the environment influences human
health, injury, and disease. According to the World Health Organization (WHO) (2018a),
environmental health is “all the physical, chemical, and biological factors external to a person
and all the related behaviors.” The science includes the assessment and control of these factors
affecting health with the goal of disease prevention and healthy environments (World Health
Organization [WHO], 2018a). Environmental health science does not include human behaviors
resulting from genetics or from the psychosocial/cultural environment (WHO, 2018a). The
American Public Health Association (APHA) denotes environmental health as a critical
component of public health systems (American Public Health Association [APHA], 2018). The
public health focus is on relationships between people and their environment for health

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promotion and safe, healthy communities (APHA, 2018). In 2012 alone, unhealthy environments
resulted in a global mortality rate of 1 in 4, accounting for approximately 12.6 million deaths
(WHO, 2016a).
Environmental Threats to Health
●
Risk factors for more than 100 injuries and diseases are environmental, including air, water and
soil pollution, chemical exposures, climate change, and ultraviolet radiation (WHO, 2016a). The
largest share of environment-related deaths results from noncommunicable diseases (NCDs),
such as cardiovascular disease, stroke, cancers, and chronic respiratory disease (WHO,
2017b). Healthy People 2020’s overview of environmental health includes natural and
technological disasters as part of the concerns (HealthyPeople.gov, n.d.a), such as injuries
sustained from a tornado, a disease outbreak due to flooding, or a nuclear leak resulting from a
breakdown in technological surveillance. Environmental health is connected to the social
determinants of health (SDOH). SDOH are conditions of living, such as housing,
socioeconomics, transportation needs, and quality of education that directly impact health and
access to health care needs. Environmental health concerns related to the SDOH center on
working conditions, housing, water, sanitation, and healthy lifestyles (Prüss-Üstün, Corvalán,
Bos, & Neira, 2016). In other words, a healthy environment contains healthy living conditions or
SDOH. Environmental barriers to healthy living conditions become detrimental to health. For
example, lack of adequate shelter to protect an individual from temperature extremes can cause
harm, as can a lack of access to healthy and ample nutrition. The poor physical conditions of
housing and high household energy costs negatively affect the health of low-income families’
economic, physical, and behavioral health and security (Hernández, 2016). Because some form
of energy is required for basic cooking, lighting, and heating, those with low incomes may face
hardships if household energy expenditures exceed 10% of their income (Hernández, 2016).
Expenditures on heating or cooling may increase due to poor housing physical conditions, such
as air leaks, broken windows, or lack of insulation. The economic situation may cause families
to consider whether they can afford to both heat and eat (Hernández, 2016). The prioritization of
resources and trade-off decisions affect physical and behavioral health through stress and
deprivation.
Higher risks of cardiovascular diseases, stroke, and diabetes result from an unhealthy diet
(Micha et al., 2017; WHO, 2017b). Recent studies find that exposure to violent crimes,
household-noise levels, proximity to traffic noise, and air pollution affect the development of
cardiovascular diseases (Chum & O’Campo, 2015). These neighborhood factors are thought to

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reduce physical activity, sleep, and rest and increase stress, depression, and anxiety, all of
which negatively impact cardiovascular health (Chum & O’Campo, 2015). Reduced access to
grocery stores, parks, and recreation and easy access to fast food in neighborhoods also
increases cardiovascular health risks (Chum & O’Campo, 2015). Poor air quality at home or
work correlates with development of lung disorders, such as chronic bronchi or alveolar
disorders. Cancer, asthma, and chronic obstructive pulmonary diseases result from exposure to
radon, smoke, lead, toxic gases and particulates, coal dust, or asbestos, with smoking being the
highest risk of death (WHO, 2017b). Thus, a poor environment increases the burden of
disease regarding NCDs. The burden of disease reflects the morbidity, mortality, financial costs,
and health disparities resulting from disease, affecting human longevity and the well-being of
countries socially and economically.
Exposure to poor environments results in poor health. Poor health results in vulnerability to
communicable disease. Proximity and specific types of behavior can lead to spread of disease.
Poor sanitation and water pollution can lead to an outbreak of cholera or other
gastrointestinal-related infectious diseases. Growth of molds, bacteria, mycotoxins in damp
housing increases respiratory infectious disease occurrence (Prüss-Üstün et al., 2016).
Uncontrolled populations of mosquitoes, ticks, fleas, lice, and sandflies increase the risk of
vector-borne diseases, such as malaria, Chagas, dengue fever, yellow fever, Zika virus, West
Nile virus, Lyme disease, typhus, and plague (WHO, 2017d). Tuberculosis, hepatitis B and C,
parasitic diseases, and sexually transmitted diseases (STDs) increase in unsafe, unhealthy
environments (Prüss-Üstün et al., 2016). A growing concern is the world’s reliance on antibiotics
to control infections and the increased development of antimicrobial-resistant pathogens. Poor
hand hygiene and contact precautions increases the transmission risk of antimicrobial-resistant
pathogens such as methicillin-resistant Staphylococcus aureus (MRSA) (Seibert, Speroni, Oh,
DeVoe, & Jacobsen, 2014). Antimicrobial resistance reduces the range of effective antibiotics
available, lengthens illness and hospital stays, and increases the risk of death (Duckworth,
2017). Crowding, skin-to-skin contact, and shared equipment, supplies, or personal items
spread MRSA in the community. Spread of MRSA within a community can occur to the point of
forcing the shutdown of public areas to decontaminate equipment and surfaces, especially
schools, day care centers, and athletic venues (Centers for Disease Control and Prevention
[CDC], 2016b). According to the National Academy of Sciences, Engineering, and Medicine
(NASEM) (2017a), the antimicrobial resistance has become an emerging and global health
condition, resulting in a number of deaths. The WHO (2017a) considers antimicrobial resistance
to be “one of the biggest threats to global health, food security, and development today” (para.
1). The commonly resistant organisms are Escherichia coli, Klebsiella pneumoniae,
Staphylococcus aureus (MRSA), Mycobacterium tuberculosis, Streptococcus pneumoniae,
Enterococci faecium (Vancomycin-resistant Enterococci or VRE) and Salmonella (National
Academy of Sciences, Engineering, and Medicine [NASEM], 2017a; WHO, 2018c). In addition,
Clostridium difficile (C. diff) is an urgent concern in U.S. health care environments (NASEM,
2017a).

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Reducing the Health Impacts of
Global Climate and
Environmental Changes
●
The current environment has modifiable health risks. For example, better environmental
conditions reduce transmission of diseases from the animal world. Animals have diseases
considered zoonotic, meaning they are transmissible to humans. Modern day communicable
disease epidemics often originate from animal transmissions. Such is the case for Ebola,
salmonellosis, severe acute respiratory syndrome (SARS), and influenzas. The WHO notes that
61% of human disease-causing microorganisms are from animal transmissions and represent
75% of emerging infectious diseases in the past decade (WHO, 2018d). The following topics are
prominent means for health promotion and disease prevention when confronting climate and
environmental changes.
One Health
●
One approach to combating climate and environmental issues is collaboration among multiple
professions and/or multiple nations. The Centers for Disease Control and Prevention (CDC),
WHO, and professional organizations use this approach. The One Health initiative uses the
concept of global interdisciplinary collaboration among physicians, “A One Health
approach is important because 6 out of every 10 infectious diseases in
humans are spread from animals.” (CDC, 2018c, para. 2)veterinarians, and other
health and environmental professionals to address all aspects of health care for humans,

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animals, and the environment (One Health Initiative, n.d.b). Joint efforts among these
professionals currently conduct public health surveillance of cross-species diseases, including
treatment and preventative measures. The initiative seeks to advance health care by
“accelerating biomedical research discoveries, enhancing public health efficacy, expeditiously
expanding the scientific knowledge base, and improving medical education and clinical care”
(One Health Initiative, n.d.a, para. 1). Efforts include multiple collaborations among professional
and educational settings for medical, veterinary, public health, and the environment sciences.
Goals include a better understanding of cross-species disease transmission and environmental
research. The initiative’s objectives aim to provide and improve diagnostics, vaccines,
prevention and control measures, and education for political leaders and the public. The
National Center for Emerging and Zoonotic Infectious Diseases (NCEZID) notes that people live
“in an interconnected world where an outbreak of infectious disease is just a plane ride away”
(CDC, 2018b, para. 1). The CDC has experts working on a One Health Zoonotic Disease
Prioritization to focus and mitigate impact of endemic and emerging zoonotic disease threats to
the public. The One Health approach is an ecosystem approach, keeping the links between
humans, animals, and the environment (Gyles, 2016; Van Helden, Van Helden, & Hoal, 2013;
Shrestha, Acharya, & Shrestha, 2018).
Sustainable Development Goals
●
Risk factors for transmission of communicable disease directly link with poor environments. The
Sustainable Development Goals (SDGs), which are holistic, people-centered global health
initiatives for the year 2030, were developed by the United Nations (UN) and the WHO. These
goals align with the concept of social justice as well as the idea that health is a right that is to be
equitably available to all. The SDGs include:
1. No poverty
2. Zero hunger
3. Good health and well-being
4. Quality education
5. Gender equality
6. Clean water and sanitation
7. Affordable and clean energy
8. Decent work and economic growth
9. Industry, innovation, and infrastructure
10. Reduced inequalities
11. Sustainable cities and communities
12. Responsible consumption and production

13. Climate action
14. Life below water
15. Life on land
16. Peace, justice, and strong institutions
17. Partnerships for the goals (United Nations, n.d.)
The various initiatives and other SDGs interact to meet SDG 3—ensure healthy lives and
promote well-being for all ages and address environmental factors (WHO, 2018f). For example,
promoting sustainable agriculture (SDG 2) helps achieve food security and reduces malnutrition,
which will promote health and well-being. Clean water and sanitation (SDG 6) targets water
shortages, poor water quality, and sanitation issues, which will reduce transmission of disease.
SDG 7’s aim for affordable clean energy addresses food production, climate change, and
economic livelihoods, thereby improving the environment and health. SDG 13 tackles actions
combating climate change.
Recent estimates hold that 92% of the global population is living in areas where the air pollution
levels exceed the WHO limits (WHO, 2016b). The BreatheLife campaign is a global
collaborative effort to increase awareness of health risks of even short-lived climate pollutants.
Poor air quality increases the global burden of disease and increases mortality. Air pollution is a
leading risk factor for the development of NCDs. Air pollution-related deaths have been linked to
the following NCDs: 36% of lung cancer, 35% of pulmonary disease, 34% of stroke, and 27% of
heart disease deaths (BreatheLife, n.d.; WHO, 2018b). Counteractive measures include
promoting green spaces and alternatives to burning waste and fuels for transportation, heating,
and cooking (WHO 2016b). Such measures are expected to help reduce climate changes as
well.
A joint effort between the WHO and the United Nations International Children’s Fund (UNICEF)
(WHO & United Nations International Children’s Fund [UNICEF]) seeks global prevention
measures for provision of safe water, sanitation, and hygiene (WASH). WASH can improve
nutritional statuses, reduce diarrheal diseases, intestinal parasite infections, and environmental
enteropathy, thereby reducing the global burden of disease and deaths (WHO & UNICEF,
2017). Billions lack safe water at home and/or have no toilets (see Figure 4.1 and Figure 4.2).
SGD 6 incorporates measures to combat this issue and the lack of soap and water for
handwashing (see Figure 4.3). These measures overlap with goals from One Health. In
addition, the measures create overall improvements in maternal, newborn, and child health.
Recently, the UN Secretary-General called for global action for WASH in all health-care facilities
noting that a survey of 100,000 facilities revealed that “more than half lacked the simple
necessities, such as running water and soap” (WHO, 2018e, para 10).
Figure 4.1
Access to Safe Water for All by 2030

Note. Adapted from “Progress on drinking-water, sanitation and hygiene, 2017: Infographics,” by the
World Health Organization.
Figure 4.2
Access to Safe Sanitation for All by 2030

Note. Adapted from “Progress on drinking-water, sanitation and hygiene, 2017: Infographics,” by the
World Health Organization.
Figure 4.3
Access to Soap and Water for Handwashing

Note. Adapted from “Progress on drinking-water, sanitation and hygiene, 2017: Infographics,” by the
World Health Organization.
Healthy People 2020 and Environmental Quality
●
Healthy People 2020 objectives focus on objectives in six categories that direct actions toward
environmental health issues involving outdoor air quality, surface and ground water, toxic

substances and hazardous waste, homes and communities, infrastructure and surveillance
(such as public health departments), and global environmental health (HealthyPeople.gov,
n.d.a). These objectives are congruent with the mission, goals, and objectives of the
Environmental Protection Agency (EPA), another U.S. government agency. The EPA’s
mission “is to protect human health and the environment” (Environmental Protection Agency
[EPA], n.d.b, para. 1). Goals and objectives of the EPA’s strategic plan include clean air, land,
and water by enforcing federal laws to protect human health and the environment and requiring
the safe use of chemicals (EPA, n.d.a). The significant emerging environmental issues involve
climate change, disaster preparedness, and nanotechnology. Nanotechnology at the EPA
involves researching how to measure the nanomaterial concentrations and seek to determine
how minute chemicals and materials in products pose risks to human health and the
environment (EPA, n.d.c). Air quality improvement measures from the EPA and Healthy People
are aimed toward the use of alternative modes of transportation, such as bicycling, walking,
mass transit, or telecommuting. Measures are in place to reduce adverse health effects
resulting from toxic emissions from manufacturing and other sources. The water quality
objectives address methods for meeting federal regulations for safe drinking water, such as the
Safe Drinking Water Act of 2008; reducing waterborne disease outbreaks; conserving water;
and sustaining coastal waters safe for swimming (HealthyPeople.gov, n.d.a). Evidence of
progress in the area of toxic substances and hazardous wastes is verified through the increase
in recycling efforts as well as the reduction in hazardous waste sites, pesticide exposure, and
serum lead levels in toddlers and preschoolers (HealthyPeople.gov, n.d.a). Residents of healthy
homes seek to reduce indoor household allergen levels from cockroaches, mice, and dust;
radon exposure risk; and lead-based paint as well as dust- and soil-lead hazards
(HealthyPeople.gov, n.d.a). In addition, the initiatives monitor the health of community
educational systems to provide healthy school environments with indoor air quality
management; a reduced amount of molds; proper use, storage, and disposal of hazardous
materials; safe drinking water; and prudent use of pesticides. Healthy People 2020 initiatives
measure the body burden of toxins or the amount of a radioactive element or toxic material in a
body, especially lead. Routes of entry include oral, integumentary, and respiratory. Storage
sometimes occurs in human or animal fat tissue.
●
Since Florence Nightingale, nurses are accountable for managing the environment to promote
health (Jackman-Murphy, 2015). In 2007, the American Nurses Association (ANA) published
ANA’s Principles of Environmental Health for Nursing Practice with Implementation Strategies.
These principles incorporated nursing’s heritage of disease prevention and social justice,
ongoing global climate changes, and increasing burdens of individual exposures (American
Nurses Association [ANA], 2007). The ANA’s Scope and Standards of Practice guides all

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nurses to practice in a safe and environmentally healthy manner (ANA, 2010). Nurses work to
counteract the direct and indirect health implications of climate changes that result in
temperature extremes, air pollution, toxic exposures, food shortages, and water scarcity.
Climate changes have health repercussions, especially in the very young, older adults, those
with preexisting chronic health conditions, immigrants, and the poor (Allen, 2015). Extreme
weather events pose risks of drowning, physical injuries, heat exhaustion, postdisaster
infections, mental health consequences, and risks of fires. In a study of weather-related
mortality among U.S. residents from 2006 to 2010, “about 31% of these deaths were attributed
to exposure to excessive natural heat, heat stroke, sun stroke, or all” (Berko, Ingram, Saha, &
Parker, 2014, p. 1). Because of extreme heat, there are about 618 preventable human deaths
each year in the United States (CDC, 2017b). The world experienced 15 of its warmest years on
record since 2000 (CDC, 2016a). The rise in the annual temperature correlates with climate
changes. The EPA (2016) monitors key indicators related to causes and effects of climate
changes as noted in the report Climate Change Indicators in the United States. The report
discusses the multiple indicators and the effects of climate on health. Nurses are in the position
of sharing this evidence-based research and increasing awareness within the nursing practice.
Nurses can subscribe to professional publications and attend workshops to foster their own
development. For example, NASEM, formerly the Institute of Medicine (IOM), sponsored a
workshop in 2017 called “Protecting Health and Well-Being of Communities in a Changing
Climate” and published on its website a brief summary of the workshop proceedings with results
from four regions of the United States (NASEM, 2017b). The Alliance of Nurses for Healthy
Environments (ANHE, pronounced Annie) recognizes nursing’s pivotal role in health promotion
and environmental health through nursing education and professional leadership, research,
evidence-based practice, and policy advocacy (Alliance of Nurses for Healthy Environments
[ANHE], 2017). All nurses have the responsibility to practice in an environmentally safe manner
and to provide evidence-based information about environmental health to the nursing field, the
patients, the public, and policy makers.
Healthy Work Environments
●
Healthy work environments are the primary focus of two U.S. federal agencies: National
Institute for Occupational Safety and Health (NIOSH) and the Occupational Safety and
Health Administration (OHSA). NIOSH is a research agency, under the auspices of the CDC,
established by the Occupational Safety and Health Act of 1970 (CDC, 2018a). NIOSH
researches workplace environments and makes recommendations for prevention of
work-related injury and illness. NIOSH maintains a list of antineoplastic and other hazardous
drugs in health care settings. OHSA is structured under the U.S. Department of Labor with the

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mission of assuring safe and healthy work conditions through writing and enforcing regulatory
standards (Occupational Safety and Health Administration [OSHA], n.d.a). OSHA has links for
filing safety and health complaints, reports of death or severe injury, and whistleblower
information regarding employee protections from retaliation when reporting injuries, safety
concerns, and similar activities. OSHA maintains eTools with information on hazards present in
health care, such as blood-borne pathogens, mercury, and workplace violence (OSHA, n.d.c).
Both NIOSH and OSHA link the public and health care professionals to topical resources for
workplace safety and health. For example, both sites have links to information regarding
ergonomics, and the agencies jointly published a hospital respiratory protection program toolkit
(CDC, 2015a).
Both agencies target prevention of harm to the human body, particularly the musculoskeletal
system through the ergonomic design and arrangement of the workplace environment, including
equipment and the persons. Nurses, for example, study body mechanics to determine the best
use of workplace equipment to make beds, move persons, and transport equipment. Lifting,
carrying, pushing, and pulling all use musculoskeletal functions. Poorly designed equipment can
be harmful. Today’s technology may have a person performing one function or movement over
long periods each day, and this repetition can be injurious to the body. The stressors to the
body often result in musculoskeletal disorders (MSD), which trigger one-third of lost work days
or workday cases. The U.S. Bureau of Labor Statistics (2017) uses the days away from work as
a measure of severity of injuries and illnesses. Specifically, health care workers have a high rate
on nonfatal occupational illness and injury (U.S. Bureau of Labor Statistics, 2017). The ANA
surveyed nurses regarding work-related injuries, and of the respondents, 62% of the nurses
reported concerns of suffering a disabling musculoskeletal injury as one of the top three
workplace safety concerns; 80% reported working despite frequent musculoskeletal pain (ANA,
2011). Therefore, nurses need to keep informed of the dangers of MSD risks in the workplace.
In 2014, the ANA published Safe Patient Handling and Mobility: Interprofessional National
Standards and Implementation Guide to Safe Patient Handling and Mobility: Interprofessional
National Standards. OHSA recommends minimization of manual lifting of patients and the
elimination of lifting when possible (OHSA, n.d.b). The nurse should monitor coworkers for risks
and educate others about ways to counteract the risks.
Hazardous waste is another area of concern in workplace safety and the environment.
Hazardous waste includes, but is not limited to, regulated medical waste (RMW) and other
hazardous substances such as chemicals, cleaning solutions, corrosives, heavy metals, and
radioactive materials. RMW must be disposed of separately, usually incinerated, from other
waste to avoid spreading communicable disease from blood, body secretions, or otherwise
potentially infectious materials. Hazardous waste and RMW has to be tracked with manifests
and signatures throughout the disposal chain of custody.
To identify hazardous waste consistently around the world, the United Nations Economic
Commission for Europe (UNECE) created an international system of chemical classifications by
types of hazard, called the Globally Harmonized System of Classification (United Nations
Economic Commission for Europe [UNECE], 2013). The Globally Harmonized System (GHS)
categorizes chemicals into classes according to either physical, health, or environmental
hazards. This system standardized these chemical classifications, labeling requirements, and

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information sheet requirements, known as Safety Data Sheets (SDS). In the United States,
OSHA requires an SDS for each hazardous item in the workplace (OSHA, n.d.b). Product labels
and the SDS communicate the hazardous nature of the chemical through the hazard
statements, signal words of “Warning” and “Danger,” and pictograms. For example, a pictogram
of skull and crossbones indicates danger of severe toxicity, and a flame indicates highly
flammable chemicals (see Figure 4.4).
Figure 4.4
Severe Toxicity and Highly Flammable GHS Symbols

Every worker should have access to the SDS for reference. Nurses need to know the location of
hazardous chemicals and the SDS. Organizations have policies and procedures in place to
meet OSHA standards. In addition, the nurse must protect and educate coworkers of these
risks, proper containment, and disposal methods according to OHSA and organizational
standards.
Check for Understanding
1. Which global environmental threats are encountered in your nursing practice?
2. How can the nurse incorporate concepts of social justice to promote environmental health?
3. What additional environmental hazards could be removed from the workplace?
U.S. Health Care System
●

According to a recent report, the U.S. health care system ranks last in overall performance
among 11 countries examined (Schneider, Sarnak, Squires, Shah, & Doty, 2017). The United
States pays the highest cost per person, yet has poor health care outcomes (Schneider et al.,
2017, The Commonwealth Fund, 2017). The bottom line is that the U.S. system is not working
as well as others (The Commonwealth Fund, 2017), which is due, in part, to the complexity of
the U.S. health care system. To advocate for health care system improvements, the nurse
needs an understanding of the current system.
Organizational Structure
Health care in the U.S. is decentralized with a variety of public and private access points. The
public health system includes government entities and collaborative efforts with community
nonprofit organizations and faith-based organizations (see Figure 4.5). Government entities
include health agencies at the federal, state, and local levels, public safety agencies, and
environmental agencies. Government agencies include state and local health departments,
providing care such as laboratory services, health screenings, treatment of disease, and
epidemiology surveillance. Private health care is delivered in inpatient, outpatient, or ambulatory
care; long-term or residential; mental health; home care; wellness center; and alternative
medicine settings. Private institutions are either for-profit private facilities or nonprofit private
facilities, with the latter being the largest component. According to the American Hospital
Association (AHA), there are more than 5,500 private, short-term care hospitals in the United
States (American Hospital Association [AHA], 2018). Both private and public health care is
offered by professionals known as providers, who include physicians, nurse practitioners,
nurses, and other ancillary professionals who deliver health care directly to their clients or
patients (Kahn, 2011). A trained workforce assists providers in care provision and are
considered resources. Other resources include technology, equipment, and supplies. The
vulnerable aspect of the system is the consumer who is at risk of harm if the health care system
does not function efficiently and safely when delivering care.
Figure 4.5
The Public Health System

Note. Adapted from “The Public Health System & the 10 Essential Public Health Services,” by the
Centers for Disease Control and Prevention, 2017.
Agencies Associated With Health Care
No matter the setting or organizational formation, the facilities have the overarching
governmental regulatory mechanisms of the Department of Health and Human Services (HHS),
Centers for Medicare & Medicaid Services (CMS), Food and Drug Administration (FDA), the
CDC, and OSHA (Healthcare Triage, 2014). Other federal agencies involved in health care
include the:
● Center for Global Health;
● Office of Noncommunicable Diseases Injury and Environmental;
● Office of Infectious Diseases;
● Office of Public Health Preparedness and Response;
● Office of Public Health and Science (OPHS);
● Office for State, Tribal, Local, and Territorial Support; and
● Office of Surveillance, Epidemiology, and Laboratory Services.
Other federal agencies with a relationship to health care entities include the
● Office of Veterans Affairs (VA),
● EPA,
● Department of Justice,
● Department of Labor,
● Department of Defense,
● Department of Agriculture, and
● National Science Foundation.
This large collection of agencies reveals the complexity and sometimes fragmentation of U.S.
health care. Agencies at state and local levels center on state and local public health care
agencies, such as state and local health boards and state, county, or city departments of health.
Multiple volunteer organizations complete the final aspect of health care services. Not all areas
have government fire, police, and emergency services. Volunteer emergency medical
technicians and paramedics provide emergency care in some locales. Other volunteer agencies
may have a national outreach. For example, Volunteers of America (VOA) (n.d.) offers
assistance for senior living and care services. The National Association of Free and Charitable
Clinics (NAFC) (n.d.), a network of volunteer agencies, provides medical services for the
underinsured.
Financing Mechanism for U.S. Health Care
Financing Costs for Individual Care
Paying for health care is a major concern in the United States. Although individuals may have
freely accessible health care at a variety of settings, the health providers and organizations
expect payment for services rendered in order to remain operational; however, transportation,
restrictions on eligibility for certain services, and ability to pay are barriers for some. The cost

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of services and has risen to new heights in this century. One means of paying for health care is
through out-of-pocket payment or self-payment of services. Most Americans have neither the
income nor savings to cover the full cost of health services when faced with more than a minor
illness or condition. Ability to pay for services often comes in the form of health insurance
coverage. Health insurance is an arrangement with the government or a private company to
guarantee payment for health care services, generally for illnesses, injuries, and health
conditions.
Federal and state governmental resources for health care are available for some (see Figure
4.6). Active duty military service members, veterans, their families as well as members of the
National Guard and military reserves have eligibility for federally government-funded health
insurance coverage through a health care program called Tricare (Tricare, n.d.). People who are
65 or older, those younger than 65 with certain disabilities, and those of any age with end-stage
renal disease are commonly eligible for Medicare, a federal health insurance program (Centers
for Medicare & Medicaid Services [CMS], 2014). Currently, more than 18% of the U.S.
population, or 57 million people, depend on Medicare (Dean, Noel-Miller, & Lind, 2017).
Medicare consists of multiple parts and eligibility stipulations, which confuses some about
whether they are eligible for these benefits. The individual must apply for Medicare enrollment
during specified times of the year, usually during the fall. The Medicare health and medications
plans change yearly, requiring the person to review and choose coverage annually. Medicare
Part A is hospitalization insurance for stays in acute care hospitals, short-term skilled nursing
facilities, and some hospice and home care (CMS, 2014). Typically, the person pays a
deductible before Medicare begins to provide compensation. Deductibles are out-of-pocket
expenses. Medicare Part B provides coverage for practitioner services, outpatient care, and
durable medical equipment, such as oxygen and wheelchairs. Medicare Part B coverage
requires user enrollment and the payment of a monthly government premium. Medicare Part B
generally provides 80% compensation for the cost of services, and the person must pay the
remaining 20% as a copayment, plus any deductible. Medicare Part C, better known as
Medicare Advantage, is not a separate Medicare benefit, but allows for Medicare coverage for
those who wish to enroll in some private insurance plans (CMS, n.d.). Medicare Part D coverage
requires user enrollment and the payment of a monthly government premium for lower cost
prescription medications.
Figure 4.6
Financing Structure of the U.S. Health Care System

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Note. Adapted from United States of America: Health System Review, by T. Rice, P. Rosenau, L. Y.
Unruh, A. J. Barnes, & R. B. Saltman, 2013, Health Systems in Transition, 15, p. 27. Copyright 2013
by Health Systems in Transition .
Medicaid is a health insurance program for certain families with low incomes, which is jointly
funded by the federal government and the state where the family resides. Note that Medicaid is
for families, not low-income adults without children, but it does provide for eligible blind or
disabled persons. Since 2014, in accordance with provisions of the Affordable Care Act (ACA),
states have the authority to expand eligibility for Medicaid to persons under the age of 65 if the
family income is below 133% of the federal poverty level (FPL) for that family’s size
(Medicaid.gov, n.d.b). The states, the U.S. territories, and the District of Columbia vary in
Medicaid coverage. Some persons receiving Medicaid are also eligible for Medicare, known as
dual eligibility.
Oversight of federal program policies and procedures for Medicaid, the Children’s Health
Insurance Program (CHIP), and the Basic Health Program (BHP) is through the Center for
Medicaid and CHIP services (CMCS) (Medicaid.gov, n.d.b). The CHIP program provides states
with federal matching funds for provision of health coverage to children of eligible families
(Medicaid.gov, n.d.b). To be eligible for CHIP coverage, the family income must be too high to
qualify for Medicaid and yet still too low to afford private coverage (Medicaid.gov, n.d.b). Most
states allow coverage for children of families at 200% or greater of FPL (Medicaid.gov, n.d.b).
More than 74 million adults and children are covered by Medicaid or the CHIP program

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(Medicaid.gov, n.d.a). The BHP is a health insurance coverage option, which is another
provision of the ACA, allowing state health benefits for low-income adults, who have eligibility to
purchase private insurance coverage through a health insurance exchange or marketplace
(Medicaid.gov, n.d.b).
The majority of the U.S. population finances health care costs through private health insurance
(Kahn, 2011). The individual pays a premium to the private insurance company. If employed,
people can often enroll in their companies’ group health plan, for which the employer typically
pays a significant portion of the premium, reducing the cost to employees. In the past century,
especially the 1960s, individuals could chose whatever health care facility and provider they
wished, and the private insurance company would compensate the services (Kahn, 2011).
Because of the rising cost of health care, insurance companies placed restrictions on choice.
Now, private health insurance companies negotiate contracts with providers and facilities for
acceptance of prearranged cost of services. Health maintenance organizations (HMOs)
provide tighter management of funds with enrollees paying a premium and predetermined fee
for services from a preset list of providers and facilities (Kahn, 2011). Ordinarily, care delivered
by those not on the preset list results in no compensation, and the individual is then responsible
for the cost, unless a preapproved referral is in place. Preferred provider organizations
(PPOs) provide a more flexible list of providers and facilities, but with higher fees (Kahn, 2011).
The ACA provided an expectation that every American have health care insurance. One of the
concepts was to provide health insurance options for those who were unemployed or uninsured
in the United States. The population had no centralized means of surveying options, leaving
many unsure of how to find a health insurance plan that was best suited for themselves or their
families. With the advent of the ACA, health insurance exchanges or marketplaces emerged.
Some exchanges are ACA government-regulated, standardized health care plans. Others are
private non-ACA exchanges, generally for small businesses. Both provide central sites for
browsing health care plans competitively offered by the private insurance companies choosing
to participate. The ACA concepts of transparency and accountability aid in the sharing of
expenses across larger groups of people, more like a group plan. Moreover, marketplace and
insurance companies share plan information through electronic data interchanges (EDIs) when
an individual enrolls. Most states use the federal marketplace, Healthcare.gov.
Public Health Financing for Populations
Population health programs cannot operate without facilities, personnel, equipment, and
supplies, all of which require funding. The most common sources of monies come from federal
grants, state and local funds, and city or county revenues (CDC, 2013). Funding also comes
from private organizations. Funding varies according to the current government’s health budget
and legislative policy making (CDC, 2013). Grants provide funds to accomplish specific public
purposes, and contracts or purchase orders with vendors normally acquire the equipment,
supplies, and other services (CDC, 2017a). The Prevention and Public Health Fund (PPHF or
The Fund), established under the ACA, is the compulsory annual funding of federal monies
directed to the improvement of the U.S. public health system for prevention, wellness, and
public health initiatives (EveryCRSReport, 2017; CDC, 2017c). For example, public health

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initiatives for smoking cessation used funds from PPHF to develop the mass media campaign,
Tips from Former Smokers (American Lung Association, n.d.).
One Family
The following is an example of how one family structure can encounter multiple methods of
financing their health care.
Mary, a retired, 65-year-old woman, now has a Medicare Part A card for health care. John, her
64-year-old husband, maintains insurance through his employer. Their daughter, Sarah, and
granddaughter, Grace, are on Medicaid, but their son, Bob, has an income too high for
Medicaid. Bob’s family is covered by CHIP.
Check for Understanding
1. How do One Health collaborations aid epidemiological surveillance?
2. How could access to health care be improved in the United States?
3. What aspects of the public health system have improved in the past decade?
4. How does an understanding of health care financing provide a foundation for advocacy related to population
health nursing practice?
Public Health Delivery and
Institute of Medicine Reports
Two major nonprofit organizations greatly influence the direction of public health care: the
Robert Wood Johnson Foundation (RWJF) and NASEM. Sometimes, the influence comes
through RWJF campaigns for action or sometimes through research reports. For example, in
2009, the RWJF requested that the IOM examine measurement, law, and funding within public
health (Institute of Medicine [IOM], 2011a). This study followed the IOM’s report, The Future of
Public Health (IOM, 1988), which scrutinized public health.
The Future of Public Health
With the advent of sanitation, safe water, protection against epidemics, and lower infant
mortality rate than in the 1900s, there has been difficulty maintaining an appreciation of the
critical nature of providing public health (IOM, 1988). The Future of Public Health was a
landmark report that revealed that the public health infrastructure was poorly focused and
inadequate (IOM, 1988). Recommendations were to regain dedication to the mission of public
health with the government playing a vital role in policy development toward its mission at
federal, state, and local levels (IOM, 1988). Government support emphasized environmental
health, mental health, social services, and medical care for impoverished people (IOM, 1988).

Shortly after The Future of Public Health was published, the IOM followed up with To Err is
Human, (IOM, 2000), which resulted in national outcry over medical errors. The RWJF and the
American Association of Retired Persons (AARP) began campaigns to correct these issues,
now reflected in the initiatives described in Culture of Health and the Future of Nursing:
Campaign for Action (American Association of Retired Persons [AARP], n.d.; Reinhard, 2018,
Robert Wood Johnson Foundation [RWJF], n.d.a; RWJF, n.d.b).
Crossing the Quality Chasm: A New Health System for
the 21st Century
Subsequent to the publication of To Err is Human, the IOM scrutinized the overall U.S. health
care system for ways to improve the quality of care in light of a new century. The report,
Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001), triggered
reactions still felt today. The publication documented that inadequate funding, insufficient
accountability, and lack of partnerships with other health care service providers continued to
plague the health care system (IOM, 2001). The IOM recommended six aims for improvement,
shifting health care’s focus to safe, effective, timely, efficient, equitable, and patient-centered
provision of care (IOM, 2001). Thus, the focus changed from errors and safety to a focus on
quality as a means of error prevention and creation of safety. Strategies incorporate
customization of care based on an individual’s needs, continuous healing care, patient control
over health care decisions, evidence-based practice, free flow of clinical information, and
transparency (IOM, 2001). In light of public health nursing, the emphasis on equitable care
aligns with the concept of social justice and reduction of health care disparities.
The Future of the Public’s Health in the 21st Century
The IOM conducted further analysis of the public health system in The Future of the Public’s
Health in the 21st Century (IOM, 2003). This report showed that there was still inadequate
funding, insufficient accountability, and lack of coordination to collaborate with other health care
services (IOM, 2003). The report distinguished three core functions of public health, which
continue in the present: assessment, policy development, and assurance of the public (IOM,
2003). Furthermore, 10 essential public health services were determined (IOM, 2003). These
core functions and essential services are now national public health performance standards
(see Figure 4.7).
Figure 4.7
The 10 Essential Public Health Services

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Advocacy for Improvement of
Population Health
●

Universal Health Coverage (UHC)
As of June 2017, the number of uninsured Americans dropped to 9% of the population, down
from 16% in 2010 (Clarke, Schiller, & Norris, 2017). This means that 28.8 million Americans are
still uninsured (Clarke et al., 2017). In addition, almost 4.6% of the U.S. population, or 15 million
people, failed to seek medical care during the previous 12 months because of cost of care
(Clarke et al., 2017). An American may have health insurance, yet fail to seek medical care
because of the out-of-pocket cost of the deductible (Chin, 2017; Olen, 2017). Some insured
Americans must make the difficult choice of whether to seek needed care and pay a medical bill
or pay for food and housing (Chin, 2017; Olen, 2017). Americans are in poorer health than other
high-income countries globally, which disputes beliefs that U.S. has the best health care
(Schneider & Squires, 2017). Many believe that the ACA is the closest to universal health
coverage (UHC) that the United States can achieve.
During the last century, the WHO declared health as a fundamental human right (WHO, 2018g).
UHC is in alignment with the SDG 3 of promoting good health and well-being for all people and
all ages (WHO, 2018d). One of the WHO’s global goals is that all people have access to needed
health promotion and prevention, curative rehabilitation, and palliative health services with
sufficient, effective quality and without financial hardship (WHO, 2018g). As of 2017, over half
the global population still does not have access to necessary health services (WHO, 2017c).
The WHO advocates equitable access to all health services, quality health services, and
protection against financial hardship when needing health care (WHO, 2018g). Out-of-pocket
expenses are minimal under UHC (Schneider & Squires, 2017). The challenge in the United
States is the hodgepodge financing, high health care costs, and accessibility to health care
(Robinson, 2016; Schneider & Squires, 2017).
●
A crucial position of the nursing profession, nationally and globally, is the provision of equitable
health care and the reduction of health disparities. As nurses know well, the perception that a
nurse merely carries out physician orders is incorrect; nurses are change agents. Since
Nightingale, nurses have acted as advocates for policy and system advancements that improve
health for every human (Thurman & Pfitzinger-Lippe, 2017). Through lifelong learning and an
understanding of change theory, nurses are engaged in transforming care for vulnerable and
at-risk populations, reducing health disparities and social injustices, and improving the global
perception of health care (Edmonson, McCarthy, Trent-Adams, McCain & Marshall, 2017;
Paquin, 2011; Walter, 2017). Nurses demonstrate this engagement when they identify
stakeholders who have a vested interest to support change or maintain the status quo,
determine sources of power to enable the change process, and examine their own professional
perspective of inequitable conditions (Walter, 2017). Evidence-based practice and mentoring by

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those already involved in advocacy for social justice provide powerful knowledge and skills for
social policy change (Paquin, 2011). Nurses recognize that social equity comprises all basic
human needs, such as food, clothing, shelter, education, and employment, extending beyond
access to health care (Walter, 2017).
Health in All Policies (HiAP)
●
A framework for governmental collaboration and decision making resulted in the Health in All
Policies (HiAP) guidelines. HiAP is a collaborative approach that “You cannot get
through a single day without having an impact on the world around you.
What you do makes a difference, and you have to decide what kind of
difference you want to make.” —Dr. Jane Goodall (The Jane Goodall
Institute, n.d., para. 1) incorporates public health considerations into government decisions
and policy making, ensuring a neutral or positive influence on the SDOH (SurgeonGeneral.gov,
n.d.). The process uses collaboration with public and private stakeholders, creating a
prevention-focused strategy that values health for the individuals, families, and public that
explores the array of possible outcomes of a new decision or policy before it is made and the
sequelae has unintended effects on health. HiAP originated as an approach through the WHO.
The guidelines have a prominent focus for the U.S. National Prevention Strategy and Healthy
People initiatives (CDC, 2016c).
As prominent problem solvers, nurses make a difference and can advocate for approaches that
reduce health inequities that a policy or decision could create. Nurses sometimes hesitate to
become active in the political arena, but they are a needed voice (Webb, 2017). The CDC
maintains a site for HiAP resources (CDC, 2015b).
Figure 4.8
HiAP Wheel

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Note. Adapted from “Health in All Policies,” by the Centers for Disease Control and Prevention,
2016. Copyright 2016 by the Centers for Disease Control and Prevention.
Advanced Nursing Leadership, the IOM, and the ACA
●

The reports by the IOM and the passage of the ACA expanded the role of nursing leadership for
the 21st century. While nursing is already the largest workforce in U.S. health care, the IOM
report, The Future of Nursing: Leading Change, Advancing Health, has created even more
opportunities for advance practice nursing (IOM, 2011b). Now with the focus of health care
moving from traditional illness to preventative care, nursing roles also are transforming (Berg &
Dickow, 2014). The new roles create leaders who seek health equity and the advancement of
the SDOH. The IOM report indicates that, with the passage of the ACA, nurses are in prime
position to now practice as fully as possible, reducing barriers to advanced practice nursing.
This has meant including nurse practitioners in Medicare compensation, just as physicians
already were. The report urged states to revise their Nurse Practice Acts to remove barriers to
advance practice (IOM, 2011b). Among the recommendations was the reduction of barriers to
furthering nursing education such as expansion of scholarships, loans, and grants, as well as
recommendations for an increase in baccalaureate-prepared nurses and development of nurse
residency programs (IOM, 2011b). The advancement of nursing leadership includes meeting the
recommendation of doubling the number of nurses with a doctorate, along with the expectation
of all nurses to incorporate theory, research, clinical competency, and leadership development
to meet the changing needs of health care (IOM, 2011b). An endorsement for placing nurses in
policy and other decision-making capacities incorporated nurses on various public and private
boards for health advancement (IOM, 2011b). The number of nurses encouraged to take the
reins of change makes for an impressive influence (Berg & Dickow, 2014). The health promotion
and preventative care aspects of the ACA are well within the leadership roles of nursing. The
United States is capable of having the best health care in the world, and nursing is on the
forefront for this change (Schneider & Squires, 2017).
Healthy People 2030
●
Every 10 years, new national goals are set for Healthy People initiatives, and, as such, the
Healthy People 2030 program is being developed. The proposed framework was open to public
comment, which the HHS reviews before making final revisions. When the time occurs for
formulation of the 2030 objectives, additional public comment is a possibility. Meanwhile, the
proposed framework for Healthy People 2030 is available on the HealthyPeople.gov website
(HealthyPeople.gov, n.d.b). Currently, the proposed framework equates health and wellness
with attaining health literacy, eliminating health disparities, and achieving health equity. Nurses
monitoring the site and health news are aware as the plans progress.
Check for Understanding

1. How does the WHO goal of universal health coverage align with U.S. goals for health care?
2. What aspects of HiAP improve quality of population health care?
3. Which aspects of public health quality monitoring have improved as a result of the IOM reports?
Reflective Summary
Public health nursing began with a focus on disease prevention and wellness by providing safe
water and sanitation. The health of the environment expanded from a focus on a neighborhood
to one of the whole world. Nurses now advocate for ongoing legislative reform, safe and
supportive communities, and environmental sustainability. The U.S. health care system’s
fragmented financing system has led to millions of Americans who are uninsured or lack access
to health care because of costs. The conditions of this century’s current health care demand
that nurses become knowledgeable about policies affecting health and health care. Nurses, as
advocates with leadership abilities, are in a position to turn health care in the United States from
being 11th to Number 1 in the world.
Key Terms
Affordable Care Act (ACA): Health care reform legislation with multiple provisions signed into
law by U.S. President Barack Obama and became known as Obamacare; among the provisions
include health insurance coverage to uninsured, measures to lower costs and improve health
care system efficiency, preventative care, extension of care to dependents under the age of 26,
and prohibited insurance claim denial or higher premiums for preexisting conditions.
Basic Health Program (BHP): Health insurance coverage option under the Affordable Care Act
that allows eligible low-income adults to receive and purchase private insurance coverage
through the health insurance marketplace.
Body Burden: The amount of a radioactive element or toxic material in a body.
Burden of Disease: Estimates of health problems’ impact on the world in terms of indicators
such as financial cost, mortality, and morbidity; estimates include statistical analyses of
disability-adjusted life year (DALYs), years of life lost (YLL), and years lost due to disability
(YLD).
Children’s Health Insurance Program (CHIP): Health insurance coverage for children of
parents whose income is too high to qualify for Medicaid but too low to pay for private health
insurance coverage.
Climate Change: Any major change in the temperature, precipitation, wind, and other
measurable weather patterns that occur for at least 10 years.
Copayment: A form of cost sharing for services; usually a fixed amount or percentage
established by the insurance plan.

Deductible: The amount an individual must pay for services prior to an insurance plan providing
compensation coverage.
Durable Medical Equipment: Equipment that serves a medical purpose in the treatment of a
health conditions, such as canes, crutches, hospital beds, oxygen, traction equipment,
ventilators, walkers, or wheelchairs.
Eligibility: Meeting criteria; allowed or permitted to take part in.
Environmental Health: The broad science focused on how the environment influences human
health, injury, and disease with the goal of health promotion, disease prevention, and safe,
healthy communities.
Environmental Protection Agency (EPA): Federal agency with the mission to protect human
health and the environment through writing and enforcing U.S. regulatory standards for
stewardship of natural resources, health, economics, energy agriculture, transportation,
industry, international trade, and reduction of environmental risks.
Equitable Care: “Providing care that does not vary in quality because of personal
characteristics such as gender, ethnicity, geographic location, and socioeconomic status” (IOM,
2001, p. 6).
Ergonomics: The science of designing and arranging the workplace equipment and
environment for safety and efficiency.
Extreme Heat: Higher temperature than average in a particular time and place, factoring in
relative humidity.
Group Health Plan: Health insurance plans offered at a group rate through an employer or
organization for the employee and employee’s family.
Health in All Policies (HiAP): A collaborative approach that incorporates public health
considerations into government decisions and policy making, ensuring a neutral or positive
influence on the social determinants of health (SDOH).
Health Insurance: An arrangement with the government or a private company to guarantee
compensation for health care services, normally for illnesses, injuries, and health conditions.
Health Insurance Exchange: Entities that foster a competitive market for the purchase of
private health insurance coverage; also known as a health insurance marketplace.
Health Maintenance Organization (HMO): A type of health insurance plan in which the
individual enrolls for a predetermined fee for services from a preset list of providers and
facilities; care delivered by providers not on the preset list will result in no compensation from
the insurance company to the provider or facility. The individual requires a referral from the
individual’s primary care provider for any other provider or services. For example, to have
coverage for a visit to a dermatologist, the individual must have the primary provider’s approval
via a referral.
Medicaid: Health insurance program for people with low incomes; jointly funded by the federal
government and the state where the persons reside.

Medicare: Federal health insurance program for most people who are 65 or older; those under
65 with certain disabilities, and those of any age with end-stage renal disease.
Nanotechnology: Technology addressing extremely small-scale measurements or nanometers,
such as maneuvering atoms, molecules, and supramolecules to achieve precise accuracy and
ultra-fine dimensions.
National Institute for Occupational Safety and Health (NIOSH): U.S. federal agency, and
part of the Centers for Disease Control and Prevention (CDC)/U.S. Department of Health and
Human Services; conducts research and makes recommendations to prevent work-related
injury and illness.
Noncommunicable Disease (NCD): Noninfectious, nontransmissible, or chronic disease
arising from a combination of factors, including genetics, environmental, physiological, and
behavioral aspects.
Occupational Safety and Health Administration (OHSA): Agency of the U.S. Department of
Labor that helps to ensure safe and healthy work conditions by setting and enforcing standards.
Out-of-Pocket: Self-payment for cost of service.
Preferred Provider Organization (PPO): A type of health insurance plan in which the individual
enrolls for a predetermined fee for services from a preset list of providers and facilities; care
delivered by those not on the preset list may result in no or less compensation from the
insurance company to the provider or facility.
Premium: Money paid for an insurance policy.
Prevention and Public Health Fund (PPHF): The permanent annual funding of federal dollars
directed to the improvement of the U.S. public health system’s prevention, wellness, and public
health initiatives; established under the Affordable Care Act; also known as The Fund.
Social Determinants of Health (SDOH): Conditions of living, such as housing,
socioeconomics, transportation needs, quality of education, that directly impact health and
access to health care needs.
Universal Health Coverage (UHC): To provide all people access to needed health promotion
and prevention; curative, rehabilitative, and palliative health services with sufficient, effective
quality and without financial hardship.
Whistleblower: Person who reports illegal, unethical, or unsafe activities of a person, employer,
or organization.
Zoonotic: Diseases that are transmissible from animals to people, such as the Ebola virus or
salmonellosis.
References

Allen, P. J. (2015). Climate change: It’s our problem. Pediatric Nursing, 41, 42-46. Retrieved
from
https://lopes.idm.oclc.org/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=
ccm&AN=103756359&site=ehost-live&scope=site
Alliance of Nurses for Healthy Environments. (2017). About. Retrieved from

Alliance of Nurses for Healthy Environments

American Association of Retired Persons. (n.d.). Public policy institute. Retrieved from
https://www.aarp.org/ppi/?intcmp=AE-SEARCH-AARPSUGG-ppi
American Hospital Association. (2018). Fast facts on U.S. hospitals. Retrieved from
https://www.aha.org/statistics/2018-01-09-fast-facts-us-hospitals-2018
American Lung Association. (n.d.). ACA prevention and public health fund. Retrieved from
http://www.lung.org/lung-health-and-diseases/protecting-your-lungs/aca-prevention-public-h
ealth-fund.html?referrer=https://www.google.com
American Nurses Association. (2007). ANA’s principle of environmental health for nursing
practice with implementation strategies. Retrieved from
http://ojin.nursingworld.org/MainMenuCategories/WorkplaceSafety/Healthy-Nurse/ANAsPrin
ciplesofEnvironmentalHealthforNursingPractice.pd
http://ojin.nursingworld.org/MainMenuCategories/WorkplaceSafety/Healthy-Nurse/ANAsPrin
ciplesofEnvironmentalHealthforNursingPractice.pd
American Nurses Association. (2010). Nursing: Scope and standards of practice. Silver Springs,
MD: Author.
American Nurses Association. (2011). 2011 ANA health and safety study. Silver Springs, MD:
Author.
American Public Health Association. (2018). Environmental health. Retrieved from
https://www.apha.org/topics-and-issues/environmental-health
Berg, J. G., & Dickow, M. (2014). Nurse role exploration project: The Affordable Care Act and
new nursing roles. Nurse Leader, 12(5), 40-44. doi: 10.1016/j.mnl.2014.07.001
Berko, J., Ingram, D. D., Saha, S., & Parker, J. D. (2014). Deaths attributed to heat, cold, and
other weather events in the United States, 2006-2010. National Health Statistics Reports,
no 76. Hyattsville, MD: National Center for Health Statistics. Retrieved from
https://www.cdc.gov/nchs/products/nhsr.htm
BreatheLife. (n.d.). Homepage. Retrieved from http://breathelife2030.org
Centers for Disease Control and Prevention. (2013). Public health financing. Retrieved from
https://www.cdc.gov/stltpublichealth/docs/finance/public_health_financing-6-17-13
Centers for Disease Control and Prevention. (2015a). Hospital respiratory program toolkit.
Retrieved from https://www.cdc.gov/niosh/docs/2015-117/default.html
Centers for Disease Control and Prevention. (2015b). Office of the associate director for policy:
Health in All Policies. Retrieved from https://www.cdc.gov/policy/hiap/resources
Centers for Disease Control and Prevention. (2016a). Climate change and extreme heat: What
you can do to prepare. Retrieved from
https://www.cdc.gov/climateandhealth/pubs/extreme-heat-guidebook
Centers for Disease Control and Prevention. (2016b). General information about MRSA in the
community. Retrieved from https://www.cdc.gov/mrsa/community/index.html

Centers for Disease Control and Prevention. (2016c). Health in All Policies. Retrieved from
https://www.cdc.gov/policy/hiap/index.html
Centers for Disease Control and Prevention. (2017a). About CDC funding. Retrieved from
https://www.cdc.gov/funding/AboutCDCFunding.html
Centers for Disease Control and Prevention. (2017b). Extreme heat. Retrieved from
https://www.cdc.gov/disasters/extremeheat/index.html
Centers for Disease Control and Prevention. (2017c). Prevention and public health fund.
Retrieved from https://www.cdc.gov/funding/pphf/index.html
Centers for Disease Control and Prevention. (2018a). About NIOSH. Retrieved from
https://www.cdc.gov/niosh/about/default.html
Centers for Disease Control and Prevention. (2018b). National Center for Emerging and
Zoonotic Infectious Diseases (NCEZID). Retrieved from
https://www.cdc.gov/ncezid/index.html
Centers for Disease Control and Prevention. (2018c). One Health. Retrieved from
https://www.cdc.gov/onehealth
Centers for Medicare & Medicaid Services. (n.d.). How do Medicare Advantage Plans work?
Retrieved from
https://www.medicare.gov/sign-up-change-plans/medicare-health-plans/medicare-advantag
e-plans/how-medicare-advantage-plans-work.html
Centers for Medicare & Medicaid Services. (2014). Medicare program—General information.
Retrieved from
https://www.cms.gov/Medicare/Medicare-General-Information/MedicareGenInfo/index.html
Chin, M. (2017). 1 in 4 Americans refuse medical care because they can’t afford it. Retrieved
from
https://nypost.com/2017/06/07/1-in-4-americans-refuse-medical-care-because-they-cant-aff
ord-it
Chum, A., & O’Campo, P. (2015). Cross-sectional associations between residential
environmental exposures and cardiovascular diseases. BMC Public Health, 15(1), 1-12. doi:
10.1186/s12889-015-1788-0
Clarke, T. C., Schiller, J. S., & Norris, T. (2017). Early release of selected estimates based on
data from the January–June 2017 national health interview survey. National Center for
Health Statistics. Retrieved from
https://www.cdc.gov/nchs/nhis/releases/released201712.htm
Dean, O., Noel-Miller, C., & Lind, K. (2017, November). Who relies on Medicare? A profile of the
Medicare population. Retrieved from
https://www.aarp.org/content/dam/aarp/ppi/2017/11/who-relies-on-medicare-a-profile-of-the-
medicare-population
Duckworth, L. (2017). Under the microscope. Community Practitioner, 90(5), 28-32. Retrieved
from
https://search-proquest-com.lopes.idm.oclc.org/docview/1894941550/fulltext/CC70921EE62
C433FPQ/27?accountid=7374
Edmonson, C., McCarthy, C., Trent-Adams, S., McCain, C., & Marshall, J. (2017). Emerging
global health issues: A nurse’s role. Online Journal of Issues in Nursing, 22(1), 3. doi:
10.3912/OJIN.Vol22No01Man02

Environmental Protection Agency. (n.d.a). EPA strategic plan. Retrieved from
https://www.epa.gov/planandbudget/strategicplan
Environmental Protection Agency. (n.d.b). Our mission and what we do. Retrieved from
https://www.epa.gov/aboutepa/our-mission-and-what-we-do
Environmental Protection Agency. (n.d.c). Research on nanomaterials. Retrieved from
https://www.epa.gov/chemical-research/research-nanomaterials
Environmental Protection Agency. (2016). Climate change indicators in the United States.
Retrieved from https://www.epa.gov/climate-indicators
EveryCRSReport. (2017). The ACA Prevention and Public Health Fund: In brief. Retrieved from
https://www.everycrsreport.com/reports/R44796.html#fn5
Gyles, C. (2016). One medicine, one health, one world. Canadian Veterinary Journal, 57(4),
345-346. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4790223
Healthcare Triage. (2014). The healthcare system of the United States. Retrieved from

HealthyPeople.gov. (n.d.a). Development of the national health promotion and disease
prevention objectives for 2030. Retrieved from
https://www.healthypeople.gov/2020/About-Healthy-People/Development-Healthy-People-2
030
HealthyPeople.gov. (n.d.b). Environmental health. Retrieved from
https://www.healthypeople.gov/2020/topics-objectives/topic/environmental-health
Hernández, D. (2016). Understanding “energy insecurity” and why it matters to health. Social
Science & Medicine, 167, 1-10. doi: 10.1016/j.socscimed.2016.08.029
Institute of Medicine. (1988). The future of public health. Washington, DC: The National
Academies Press.
Institute of Medicine. (2000). To err is human: Building a safer health system. Washington, DC:
The National Academies Press.
Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st
century. Washington, DC: The National Academies Press.
Institute of Medicine. (2003). The future of the public’s health in the 21st century. Washington,
DC: The National Academies Press.
Institute of Medicine. (2011a). For the public’s health: The role of measurement in action and
accountability. Washington, DC: The National Academies Press.
Institute of Medicine. (2011b). The future of nursing: Leading change, advancing health.
Washington, DC: The National Academies Press.
Jackman-Murphy, K. P. (2015). Environmental health 101: Incorporating environmental health
into the nursing curriculum. Teaching and Learning in Nursing, 10(4), 192-195. doi:
10.1016/j.teln.2015.05.005
Kahn, S. (2011). Healthcare system overview. Retrieved from

Ki-moon, B. (2011, September 21). Address to the 66th General Assembly: “We the peoples.”
Retrieved from
https://www.un.org/sg/en/content/sg/speeches/2011-09-21/address-66th-general-assembly-
we-peoples

Medicaid.gov. (n.d.a). Monthly Medicaid and CHIP application, eligibility determination, and
enrollment reports & data: Preliminary December 2017 report. Retrieved from
https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data
/monthly-reports/index.html
Medicaid.gov. (n.d.b). Program history. Retrieved from
https://www.medicaid.gov/about-us/program-history/index.html
Micha, R., Peñalvo, J. L., Cudhea, F., Imamura, F., Rehm, C. D., & Mozaffarian, D. (2017).
Association between dietary factors and mortality from heart disease, stroke, and type 2
diabetes in the United States. JAMA, 317(9), 912-924. doi: 10.1001/jama.2017.0947
National Association of Free and Charitable Clinics. (n.d.). About us. Retrieved from
http://www.nafcclinics.org/content/about-us
National Academies of Sciences, Engineering, and Medicine. (2017a). Combating antimicrobial
resistance: A One Health approach to a global threat: Proceedings of a workshop.
Washington, DC: The National Academies Press.
National Academy of Sciences, Engineering, and Medicine. (2017b). Protecting health and
well-being of communities in a changing climate: Proceedings of a workshop—in brief.
Retrieved from
https://www.nap.edu/catalog/24797/protecting-the-health-and-well-being-of-communities-in-
a-changing-climate
Occupational Safety & Health Administration. (n.d.a). About OSHA. Retrieved from
https://www.osha.gov/about.html
Occupational Safety & Health Administration. (n.d.b). Hazards communication standard: Safety
data sheets. Retrieved from https://www.osha.gov/Publications/OSHA3514.html
Occupational Safety & Health Administration. (n.d.c). Healthcare wide hazards. Retrieved from
https://www.osha.gov/SLTC/etools/hospital/hazards/hazards.html
Olen, H. (2017). Even the insured often can’t afford their medical bills. Retrieved from
https://www.theatlantic.com/business/archive/2017/06/medical-bills/530679
One Health Initiative. (n.d.a). About the One Health initiative. Retrieved from
http://www.onehealthinitiative.com/about.php
One Health Initiative. (n.d.b). One Health initiative will unite human and veterinary medicine.
Retrieved from http://www.onehealthinitiative.com/index.php
Paquin, S. O. M. (2011). Social justice advocacy in nursing: What is it? How do we get there?
Creative Nursing, 17(2), 63-67.
Prüss-Üstün, A., Corvalán, C., Bos, R., & Neira, M. (2016). Preventing disease through healthy
environments: A global assessment of the burden of disease from environmental risks.
Geneva, Switzerland: World Health Organization. Retrieved from
http://www.who.int/quantifying_ehimpacts/publications/preventing-disease/en
Reinhard, S. (2018, February 7). Seeding a culture of health by spreading innovative ideas.
Retrieved from https://www.aarp.org/ppi/?intcmp=AE-SEARCH-AARPSUGG-ppi
Robert Wood Johnson Foundation. (n.d.a). Culture of health initiative. Retrieved from
https://www.rwjf.org/en/how-we-work/building-a-culture-of-health.html
Robert Wood Johnson Foundation. (n.d.b). Future of nursing: Campaign for action. Retrieved
from

https://www.rwjf.org/en/how-we-work/grants-explorer/featured-programs/future-of-nursing–c
ampaign-for-action.html
Robinson, M. D. (2016). Universal healthcare coverage around the globe: Time to bring it to the
United States? Journal of Health Care Finance, 43(3), 1-10. Retrieved from
http://healthfinancejournal.com/index.php/johcf/article/view/53
Schneider, E. C., Sarnak, D. O., Squires, D., Shah, A., & Doty, M. M. (2017). Mirror, mirror
2017: International comparison reflects flaws and opportunities for better U.S. health care.
Commonwealth Fund. Retrieved from http://resource.nlm.nih.gov/101712671
Schneider, E. C., & Squires, D. (2017). From last to first—Could the U.S. health care system
become the best in the world? New England Journal of Medicine, 377(10), 901-904. doi:
10.1056/NEJMp1708704
Seibert, D. J., Speroni, K. G., Oh, K. M., DeVoe, M. C., & Jacobsen, K. H. (2014). Preventing
transmission of MRSA: A qualitative study of health care workers’ attitudes and
suggestions. American Journal of Infection Control, 42(4), 405-411. doi:
10.1016/j.ajic.2013.10.008
Shrestha, K., Acharya, K. P., & Shrestha S. (2018). One Health: The interface between
veterinary and human health. International Journal of One Health, 4, 8-14. doi:
10.14202/IJOH.2018.8-14
SurgeonGeneral.gov. (n.d.). National prevention strategy. Retrieved from
https://www.surgeongeneral.gov/priorities/prevention/strategy/index.html
The Commonwealth Fund. (2017, July 14). New 11-country study: U.S. health care system has
widest gap between people with higher and lower incomes. Retrieved from
http://www.commonwealthfund.org/publications/press-releases/2017/jul/mirror-mirror-press-
release
The Jane Goodall Institute New Zealand. (n.d.). Choose the impact of your choices. Retrieved
from http://www.janegoodall.org.nz/jgi-nz-campaigns/sustainable-selves-tacare-nz/
Thurman, W., & Pfitzinger-Lippe, M. (2017). Returning to the profession’s roots: Social justice in
nursing education for the 21st century. Advances in Nursing Science, 40(2), 184-193. doi:
10.1097/ANS.0000000000000140
Tricare. (n.d.). Eligibility. Retrieved from https://tricare.mil/Plans/Eligibility
United Nations Economic Commission for Europe. (2013). Globally harmonized system of
classification and labeling of chemicals (GHS) (5th ed.). New York, NY: United Nations
Publications. Retrieved from
http://www.unece.org/trans/danger/publi/ghs/ghs_rev05/05files_e.html
United Nations. (n.d.). Sustainable development goals: 17 goals to transform our world.
Retrieved from https://www.un.org/sustainabledevelopment/sustainable-development-goals/
U.S. Bureau of Labor Statistics. (2017, November 9). Employer reported workplace injuries and
illnesses–2016. Retrieved from https://www.bls.gov/news.release/pdf/osh
Van Helden, P. D., Van Helden, L. S., & Hoal, E. G. (2013). One world, one health: Humans,
animals and the environment are inextricably linked—A fact that needs to be remembered
and exploited in our modern approach to health. EMBO reports, 14(6), 497-501. doi:
10.1038/embor.2013.61
Volunteers of America. (n.d.). Senior living and care. Retrieved from
https://www.voa.org/senior-living-and-care

Walter, R. R. (2017). Emancipatory nursing praxis: A theory of social justice in nursing.
Advances in Nursing Science, 40(3), 225-243. doi: 10.1097/ANS.0000000000000157
Webb, J. K. (2017). Why nurses need to be involved. Nurse Leader, 15, 323-324. doi:
10.1016/j.mnl.2017.07.006
World Health Organization. (2016a). An estimated 12.6 million deaths each year are attributable
to unhealthy environments. Retrieved from.
http://www.who.int/mediacentre/news/releases/2016/deaths-attributable-to-unhealthy-enviro
nments/en
World Health Organization. (2016b). WHO releases country estimates on air pollution exposure
and health impact. Retrieved from
http://www.who.int/mediacentre/news/releases/2016/air-pollution-estimates/en
World Health Organization. (2017a). Antibiotic resistance. Retrieved from
http://www.who.int/mediacentre/factsheets/antibiotic-resistance/en
World Health Organization. (2017b). Preventing noncommunicable diseases (NCDs) by
reducing environmental risk factors. Retrieved from
http://www.who.int/quantifying_ehimpacts/publications/preventing-ncds/en
World Health Organization. (2017c). Tracking universal health coverage: 2017 global monitoring
report. Retrieved from
http://www.who.int/healthinfo/universal_health_coverage/report/2017/en
World Health Organization. (2017d). Vector-borne diseases. Retrieved from
http://www.who.int/mediacentre/factsheets/fs387/en
World Health Organization. (2018a). Environmental health. Retrieved from
http://www.searo.who.int/topics/environmental_health/en
World Health Organization. (2018b). Health and sustainable development: BreatheLife.
Retrieved from http://www.who.int/sustainable-development/news-events/breath-life/en
World Health Organization. (2018c). High levels of antibiotic resistance found worldwide, new
data shows. Retrieved from
http://www.who.int/mediacentre/news/releases/2018/antibiotic-resistance-found/en
World Health Organization. (2018d). Neglected zoonotic diseases. Retrieved from
http://www.who.int/neglected_diseases/diseases/zoonoses/en
World Health Organization. (2018e). Secretary-General, at launch of international decade for
action, supports new approaches for better managing fresh water scarcity. Retrieved from
https://www.un.org/press/en/2018/sgsm18951 .htm
World Health Organization. (2018f). Sustainable development goals. Retrieved from
http://www.who.int/sdg/en
World Health Organization. (2018g). What is universal coverage? Retrieved from
http://www.who.int/health_financing/universal_coverage_definition/en
World Health Organization & United Nations Children’s Fund. (2017). Progress on drinking
water, sanitation, and hygiene: 2017 update and SDG baselines. Geneva, Switzerland:
Authors.

CHAPTER 5
Disaster Management
By Angel Falkner
Essential Questions
● What responsibilities does the community/public health nurse have in disaster nursing?
● What is the chain of command and communication process when a disaster occurs?
● What is the nursing process in disaster management?
● What are the different types of disasters?
● Identify the common physical, psychological, and social effects on disaster victims and
workers.
Introduction
Over the past decade, the incidence of natural and man-made disasters has increased
substantially, warranting the attention of federal and health care agencies. Public health nurses
(PHNs) play a vital role in the disaster management process. PHNs are involved in the
prevention, preparation, intervention, and aftermath-management processes involved in
handling disasters; this is called disaster nursing. PHNs are also actively involved in educating
and preparing members of the community for disasters. In all cases, PHNs must demonstrate
cultural competence when caring for victims of disaster.
What is a Disaster?
●
According to the International Federation of Red Cross and Red Crescent Societies (IFRC) a
disaster is “a sudden, calamitous event that seriously disrupts the functioning of a community or
society and causes human, material, and economic or environmental losses that exceed the
community’s or society’s ability to cope using its own resources,” (International Federation of
Red Cross and Red Crescent Societies, n.d.). There are two major types of disasters,

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man-made and natural. Man-made disasters include terrorism, transportation accidents, food
and water contamination, and building collapse (see Figure 5.1). Natural disasters include
forces of nature such as hurricanes, blizzards, mudslides, earthquakes, tsunamis, epidemics,
and fires (see Figure 5.2). In either type of disaster, there is a primary agent and a secondary
agent that cause damage. The agent is the cause of injury or insult during a disaster. During
Hurricane Irma in 2017, the primary agent that caused damage was the flood waters from the
storm. The secondary agents were the viruses and bacteria that cultivate in stagnant water and
have the propensity to spread disease. When the outcomes of the event supersede the
community’s ability to manage the effects on their own, involvement of federal agencies to
provide assistance on multiple levels is warranted.
Figure 5.1
Types of Natural Disasters

Figure 5.2
Types of Man-Made Disasters

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Several terms define the severity of casualties associated with disasters. Multiple casualty
incident occurs when the casualty toll is isolated to fewer than 100 people. A mass casualty
incident involves larger numbers, typically more than 100 people, and has an apparent effect
on local emergency medical services and resources. Mass casualties can occur in any type of
disaster.
Many factors will impact the individuals directly affected by the event during a disaster.
Individuals who typically require the care of another are often at the greatest degree of risk.
These vulnerable population groups include young children, the geriatric community, persons
with severe mental or physical handicaps, and those physically dependent upon medical
equipment either in acute or long-term care facilities. Individuals who fall into the vulnerable
population category may not be able to evacuate during a disaster event and may require
high-priority assistance because of advanced medical needs.
Dimensions of a Disaster

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●
Disasters are made up of multiple dimensions. A disaster’s predictability is based upon the
ability to foresee the impending event, such as with weather forecasting systems that have the
ability to deliver a hurricane or tornado warnings. Man-made disasters, such as a terrorist
attacks or vehicle accidents, are more difficult to predict as they can occur without warning and
are often dependent on the behaviors and perceptions of specific individuals or groups.
Geographic areas can help to determine the frequency of disasters. For instance, those living
in the Midwest area of the United States known as “Tornado Alley” have a greater risk of
experiencing a natural disaster from a tornado. People living in the state of Florida have a
higher incidence of experiencing a hurricane because of their proximity to the coastline.
Controllability refers to the ability to plan ahead for the possibility of an event in the future.
Though the event itself cannot be controlled or even predicted, people can prepare and plan for
it. An example of this would be having an emergency kit in the house at all times in the event of
a disaster such as a fire, tornado, or hurricane. These kits should include basic household items
such as canned foods and bottled water. Such planning is described as mitigation. The
Federal Emergency Management Agency (FEMA) describes mitigation as the effort to reduce
loss of life and property by lessening the impact of disasters (Federal Emergency Management
Agency [FEMA], 2018).
Time is yet another uncontrollable factor. For instance, in the event of a hurricane, the
developments in weather forecasting have made it possible for warnings to be issued days in
advance, allowing time for people to evacuate and prepare for the upcoming event. Other
events such as tornadoes, flash floods, or man-made events such as terrorist attacks, offer little
to no warning.
Scope and intensity refer to the scale of damage upon the community and the casualties that
occur as a result of the event. Scope is more specific to the depletion of typical resources within
the effected community, while intensity evaluates the effect on the community’s health and loss
of life. The greater the scope and intensity, the larger the disaster and the more resources and
support are required.
Disaster Phases

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●
Phases during a disaster include preimpact, impact, and postimpact. See Table 5.1 for
information on the disaster phases and the nursing process (Millet, 2013; Jakeway, LaRosa,
Cary, & Schoenfisch, 2008; Association of Public Health Nurses, 2013).
Preimpact
During the preimpact phase, preparation or mitigation occurs. This phase is optimal for
planning and preparing for a disaster as individuals and as a community. Individuals may plan
and prepare by gathering items for an emergency kit for the home or discussing where to meet
family members in the event of an emergency. On a community level, planning and preparing
may involve government agencies and health care facilities assessing inventories for resources
and equipment necessary in the event of a disaster. This phase also provides emergency
management services as well as health care facilities time to orchestrate drills and review policy
and procedures that need to be followed in a disaster. When an impending disaster is predicted,
PHNs may be called upon to set up shelters or emergency aid centers preemptively. Nurse
managers and team leaders in health care facilities may help coordinate practice drills or
meetings with staff for discussion of how to navigate the influx of patients expected during and
after the event.
Impact
The impact phase occurs during the actual disaster event, which may last for minutes, days, or
even weeks depending on the type of disaster. The priority for this phase is survival. The extent
of predicted damage must be assessed in order to disseminate the appropriate resources. This
assessment includes determining the appropriate number of health care workers and
emergency first responders necessary to provide care to victims. The impact phase is also when
search and rescue efforts are coordinated and executed. The PHN in this phase is a provider of
physical and psychological care who helps to triage victims according to their injuries.
Postimpact
The postimpact phase occurs once imminent danger has ceased. During this period, rescue
and emergency medical care becomes the primary focus. Once victims are treated and
transported to safety, the process of recovery can begin. This disaster phase can last months or
years and, depending on the scope and intensity of the disaster, may even have lifelong effects.
The postimpact phase includes debriefing and reevaluation of disaster and emergency
preparedness and prevention strategies to improve outcomes should another disaster occur.

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Table 5.1
Disaster Phases and the Nursing Process
Disaster
Phase
Prevention (Mitigation) Preparedness Response Recovery
Definition ● Planning for
disasters or
emergencies to
reduce
vulnerability/damag
e/injury should an
event occur.
● Develop
capacity
to
respond
swiftly,
efficientl
y, and
effectivel
y to
disasters
and
emergen
cies.
● Provide
support
to
populatio
ns
affected
by
disasters
and
emergen
cies.
● Restore
support
systems
to
functional
levels.
Assessment ● Assess population
groups for
awareness of
potential disasters.
● Assess
special
needs of
populatio
n groups
in the
event of
a
disaster.
● Conduct
assessm
ent of
threats
or
hazards
that pose
the
greatest
risk to
the
● Use
public
health
incident
triages
and
teams to
assess
the
impact of
and
health
needs
arising
from the
disaster.
● Participat
e in the
incident
response
assessm
ent of
postdisas
ter
communi
ty needs
for health
care and
health
resources
.

populatio
n.
Planning ● Develop emergency
awareness
programs to
increase awareness
of potential
emergency or
disaster events.
● Develop
plans to
address
access
to and
needs of
populatio
ns in the
event of
a
disaster.
● Plan for
the
needs of
small or
large
populatio
ns to
shelter in
place,
evacuate,
and
mass
casualty
surges.
● Develop
plans in
collabora
tion with
incident
triages
and
teams to
determin
e care
and care
logistics
needed
to serve
the
populatio
ns and
reduce
stress
and
burnout
among
responde
rs.
● Collabora
te with
communi
ty
stakehold
ers and
partnershi
ps to plan
long-term
recovery
priorities,
resources
, and care
logistics.

Implementati
on
● Conduct community
education programs
to increase
awareness with a
variety of media
approaches.
● Conduct
exercises
and
training
drills to
care for
various
size
populatio
ns.
● Include
training
scenario
s
involving
persons
with
special
needs
and
family
separatio
ns.
● Follow
incident
emergen
cy
response
plans to
deploy
personne
l to
locations
with
affected
populatio
ns such
as
emergen
cy
shelters.
● Conduct
ongoing
assessm
ent of
needs.
● Participat
e in
restoratio
n of
health
care
services.
Evaluation ● Evaluate
community
education activities
for effectiveness.
● Evaluate
exercises
and
training
drills for
gaps and
remainin
g
educatio
n and
training
needs.
● Participat
e in
incident
emergen
cy
response
evaluatio
ns,
including
gap
analysis
and
planning
for future
events.
● Participat
e in
evaluatio
n of the
long-term
conseque
nces of
the
populatio
ns who
experienc
ed or
responde
d to the
disaster.

Self-Protection
In times of crisis, caregivers and health providers become first responders, providing aid to
those in need; however, it is essential for providers to care for themselves first before rendering
aid. FEMA reiterates the steps of initiating an emergency response in their Community
Emergency Response Team (CERT) training, stating, a CERT member’s first job is to stay
safe (PerformTech, Inc., 2011). One of the primary ways providers can ensure their own safety
on the scene of a disaster is with the use of personal protective equipment (PPE). Nurses use
PPE in practice on a regular basis, but there are some differences in PPE at the bedside in
nursing versus during disaster relief efforts.
Figure 5.3
PPE

Prior to assessing a scene, the first thing anyone responding to a disaster must do is to
determine the level of safety risk. A firm awareness of one’s surroundings does not stop during
rescue efforts. Disaster scenes often change quickly, and responders must remain vigilant.
During the Ebola epidemic, a series of transmissions among health care providers revealed
gaps in infection prevention and control (IPC) procedures (Hageman et al., 2016). To address
this gap, the CDC worked with facilities in the United States to provide new and improved IPC
training in order to prevent further transmission of the Ebola epidemic (Hageman, et al., 2016).
Health care providers and volunteers responding to a disaster where the spread of infectious
disease is a concern should be cautious, particularly when caring for victims, and use the
appropriate protocol when handling patients and bodily fluids. Though nurses are familiar with
universal precautions enforced in clinical settings, they must also follow protocols in the field to
ensure their safety and the safety of colleagues, other volunteers, and effected persons.
Disaster Management Services
There are multiple federal and local agencies involved in disaster management that contribute
to safety and survival of citizens in the event of a disaster. Disaster response begins at a local
level and then, if necessary, proceeds to a state and federal level. The PHN should be familiar
with such systems and how they function.

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National Disaster Medical System (NDMS)
The National Disaster Medical System is a division of the U.S. Department of Health and
Human Services (HHS) and is composed of health professionals who are allocated to respond
in the event of a disaster. These well-trained professionals are hired as intermittent federal
employees and have an expected on-call deployment of a minimum of 2 weeks per year. They
undergo a rigorous applicant screening process that ensures physical and psychological ability
to fulfill expected duties. Once hired to be a part of this program, there are various teams that
the health care professionals can be assigned to depending on background and expertise.
These include Disaster Medical Assistance Teams (DMAT), Trauma and Critical Care Teams
(TCCT), Victim Information Center Teams (VIC), Disaster Mortuary Operational Response
Teams (DMORT), or and the National Veterinary Response Team (NVRT) (Public Health
Emergency, 2018). Each of these respective teams are deployed to the sites of various natural
and man-made disasters. Nurses typically serve on the DMAT or TCCT teams where their
specialized skills can be best utilized. Nurses who are part of these teams have responsibilities
similar to those within the area for which they are trained. For instance, a trauma critical care
nurse would provide this type of nursing care to victims at the scene.
Federal Emergency Management Agency (FEMA)
Established in 1979 by President Jimmy Carter, FEMA is a division of the Department of
Homeland Security (DHS) and is the coordinating agency for allocation of assistance in the
event of disasters in the United States. “FEMA’s mission is to support citizens and first
responders to ensure that as a nation we work together to build, sustain and improve our
capability to prepare for, protect against, respond to, recover from and mitigate all hazards”
(FEMA, 2017).
FEMA works with state and local governments to provide assistance, preparation, and training
associated with disaster management. Since its inception, the department has been reformed
several times to optimize its ability to provide necessary resources during disasters, with the
most recent reformation occurring in 2006 following Hurricane Katrina. FEMA is responsible for
formulating the National Response Framework (NRF), which is a guide that helps the nation
understand how to respond to disasters and emergencies. FEMA outlines four primary phases
regarding disaster management: mitigation, preparedness, response, and recovery (see Table
5.2) (FEMA, 2016).
It is important to note that in order for FEMA to provide aid during the recovery phase of disaster
management, the disaster must be declared a major disaster by the acting President of the
United States. This is a process that begins with the local governor of the affected area applying
to FEMA to declare the affected region a major disaster area. Once this occurs, the allocation of
resources, such as grant funding, is provided by FEMA.

●
●
Table 5.2
Elements of Disaster Management
Disaster/Emergency
Management Phases
Definition/Characteristics Role/Responsibilities of the
Nurse and/or the PHN
Mitigation ● Any activity that
prevents or reduces the
impact of unavoidable
emergencies
● Acquiring insurance
such as flood or fire
protection
● Takes place before and
after events
● Provide education to
public regarding
planning and reaction in
the event of
emergencies
● Coordination of
preparation drills, such
as mass casualty drills
Preparedness ● Plans and preparation
for life-saving efforts,
including rescue and
response
● Evacuation plans, such
as creating a disaster
kit
● Education of the public
● Helping the public and
families create disaster
kits and plans of action
in the event of an
emergency
● Helping coordinate and
institute plans of action
in facilities (e.g.,

Note. Adapted from Infection Prevention Orientation Manual: Section 15: Emergency Preparedness,
by K. Bryan & B. Wardle, 2014. Copyright 2014 by the Wyoming Department of Health.
National Response Framework (NRF)
The NRF was developed by FEMA as a guide for preparedness in the event of a disaster or
crisis situation. The framework recognizes the need for involvement beyond the federal
government and incorporates the assistance of local, tribal, and state government agencies as
well as assistance from the private sector and nonprofit organizations. Five key principles guide
the framework (FEMA, 2016).
1. Engaged Partnership: All sectors of the community are involved and do not solely rely on
governmental agencies. This involvement includes the private sector as well, including
volunteer organizations such as the American Red Cross and Christian Disaster
Response.
2. Tiered Response: Assistance begins at the local level where the event occurs and then
branches outward as assistance is needed.
3. Scalable, Flexible, and Adaptable Operational Capabilities: The amount of allocated
resources must expand to meet the needs the disaster has created.
4. Unity of Effort and Unified Command: The allocation of assigned roles during disaster
management must be understood, meaning that each agency involved maintains its own
respective authority, responsibility, and accountability.
5. Readiness to Act: Organizations’ members and volunteers must be adequately prepared
prior to disaster events and understand the risk associated with responding to the needs
hospitals, care homes,
schools)
Response ● Safety is the priority
● Activation of
preparation plans made
during mitigation and
preparedness phases
● Seeking shelter
● Helping citizens find
appropriate shelter
● Personal accountability
for self and one’s own
family
Recovery ● Medical assistance
● Rescue and recovery of
victims
● Physical and
psychological healing
● Begin to rebuild
● Mitigation continues
● Provide medical
attention to victims
● Help provide emotional
support
● Begin planning for
mitigation phase

of victims. It is important to follow regulated processes and procedures to operate
effectively.
Figure 5.4
National Response Framework

Note. Adapted from National Response Framework (3rd ed.), by the Federal Emergency
Management Agency, 2016.
National Incident Management Systems (NIMS)
National Incident Management Systems (NIMS) is a division of FEMA and DHS that helps
provide prevention training and coordination between public and private entities in managing
disaster incidents across the nation. They utilize the Incident Command System (ICS), which
provides protocols and structure that helps coordinate various parts of disaster management,
such as operations, planning, logistics, and finances (see Figure 5.5). The system has various
leadership roles, such as the incident commander who helps oversee the various areas that
need to be managed in an organized manner during disasters. While in use, the ICS works from
an Emergency Operations Center (EOC) that can vary depending on the type of disaster.
Figure 5.5
Incident Command System

Note. Adapted from “Incident Management,” by Ready.gov.
Emergency Operations Center (EOC)
The Emergency Operations Center (EOC) serves as a command center where government
agencies can manage the disaster response. According to FEMA, “EOC core functions include
coordination; communications; resource allocation and tracking; and information collection,
analysis, and dissemination,” (FEMA, n.d., para. 28). The EOC may be any type of building or
structure, from a warehouse to a gymnasium, that provides ample space and is safe from the
effects of the disaster. This is where coordination efforts occur, but it is also where emergency
medical aid may be provided to the first survivors of the event.
Emergency Medical Services
Traditionally, Emergency Medical Services (EMS) is thought of as the phone call to 9-1-1 in
times of danger. From a young age, children are taught the importance of learning how to dial
9-1-1 in the event of a crisis in order to receive help from first responder medical personnel and
law enforcement as quickly as possible. The Federal Interagency Committee on EMS (FICEMS)
was established by Congress in order to streamline coordination between local EMS chapters
and the federal government to improve the delivery of EMS to citizens across the country in
times of crisis (Federal Interagency Committee on EMS, n.d.). In addition, the U.S. Department
of Defense (DOD) provides specialized training to EMS workers in preparation for deployment to
hostile or combat areas around the world. EMS also works with FICEMS to coordinate and
institute casualty drills and provide preparedness education to the public. Courses such as
pediatric and mass casualty triage training are available for free on their website. Nurses may
be involved in the coordination and the execution of such training and drills throughout the
community.

American Red Cross
The American Red Cross (ARC) is an organization that provides aid during disasters and is
composed of nearly 90% specially trained volunteers. Founded by renowned nurse, Clara
Barton, ARC’s mission is to provide assistance to those in dire need of emergency services
related to any disaster occurrence. ARC works in conjunction with FEMA and other federal
emergency response agencies and Community Emergency Response Teams (CERTs) to
coordinate relief efforts for victims of disasters across the country. ARC assists with providing
medical care, emergency supplies, and education and preparedness strategies as well as
setting up and running emergency shelters among communities across the United States
(American Red Cross, n.d.). Nurses can apply to volunteer for the ARC and will go through
required volunteer training. After training, nurses will be utilized depending upon the need within
the community and the volunteers’ availability.
Faith-Based Disaster Response Organizations
There are a plethora of faith-based, nonprofit organizations that provide support during disaster
relief throughout the United States. Each organization provides resources such as food, water,
and basic necessities as well as volunteer relief workers who assist in many capacities and work
in conjunction with government agencies to assist victims of disasters when they occur. In
addition, many of these organizations provide training and assistance in the planning process to
help improve efforts when the next disaster hits. These faith-based organizations provide
support and assistance following their religious doctrines that speak largely of compassion,
caring, and helping the less fortunate. Some commonly known faith-based disaster
organizations include Catholic Charities USA, United Methodist Committee on Relief (UMCOR),
and Lutheran Disaster Response. During recent events, such as Hurricane Irma in Florida, the
United Methodist Committee on Relief provided a tremendous amount of support to relief
efforts, including clean up following the hurricane and helping citizens with organization of aid
and insurance to help them begin to rebuild their lives. Another organization, The Convoy of
Hope, deployed several trailer trucks stocked with food and water prior to the impact of the
hurricane to help prepare for the impending needs of the community (Rehwald, 2017).
Community Emergency Response Teams (CERTs)
Community Emergency Response Teams (CERTs) are composed of community volunteers who
work to prepare their communities against threats. Though they are not first responders to
disaster events, they are well trained to assist first responders (Ready.gov, n.d.a). CERT
volunteer teams are valued members of the community who provide aid to victims quickly and
assist first responders in the management of disaster scenes. Nurses may volunteer for CERT
teams, but they would be completing the duties as described in their CERT training for
volunteers rather than providing nursing care to victims.
Some of the things CERT volunteers are trained to do include:
● Prepare for the hazards that threaten their communities.
● Apply size-up and safety principles.

● Locate and turn off utilities.
● Extinguish small fires.
● Identify hazardous materials situations.
● Triage and treat victims.
● Set up a medical treatment area.
● Conduct search and rescue operations in lightly and moderately damaged structures.
● Understand the psychological impact of a disaster on themselves and others.
● Organize CERT members and spontaneous volunteers for an effective and safe
response.
● Apply response skills in a disaster simulation.
Hospital Disaster Plans
●
●
●
Hospitals play a critical role in responding to and preparing for disasters. Hospitals have policies
and procedures in place in the event of a disaster that may vary slightly from facility to facility,
but they cover the basics of disaster management and response. The Centers for Disease
Control and Prevention (CDC), World Health Organization (WHO), American Nurses
Association (ANA), and FEMA provide advice on the components that should be incorporated
into a hospital disaster plan. The Joint Commission requires every hospital to have a disaster
plan in place. These plans should include management of internal and external disasters and
are to be practiced several times a year. Nurse leaders will be involved in the planning,
coordination, and incorporation of such drills to prepare employees. Internal disasters might

include the rapid spread of an infectious disease process within the patient population inside the
hospital. An external disaster would include any natural or man-made disaster that occurs within
the nearby communities.
Nurses’ Duty to Respond
●
Nurses are licensed providers who have an obligation to respond in emergency situations.
When disaster strikes, nurses are faced with numerous challenges, including the care of
multiple stakeholders. According to the Provision 2 of the ANA Code of Ethics, the nurse retains
a primary commitment to the patient at all times (American Nurses Association, 2015). However,
this does not to negate Provision 5, which emphasizes self-care as equally important. Nurses
have a moral obligation to uphold their fundamental duty to care, but this does not mean
jeopardizing their own safety or the safety of others in times of crisis.
Social Justice
●
●

●
The Agency for Healthcare Research and Quality (AHRQ) and the Institutes of Medicine (IOM)
have developed a framework that includes six aims for the health care system. These aims
indicate that patient care should be safe, effective, patient-centered, timely, efficient, and
equitable. When discussing health equity, it is essential to underline the importance of providing
disaster victims with equitable care despite social determinants of health (SDOH).
In areas that are impoverished or have a high number of immigrants or diverse cultures, special
attention and care must be considered when providing support to victims following a disaster.
This issue was highlighted in the aftermath of Hurricane Katrina in the Gulf Coast area. Many
communities affected by the hurricane’s impact were impoverished, and it became evident very
quickly that planning and response for these types of communities was not adequate. Victims
did not receive the financial support, supplies, or medical attention they needed in a timely
manner, extending their recovery time and leading to poor outcomes. The devastation that
occurred in these areas gave rise to the development of more particular and critical response
methods that addressed special issues such as poverty and culture (Lichtveld, 2018). This
might include ensuring appropriate translation services are provided in order to communicate
needs to communities that do not speak English.
Evacuation
●
In the event of an impending disaster, the best-case scenario would allow a few days to
coordinate evacuation efforts. In events when early warnings are not possible, evacuation
efforts may prove to be more chaotic. Properly planning ahead helps to ensure safe and prompt
escape from the area of threat. Planning involves identifying the types of disasters that could
occur in the surrounding area, identifying where to go when evacuation is necessary, preparing
a safe places for pets, and being familiar with escape routes and alternate routes out of the
area. Families should also determine a location where they should meet if they become
separated for any reason. Keeping a bag containing household essentials, including

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nonperishable food, bottled water, flashlights, batteries, and a first-aid kit, is another necessary
item to have in the home at all times. Before returning home, always check with local authorities
to make sure it is safe to do so. Nurses should be careful when reporting for duty in response to
a disaster; they should ensure their families’ safety first and that the route and available
transportation to the hospital is safe before embarking on the journey.
Rescue and Recovery
Once the imminent threat of the disaster’s effects are over, the rescue and recovery process
begins. This process is commonly referred to as search and rescue (SAR). The rescue process
begins at the local level, with first responders from the local fire and police departments as well
as emergency management personnel being on the scene. The largest SAR system was
established under FEMA and includes 28 urban rescue task forces that are deployed in the
event of disasters around the nation. The local emergency manager may request assistance
from the state and, if necessary, FEMA will deploy its three closest SAR task forces to
intervene. The scene is assessed for safety before the search and rescue crew is sent in, and
heavy equipment is used to clear away large pieces of debris that may be trapping survivors.
Emergency health care workers are on scene to provide stabilizing medical treatment once
survivors are extricated. During the process, hazardous material specialists are also on scene to
evaluate for possible contamination that could pose a threat to the rescue team (FEMA, 2017).
Principles of Disaster
Management
Disaster Preparedness
●

●
The concepts of primary, secondary, and tertiary prevention have been described in detail
throughout the baccalaureate-nursing program. These concepts can also be applied to disaster
preparation as well. Prevention is a key component in the NRF for disaster management that
warrants further discussion and elaboration. Though true prevention of disasters is not possible,
prevention in disaster preparation is described in terms of management versus total aversion of
disaster occurrence.
Preventable Versus Nonpreventable
Disasters cause destruction in part because of their unpredictable nature, which warrants proper
preparation versus true prevention. Prevention measures, such as mitigation efforts, are the
best ways that the impact of disaster can be lessened. The major difference between mitigation
and preparedness is that mitigation looks at long-term solutions that help to reduce risk instead
of merely reacting to consequences of disaster events once they have occurred (FEMA, 2018).
Though impossible to stop disasters altogether, it is possible to educate, plan, and collaborate
efforts to prepare communities to withstand, survive, and recover from events that are not in
anyone’s control.
Primary
Primary prevention in disaster management involves planning prior to the occurrence or onset
of a disaster event. The PHN assists in educating the community and families about having
plans in place in the event of a disaster and being aware of the local resources families may
need during a disaster. This is particularly important for families with small children and those in
care of persons who are severely disabled or in need of continual medical care and treatment.
Ready.gov is a government website that provides a wide range of information regarding
preparation for common emergencies and disaster events. The website is a resource the PHN
can recommend to people for assistance in creating a plan that includes evacuation, safety
skills, and financial concerns (Ready.gov, n.d.c). Another tool this website provides is a list of
supplies recommended for preparing an emergency supply kit (see Figure 5.6). Preparedness is
essential, yet is often overlooked as a necessity in American society. A recent national survey
conducted by Columbia University determined that two-thirds of American households do not
have adequate plans for disasters (Petkova et al., 2016).
Figure 5.6
Emergency Supply List

Note. Adapted from “Emergency Supply List,” by the Federal Emergency Management Agency,
2014.

●
●
Mitigation
Mitigation refers to the specific measures taken prior to the onset of a disaster event
that help to decrease or eliminate the disaster’s associated risks. Though the levee
system in Louisiana failed during Hurricane Katrina in 2005, their original construction
and institution is an example of mitigation. The levees were meant to help diminish the
floodwaters associated with massive storms such as Katrina, thereby decreasing the
damage. According to FEMA the following are also examples of mitigation:
● Complying with or exceeding National Flood Insurance Program floodplain
management regulations
● Enforcing stringent building codes, flood-proofing requirements, seismic design
standards, and wind-bracing requirements for new construction or repairing
existing buildings
● Adopting zoning ordinances that steer development away from areas subject to
flooding, storm surge, or coastal erosion
● Retrofitting public buildings to withstand ground shaking or hurricane-strength
winds

● Acquiring damaged homes or businesses in flood-prone areas, relocating the
structures, and returning the property to open space, wetlands, or recreational
uses
● Building community shelters and tornado-safe rooms to help protect people in
their homes, public buildings, and schools in hurricane- and tornado-prone areas
(FEMA, 2018).
Secondary
Secondary prevention may occur when the onset of the disaster has occurred or within hours of
its impact; this is when response occurs during a disaster. Response in disaster management
indicates the period of time for emergency assistance with the goal of maintaining and saving
lives, improving health, surviving the disaster event, and supporting victims (National Disaster
Recovery Framework, 2016). The priority is safety and survival during the response phase and
occurs when it is necessary to evacuate or, if more appropriate, find and take shelter. Families
and individuals can prepare for this phase by having a designated safe area or location in which
they plan to take refuge. PHNs educate families on possible evacuation and alternative routes
as well as locating places of refuge when evacuation is not an option.
Tertiary
Tertiary prevention occurs after the offending event has ceased and the focus is on recovery.
The tertiary and recovery phases may last weeks, months, or even years and involves property
damage recuperation, physical rehabilitation of those injured, mental illness evaluation and
treatment, planning for future disasters, and financial recuperation. While the focus is on
recovering from the event, thought should be given to how well the first two prevention phases
went and what can be done to improve them. PHNs can help to evaluate the process and
devise and implement changes in the prevention plan that may help to avoid devastating results
in the next disaster event.
Community Reaction
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●
●
The effects of a disaster can be longstanding and life changing for individuals and communities.
Effects can be on many levels, from the psychological to spiritual. All varying needs must be
taken into consideration when caring for those affected following a disaster event.
Psychological Impact
Following disasters, individuals within the affected community may have varying emotional
reactions. It is normal to see a degree of panic within the community when the disaster is
occurring. Panic is the sudden onset of excited feelings brought on by the fear of impending
danger; this is what causes people to run franticly from buildings or the scene of a disaster in
search of refuge.
Shock is defined as a period of disbelief that may render a person incapable of typical thought
processes or role function; this usually sets in once the imminent danger of the disaster has
ended. This is a very typical reaction following a disastrous event and, while usually temporary,
may have a profound impact on a person’s sense of normalcy and control. If the initial shock of
the event does not dissipate, the emotional strain may lead to long-term mental disorders such
as depression or post-traumatic stress disorder (PTSD).
There are a wide range of psychological effects following a disaster. Some level of distress is
considered typical; however longstanding depression, anxiety, and PTSD may affect individuals
for years following the disaster event itself (Martin, 2015). The psychological effects can last
years and have a devastating effect on the daily lifestyle, personal relationships, and return of
typical daily functions in individuals struggling with such diagnoses. There are also correlations
between exposure to a disaster and increased incidence of drug and alcohol abuse as a means
of coping with the stress of the experience (Maclean, Popovici, & French, 2016).
Nurses within the community must take this into account when caring for survivors of such
events, remembering to consider that the event may have occurred many years ago and still
have an impact on the patient. Nurses should refer patients to case management, chaplain

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services, and social work as well as coordinate counseling services or other appropriate
resources for mental health when indicated. The Disaster Distress Hotline, a free telephone
hotline offered by the Substance Abuse and Mental Health Services Administration (SAMHSA),
is available for people seeking help following a disaster event (Substance Abuse and Mental
Health Services Administration [SAMHSA], 2012). People can call or text 365 days a year, 24
hours a day to receive free emotional support related to being involved in a disaster; these
services are provided in English, Spanish and accommodations are made for the hearing
impaired (SAMHSA, 2012).
Under normal, controlled circumstances, the business of caring for the sick is emotionally
draining; therefore, doing so in the midst of total chaos adds additional strain and may have an
impact on health care professionals that warrants attention. Nurses should stay aware of their
own emotional health during these times and reach out for support when needed. Nurses may
fall victim to the psychological affects following a disaster and should be supported by their
managers, peers, and other health care professionals to provide them with the care they may
need.
Spiritual and Cultural Considerations
As previously discussed, disasters take a significant toll on mental health, causing short and
long-term distress. During these times, the need for spiritual care may become dire. Regardless
of religious affiliation, chaplains play an important role in supporting the communities’ emotional
needs during and after a devastating event (Graham, 2014). Nurses working with the victims
can advocate for the spiritual needs of patients by locating the chaplain whenever possible and
facilitating the incorporation of spiritual practices that do not interfere with patient safety or the
course of treatment to provide comfort. Reaching beyond spiritual guidance, chaplains are
trained to provide psychological support. Chaplains are valuable members of society, providing
counsel and comfort to the shocked, grieving, and emotionally devastated victims in disasters.
Cultural needs must also be considered when preparing for disasters and caring for survivors.
Different cultures may respond to a traumatic event differently, whether it be with prayer, crying,
or stoic affect. The PHN should be aware of cultural differences and approach each patient with
sensitivity and respect, allowing them to grieve, react, and respond the way that is appropriate
for them, as long as they are not causing self-harm or harming others. In areas where
populations are extremely vulnerable, such as areas of high poverty, their ability to cope and
recover financially as well as psychosocially following a disaster may be severely impaired
(Knox & Haupt, 2015). These individuals will require more support from local and federal
agencies to move forward with the recovery process. PHNs are valuable advocates helping to
allocate resources for those with limited capacity to do so on their own. In preparing a
community for disaster, the community’s culture should be examined, and appropriate
adjustments should be made to account for cultural differences. This may mean PHNs must
adjust how they educate community members about disaster preparations or utilizing translation
services if needed.
Physical Impacts

Beyond the short-term injuries that may be sustained during a disaster event, some survivors
may experience life-long effects on their health. These effects stem from a number of things,
including severe injuries or exposure to carcinogenic, toxic, or radioactive substances during or
after the event.
Fertility
One major longstanding physical impact seen in disaster survivors is a decrease in fertility. This
is due to a variety of reasons associated with the disaster, including exposure to toxic agents,
psychological trauma, and general exposure to the traumatic event (Zotti, Williams, Robertson,
Horney & Hsia, 2013). Along with decreased rates of fertility, studies have shown an impact on
pregnancy loss, birth defects, low-birth weights, and preterm births (Zotti et al., 2013). Studies
point to the stress of the disaster event having profound negative effects on women in their
child-bearing years. These negative effects may inhibit women from conceiving or carrying to
term, which may cause an increase in emotional strain on the woman and her partner. While
there are promising infertility treatments that can be offered to a struggling couple, their mental
health and coping must be of concern as well. Nurses must consider offering services that will
address the issue of fertility and childbearing as well as mental well-being.
Toxic Exposure
Regardless of the type of disaster, there is always risk of exposure to toxic substances or
carcinogens that have the potential to impact health throughout one’s lifetime. A prime example
of this type of exposure that is still being researched and studied is the exposure to various toxic
inhalants during the September 11, 2001 terrorist attack on the World Trade Center in New York
City. During this terrorist attack, high concentrations of dense dust particles were inhaled and
swallowed by survivors and first responders in the surrounding area, causing a host of
respiratory and digestive issues that continue to cause these individuals health problems, such
as gastroesophageal reflux (GERD) and lung cancer (Lippman, Cohen & Chen, 2015).
Nurses must understand that the health effects following a disaster can have lifelong impacts
that cause a multitude of issues long after the disaster occurrence. The skill of history taking is
essential in these instances. The patient may not mention being a survivor of a disaster,
especially if it was many years ago, and they see no reason to bring it up. Discovering that a
patient is a survivor of a disaster event and was exposed to toxic agents may indicate a need for
different diagnostic procedures, which highlights the importance of detailed and thorough health
history taking. In addition, the patient may be suffering from other effects of surviving a disaster
as well, such as PTSD or other mental health issues, and may require appropriate referral and
support from other members of the health care team, such as social work and case
management.
Population Health Considerations Post Disaster
There are a great number of considerations to be made during the recovery phase to help the
affected community fully recover. Beyond the physical injuries and loss of lives, there is damage
to buildings and property, loss of housing, lack of running water and electricity, overwhelmed
emergency services and local hospitals, and inadequate financial resources to provide the

necessary items for relief and recuperation. Each of these issues warrants time, resources,
collaborative planning, and efforts in order to restore balance to a community that has suffered
immeasurable losses. PHNs are instrumental to this process by evaluating patients in the
community, assessing their needs, and providing necessary education for health promotion
measures and/or preparation for the next disaster that may occur.
Economic Impact
The economic impact on communities after a disaster can vary depending on various elements
of the disaster itself and the severity of its impact. According to FEMA, in the 1990s more than
$25 billion was allocated to provide disaster assistance in the United States, and money sent to
assist after disasters worldwide skyrocketed to over $608 billion (FEMA, 2009). While the costs
and lives lost are seemingly unavoidable, proper preparation and improvement of preparation
processes are essential to decreasing cost as well as saving lives. PHNs can contribute to this
by being involved in the mitigation and preparation processes in disaster management, as well
as the evaluation postdisaster to help improve preparation plans before the next disaster strikes.
Table 5.3 provides information on the five costliest hurricanes on record to strike the United
States (Office for Coastal Management, n.d.).
Table 5.3
Economic Impact
Nurse’s Role in Disaster
Management
Name Year Cost
Katrina 2005 $161 billion
Harvey 2017 $125 billion
Maria 2017 $90 billion
Sandy 2012 $71 billion
Irma 2017 $50 billion

●
●
●
PHNs play an integral role in the community as trusted and esteemed caregivers. PHNs not only
have a responsibility to their patients, but also to their community as a whole. Whether natural
or man-made, disasters are inevitable, and nurses must be prepared to respond. Nurses have a
long and proud history of caring for the sick and injured in tumultuous times, most notably in the
days of Florence Nightingale during the Crimean War. These roots remain a driving force that
inspires nurses to dutifully and skillfully care for patients. PHNs take this care a step further by
helping to plan for the sustainability of their communities, especially during times of disaster.
According to the Association for Public Health Nurses (APHN), the role of public health nurses
in disaster management includes “population based practice like rapid needs assessments of
communities impacted by the incident, population based triage, mass dispensing of preventive
or curative therapies, community education, and providing care or managing shelters for
displaced populations” (Association of Public Health Nurses, 2013, p. 4). The basic steps of the
traditional nursing process—assessment, planning, implementation, and evaluation— is the
same process utilized for nursing during disaster management with some modification
necessary to address public health (see Table 5.4).
Table 5.4
Nursing Process in Disaster Management
Nursing Process Step Description

Note. Adapted from The Role of the Public Health Nurse, by the Association of Public Health
Nurses, 2014.
Disaster Management in Years to
Come
●
Assessment ● PHNs are responsible for assessment of the local population
for risks and needs during times of disaster
● PHN may also conduct a hazard vulnerability assessment,
which involves identifying threats and hazards in the area that
pose the greatest amount of risk.
Planning ● PHNs formulate plans of care that address functional needs of
the population during a disaster.
● PHNs then work with key stakeholders within the community to
address these needs, which might include sheltering,
evacuation planning, and mass casualty capabilities.
Implementation ● PHNs participate in training for community health care
providers, including forming and conducting casualty drills and
education regarding protocol during a disaster
Evaluation ● PHNs evaluate training, drills, and education
● PHNs evaluate operational plans and protocols to make
improvements in the future

●
●
●
With political shifts, climate changes, and increasing populations worldwide, both natural and
man-made disasters have and will continue to change. The threat of impending disasters will
continue to warrant appropriate action and planning. PHNs need to remain aware of these
changes to prepare themselves and their communities adequately.
Mass Shootings
Over the past few decades, there has been an increase in mass shootings in the United States.
Such events often result in multiple casualties, many more injuries, and often a lifetime of
devastation for the victims and victims’ loved ones (Terrades, 2017). Because of this, it is
essential that PHNs and all health care professionals take steps to prepare for such an event in
their local communities. This involves education regarding response and survival during an
active shooter event in every setting, from schools to churches to businesses. This also involves
preparing acute care facilities, emergency management plans and processes, and drills to
practice proper response efforts in advance. Educating parents and caregivers regarding gun
safety and the importance of keeping guns unloaded and in a locked safe at all times should be
reiterated and stressed at every opportunity. Mandatory survival training and education is often
being implemented in many workplaces that help employees to understand how to respond in
case of an active shooter event in their place of business (U.S. Department of Homeland
Security [DHS] 2017). The DHS offers several training handouts and videos that are free for use
in educating the public regarding surviving active shooter situations (see Figure 5.7).

Figure 5.7
Active Shooter Response

Note. Adapted from “Active Shooter Pocket Card,” by the U.S. Department of Homeland Security.
Terrorism
After the events of September 11, the thought process regarding mitigation and preparedness
for terrorist events shifted. In 2002, President George W. Bush enacted the Homeland Security
Act with the goal of reducing the nation’s vulnerability to terrorism, protecting the United States
from future attacks, and minimizing the damage in the event of terrorist and disaster attacks
(FEMA, 2008). Mitigation strategies, such as enhanced security procedures, were elevated and
continue to be the gold standard in the effort to prevent terrorist attacks. The DHS also started a
campaign called “See Something, Say Something” that emphasizes public awareness and
involvement in reporting suspicious activity of any kind in order to assist in prevention measures
(DHS, n.d.). PHNs can be actively involved in educating members of the community about
safety and reporting suspicious activity to help keep their community safe.
Bioterrorism
In recent years, the threat of impending terrorist attacks has warranted the attention of health
care professionals in collaboration with federal agencies to help prevent and respond to an act
of bioterrorism. The act of bioterrorism, or chemical terrorism, is defined as the use of
biological or chemical agents as a weapon to cause injury, death, and disruption (Centers for
Disease Control and Prevention [CDC], 2017). In response to the impending threat of anthrax
attacks, the CDC (1999) published the National Bioterrorism Preparedness and Response
Initiative, which is a guide for prevention and response to bioterrorism attacks. The CDC’s five

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primary focus areas are preparedness, detection, diagnosis, response, and communication
(CDC, 2016).
Health care facilities have their own protocols to follow when dealing with bioterrorism threats.
The protocol is largely directed by recommendations from the CDC. Nurse leaders are an
important part of the process of understanding the protocol and knowing how to properly
educate their staff regarding procedures in the event of a bioterrorist attack. The protocol details
procedures such as isolation precautions, handling of patient specimens, decontamination
following exposure, patient placement, and postmortem care of infected patients. In addition, it
provides an overview of a handful of bioterrorism agents, their expected clinical features, and
recommendations for treatment and care for agents such as botulism, anthrax, and plague
(CDC, 2018).
Within hospital settings, the Occupational Safety and Health Administration (OSHA) has
published guidelines to assist hospitals with response to an attack of this nature. These
guidelines discuss preplanning, care of the victims, and avoidance of cross contamination
(Occupational Safety & Health Administration, 1997). Health care personnel must be
familiarized and educated on bioterrorism agents and how to protect themselves and the victims
of the event. Because nurses have a great deal of contact with patients, providing them with the
education necessary to work in these conditions is crucial. PHNs can be advocates for such
education in order to protect their own health, the health of their colleagues, and the health of
their patients. Nurses working at the bedside or in leadership roles can help to establish and
implement education plans that would inform nurses of proper protocol in a bioterrorism event.
Nuclear Threats and Response
In light of political tension around the globe, it behooves any well-organized government to be
well prepared for any disaster, including one as devastating as a nuclear detonation. FEMA and
the CDC have plans in place to respond in the event that nuclear war were to become aa reality.
PHNs serve as educators of the community, helping to institute plans for survival and safety in
the event of a nuclear detonation. The website Ready.gov also provides numerous tips and
advice regarding surviving a nuclear blast and necessary steps to survive after detonation.
Three of the primary factors reiterated in survival of a nuclear blast are distance, shielding, and
time. Individuals should be instructed to put as much distance and protection between
themselves and the fallout particles as possible, this means immediately heading indoors and
staying there. The thicker the walls of the structure or the deeper underground the individuals
can go, the safer they are from the nuclear fallout materials. Time is the final factor; following a
nuclear detonation, the first few weeks pose the greatest amount of risk. People are advised to
stay indoors for a minimum of two weeks, as the nuclear materials can cause the greatest
degree of damage in this time period (Ready.gov, n.d.b). PHNs can be valuable in providing
education regarding these important survival guidelines to the communities they serve.
Reflective Summary

Preparation for a disaster is something all nurses must be involved with no matter what area of
expertise they choose. With proper preparation and intervention, the impact and consequences
following a disaster can be reduced greatly. Nurses are often called to respond in the event of
disaster events and must prepare themselves and their families for such an occurrence. PHNs
are valued and important responders, often acting as coordinators of care in the prevention and
management of disaster occurrences.
Key Terms
Bioterrorism: The use of biological or chemical agents as a weapon to cause injury, death, and
disruption.
Community Emergency Response Team (CERT): Team of volunteers within a community
trained on disaster management skills, such as fire safety and search and rescue.
Controllability: The ability to plan ahead for the possibility of an event in the future.
Disaster Nursing: Nursing that specifically involves disaster planning, prevention, and
response.
Emergency Preparedness: A continuous cycle of planning, organizing, training, equipping,
practicing, evaluating, and taking corrective action in an effort to ensure effective coordination
during incident response.
Evacuation: Temporary and rapid removal of people from an area or building that has an
impending threat of disaster whether man-made or natural.
Federal Emergency Management Agency (FEMA): U.S. federal agency that coordinates the
response to disasters.
Frequency: Probability of occurrence of a potentially damaging phenomenon within a given
time period and geographic area.
Impact: Phase of disaster planning that occurs during the actual event; may last for minutes,
days, or even weeks depending on the type of disaster; focus is on survival.
Intensity: Specific to the effect of the disaster on the community’s health outcomes and loss of
life.
Man-Made Disaster: Occurs as a result of human involvement, such as terrorism,
transportation accidents, food and water contamination, and building collapse.
Mass Casualty Incident: Involves larger numbers, typically more than 100 people, and has an
apparent impact on local emergency medical services and resources.
Mitigation: Measures that eliminate or reduce the impacts and risks of hazards through
preventative measures taken before disaster occurs.
Multiple Casualty Incident: Occurs when the casualty toll is isolated to fewer than 100 people.

Natural Disaster: Caused by forces of nature such as hurricanes, blizzards, mudslides,
earthquakes, tsunamis, epidemics, and fires.
Postimpact: Phase of disaster planning that occurs once imminent danger has ceased; during
this period, rescue and emergency medical care becomes the primary focus.
Post-Traumatic Stress Disorder: Disorder that develops in some people who have
experienced a shocking, scary, or dangerous event.
Predictability: Based upon the ability to foresee the impending event, such as with weather
forecasting systems that may have the ability to deliver a hurricane or tornado warning.
Preimpact: Phase of disaster planning that is optimal for planning and preparing for a disaster.
Primary Agent: Offending cause that creates primary damage, such as a tornado or bomb.
Recovery: Period of time that may last weeks, months, or even years and involves property
damage recuperation, physical rehabilitation of those injured, mental illness follow up, extended
care, planning for future disasters, and financial recuperation.
Response: Indicates the period of time for emergency assistance with the goal of maintaining
and saving lives, improving health, surviving the disaster event, and supporting victims.
Scope: Specific to the depletion of typical resources within the effected community.
Secondary Agent: Offending cause that is created as a result of the primary agent, such as the
bacteria that grows in stagnant water following a flood.
References
American Nurses Association. (2015). Code of ethics with interpretive statements. Silver
Springs, MD: Author. Retrieved from
http://nursingworld.org/DocumentVault/Ethics-1/Code-of-Ethics-for-Nurses.html
American Red Cross. (n.d.). Mission and values. Retrieved from
http://www.redcross.org/about-us/who-we-are/mission-and-values
Association of Public Health Nurses. (2013). The role of the public health nurse in disaster
preparedness, response, and recovery: A position paper. Retrieved from
http://www.achne.org/files/public/APHN_RoleOfPHNinDisasterPRR_FINALJan14
Centers for Disease Control and Prevention. (1999). National bioterrorism preparedness and
response initiative. Atlanta, GA: Author.
Centers for Disease Control and Prevention. (2016). Anthrax: Bioterrorism. Retrieved from
https://www.cdc.gov/anthrax/bioterrorism/index.html
Centers for Disease Control and Prevention. (2017). Emergency preparedness and response:
Preparation and planning for bioterrorism emergencies. Retrieved from
https://emergency.cdc.gov/bioterrorism/prep.asp
Centers for Disease Control and Prevention. (2018). Emergency preparedness and response:
Bioterrorism agents/diseases. Retrieved from https://emergency.cdc.gov/agent/agentlist.asp

Federal Emergency Management Agency. (2008). FEMA strategic plan: Fiscal years
2008-2013. Washington, DC: Author. Retrieved from
https://www.fema.gov/pdf/about/fy08_fema_sp
Federal Emergency Management Agency. (2009). Federal assistance in Hurricane Ike disaster
tops $2.5 billion. Retrieved from
https://www.fema.gov/news-release/2009/08/20/federal-assistance-hurricane-ike-disaster-to
ps-25-billion
Federal Emergency Management Agency. (2016). National response framework (3rd ed.).
Washington, DC: U.S. Department of Homeland Security.
Federal Emergency Management Agency. (2017). FEMA’s mission statement. Retrieved from
https://www.fema.gov/media-library/assets/videos/80684
Federal Emergency Management Agency. (2018). What is mitigation? Retrieved from
https://www.fema.gov/what-mitigation
Federal Emergency Management Agency. (n.d.). Lesson summary. Retrieved from
https://emilms.fema.gov/IS800B/lesson4/L4_Print.htm
Federal Interagency Committee on EMS. (n.d.). FICEMS. Retrieved from
https://www.ems.gov/ficems.html
Graham, L. K. (2014). Political dimensions of pastoral care in community disaster responses.
Pastoral Psychology, 63(4), 471-488.
Hageman, J. C., Hazim, C., Wilson, K., Malpiedi, P., Gupta, N., Bennett, S., … Park, B. J.
(2016). Infection prevention and control for Ebola in health care settings – West Africa and
United States. Morbidity and Mortality Weekly Report Supplement, 65(3), 50-56. doi:
10.15585/mmwr.su6503a8
International Federation of Red Cross and Red Crescent Societies. (n.d.). What is a disaster?
Retrieved from
http://www.ifrc.org/en/what-we-do/disaster-management/about-disasters/what-is-a-disaster/
Jakeway, C. C., LaRosa, G., Cary, A., & Schoenfisch, S. (2008). The role of public health
nurses in emergency preparedness and response: A position paper of the association of
state and territorial directors of nursing. Public Health Nursing, 25(4), 353-361.
Knox, C.C., & Haupt, B. (2015) Incorporating cultural competency skills in emergency
management education. Disaster Prevention and Management: An International Journal;
24(5), 619-634. doi: 10.1108/DPM-04-2015-0089
Lichtveld, M. (2018). Disasters through the lens of disparities: Elevate community resilience as
an essential public health service. American Journal of Public Health, 108, 28-30.
doi:10.2105/AJPH.2017.304193
Lippmann, M., Cohen, M. D., & Chen, L. (2015). Health effects of World Trade Center (WTC)
dust: An unprecedented disaster with inadequate risk management. Critical Reviews in
Toxicology, 45(6), 492-530. doi: 10.3109/10408444.2015.1044601
Maclean, J. C., Popovici, I., & French, M. T. (2016). Are natural disasters in early childhood
associated with mental health and substance use disorders as an adult? Social Science &
Medicine, 151, 78-91. doi:10.1016/j.socscimed.2016.01.006
Martin, U. (2015). Health after disaster: A perspective of psychological/health reactions to
disaster. Cogent Psychology, 2(1). doi: 10.1080/23311908.2015.1053741

Millet, C. (2013). The public health nurse’s role in disaster preparedness. Retrieved from
https://www.maphn.org/Resources/Documents/CMilletpostver073113
National Disaster Recovery Framework. (2016). Retrieved from
https://www.fema.gov/media-library-data/1466014998123-4bec8550930f774269e0c5968b1
20ba2/National_Disaster_Recovery_Framework2nd
Occupational Safety & Health Administration. (1997). Hospitals and community emergency
response – What you need to know. Washington, DC: U.S. Department of Labor. Retrieved
from https://www.osha.gov/Publications/OSHA3152/osha3152.html
Office for Coastal Management. (n.d.). Fast facts: Hurricane costs. Retrieved from
https://coast.noaa.gov/states/fast-facts/hurricane-costs.html
PerformTech Inc. (2011). Community Emergency Response Team: Basic training instructor
guide. Washington, DC: Federal Emergency Management Agency. Retrieved from
https://www.fema.gov/media-library-data/1448914296662-6907d9939a58ca269944137d1d
232c6a/cert_basic_training_instructor_guide_compiled_508_102815
Petkova,E. P., Schlegelmilch, J., Sury, J., Chandler, T. E., Herrera, C. D., Shwetha Bhaskar, S.,
. . . Redlener, I. E. (2016). Children in disasters: Do Americans feel prepared? A National
Survey. Columbia University Academic Commons. doi.:10.7916/D85M65J9
Public Health Emergency. (2018). NDMS teams. Retrieved from
http://www.phe.gov/Preparedness/responders/ndms/ndms-teams/Pages/default.aspx
Ready.gov. (n.d.a). Community emergency response team. Retrieved from
https://www.ready.gov/community-emergency-response-team
Ready.gov. (n.d.b). Nuclear explosion. Retrieved from https://www.ready.gov/nuclear-explosion
Ready.gov. (n.d.c). Home. Retrieved from https://www.ready.gov
Rehwald, J. (2017). “To the max:” Simultaneous disasters stretch Springfield-based Convoy of
Hope. Retrieved from
https://www.news-leader.com/story/news/2017/09/07/max-simultaneous-disasters-stretch-s
pringfield-based-convoy-hope/633260001
Substance Abuse and Mental Health Services Administration. (2012). Disaster Distress Helpline
brochure. Retrieved from
https://store.samhsa.gov/product/Disaster-Distress-Helpline-Brochure/PEP12-DDHBRO
Terrades, V. (2017). Mass shootings and offenders’ motives: A comparison of the United States
and foreign nations. ILSA Journal of International & Comparative Law, 23(3), 399-423.
U.S. Department of Homeland Security. (2017). Active shooter preparedness. Retrieved from
https://www.dhs.gov/active-shooter-preparedness\
U.S. Department of Homeland Security. (n.d.). If you see something, say something. Retrieved
from https://www.dhs.gov/see-something-say-something
Zotti, M. E., Williams, A. M., Robertson, M., Horney, J., & Hsia, J. (2013). Post-disaster
reproductive health outcomes. Maternal and Child Health Journal, 17(5), 783-796.
doi:10.1007/s10995-012-1068-x

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