community health nursing

Community and Public Health Nursing | 3rd edition EVIDENCE FOR PRACTICE

Rosanna F. DeMarco, PhD, RN, FAAN Chair and Professor Department of Nursing College of Nursing and Health Sciences University of Massachusetts Boston Boston, Massachusetts

Judith Healey-Walsh, PhD, RN Clinical Associate Professor Director of the Undergraduate Program Department of Nursing College of Nursing and Health Sciences University of Massachusetts Boston Boston, Massachusetts

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3rd Edition

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Copyright © 2016 Wolters Kluwer. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins. All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Wolters Kluwer at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at permissions@lww.com, or via our website at shop.lww.com (products and services).

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Library of Congress Cataloging-in-Publication Data

Names: DeMarco, Rosanna F., author. | Healey-Walsh, Judith, author. | Preceded by (work): Harkness, Gail A. Community and public health nursing. Title: Community and public health nursing : evidence for practice / Rosanna F. DeMarco, Judith Healey-Walsh. Description: 3. | Philadelphia : Wolters Kluwer, [2020] | Preceded by Community and public health nursing / Gail A.

Harkness, Rosanna F. DeMarco. Second edition. [2016]. | Includes bibliographical references and index. Identifiers: LCCN 2018058862 | eISBN 9781975144500 Subjects: | MESH: Community Health Nursing | Public Health Nursing | Evidence-Based Nursing | Nursing Theory | United States Classification: LCC RT98 | NLM WY 108 | DDC 610.73/43—dc23 LC record available at https://lccn.loc.gov/2018058862

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Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in his or her clinical practice.

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Contributors

Stephanie M. Chalupka, EdD, RN, PHCNS-BC, FAAOHN, FNAP Associate Dean for Nursing Department of Nursing Worcester State University Worcester Visiting Scientist Environmental and Occupational Medicine and Epidemiology Program Department of Environmental Health Harvard T. H. Chan School of Public Health Boston, Massachusetts (Chapter 9, Planning for Community Change)

Susan K. Chase, EdD, RN, FNAP Professor College of Nursing University of Central Florida Orlando, Florida (Chapter 23, Faith-Oriented Communities and Health Ministries in Faith Communities)

Sabreen A. Darwish, RN, BScN, MScN Second Year PhD Student/Research Assistant College of Nursing and Health Sciences University of Massachusetts Boston, Massachusetts (Chapter 3, Health Policy, Politics, and Reform)

Karen Dawn, RN, DNP, PHCNS, CDE Assistant Professor School of Nursing George Washington University Ashburn, Virginia (Chapter 4, Global Health: A Community Perspective)

Pamela Pershing DiNapoli, PhD, RN, CNL Associate Professor of Nursing and Graduate Programs College of Health and Human Services University of New Hampshire Durham, New Hampshire (Chapter 22, School Health)

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Merrily Evdokimoff, PhD, RN Consultant Clinical Associate Lecturer Department of Nursing University of Massachusetts Boston, Massachusetts (Chapter 20, Community Preparedness: Disaster and Terrorism)

Barbara A. Goldrick, MPH, PhD, RN Epidemiology Consultant Chatham, Massachusetts (Chapter 8, Gathering Evidence for Public Health Practice; Chapter 14, Risk of Infectious and Communicable Diseases; Chapter 15, Emerging Infectious Diseases)

Patricia Goyette, DNP-PHNL, RN Educational Consultant Everett, Massachusetts (Chapter 25, Occupational Health Nursing)

Cheryl L. Hersperger, MS, RN, PHNA-BC, PhD Student Assistant Professor Department of Nursing Worcester State University Worcester, Massachusetts (Chapter 9, Planning for Community Change)

Anahid Kulwicki, PhD, RN, FAAN Dean and Professor School of Nursing Lebanese American University Beirut, Lebanon (Chapter 3, Health Policy, Politics, and Reform)

Carol Susan Lang, DScN, MScN(Ed.), RN Associate Director of Global Initiatives Assistant Professor of Global and Population Health George Washington University School of Nursing Washington, DC

Annie Lewis-O’Connor, PhD, NP-BC, MPH, FAAN Senior Nurse Scientist and Founder and Director of C.A.R.E Clinic Brigham and Women’s Hospital Boston, Massachusetts (Chapter 16, Violence and Abuse)

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Patricia Lussier-Duynstee, PhD, RN Assistant Dean Assistant Professor School of Nursing MGH Institute of Health Professions Boston, Massachusetts (Chapter 6, Epidemiology: The Science of Prevention; Chapter 7, Describing Health Conditions: Understanding and Using Rates)

Kiara Manosalvas, MA Reseach Assistant II The Following & Mental Health Counselor Teachers College Columbia University Chestnut Hill, Massachusetts (Chapter 16, Violence and Abuse)

Patrice Nicholas, DNSc, DHL (Hon.), MPH, MS, RN, NP-C, FAAN Professor School of Nursing MGH Institute of Health Professions Director, Global Health and Academic Partnerships Brigham and Women’s Hospital Boston, Massachusetts (Chapter 6, Epidemiology: The Science of Prevention; Chapter 7, Describing Health Conditions: Understanding and Using Rates)

Christine Pontus, RN, MS, BSN, COHN-S/CCM Associate Director in Nursing and Occupational Health Massachusetts Nurses Association (MNA) Canton, Massachusetts (Chapter 25, Occupational Health Nursing)

Joyce Pulcini, PhD, RN, PNP-BC, FAAN, FAANP Professor Director of Community and Global Initiatives Chair, Acute and Chronic Care Community School of Nursing George Washington University Washington, DC (Chapter 4, Global Health: A Community Perspective)

Teresa Eliot Roberts, PhD, RN, ANP Clinical Assistant Professor College of Nursing and Health Sciences University of Massachusetts Boston Boston, Massachusetts

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(Chapter 10, Cultural Competence: Awareness, Sensitivity, and Respect)

Judith Shindul-Rothschild, PhD, MSN, RN Associate Professor Connell School of Nursing Boston College Chestnut Hill, Massachusetts (Chapter 17, Substance Use; Chapter 21, Community Mental Health)

Joy Spellman, MSN, RN Director, Center for Public Health Preparedness Mt. Laurel, New Jersey (Chapter 20, Community Preparedness: Disaster and Terrorism)

Tarah S. Somers, RN, MSN/MPH Senior Regional Director Agency for Toxic Substances and Disease Registry, New England Office US Public Health Service Commissioned Corps Boston, Massachusetts (Chapter 19, Environmental Health)

Patricia Tabloski, PhD, GNP-BC, FGSA, FAAN Associate Professor Connell School of Nursing Boston College Chestnut Hill, Massachusetts (Chapter 24, Palliative and End-of-Life Care)

Aitana Zermeno, BS Research Assistant Connors Center for Women’s Health and Gender Biology Division of Women’s Health Brigham and Women’s Hospital Boston, Massachusetts (Chapter 16, Violence and Abuse)

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Reviewers

Elizabeth Armstrong, DNP, MSN, RN, CNE Assistant Professor School of Nursing University of Bridgeport Bridgeport, Connecticut

Karen Cooper, MS, RN Clinical Assistant Professor Department of Nursing Towson University Towson, Maryland

Teresa E. Darnall, PhD, MSN, RN, CNE Assistant Dean Assistant Professor May School of Nursing and Health Sciences Lees-McRae College Banner Elk, North Carolina

Florence Viveen Dood, DNP, MSN, BSN, RN RN-BSN Program Coordinator Assistant Professor School of Nursing Ferris State University Big Rapids, Michigan

Aimee McDonald, PhD, RN Assistant Professor Department of Nursing William Jewell College Liberty, Missouri

Rita M. Million, PhD, RN, PHNA-BC, COI Nursing Faculty School of Nursing College of Saint Mary Omaha, Nebraska

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Deanna R. Pope, DNP, RN, CNE Professor School of Nursing Marshall University Huntington, West Virginia

Kendra Schmitz, RN, MSN Assistant Professor School of Nursing D’Youville College Buffalo, New York

Kathleen F. Tate, MSN, MBA, CNE, RN Assistant Professor School of Nursing Northwestern State University Natchitoches, Louisiana

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Preface

“If you want to go quickly, go alone. If you want to go far, go together.” African Proverb

“The idea that some lives matter less is the root of all that is wrong in the world.” Paul Farmer

“No matter what people tell you, words and ideas can change the world.” Robin Williams

e are experiencing extraordinary changes in healthcare in this new century; changes that call upon the most creative, analytical, and innovative skills available. While the world has the resources to reduce healthcare disparities and eliminate the differences

in healthcare and health outcomes that exist between various population groups across the globe, accomplishing this is a long-term and complicated task. Improvement in the social structure within which people live, and a redistribution of resources so that all people have access to the basic necessities of life, require an unprecedented global consciousness and political commitment.

Ultimately, reducing health disparities and promoting health equity occur within the local community where people reside. Nurses are by far the largest group of healthcare providers worldwide and, as such, have the ability and responsibility to be change agents and leaders in implementing change in their communities. They can be the primary participants in the development of health policy that specifically addresses the unique needs of their communities. Through implementation and evaluation of culturally appropriate, community-based programs, nurses can use their expertise to remedy the conditions that contribute to health disparities. People need to be assured that their healthcare needs will be assessed and that healthcare is available and accessible.

In the United States, public health has resurged as a national priority. Through Healthy People 2020, national goals have been set to promote a healthy population and address the issue of health disparities. The process of implementing the Healthy People 2020 objectives rests with regional and local practitioners, with nurses having a direct responsibility in the implementation process. The nurse practicing in the community has a central role in providing direct care for the ill as well as promoting and maintaining the health of groups of people, regardless of the circumstances that exist. Today, there are unparalleled challenges to the nurse’s problem-solving skills in carrying out this mission.

Whether caring for the individual or the members of a community, it is essential that nurses incorporate evidence from multiple sources in the analysis and solution of public health issues. Community and Public Health Nursing: Evidence for Practice focuses on evidence-based practice, presenting multiple formats designed to develop the abstract critical thinking skills and complex reasoning abilities necessary for nurses becoming generalists in community and public health nursing. The unique blend of both the nursing process and the epidemiologic process provides a framework for gathering evidence about health problems, analyzing the information, generating diagnoses or hypotheses, planning for resolution, implementing plans of action, and evaluating the results.

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“To every complex question there is a simple answer…and it is wrong.” H. L. Mencken (writer and wit, 1880–1956)

CONTENT ORGANIZATION It is the intention of Community and Public Health Nursing: Evidence for Practice to present the core content of community and public health nursing in a succinct, logically organized, but comprehensive manner. The evidence for practice focus not only includes chapters on epidemiology, biostatistics, and research but also integrates these topics throughout the text. Concrete examples assist students in interpreting and applying statistical data. Healthy People goals and measurable objectives serve as an illustration of the use of rates throughout the text. Additionally, we have added brief learning activities and questions throughout the text to allow students to apply the Healthy People goals to real-life scenarios. Groups with special needs, such as refugees and the homeless, have been addressed in several chapters; however, tangential topics that can be found in adult health and maternal-child health textbooks have been omitted. A chapter on environmental health concerns has been included, along with a chapter on community preparedness for emergencies and disasters. Also, a global perspective has been incorporated into many chapters.

Challenges to critical thinking are presented in multiple places throughout each chapter. Case studies are integrated into the content of each chapter and contain critical thinking questions imbedded in the case study content. Also, a series of critical thinking questions can be found at the end of each chapter. (Please see the description of features below.) Considering the onus presented by Mark Twain: “Be careful about reading health books. You may die of a misprint,” every attempt has been made to present correct, meaningful, and current evidence for practice.

Part One presents the context within which the community or public health nurse practices. An overview of the major drivers of healthcare change leads to a discussion of evolving trends, such as the emphasis on patient/client-centered care, the effects of new technology upon the delivery of care, and the need for people to assume more responsibility for maintaining their health. Community and public health nursing as it presently exists is analyzed and reviewed from a historical base, and issues foreseen for both the present and immediate future are discussed. The nursing competencies necessary for competent community and public health practice are also presented.

A more in-depth discussion of the complex structure, function, and outcomes of public health and healthcare systems follows. National and international perspectives regarding philosophical and political attitudes, social structures, economics, resources, financing mechanisms, and historical contexts are presented, highlighting healthcare organizations and issues in several developed countries. The World Health Organization’s commitment to improving the public’s health in developing countries follows, with an emphasis on refugees and disaster relief. With the burden of disease growing disproportionately in the world, largely due to climate, public policy, socioeconomic conditions, age, and an imbalance in distribution of risk factors, the countries burdened by disease often have the least capacity to institute change. Part One concludes with examination of the indicators of health, health and human rights, factors that affect health globally, and a framework for improving world health.

Part Two provides the frameworks and tools necessary to engage in evidence-based practice focused on the population’s health. Concepts of health literacy, health promotion, disease prevention, and risk reduction are explored, and a variety of conceptual frameworks are presented with a focus on both the epidemiologic and ecologic models. Epidemiology is presented as the science of prevention, and nurses are shown how epidemiologic principles are

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applied in practice, including the use of rates and other statistics as community health indicators. Specific research designs are also explored, including the application of epidemiologic research to practice settings.

Part Three is designed to develop the skills necessary to implement nursing practice effectively in community settings. Since healthcare is in a unique state of transformation, planning for community change is paramount. The health planning process is described, with specific attention given to the social and environmental determinants of change. Lewin’s change theory, force-field analysis, and the effective use of leverage points identified in the force-field analysis demonstrate the change process in action.

Changes directed at decreasing health disparities must be culturally sensitive, client- centered, and community-oriented. A chapter on cultural diversity and values fosters the development of culturally competent practitioners, and the process of cultural health assessment is highlighted. Frameworks of community assessment are presented and various approaches are explored. Management of care and the case management process follows. The role and scope of home care nursing practice and the provision of services is presented along with the challenges inherent with interdisciplinary roles, advances in telehealth, and other home care services.

Although content on family assessment can be found in other texts, it is an integral component of community and public health practice. Therefore, theoretical perspectives of family, and contemporary family configurations and life cycles are explored. Family Systems Nursing and the Calgary Family Assessment and Intervention Model are provided as guides to implementing family nursing practice in the community. Evidence-based maternal-child health home visiting programs and prominent issues related to family caregiving are also highlighted.

Part Four presents the common challenges in community and public health nursing. The chapter addressing the risk of infectious and communicable diseases explores outbreak investigation with analysis of data experience provided by the case studies. Public health surveillance, the risk of common foodborne and waterborne illnesses, and sexually transmitted diseases are followed by a discussion of factors that influence the emergence/reemergence of infectious diseases, examples of recent outbreaks, and means of prevention and control.

The challenge presented by violence in the community is presented with an emphasis on intimate partner violence and the role of the healthcare provider. Because of the cultural variations in substance use disorder, multifaceted approaches to the problem are discussed with the recommendation that evidence-based prevention and treatment protocols for substance use disorder are incorporated by community health nurses in all practice settings. Meeting the healthcare needs of vulnerable and underserved populations is another challenge. Health priorities for people who live in rural areas; are gay, lesbian, bisexual, or transgender; are homeless; or live in correctional institutions are reviewed.

The issues of access to quality care, chronic disease management, interaction with health personnel, and health promotion in hard-to-reach populations among these populations are also presented.

The environmental chapter demonstrates how to assess contaminants in the community by creation of an exposure pathway. The health effects of the exposure pathway can then be ascertained. Individual assessment of contaminant exposures, interventions, and evaluations are also explored, ending with a focus on maintaining healthy communities. The final chapter in Part Four presents the issue of community preparedness. The types of disasters along with classification of agents are described, disaster management outlined, and the public health response explained. The role and responsibility of nurses in disasters and characteristics of the field response complete the content.

Part Five describes five common specialty practices within community and public health nursing. All have frameworks that define practice and reflect the competencies necessary for competent practice in a variety of community settings. These include application of the

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principles of practice to community mental health, school health, faith-oriented communities, palliative care, and occupational health nursing.

Features Found in Each Chapter

CHAPTER HIGHLIGHTS Brief outline of the content and direction of the chapter

OBJECTIVES Observable changes expected following completion of the chapter

KEY TERMS Essential concepts and terminology required for comprehension of chapter content

CASE STUDIES

Vignettes presented throughout the content of each chapter, designed to stimulate critical thinking and analytic skills

Evidence for Practice

Examples of objective evidence obtained from research studies that provide direction for practice

Practice Point

Highlighting of essential facts relevant to practice

Student Reflection

Student stories of their own experience and reflections

KEY CONCEPTS Summary of important concepts presented in the chapter

CRITICAL THINKING QUESTIONS

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Problems requiring critical analysis that combines research, context, and judgment

COMMUNITY RESOURCES List of resources that support the content of selected chapters

I didn’t fail the test, I just found 100 ways to do it wrong. Benjamin Franklin

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Acknowledgments

It is difficult to embark on the development of a new textbook without the support of colleagues, family, and friends. A special thanks belongs to our contributors, both returning and new, who were willing to share their expertise by writing chapters filled with the passion and commitment to community and public health. In addition, we are thankful for the invaluable experiences we obtained from our community and public health work that interfaced and informed the production of this book. Those experiences ranged from developing interventions with and for women living with HIV/AIDS in Boston, to implementing community-based programs that addressed the health needs of diverse populations, to teaching students about the social determinants of health, and to assuming leadership roles on local boards that are responsible for the health of our local communities. Our editorial coordinator, John Larkin, was very helpful in answering questions, calming frustrations, and solving problems. Greg Nicholl, our development editor, provided the consistency found throughout the chapters. Thank you all for helping us create this unique approach to community and public health nursing!

Rosanna F. DeMarco Judith Healey-Walsh

A Special Thanks in Memoriam to Dr. Gail A. Harkness, DPH, FAAN The first and second editions of this textbook were led by the efforts of Dr. Gail Harkness. Gail was a mentor and friend. While she is no longer with us to help support, guide, and enliven this newest edition, we wanted to take time to honor her memory and produce this edition in her honor.

Gail was such an intelligent, warm, and wise public health expert who was most passionate about population health and epidemiology, and particularly infectious diseases past, present, and evolving. She was a prolific writer and teacher. When I met her, she reached out to me, asking if I could help her with her vision of a community health and public health textbook for nursing

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students that was affordable and succinct and did not just “rattle on” with facts but situated public health ideas in the context of evidence, student stories, and current disease prevention and health promotion innovations. She brought to my mentorship opportunity her global experiences from the UK (University of Leeds) to Japan (Osaka), as well as her own local work on a town Board of Health in Massachusetts. Gail loved public health research and the evidence it yielded to inform policy decisions toward all our health. She was a graduate of the University of Rochester (undergraduate and graduate programs) in Nursing and received her Doctorate in Public Health from the University of Illinois, School of Public Health in Epidemiology and Biometry (the application of statistical analysis to biologic data).

More than being an epidemiologist, she loved the opportunity as an academician to teach nursing students at all levels to be as passionate about public health as she was. She was a professor emerita from University of Connecticut. We know her family and friends miss Gail very much, but her energy and spirit will always be in this textbook.

Rosanna F. DeMarco

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Contents

PART ONE The Context of Community and Public Health Nursing

Chapter 1 Public Health Nursing: Present, Past, and Future Healthcare Changes in the 21st Century Public Health Nursing Today Roots of Public Health Nursing Challenges for Public Health Nursing in the 21st Century

Chapter 2 Public Health Systems Importance of Understanding How Public Health Systems are Organized Structure of Public Healthcare in the United States Functions of Public Health in the United States Trends in Public Health in the United States Healthcare Systems in Selected Developed Nations Public Health Commitments to the World: International Public Health and Developing Countries

Chapter 3 Health Policy, Politics, and Reform Healthcare Policy and the Political Process Healthcare Finances and Cost–Benefit Access to Care and Health Insurance Healthcare Workforce Diversity Nursing’s Role in Shaping Healthcare Policy Advocacy Activities of Professional Nursing Organizations Current Situation of Nursing Political Involvement: Challenges and Barriers Quality of Care Information Management Equity in Healthcare Access and Quality Community-Based Services Associated With Healthcare Reform Ethical Consideration Health Advocacy and Healthcare Reform Overview of the ACA Prior to the End of Obama Presidency Health Services Research Conclusion

Chapter 4 Global Health: A Community Perspective Definitions of Health Global Health Concepts Women, Poverty, and Health Sustainable Development Goals Other Factors That Affect Global Health Role of Nurses

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PART TWO Evidence-Based Practice and Population Health

Chapter 5 Frameworks for Health Promotion, Disease Prevention, and Risk Reduction Introduction Health Promotion, Disease Prevention, and Risk Reduction as Core Activities of Public Health Healthy People Initiatives Road Maps to Health Promotion Behavior Models Use of the Ecologic Model: Evidence for Health Promotion Intervention Health Promotion and Secondary/Tertiary Prevention for Women Living With HIV/AIDS Health Literacy Health Literacy and Health Education Health Literacy and Health Promotion Role of Nurses

Chapter 6 Epidemiology: The Science of Prevention Defining Epidemiology Development of Epidemiology as a Science Epidemiologic Models Applying Epidemiologic Principles in Practice

Chapter 7 Describing Health Conditions: Understanding and Using Rates Understanding and Using Rates Specific Rates: Describing by Person, Place, and Time Types of Incidence Rates Sensitivity and Specificity Use of Rates in Descriptive Research Studies

Chapter 8 Gathering Evidence for Public Health Practice Observational Studies Intervention (Experimental) Studies

PART THREE Implementing Nursing Practice in Community Settings

Chapter 9 Planning for Community Change Health Planning Community Assessment Systems Theory Working With the Community Social Ecologic Model Health Impact Pyramid Multilevel Interventions Social Determinants of Health Change Theory Planning Community-Level Interventions Collaboration and Teamwork Evaluating Community-Level Interventions

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Funding Community-Level Intervention Programs Social Marketing Nurse-Managed Health Centers

Chapter 10 Cultural Competence: Awareness, Sensitivity, and Respect Culture and Nursing Western Biomedicine as “Cultured” Aspects of Culture Directly Affecting Health and Healthcare Cultural Health Assessment

Chapter 11 Community Assessment Introduction Defining the Community and Its Boundaries Frameworks for Community Assessment

Chapter 12 Care Management, Case Management, and Home Healthcare Care Management Case Management Home Healthcare Case Management, Home Healthcare, and Current Healthcare Reform

Chapter 13 Family Assessment Introduction Family Nursing Practice Understanding Family Family Nursing Theory How Community Health Nurses Support Families Community Health Nurses’ Responsibility to Families

PART FOUR Challenges in Community and Public Health Nursing

Chapter 14 Risk of Infectious and Communicable Diseases Introduction Epidemiology of the Infectious Process: The Chain of Infection Outbreak Investigation Healthcare-Associated Infections Public Health Surveillance Specific Communicable Diseases Other Sexually Transmitted Diseases Prevention and Control of Specific Infectious Diseases

Chapter 15 Emerging Infectious Diseases Introduction Factors That Influence Emerging Infectious Diseases Recent Emerging and Reemerging Infectious Diseases Reemerging Vaccine-Preventable Diseases Antibiotic-Resistant Microorganisms Conclusions

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Chapter 16 Violence and Abuse Overview of Violence Intimate Partner Violence Mandatory Reporting of Abuse Intervention Human Trafficking Model of Care for Victims of Intentional Crimes Forensic Nursing

Chapter 17 Substance Use International Aspects of Substance Abuse Health Profiles and Interventions for High-Risk Populations Impact on the Community Public Health Models for Populations at Risk Treatment Interventions for Substance Abuse Goals of Healthy People 2020

Chapter 18 Underserved Populations The Context of Health Risks Rural Populations Correctional Health: Underserved Populations in Jails and Prisons Gay, Lesbian, Bisexual, Transgender, and Queer Community Veterans and Health Human Trafficking Homeless Populations

Chapter 19 Environmental Health Introduction Human Health and the Environment Assessment Interventions Evaluation Environmental Epidemiology Working Toward Healthy Environments Children’s Health and the Environment Environmental Justice Global Environmental Health Challenges

Chapter 20 Community Preparedness: Disaster and Terrorism Introduction Emergencies, Disasters, and Terrorism Disaster Preparedness in a Culturally Diverse Society Disaster Management MRC and CERT Groups Roles of Nurses in Disaster Management Bioterrorism Chemical Disasters Radiologic Disasters Blast Injuries Public Health Disaster Response

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PART FIVE Specialty Practice

Chapter 21 Community Mental Health Cultural Context of Mental Illness Definitions of Mental Illness Scope of Mental Illness Some Major Mental Illnesses Evolution of Community Mental Health Legislation for Parity in Mental Health Insurance Benefits Roles and Responsibilities of the Community Mental Health Practitioner Psychological First Aid

Chapter 22 School Health Introduction Historical Perspectives Role of the School Nurse Common Health Concerns The School Nurse as a Child Advocate The Future of School Health: Whole School, Whole Community, Whole Child (WSCC) Model

Chapter 23 Faith-Oriented Communities and Health Ministries in Faith Communities Nursing in Faith Communities History of Faith Community Nursing Models of Faith Community Practice The Uniqueness of Faith Communities Roles of the Faith Community Nurse Healthy People 2020 Priorities Scope and Standards of Practice The Nursing Process in Faith Community Nursing Ethical Considerations Education for Faith Community Nursing

Chapter 24 Palliative and End-of-Life Care Nursing and Persons With Chronic Disease Death in the United States Nursing Care When Death Is Imminent Palliative Care Hospice Care Caring for Persons at the End of Life Nursing Care of Persons Who Are Close to Death Complementary and Alternative Therapies

Chapter 25 Occupational Health Nursing Introduction The Worker and the Workplace Occupational Health Nursing Conceptual Frameworks Occupational Health Nursing: Practice Implementing Health Promotion in the Workplace

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Implementing a Program: Example, Smoking Cessation Epidemiology and Occupational Health Emergency Preparedness Planning and Disaster Management Nanotechnology and Occupational Safety and Health

Index

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Part 1 The Context of Community and Public Health Nursing

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Chapter 1 Public Health Nursing: Present, Past, and Future Judith Healey-Walsh

For additional ancillary materials related to this chapter. please visit thePoint

Nursing is based on society’s needs and therefore exists only because of society’s need for such a service. It is difficult for nursing to rise above society’s expectations, limitations, resources, and culture of the current age. Patricia Donahue, Nursing, the Finest Art: An Illustrated History

I believe the history of public health might be written as a record of successive redefinings of the unacceptable. George Vicker

Some people think that doctors and nurses can put scrambled eggs back into the shell. Dorothy Canfield Fisher, social activist and author

The only way to keep your health is to eat what you don’t want, drink what you don’t like, and do what you’d rather not. Mark Twain

CHAPTER HIGHLIGHTS Healthcare changes in the 21st century Characteristics of public health nursing Public health nursing roots Challenges for practice in the 21st century

OBJECTIVES Outline three major changes in healthcare in the 21st century. Identify the eight principles of public health nursing practice. Explain the significance of the standards and their related competencies of professional public health nursing practice. Discuss historical events and relate them to the principles that underlie public health nursing today. Consider the challenges for public health nurses in the 21st century.

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KEY TERMS Aggregate: Population group with common characteristics. Competencies: Unique capabilities required for the practice of public health nursing. District nurses: Public health nurses in England who provide visiting nurse services; historically,

they cared for the people in the poorest parish districts. Electronic health records: Digital computerized versions of patients’ paper medical records. Epidemiology: Study of the distribution and determinants of states of health and illness in

human populations; used both as a research methodology to study states of health and illness, and as a body of knowledge that results from the study of a specific state of health or illness.

Evidence-based nursing: Integration of the best evidence available with clinical expertise and the values of the client to increase the quality of care.

Evidence-based public health: A public health endeavor wherein there is judicious use of evidence derived from a variety of science and social science research.

Health disparities: Differences in healthcare and health outcomes experienced by one population compared with another, frequently associated with race/ethnicity and socioeconomic status

Health information technology: Comprehensive management of health information and its secure exchange between consumers, providers, government and quality entities, and insurers.

Public health: What society does collectively to ensure that conditions exist in which people can be healthy.

Public health interventions: Actions taken on behalf of individuals, families, communities, and systems to protect or improve health status.

Public health nursing: Focuses on population health through continuous surveillance and assessment of the multiple determinants of health with the intent to promote health and wellness; prevent disease, disability, and premature death; and improve neighborhood quality of life (American Nurses Association [ANA], 2013).

Telehealth: Use of electronic information and telecommunications technologies to support long- distance clinical healthcare, patient and professional health-related education, public health, and health administration.

Social determinants of health: Social conditions in which people live and work.

CASE STUDY

References to the case study are found throughout this chapter (look for the case study icon). Readers should keep the case study in mind as they read the chapter.

The Department of Health and Human Services (HHS) in a southeastern state has begun implementing the recommendations from both the U.S. Institute of Medicine’s publication The Future of the Public’s Health in the 21st Century and the 10-year national objectives for promoting health and preventing disease in the United States established by Healthy People 2020. A task force is developing a new vision for public health in the state. Sandy is a program developer in the state’s Department of Public Health, with the primary responsibility of assisting local public health departments in developing, implementing, and evaluating public health nursing initiatives. Sandy represents public health nursing on the task force. (Adapted from Jakeway, Cantrell, Cason, & Talley, 2006).

HEALTHCARE CHANGES IN THE 21ST CENTURY

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A worldwide phenomenon of unprecedented change is occurring in healthcare. There are new innovations to test, ethical dilemmas to confront, puzzles to solve, and rewards to be gained as healthcare systems develop, refocus, and become more complex within a multiplicity of settings. Nurses, the largest segment of healthcare providers in the world, are on the frontline of that change.

Demographic characteristics indicate that people in high-income countries are living longer and healthier lives, yet tremendous health and social disparities exist. The social conditions in which people live, their incomes, their social statuses, their educations, their literacy levels, their homes and work environments, their support networks, their genders, their cultures, and the availability of health services are the social determinants of health. These conditions have an impact on the extent to which a person or community possesses the physical, social, and personal resources necessary to attain and maintain health. Some population groups, having fewer resources to offset these effects, are affected disproportionately. The results are health disparities, or differences in healthcare and health outcomes experienced by one population compared with another.

For example, the World Health Organization (WHO) estimates that almost half of all countries surveyed have access to less than half the essential medicines they need for basic healthcare in the public sector. These essential medicines include vaccines, antibiotics, and painkillers. Children in low-income countries are 16 times more likely to die before reaching the age of 5 years, often because of malnourishment, than children in high-income countries. The double burden of both undernutrition and overweight conditions causes serious health problems and affects survival (WHO, 2017). Globally, resources exist to remedy these circumstances, but does the political commitment exist?

The development of society, rich or poor, can be judged by the quality of its population health, how fairly health is distributed across the social spectrum, and the degree of protection provided from disadvantage as a result of ill health. World Health Organization

Role of the Government in Healthcare A government has three core functions in addressing the health of its citizens: (1) it assesses healthcare problems; (2) it intervenes by developing relevant healthcare policy that provides access to services; and (3) it ensures that services are delivered and outcomes achieved. The United States, the United Kingdom, the European community, and some newly industrialized countries have embraced these principles. However, governments in other countries struggle to build any semblance of a health system. Unstable governments struggle with mobilizing the concern, motivation, or resources to address healthcare issues.

There were unprecedented public health achievements in the United States during the 20th century. The Centers for Disease Control and Prevention (CDC) has listed the Ten Great Public Health Achievements as the legislature amends the law based on supportive epidemiologic analyses and comparisons of health factors over 30 years (Box 1.1). However, healthcare expenditures are now more than $3.2 trillion per year (CDC, 2016). Infant mortality, longevity, and other health indicators still fall behind those of many other industrialized nations. The current U.S. healthcare system faces serious challenges on multiple fronts. Although the United States is considered the best place for people to obtain accurate diagnoses and high-quality treatment, until 2014 nearly 45 million Americans lacked health insurance and therefore access to care. These uninsured Americans were primarily young people, low-income single adults, small-business owners, self-employed adults, and others who did not have access to employer- sponsored health insurance.

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1.1 Ten Great Public Health Achievements in the United States, 1900 to 1999

Vaccination Motor vehicle safety Safer workplaces Control of infectious diseases Decline in coronary heart disease and stroke deaths Safer and healthier foods Healthier mothers and babies Family planning Fluoridation of drinking water Recognition of tobacco as a health hazard

Source: Centers for Disease Control and Prevention. (1999). Ten great public health achievements—United States, 1900–1999. Morbidity Mortality Weekly Report, 48(12), 241–243.

The Patient Protection and Affordable Care Act (PPACA) was signed into law by President Barack Obama in 2010. The goal of the PPACA is to help provide affordable health insurance coverage to most Americans, lower costs, improve access to primary care, add to preventive care and prescription benefits, offer coverage to those with pre-existing conditions, and extend young adults’ coverage under their parents’ insurance policies. It is estimated that 95% of legal U.S. residents will ultimately be covered by health insurance, although implementation will evolve over time (Doherty, 2010). The passage of the PPACA was the first step in providing Americans with the security of affordable and lifelong access to high-quality healthcare. More information about the Affordable Care Act is found in Chapter 3.

It is cheaper to promote health than to maintain people in sickness. Florence Nightingale

Practice Point

Making healthcare a right rather than a privilege has global implications.

The United States assesses and monitors people’s health through an intricate system of surveillance surveys conducted by the HHS, the CDC, and the state and local governments. Health policy development focuses on cost, access to care, and quality of care. Access is defined as the ability to get into the healthcare system, and quality care is defined as receiving appropriate healthcare in time for the services to be effective. Outcomes are ensured by a continual evaluation system linked in part with the CDC surveys. Despite this elaborate healthcare system, health disparities related to race, ethnicity, and socioeconomic status still pervade the healthcare system. Health disparities vary in magnitude by condition and population, but they are observed in almost all aspects of healthcare, in quality, access, healthcare utilization, preventive care, management of chronic diseases, clinical conditions, and settings, and within many subpopulations.

The National Healthcare Quality and Disparities Report (NHQDR) measures trends in the effectiveness of care, patient safety, timeliness of care, patient centeredness, and efficiency of care. The report presents, in chart form, the latest available findings on quality of and access to healthcare (Agency for Healthcare Research and Quality [AHRQ], 2018). For example, Figure 1.1 indicates that quality of healthcare improved overall from 2000 to 2014, although the pace of improvement varied based on priority area. In addition, as Figure 1.2 demonstrates, that although some gaps in measures by race/ethnicity are improving, health disparities in quality

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healthcare remain.

FIGURE 1.1 Number and percentage of all quality measures that were improving, not changing, or worsening, total and by priority area, from 2000 through 2014.

The challenge for the United States in the 21st century is to create a dynamic, streamlined healthcare system that produces not only the finest technology and research, but also the most accessible, efficient, low-cost, and high-quality healthcare in the world. The current healthcare system also must be transformed to become one of the most competitive and successful systems in the world. Innovative and creative changes will be needed to create a patient/client-centered, provider-friendly healthcare system that is consumer-driven. The political will does exist to create a better future: patient/client-centered care is evolving, new technology is shaping delivery of care, and people are assuming more responsibility for maintaining their health.

Patient/Client-Centered Care Healthcare has been evolving toward a multifaceted system that empowers patients and clients

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rather than providers, as was common in the past. This transformation is considered the best way to ensure that patients have access to high-quality care, regardless of their income, where they live, the color of their skin, or how old or ill they are.

Patient/client-centered care considers cultural traditions, personal preferences, values, families, and lifestyles. People requiring healthcare, along with their families or significant others, become an integral part of the healthcare team, and clinical decisions are made collaboratively with professionals. Clients become active participants in their own care, and monitoring health becomes the client’s responsibility. Support, advice, and counsel from health professionals are available, along with the tools that are needed to carry out that responsibility.

The shift toward patient/client-centered care means that a broader range of outcomes needs to be measured from the patient’s perspective to understand the true benefits and risks of healthcare interventions.

Practice Point

The AHRQ has developed a series of tools to assist clients in making healthcare decisions.

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FIGURE 1.2 Number and percentage of quality measures with disparity at baseline for which disparities related to race and ethnicity were improving, not changing, or worsening (2000 through 2014 to 2015).

To help clients and their healthcare providers make better decisions, the AHRQ has developed a series of tools that empower clients and assist providers in achieving desired outcomes. Tools include questionnaires to help determine important treatment preferences and decisions, symptom severity indexes, client fact sheets, client-reported functional status indicators, and other helpful decision-making guidelines. AHRQ (2016) developed the SHARE Approach, a model to promote shared decision-making between a healthcare provider and patient/client. The model has five steps that encourage a conversation between the provider and patient in order to gain a clear understanding of the benefits, harms, and risks of the care options and to identify the patient’s values and preferences. The steps include:

1. Seek the patient’s participation 2. Help the patient to review and compare care options 3. Assess the patient’s values and preferences

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4. Reach a consensus decision with the patient 5. Evaluate the decision

These tools are available to both consumers and healthcare providers at the AHRQ website. For the system to work effectively, transitions between providers, departments, various

healthcare settings, and the home must be coordinated and efficient so that unneeded or unwanted services can be reduced. Americans are sophisticated, empowered consumers in almost every aspect of their lives and will make the best decisions both for themselves and collectively for the healthcare economy and society itself.

Technology Rapidly advancing forms of technology are dramatically improving lives. Thousands of new ideas are investigated each year, with hundreds of new medical devices submitted to the U.S. Food and Drug Administration annually. Medical devices vary considerably, such as computer- assisted robotic surgical techniques, artificial cervical disks, new diagnostic techniques, implantable microchip-containing devices that control dosing from drug reservoirs, continuous glucose-monitoring systems for detecting trends and tracking patterns in people with diabetes, and many more.

The benefits of biomedical progress are obvious, clear, and powerful. The hazards are much less well appreciated. Leon Kass, physician

Although massive investments in medical research have been made, there has been an underinvestment in both research and the infrastructure necessary to translate basic research into results. For example, studies indicate that it takes physicians an average of 17 years to adopt widely the findings from basic research. The healthcare sector invests nearly 50% less in information technology than any other major sector of the U.S. economy. More comprehensive knowledge bases of healthcare information, computerized decision support, and a health information technology (HIT) infrastructure with national standards of interoperability to promote data exchange are necessary.

Health Information Technology Health information technology is defined as the comprehensive management of health information and its exchange between consumers, providers, government, and insurers in a secure manner. HIT makes it possible for healthcare providers to better manage patient care through secure use and sharing of health information. It is viewed as the most promising tool for improving the overall quality, safety, and efficiency of the health delivery system.

Health information technology and electronic health information exchange have emerged as a primary means of shaping a healthcare system that is effective, safe, transparent, and affordable. When linked with other health system reforms, technology can support better quality healthcare, reduce errors, and improve population health. State Alliance for e-Health

Health information technology includes the use of electronic health records (EHRs), digital computerized versions of patients’ paper medical records, to maintain people’s health information. EHRs and other HIT systems are powerful tools that are having a significant impact on healthcare. Consumers are empowered with more information, choices, and control, and providers have reliable access to complete personal health information that can help them make

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the right decisions. All necessary health information, from medical histories to billing information, will be accessible from the internet and readily available to all appropriate healthcare facilities and providers of care (with permission of the client). With faster diffusion of medical knowledge through the internet, decision-making will be expedited, medical errors reduced, and duplication of tests and misdiagnosis decreased. However, to protect these records from unauthorized, inappropriate, or unethical use, national privacy laws must be in place.

In the United States, the Office of the National Coordinator for Health Information Technology (ONC) is the principal federal entity responsible for the coordination and safety of information technology issues. It is a resource to the entire health system to support the adoption of HIT and to promote nationwide health information exchange to improve healthcare. ONC is organizationally located within the Office of the Secretary for the U.S. HHS. The ONC has developed SAFER guides for EHRs, consisting of nine guides organized into three broad groups that enable healthcare organizations to address EHR safety in a variety of areas. The guides identify recommended practices to optimize the safety and safe use of EHRs and can be found on the ONC website (see web Resources on ).

The ONC funds the Nationwide Health Information Network (NwHIN, 2013), a collaborative organization of federal, local, regional, and state agencies. Its mission is to develop the envisioned secure, nationwide, interoperable health information infrastructure to connect providers, consumers, and organizations involved in supporting health and healthcare. The major goals of NwHIN are to enable health information to follow the consumer, to be available for clinical decision-making, and to support appropriate use of healthcare information beyond direct client care to improve the health of communities. The conceptual model that guides NwHIN is illustrated in Figure 1.3. The NwHIN has developed a set of standards, services, and policies that enable the secure exchange of health information nationwide over the internet. Health information will follow the patient and be available for clinical decision-making as well as for uses beyond direct patient care, such as measuring quality of care. It is proposed that the NwHIN will be the vehicle through which health information will be exchanged.

Telehealth Telehealth is the use of electronic information and telecommunications technologies to support long-distance clinical healthcare, patient and professional health-related education, public health, and health administration (Health Resources and Services Administration, 2014). Telehealth is becoming a necessity, due in part to the aging population, the rising number of people with chronic conditions, and the need to increase healthcare delivery to medically underserved populations. Findings from the 2015 National Nursing Workforce Survey indicated that nearly half of the registered nurses surveyed had provided nursing services through the use of telehealth products (Budden, Moulton, Harper, Brunell, & Smiley, 2016).

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FIGURE 1.3 The nationwide health information network conceptual model. (From Nationwide Health Information Network [NwHIN]. Retrieved from http://www.ahrq.gov/research/findings/nhqrdr/nhdr12/highlights.html.)

Advances in technology, specifically those involving videoconferencing, medical devices, sensors, high-speed telecommunication networks, store-and-forward imaging, streaming media, and terrestrial and wireless communications have made it possible to assess clients’ conditions remotely in their homes. Information can be stored for later access or assessments can be performed in real time using internet video systems. It is also possible to obtain the advice of expert specialty consultants without meeting in person. The increasing complexity of telehealth requires ongoing communication, training, cultural sensitivity, and customization for individual clients. However, access, availability, and cost issues can be barriers to use of this technology (Standing, Standing, McDermott, Gururajan, & Mavi, 2016; Tuckson, Edmunds, & Hodgkins, 2017).

Evidence for Practice

The use of home telehealth devices as an alternative for chronic disease management by nurses has the potential to assist many older people in their homes with the goal of decreasing hospital readmission, and improving the quality of life through early detection and prompt treatment of symptoms. However, long-term outcomes and sustainability have been a concern and challenge. Radhakrishnan, Xie, and Jacelon (2015) studied a telehealth program at a home health agency (HHA) in Texas that ended the program after 10 years of service. The researchers designed a descriptive qualitative study using semistructured interviews to explore the reasons for starting the program, the progressive decline, and the barriers to and facilitators for sustainability of home telehealth programs. The sample included 13 home health staff, including six visiting nurses, two telehealth

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nurses, four nursing administrators, and nine adult patients, all of whom were over 55 years of age.

Of them, 77% were over 60, and all had Medicare benefits. The service was provided on average for 60 days to patients who were dealing with self-management of chronic diseases, such as cardiovascular disease, respiratory conditions, and diabetes. The telehealth system used at the agency transmitted the patient’s biometric and symptom status data to the HHA, but it did not have audio or video capacity. A technician and LVN trained the patient on the use of the device. The telehealth nurse would review the data, and if they were above or below the pre-determined parameters, the nurse would call the patient and the visiting nurse, who would call or visit the patient or contact the MD.

Data on telehealth utilization and patient outcomes were tracked by the HHA. The researchers used conventional content analysis (reading and coding) of the interview transcripts, from which five themes emerged. Subthemes and the barriers and facilitators toward program sustainability were identified. The five themes and aligned subthemes included (a) impact on patient-centered outcomes (self-management, quality of life, and patient characteristics); (b) impact on cost-effectiveness (return on investment), impact on healthcare utilization, and telehealth update and maintenance costs; (c) patient–clinician and interprofessional communication (nurse–patient, nurse–physician, and patient– physician communication); (d) technology usability (cumbersome installation process, device usability); and (e) home health management culture (top-down decision-making, support for supplementary telehealth resources.)

The major barriers were lack of reimbursement, fewer than expected referrals from MDs, minimal impact on re-hospitalization rate, nurses’ caseloads usability of the device, high maintenance time and costs, poor interoperability with MD offices, frustration with the amount and delays in communication, lack of administrative and technical support, and patient preference for in-person interaction. Positive features and outcomes that could support sustainability included early identification of a problem and ability to intervene quickly, at-home convenience and ability to remain at home, family caregiver support, feeling of security and support for the patient and family, cost-sharing with other institutions, understanding and buy-in at all levels of management, ease of use and communication to the nurse, and MD involving end users in decision-making in all aspects of program development.

The study’s findings support the complexity of a telehealth program, as having potentially positive and negative features. Program design and implementation needs to be intentionally addressed with involvement of the end users nurses, patients, and MDs. The program also must have an ongoing assessment and quality improvement approach, so that barriers are identified early and solutions found to maximize the benefits and sustainability of the program.

Personal Responsibility for Health Increased personal responsibility for preventing disease and disability is a vital component of healthcare change. The underlying premise holds that if people have a vested interest in their health, they will do more to maintain it. However, if a person is healthy, he or she may not focus on maintaining individual health, yet no one is more seriously affected when illness or disability occurs. Preventing or modifying unhealthy behaviors can save both lives and money, but can personal responsibility regarding one’s health be truly mandated and regulated?

1.2 Healthy People 2020 Overarching Goals

1. Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death. 2. Achieve health equity, eliminate disparities, and improve the health of all groups. 3. Create social and physical environments that promote good health for all. 4. Promote quality of life, healthy development, and healthy behaviors across all life stages.

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Personal responsibility for health involves active participation in one’s own health through education and lifestyle changes. It includes responsibility for reviewing one’s own medical records, including laboratory test results, and monitoring both the positive and negative effects of prescription and over-the-counter medications. It means showing up for scheduled tests and procedures, following dietary recommendations, losing weight if needed, avoiding tobacco and recreational drug use, engaging in exercise programs, and educating oneself about one’s own conditions. Ultimately, people must take the responsibility for making their own choices and healthcare decisions.

The patient should be made to understand that he or she must take charge of his own life. Don’t take your body to the doctor as if he were a repair shop. Quentin Regestein, psychiatrist, Harvard University

U.S. government initiatives have been implemented to encourage personal responsibility for health. Healthy People 2020 is a national, science-based plan designed to reduce certain illnesses and disabilities by reducing disparities in healthcare services in people of different economic groups. Since 1979, Healthy People programs have measured and tracked national health objectives to encourage collaboration, guided people toward making informed health decisions, and assessed the impact of prevention activity. Specific objectives with baseline values for measurement are developed, setting specific targets to be achieved by 2020. The four major overarching goals that incorporate these objectives are listed in Box 1.2 (Healthy People 2020, n.d.).

PUBLIC HEALTH NURSING TODAY The shorter length of stay in acute care facilities, as well as the increase in ambulatory surgery and outpatient clinics, has resulted in more acute and chronically ill people residing in the community who need professional nursing care. Fortunately, these people can have their care needs met cost-effectively outside of expensive acute care settings. As a result, demand has increased for nurses in ambulatory clinics, home care, and care management.

Hospitals remain the most common workplace for RNs in the United States (54%) (Budden et al., 2016). However, the number of RNs working in home health service units or agencies is increasing (13%) (U.S. Department of Labor, 2017). Public health, ambulatory care, and other noninstitutional settings have historically had the largest increases in RN employment. These statistics indicate a shift in the roles of nurses, particularly for those working in public health settings.

Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations. American Nurses Association

Public Health Nursing A decades-long debate about terminology has fostered confusion regarding the roles of nurses who serve the community. However, public health professionals nationwide have come together to define the principles of public health (Box 1.3). Embracing these fundamental principles for all public health professionals, the Quad Council of Public Health Nursing Organizations established eight principles of public health nursing practice (Box 1.4). The Quad Council of

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Public Health Nursing Organizations is an alliance of four national nursing organizations that address public health nursing issues in the United States, comprising the following:

Association of Community Health Nurse Educators (ACHNE) ANA’s Congress on Nursing Practice and Economics (CNPE) American Public Health Association (APHA)—Public Health Nursing Section Association of State and Territorial Directors of Nursing (ASTDN)

Public health is what we, as a society, do collectively to assure the conditions in which people can be healthy. Institute of Medicine, 1988

1.3 Principles of Public Health

Focus on the aggregate. Promote prevention. Encourage community organization. Practice the ethical theory of the greater good. Model leadership in health. Use epidemiologic knowledge and methods.

1.4 Principles of Public Health Nursing: The Public Health Nurse Is Guided by Adherence to All of the Following Principles

The client or unit of care is the population. The primary obligation is to achieve the greatest good for the greatest number of people or number of

people as a whole. Public health nurses collaborate with the client as an equal partner. Primary prevention is the priority in selecting appropriate activities. Public health nursing focuses on strategies that create healthy environmental, social, and economic

conditions in which populations may thrive. A public health nurse is obligated to actively identify and reach out to all who might benefit from a

specific activity or service. Optimal use of available resources and creation of new evidence-based strategies is necessary to assure

the best overall improvement in the health of populations. Collaboration with other professions, populations, organizations, and stakeholder groups is the most

effective way to promote and protect the health of the people.

Source: American Nurses Association (ANA). (2013). Public health nursing: Scope and standards of practice. Silver Spring, MD: Nursesbooks.

Scope and Standards of Practice The ANA sets the scope and standards for all professional nursing practice. The publication Public Health Nursing: Scope and Standards of Practice establishes the characteristics of competent public health nursing practice and is the legal standard of practice. It defines the essentials of public health nursing, the activities, and the accountabilities that are characteristics of practice at all levels and settings. An important component of this document is the designation of competencies required to meet each standard of practice. This scope and standards document can be used by PHNs from entry-level to senior management in a variety of practice settings and is an indispensable publication reference for every practicing PHN (ANA, 2013).

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Competencies for Public Health Nursing Practice The core competencies for public health nurses (CCPHN) defined in the ANA (2013) publication are aligned with core competencies developed by other public health organizations. The CCPHN reflect the unique capabilities required for the practice of public health nursing. Three tiers of practice are defined, along with competencies associated with that level of practice. Tier 1 core competencies apply to entry-level public health professionals at the basic or generalist level. For example, individuals who have limited experience working in the public health field and are not in management positions would be considered practicing at Tier 1. Tier 2 core competencies apply to individuals with management and/or supervisory responsibilities and are considered specialists or mid-level practitioners. Tier 3 core competencies apply to senior managers and leaders at the executive level who deal with multisystems. Essentially, these competencies underlie the wide variety of roles and responsibilities that PHNs accept in the workplace.

The CCPHN are integrated into the Standards of Practice for Public Health Nursing (ANA, 2013). Each standard of practice is followed by the essential competencies required to meet that standard. Following each standard of practice, additional competencies are presented for practice as an advanced PHN.

Public Health Nursing Interventions The public health intervention (wheel) model illustrated in Figure 1.4 is (1) a population-based model that (2) is applied to individuals, families, communities, or within systems and (3) defines 17 public health interventions focusing upon prevention. It is a way of defining public health nursing by the type of actions taken on behalf of clients to protect or improve health status. The interventions in the wheel model complement the competencies that each PHN must demonstrate for safe practice. The competencies define what should be done while the interventions provide a means to accomplish those actions. Table 1.1 describes the 17 interventions illustrated in the wheel. Other interventions have been suggested, such as that of change agent, culture broker, and researcher. The wheel creates a structure for identifying and documenting interventions, thereby capturing the nature of public health nursing practice.

Two years ago, Sandy participated in a statewide survey of both the public health nurses in the state as well as their employers. The purpose of the survey was to determine the characteristics of public health nursing practice, especially the use of principles of population health. Results indicated that the majority of the public health nurse’s time is spent in the provision of primary care and clinical services to individual clients. The major factors that contribute to this finding include the number of uninsured people (16%) and a large population of medically underserved people.

Define the type of practice (tier) that the public health nurses were performing.

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FIGURE 1.4 Public health intervention wheel.

The new vision for public health being designed by the task force promotes a shift from a predominantly individual and clinic-based care model to a population health practice model. The public health nurses in the state were unprepared for this transition and lacked a strong understanding of population health concepts and competencies. Using the standards of practice and associated competencies outlined in Public Health Nursing: Scope and Standards of Practice, and with assistance from faculty members at the state university, the task force is helping to develop an online population-based health course to meet the needs of the public health nurses in the state. The priorities of the online course are as follows:

Community assessment and diagnosis Interpreting and presenting health information Using computer technology in health planning and policy development Building community coalitions

Using Public Health Nursing: Scope and Standards of Practice, choose the appropriate standards and competencies that the public health nurses should demonstrate to meet these priorities.

Education for Public Health Nursing Practice

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The educational credential for entry into public health nursing practice is the baccalaureate degree in nursing. This can be a baccalaureate in nursing (BS or BSN) or a generalist master’s degree as a clinical nurse leader (CNL). Public health nursing specialists in population health may have a master of science in nursing (MSN), master of public health (MPH), a joint MSN/MPH, or a doctoral degree. Doctoral degrees may be doctor of philosophy (PhD), doctor of nursing practice (DNP), or doctor of public health (DrPH). Diploma- and associate degree- prepared RNs and licensed practical nurses may practice in some public health settings. In these positions, nurses provide care for individuals or families but not for populations (ANA, 2013).

TABLE 1.1 Public Health Nursing Interventions

Intervention Definition Surveillance Monitors health events through ongoing, systematic collection, analysis and

interpretation of health data for planning, implementing, and evaluating public health interventions

Investigation of disease and other health events

Systematically gathers and analyzes data about threats to population health, determines the source, identifies cases and those at risk, and determines control measures

Outreach Locates populations at risk, provides information, identifies possible actions, and identifies access to services

Screening Identifies individuals with unrecognized risk factors or asymptomatic conditions Case-finding Locates individuals and families with identified risk factors and connects them

with resources Referral and follow-up Assists in identifying and accessing necessary resources to prevent or resolve

concerns Case management Coordination of a plan or process to bring health services and the self-care

capabilities of the client together as a common whole in a cost-effective way Delegation Direct care tasks an RN entrusts to other appropriate personnel Teaching Develops a health education plan and teach clients and other caregivers

leading to behavior change Counseling Develops an interpersonal relationship with the client to increase his or her

capabilities to address or solve issues Consultation Seeks information and generates solutions to health problems or issues through

interactive problem-solving Collaboration Works with people or representatives of organizations to achieve a common

goal Coalition-building Fosters, mobilizes, and participates in community-wide alliances to achieve a

specific goal Community organizing Helps community groups to identify common problems or goals, mobilizes

resources, and develops and implements strategies for reaching those goals Advocacy Acts on behalf of clients who have lost control of factors that affect their health

and a need is unmet; strengthens clients’ capacity to act Social marketing Uses marketing principles and technology to design programs to address needs

of the client Policy development Promotes beneficial social changes that influence the health of groups and

populations Policy enforcement Compels others to comply with the laws, rules, regulations, and ordinances

created in conjunction with policy development

Source: Adapted from Public Health Interventions: Application for Nursing Practice. Retrieved from www.health.state.mn.us/divs/opi/cd/phn/wheel.html.

ROOTS OF PUBLIC HEALTH NURSING Exploring the roots of the healing professions provides the background for understanding the characteristics of nursing practice today (Table 1.2). Since the beginning of civilization, people in all cultures have focused on birth, health, illness, and death. Historical records indicate that early societies engaged in public health measures by burying wastes away from water supplies,

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developing sewage systems, and draining marshes to control communicable disease. In these times, people spent their lives with their family and community, especially when they were ill and needed care. Early caregivers, usually women, cultivated healing herbs, applied poultices, applied heat and cold, immobilized fractures, delivered babies, and attended the dead.

In the Middle Ages, care of ill people was based in the household. Care was haphazard. The few hospitals that existed were run by monks and nuns, primarily for residents of monasteries, and only the wealthy could afford assistance with their care. Changes in social structures encouraged the development of cities, but overcrowding, lack of sanitation, and an ever- increasing susceptible population contributed to recurring epidemics. During the 14th century, the Black Plague alone killed approximately one fourth of the population of Europe. From the 1500s through the 1700s, the Renaissance in Europe stimulated the rise of scientific thought and inspired social consciousness.

The English Poor Law of 1601 marked the beginning of state-provided relief for the poor, placing a legal responsibility on each district to care for people within its boundaries who, either because of age or infirmity, were unable to work. The Sisters (or Daughters) of Charity, known as the “Grey Sisters,” was founded in 1617 in France, with members taking vows to provide care to the sick poor. The organization was so successful that it spread from the rural districts to Paris, and a training program was established in 1633 for young women who were devoted to serving people in need. From that time through the 19th century, this nursing community spread throughout the world. Today, the mother house is located in Paris.

TABLE 1.2 Milestones in Public Health and Public Health Nursing 1601 Poor Law instituted in England; beginning of state-supported assistance for the

poor 1617 Sisters (or Daughters) of Charity founded in France 1789 First local permanent health department in the United States founded in

Baltimore, MD 1798 Marine Hospital Service established in the United States; later became the

Public Health Service 1809 Sisters of Charity founded by Elizabeth Ann Seton in Maryland 1813 Ladies’ Benevolent Society of Charleston, SC, established to provide home

care to the sick 1825 154 hospitals had been established in England 1836 Training school for deaconesses established by Theodore Fliedner, a German

Lutheran pastor 1840/1841 Dorothea Dix began her lifelong campaign to improve the life of the mentally ill 1850 Shattuck Report published by the Massachusetts Sanitary Commission;

recommended the establishment of a state health department and local health boards in every town, collection of vital statistics, sanitation, disease control, health education, town planning, and teaching of prevention in medical schools

1851 Florence Nightingale attended Fliedner’s school for deaconesses 1859 William Rathbone established district nursing in England 1860 Florence Nightingale established the first school for nurses at St. Thomas

Hospital in London 1861 Soldiers in the American Civil War attended by visiting nurses 1870s First nursing schools opened in the United States based on the Nightingale

model 1872 American Public Health Association established 1882 Clara Barton convinced the U.S. Congress to establish the American Red Cross

with an extended mission to provide aid for natural disasters 1885/1886 Visiting nurse associations established in Boston, Philadelphia, and Buffalo 1893 Lillian Wald established the Henry Street Settlement in New York City for the

sick poor 1895 Ada Steward employed by Vermont Marble Works as the first occupational

health nurse

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1898 Significant use of trained nurses in military hospitals 1901 U.S. Army Nurse Corps established 1908 U.S. Navy Nurse Corps established 1912 National Organization for Public Health Nursing established, with Lillian Wald

the first President; U.S. Children’s Bureau established; Marine Hospital Service changed to U.S. Public Health Service

1914 First postgraduate program in public health nursing at Teachers College in New York City, affiliated with the Henry Street Settlement, established by Mary Adelaide Nutting

1920 90% of the ill were cared for at home with assistance from the community 1925 Frontier Nursing Service in the United States established by Mary Breckinridge

to provide access to healthcare in remote Appalachian regions of southeastern Kentucky

1933 Pearl McIver became the first nurse employed by the U.S. Public Health Service 1935 U.S. Social Security Act passed 1943 Frances Payne Bolton was instrumental in founding the Cadet Nurse Corps as

a part of the Public Health Service to train nurses during World War II 1953 U.S. Department of Health, Education, and Welfare established 1957 Nationalized Canadian healthcare system established 1965 Public health pediatric nurse practitioner program established at University of

Colorado 1966 Medicare for the elderly established in the United States 1967 Medicaid for the medically indigent established in the United States 1970 Occupational Safety and Health Administration established 1974 National Health Planning and Resources Development Act passed 1975 Certification for community health nurses established by the American Nurses

Association (ANA) 1979 Smallpox eradication worldwide certified by the WHOa 1980 First national health objectives for the United States established: Promoting

Health/Preventing Disease: Objectives for the Nation 1980 Direct reimbursement through Medicaid for nurse practitioner in rural health

clinics, United States 1984 Behavioral Risk Factor Surveillance System (BRFSS) established 1989 Guide to Clinical Preventive Services (standardizing screening and prevention

strategies) published by the U.S. Public Health Services Task Force 1990 Healthy People 2000: National Health Objectives for Health Promotion and

Illness Prevention published 1991 Nursing’s Agenda for Health Care Reform published by a coalition of more than

60 nursing organizations 1998 The Public Health Workforce: An Agenda for the 21st Century published by U.S.

Public Health Service 2000 Healthy People 2010 published 2002 European region of WHO declared free of polio 2002 U.S. Office of Homeland Security established 2003 U.S. Institute of Medicine recommends that undergraduate nursing students

understand the ecological model of health and core competencies of population-based practice

2010 Patient Protection and Affordable Care Act (PPACA) passed aWHO, World Health Organization.

In the 1800s, a variety of reforms were initiated to care for the sick poor throughout Europe that interacted and built on one another. Hospitals were established. By 1825, there were 154 in England alone. However, the fatality rates in these institutions were high, particularly for newborns and people with open wounds; the hospitals were called “death houses.” So-called “ward maids,” equivalent to housekeepers, provided care.

In Holland, Mennonites recruited women of the church to form deaconess groups to care for the poor. In 1836, Theodore Fliedner, a German Lutheran pastor, established a three-year training school for deaconesses, which was associated with a new hospital. Fliedner also founded parish districts by dividing towns geographically into smaller areas to provide care to

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residents. In Victorian times, poorhouses or workhouses existed for chronically ill poor people who

were often elderly, without families. The primary reason for poverty was illness, and tuberculosis was rampant. Each parish had its own poorhouse. “Pauper nurses” were poor residents themselves, given the responsibility to care for the destitute. Conditions in many of these poor houses were deliberately harsh and often abysmal. Unfortunately, some pauper nurses were illiterate, irresponsible drunks who were vicious to residents, prolonging their illness (The Public Health [Scotland] Act, 1897). One of the most famous comical, fictional characters in Charles Dickens’s works is Nurse Sairey Gamp in The Life and Adventures of Martin Chuzzlewit. She was a nurse of sorts who dealt with the “lying in and the laying out” extremities of life, representing some of the more questionable characteristics of the so-called nurses at the time (Fig. 1.5).

During the latter part of the 19th century, when district nursing was established, meeting the needs of the ill became more organized in England. At that time, William Rathbone, a Quaker merchant and philanthropist in Liverpool, England, organized help for the poor. In 1859, he hired Mary Robinson, a nurse who previously had cared for his terminally ill wife, to provide care for the people in one of the poorest parish districts in Liverpool. Mary became the first district nurse in England. Box 1.5 lists the duties of district nurses in Liverpool. District nursing soon sprang up in other towns, cities, and rural areas in England, funded by local philanthropists.

Rathbone devoted the rest of his life to expanding services for the sick poor, with assistance from his friend Florence Nightingale and others. Nightingale, the daughter of a wealthy English landowner, devoted her life to the prevention of needless illness and death. In 1851, she attended Theodore Fliedner’s program for deaconesses—for nurse training—in Kaiserswerth, Germany. She formed a team of nurses that assisted soldiers during the Crimean War (1854 to 1856) and statistically documented her successes saving lives through prevention of infections and improving environmental conditions (Fig. 1.6). In 1860, following the war, Nightingale opened the first school of nursing, and Rathbone hired several graduates as district nurses. Two years later, with Nightingale’s assistance, he established a nursing school in Liverpool.

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FIGURE 1.5 Dickens’s character, Sairey Gamp. (From Kalisch, P. A. & Kalisch, B. J. [2004]. American nursing: A history. Philadelphia, PA: Lippincott Williams & Wilkins.)

1.5 Duties of District Nurses in Liverpool, England: 1865

Investigate new referrals as soon as possible. Report to the superintendent situations in which additional food or relief would improve recovery. Report neglect of patients by family or friends to the superintendent. Assist physicians with surgery in the home. Maintain a clean, uncluttered home environment and tend fires for heat. Teach the patient and family about cleanliness, ventilation, giving of food and medications, and

obedience to the physician’s orders. Set an example for “neatness, order, sobriety, and obedience.” Hold family matters in confidence. Avoid interference with the religious opinions and beliefs of patients and others. Report facts to and ask questions of physicians. Refer the acutely ill to hospitals and the chronically ill, poor without family to infirmaries.

Source: Brainard, M. (1985). The evolution of public health nursing (pp. 120–121). New York: Garland. (Original work published in 1922. Philadelphia, PA: W.B. Saunders.)

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Public Health Initiatives in Early America American social values were strongly influenced by British traditions, including care for the sick poor. Care of destitute and infirm residents was the responsibility of the town or county, similar to the English Poor Law of 1601. In the 1700s, early public health efforts in the colonies were focused on sanitation, collection of vital statistics, and control of infectious diseases. People with contagious diseases were isolated in “pesthouses,” and home quarantines were instituted. Women of the house were responsible for care of the ill, and treatments consisted of home remedies that were often passed down through generations.

Occasionally, a board of health would be established to address a specific problem, but it was then disbanded. In 1789, the first local health department with a permanent board of health was formed in Baltimore, MD. In 1798, the Marine Hospital Service was established by Congress to provide for the temporary relief and maintenance of sick and disabled seamen, as a means to protect the public from contagious diseases brought into port by the sailors. This was the first prepaid medical care program in the United States, financed through compulsory employer tax and federally administered.

At the beginning of the 1800s, people recognized that they needed a more organized public health system. In 1809, Elizabeth Ann Seton founded the Sisters of Charity in Maryland. The Sisters of Charity (also called Daughters of Charity) established and operated many hospitals, orphanages, and educational institutions over the years. In 1813, the Ladies’ Benevolent Society of Charleston, SC, was established to provide organized home care to the sick. Knowing the threats that sick merchant seamen posed to the general population, Congress passed the Act for the Relief of Sick and Disabled Seamen in 1798 (amended in 1802) to establish hospitals for merchant seamen. However, conditions in many cities remained nearly intolerable.

The Industrial Revolution resulted in the transformation of primarily agricultural economies to large industrial centers. Large numbers of people migrated into cities, living in crowded tenement houses. Working conditions were poor, people were overworked and underpaid, and child labor was prevalent. Poor nutrition and overcrowded living conditions led to the rapid spread of communicable diseases. For example, New York City’s streets were piled with garbage and sewage, and tenements were filthy and crowded, providing breeding grounds for tuberculosis, smallpox, and typhus. Although initial attempts were made to protect residents from infectious diseases by providing healthcare to merchant seamen, diseases became epidemic and quarantine became inadequate. Few advances in public health were made other than scattered smallpox regulations until the Shattuck Report was published.

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FIGURE 1.6 Florence Nightingale, the “Lady with the Lamp.” (From Kalisch, P. A. & Kalisch, B. J. [2004]. American nursing: A history. Philadelphia, PA: Lippincott Williams & Wilkins.)

Lemuel Shattuck Lemuel Shattuck prepared a report for the Massachusetts Sanitary Commission that pointed out that much of the ill health and disability in American cities in 1850 could be traced to unsanitary conditions. The report is now considered one of the fundamental documents in public health in the United States. It provided for the first systematic use of birth and death records and demographic data to describe the health of a population. The recommendations became the foundation of the sanitation movement in the United States, which laid the framework for the dramatic increase in life expectancy that occurred in the next 150 years. In 1850, the average lifespan was 25 years, and by 2000, it was more than 75 years. The Shattuck Report recommended the establishment of a state health department and local health boards in every town, and resulted in the first attempt to write a comprehensive public health code. Following the Civil War, many states and localities adopted these recommendations, ultimately resulting in the public health system that exists today.

Perhaps the most significant single document in the history of public health—I know of no single document in the history of that science quite so remarkable in its clarity and completeness and in its vision of the future. C. E. A. Winslow, bacteriologist and public health expert, on the Shattuck Report

Dorothea Dix Dorothea Dix was also an American political activist in the 19th century who became aware of the dreadful conditions in prisons and mental hospitals, and she vigorously lobbied state and federal officials to remedy the situation. She had traveled to England in 1836, and during her time there, she met William Rathbone, who was spending a year as a guest at the family estate in

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Liverpool. In addition, she met political activists who believed that government should take an active role in social welfare. The lunacy reform movement was underway in England at the time, and the detailed investigations of the madhouses were published, resulting in legislative changes. After returning from England in 1840, Dix traveled the state of Massachusetts, visiting jails and insane asylums. She was appalled by conditions there and compiled a report that she presented to the Massachusetts Legislature. Considered the most progressive state in the union, Massachusetts quickly allocated funds to establish the first hospitals for the mentally ill. After making changes in Massachusetts, Dorothea moved on to other states and other countries, establishing hospitals and improving life for the mentally ill.

I proceed, Gentlemen, briefly to call your attention to the present state of Insane Persons confined within this Commonwealth, in cages, stalls, pens! Chained, naked, beaten with rods, and lashed into obedience. Dorothea Lynde Dix

Clara Barton Clara Barton achieved widespread recognition during the Civil War, distributing supplies to wounded soldiers and caring for the casualties with the help of her team of nurses. As a result of these experiences, she recognized the need for a neutral relief society in the United States that could be activated in times of war, similar to the International Committee of the Red Cross that was founded in 1863 in Geneva, Switzerland, by Henry Dunant. Barton lobbied tirelessly, and in 1882, she convinced Congress to ratify the Treaty of Geneva, and the American Red Cross was established with an extended mission—to provide aid for natural disasters.

Lillian Wald In the 1880s, 20 years following the establishment of district nursing in England, a similar movement began in the United States. Urban tenement houses in the large American cities across the country were crowded and unsanitary, and infectious diseases such as tuberculosis, typhoid fever, smallpox, and scarlet fever were prevalent. A number of initiatives were undertaken in the major cities to improve the life of residents. An increased understanding of communicable disease indicated that education about prevention of infections would reduce these illnesses. Teaching methods to prevent infectious disease, implementing sanitary reforms, and fostering better nutrition became the foundations of community nursing practice in the United States.

Lillian Wald, the founder of public health nursing, was born into a life of privilege (as was Florence Nightingale) (Fig. 1.7). At the age of 22, Wald attended the New York Hospital School of Nursing. While taking classes at the Women’s Medical College, she became involved in organizing a class in home nursing for poor immigrants on New York’s Lower East Side. Distressed by the living conditions in the dingy multistorey flats, Wald moved to the neighborhood, and she and her classmate Mary Brewster volunteered their services. With the aid of several patrons, they founded the Henry Street Settlement in 1893; fees were based on the patient’s ability to pay. In addition to providing acute and long-term care for the sick, Wald and Brewster taught health and hygiene to the immigrant women, stressing the importance of preventive care. Wald called her services “public health nursing.” Similar settlement houses in other American cities developed rapidly.

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FIGURE 1.7 Lillian Wald (center, second row) and nurses of the Henry Street Settlement. (From Kalisch, P. A. & Kalisch, B. J. [2004]. American nursing: A history. Philadelphia, PA: Lippincott Williams & Wilkins.)

The vermin in these old houses are terribly active at night…there is nothing harder to endure than to watch by a night sickbed in these old worn houses and see the crawling creatures, and the babes so accustomed to them that their sleep is scarcely disturbed. Lillian Wald, The House on Henry Street

Wald devoted herself full time to the Lower East Side community, ultimately becoming one of the most influential and respected social reformers and humanitarians of the 20th century. Within a decade, the Henry Street Settlement included a team of 20 nurses, and it offered an astonishing array of innovative and effective social, recreational, and educational services. Eventually, the organization incorporated housing, employment, educational assistance, and recreational programs. It also placed nurses in public schools and businesses. Later, the Henry Street Settlement became the Visiting Nurse Association of New York City (Henry Street Settlement, 2004).

Nursing is love in action, and there is no finer manifestation of it than the care of the poor and disabled in their own homes. Lillian Wald

In 1912, Wald helped found the National Organization for Public Health Nursing, which set the first professional standards for the practice of public health nursing. These standards were a precursor to ANA’s Public Health Nursing: Scope and Standards of Practice, which guides the practice of public health nursing today. As a founder of Columbia University’s School of Nursing, she persuaded the administration to appoint the first professor of nursing in the country, laying the foundation for nursing education in institutions of higher learning. Wald also was an advocate for children and women’s rights, helping with the establishment of the United States Children’s Bureau, National Child Labor Committee, and the National Women’s Trade Union League (Ruel, 2014).

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Public Health Initiatives in the 20th Century Public Health in the First Half of the Century Public health and nursing initiatives grew exponentially in the 1900s, a century dominated by two world wars and an astounding increase in scientific knowledge. Recognition of public health nursing as a necessary function of government came about gradually in the early part of the 20th century. Local health departments, charged with control of communicable diseases, sanitation, maintaining a safe water supply, food inspection, health education, and other functions, began hiring more nurses. Although there was a rapid growth in the number of hospitals, few resources were available to people who had to be cared for in their homes. The first PHNs focused on care at the bedside, but they soon realized that their efforts had little effect if conditions were unsanitary and if there was no food in the house. PHNs effectively served as sanitary inspectors, tenement house inspectors, probation officers, and social welfare service workers. Before long, it was clear that nursing practice demanded psychosocial and political skills, along with a broad understanding of the community.

As demand for services grew, the role of PHNs became more focused on teaching and counseling, showing others how to care for the sick, instructing them on how to prevent illness, and promoting maternal and child health (Kalisch & Kalisch, 1978). Health promotion and disease prevention began with the need for health education during home visits to the poor living in large cities and expanded over time to schools, employees, and the rural population.

Mary Breckinridge An innovation in the provision of health services occurred when Mary Breckinridge founded the Frontier Nursing Service in 1925 (Fig. 1.8). Following the death of her two children, she decided to devote her life to improving the health of children and developing a system of rural healthcare in the remote regions of Kentucky and throughout the world. Traveling on horseback, Breckinridge studied the health needs of the mountain people. She found that women lacked prenatal care, gave birth to an average of nine children, and primarily had self-taught midwives in attendance at their delivery. Maternal and infant mortality were high. Breckinridge realized that children’s healthcare must begin before birth with care of the mother and continue throughout childhood, while including care for the entire family (Schminkey & Keeling, 2015). She founded the Frontier Nursing Service, which continues to provide family-oriented healthcare to rural and underserved populations today. In 1939, she helped establish the Frontier Graduate School of Midwifery, one of the first midwifery programs in the country (Frontier Nursing Service Inc., n.d.)

Our aim is to see ourselves surpassed. Mary Breckinridge

Early 20th Century Federal Healthcare Initiatives The Spanish–American War of 1898 led to a significant use of trained nurses in military hospitals. For the first time, the graduates of nearly 200 nurse training schools throughout the country were incorporated into a single nursing corps. These nurses were the forerunners of women in the armed services. A permanent Army Nurse Corps was established in February, 1901, followed by creation of a Navy Nurse Corps in 1908 (Kalisch & Kalisch, 1978).

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FIGURE 1.8 Mary Breckinridge and a frontier nursing visit. (From Kalisch, P. A. & Kalisch, B. J. [2004]. American nursing: A history. Philadelphia, PA: Lippincott Williams & Wilkins.)

Prior to the 20th century, government involvement in healthcare was left to the states. By 1900, health departments had been established in the majority of states, but their function was limited. By 1912, there was a growing acceptance that the U.S. government should take an active role in the health and welfare of the people. The need for a permanent federal agency that was responsible for the health of citizens was recognized, and the Marine Hospital Service, originally established in 1798 for seamen, was reorganized to form the U.S. Public Health Service (USPHS). The office of the U.S. Surgeon General was also founded that year. Federal programs focused on the health of mothers and children, the poor, the mentally ill, and those with sexually transmitted diseases were implemented. For example, the Maternal and Infancy Act (Sheppard–Towner Act), passed in 1921, provided matching funds to states that developed maternal and child divisions in their health departments. Home visits by PHNs encouraged prenatal care and health promotion for mother and child, and maternity centers and child health clinics were established (Kalisch & Kalisch, 2004).

World War I (1914 to 1918) was a military conflict centered in Europe that involved most of the world’s great powers. Although the Army Nurse Corps and the Navy Nurse Corps had expanded, care of the wounded was still insufficient, and civilian nurses were in short supply. The types of wounds from modern weapons and the use of poisonous gases required new nursing skills, and wound infections were rampant. Then, in late 1918, when the armistice occurred, an influenza pandemic spread throughout the world, with soldiers becoming vectors of the viral infection.

By 1920, there was a significant shortage of nurses, and patient care suffered. It was estimated that 90% of ill people were cared for at home with assistance from the community (Kalisch & Kalisch, 1978). The Great Depression began in 1929, resulting in widespread unemployment, including nurses. At the same time, the need for health services expanded, especially for charity cases. The federal government became even more active in health and social welfare programs, employing nurses through the Federal Emergency Relief Act, the Civil Works Administration, and other agencies. In 1933, Pearl McIver became the first nurse to be

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employed by the USPHS. Her primary role was to provide consultation services to state public health departments, resulting in an increase in local PHN employment.

The Social Security Act of 1935 was passed to help prevent a recurrence of the problems associated with the Depression, especially for poor elderly people. It provided a system of federal old-age benefits and enabled states to make more adequate provision for elderly people, the blind, dependent and crippled children, maternal and child welfare, public health, and the administration of state unemployment compensation laws. Financial support was provided to increase public health programs, particularly for mothers and children in rural areas. Local health departments designed their programs on the basis of the funding that was available, rather than directing their efforts toward a comprehensive community health program. A component of the federal approach to health policy today still directs funding to special population groups or to the prevention and control of specific diseases.

With the onset of the United States’ involvement in World War II, it became clear that the United States would soon face a critical shortage of nurses nationwide. Through the work of Congresswoman Frances Payne Bolton, the Cadet Nurse Corps was founded as a part of the USPHS to train nurses during World War II. Applicants were granted subsidization of nursing school tuition and associated expenses, and schools were funded to provide expedited training. In exchange, applicants agreed to provide nursing services to the military or other essential civilian industries for the duration of the war. The number of PHNs employed by industry almost doubled during this time. Public health nursing also expanded in rural areas during World War II, and some official agencies began to offer bedside care.

Public Health in the Second Half of the Century After the war, the increased demand for healthcare services led to increased opportunities for PHNs, changes in healthcare delivery and financing, and the growth of health insurance. Local health departments faced increases in demand for services related to community problems such as alcoholism and mental illness. Their services increased to include screening for tuberculosis and sexually transmitted diseases as well as treatment of infectious diseases, and services were extended to rural areas.

By mid-century, a number of social improvements resulted in an increased lifespan. Public health measures such as improved sanitation, provision of potable water, better nutrition, and better housing contributed to this phenomenon, along with medical developments such as immunizations and antibiotics. Childhood mortality decreased, and more Americans lived into middle and old age. Infectious diseases were the leading causes of mortality in 1900; by 1950, the leading causes of death were heart disease, cancer, and cerebrovascular disease, as they remain today. With the increased lifespan, new challenges related to chronic diseases emerged.

In 1966, the Social Security Act was amended and Medicare was created to provide healthcare funding to the elderly. The next year, Medicaid was established to provide funding for the indigent (see Chapter 2). These programs contributed to the continued increase in demand for services, and costs of healthcare escalated. Some people perceived these programs to be the first step toward universal healthcare coverage in the United States. To address increased demands, the federal government passed health planning legislation to meet differing needs throughout the country. Although this legislation had merit, it failed to produce expected results. Federal efforts to reform healthcare continued to focus on organization of services and financing, rather than implementing changes in the social conditions that led to health disparities.

The roles and responsibilities of PHNs continued to expand during the 1970s, and they contributed significantly to the improvement of the health of communities. A wide variety of programs were implemented according to need. Hospice services, day care centers for the disabled, alcohol and drug abuse programs, halfway houses, and rehabilitation centers are just a

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few of the public health initiatives that nurses helped create. Home nursing visits increased following Medicare’s implementation of diagnosis-related groups (DRGs) that were designed to lower costs through reduced hospital stays. Medicaid also reimbursed some home care services, as did the Veterans Administration and private medical insurance. More and more acutely ill people were cared for in the home, creating an ongoing demand for PHNs.

Despite the increased need for nursing services, public health as a whole declined in the 1980s. The economic recession resulted in decreased funding for social programs. The Institute of Medicine (IOM) published The Future of Public Health in 1988, finding that public health services varied considerably across the United States. The system was in disarray, controlled more by the political system than by public health professionals. This study set the stage for the development of the Healthy People initiative that designed a national strategy to improve the health of Americans. Healthy People 2020, discussed earlier in this chapter, is the most recent vision for the next decade. Many of these measurable objectives (see Box 1.2) are discussed throughout this text.

The task force decides that a written and pictorial presentation on the historical roots of public health nursing practice will be a component of the online course.

Describe three characteristics of population-based nursing practice that have been present since the first district nurse was appointed in England.

The First Decade of the 21st Century The Department of Homeland Security (DHS) was created by the Department of Homeland Security Act of 2002 and is an outgrowth of the Office of Homeland Security established by President George W. Bush shortly after the terrorist attacks of September 11, 2001. The primary mission of DHS is to lead the unified national effort to secure the United States, reducing the vulnerability of the United States to terrorism and protecting against and responding to threats and hazards to the United States.

The DHS fosters an all-hazards, all-disciplines approach to emergency management that allows effective response to all emergencies, whether natural or human-made, or caused by terrorists. To meet this mission, the DHS builds collaboration and partnerships with all levels of government, the private sector, academia, and the general public. Because all disaster response begins at the local level, all cities and towns in the United States are now required to have all- hazards local emergency preparedness plans (see Chapter 20). The National Response Framework, established by DHS, guides the overall conduct and coordination of all-hazards incident responses when the scope of a disaster extends beyond the capability of local and state governments to respond.

Through education and outreach, homeland security expertise is fostered across multiple disciplines to serve as an indispensable resource for the United States. The Federal Emergency Management Agency, as the lead agency for emergency management, offers courses for first responders. The CDC also offers many online training sessions, and many states and localities have developed their own training programs.

The aftermath of the destruction of the World Trade Center in 2001 also identified a lack of trained leaders and workers in all areas of public health service. In an era in which public health threats range from pandemics of emerging infectious diseases to obesity epidemics to the opioid epidemic to bioterrorism, the need for an effective public health workforce is paramount. PHNs constitute the single largest group of professionals practicing public health; however, all nurses, to some degree, are involved in public health. Therefore, the IOM (2003) has recommended that

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undergraduate nursing students have an understanding of the ecological model of health (see Chapter 5) and the core competencies of population-based practice discussed earlier in this chapter.

Some of the issues that were characteristic of public health nursing in the past are still prevalent today, and a multitude of new challenges exists. To provide the most comprehensive care to clients, whether individual people, families, or groups, PHNs must be flexible, be politically active, embrace change, and refresh their knowledge of public health issues on a continual basis.

CHALLENGES FOR PUBLIC HEALTH NURSING IN THE 21st CENTURY Many yet-unknown challenges will develop during the 21st century. Communities will evolve and change, cultures will merge, environments worldwide will undergo transformation, and advances in technology and therapeutic techniques will result in dramatic changes to healthcare. The following are some of the challenges for PHNs foreseen at present.

Engaging in Evidence-Based Practice Nurses have always used the knowledge gained through education and experience in making decisions about the care of clients—accentuated by a dose of intuition. The challenge today and for the future is to document and use the best evidence available in making decisions with clients about their care. Evidence-based nursing is the integration of the best evidence available with clinical expertise and the values of the client to increase the quality of care. Similarly, evidence-based public health is a public health endeavor in which there is judicious use of evidence derived from a broad variety of science and social science research. In addition to published research, PHNs can gather information from interviews and through observation of specific population groups and gather pertinent information about the geographic locale.

Epidemiology is the science of prevention. Epidemiologic research has provided knowledge of the natural history of diseases and identified the (risk) factors that increase a person’s susceptibility to illness. Nurses use the evidence that epidemiologic research has established when assessing clients and using data for planning and implementing interventions. Using the epidemiologic body of knowledge that has been developed for specific conditions, nurses can determine the stage of the illness in question and decide with the client what type of interventions are most appropriate for preventive or therapeutic purposes (see Chapters 5 and 6 for discussions of primary, secondary, and tertiary prevention strategies). Nurses engaging in community assessment also use epidemiologic methods to determine the assets and health needs of populations, and the evidence is used to create a variety of intervention programs. The public health approach to problem-solving is illustrated in Figure 1.9.

Sandy and other members of the task force think that evidence-based practice should be part of the online population-based health course.

What activities could be assigned that would foster evidence-based practice?

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Practice Point

Systematic reviews of research evidence, such as those included in the Cochrane Database of Systematic Reviews, are instrumental in implementing evidence-based practice.

Helping Eliminate Health Disparities in Underserved Populations Eliminating health disparities is a combined effort of health professionals in all settings, but PHNs deal directly with these issues, often on a personal basis. Ultimately, the most important changes occur at the local level. By participating in the development, implementation, and evaluation of culturally appropriate, community-based programs, nurses use their expertise to remedy the conditions that contribute to health disparities.

Demonstrating Cultural Competence Countless cultures in the world are constantly changing. The shared cultural symbols and meanings that are a part of people’s daily social interactions have an impact on their acceptance or rejection of actions taken to promote their health. Therefore, nursing strategies that are focused on people with little attention as to how they think, feel, and interact with their world are not sufficient.

FIGURE 1.9 The public health approach to problem-solving.

Cultural competency is an expected component of nursing practice, but it will become even more essential as interaction and integration among cultures increases. The characteristics of the major cultural groups that make up a community must be understood, along with those aspects of the community that give it its own unique subculture. It is necessary for nurses to be aware of cultural interpretations of healthcare activities so that they know what questions to ask and

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interventions to suggest. To achieve cultural competence, nurses should respect differences, understand their own beliefs, and not let personal beliefs have an undue influence on others. Nurses need to communicate curiosity and openness to others’ ideas and ways of life, respect their decisions, and demonstrate patience and humility (see Chapter 10).

Misunderstanding a culture’s symbols is a common root of prejudice. Dan Brown, The Lost Symbol

Evidence for Practice

The delivery of culturally competent public health nursing that can address health disparities depends on competent nursing practice. Understanding the nurse characteristics, care situations, and training associated with culturally competent awareness and behavior provides a basis for planning and developing interventions to ensure competent nursing care. To meet this objective, a cross-sectional, descriptive, and exploratory study was conducted among 31 PHNs in a southeastern U.S. public health department using a cultural competence assessment tool with an internal consistency reliability of 0.90.

The self-reported study findings showed moderate competence in awareness and sensitivity. Although nursing care was consistent with guidelines and mandates found in the National Standards for Culturally and Linguistically Appropriate Services in Healthcare (U.S. Office of Minority Health), the nurses did not assess their behaviors at comparable levels. While providing care, the nurses encountered multiple racial/ethnic and special population groups, including many that are at risk for or experiencing health disparities and poor outcomes. Therefore, being culturally competent in both thought and actions is necessary and important for these nurses. These nurses felt frustrated in their attempts to provide care that was consistent with their perceptions of culturally competent care. Lack of human or financial resources, interpreters, gender-specific providers, and time were the most common barriers. In addition, the nurses expressed a desire for additional diversity training. To meet the goals of a culturally competent workforce, formal courses, continuing education programs, and practical experiences should focus on awareness, sensitivity, and behaviors consistent with culturally competent care. To develop additional evidence-based knowledge for practice, additional studies of clients’ perceptions and evidence of culturally competent care are needed. This information is necessary for the development of practice interventions with measurable outcomes that can be evaluated for effectiveness in addressing health disparities (Starr & Wallace, 2009).

Planning for Community Change Change in healthcare at all levels can occur through behavior change, or through modifications in the environment, public policy, social or cultural norms, or healthcare delivery. Often, interventions at institutional or societal levels may lead to significant changes in public health without the need for behavior change on the part of individual people; fluoridation of water is an example. Even small changes in health behavior at the community or population level have the potential to significantly affect health status. The use of gel alcohol in hospitals and the availability of disinfectant wipes in grocery stores and other public places are examples.

Change should be planned and should meet specific needs to be the most effective. The impetus for change varies considerably. For example, installation of home monitoring devices may require new responsibilities, an influx of immigrants may increase the healthcare needs of a community, data may indicate that substance use disorder and violence are increasing in specific groups, or new state regulations may require the establishment of new programs. On a

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community basis, health planning occurs on both an ongoing and an episodic basis depending on the need and usually is a collaborative effort between multiple groups and organizations. A good example is the development of emergency preparedness plans in cities and towns (see Chapter 20).

Monitoring and evaluating the health status of individual people, families, and community groups are primary components of nursing practice in the community, as is the investigation of emerging health and environmental problems. Therefore, accepting responsibility for contributing to community health change as a policy advocate and political activist is essential. Few practitioners are as well prepared to address community health issues as PHNs. See Chapter 9 for more information on planning for community change.

The state department of public health recognizes that increasing the knowledge base of PHNs in population-based practice is just one step in implementing the new vision of public healthcare delivery. Knowledge alone cannot change practice from a clinical focus to a population-based focus if the work environment does not support the transition. Sandy is preparing another survey to determine current practices that need to be discontinued, strengthened, or developed within the next five years. Although the new vision for PHNs will include primary care, the majority of skills in the new model of practice will focus on population-based competencies.

Design a simple public health nursing model that incorporates the basic principles of population-based nursing.

Evidence for Practice

Intimate partner violence (IPV) is a serious and prevalent public health issue. Given the complexity of IPV, there have been efforts to integrate social and healthcare services. Public health nurses are well positioned to work collaboratively with social service agencies to provide health education and assistance in accessing healthcare services. Providing health education at social service agencies gives public health nurses access to IPV survivors and is also convenient for the IPV survivors, who typically spend significant amounts of time at the agencies. Prior to developing any educational offering it is imperative that the nurse assess the perceived needs of the survivors. Ferranti, Lorenzo, Munoz- Rojas, and Gonzalez-Guarda (2017) studied the health education needs and learning preferences of female IPV survivors who were receiving assistance at a social service agency in South Florida. Using an exploratory two-phase sequential mixed method, the researchers first conducted semistructured interviews with 10 service providers to gain their perspective on the health needs of women they served. The interviews were analyzed to extract themes, and the themes guided the development of a survey that contained 10 close-ended questions. Three themes were identified: (a) multidimensional health needs of families (primary care, mental health, reproductive/sexual health, chronic disease management); (b) complexities of navigating the health system, including structural barriers (insurance, transportation, finances, and immigration status) and health literacy (finding a doctor); and (c) self-improvement specific to IPV survivors (empowerment and vocational skills).

There were 122 female IPV survivors who completed the survey. The sample was primarily Hispanic, ranging in age from 19 to 65, with a mean age of 34.8 and the majority having a high school education or higher (81%). Of them, 57% were born outside of the United States. Physical health proved to be a lower priority for the participants, as almost 70% of them identified depression as the top health education need. Over 50% of the women chose abuse and mental health as the next greatest concerns, with anxiety selected by 45%. For health topics, over half of the women selected self-esteem, nutrition, and women’s health, with 45% identifying children’s health as an important health topic. With respect to learning preference, hands-on activities and talking to an expert were the top two

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choices, with 50% of the participants selecting them. The relationships between most learning preferences and demographic factors, as analyzed using chi-square and t-tests, were nonsignificant. However, age was significantly related to learning preference of brochures/books. Those who selected brochures/books were significantly older (mean = 37.6) compared to those who did not. Also, language preference (English vs. another language, Spanish or Creole) was significantly associated with presentation preference and group discussion. The women who preferred English were more apt to select both presentation and group discussion when compared with those who preferred another language.

The study highlights the importance of health education in the continued recovery of IPV survivors. The differences that were found between the service providers and recipients supports the critical importance of public health nurses including the IPV survivors prior to planning any health education program so that it targets the participants’ priorities and learning preferences. The strong emphasis on mental health acknowledges the psychological toll that IPV has on the survivors.

Contributing to a Safe and Healthy Environment Where people live, work, and spend their time can have direct consequences on their health. In every community in the world, clients are part of the environment, which has a direct impact on their health and well-being. The WHO (2016) reports that 23% of the global burden of disease is attributable to the environment. There are two ways to examine the effects of the environment on human health. The first focuses on how contaminants in the environment, such as asbestos, lead, or radon, influence human health. The second focuses on how the entire environment surrounding the community, such as the climate, neighborhood safety, access to grocery stores, and the physical layout of the community, affects health. Often, the two types of environmental effects interact.

The challenge for environmental health nurses is to use the best science available to assess how the local environment affects human health, to formulate evidence-based or best-practice interventions, and to evaluate the effectiveness of those interventions. Nurses are in a strong position to advocate for healthier environments in both the workplace and community (see Chapter 19).

Responding to Emergencies, Disasters, and Terrorism All disaster response begins at the local level, and PHNs have always responded to community emergencies and disasters. They play an important role in all phases of the disaster management continuum, whether anticipating potential emergencies, developing appropriate community preparedness plans, building system-wide partnerships, practicing implementation of disaster management plans and skills on a regular basis, or evaluating outcomes (see Chapter 20).

Disaster preparedness plans are proactive planning efforts that are developed in anticipation of disaster scenarios, providing structure to a response before the disaster occurs. In an all- hazards event plan, the response must be a coordinated community effort in which members of the community are engaged in ongoing preparedness activities focused on a variety of disaster situations. The capacity to respond to threats depends in part on the ability of healthcare professionals and public health officials to rapidly and effectively detect, manage, and communicate during an event. The terrorist attacks in 2001 identified a lack of workers in all areas of public health, as well as a growing appreciation of the first responders, primarily firemen, police, and healthcare personnel. Increased competency in disaster response added a new dimension to nursing practice. The public health workforce continues to be mobilized to ensure the training and education of communities across the nation regarding biological,

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chemical, and radiological attacks. It is necessary to learn how to prepare for events that are difficult to imagine, and it is even more challenging to mount a response.

Responding to the Global Environment The burden of disease is growing disproportionately in the world and is largely affected by climate, public policy, age of the population, socioeconomic conditions, and factors that place people at risk for illness. Most of the countries burdened by disease have the least amount of human and economic capacity to effect change. Extreme poverty is the driving force behind increased mortality, and women are disproportionately affected.

Although maternal deaths have dropped worldwide by almost 50% in the last decade, maternal mortality is still unacceptably high. On any given day, approximately 800 women die from preventable causes related to pregnancy and childbirth, nearly all (99%) occurring in low- income countries. Many of the complications resulting from childbirth can be prevented by skilled care before, during, and after childbirth by midwives and nurses. When a mother dies or is disabled, her children may be forced to live in poverty. Presently, about 6.6 million children younger than 5 die each year; poor nutrition is the underlying cause of death (WHO, 2017).

FIGURE 1.10 The top 10 global causes of death in 2016.

The leading causes of mortality and global burden of disease worldwide have shifted from communicable to noncommunicable chronic diseases as a result of population aging and better control of infectious diseases. Cardiovascular disease is already the leading cause of death in the world, followed by stroke. Figure 1.10 shows the 10 leading causes of death worldwide. Only

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lower respiratory infections, diarrheal diseases, and tuberculosis are infectious diseases remaining in the top 10. Chronic diseases such as COPD; Alzheimer disease; tracheal, broncial, and lung cancers; and diabetes mellitus are causing increased numbers of deaths worldwide. Traffic injuries worldwide are expected to grow from the eighth leading cause of death in 2016 to the fifth in 2030. The global burden of disease and methods to improve global quality of care are discussed in Chapter 4.

With the world becoming a global village, problems that affect people in other countries also affect people in their own countries. Nurses and community healthcare providers need to be knowledgeable about the needs of all people, as well as their patients, in the global society. Opportunities have expanded for nurses to work internationally in a wide variety of roles: working side by side with local people in healthcare, initiating health education programs, establishing local primary healthcare programs, and participating in countless other activities. Advanced technology and knowledge transfer techniques will allow rapid transfer of information from electronic monitoring equipment, presenting exciting opportunities to improve health in remote locations. New cooperative healthcare ventures will occur throughout the world in the 21st century.

Practice Point

In this dynamic time, care will be transformed as needs rapidly evolve. Newly prepared nurses will experience events never before thought possible.

Student Reflection

Over the spring vacation, a group of eight undergraduate nursing students, three graduate students, and three faculty members flew to Nicaragua to work in a clinic for the week. There was one person who stands out in my mind. She was a 25-year-old woman who came to the clinic complaining of diarrhea, accompanied by her 6-year-old son and 3-year- old daughter. One of our nurse practitioners (NPs) cared for her while I observed. After the NP determined that the woman had a gastrointestinal parasite that was common in Nicaragua and prescribed treatment, the nurse asked the client about her wishes to have more children. The woman responded quietly that she did not want more children, but that her husband was adamant that she did not use birth control. When the NP asked if birth control was a sensitive subject between them, the woman began to cry. She told us that after the birth of her daughter, she began birth control without consulting her husband, and when he found out, he became verbally and physically abusive. Since that point, their relationship had become increasingly violent and the woman said she feared for her life, along with the lives of her children. Her husband felt that if she used birth control she was cheating. He told her that he was not going to use a condom, and if she did not want to have his children, she didn’t love him.

This situation made me realize just how dismal it can be for women in violent relationships. Because of lack of resources, it is very difficult for abused women to find help, and many lose hope, believing that nothing can be done. Their situation is complicated since the majority of women are financially dependent on their partners. Our client was in a similar situation. She was afraid of her husband, vulnerable financially, and had two children to protect. Her situation would be further complicated if she continued without birth control. During the visit, the NP and I listened and provided the emotional support that she so desperately needed. We began to discuss some options and actions that she might be able to take. Just as we would in the United States, we discussed the necessity of formulating a

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plan before acting, helping to ensure success and safety. We talked about the possibility of staying with a family member and reviewed the important documents and birth certificates that she should take with her. Also, I told her about a domestic violence support group that the clinic provided. Finally, we discussed multiple forms of birth control that she could use, such as the hormone injection that lasts for three months to prevent pregnancy, if she were unable to leave for any reason. I think the woman left feeling relieved and somewhat hopeful for what the future held for her family. Even if I was only able to get my client thinking about her options, I feel that our time together was a success.

KEY CONCEPTS Three major changes in healthcare in the 21st century include the development of patient/client-centered care, increased use of technology, and increased personal responsibility for health. The practice of public health nursing is defined in the ANA (2013) publication Public Health Nursing: Scope and Standards of Practice. It defines the essentials of public health nursing, the activities, and the accountabilities that are characteristic of practice at all levels and settings. It is the legal standard of practice set by the profession. In the ANA (2013) publication, each standard of practice is followed by the essential competencies required to meet that standard. The Public Health Intervention Wheel defines 17 interventions—actions taken on behalf of individuals, families, communities, and systems to protect or improve health status. Entry into public health nursing practice requires a baccalaureate degree. The historical roots of public health nursing have set the framework for current nursing practice in the community. Multiple challenges face PHNs in the 21st century:

Engaging in evidence-based practice

Helping eliminate health disparities in underserved populations

Demonstrating cultural competence

Planning for community change

Contributing to a safe and healthy environment

Responding to emergencies, disasters, and terrorism

Responding to the global environment

CRITICAL THINKING QUESTIONS

1. Review the public health milestones presented in Box 1.1. What potential health successes might be cited in the next decade?

2. Identify a new role for nursing that will most likely evolve in the first half of the 21st century. 3. Analyze the roots of public health nursing and its influence on practice today.

HEALTHY PEOPLE 2020 LEARNING ACTIVITY

Social Determinants of Health Healthy People 2020 provides a blueprint which identifies nationwide health improvement priorities. This national consensus plan includes 42 topics, with a subset of 12 leading health indicators (LHI) and over 1,200 objectives. It offers a framework for strategic planning to promote health improvement and achieve health equity through measurable objectives and deliberate actions. The Healthy People 2020 website is dense with important information on the development, implementation, and progress of this national plan. Learning to

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navigate the website, to access the rich materials offered is vital to gain a deep understanding of the national health improvement priorities, specific objectives, and initiatives seeking to achieve the national goals and objectives.

Social Determinants of Health is a new topical area identified as a priority in Healthy People 2020. To learn more about this topic go to: https://www.healthypeople.gov.

Click on Topics & Objectives: Topics are listed alphabetically, scroll down to “S” and click on Social Determinants of Health.

Click on “Overview” and find the answers to the following questions:

What is the goal for this topic? What are some examples of social and physical determinants of health? What are the five determinants selected for Healthy People 2020?

Click on “Objectives” and select one objective from each of the five determinants: Analyze the data, looking specifically at any disparities, progress made, and thinking about continued barriers to achievement.

Click on “Resources and Interventions” and select one resource from the national, state, and local groupings:

Review the resource to explore how community and public health groups are working to address and improve the social determinants of health across the nation.

REFERENCES Agency for Healthcare Research and Quality (AHRQ). (2016). The SHARE approach: A model for shared

decision-making. Retrieved from https://www.ahrq.gov/professionals/education/curriculum- tools/shareddecisionmaking/index.html

Agency for Healthcare Research and Quality (AHRQ). (2018). National health care quality and disparities report, 2016. U.S. Department of Health and Human Services. Retrieved from https://nhqrnet.ahrq.gov/inhqrdr/reports/qdr

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

Budden, J.S., Moulton, P., Harper, K. J., Brunell, M. L., & Smiley, R. (2016). The 2015 national nursing workforce survey. Journal of Nursing Regulation, 7(1), S1–S90.

Centers for Disease Control and Prevention. (1999). 10 great public health achievements—United States, 1900–1999. Morbidity Mortality Weekly Report, 48(12), 241–243.

Centers for Disease Control and Prevention (CDC). (2016). FastStats: Health expenditures. Retrieved from https://www.cdc.gov/nchs/fastats/health-expenditures.htm

Doherty, R. B. (2010). The certitudes and uncertainties of health care reform. Annals of Internal Medicine, 152(10), 679–682.

Ferranti, D., Lorenzo, D., Munoz-Rojas, D., & Gonzalez-Guarda RM, (2017). Health education needs of intimate partner violence survivors: Perspectives from female survivors and social service providers. Public Health Nursing, 35, 118–125.

Frontier Nursing Service Inc. (n.d.). A brief history of the Frontier Nursing Service. Retrieved from http://www.frontiernursing.org

Health Resources and Services Administration. (2014). Retrieved from http://www.hrsa.gov/ruralhealth/about/telehealth/

Healthy People 2020. (n.d.). Retrieved from http://www.healthypeople.gov/2020/about/default.aspx Henry Street Settlement. (2004). About our founder, Lillian Wald. Retrieved from

http://www.henrystreet.org/about/history/.org/ Institute of Medicine (IOM). (2003). Who will keep the public healthy? Educating public health

professionals for the 21st century. Retrieved from http://books.nap.edu/openbook.php? record_id=10542&page =R2

Jakeway, C. C., Cantrell, E. E., Cason, J. B., & Talley, B. S. (2006). Developing population health competencies among public health nurses in Georgia. Public Health Nursing, 23(2), 161–167.

Kalisch, P. A., & Kalisch, B. J. (1978). The advance of American nursing. Boston, MA: Little Brown. Kalisch, P. A., & Kalisch, B. J. (2004) American nursing: A history. Philadelphia, PA: Lippincott,

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Williams & Wilkins. Nationwide Health Information Network (NwHIN). (2013). Retrieved from

https://www.healthit.gov/sites/default/files/hie-interoperability/nationwide-health-information-network- exchange-data-sheet.pdf

The Public Health (Scotland) Act. (1897). Pauper nurses. The British Medical Journal, 2, 104. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2407239/pdf/brmedj08725–0040a.pdf

Radhakrishnan, K., Xie, B., & Jacelon, C. S. (2015). Unsustainable home telehealth: A Texas qualitative study. Gerontologist, 58(5), 830–840.

Ruel, S. R. (2014). Lillian Wald. Home Healthcare Nurse. Home Health Nurse, 32(7), 597–600. Standing, C., Standing, S., McDermott. M. L., Gururajan, R., & Mavi, R. K. (2016). The paradoxes of

telehealth: A review of the literature 2000–2015. Systems Research and Behavioral Science. 35, 90–101. Schminkey, D. L., & Keeling, A. W. (2015). Frontier nursemidwives and antepartum emergencies, 1925 to

1939. Journal of Midwifery & Women’s Health, 60(1), 48–55. Starr, S. & Wallace, D. C. (2009). Self-reported cultural competence of public health nurses in a

southeastern U.S. public health department. Public Health Nursing, 26(1), 48–57. Tuckson, R. V., Edmunds, M., & Hodgkins, M. L. (2017). Telehealth. New England Journal of Medicine.

377(16), 1585–1592. U.S. Department of Labor. (2017). Bureau of labor statistics: Occupational employment and wages

registered nurses. Retrieved from https://www.bls.gov/oes/current/oes291141.htm World Health Organization. (2016). Preventing disease through healthy environments: A global assessment

of the burden of disease from environmental risks. Retrieved from http://www.who.int/quantifying_ehimpacts/publications/preventing-disease/en/

World Health Organization. (2017). World health statistics 2017. Retrieved from http://www.who.int/gho/publications/world_health_statistics/2017/en/

WEB RESOURCES

• Please visit thePoint for up-to-date web resources on this topic.

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Chapter 2 Public Health Systems Rosanna F. DeMarco

For additional ancillary materials related to this chapter. please visit thePoint

It is no measure of health to be well adjusted to a profoundly sick society. Jiddu Krishnamurti

Without health, life is not life; it is only a state of languor and suffering—an image of death. Buddha

America’s healthcare system is neither healthy, caring, nor a system. Walter Cronkite

Everyone should have health insurance? I say everyone should have healthcare. I’m not selling insurance. Dennis Kucinich

CHAPTER HIGHLIGHTS Public health and healthcare systems as a complex organization of institutions and structures National and international perspectives on public health structure, function, and outcomes differ by fiscal support and philosophical attitudes concerning health Public health administration as a reflection of health, politics, economics, and social structures Influences of history, resources, financing mechanisms, interest groups, and environmental conditions on public health Governmental and nongovernmental organizations and public health

OBJECTIVES Understand and describe the challenges in reducing the gap between healthcare expenditures and healthcare disparities. Compare and contrast differences across international public health systems. Explain the different contributions of governmental and nongovernmental structures in public health systems in different countries.

KEY TERMS Bilateral agency: Refers to two agencies that conduct business within one country.

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Department of Health and Human Services: U.S. branch of government responsible for health and welfare of citizens.

Health disparities: Difference in the quality of healthcare delivered or obtainable, often tied to race or ethnicity or socioeconomic status.

Healthy People 2020: A U.S. national consensus plan with specific health goals. International Council of Nurses (ICN): A federation of more than 130 national nurses

associations (NNAs), representing the more than 16 million nurses worldwide. Millennium Development Goals (United Nations): Eight goals that all 191 UN member states

have agreed to try to achieve by the year 2015 to combat poverty, hunger, disease, illiteracy, environmental degradation, and discrimination against women.

Multilateral agencies: Agencies that use both governmental and nongovernmental resources. National Health Expenditure Accounts (NHEA): Comprised of measures of costs of healthcare

goods and services in the United States. Nongovernmental organization (NGO): Agency that acquires resources to help others from

private (vs. public) sources. Organization for Economic Cooperation and Development (OECD): A group that collects

data related to healthcare use across a variety of professional and service parameters. Philanthropic organization: An organization that uses endowments or private funding to

address the needs of individuals, families, and populations. Refugee: Person who leaves his or her place of origin and cannot return because of a well-

founded fear of being persecuted for reasons that include race, religion, nationality, membership of a particular social group, or political opinion.

United Nations Educational, Scientific, and Cultural Organization (UNESCO) Sustainable Development Goals: A global framework of 17 goals to coordinate efforts from 193 nations represented by the United Nations around ending poverty and hunger, combating inequality and disease, and building a just and stable world.

World Bank: International organization that uses funds from developed countries to help initiatives of developing countries.

World Health Organization (WHO): International center that collects data, advances initiatives, and offers support related to public health.

CASE STUDY

References to the case study are found throughout this chapter (look for the case study icon). Readers should keep the case study in mind as they read the chapter.

When Clara arrived in the United States as a refugee* after surviving many years of violence and brutality in her native Sudan, she was barely 20 years of age (an estimate). Many girls like Clara do not know their age; they often do not know the year in which they were born. Clara represents a community or population of women who have experienced hard realities related to the genocide in Sudan. War between the North and the South, which still continues, results from different religious views and ethnicity, and it puts all people, particularly some young women, in a vulnerable position. In their commitment to ethnic cleansing, men in the army have raped young girls without hesitation, leaving them to face pregnancy with no women’s healthcare and with very little support to change their future circumstances in a patriarchal society.

Clara has found asylum in the United States through the generosity of a nongovernmental health organization. She now enters a healthcare system that offers screening, care, follow-up, and support as she learns that she and her child are human immunodeficiency virus (HIV)-seropositive. Although Clara and her young child face the prospect of a life-threatening illness, she is supported by a system that seems to care about her progress and future health, as well as the health of the entire population. *The United States provides refuge to persons who have been persecuted or have well-founded fear of persecution through two programs: one for refugees (persons outside the United States and their immediate relatives) and one for asylees (persons in the United States and their immediate relatives) (https://www.dhs.gov/sites/default/files/publications/Refugees_Asylees_2015.pdf).

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C omparing healthcare systems allows for an examination of how these systems, whichhelp ensure the health or wellness of populations, are organized and financed; costcontrol is important. Comparing helps develop standards and initiatives directed by organizations discussed in this chapter, such as the World Health Organization (WHO), the World Bank, and the Organization for Economic Cooperation and Development (OECD). In addition, such comparisons aid researchers who study specific healthcare interventions and outcomes internationally. The fundamental challenge in making comparisons is the difficulty in finding universal measures of health which can be compared fairly. In the final analysis, what should be of most interest is learning which healthcare system yields the highest quality of care and universal access at a reasonable cost.

IMPORTANCE OF UNDERSTANDING HOW PUBLIC HEALTH SYSTEMS ARE ORGANIZED Public health involves organized efforts to improve the health of communities rather than individual people. Thus, the central goal of public health is the reduction of disease through prevention and the improvement of health in the community, both nationally and internationally (Schnieder, 2017). As shown in Chapter 1, it has been the characteristics of population health and illness over time that have directed how public health is defined, organized, delivered, and evaluated. But it would be naive to believe that these characteristics are the only things that contribute to the ways in which public health initiatives and the structure behind them have developed. So, to understand how public health systems are organized in a city, state, or country, it seems logical and necessary to explore a variety of components to fully realize why public health systems exist and how they function. To that end, the following section explores a variety of general health and public health systems ranging from those in industrialized countries to those in developing countries. The text discusses the role of public health personnel in the context of how local and global communities organize their efforts to keep the population disease- and injury-free. For people who are committed to the ideals of prevention and access to care for all, public health is not without challenges.

STRUCTURE OF PUBLIC HEALTHCARE IN THE UNITED STATES In the midst of many successes and challenges related to health and illness, the public health delivery system in the United States supports efforts to address significant healthcare concerns that affect both citizens and refugees/asylees through government agencies, nongovernmental organizations (NGOs), and philanthropic organizations (Office for Refugees and Immigrants [ORI], 2017). The following section describes the complexity of relationships among the agencies devoted to public health delivery at the local and state levels. The activities of these agencies vary widely because local priorities and values influence availability and operations.

Government Agencies and Public Health Through public efforts, the U.S. government becomes involved with providing services that benefit the social welfare of citizens in terms of health at national, state, and local levels. The federal government creates policy, financing, and regulatory enforcement when a service that

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would benefit citizens is identified and available (Shi & Johnson, 2014). Good examples of government efforts to improve public health include providing free drug information on government published databases, establishing disaster preparedness plans, and creating quality indicators for child health (Agency for HealthCare Research and Quality [AHRQ], 2017a; American Red Cross, 2017; National Library of Medicine, 2017).

The federal government plays an important role in regulation. Public health entities of regulation are often related to (1) food, (2) drugs, (3) devices, (4) occupation health, and (5) the environment through the Centers for Disease Control and Prevention (CDC) Public Health Law Program (2017) and Department of Health and Human Services, National Prevention Strategy created by the National Prevention Council (2011). However, out of concern related to the quality of healthcare, the government can “step in” to assist private citizens on different occasions. Two examples are federal regulations related to women delivering children who need at least 48 hours of inpatient care and making sure that mental healthcare is in parity with medical care (Harwood et al., 2017).

The federal government allocates tax funds to state governments in support of specific public health programs. For example, block grants give money to specific programs and providers based on state health needs (Urban Institute, 2013). Some examples of block grants include Maternal and Child Health Services and Prevention and Treatment of Substance Abuse Block Grants. Entitlement programs to support the healthcare needs of low-income families come from the federal government. Three important examples of entitlement programs are Medicare, Medicaid, and the Special Supplemental Food Program for Women, Infants, and Children (WIC) (Jackson & Mayne, 2016). The Medicaid program requires matching funds from the states to provide for the healthcare needs of citizens (Fig. 2.1) (Centers for Medicare and Medicaid Services [CMS], 2018).

State governments also play a large role in public health regulatory activities, program responsibility, and resource allocation—to varying extents. Local governments implement the public health activities within communities.

Generally, from either an economic or theoretical perspective, the private sector often does not provide services that would improve social welfare, although in many ways, private organizations often directly assist the common good of populations through their endowment funds (endowed with monies often directly assists the common good of populations); they direct their efforts to key initiatives that are altruistic and very helpful to community dwellers. Examples include philanthropies such as the Kellogg Foundation and the Robert Wood Johnson Foundation (Kellogg Foundation, 2017; Robert Wood Johnson Foundation, 2017).

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FIGURE 2.1 Sample configuration of health department structures in the United States. USDHHS, U.S. Department of Health and Human Services. (From http://www.hhs.gov/about/orgchart.)

Clara is a good example of a person who came to the United States with no resources. She has no income and is trying to find a way to sustain herself and her child while dealing with the trauma of her past life, and her future life with a chronic life-threatening illness. She is receiving Medicaid from the state in which she now lives in the United States, WIC for her child, and support from the Ryan White HIV/AIDS Program. Since 1991, this program has provided supplemental support for medical care, medications, housing, and public health services for those living with HIV.

Evidence for Practice

The Ryan White Program funds networks of care, which include medical care providers and support services, for people living with HIV or acquired immunodeficiency syndrome (AIDS) (PLWHA) in 51 eligible metropolitan areas (EMAs). Researchers created a survey to measure characteristics of care networks and the quality, accessibility, and coordination of services from the perspective of case management and medical providers, administrators, and consumers (Hirschhorn et al., 2009), and they administered the surveys in 42 EMAs.

The investigators then rated the care networks highly on access, quality, and coordination between case management and primary care providers. However, there were frequent differences in ratings of quality and barriers by the type of respondents (consumer representatives, grantees, and providers). There were also substantial variations across EMAs in network characteristics, perceived effectiveness, performance measurement, and quality improvement activities. The results indicated that the Ryan White Program has been somewhat successful in developing networks of care. However, support is needed to strengthen the comprehensiveness and coordination of care.

Specific Agencies

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United States Department of Health and Human Services The U.S. Department of Health and Human Services or USDHHS (USDHHS, 2017a) is the federal agency that is directly involved with the health and healthcare of U.S. citizens or refugees/asylees. The Office of the Secretary of Health and Human Services oversees the work of 11 agencies (Fig. 2.2). These agencies work in collaboration with state and local governments in the United States to provide (1) assessment information regarding the level of health or illness in the nation; (2) assurance that the infrastructure, including trained personnel, is available to all citizens and refugees/asylees; and (3) legislation and implementation of health policy. The federal government makes public health policy. By producing information gathered through research, it provides evidence that can effectively change public health practice (Bekemeier, Zahner, Kulbok, Merrill, & Kub, 2016). Thus, the federal government supports research efforts that can help citizens improve their health significantly, and promotes ways to implement the evidence from a culturally relevant and sensitive perspective. For example, the National Institutes of Health (NIH, 2017), Agency for Healthcare Research and Quality (AHRQ, 2017b), and the Centers for Disease Control and Prevention (CDC, 2017a) are three important organizations in which research is undertaken and used effectively to address healthcare concerns such as HIV screening and care, adverse events in hospital settings, and measures to decrease the rates of emerging infectious diseases (USDHHS, 2017a).

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FIGURE 2.2 Federal agencies with public health responsibilities. (Redrawn from U.S. Department of Health and Human Services organizational chart.) *Designates components of the Public Health Service. (From http://www.hhs.gov/about/orgchart.)

State and Local Health Departments State agencies, which administer specific federal public health activities throughout a particular state, are influenced from a structural and functional perspective by the federal government. However, state departments of health can be diverse for political and environmental reasons (CDC, 2017a), and they influence NGOs as well as local health departments.

According to Schneider (2017), there are several types of models of health department structure. Most commonly, a state health department is an independent organization that is in communication with the head of the executive branch of the state government (governor). (Within the health department are core public health areas, such as infectious disease control, preventive health, health institution licensing, and epidemiology, but they may relate to a political agenda or worldview of the state leadership.) The head of the state health department can be, but is not necessarily, a physician, although in some states, this is a statutory requirement. The state governor may choose the head of the department of health, or members of a state board of health may make the appointment. These boards of health are representative of the state demographics and may include residents who may be health professionals or may simply be healthcare consumers.

Another model is the state department of health and human services. This model focuses on public health, social service, and medical assistance programs. This relationship between public health and social services often helps bring together related expertise to address complex problems that frequently require coalition building with the public (Janosky et al., 2013).

Although local health departments (city or county) can be governed by state health departments, the local departments often create their own structure based on the needs of the local community, and these local health departments implement programs that serve local citizens. In a county health department, it would not be unusual to see a functioning tuberculosis clinic and tuberculosis surveillance program that works in collaboration with the state health department to care for patients exposed to or infected with the tuberculosis bacillus.

Finally, many other contributors to public health initiatives have strong relationships and interagency affiliations with state and local health departments. They include social service agencies, elementary and secondary schools, housing departments, police and fire departments, parks and recreation departments, libraries, public transportation systems, and water and sewer authorities. Government authorities are often involved in these areas within the context of public health. Generally, localities create relationships and lines of authority that make sense for the particular needs of their citizens (see Fig. 2.1).

FUNCTIONS OF PUBLIC HEALTH IN THE UNITED STATES In the chapters that follow, there are specific explanations with examples of the functions that public health offers to people in the United States. However, it is important to review several key components of the function public health serves, including a national consensus on goals (USDHHS, 2017b); provision of systems of health insurance based on risk, not necessarily on health; and the role of nongovernmental entities in disease prevention and health promotion. In the United States, public healthcare includes disease prevention and health promotion based on science and cultural relevance. It is not focused on the health of the individual person, but on the population as a whole. The goal of public healthcare is to keep populations healthy through a

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broader “reach” than connection at the individual level.

One way to develop a system that advises people with backgrounds similar to Clara’s involves strategically putting language-sensitive notices in places where these people live, congregate, or travel. They need to (1) go to their local healthcare centers to get tested for the HIV virus and (2) receive appropriate care. This “reach” may help more at- risk members of a community than discussing the HIV-testing program with people at healthcare facilities. This approach uses broad strategic planning, including the voices of community members, multidisciplinary teams, and nongovernmental not-for-profit sectors of health organizations, which focuses on key target objectives.

Public health goals and focused target objectives are identified and promulgated by a national publication called Healthy People 2020. Healthy People 2020 is a national consensus plan identifying focal areas which need active and specific plans and implementations, based on levels of illness (morbidity) and death (mortality) that account for the physical, psychosocial, and financial suffering of citizens (USDHHS, 2017a). Healthy People 2020 is mentioned throughout this book as a source of goals and indicators that should direct community healthcare at the local, state, and federal level. However, the United States and its system of healthcare have historically given, and continue to give, stronger support to (1) individual rather than community care and (2) cure rather than prevention. It involves highly specialized healthcare providers who have little contribution to community outreach.

Funding for the healthcare system in the United States comes primarily from privately owned health insurance companies. Exceptions include programs that are publicly funded, such as Medicare, Medicaid, TRICARE (civilian health benefits for military personnel, retirees, and dependents), Children’s Health and Insurance Program (CHIP), and Veterans Health Administration (Centers for Medicare and Medicaid Services, 2017; Children’s Health Insurance Program, 2017; U. S. Department of Veterans Affairs Health Benefits, 2017). At least 15.7% of the U.S. population is completely uninsured (Kaiser Foundation, 2013), and a substantial portion of the population (35%) is underinsured. More is spent on healthcare in the United States than in any other nation in the world. Even though not all citizens have health insurance, according to the OECD, the United States has the third highest public healthcare expenditure per capita, and still lags behind in measures to decrease infant mortality and raise life expectancy, as compared with other nations in the world (Table 2.1) (OECD, 2017a). Active debate about healthcare in the United States includes serious ethical questions about whether health is a right or a privilege, and whether all people should have equal access to quality healthcare. In 2010, controversial federal legislation took positive steps to give access to healthcare to all citizens through private and public funding through health insurance. This effort evolved into a federal program called Obamacare after then President Barack Obama and has since been evolving into a new health coverage program that seems to hold a difficult political road ahead. Taking into account the expense and the assurance of efficiency, effectiveness, access, and quality for all to be insured will be the challenge of the current White House administration (The White House, 2017).

TABLE 2.1 Measures of Healthcare in Selected Developed Countries

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Beyond the system of public and private control and ownership of healthcare services in the United States, a vast array of NGOs helps keep people healthy through voluntary and philanthropic services. For example, private community hospitals are sometimes supported by community groups which ensure that vulnerable populations have access to healthcare. The care may be free. In addition, the community facility may sponsor community health education programs and prevention/screening clinics for underserved populations. Although many states provide communities with (community) municipal or neighborhood health centers and ambulatory/outpatient services through local or federal funding, health services can be offered through private groups who are interested in supporting specific areas of need, such as migrant or school-based health programs (McGuire, 2014). These programs are often run by altruistic, nonprofit organizations. Examples of some NGOs in the United States include the American Diabetes Association, Citizens for Global Solutions, AmeriCorps, and the U.S. Fund for UNICEF (United Nations Children’s Fund, 2017).

TRENDS IN PUBLIC HEALTH IN THE UNITED STATES In the United States, the federal government expends time and effort every year to create a report of the trends in the following areas: (1) health status and what determines health (determinants), (2) how communities use healthcare services (health utilization) and healthcare resources to help communities stay healthy, (3) how much money is spent on healthcare (expenditures), and (4) which citizens are the most vulnerable. The following sections explain these four areas more specifically.

Health Status and Its Determinants Measuring the health status of citizens in communities helps the U.S. public health system determine how to direct resources (money and services) to keep people healthy. Despite the fact that life expectancy is higher for both men and women in countries such as Japan, the overall health of people in the United States has improved over the years. However, in the United States, current data show a downward shift related to malignancies, obesity, and dental care (Organization of Economic Cooperation and Development [OECD], 2017a). It is believed that the health successes found in the United States result from money spent on health education programs, public health programs, health research, and healthcare itself. The trend has been

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toward using larger sums of money to help Americans keep healthy. Much of the funding currently spent on healthcare is spent on prescription drugs and care of chronic conditions, which often affect the elderly or disabled. A good example of how increases in funding have improved health is the significant improvement in mortality (numbers of deaths) and morbidity (numbers of recorded illnesses) statistics in a variety of health-related actions, such as the use of corticosteroids in acute lung injury or disease (Tang, Craig, Eslick, Seppelt, & McLean, 2009).

Mortality (death rates) and morbidity (illness rates) have improved for many reasons, but a primary reason is that an organized effort on the part of the American public health system has injected resources to study certain prominent problems in the United States. A good example is the provision of services to prevent progression of cardiac illness. Thus, the death rate from heart disease has decreased, primarily because health education has emphasized a healthier lifestyle and cholesterol screening (Speroni, Williams, Seibert, Gibbons & Early, 2013). Another example is the decrease in mortality and morbidity rates of individuals living with HIV/AIDS. The use of highly active antiretroviral therapy, including protease inhibitors, has dramatically changed patterns of survival; these patterns now assume the trajectory of a chronic illness. Regardless of inequalities in gender, race, and socioeconomic status, people who once lived for five years after being diagnosed with HIV now live for 15 years, and children born with HIV infection from perinatal transmission are now teens who deal with HIV, safe sex behaviors, and disclosure issues with sexual partners (Regidor et al., 2009).

Practice Point

It is easy to receive morbidity and mortality information in the United States by going to the CDC website and electronically subscribing to the Morbidity and Mortality Weekly Report (MMWR) for free. The MMWR reports are very informative about trends in assessing the public health status of the United States. More specifically, the MMWR reports publicly, in a systematic way, the frequencies of diseases, disabilities, or health-related events, and it supplies information about trends provided by the CDC and other health officials.

Despite these successes, key social and behavioral determinants of health still need to be addressed. For example, obesity, diabetes, and cigarette smoking are significant risk factors for diseases that may interfere with healthy brain functioning (Lal, Strange, & Bachman, 2012). Although much effort has been given to preventive education in these areas, a high percentage of adults and adolescents continue to make no effort to change their exercise, smoking, or eating patterns. In addition, rates of reportable childhood infectious diseases have decreased and cancer has declined in men, but there has been no significant change in the rates for women’s cancers. In fact, many believe that there has been an epidemic of breast cancer in non-Hispanic white women in recent years (Sexton et al., 2011).

Utilization of Healthcare Resources Changes in payment policies, which are intended to decrease direct and indirect costs, as well as losses from billing fraud/abuse, continue to change healthcare delivery in the United States. There is less use of institutions (i.e., hospitals). Highly complex diagnostic procedures and surgical interventions like cardiac surgery are more likely to take place in hospitals. However, emergency departments and office-based physician and physician-group visits, as well as ambulatory surgical procedures, have increased. In particular, emergency department admissions have increased for those citizens who are asthmatic, especially children (Banda et al., 2013). At the same time, there has been a significant decrease in Medicare-certified home health agencies.

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In 1997, there were 10,800 agencies, and in 2002, there were 6,800 agencies, primarily because the Balanced Budget Act of that year forced either consolidations or closing of existing services (Center of Budget and Policy Priorities, 2017).

Prevention-oriented approaches and services decrease morbidity and mortality rates (Friis & Sellers, 2014). For example, distribution of flu or pneumonia vaccines as a form of prevention and a common public health campaign demonstrates a commitment of public health to decreasing morbidity and mortality. However, the funding for such programs is often slashed when fiscal constraints cause fiscal intermediaries to (address) pay for treatment of well-known illnesses and disabilities, rather than provide funding for prevention programs which have the potential to impact large populations. Despite decreases in financial support for vaccination programs, there have been increases in the number of children 19 to 35 months of age who have received combined vaccinations (Chidiac & Ader, 2009). In addition, the number of women older than 18 obtaining a Papanicolaou (Pap) smear screen has also increased. However, there is a link between this preventive intervention, some college training, and the vaccine that counters certain strains of human papillomavirus (HPV) (CDC, 2017b).

Practice Point

Assurance is a word used in public health to identify an important concept: that individual people, families, and populations have the healthcare personnel and systems needed to address their respective healthcare needs. Assurance as a goal is highly related to the goal of maintaining healthcare professionals in the work force who are competent and stay in the work force. It is possible to think about schools of nursing as a way in which nursing programs are supporting assurance. To understand the level of commitment to healthcare education for nursing professionals in the state in which you live, determine the number of schools of nursing in the state, which ones specifically offer advanced practice specialties in community/public health, the number of schools of public health, and the number of medical schools. In addition, check labor statistics related to trends in the retirement of health professionals. Each of these efforts can help make it possible to understand trends in the preparation of healthcare providers and also help assess needs for the future from the local perspective. Comparison among states gives a larger perspective and can be obtained by accessing the Health Resources and Services Administration (HRSA) website, which is the federal organization specifically responsible for health professional resources in the United States.

Expenditures and Health: Trying to Improve Public Health Economically Access to healthcare is critical for prevention and treatment of illness and injury. Health insurance and appropriate coverage often determine access. Lack of health insurance is related to poverty, and puts residents in a position of vulnerability. The United States spends more on healthcare than any industrialized country. Although hospital care accounts for the largest share of healthcare spending, prescription drugs are the fastest growing healthcare expenditure. Medicare pays for only a little of this expense, even though citizens aged 65 and older, who are the primary recipients of Medicare, have the greatest need for therapeutic drugs. Thus, people whose income is reduced through retirement, or death of a family member, may have a substantial out-of-pocket expense (Baird, 2016).

National Health Expenditure Accounts (NHEAs) are a measure of expenditures on healthcare goods and services in the United States. These accounts are prepared by the National

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Health Statistics Group. Government public health activity constitutes an important service category in NHEAs. In the most recent set of estimates, expenditures totaled $56.1 billion in 2004, or 3.0% of total U.S. health spending (CMS, 2017). What becomes challenging is specifically identifying what is considered “public health” in an expenditure.

Vulnerable Populations and Healthcare Key indicators in the United States reveal a healthcare gap between the overall American population and people of different genders and ethnicities. There is also a healthcare gap for those who have less education, lower socioeconomic status, and live in certain geographic areas in the United States. These disparities are characteristic of people who have been marginalized and oppressed. Marginalization often occurs in people who live below the poverty level in the United States, and these people frequently are poorly educated. In the chapters that follow, higher rates of morbidity, mortality, difficulty in accessing care, and negative outcomes when receiving care will be seen as key issues in such populations.

Clara is a good example of someone who has been courageous in coming to the United States but is compromised in terms of literacy and socioeconomic needs. She also is unfamiliar, at a basic level, with how healthcare systems work, and how to access them effectively. She needs someone to advocate for her. Even if there are services available to help her, she may not know how to gain access to these services.

Historically, in 2002, the Institute of Medicine released a document called Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare (Institute of Medicine, 2002). The report defines health disparities as “racial or ethnic difference in the quality of healthcare which is not due to access-related factors or clinical needs, preferences, and appropriateness of intervention” (Institute of Medicine, 2002, p. 3). Disparities are found in certain types of illness, such as cardiovascular disease, cancer, HIV, diabetes, end-stage renal disease, and certain surgical procedures. Surgical procedures such as amputations have been found to be more common within minority groups.

The Department of Health and Human Services has identified six areas for which it has oversight. These areas are (1) infant mortality, (2) cancer screening, (3) cardiovascular disease, (4) diabetes, (5) HIV/AIDS, and (6) immunizations. In addition, there are also several areas that need special emphasis, including mental health, hepatitis, syphilis, and tuberculosis.

HEALTHCARE SYSTEMS IN SELECTED DEVELOPED NATIONS Overall, the commitment to prevention and the cost savings, whether a personal commitment or an economic commitment, is yet to become effective in the United States across a variety of parameters. However, other countries have been able to achieve success with their healthcare system structure, function, and outcomes. Figure 2.3 provides an overview of selected healthcare indicators of 17 countries including the United States. For purposes of comparison and contrast, the following section discusses how Canada, France, Germany, the Netherlands, and the United Kingdom keep their citizens healthy and well. These countries were chosen because they historically have had healthcare philosophies that are based on inclusivity of all citizens, lower cost, quality, and a perspective that healthcare is a right. No country is perfect, and many face

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the same escalating costs as the United States. However, a key international source, the OECD (OECD, 2017a), presents comparative data that demonstrate that these countries have better morbidity and mortality rates, as well as other health-related factors, than the United States. The approaches of these countries to the healthcare of their citizens can serve as important examples of goals which other countries may want to pursue. Key components to advancing public health and public health systems are (1) identifying indicators of health, (2) being committed to providing healthcare professionals and the public with a system that works, and (3) generating policy that allows for the production of positive outcomes. The following countries have been selected because of unique positive contributions they have made in healthcare outcomes, through creative funding and infrastructure adjustments to meet the unique needs of their respective populations. In many cases, comparisons have been made to these countries because of the positive experiences that have been reported from health outcome data as it relates to costs.

FIGURE 2.3 Overall ranking of countries according to various healthcare indicators (2007). *2003 data. (From The Commonwealth Fund. [2013]. International Health Policy Survey, the Commonwealth Fund 2005; International Health Policy Survey of Sicker Adults; the 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians; and the Commonwealth Fund Commission on a High-Performance Health System National Scorecard.)

Canada According to Health Canada (2017) and the OECD Canada (2017b), Canada is the second largest country in the world, with 10 provinces and two territories. Its 31.5 million people have a life expectancy of 78 years (men) and 82 years (women). Seventeen percent of the population is older than 60 years of age. Cancer is the leading cause of mortality, followed by congestive heart failure.

Canada’s healthcare system is a national health program; it is considered a single-payer system with universal coverage. This means that all Canadian citizens are covered for healthcare by one government-run system. Canadian Medicare, the healthcare insurance coverage for all, began in 1968 to eliminate financial barriers to care and to allow citizens to have choice in what physician they chose for their care (Health Canada, 2017). Culturally, Canada is made up of multicultural and multilingual populations because of high immigration rates over the years.

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Canadians view healthcare as a right, not a privilege, and more specifically, as a social responsibility.

Funding for the Canadian healthcare system comes from personal, sales, and corporate taxes, and federal transfer payments (<25%). The federal government provides healthcare only for special populations (military personnel, native Canadians, and federal prisoners [<2% of the population]). The government of Canada has the responsibility for what are considered the public health arms of the National Institutes of Health, occupational and environmental health, health promotion, Indian Health Service, and health protection.

Despite a single-payer reimbursement system, the 12 provinces determine the management, delivery, and financial arrangements for the Canadian Medicare services. Private insurance exists to cover services not covered under Medicare, such as vision needs, dental services, and pharmaceuticals for nonelderly people. This type of private insurance is acquired through employment contributions, and represents a small portion of total health expenditures (15%). Provinces raise money specifically for Medicare through taxes, corporate contributions, personal income, fuel taxes, and lottery profits.

The money allocated through these approaches supports the individual health costs of citizens in each unique province or territory, hospital payments, and physician salaries which are capped and negotiated, drugs, long-term care and mental health institutions, and provincial healthcare planning. At the national level, there is oversight of the development and safety of pharmaceuticals and reviews that survey physician production, practice, and quality.

The most powerful individuals in the healthcare system are health administrators, not physicians. These health administrators put an emphasis on cost, efficiency, and social responsibility. Unlike in the United States, most of the physicians are generalists who are reimbursed by provincial health plans (99%) through fee-for-service, capitation (maximal amount of money based on patient caseload), or salaries in health centers. Nevertheless, the majority of care occurs in the private physician’s office. Nurses have little autonomy and often migrate to the United States to practice in order to gain higher salaries (Health Canada, 2017).

Capital expenditures are separate from operating expenditures, which gives provinces control over facility development and renovation. There is a trend toward delivering healthcare and performing medical and surgical procedures outside of hospital settings, with an increasing focus on health promotion and disease prevention. Most procedures are scheduled in advance and take place in outpatient or ambulatory areas. Although there may be long waits for care, it is important to remember that the wait time is not for emergency or life-threatening conditions. It is a way to distribute care more evenly and to control costs.

Individual provinces closely monitor quality of care, with strong emphasis on decreasing duplication of services across all levels of care. Hospitals, in particular, are used not just for acute care, but for long-term care of patients (23% of hospital beds). There have been reports of inequities between provinces (Health Canada, 2017) and fear that cost containment may limit the use of newer and developing technologies. The balanced benefit of this approach is that Canada has better health outcomes than the United States (30th vs. 37th) in OECD rankings (OECD Canada, 2017b) while spending less money per person on healthcare. Many people believe that it is far better to wait for nonemergent care than to be uninsured (see Table 2.1).

Evidence for Practice

Brehaut and colleagues (2009) used population-based data to evaluate whether caring for a child with health problems had implications for caregiver health after controlling for relevant covariants. They used data on 9,401 children and their caregivers from a population-based

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Canadian study to analyze and compare 3,633 healthy children with 2,485 children with health problems. Caregiver health outcomes included chronic conditions, activity limitations, self-reported general health, depressive symptoms, social support, family functioning, and marital satisfaction. Covariants included family (single-parent status, number of children, income adequacy), caregiver (gender, age, education, smoking status, biologic relationship with child), and child (age, gender) characteristics. Their findings showed that caregivers of children with health problems had more than twice the odds of reporting chronic conditions, activity limitations, and elevated depressive symptoms, and had greater odds of reporting poorer general health than did caregivers of healthy children. This study points out that caregivers of children with health problems had substantially greater odds of also having health problems than did caregivers of healthy children. From a public health assurance perspective, this indicates that healthcare initiatives need be directed not only to individual children who are chronically ill but also to families. There is an important link between those with chronic illness and those who care for them.

Student Reflection

We were asked in clinical seminar to think about and discuss the prejudices we may have heard about other healthcare systems in the world, and I immediately thought of Canada because it is our next-door neighbor. Everybody says that healthcare is rationed, there aren’t enough doctors, the quality of care is poor, and that it is “socialized medicine.” I have realized that although there may be a wait for specialist care, there is no wait for the most common need for care…primary care. There is rationing related to immediate need versus needs that can be delayed. The most important thing is that everybody has insurance, and nobody is denied care because they can’t pay for it. Although there are some shortages of physicians, there is more of a sense of balance in having more physicians available to take care of the common illnesses of the population (primary care). From what I have read, the quality of care is acceptable, especially in light of the fact that in our own country some have no ability to obtain care. I guess the bottom line is, as I prepare to practice nursing, I am keenly aware of the need to ensure all populations of having access to get help for common problems and to have, most importantly, equal access to quality care.

France Despite the French people’s dissatisfaction with their healthcare system, many consider their system one of the best in the world (Bourdelais, 2010). According to the OECD (OECD, 2017c), France, a republic with a population of 61,000,000, is a healthy country in terms of infant mortality, life expectancy, and healthcare-related costs (see Table 2.1).

The Ministry of Health runs two large organizations that cover the funding and provision of health services in 22 regional services agencies: (1) General Health Management and (2) Hospital and Healthcare Management. The structure of the healthcare system in France includes the National Institute of Health, established in 1998; the French Agency of Health Safety of Health Products, which functions similarly to the Food and Drug Administration (FDA) of the United States, also established in 1998; the Agency of Environmental Health Safety (established in 2000); French Institute of Blood, established in 1992; French Institute of Transplants (established in 1994); and the Ministry for Health, Family and the Disabled.

The government presents a law to the parliament every year as a way to use public policy to finance a social security fund, which includes the national expenditure on health insurance. This public policy effort also specifies goals for the healthcare system, similar to the Healthy People 2020 effort in the United States. The Ministry of Health delegates the planning and

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implementation of health initiatives to regions that make up the country in order to decentralize and make care plans specific to each region. A national health insurance guarantees universal access to 80% of the French people by offering health coverage to wage earners through what is called the CNAMTS (Caisse Nationale de l’Assurance Maladie des Travailleurs Salariés or French National Health Insurance Agency for Wage Earners). The rest of the national funding is divided among other funds that are occupationally specific (physicians, agricultural workers, and students). Therefore, the French population is 100% covered by a public mandatory health insurance. Funds are financed by payroll taxes (60%) and since 1990, by a proportional income tax (40%) called the CSG (“contribution sociale généralisée”). The funds are governed by boards with representatives of the government, the main workers unions, and the association of French manufacturers. France has an essential single-payer system. More than 80% of French people carry a supplemental form of private insurance often linked to employment. Public payment covers 76% of French health expenditure. Patients pay physicians directly and apply for reimbursement, and 21% of expenditures are on pharmaceuticals. For 96% of the population, healthcare is entirely free; it is reimbursed up to 100%. Users of this system can select any physician—even a specialist and hospital (public or private)—with the belief that choice leads to successfully managed competition and quality care.

In France, there are more than 1.2 million employees in the health service sector. Physicians consider public hospital jobs undesirable, and often foreign physicians fill these positions. The majority of physicians in private practice participate in a government-fixed fee-for-service scheme, and the remainder charge what they wish. Physicians accept what the government pays, and the patient pays the difference. French general practitioners earn the equivalent of about $55,000 per year. Other characteristics of physicians working in France are presented in Box 2.1.

2.1 Characteristics of Physicians in France

Physicians are unevenly distributed between rural and urban areas. About 50% of physicians are women. Physician visits can take 15 to 30 minutes. Physicians see about 10 patients per day. Medical education for physicians is publicly funded. Ratio of generalists to specialists is 1:1. Ranking system of hospital practitioners is nationwide. Physicians, biologists, and dentists are all salaried hospital practitioners. Advancement is based on seniority.

Source: Organization of Economic Cooperation and Development. (2006). The supply of physician services in OECD countries (OECD health working papers No. 21). Retrieved from http://www.oecd.org/els/health-systems/35987490.pdf.

The French healthcare system is made up of public, private, and not-for-profit sectors, which avoids the long waiting lists characteristic of other socialized medicine systems. Health insurance supplies a large majority (91%) of the funds for the 1,032 (85% of total) public hospitals, which account for 65% of all hospital beds in France. Private, not-for-profit hospitals account for 15% of all hospital beds, and specialize in medium- to long-term care. Private, for- profit hospitals account for 20% of all hospital beds. The private hospitals conduct 50% of surgeries and 60% of cancer care.

A key ethic of this system is individual choice of physician and place of service, including a tradition of long-term care in the private home. France maintains strict boundaries between health and social services, and outcomes and performance are benchmarks for both home

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healthcare and nursing homes. Financial aid is given to people in the form of allocation personnalisée d’autonomie, or allocation for loss of autonomy, to purchase care—even from family members or other unskilled labor—as a way to promote employment.

Evidence for Practice

The following two survey studies are examples of this commitment to the health of the French population.

1. Constant, Salmi, Lafont, Chiron, and Lagarde (2009) investigated behavioral changes in a cohort of car drivers to understand why there was a decrease in motor vehicle road casualties in France. Researchers offered self-report survey questions to more than 11,000 people between 2001 and 2004 to explore attitudes related to road safety and driving behaviors. Investigators found that adequate sleep was related to positive outcomes in road safety. Decreases in cell phone use and speeding over this time period demonstrated decreases in road mortality in France.

2. Nayaradou, Berchi, Dejardin, and Launoy (2010) elicited preferences of the population for willingness to participate in a mass colorectal cancer screening initiative in northwest France. (The implementation of a mass colorectal cancer screening program is a public health priority.) They interpreted the results of a survey conducted by mail from June 2006 to October 2006 on a representative random sample of 2,000 inhabitants, aged 50 to 74 years. On the questionnaire, each person made three or four discrete choices between hypothetical tests that differed in eight ways: how screening is offered, process, test sensitivity, rate of unnecessary colonoscopy, expected mortality reduction, method of screening, test result transmission, and cost. Results from the 32.8% of respondents indicated that expected mortality reduction, sensitivity, cost, and process were among the population preferences. Researchers found that the sensitivity of the test was most important in respondents with higher financial resources. Key implications included how adherence to screening could be accomplished in light of these data.

Clients in nursing homes pay for their room and board separately from nursing/healthcare, and these costs come from pension funds or welfare funds. The residents of nursing homes are legally entitled to be involved in the governance of their home, and in France, this system is highly respected and well run with little inefficiency. Finally, there is a strong emphasis on prevention as a priority.

Germany Germany, the largest country in Europe, is made up of 82.4 million people divided into 16 states. From a vital statistics perspective, life expectancy varies between men and women (76 and 82 years, respectively), and 19% of the population is older than 65 years of age. The leading causes of death include heart disease and lung cancer (OECD, 2017d).

Germany has a universal healthcare system (OECD, 2017d). Historically, health insurance was a requirement and directed at low-income workers and certain government employees. Eventually, all people were able to obtain insurance. Currently, physicians in private practice provide ambulatory care, and centralized nonprofit hospitals offer the majority of inpatient care. Most of the population has health insurance; individuals can obtain coverage from a variety of “sickness funds” financed by public and private sources. Funds for standard insurance come

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from a combination of employee/employer contributions and government subsidies, which are scaled on the basis of need. An option exists for individuals to choose to pay a tax and opt out of the standard plan in favor of “private” insurance. Many people with higher salaries choose this option, but their premiums are linked to health status, not to income level.

Regional physicians’ associations negotiate provider reimbursement for specific services. A commission composed of representatives of business, labor, physicians, hospitals, and insurance and pharmaceutical industries meets annually. The commission takes into account government policies and makes recommendations on overall expenditure targets to regional associations. Although reimbursement of providers is on a fee-for-service basis, including co-payments, the amount to be reimbursed for each service is determined retrospectively to ensure that spending targets are not exceeded. The average length of hospital stay in Germany has decreased in recent years from 14 to nine days, still considerably longer than the five- to six-day average in the United States (OECD, Health Statistics, Definitions, Sources, and Methods, 2016). Drug costs have increased substantially each year, despite attempts to contain costs. Overall healthcare expenditures have risen, but costs are substantially less than those in the United States (OECD, 2017d).

The reunification of East and West Germany, which occurred in 1990, did increase variation in health statistics by lowering infant mortality and increasing life expectancy. However, differences continue to exist between the two parts of the country because of differences in philosophy and distribution of care in the past. Philosophically, the idea that all people should have health insurance and that the nation is responsible to provide systems of healthcare to its citizens is common to both regions. Health insurance coverage is maintained by all citizens sharing in the effort to have an insurance pool, and payment is based on income, not risk. The healthcare benefits are extremely comprehensive and include medications, dental, vision, medical treatments, and even health spas. Decentralization of healthcare administration includes a federal institute for communicable and noncommunicable disease similar to the CDC in the United States. The organizations of a variety of institutes are grouped across a regional healthcare system which is managed by the sickness funds and physician associations.

Prevention has an important role in the German system, not only as an effort toward cost saving but also in increasing the quality of life of citizens. Public health efforts include not only primary prevention but also health screening with a special emphasis on youth development.

Evidence for Practice

Stolle, Sack, and Thomasius (2009) have expressed concern about episodic excessive alcohol consumption (binge drinking) in children and adolescents as a serious public health problem in Germany because of its associated risks with further morbidities and mortality. An extensive literature search for evidence related to binge drinking from 1998 to 2008 revealed that episodic excessive alcohol consumption is associated not only with somatic complications, but also with traffic accidents and other types of accidents, violent behavior, and suicide. The more frequently a child or adolescent drinks to excess, and the younger he or she is, the greater is the risk of developing an alcohol-related disorder (alcohol misuse or dependence syndrome). Although in the United States, brief motivational interventions have been shown to have a small to medium-sized beneficial effect in reducing further binge drinking and its complications, the Germans use an intervention called HaLT (“stop,” also an acronym for hart am limit—“near the limit”). Further types of brief motivating intervention could be integrated in this approach as another variable to decrease binge drinking behavior and prevent the development of alcohol-related disorders.

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Nurses in the German healthcare system are mostly diploma-educated individuals working with a physician. There has been a protracted history of shortages of nurses in the 831 public hospitals, 835 independent nonprofit hospitals, and 374 private hospitals. As a final comparison, Germany’s healthcare system is sixth in financial fairness, 14th in overall goal attainment, and 14th in terms of overall performance. America’s system is 54th in financial fairness, 15th in goal attainment, and 37th in overall performance.

Student Reflection

It is stunning to me that when you explore different healthcare systems in the United States, the systems seem so wasteful or greedy or just not inclusive enough to allow everyone to have the same healthcare opportunities. One of the things I was thinking about is that, in the United States, we have accepted for a long time the necessity of education. Whether the quality of the education is there or not…the idea is that education is a significant predictor of success and gainful employment in life. Well, if that is the case why would we not have the same perspective for health? Isn’t good health a predictor of future good health? Recently, some people in the United States were very worried about the effort to create opportunities for all people to have access to healthcare…not necessarily effective or efficient healthcare but healthcare, period. My sense was that people were divided about using tax money for healthcare. Some felt that the United States was becoming “socialized.” I guess it made me sad to think about so many people I have met in poor, run-down neighborhoods who could use the benefits of a philosophy that does not forget them, that cares for them, and wants them to have an equal share of a quality life.

The Netherlands According to the OECD (2017e), total health spending in the Netherlands accounted for 9.8% of the GDP, slightly more than the average of other OECD countries. The Netherlands also ranks above the OECD average in terms of health spending per capita, with current spending of U.S.$3,52 (adjusted for purchasing power parity), compared with an OECD average of U.S.$2,964. Health spending per capita in the Netherlands remains much lower than in the United States, Norway, Switzerland, and Luxembourg.

The Netherlands has a dual-level healthcare payment system. All primary and acute care is financed from private mandatory insurance. Long-term care for the elderly, dying, long-term mentally ill, and so on is covered by money acquired from taxation and is considered a “social insurance.” Insurance companies must offer a core universal insurance package for universal primary, curative care, which includes the cost of all prescription medicines at a fixed price without discrimination by age or levels of health or illness. Otherwise, they are considered to be operating illegally.

According to OECD health data (2017e), for people whose health expenses are higher because of illness, insurance companies receive more compensation if they have to pay out more than might be expected. This allows them to accept all patients in an ethically sound way and take care of their needs, rather than strategizing savings by not insuring those who have expensive, long trajectories of needed care. Insurance companies compete with each other on price for insurance premiums and negotiate deals with hospitals to keep costs low and quality high. There is formal regulation that includes checking for abuse and for acts that are against consumer interests. An insurance regulator ensures that all basic policies have identical coverage rules so that no person is medically disadvantaged by his or her choice of insurer.

Payroll taxes paid by employers and a fund controlled by the health regulator, or the

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“regulator’s fund,” finance the healthcare system. The government contributes 5% to the regulator’s fund. The remaining money needed to cover the country’s health expenses is collected as premiums paid by those insured. Insurance companies, many of which are private, can offer additional services, such as dental care, at extra cost over and above the universal system. The standard monthly premium for healthcare paid by individual adults is about €100 (currently about U.S.$129) per month, and people with low incomes can get help from the government to pay for the premiums. The regulator’s fund pays for all children’s healthcare in the country.

Hospitals in the Netherlands, which have been advancing in quality over time, are regulated and inspected regularly. They are privately run and for-profit. People can choose where they want to be treated; on the internet, they can obtain access to information about the performance and waiting times at each hospital. Those who are dissatisfied with their insurer and choice of hospital can cancel at any time, but they must make a new agreement with another insurer.

The Netherlands primarily funds what is considered one of the best long-term care systems through non–means-tested social insurance programs financed by national premiums. The programs cover a broad range of institutional and noninstitutional services (OECD, 2017e). This system includes mental health and substance abuse care. Prescriptions are covered by insurers who use specific cost formularies. Generally, co-payments, with options to pay more for certain drugs, are available.

Evidence for Practice

Investigators in the Netherlands examined the association between dairy product intake and the risk of bladder cancer in 120,852 men and women 55 to 69 years of age (Keszei, Schouten, Goldbohm, & Van Den Brandt, 2009). By using a 150-item food frequency questionnaire, several researchers studied a cohort for 16 years and identified and examined 1,549 people. The findings suggested a positive correlation in women between butter intake and bladder risk.

United Kingdom The National Health Service (NHS), which provides healthcare in the United Kingdom, began in 1948 (U.K. Department of Health, 2017). The system operates across the four countries that make up the United Kingdom (England, Scotland, Wales, and Northern Ireland). Although there are differences in how the health system is implemented, its basic organization and functions are detailed in a constitution which includes specific rights and governance.

The NHS constitution states that healthcare will be provided for all permanent residents of the United Kingdom, regardless of age, gender, disability, race, sexual orientation, religion, or belief, and access to healthcare is based only on need. People are able to choose their own physician; if necessary, this may involve traveling outside the United Kingdom to see other medical professionals for healthcare. About 36% of clients wait for hospital admission for treatment of nonacute conditions, and emergencies are addressed immediately. Two-thirds of patients are treated in less than 12 weeks (OECD, 2017f).

The NHS system is decentralized, with access to care and prevention provided by the Strategic Health Authorities. The primary treatment centers are structured like departments of health in the United States and are responsible for (1) assessing healthcare needs of communities, (2) commissioning health services needed by these communities based on this assessment, (3) identifying goals for improving the health of communities, (4) ensuring access to

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care, (5) assessing the interaction between healthcare organizations and social services organizations, and (6) assessing the quality of healthcare personnel.

Each of the foundation trusts, which are decentralized departments whose goal is the health of specific sectors of the population, acts as a department of health (U.K. Department of Health, 2017). There is also a central Department of Health which is not involved in day-to-day decision-making and implementation of care. This department makes policy decisions on a large scale, and local governments can define how they will uniquely carry out those policies for their citizens. The NHS provides primary, inpatient, long-term, psychiatric, and eye care free to many people, including children, the elderly, the unemployed, and low-income residents. Private healthcare does exist in the United Kingdom, but only a small percentage of the population use it, generally for specialty care. Private insurance does not cover the cost of pre-existing conditions, chronic conditions, or pregnancy.

Access to medications and healthcare personnel and facilities include prescriptions which are paid by either a flat rate or through annual capped charges. Physicians contract with the NHS to provide services and receive a salary. The majority of the hospitals are owned and run by the NHS trusts. Of the 2.1 physicians per 1,000 population, most are general practitioners. They can have both a public and private practice. They are paid by a mix of capitation, salary, and fees. Those physicians who are specialists are called “consultants,” and they are based in hospitals. Nurses make up the largest group of NHS staff and are paid from 40% of the NHS budget. As in most parts of the world, there is a nursing shortage. Although most nurses work in hospital systems, they are educated as specialists, and focus on particular specialty areas such as maternal health.

Revenues for all NHS health services come from taxes (83%), employer–employee contributions (13%), and user fees or co-payments (4%). Expenditures come from the NHS (88%) and private insurance (12%). All people in the United Kingdom have health insurance; in comparison, 44 million in the United States are uninsured, with no access to healthcare. Although there are questions about the level of quality of care in the NHS when compared to the United States, there is much better cost control, and access to care for all people, which translates into better health for the U.K. population.

Evidence for Practice

The Royal College of Paediatrics and Child Health (RCPCH) in the United Kingdom introduced guidelines for re-immunization of children after completion of standard-dose chemotherapy and after hematopoietic stem cell transplantation (HSCT) (Patel, Chisholm, & Health, 2008). To understand if the guidelines were properly applied and whether they created a positive standard, researchers offered an online anonymous survey to pediatric principal treatment center (PTC) consultants and shared care (SC) consultants. Results from 55 PTC consultants and 54 SC consultants demonstrated that most PTC and SC consultants recommend initiating re-immunization at six months after completion of standard-dose chemotherapy. Between 93% and 100% of respondents reported re- immunization at the recommended time after HSCT for each transplant type. (Physicians recommended pneumococcal conjugate vaccine after chemotherapy by 58.3% (35/60) of respondents and by 51.7% (30/58) after HSCT.) There were distinct differences between PTC and SC consultants in their choice of varicella postexposure prophylaxis.

PUBLIC HEALTH COMMITMENTS TO THE WORLD:

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INTERNATIONAL PUBLIC HEALTH AND DEVELOPING COUNTRIES The following section addresses public health commitment from an organizational perspective. The WHO will be discussed, especially in relation to its current health goals, and the structures and processes which are intended to yield positive outcomes. Initiatives to address refugees internationally through the United Nations and other organizations across the globe (bilateral, multilateral, NGOs) will also be considered. In addition, the international face of nursing will be discussed with its focus on offering nursing science and evidence-based practice internationally.

World Health Organization When the United Nations was established in 1945, a key directive and commitment was to protect human rights, security, and the social development of all countries. The WHO was established in 1946 as part of the United Nations to maximize health and wellness for all (World Health Organization [WHO], 2017a). The WHO is located in Geneva, Switzerland, and has six regional offices, including a U.S. branch located in Washington, DC (Pan American Health Organization, PAHO). The relationship of the United Nations to the WHO is similar to that of the USDHHS and the NIH to the CDC. For example, there is a keen focus on supplying current information about disease and disability and establishing standards of care on the basis of evidence found in health research. In the WHO, efforts are directed primarily to safely conquer disease and to help advance professionals and healthcare systems which allow this to occur with efficiency and effectiveness. In addition, the WHO, led by Director General Adhanom Ghebreyesus (Fig. 2.4), focuses on policy development through a process of supporting annual commissions and assemblies (e.g., World Health Assembly) as a means of advancing policies and guidelines to countries with common, or uniquely specific, healthcare problems (WHO, 2013b). The development of the WHO’s Child Growth Standards used data collected in the WHO Multicentre Growth Reference Study. The WHO provides international access to documentation on how physical growth curves and motor-skill milestones of achievement were developed, as well as application tools to support implementation of the standards (WHO, 2013c).

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FIGURE 2.4 World Health Organization Director General Adhanom Ghebreyesus (Image courtesy of the World Health Organization).

The 63rd session of the World Health Assembly in Geneva in May 2010 (WHO, 2017d) discussed a number of public health issues, including (1) implementation of the International Health Regulations (IHR), (2) monitoring of the achievement of the health-related Millennium Development Goals (MDGs), (3) strategies to reduce the harmful use of alcohol, and (4) counterfeit medical products.

The IHR document is a legal brief that addresses transnational control of infectious diseases and was developed as a response to the increase in international travel and trade. On June 15, 2007, the IHRs became international law; 194 countries have agreed to implement the regulations. The IHR requires nations to strengthen core surveillance and response capacities to infection control at the primary, intermediate, and national level, as well as at designated international ports, airports, and ground crossings. The regulations further introduce a series of health documents, including ship sanitation certificates and an international certificate of vaccination or prophylaxis for travelers. The document is available at the WHO website.

Historically, the United Nations MDGs were eight goals that all 189 UN member states at the time agreed to try to achieve by the year 2015 (WHO, 2017d). The United Nations Millennium Declaration, signed in September 2000, committed world leaders to combat poverty, hunger, disease, illiteracy, environmental degradation, and discrimination against women. The MDGs were derived from this Declaration, and all have specific targets and indicators. The following are the specific goals:

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1. To eradicate extreme poverty and hunger 2. To achieve universal primary education 3. To promote gender equality and empowering women 4. To reduce child mortality rates 5. To improve maternal health 6. To combat HIV/AIDS, malaria, and other diseases 7. To ensure environmental sustainability 8. To develop a global partnership for development

The UN MDGs have, overall, been remarkably successful in focusing attention and mobilizing resources to address the major gaps in human development. Some of the MDGs’ key targets, such as halving the poverty rate were met; however, achieving the health goals continues to look very challenging (Center for International Governance Innovation, 2017).

These goals are now further empowered with the United Nations Educational, Scientific, and Cultural Organization (UNESCO) Sustainable Development Goals. The Sustainable Development Goals, or SDGs, are a global framework to coordinate efforts around ending poverty and hunger, combating inequality and disease, and building a just and stable world. There are 17 goals in all, and all 193 nations represented at the United Nations agreed to them (UNESCO, 2017).

The World Bank, the International Monetary Fund, and the African Development Bank agreed to cancel debt of the poorest countries so that resources could be used to improve health. Key criticisms about this monetary support has been related to the fact that much of the money (at least 50%) was diverted to disaster relief and military aid, areas for which it was not intended (World Bank Annual Report, 2010).

Refugee and Disaster-Relief Assistance A refugee is defined as “any person who is outside his or her country of origin and who is unwilling or unable to return there or to avail him or herself of its protection because of a well- founded fear of being persecuted for reasons of race, religion, nationality, membership in a particular social group, or political opinion or a threat to life or security as a result of armed conflict and other forms of widespread violence which seriously disturb the public order” (Office of the United Nations High Commissioner for Human Rights [UNHCR], 2017). The United Nations High Commissioner for Refugees (UNHCR) was established by the International Refugee Organization, an organization that was founded on April 20, 1946, to deal with the massive refugee problem created by World War II.

Internally displaced persons are people who have been forced to flee their homes suddenly or unexpectedly in large numbers because of armed conflict, internal strife, systematic violations of human rights, or natural disasters, and who are within the territory of their own country (Office of the United Nations High Commissioner for Human Rights [OHCHR], 2017).

Most conflicts occur within rather than between countries. Compared with other continents, Africa and Asia have consistently registered high numbers of civil armed conflicts (Relief Web, 2013). Some of the countries that have experienced violent conflicts and prominent humanitarian interventions in the past two decades include Liberia, Angola, Sierra Leone, Rwanda, Sudan, Chechnya, Bosnia and Herzegovina (formerly Yugoslavia), Somalia, Sri Lanka, Azerbaijan, Armenia, Democratic Republic of Congo (DRC), Kosovo, East Timor, Afghanistan, and Iraq (Relief Web, 2017).

The health consequences experienced by populations affected by armed conflict are generally similar in nature. War-induced displacement is psychologically and physically traumatizing to everyone affected. People are rarely prepared for flight and have no time to

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gather clothes, food, or anything that can sustain their lives during displacement. Their search for safety can last for long periods, depending on the nature of war, prevailing geographical conditions, and the willingness of host communities to welcome them. Relatives and family members are often separated. Some are lost to capture, displacement, and/or death (Brown, deGraaf, Annan, & Betancourt, 2016).

The health effects of armed conflict may be direct or indirect. The direct effects include injuries (e.g., due to land mines, weapons), sexual violence, human rights violations, psychological trauma, and death. Indirect effects include food scarcity, population displacement, high levels of morbidity and mortality, infectious disease, complications of chronic disease, reproductive health morbidities, malnutrition, and disruption of health services (Levy & Sidel, 2016). It is significant that the United Nations, in its human rights activities, works with bilateral and multilateral agencies, NGOs, and the World Bank to offer health assistance in addition to the many other competing direct and indirect needs related to refugees.

Multilateral, Bilateral, and Nongovernmental Organizations as International Organizations for Health International health organizations are classified on the basis of their relationships with other distinguished organizations which match their commitment to specific aspects of population- based health, the specific implementation of health goals both directly and indirectly, and their particular resources, including financial contributions. Multilateral agencies and organizations receive funding from both governmental and nongovernmental sources. Examples of these multilateral agencies include the United Nations and the WHO, which were discussed previously. The World Bank is another multilateral organization. Its major goal is to lend money to countries in need of developing their infrastructure on a variety of fronts. Some of the projects undertaken by the World Bank and related to health include addressing access to safe drinking water, soil development so that healthy foods can be grown and eaten, building sanitation systems so that water drainage is not connected directly to sewage, and promotion of vaccination programs, as well as promoting primary healthcare, which includes screening programs. Specific programs include Roll Back Malaria, the Joint United Nations Programme on HIV/AIDS, the Global Alliance for Vaccines and Immunizations, Onchocerciasis Control Program (river blindness control), and the Global Water Project (World Bank, 2017). (See the earlier discussion of WHO, United Nations, and MDGs for a critique of the use of promised monies to assist with health goals by World Bank and other funding organizations.)

Bilateral agencies and organizations conduct their services within one specific country. The U.S. Agency for International Development (USAID) is a good example in the United States. It is a committed initiative which works with developing countries to enhance systems to fortify the health and welfare of international populations. USAID focuses specifically on support directed to sub-Saharan Africa, Asia, Latin America, the Caribbean, Eurasia, and the Middle East. Key health prevention initiatives focus on larger areas of child, maternal, and reproductive health, and have specific interests in HIV/AIDS, malaria, and tuberculosis care (USAID, 2017). Many of the healthcare systems in countries described earlier in this chapter have parallel organizations to USAID.

NGOs, discussed earlier in this chapter, are private agencies that voluntarily use their resources to address a variety of healthcare initiatives in the United States. Some of these organizations have specific goals or roles in global health. For example, the International Committee of the Red Cross (2017) is known most for its role in disaster relief. Some groups, such as Catholic Relief Services, (2017), have a particular religious affiliation, and others, such as Oxfam International (2017), are directed specifically to issues related to hunger and nutritional health. Philanthropies are organizations that are similar to NGOs, but they receive

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funding through personal endowments. For example, the Bill and Melinda Gates Foundation (2017) focuses on health, poverty, and development in Africa, South America, Asia, and Australia. Specifically, The Living Proof Project supports vaccine and nutrition programs, as well as decreasing the incidence of diseases such as polio, HIV/AIDS, and tropical illnesses. In all cases, NGOs and philanthropies view human rights as a fundamental (motivation) basis for addressing the unseen and unfelt pain of many people in the world who suffer needlessly.

Practice Point

The United States offers a process of applying for tax-exempt status for not-for-profit NGOs, which are focused on national or international public health. This process requires filing specific forms with the Internal Revenue Service (IRS) and a fee, and there must be no involvement with or by any political campaigns. The organizational status acquired through this process is a tax-exempt, nonprofit corporation or association (a 501c3). It requires a board of directors be formed, with a stipulation in its by-laws which states the work intended to be done by the organization. In return, the IRS gives the organization tax exemption for purchases aligned with the mission of the organization, as well as other benefits and protections. Donations and contributions made to nonprofit organizations may be claimed as tax deductions on individual or corporate tax returns. Check out your local rules and regulations, or discuss this idea with any legal consultant you may know (perhaps a law student at your university or town).

International Council of Nurses The International Council of Nurses (ICN) is a federation of more than 130 national nurses associations (NNAs), representing more than 13 million nurses worldwide. Founded in 1899, ICN is the world’s first and widest-reaching international organization for health professionals. Operated by internationally prominent nurses, ICN works to ensure quality nursing care for all, sound health policies globally, the advancement of nursing knowledge, and the presence worldwide of a respected nursing profession and a competent and satisfied nursing work force (International Council of Nurses [ICN], 2017).

ICN advances nursing, nurses, and health through its policies, partnerships, advocacy, leadership development, networks, congresses, and special projects, and by its work in the arenas of professional practice, regulation, and socioeconomic welfare. ICN is particularly active in the following:

International classification of nursing practice Advanced nursing practice Entrepreneurship HIV/AIDS, tuberculosis, and malaria Women’s health Primary healthcare Family health Safe water

Despite the variation in healthcare structures between countries, and the varying degrees of both fiscal and health outcomes, nurses continue to advance the health of the public. Through (1) assessment of health across a variety of specialties and patient groups, (2) education of other nurses in health promotion and disease prevention, and (3) contributions to health policy development, nurses represent the voice of patients and clients worldwide.

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KEY CONCEPTS Healthcare systems are organized based on philosophies of care and are culturally influenced. The United States healthcare system includes structure and functions to support assessment, assurance, and health policy related to the health of populations. Despite the economic strength of the United States and other industrialized nations, many countries have found more efficient and effective ways to care for all by decreasing health disparities and giving equal access to care. Public, philanthropic, and nongovernmental agencies all contribute to the health of populations through diverse structures, financing, and personnel approaches to the health needs of citizens.

CRITICAL THINKING QUESTIONS

1. Give three reasons why you think that comparing healthcare systems between countries is an important approach to serving the healthcare needs of people.

2. In thinking about multilateral, bilateral, and nongovernmental organizations, where would you see the role of a community/public health nurse? Give some examples, and explain why public health nurses provide a unique contribution.

3. How do cultural and philosophical factors play an important role in how healthcare systems are developed and supported? Give explicit examples.

COMMUNITY RESOURCES Local philanthropies and foundations with goals focused on healthcare State Department of Health Organizational chart of the (state house) legislative governance in your state (look for Health and Human Services) Insurance companies (private, HMOs) Departments of Social Services (Medicaid Division)

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Chapter 3 Health Policy, Politics, and Reform Anahid Kulwicki and Sabreen A. Darwish

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