Underserved Populations And Environmental Health

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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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

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

Healing is a matter of time, but it is sometimes also a matter of opportunity. Hippocrates

Disruptive innovation is not about pushing out the incumbent, it’s about giving the consumer a choice.

Dr. Jason Hwang, co-author of The Innovator’s Prescription: A Disruptive Solution for Healthcare

CHAPTER HIGHLIGHTS Healthcare policy and the political process Healthcare finance and cost–benefit in relation to health policy Access to healthcare and insurance facts in the United States Healthcare workforce diversity and its effects on the quality of healthcare Nursing’s role in shaping healthcare policy Quality of care and evaluation Information management facts Equity in healthcare access Ethical consideration in health policy Political advocacy, how to be politically active and advocate Health advocacy and healthcare reform Affordable Care Act (ACA) overview and updates Community-based services and healthcare reform Health services research application to healthcare policy

OBJECTIVES Define public health, policy, and politics while identifying the relationships between concepts. Explain the effect of politics in healthcare policy. Identify the steps of policymaking and understand them comprehensively. Apply the process of policymaking to explain daily decisions regarding health and health choices.

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Understand facts regarding the healthcare system, access to care, and insurance issues. Identify the basic economic and financial concepts in relation to healthcare services. Identify the definition and determinants of quality of care. Understand the critical role of nurses in healthcare reforms through political advocacy. Explain the importance of workforce diversity, and the concept of cultural competency. Understand the information management involved in the healthcare system. Explain the ethical and legal considerations in the policymaking process. Explain the major reforms in the healthcare system in the United States. Understand the main foundations and premises of the Affordable Care Act (ACA), community health services, and the role of the ACA Understand the value of health services research in the healthcare system.

KEY TERMS Affordable Care Act (ACA): The comprehensive healthcare reform law enacted in March 2010

(sometimes known as the Patient Protection and Affordable Care Act [PPACA], the Health Care and Education Reconciliation Act, or “Obamacare”) designed to improve the quality and accessibility of healthcare while reducing its cost.

Centers for Medicare and Medicaid Services (CMS): Federal agency that runs the Medicare, Medicaid, and Children’s Health Insurance Programs, and the federally facilitated marketplace that was designed to enact and achieve the goals of the ACA, which were first articulated by the Institute for Healthcare Improvement.

Cost–benefit: An economic approach or analysis tool used to evaluate the effectiveness of a treatment or intervention. Mathematically speaking, the net economic benefit can be calculated by subtracting the costs for a service from the benefits of this service. If this value is positive, it implies that the benefit from a specific intervention exceeds its cost. An intervention is judged to be unworthy if its cost exceeds the benefits gained from carrying it out.

Cost sharing: The arrangement that defines how you and an insurer pay for insured services or items. Coinsurance, copayment, and deductibles are all forms of cost sharing. Premiums, payments for uncovered healthcare supplies or services, or fees paid to out-of-network providers are not shared costs.

Cultural competency: The knowledge, skills, attitudes, and behaviors that are learned in order to provide the optimal health service to individuals from a variety of ethnic, racial, and cultural backgrounds.

Deductibles: The amount you pay in a calendar year before your health plan begins to pay. For instance, if your deductible is $2,000, you must pay that amount out-of-pocket for covered health services before your insurer begins paying your healthcare costs.

Economics: The study of how individuals, groups, organizations, and society allocate and utilize finances, personnel, time, and physical space as components of resources. Economic tools and other quantitative financial measures are used as a method of evaluating the existing governmental, private programs or public, and private policy alternatives.

Equity: As applied to healthcare, the notion that healthcare does not vary in quality because of gender, race, age, ethnicity, geographic location, or socioeconomic status.

Gross domestic product (GDP): The main economic indicator used to evaluate the degree of economic growth in the United States. It is defined as the final and total output of goods and services produced in 1 year by labor input within the United States. The figure of GDP is reported quarterly.

Health policy: Policy that has an impact on the health of an individual, a family, a population, or a community and is created by the government, institution(s), or professional association(s).

National health expenditure: The total spending in dollars for the costs of healthcare goods and services in a 1-year period. National health spending is one of the many parts that constitute the GDP, and the growth in health expenditure is usually compared to the GDP growth.

Out-of-pocket costs: The costs that aren’t covered by your health plan. Deductibles, coinsurance, copayments, and some supplies or services are examples.

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B

Patient advocacy: A vital nursing professional duty of supporting actions that are in the best interest of patients’ health and that defend patient rights via speaking on patients’ behalf. Such support is targeted toward the overall well-being and the contribution to the healing process.

Policy: Principles that govern an action to achieve a given outcome. Policies are guidelines that direct individuals’ behavior toward a specific goal. They are deliberate courses of action chosen by an individual or group to confront problems.

Politics: Process of influencing the allocation of resources (financial, human, time, or physical space). Additionally, politics represents how conflicts are expressed and resolved in a society. Politics also may be a factor in deciding who participates or who influences governmental decision-making.

Public health policy: A set of policies (governing principles) that has a health-related mission and has an impact on the health and well-being of the population.

Political advocacy: Being involved in the legislative process and influencing decision-making in relation to healthcare to best serve the public interest as well as the profession by enacting the advocacy role to influence a change in policies, laws, or regulations that govern the larger healthcare system.

Quality of care: A concept used to evaluate the extent of how efficiently and effectively healthcare systems provide safe patient care at a reasonable cost to people in need. It is the degree to which health services for individuals and populations increase the likelihood of a desired health outcome.

Reform: Form again; improvement of what is wrong or unsatisfactory. It is for the better, especially as a result of improvement of legal or political abuses or malpractices.

Workforce diversity: The presence of a variety of ethnic, religious, age, gender, sexual orientation, socioeconomic status, nationality, disability, geographic location, racial, and cultural backgrounds of the workers in a specific area such as the health sector.

CASE STUDY

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

You are caring for an 8-year-old African American female patient on the general pediatrics floor. She was transferred from the PICU, where she was admitted for respiratory failure and status asthmaticus. She has a history of “wheezing” but has never been diagnosed with asthma. She receives the majority of her care in the emergency department (ED) and urgent care centers. She has never been on asthma medications. She lives at home with her mother and two siblings. Her mother is employed as a clerk at a hospital and earns $29,942 per year. Her mother’s employer provides health insurance. However, she cannot afford to add all three of her children to her health insurance plan. As you read through the chapter, consider the following questions.

Lack of health insurance limits this patient’s access to quality asthma care. Barriers to quality care exist even for those who are insured. What are some of those barriers? Are there differences in asthma prevalence by race and income? Are there differences in how children in minority groups access medical care? How do these differences affect asthma care? How are most children in the United States insured? Do you think it is common for a person to have a job yet not have health insurance coverage for their children? What are other health insurance options available to this family? How can you advocate for this child? How can you help ensure improved asthma care for all?

eing engaged in the healthcare system as a healthcare professional providing care, as an administrator, or even as a client, it is important to have a general understanding of how the healthcare system works. What are the guiding principles that affect individuals’

daily decisions regarding their health and health choices? Who is involved in the process of

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decision-making? What are the steps that are followed during this process? How can nurses be an active part in the process of developing or changing healthcare policies? Do patients have input into these policies? How does a healthcare policy affect an individual’s access to healthcare? Are politics different from healthcare policies? Are politics isolated from any ethical or legal considerations? As healthcare providers, how can nurses be involved in reforming the healthcare system? How can they do so by using research or evidence in reforming healthcare?

This chapter will answer these questions. Moreover, it will give the reader the opportunity to start thinking about the challenges and problems in the healthcare system in a broad and comprehensive manner, to analyze these problems critically, and to find solutions by considering the political process and policy actions. In other words, the reader will be able to better understand challenges addressed by health policies and understand researcher input that may improve the U.S. healthcare system.

HEALTHCARE POLICY AND THE POLITICAL PROCESS Policy can be created in the form of a law or a guideline of public and private institutions (Centers for Disease Control and Prevention [CDC], 2015). Health policy refers to decision- making to reach health goals and these decisions are made to direct future health planning and outcomes within a framework of time (World Health Organization [WHO], 2017).

Porche (2012) defines policies as a set of principles that govern an action to achieve a given outcome, or guidelines that direct individuals’ behavior toward a specific goal. Kraft and Furlong (2013) define policy as decisions characterized by behavioral consistency, which reflect the values and beliefs of two parties, namely, policymakers and policy followers. Moreover, they claim that policy refers to the goals, plans, and specific strategies or programs used in achieving a given outcome. Public policies address community problems and are developed by public or government officials (Kraft & Furlong, 2013). Health policy broadly describes the actions taken by governments—national, state, and local—to advance the public’s health (Acuff, 2017).

Health policies are those policies that have an impact on the health of an individual, a family, and a population or community and are created within the government, institution, or professional association (Porche, 2012). Health policies are crafted to alleviate issues of health or healthcare (Mason, Leavitt, & Chaffee, 2012). “States use health policies to specify requirements for licensure in the health professions, to set criteria for eligibility for Medicaid, and to mandate immunization requirements for public university students” (Mason et al., 2012, p. 3). Furthermore, U.S. states are involved with healthcare policy in many ways; some directly operate public hospitals and mental health facilities, while others administer public health departments that operate public health clinics (Acuff, 2017). In addition to the state level, policies can be separated into local or national. An example of a state-level policy would be a school board crafting a policy in regard to contraceptive care, whereas an example of national policies would include laws and regulations in regard to access to care and reimbursement for advanced practice nurses (Leavitt, 2009). In times of emergency at the local, state, or national levels there is concentration of effort through the Federal Emergency Management Administration (FEMA). The FEMA addresses through organized coordination of a variety of key services assistance when natural and man-made disasters occur but they also do this work successfully by being responsible in getting all of these levels of services prepared in light of a disaster or any kind (Acuff, 2017).

Moreover, three main components of public health policy are reported consistently in the literature, namely, (1) health-related decisions guided by the stated laws written by legislators,

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(2) rules and regulations designed to operate the health-related activities and programs, and (3) the judicial decisions related to health, which involve both federal and state governments (Porche, 2012).

Practice Point

As was previously discussed, politics cannot be separated from the process of policymaking. There are many different ways to describe the impact of politics. First, politics are concerned with the exercising of power and decision-making in a society (Kraft & Furlong, 2013). Second, politics are usually studied as the process of formulating and adopting policies along with focusing on the role of both governmental institutions and the public.

Involving Politics Politics are the process of influencing the allocation of resources needed to enable policies, and involves the strategies needed to achieve the desired goals (Mason et al., 2012). Politics also reflects how conflicts and problems are expressed and resolved in the context of society, and involves choices and influences based on power dynamics (Leavitt, 2009). Additionally, politics helps in answering questions regarding who participates or who influences governmental decision-making, and who benefits or who does not. Therefore, it is impossible to understand health policy or any type of public policy without considering political factors, which affect every level of policy formulation.

Kraft and Furlong (2013) discussed many reasons to involve the government in the policymaking process. These reasons usually reflect political, moral, ethical, and economical responsibilities. The two latter reasons will be discussed later in this chapter. In reference to a political issue, the government should be interested in problems that affect a specific group or a whole population. This interest usually takes the form of legislations that provide substantial solutions for the health problems that threaten the safety of the citizens and/or their environment. There are many examples of the positive role that governments play through policies and legislations—to name a few: providing equal opportunity through universal provision of education, healthcare, and often, housing and nutrition programs (Grogan, 2012).

Solutions can be achieved by working at either the federal or the state level. However, Rice and team (2013) explain that there is little agreement between the two major U.S. political parties (Democrats and Republicans) when it comes to how, when, to whom, and what kind of healthcare should be provided, and who should pay for it. Rice and colleagues (2013) concluded that in attempting to answer healthcare-related critical questions, disagreement between the two major political parties can create difficulty in finding solutions to the problems of the society, and hence to policies, including those of healthcare. Consequently, this can influence access to healthcare and the possibility of improving the quality of care provided (Rice et al., 2013).

Additionally, politics interacts with every aspect of healthcare in the United States (Morone, Litman, & Robins, 2008). Accordingly, U.S. politicians are interested in making decisions for the society that can be enforced by rules, laws, and regulations. Politics is sometimes perceived as a negative and unfavorable way to deal with social issues. However, politics provides the power needed to influence critical decisions regarding the allocation and distribution of resources in a society. Moreover, political actions are the tools used by politicians and the official representatives of the citizenry to shape decisions.

In summary, Mason and colleagues (2012) identified three common themes, which can be extracted from the different definitions of politics. First, the power of influence implies there is

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room for shaping desired outcomes by having an impact on the decisions made by governments, communities, or associations. Second, the most critical process for politics is to make decisions regarding the distribution and allocation of resources. Third, resources vary and include financial, human (personnel), time, and physical space. These resources are often found to be scarce. It is argued by Brownson, Fielding, and Maylahn (2009) that the availability of adequate resources can strongly affect the decision-making process. Accordingly, resources are believed to affect the desired outcome and outputs from a given policy.

While the previous themes of governmental power, decision-making, and resources are vital in understanding the political role in decision-making, it is crucial to acknowledge the fact that healthcare professionals, namely nurses, have political skills and active roles in healthcare leadership. As highlighted by Mason and colleagues (2012), those skills are as follows:

1. Having social skills and the ability to understand, interpret, and represent one’s own and others’ behaviors

2. Having the ability, qualifications, and power to influence others and make changes 3. Networking ability to develop, connect, and use different social networks 4. Having a high level of integrity, sincerity, and genuineness

Des Jardin (2001) notes that nurses, in the role of negotiating and finding moderating points of agreement in political charged areas of concern, are very skilled in negotiating, communicating clearly, solving problems and creating consensus (Boswell, Cannon, & Miller, 2005). Nurses are trusted nationally and internationally and trust is a significant ingredient to assisting with agendas focused on change and consequently to help in making improvements in healthcare and the healthcare system (Boswell et al., 2005; Williams, 1993). Because nurses are active at the point of care with many patients and families it brings them to see their role and act in the capacity to influence changes in policies, laws, or regulations that govern the larger healthcare system (Oestberg, 2013).

Politics are interconnected with policymaking because politicians can control and determine the allocation of resources. To put health policies in place, politicians must agree on the most prevalent health issues and on how to address these issues, as they greatly impact the nation’s health (Porche, 2012). To best serve their patients and best understand their field, nurses and other healthcare professionals are encouraged to be involved in the political process and in the development of health policies.

For the previously mentioned reasons, it is important for healthcare professionals to understand some of the important terms and concepts that are related to healthcare politics and policy. Putting policies in place is a process. Policymaking takes a great deal of effort, time, and commitment. Porche (2012) laid out a dynamic series of events that take place in the policymaking process (Fig. 3.1).

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FIGURE 3.1 Policy cycle.

Setting an agenda: the crucial basic phase when the problem of common interest is identified for a specific community or a group. Three factors were found to play a role in this stage and were identified by Porche (2012): (1) the significance of the problem, (2) the political support for addressing the problem, and (3) the ability to perceive the viability of proposed alternative solutions for the problem. For example, tobacco use is a major contributor to morbidity and mortality, which threaten populations globally. Consequently, governments play a critical role in encouraging or discouraging smoking behavior through different policies along with the role of nurses as political advocates for achieving health improvements. Policy formulation: the stage in which the possible and available alternative policies are identified and a specific policy is selected. Continuing the discussion on tobacco use, all possible and effective policy measures, such as smoke-free indoor air laws, tobacco industry–regulating policies at all levels—state, local, and national—should be addressed and discussed to select the most effective policy in reducing the prevalence of smoking. Policy adoption: the process of selecting the policy that should gain support, power, and directions for the legislators. In order to proceed in the process of fighting tobacco use, all proposed policies need to gain support from stakeholders at the different levels starting from state level and ending at the local level, along with nursing’s role in reflecting and directing the selection of policies. Policy implementation: the stage in which the actual carrying out of the policy takes place by using the available human and financial resources. In terms of tobacco use, in this stage, real application of the anti-tobacco policies takes place when representatives at different political levels, including nurses, start to enhance and reinforce the application of smoke-free environments using all possible resources. Law enforcement is critical in this stage. Policy assessment: evaluation of the implemented policy in terms of being compliant or congruent with the statutory requirements, and whether it really serves the goal of solving the problem. Because the goal of anti-tobacco policies and regulations is to prevent tobacco-related diseases through reducing smoking prevalence, the success of these policies can be evaluated mainly by assessing the extent of achieving

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these goals, along with consideration for cost containment and effectiveness of policy-based interventions. Policy modification: depending on the prior step, the policy can be maintained, changed, or eliminated, according to its level of appropriateness. In this step, a decision takes place either to maintain working according to the anti-tobacco policies or to modify them and replace them, considering other alternative policies, and the process of policymaking repeats itself.

Evidence for Practice

Tobacco use is a major global contributor to illness and is projected to kill more than 1 billion people during this century if present trends continue (WHO, 2008). Nurses are increasingly engaged in community- and policy-level activities to improve health and prevent disease and disability by conducting research that focuses on the tobacco industry and related policies. Malone (2009) conducted a literature review on research studies conducted by nurses on the tobacco industry. The epidemic of tobacco and its health consequences result primarily from the industry’s promotion through marketing to groups who already struggle with health challenges and may have literacy challenges. These approaches undermine public health interventions to address smoking behavior. The notion that smoking is a behavioral choice of individuals creates further barriers to understanding the larger social and political context within which individuals use and attempt to quit tobacco.

Nurses have been among the researchers worldwide who are studying tobacco industry activities and their role in policy and public health. Much of the nursing research to date focuses on four broad areas: (1) the tobacco industry’s influence on policy, (2) its strategic responses to public health efforts, (3) its targeting of marginalized groups, and (4) its influence on research processes and outcomes.

Recommendations:

1. Traditional tobacco prevention and cessation efforts must accompany understanding of the role of the tobacco industry in shaping and contextualizing counseling programs.

2. Nurses need to be prepared to intervene as clinicians, community health proponents, policy advocates, researchers, and educators.

3. Nurses have the political power to influence perceptions about tobacco and the tobacco industry because they are highly trusted by the public and respected by policymakers for their numbers and political savvy.

4. Innovative archival research on the tobacco industry can help nurses reframe tobacco as a nursing issue, and link practices and government policies to their clinical practice.

5. Finally, nurses working in public health and policy arenas can help educate the public about the tobacco industry’s ongoing efforts to encourage tobacco use, with major health consequences.

In the United States, both state legislatures and the U.S. Congress are responsible for determining appropriate healthcare policies. These state and national government representatives work on creating policies to solve problems affecting a specific group, a geographic area, or the entire population (Kraft & Furlong, 2013). These policies usually take the form of legislation, which provides substantial solutions for the health problems that threaten the health and safety of the citizens. This legislation can be achieved by working at either the federal or the state level. Health policy is not a single action but needs a range of legislative and regulatory efforts from ensuring air and water quality to supporting health-related research (Acuff, 2017). Although state legislatures and members of Congress can work collaboratively to solve

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problems and distribute resources, there is often much delay and disagreement between major political parties such as the Democratic and Republican parties (Rice et al., 2013). Because of such disagreements, it is difficult to build an effective collaboration in healthcare policymaking, and this can influence the individual’s access to care and the possibility of improving the quality of care (Rice et al., 2013).

HEALTHCARE FINANCES AND COST–BENEFIT Economics is the study of how individuals, groups, organizations, and society allocate and utilize resources (Porche, 2012). Consequently, it is critical to apply economic tools and various quantitative measures as a method of evaluating the existing governmental programs or public policy alternatives (Kraft & Furlong, 2013). Politics and economics interact at either the microeconomic level, which concerns the allocation of resources at the individual decision- making level, or the macroeconomic level (Porche, 2012). Economically speaking, any process of allocating fiscal resources is usually directed to best meet the human need and to improve their well-being (Kraft & Furlong, 2013). In the health context, for example, if the government spends more on medical visits than is needed to benefit its populations, this will lead to a decrease in resources available for other services such as education. Hence, the role of economics is extremely vital to enforce appropriate, effective, and efficient allocation of resources on the different areas of services provided for populations, and to achieve balance and justice reinforced by policies, laws, and regulation.

In studying health finance, it is critical to understand key terms. In the United States, the gross domestic product (GDP) is the main economic indicator used in the processes of evaluating policies in terms of their contribution to the economic growth. GDP is defined as the final and total output of goods and services produced by labor input within the United States in 1 year as determined by the Bureau of Economic Analysis (USBEA, 2013) in the U.S. Department of Commerce. The GDP figure is reported and released quarterly each year by the BEA. National health expenditure is one of the many components of the GDP, and the growth in health expenditure is usually compared to the GDP. As highlighted by Hartman, Martin, Benson, and Catlin (2013), the total U.S. healthcare spending reached $2.7 trillion in 2011, representing a 3.9% increase from 2010.

There is a set of economic analysis processes used to evaluate economic policy outcomes. The cost–benefit approach has been considered pivotal in evaluating the effectiveness of a treatment or intervention (Sorbello, 2008). It is the most frequently used approach because it serves to illustrate both the strengths and weaknesses of a given policy (Kraft & Furlong, 2013). Consequently, economists were found to be continuously interested in finding answers for the questions such as who gets the benefit and who bears the burden of a policy? How should we measure the values, costs, and benefits of a specific policy? In this type of analysis, economists are concerned with measuring the relative costs (in actual monetary value) against the benefits (both monetary and quality-of-life value) of a given program or any aspect of healthcare (Sorbello, 2008).

Practice Point

Mathematically speaking, the net economic benefit can be calculated by subtracting the costs from the benefits. If this value is positive, this implies that the benefit from a specific intervention exceeds its cost, so a decision is made to adopt such intervention. In contrast, an intervention is judged to be ineffective in terms of its costs if its cost exceeds the benefits

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gained from carrying it out. Although this process seems to be easily accomplished, it is a complicated process when it involves the healthcare system.

As described by Sorbello (2008), cost can be direct, in which the patient as a consumer is supposed to pay these costs at the time of service. For example, direct costs can be supplies or medications. Indirect costs are costs that are not assigned directly to the patient, but are related to the provision of services at the organizational level. Similarly, health benefits or outcomes can vary from simple, direct benefits to more complicated benefits. Outcomes should be objective, measurable, and representative of the treatment interventions, which is not an easy task to calculate, especially if the outcomes need to be expressed in dollars (Kraft & Furlong, 2013). However, less tangible outcomes, such as prevention of long-term suffering or disability, and quality of life, are more difficult to quantify. On the other hand, hospital days or dollars spent in a specific health service, for example, can be easily measured and evaluated.

There is one important process, which should not be ignored in cost–benefit analysis. Economists in their analysis of the costs and benefits must involve the perspectives of the different healthcare components that are participants in providing or receiving this service. Morone and colleagues (2008) explain there are many perspectives that should be considered and satisfied when providing a specific healthcare service. In other words, it is crucial for economists to consider the costs of the people who are counted, the type of costs involved, and the type of outcome that is desired. From the patients’ perspectives, patients usually are more interested in their own costs and benefits. In other words, they are interested in their own expenses and out-of-pocket (OOP) expenses. Patients are also concerned about other types of costs, such as their psychological costs, suffering, and pain, which are difficult to quantify yet have long-lasting negative effects. Regarding the payer’s perspective, the actual payment for the service is usually what matters. The providers are usually concerned with the actual and direct cost of providing a service.

Finally, it is critical to consider the societal concern, which usually includes all direct and indirect costs and benefits at the broader community level regardless of who benefits from or pays for the services. However, using the cost–benefit analysis as the only criterion in evaluating the efficiency and effectiveness of a policy is restricted by the fact that cost and benefits are not distributed evenly among individuals, consumers, or providers (Kraft & Furlong, 2013). In other words, the economic analysis should involve the distribution of costs and accessibility of the benefits in their analysis. Equity will be discussed in the following sections.

In summary, health spending is a product of services and the cost associated with those services. When a policy is evaluated for its effectiveness, there is an interest in keeping the cost of a specific health program within reason. Moreover, there is consideration for the overall costs and benefits of the existing program, in the event a more efficient and effective service is identified.

ACCESS TO CARE AND HEALTH INSURANCE Before discussing access to care and health insurance, it is important first to understand the nature of the U.S. healthcare system, which is a unique system of independent and collaborative powers of both federal and state governments (Morone et al., 2008).

Evidence for Practice

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In a large exploratory study comparing the U.S. healthcare system with that of other countries, Rice and colleagues (2013) highlighted the following facts about the U.S. system:

1. Private sector stakeholders play a stronger role in the U.S. healthcare system than in other high-income countries.

2. The major federal government health insurance programs Medicare and Medicaid were established in the mid-1960s.

3. Medicare provides coverage for seniors and the disabled, while Medicaid covers healthcare services for qualified low-income individuals (also covering limited care needs for qualifying seniors).

4. Public sources constitute 48% of healthcare expenditures in the United States. 5. Private third-party payers pay 40%, with the remaining 12% being paid OOP by

individuals. 6. Only a minority (30%) of the U.S. population is covered by the public financing system,

mainly through Medicare and Medicaid. Currently, 54% of Americans receive their coverage from private health insurance, with most (36%) privately insured individuals obtaining coverage through an employer.

7. One in six Americans is uninsured and over 17% of the population are without health. Because of the Affordable Care Act, the number of nonelderly who was at 10.3% in 2016.

8. Even among those with coverage, high OOP costs can be a barrier to receiving timely care and medications. Many others face high OOP expenses due to underinsurance.

9. The underinsured include elderly individuals who receive Medicare but cannot afford supplemental insurance or the OOP expenses associated with Medicare.

10. Those covered by Medicaid have insurance, but may experience problems accessing primary care due to their inability to find a private physician who accepts Medicaid patients. OOP expenses may also be a factor in inability to access care.

11. Patients in rural areas may find it impossible to get to primary care facilities. Medical costs are responsible for over 60% of personal bankruptcies in the country.

Concerns regarding racial/ethnic minorities, low-income groups, and uninsured groups overlap because of similar barriers these populations experience in accessing healthcare and obtaining quality services. Many low-income and uninsured populations are from diverse racial and ethnic minorities. National programs for improvement of access to quality healthcare for low-income and ethnic and racial minorities in United States are often addressed simultaneously. There are, of course, special issues within each population that need to be taken into consideration. Frequently, community health agencies play an important role in providing access to healthcare for underserved groups, especially those who are uninsured and with low income.

HEALTHCARE WORKFORCE DIVERSITY The United States is a home for individuals from different ethnic backgrounds. Although the numbers are not growing as rapidly as the immigration of ethnically diverse populations, the United States has had an increase in the number of healthcare professionals immigrating to the United States from other countries (Hohn, Lowry, Witte, & Fernadez-Pena, 2016). Workforce diversity can address two important areas of outreach and support to communities affected by health disparities by reducing health disparities themselves and encouraging minority health professionals to work in these areas of underrepresented racial and ethnic minority groups (White, Zangaro, Kepley, & Camacho, 2014). However, the shortage of healthcare providers in

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the United States and the higher pay of health professionals in high-income countries have led to the migration of healthcare professionals from developing countries. In addition to the higher wages in United States, the opportunities for advancement are an incentive for health professionals’ migration to the United States. Although healthcare professionals emigrating from other countries have filled critical vacancies, helped improve culturally competent care, and played important roles in innovations to substantially improve healthcare for hard to reach populations, they have created global challenges to low-resource countries. When nurses’ education was publicly funded or subsidized and then those nurses moved to work in wealthier countries, their countries of origin suffer the loss of intellectual and practice evolution (Li, Nie, & Li, 2014).

Evidence for Practice

The 2016 American Association of Colleges of Nursing policy brief and the 2015 National Council of State Board of Nursing (NCSBN) survey reported that minority nurses represent 19% to 19.5%, respectively, of the total of all registered nurses (RNs) in the United States. The Office of Health Resource Service Administration’s (HRSA) brief on gender and racial/ethnic diversity in U.S. health occupations for 2010 to 2012 describes a rate of ethnic minorities of 21.4% (HRSA, 2015). These estimates are below the almost 40% of ethnic minorities in the U.S. population (U.S. Census Bureau, 2015). According to the 2016 National Healthcare Quality and Disparities Report, released by the Agency for Health Quality and Research (AHQR, 2016), it was reported that in 2015, there were also 2.7 million RNs. In terms of nursing workforce, current estimates show that men are approximately 9% to 11% of the nursing workforce (Budden, Shong, Moulton, & Cimiotti, 2013; HRSA, 2013), while racial and ethnic minorities compose 33% of the U.S. workforce. However, only 25% of the nursing workforce shows a modest increase in racial and ethnic minority nurses (HRSA, 2013). RNs in a recent national workforce survey by the NCSBN were 83% white/Caucasian, 6% black/African American, 6% Asian, 3% Hispanic/Latino, 1% Native Hawaiian or Pacific Islander ethnicity, and 1% other (Budden et al., 2013). The difference in the proportion of white RNs in this study and the 75% proportion reported by HRSA in a recent report (HRSA, 2013) was attributed to the different sampling method, in which the NCSBN drew its sample from RN licensing data and represents all RNs licensed in the United States. Meanwhile, the HRSA sample included currently employed RNs and those seeking employment as RNs (National Advisory Council on Nurse Education and Practice [NACNEP], 2013).

Reports indicate that while 6.7% of the RN workforce was made up of foreign-educated nurses, some states like California, Hawaii, Nevada, New Jersey, New York, and Washington, D.C., were found to have an amount greater than 10% of foreign-educated nurses who are currently practicing (NCSBN, 2015). There has been an incremental increase in nursing workforce diversity for RNs. HRSA reported in a survey that the number of RNs from minority or ethnic backgrounds has grown from 119,512 in 1980 to 513,860 in 2008 (HRSA, 2010). The survey also revealed that while only 65.6% of the U.S. population is white and non-Hispanic, 83.3% of RNs were white and non-Hispanic. RNs from Asian backgrounds were overrepresented at 5.8%, compared to 4.5% of the U.S. population. This imbalance of RNs from Asian ethnicity in the United States can be explained by the U.S. recruitment efforts directed toward RNs primarily from the Philippines and/or India as shown in Figure 3.2. In this survey, in terms of languages spoken, most RNs spoke only English. Only 5.1% spoke Spanish, 3.6% spoke Filipino languages, 1.1% spoke French, and less than 1% spoke Chinese, German, or other languages. There are 165,539 RNs living in the United States who were educated in other countries. This number accounts for 5.6% of the entire licensed RNs workforce in the United States.

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FIGURE 3.2 National Sample Survey of Registered Nurses (HRSA, 2010). (From U.S. Department of Health and Human Services, Office of Health Resources and Services Administration. [2010]. Findings From the 2008 National Survey of Registered Nurses [Chap 8, p. 192]. Retrieved from http://www.hrsa.gov/About/News/Pressreleases/2010/100922nursingworkforce.html.)

Practice Point

In the NCSBN survey, an examination of RNs by job title showed that “nurse executive” and “nurse faculty” roles had the least diversity, while “staff nurse” had the most diversity (Budden et al., 2013). Additionally, newly licensed nurses had a more diverse racial/ethnic composition (NCSBN, 2015). These data illustrate the need for diversity programs that focus on educational and career advancement for underrepresented minority RNs.

As minority populations increase at rapid rates, there is an increasing need for a diverse workforce of healthcare providers who can provide culturally competent care.

Transcultural and cultural competency is very important when addressing needs of diverse multicultural populations. Leininger (1999) defined transcultural nursing as a formal area of study, research, and practice focused on culturally based care beliefs, values, and practices to help achieving the goal of well-being, and prevention of disability in a culturally congruent and beneficial ways. Culture encompasses human beings, religion, kinship, education, technology, language, environmental context, and worldviews, and needs to be integrated into nursing care (Leininger, 1999). As defined by Bearskin (2011), cultural competence refers to the skills, knowledge, and attitudes required to provide care with consideration for various cultural differences. HRSA acknowledged that the most dominant determinant in RN cultural competency is the language used to communicate with the population being served by the RN. Similarly, a number of critical cultural competency interventions were proposed by Betancourt, Green, Carrillo, and Ananeh-Firempong (2003), which included minority recruitment into health professions, development of interpreter services and language-appropriate health educational materials, and education of healthcare providers on cross-cultural issues in order to best address health and healthcare disparities.

Consistently, Purnell has emphasized that healthcare providers must recognize, respect, and integrate clients’ cultural beliefs and practices into health prescriptions allowing for the provider to be culturally aware, culturally sensitive, and have some degree of cultural competence to be effective in integrating health beliefs and practices into plans and interventions (Purnell, 2002; 2012). Purnell added that while cultural awareness has more to do with an appreciation of the external signs of diversity (e.g., arts, music, dress, etc.), cultural sensitivity has more to do with personal attitudes and not saying things that might be offensive to someone from a cultural or ethnic background different from what is considered normal.

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FIGURE 3.3 A, B: Surrounded by registered nurses and legislators, on July 2, 2010, Gov. Deval Patrick signed into law a bill. C: Nurses testifying for one of the bills. (Adopted from the Massachusetts Nurse Newsletter July/August 2010.)

Practice Point

Purnell (2002) has identified cultural competence as having several characteristics that include knowledge and skills as well as the following:

Exploring one’s culture in a context of not trying to change others’ cultures Making the effort to learn about others’ cultures and cultural meanings Tolerating and embracing different ways of knowing and experiencing life by others Making no assumptions about what others believe Avoiding judgements around differences Opting to be available and being comfortable to experience other cultural interactions in persons or events Being versatile with other cultures Cultural competence is an individualized plan of care that begins with performing an assessment through a cultural lens.

It is also clear that cultural competency is required for achieving the aims of public health in the context of the client, individual, family, or community. Because healthcare professionals are involved in the process of policy formation, it is logical that the less diverse the workforce is, the less appropriate and effective the healthcare policies will be for disadvantaged populations. Healthcare professionals continue to report that marginalized (minority) populations experience greater healthcare needs and receive lower quality of care (Bearskin, 2011). As a result, the U.S. Health and Human Services and the Office of HRSA have taken bold steps to increase workforce diversity by providing funds for programs that address this important issue.

Despite all national efforts to improve the diversity of the healthcare workforce, Hunt (2007) reported that managing a racially and culturally diverse workforce is complex and challenging for nurses. He stated, “There are no ready-made tools to show them how to do so…Achieving effective management of a culturally diverse workforce comes from an intrinsic motivation to

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develop the cultural competence to engage with them” (Hunt, 2007, p. 2252).

NURSING’S ROLE IN SHAPING HEALTHCARE POLICY Historical Highlights on Nursing Political Involvement Nurses have long been recognized as patient advocates. Today, more than ever, nurses need to be politically involved personally and professionally in the complex healthcare arena (Fig. 3.3). The process of gaining a position of influence in the legislative arena takes time.

William (1993) argues that the history for nurses being involved in political endeavors started in the mid-’70s and early ’80s when nursing scholars and leaders advocated for political involvement of nurses. Furthermore, debate about nursing involvement in political issues within the profession and in societal issues occurred during 1976 (Powell, 1976). Nursing education efforts focused on legislative involvement at all government levels in this important year of advocacy (Williams, 1977). While Leininger (1978) described the need for political activism within the instruction of nursing students, Cowart and Allen (1981) described the rationale for curricular inclusion of politics and health policy content. Successful legislative lobbying toward healthcare policy formation included the voices of nurses in the 1990s (Milstead, 2013). Since then, organized nursing is included in the debates about healthcare reform. Nursing’s presence in these debates was credited to the many years of public involvement by selected leaders in the nursing profession (Magnussen, Itano, & McGuckin, 2005.) There are many examples of the tremendous influence of nurses on healthcare. Nursing has a rich history of political activists in Florence Nightingale, Lillian Wald, and many others (Selanders, Louise, Crane, & Patrick, 2012).

Evidence for Practice

In a historical literature review of political activism in nursing conducted by Rubotzky (2000), it has been stressed that the years 1992 to 1994 were very influential.

1. Nursing in the United States started 1992 as an assertive, organized professional discipline with the intention of influencing national public policy. Such organized movement resolve was a clear break from the traditional, historical role of this traditionally women’s profession.

2. The subsequent events of 1992 to 1994 illustrate a pivotal story of a discipline becoming an advocate of political signicance, overcoming the barriers of traditional views, organizing as an identiable political interest group, and speaking out with clarity as an advocate for the health of all Americans.

3. In 1993, the newly elected President of the United States, William Clinton, directed the formation of a national Task Force for Health Care Reform, including professional nurses in its membership. In the modern era, there have been outstanding examples of individual nurses as well as

associations throughout the history of the profession who have demonstrated their capacity to shape healthcare by being active in directing healthcare through legislation. Nurses have done this through initiating/revising healthcare goal policy proposals and influencing the implementation of health policy. For example, nurses who wanted to secure state registration for Michigan nurses created the Michigan Nurse Association. It took them over 5 years of lobbying to accomplish their goal and that was before women could even vote

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(Nault & Sincox, 2014).

What Does It Mean to Be Politically Active and Involved? It’s been argued that being personally involved in politics means being active in the political process as a citizen of the country. A good example of personal involvement is voting (Boswell et al., 2005). Nurses have long been recognized as patient advocates. Today, more than ever, nurses need to be politically involved personally as well as professionally in the complex healthcare arena. However, being politically involved means being knowledgeable about issues, laws, and health policy. Nurses need to be both personally and professionally involved but they need to be involved in an informed way more than ever today.

Oestberg (2013) highlighted many important reasons why nurse-informed political involvement is necessary: (1) nurses are direct caregivers, who spend more time with patients than other healthcare providers; (2) nurses come face to face with issues associated with patient safety and satisfaction, access to services, clinical outcomes, and health disparities and (3) nurses are positioned on a daily basis to see not only the impact of health policy on individual patients but also the need for more comprehensive changes in the policies that address many health-related issues. Nursing exists to serve the public. It is a duty to be active politically and work to influence public policy especially when nurses are in a position to be aware of injustices in the healthcare system and the political arena. Nurses have a duty to set an example and become involved (Des Jardin, 2001; King, 2015).

In addition to their clinical expertise, nurses are being sought out to serve in a variety of leadership positions and develop policy recommendations related to a wide range of healthcare policy issues (Dean, 2011). Accordingly, policymakers need to hear nurses articulate their perceptions of needed change in policy or the need to create policy anew because they are in the best position to communicate citizens’ problems and be advocates for individual, family, and community rights and healthcare needs.

As highlighted by Porche (2012), nurses and other healthcare professionals have a rich preparation in knowledge and personal and professional experiences within the healthcare system that enable them to influence the development of health policy. Nurses are experts as clinicians, educators, researchers, and administrators and need to acknowledge and use the power they have in numbers in public policy. Nurses are experts and should use their expertise to translate new worldviews into the policy arena. In the policy arena, they can utilize their knowledge, perspective, experiences, and skills to be change agents for public policy at all levels of government (Leavitt, 2009). Nurses also represent communities and speak as trusted and respected professionals, evidenced by annual surveys, which indicate that the public continues to rate RNs as the most trusted profession on the basis of their professional honesty and ethical standards (Norman, 2016; Williamson, 2017).

Nursing Advocacy and Policy Participation “Nurses are natural advocates, but this advocacy does not stop at the patient and family level. Every nurse has a voice and can lead change locally and globally” (Carol Ann King, 2015, p. 13). Nurses consistently play the role of advocate as they support each patient’s emotional well- being, contribute to the healing process and speak on their patients’ behalf. On the other hand, nurses can use their patient advocacy and political advocacy skills to work in supporting each other and for the nursing profession as a whole (Krischke, 2011). Fulfilling the role of patient and public advocate, requires nurses to support actions that are in the best interest of public health and also that defend patient as well community rights. Therefore, nurses have a

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professional duty to protect many interests (Des Jardin, 2001; King, 2015). As indicated by Milstead (2008, 2013), nurses are experts who can address both the rational shaping of the policy, and the emotional aspects of the process, and should feel morally obligated to advocate for their patients.

“As nursing advocates, we start with the foundation that we are servants to others and stewards of our profession. We choose to lead from that servant position, making sure peoples’ needs are being met through wise and thoughtful interactions.” (Noel, in Krischke, 2011). When nurses act as patient advocates, many of them are referencing to what happens at the point of care. It is often not the case to see oneself as a nurse equipped of able to discuss concerns related to health and healthcare with legislators (Nault & Sincox, 2014). Many nurses today are inspired to take on some form of advocacy to bring about change in the current policies, laws, or regulations that govern the larger healthcare system (Abood, 2007).

How to Be Politically Involved? Nursing as an organized labor force makes up the largest group of healthcare professionals. Because of the extent of their knowledge of health principles and their ability to shape healthcare policy, nurses have a valuable part to play. According to Catalano (2015), political involvement comprises activities, methods, tactics, and behaviors that shape or have the possibility to affect governmental and/or legislative strategies and outcomes. Dealing with numerous concerns daily and other workplace issues, nurses have the choice to motivate themselves to act and find opportunities to bring about change in the healthcare system itself (Abood, 2007). Additionally, nurses can play a leading role in influencing their elected representatives to enact needed changes in healthcare and nursing policy and electing pro- nursing politicians to make sure that nurses and patients have partners at the state level and federal levels in gaining quality, affordable, and accessible healthcare (Artz, 2006).

Practice Point

Oestberg (2013) indicates that nursing and nurses can only be effective if they not only have deep knowledge about how the health system functions (structure and process) but also understand who are the decision-makers in the context of structure and process that can impact policy. In being knowledgeable in these areas, nurses can strategize effectively to impact policy development and change at the local, state, and federal level.

Nurses continuously demonstrate evidence-based care, and they share decision-making with patients and families, resulting in improved quality and reduced cost. Nurses have also been active in the development of public policies as members of the legislative and executive branches at national and state levels (Dean, 2011; Leavitt, 2009). Furthermore, elected officials are selected as representatives and they make decisions based on the information that is shared with them. Therefore, it is critical for nurses to become one of the key sources of information to legislators when the issues with which they deliberate on impact healthcare and the well-being of our population (King, 2015).

Oliver (2012) argued that legislators must make decisions about a large number of issues in a short time frame as they cannot be experts in every field, so they rely heavily on their staffers to research issues and on the experts in those fields with whom they have developed. In the research arena, all nurses engaged in research usually consider the policy implications of their work, and even if the researcher is not the advocate, those who are engaged in workplace,

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organizational policy, or public policy can use research studies to propose policy alternatives and enhance policy modification accordingly (Leavitt, 2009). Evidence-based practice is the gold standard for the interventions used in individual, family and community care efforts. Evidence-based practice examples are needed in nursing advocacy efforts because through research evidence can be gathered to be presented to decision makers about the changes nurses want to see and strive to accomplish (Oestberg, 2013). Nurses have many milestones in policy development as addressed by Leavitt (2009) through their practice and research, which have contributed to (1) quality outcomes, (2) decreases in cost, (3) expanded access, and (4) major differences to the health of the nation. To name a few:

1. The magnet process, which was originated by the American Academy of Nursing (AAN), has been integrated into The Joint Commission’s standards.

2. School-based health centers, as demonstrated by advanced practice and public health nurses, can improve access for underinsured and uninsured children and can reduce some of the disparities in healthcare access.

3. Linda Aiken and colleagues’ groundbreaking research on nurse staffing and the effect on patient outcomes has resulted in laws and regulations that created guidelines for staffing criteria of hospital units in many states (Aiken, Xue, Clarke, & Sloane, 2006).

In terms of policymaking, nurses have the basic vital evidence either supporting or opposing a policy. Nurses can also serve on a personal and professional level in the process of political election to be instrumental in serving the nation’s health (Porche, 2012). They can be members of an organization or a group, which enables them to be involved in agenda setting and the introduction of a specific problem into the national agenda, identifying the goals and tools, and advocating and disseminating health issues through the media (Milstead, 2008).

ADVOCACY ACTIVITIES OF PROFESSIONAL NURSING ORGANIZATIONS Central to all nursing practice is the role of nurses as advocates. Advocacy allows nurses to use their voice of experience to represent patients, families, causes, and professional issues. Nurses who are advocates in these areas often use their moral and ethical decision-making based on principles of fairness and equity and use them to influence political process that can lead to decisions in resource allocation (Matthews, 2012).

The Role of Professional Nursing Organizations The American Nurses Association (ANA) is the only full-service professional organization representing the interests of the nation’s 3.1 million registered nurses through its constituent member nursing associations and its organizational affiliates (Mathews, 2012). The ANA has issued Nursing’s Agenda for Health Care Reform, endorsed by over 60 other nursing groups (ANA, 2010a). Myers (2010) pointed out that the ANA which serves as the strongest nursing organization in the United States, has been engaged in helping its members play a significant role in advocating for their patients by closing the gaps in the healthcare access for patients and their families through testifying at congressional hearings, healthcare summits, and regional forums. For example, nurses who are members of the ANA and their state nurses’ association can apply to participate in the American Nurses Advocacy Institute (ANAI) which focuses on advocacy initiatives and political strategies (Vencill & Lemmons, 2015). Furthermore, ANA works with other health coalitions and advocates for nurses to serve as members of governing

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boards in each state, to advance the role of and recognition of nurses, to prevent potential declines in quality, and to communicate with the Congress in the prevention of harmful changes in Medicare actions (Dean, 2011; Spring, 2013). However, Myers (2010) stated there is a concern that too many nurses have been absent from policy deliberations despite ANA’s calls for advocacy, minimizing the collective power of nurses in the legislative process.

Nursing organizations with legislative departments provide analysis on current issues in health policy and tips on how to communicate with legislators. Many also offer workshops on nursing advocacy, or legislative days at the state house, both excellent opportunities to begin an advocacy career (Oestberg, 2013). For example, the National League for Nursing (NLN) advocates a curriculum revolution and incorporates political activism in their strategic plan (Williams, 1993). The International Council of Nurses (ICN) is a federation of more than 130 national nursing associations where the ANA is the U.S. representative, along with other nursing associations, representing more than 13 million nurses worldwide. The ICN was founded in 1899 as an international center for nurses and other health professionals. The goal of the organization is to assure that quality nursing care is rooted in reasonable and effective health policies through the generation of nursing knowledge (research). The primary focus of this work is to benefit patients, families, communities, and the professional nurse workplace on the global stage (ICN, 2011).

CURRENT SITUATION OF NURSING POLITICAL INVOLVEMENT: CHALLENGES AND BARRIERS Among the challenges that have been identified as negatively affecting nursing’s political involvement include (1) living a fast-paced stressful life in today’s world with not enough time to get involved; (2) heavy workloads with understaffing; (3) a perception of powerlessness; (4) gender issues that often support not being direct but indirect with upset and concerns; (5) fear that political action will create a breach of family time; (6) anxiety with public speaking; (7) complex public policy coupled with lack of knowledge in the legislative process; and (8) fear of retaliation for raising controversial positions related to justice and parity (Des Jardin, 2001). Furthermore, Boswell and colleagues (2005) added that time constraints, lack of resources, political awareness, role modeling, peer support, frustration, and burnout may also lead to minimal political involvement. Last, political involvement is further weakened by role ambiguity, role issues, and role incongruity (Des Jardin, 2001; Oliver, 2012).

Strategies for Nursing Involvement in Policy and Politics There have been many co-authors in the policy arena who have developed strategies to guide nurses to find the best opportunity for policy involvement. Oestberg (2013) highlighted that nurses can make phone calls to elected representatives about bills under consideration, testify before committees, become involved in practice councils or boards at the workplace, and even run for elected office. Oestberg (2013) added that other strategies can include (1) establishing a mentor relationship with an experienced nurse advocate; (2) seeking formal education on health policy or public health, (3) searching for an internship with one’s local or state representative to work on health-related legislation to understand how the system works and gain networking contacts; (4) using local and state resources or national nursing advocacy groups to gain an understanding of current issues and learn about involvement; (5) networking with other nurses to create a unified voice in addition to the elected representatives and their staff by first building credibility with them; and (6) avoiding underestimating personal experiences because legislators like to hear how legislative issues would affect their constituents. An example of nursing

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involvement in policy and passing laws that had a direct impact on the nursing profession is when Governor Patrick signed the Assault Bill announcing a zero tolerance for violence against healthcare professionals, namely nurses.

Practice Point

Nurses as educators have a particular responsibility to teach students how to translate issues into health policy. They can serve as both role models and teachers when there is a need to include political competence and citizenship in the education system (Carnegie & Kiger, 2009). Because nursing roles are interrelated, educators can work with researchers, and administrators can work with clinicians to share their perspectives and diverse knowledge to make tremendous contributions to policy development (Hewlett et al., 2009). Whitehead (2003) highlighted the vital role of the nursing education curriculum as an integral part in achieving many goals for nurses early on in their careers. These goals are: (1) reinforcing and ensuring nursing’s active role in initiating and developing health policy; (2) creating politically involved nurses; and (3) developing nurses who are health policy experts and entrepreneurs. However, he observed that the available literature suggests that the majority of nursing curricula are yet to fulfil this role.

In summary, the nursing profession is one of the largest sectors of the healthcare industry in the United States and has a rich history as a unique profession with its own values, ethics, respect, integrity, and responsibility. Nurses’ opportunities for contributions to healthcare policies are unlimited. As Fyffe (2009) pointed out, there is a need for greater coordination of action to ensure that nursing is represented and actively supported in influencing and shaping health and healthcare policy.

QUALITY OF CARE The healthcare system in the United States is very complex, made up of diverse patients, healthcare providers, and healthcare payers. With patients, providers, and payers constantly interacting for varying reasons and in a variety of environments, it is extremely difficult to evaluate the complexities of the quality of care for the U.S. population. Despite the difficulties in evaluating the quality of healthcare, much is being done by the federal government, U.S. Department of Health and Human Services, the Centers for Medicaid and Medicare Services (CMS), and private institutions and organizations to examine the healthcare system in terms of quality, access, and cost. Mason and colleagues (2012) report several examples as to how efficiently and effectively healthcare systems provide safe patient care to people in need at a reasonable price and with equal distribution. Mason and colleagues (2012) reference the Institute of Medicine report (2001), which lists the following dimensions of healthcare systems that should be considered when quality, cost, and access are examined:

1. Safety: avoiding injury and harm from care that is meant to aid patients 2. Effectiveness: assuring that “evidence-based” care is actually delivered by avoiding overuse

of medically unproven care and underuse of medically sound care 3. Patient-centeredness: involving patients thoroughly in the decision-making process about their

care, thereby respecting their cultures, social circumstances, and needs 4. Timeliness: avoiding unwanted delays in treatment 5. Equality: closing racial, ethnic, gender, and socioeconomic gaps in care and outcomes

Quality of care is defined by the Institute of Medicine (2001) as the degree to which health

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services for individuals and populations increase the likelihood of desired outcomes and are consistent with current knowledge. Additionally, the U.S. Department of Health and Human Services (HHS) defines quality improvement efforts as “systematic and continuous actions that lead to measurable improvement in healthcare services and the health status of targeted patient groups” (AHRQ, 2016).

In demonstrating quality care, patients receive correct assessment and diagnosis, are given appropriate and effective treatment, and are monitored closely.

The Commonwealth Fund Commission on a High Performance Health System (Mongan, 2006) states the following six drivers of high performance in healthcare systems: (1) patient information is available to patients and all providers through health record systems; (2) patient care is coordinated among multiple providers and managed accurately; (3) all providers have accountability to each other and to the patient and collaborate to reliably deliver high-quality care; (4) patients have access to appropriate and culturally competent care and information; (5) accountability is present for the care of patients; and (6) the system is working to improve the quality of healthcare.

In an update on U.S. healthcare quality improvement efforts cited by Harvard School of Public Health, it has been reported that “Healthcare quality in the United States is improving, but there is still a lot that needs to be done. The National Healthcare Quality and Disparities Report (NHQDR) gives one benchmark we can use to assess the impact of current improvement efforts on healthcare outcomes” (Berger, 2015). The report added that the ACA mandated that the National Strategy for Quality Improvement in Health Care established in March 2011 by the Agency for Healthcare Research and Quality (AHRQ) to guide quality improvement efforts at the local, state, and national levels through three key aims (below) and six priorities:

1. Improving overall quality by making healthcare more patient-centered, reliable, accessible, and safe

2. Improving the health of the population by supporting proven interventions to address behavioral, social, and environmental determinants of health

3. Reducing the cost of quality care for individuals, families, employers, and government

Priority 1: Making care safer by reducing harm caused in the delivery of care Priority 2: Ensuring that each person and family are engaged in care Priority 3: Promoting effective communication and care coordination Priority 4: Promoting the most effective prevention and treatment practices for the leading

causes of mortality, starting with cardiovascular disease Priority 5: Working with communities to promote wide use of best practices to enable healthy

living Priority 6: Making quality care more affordable for individuals, families, employers, and

governments by developing new healthcare delivery models

Evidence for Practice

On the global level, quality of care is tracked based on attainment, equity of health outcomes across populations, and fairness of financial contributions. Additional measures include how investments in public health impact social objectives like reducing health disparities, improving health, and providing responsive services that best assist patients (Murray & Frenk, 2010). On the basis of these measures, the World Health Organization (WHO) public health leaders (2010) explained that governments including the Americas on average allocate more to health than the other regions. Americans spend a significant

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amount for health insurance but receive little in terms of quality of care. As described in Chapter 2, comparative evidence has shown that the U.S. healthcare system is gradually slipping behind less-industrialized countries each year, and improvements in healthcare have been slower when compared to other industrialized or developed countries (Murray & Frenk, 2010). Furthermore, the U.S. healthcare system has been deemed broken by many people, with skyrocketing costs and plummeting coverage for middle-class and low-income families (Jacobs & Skocpol, 2012).

In evaluating the extent that the goals and priorities addressed by the AHRQ have been achieved, in 2013 (Berger, 2015), the NHQD found the following:

Half of all patient safety measures improved, with a median improvement of 3.6% per year. There was a 17% reduction in hospital-acquired conditions (including pressure ulcers, falls, and infections), resulting in approximately 50,000 fewer patient deaths and $12 billion in healthcare cost savings. A significant reduction in adverse drug reactions Patient–provider communication improved from 2005 to 2012, with the percentage of adults who reported poor communication with health providers decreasing. Parents also reported a significantly lower degree of poor communication with their children’s health providers. Healthcare facilities saw improved discharge processes and care coordination, facilitated by the adoption of health information technologies such as electronic medical records. A significant increase in the percentage of patients with serious conditions who received complete written discharge instructions. For example, the percentage of heart failure patients who received full discharge instructions increased by 35%. Half of effective treatment measures improved for life-threatening conditions. For instance, from 2005 to 2012, the percentage of heart attack sufferers treated within 90 minutes of their arrival to a hospital increased. The overall performance of 10 other treatment measures improved, leading to better outcomes in cancer, pneumonia, and HIV care. Half of measures of healthy living improved. Adolescent vaccines were among notable improvements from 2008 to 2012—including increases in the percentage of adolescents receiving the meningococcal and tetanus-diphtheria-acellular pertussis vaccines. The recent anti-vaccination movement seems to be reversing this trend. Access and cost barriers to health insurance are being targeted through tax credits, more coverage options within the Health Insurance Marketplace, and cost-sharing reductions. According to the Kaiser Family Foundation, the average U.S. insurance premium increased by 3% in 2014, which is the smallest increase since 1999.

However, the NHQD reported several areas where disparities and gaps were evident in quality: (1) the development of special efforts is under way to address disparities; for instance, only 70% of people with high blood pressure are receiving the recommended level of care; (2) disparities in two areas—hospice care and chronic disease management— increased; (3) healthcare affordability is not yet decreasing; and (4) across all six priorities, disparities still exist according to income, race, and ethnicity.

To overcome this downward spiraling of quality and access to healthcare, it is essential that the United States better evaluate performance of healthcare and compare results with other countries (refer to Chapter 2 comparisons for data supporting this key point) (Murray & Frenk, 2010).

INFORMATION MANAGEMENT As highlighted earlier in this chapter, information management of the U.S. healthcare system must be improved to advance the overall delivery of healthcare. Healthcare experts and the U.S.

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Congress overwhelmingly agree that implementing electronic information systems could greatly improve the efficiency of the healthcare system and the health of Americans (Blumenthal, 2009). In such efforts, U.S. policymakers have adopted the health information technology (HIT), labeled HITECH in law, a high priority through the American Recovery and Reinvestment Act (ARRA) (Jha, DesRoches, Kralovec, & Joshi, 2010). The ARRA offers significant incentives through Medicare and Medicaid funding to physicians and hospitals if they adopt effective HIT and electronic health records (EHRs). Through ARRA, $17 billion in financial aid was used as incentive for doctors and hospitals to utilize EHRs. Physicians who adopt and use EHRs meaningfully can be reimbursed for their services up to $44,000 over 5 years. Similarly, hospitals that effectively utilize EHRs earn an incentive of $2 million through a one-time bonus. Furthermore, HITECH provides $2 billion in assistance to put systems in place and offers grants that assist providers’ installation of EHRs. Physicians and hospitals refusing to implement EHRs face penalties, such as losing a percentage of their Medicare fees (Blumenthal, 2009; Fonkych & Taylor, 2005). HITECH “provisions created an essential foundation for restructuring healthcare delivery and for achieving the key goals of improving healthcare quality; reducing costs; and increasing access through better methods of storing, analyzing, and sharing health information” (Buntin, Jain, & Blumenthal, 2010, p. 1).

The Office of the National Coordinator for Information Technology (Charles, Gabriel, & Searcy, 2015, OCN Data Brief) reported that in 2014, three out of four (76%) of hospitals had adopted at least a basic EHR system which represents an increase of 27% from 2013 and an eightfold increase since 2008 (Charles, Gabriel, & Searcy, 2015, OCN Data Brief). Nearly all reported hospitals (97%) possessed a certified EHR technology in 2014, increasing by 35% since 2011. Fewer hospitals are using basic EHRs without clinical notes, while the systems with more advanced functionality have increased significantly. Additionally, hospital adoption of comprehensive EHR systems has increased 11-fold since 2009, rising to a third (34.4%) of hospitals in 2014 (Charles et al., 2015, OCN Data Brief). Barriers to adopting systems include, but are not limited to, high costs, technical challenges in implementing and maintaining the system, and concerns of privacy (Blumenthal, 2009; Fonkych & Taylor, 2005). Providers who have not implemented an EHR system have difficulty in coordinating care, evaluating quality of care, and avoiding medical errors.

EQUITY IN HEALTHCARE ACCESS AND QUALITY Equity is defined by the Institute of Medicine (2001) as healthcare that does not vary in quality because of gender, race, ethnicity, geographic location, or socioeconomic status. The U.S. Department of Research and Quality (USDHHS, AHRQ, 2007) indicates that significant healthcare disparities exist and the progress in eliminating health disparities is limited. Eliminating health disparities has became a priority of the Barack Obama administration as the U.S. population became increasingly diverse (Mason et al., 2012). Furthermore, insurance rates are rising more rapidly than wages, and middle- and low-income families and employers are having great difficulty affording insurance (Institute of Medicine, 2003).

Schoen, Davis, How, and Schoenbaum (2006) developed a scoring system of equity in the U.S. healthcare system and concluded that there were major inequities in health, quality, access, and efficiency. More researchers have reported that individuals living in low-income communities are associated with significant disparities. For example, researchers found that whites, blacks, and Hispanics with cancer who lived in high-poverty geographic areas, experienced a systematically lower 5-year survival rate. In addition to disparities due to poverty, there were disparities found in terms of race and ethnicity as well. In terms of getting effective and appropriate care, white patients were more likely to receive timely, patient-centered care

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than African Americans and Hispanics. Additionally, African Americans and Hispanics had higher mortality rates than were whites. Researchers went further to explain, “black, Hispanic, low-income and uninsured patients are less likely to have primary care providers to coordinate care, are more likely to experience test results/records delays and duplication, are more likely to go to the emergency departments when other care was not available, and more likely to be admitted to the hospital for potentially preventable conditions, than white, higher-income, and insured patients” (Schoen et al., 2006, p. 472). In summary, because there is an abundance of evidence indicating increased disparities in healthcare delivery when assessed by income, insurance, and race, it is imperative that appropriate efforts continue in reducing health disparities in the United States.

Because of such vast disparities in healthcare access and quality, President Obama made healthcare a priority issue. In March of 2010, President Obama signed the Patient Protection and Affordable Care Act (ACA) into law (Jacobs & Skocpol, 2010). As of late 2018, different measures of the law had been diminished and were being challenged by the Trump administration and a majority-Republican Congress.

COMMUNITY-BASED SERVICES ASSOCIATED WITH HEALTHCARE REFORM Efforts put forth through the ACA, such as the Community Transformation Grant (CTG) program, provide funds to organizations, health centers, and initiatives with goals of creating healthy communities and assisting vulnerable populations (Hennrikus, 2013). The CTG grants fund programs that promote tobacco-free living, physical activity, healthy eating, services to prevent and control high blood pressure and high cholesterol, social and emotional wellness, and healthy and safe environments. It is estimated the CTG program will affect 40% of the U.S. population with health promotion and disease prevention efforts with vast opportunities for nurses to get involved.

Achieving health equity is and must continue to be a priority for this country to move forward. It is critical that nurses stay involved and offer their expertise. Nurses’ involvement with research, advocacy, community outreach, and policy efforts will help underserved populations receive the care that they need and deserve (Mason et al., 2012). Community-based prevention commonly refers to a range of prevention strategies including upstream interventions that address underlying social and economic factors; public policies, including regulations and legislation, that support healthy behaviors; and interventions directed at high-need, low-income neighborhoods (Goodman, 2009).

There is also a critical need to increase the prevention resources available in impoverished communities to achieve the breadth and depth of influence necessary to shift the distribution of risk factors, exposures, and chronic diseases to healthier patterns. Finally, there needs to be better alignment with and support for community programs that have been traditionally viewed as outside of the public health sector but which nonetheless exert a fundamental influence on population health (e.g., early childhood development, income support for families living in poverty, and access to quality schools and educational opportunities). Such interventions create an infrastructure in public health departments to support and implement community-based prevention programs aimed at improving population health (Goodman, 2009).

The website, Healthcare.gov referred to home and community-based services (HCBS) as the services and support provided by most state Medicaid programs in a home or community that give help with such daily tasks as bathing or dressing where such care is covered when provided by care workers or by a family member if permitted. Calman, Golub, and Shuman (2012) have highlighted four vital models that are congruent with the ACA Triple Aim that includes: (1)

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better healthcare for individuals; (2) better health outcomes in the community; and (3) lower healthcare costs. Healthcare reform was designed to address both the quality and accessibility of healthcare while reducing its cost. This article by Calman and colleagues (2012) provides an overview of models that are considered as foundations for healthcare reform and are supported by the ACA and its core principles of primary care: comprehensive, coordinated and continuous primary care; preventive care; and the sophisticated implementation of HIT designed to promote communication between healthcare providers, enhance coordination of care, minimize duplication of services, and permit reporting on quality. These models included:

1. Federally qualified health centers: also, known as community health centers, have been a key component of the primary care safety net in the United States since 1965 and became a focus of the Obama administration’s health-reform plan.

2. Patient-centered medical home (PCMH): describes the model of care in the most advanced primary care centers, focus is on the provision of primary and preventive care by qualied primary care providers, supported by an interdisciplinary team of health professionals. Care must be accessible, high-quality, safe, and efcient, as well as continuous, comprehensive, and coordinated with other healthcare providers as needed. The basic requirements to achieve PCMH recognition include measures in the following areas: (1) access and communication, (2) patient tracking and registry functions, (3) care management, (4) patient self-management and support, (5) electronic prescribing, (6) test tracking, (7) referral tracking, (8) performance reporting and improvement, and (9) advanced electronic communication.

3. Accountable care organizations (ACOs): an initiative supported by the ACA. ACOs are based in part on the models developed between 2005 and 2010 by the CMS demonstration project, the Physician Group Practice Demonstration. Like PCMHs and health homes, ACOs provide a structure for reforms in the way that healthcare is nanced in order to incentivize collaborating organizations to provide better care at lower costs, with the goal of generating both overall savings and greater earnings for the provider organization.

4. Meaningful use: The goals of the meaningful use (MU) initiative are to (1) improve the quality, safety, and efciency of care and to reduce health disparities; (2) engage patients and their families; (3) improve care coordination; (4) improve population and public health; and (5) ensure adequate privacy and security protection for personal health information.

Evidence for Practice

A program designed and implemented in collaboration with a Certified Home Healthcare Agency and regional hospital addresses the serious issue of increasing hospital readmission rates by focusing on transitional care needs of patients and families. The researchers who designed this experiment to see how re-hospitalization could be affected compared the odds of re-hospitalization among patients who received the transitional care services (n = 223) and a similar group of patients who received usual home care services (n = 224). Findings indicate that patients who received the transitional care services were significantly less likely to be readmitted to the hospital than the patients in the control group who received usual care (Russell, Rosati, Sobolewski, Marren, & Rosenfeld, 2011).

ETHICAL CONSIDERATION Nursing has an ethical obligation to society to improve quality of life by maximizing the potential of the individual patient according to his or her needs (Des Jardin, 2001). In that

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capacity, nurses have a duty to support professional nursing goals that relate to healthcare for consumers; yet, each distinct group of healthcare professionals has its own priorities that might not be congruent with the institutional values (Indiana State Nurse Association, 2013). This section will explain how the Nursing Code of Ethics strengthens nursing’s position as an advocate and will describe how professional associations advocate for the nursing profession, nurses, and healthcare for the citizens of the United States.

Practice Point

Des Jardin (2006) states clearly that differences in stakeholder interests puts parties such as nurses, patients, and institutions into a political-ethical clash at times. Guidelines are available to help nurses know how they can be involved in the political process.

By using these guidelines and an ethical framework for political decision-making, nurses can evaluate issues while assessing problems, planning for action, and evaluate the effectiveness and benefits of those strategies effectively.

Individuals have their own moral lens through which they view the world, and where they can judge what is right and wrong. No matter what a nurse’s personal moral views may be, employers establish policies regarding appropriate behavior in the workplace and these expectations are known as organizational ethics, which are defined as expectations about the “right” behaviors for healthcare professionals in the work setting (Indiana State Nurse Association, 2013). An example of such ethics are the standards provided in the Code of Ethics for Nurses (ANA, 2010a). Advocacy by the profession of nursing developed within the United States as visionaries, leaders, and nurses from across the nation formulated the first (and subsequent) revisions of the Code of Ethics for Nurses with Interpretive Statements, often referred to as the Code of Ethics (ANA, 2001). The concluding statement of the Code of Ethics preface states: “…the Code of Ethics is the ethical standard for all members of the profession. No one outside of nursing can alter it” (Mathews, 2012). The ANA Code of Ethics with Interpretive Statements has been updated in later versions (ANA, 2015a, 2015b) and have addressed nine main nursing ethical principles or known as provisions:

1. Provision 1: The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person.

2. Provision 2: The nurse’s primary commitment is to the patient, whether an individual, family, group, community, or population.

3. Provision 3: The nurse promotes, advocates for, and protects the rights, health, and safety of the patient.

4. Provision 4: The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to promote health and to provide optimal care.

5. Provision 5: The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth.

6. Provision 6: The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality healthcare.

7. Provision 7: The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy.

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8. Provision 8: The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities.

9. Provision 9: The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain integrity of the profession, and integrate principles of social justice into nursing and health policy.

It’s noteworthy to address the role of the ANA in the following:

1. The Code of Ethics for Nurses—asserts the values and commitment to excellence for patients, society, and nurses individually and collectively as a profession (ANA, 2015a, 2015b);

2. The Social Policy Statement—details the authority based on the social responsibility of the profession to society. It serves as nursing’s contract between the profession of nursing and society to uphold the highest values and standards in delivering its service of nursing care (ANA, 2010a); and

3. The Scope and Standards of Practice in Nursing—delineates the scope of nursing practice and then defines the standards of professional nursing practice and accompanying competencies (ANA, 2010b).

Healthcare workers encounter complicated ethical issues in their practice, however, and nursing particularly is involved in infinite judgments regarding the morality and immorality of their actions or interventions toward their patient. This has resulted mainly from the radical progress in biomedical sciences and the technological piece of the healthcare, which affects the lives of billions of people throughout the world. Consequently, nurses are required to hold the responsibility of both safeguarding the values of their society and developing their own moral framework for dealing with the moral dilemmas. The role of the nurse as a member of the interprofessional care team is to identify potentially ethics-related situations, work with others to address these issues, and provide holistic support for patients, families, and colleagues. Thus, in order to guide the process of moral decision-making, for example, the Ohio Nurses Association (2013) developed a process to guide RNs in the process of working through ethical ambiguity or dilemmas, which includes the following:

1. Identifying the existence of the ethical dilemma (conflict in values) 2. Gathering and analyzing relevant information—including identification of stakeholders,

interdisciplinary team members, and other sources of relevant information 3. Clarifying personal values and moral position, including the moral perspectives of other

“players” in the scenario 4. Determining options, based on careful consideration of alternatives’ benefits and risks 5. Making responsible decisions about actions or recommendations, in collaboration with other

interested parties 6. Evaluating the impact of the action and outcomes

Evidence for Practice

Technological and societal changes have created both ethical issues and new requirements for nursing education in the context of ethics (Ramos et al., 2013). However, a lack of ethical confidence is reported among newly graduated nurses (Park, 2009). In a qualitative case study conducted by Ramos and colleagues (2013), the participants, who were nursing teachers, expressed that reflection on nurses’ ethics education should take place and that this reflection should not be limited to discussing content or instructional methods but

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should be extended to engage the student in critical analysis of moral scenarios. Students should actively pursue the building of their professional values (Ramos et al., 2013).

As concluded by Park (2009), nursing students have not been prepared to encounter ethical dilemmas in their nursing practice. The author also proposes the need for pragmatic teaching methods as a solution. In other words, planned ethics content in the nursing curriculum is necessary to improve moral sensitivity and moral reasoning of students (Park et al., 2012). Students must also be prepared to adopt different ways of thinking, to be open to the ethical issues by utilizing their absolute professional values and their professional code of ethics, and to apply them by using the lenses of their clients in order to achieve moral sensitivity.

HEALTH ADVOCACY AND HEALTHCARE REFORM The concept of advocacy is both a morally and professionally important duty in nursing practice. This implies that nurses are required to help the patient make decisions according to their personal beliefs and values and to protect the patient’s right through communicating with other healthcare providers (Leavitt, 2009; Park, 2009). Advocacy is a requirement for nurses. Advocacy is collaborating with colleagues or other healthcare professionals and engaging in conversations with decision-makers (Carnegie & Kiger, 2009). Because nurses have the position of communicating, interacting with, and caring for individuals and communities, it is extremely important that they listen to the experiences of individuals, and offer them the opportunity to address, and contribute to policies that affect their health (Carnegie & Kiger, 2009).

Healthcare systems are dynamic. Overall, they have been changing worldwide for decades, particularly in the United States. O’Grady (2009) made it clear that as communities are engaging in complex and dynamic health reforms, nurses are required to develop the language for a healthcare delivery system that is patient-centered, longitudinal and sustainable, relationship- based, and evidence-based. RNs are increasingly being recognized as leaders in transforming the healthcare system to meet the demand for illness prevention, wellness, and primary care services, with special attention to improving quality and managing costs (Dean, 2011).

Prior to the signing of the ACA in 2010, efforts were made for universal health insurance coverage dating back to the 1910s during the presidential campaign of Theodore Roosevelt. Even though such coverage has been established in all other industrial or industrializing nations, healthcare reformers have faced daunting political opposition in attempts at universal coverage in the United States (Jacobs & Skocpol, 2010). Although halted on universal coverage in the 1960s, reformers were able to establish Medicare to help cover costs for the elderly and Medicaid to help cover costs for low-income individuals. After incredible efforts that lasted over a decade, the ACA of 2010 became a monumental milestone but currently may be in jeopardy of being repealed under a new presidential administration and worldview as mentioned previously.

OVERVIEW OF THE ACA PRIOR TO THE END OF OBAMA PRESIDENCY Generally speaking, health insurance is a contract that requires the health insurer to pay some or all of one’s healthcare costs in exchange for a premium (Centers for Medicare and Medicaid Services [CMS], 2017; Healthcare.gov, 2017). The comprehensive healthcare reform law enacted in March 2010 (sometimes known as ACA, PPACA, or Obamacare), has two parts: (1) the Patient Protection and Affordable Care Act and (2) the Health Care and Education Reconciliation Act. The ACA is designed to address these concerns by improving the quality and accessibility of healthcare while reducing its cost. First articulated by the Institute for

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Healthcare Improvement as the Triple Aim and later by the CMS as the Three-Part Aim, the goal of the ACA is to achieve better healthcare for individuals, better health outcomes in the community, and lower healthcare costs.

In May 2017, among the 48 states reporting both total Medicaid and CHIP enrollment and child enrollment data for the current period, total enrollment was comprised of 50.3% enrolled in the Medicaid child and CHIP, while 49.7% of adults were enrolled in Medicaid. Medicaid provides health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults and people with disabilities. Medicaid is administered by states according to federal requirements. The program is funded jointly by states and the federal government. Sixty-nine million people are covered. On the other hand, Medicare is a health insurance program for people age 65 or older, people under age 65 with certain disabilities, and people of all ages with end-stage renal disease (permanent kidney failure requiring dialysis or a kidney transplant). Medicare has three parts:

1. Part A hospital insurance—Most people don’t pay a premium for Part A because they or a spouse already paid for it through their payroll taxes while working. Medicare Part A (hospital insurance) helps cover inpatient care in hospitals, including critical access hospitals, and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home healthcare. Beneficiaries must meet certain conditions to get these benefits.

2. Part B medical insurance—Most people pay a monthly premium for Part B. Medicare Part B (medical insurance) helps cover doctors’ services and outpatient care and some other medical services that Part A doesn’t cover (e.g., services of physical and occupational therapists) while Part B helps pay for these covered services and supplies when they are medically necessary.

3. Prescription drug coverage—Most people will pay a monthly premium for this coverage while everyone with Medicare can get this coverage that may help lower prescription drug costs and help protect against higher costs in the future. Medicare prescription drug coverage is insurance that is provided by private companies. Beneficiaries choose the drug plan and pay a monthly premium.

Through the Patient Protection and ACA, the Obama administration’s goals in improving the overall healthcare system and the quality of care included expanding health insurance coverage, shifting the focus of the healthcare delivery system from treatment to prevention, and reducing the costs and improving the efficiency of healthcare (Hellerstedt, 2013). The ACA was put in place to improve the quality, access, and affordability of healthcare. “The American College of Physicians hopes that the legislation will advance key priorities on coverage, workforce, and payment and delivery system reform” (Doherty, 2010, p. 679).

Additionally, the ACA expanded healthcare access to children (Oberg, 2013). Through the ACA, youth are allowed to remain on their parents’ healthcare plan to the age of 26, insurers are no longer allowed to exclude children from coverage because of preexisting conditions, and access had been expanded through state-based health insurance exchanges for uninsured families (Oberg, 2013). Medicaid and Children’s Health Insurance Program (CHIP) provisions have been administered through the ACA with goals of enrolling uninsured children. Such reforms will work to insure vulnerable childhood populations like children aging out of the foster care system (Oberg, 2013). Furthermore, reforms in healthcare for children will help reduce the cost of healthcare for families so that more children will be covered.

The U.S. Department of Health and Human Services, AHRQ (2012) reported that although indicators have shown that quality of healthcare for the general population is improving, quality of care is still not up to par for minorities and low-income communities. Furthermore, although the ACA has made strides for healthcare for all, an estimated 49 million Americans are still

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without health insurance (Hellerstedt, 2013).

Evidence for Practice

There has been considerable debate on repealing, replacing, or updating the ACA by President Donald Trump and his administration as well as members of the Congress. The proposed revised version of the ACA was reviewed by the Congressional Budget Office (CBO) and concluded that the new proposed version of the ACA would reduce the deficit by $337 billion in the next 10 years due to removal of premium tax credits and cuts in Medicaid. However, if the revised bill is enacted, it is estimated that 24 million people will lose health coverage by 2026. On March 24, 2017, the Speaker of the House of Representatives withdrew the ACA repeal-and-replace bill and stated that the ACA will be left intact for the time being. On March 6, 2017, House Republicans announced a bill to partially repeal and replace the ACA. There remains disagreement among members of Congress as to the details of the bill.

Next Steps

1. Elimination of additional Medicare taxes There has been considerable discussion about repealing the additional Medicare tax, which imposes additional tax to individuals with high incomes. The repeal of the current bill will have considerable payroll implications. Effective January 2018, the bill would repeal the additional Medicare tax that imposes an additional tax on income of $200,000 or more for individuals, $250,000 or more for joint returns, and $125,000 or more for married taxpayers filing separate returns. This would have payroll implications as employers have been required to withhold an additional 0.9% of Medicare subject wages over $200,000 to support the additional tax.

2. Premium tax credits and subsidies repealed The proposed bill would eliminate premium tax credits for individuals who obtain health insurance through a federal or state health insurance marketplace (exchange) as of January 1, 2020. It would also repeal cost-sharing reductions (and payments to issuers for such reductions) for plan years beginning after December 31, 2019. More changes have included the following areas as well:

3. Health insurance tax credit 4. Continuous coverage 5. Elimination of other ACA taxes

For more information on the ACA updates, please visit https://www.paychex.com/articles/health-reform/aca-update-march-2017.

Evidence for Practice

In measuring the equity of healthcare and in working on reform, it is also important to review the effects of social determinants of health, which include early childhood education, employment opportunities, treatment of women, the effects of poverty, and individual empowerment on humans’ health status and life expectancy (Wilensky & Satcher, 2009). The WHO’s Commission on the Social Determinants of Health was created in 2005 to focus on the social determinants as a means of reducing health disparities (Wilensky & Satcher, 2009). This group explains that healthcare reform must focus on nutrition, education, reducing substance abuse, and access to care. In the United States, the following four

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components have been, or need to be, addressed in the following ways:

1. Nutrition: Over the years, the federal government has put in place systems that work to improve nutrition for low-income communities such as the federal food stamp program and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC and SNAP, respectively).

2. Education: Programs like the No Child Left Behind Act and the Action for Healthy Kids Program work to help low-income students by providing additional academic support and proper nutrition and physical activity.

3. Reducing substance use: Because many children are born with medical challenges due to their mother’s substance abuse, more aggressive intervention must be put in place to help pregnant women deal with substance abuse. Programs for mothers should be free to those who cannot afford them.

4. Access to care: Medicaid and the State Children’s Health Insurance Program (SCHIP) were put in place to ensure low-income children were provided with appropriate care. Although such systems were put in place, many children who are eligible are not enrolled. More aggressive outreach campaigns must be established to educate families on the care they are eligible to receive.

HEALTH SERVICES RESEARCH Although the ACA has been passed and efforts to improve healthcare are increasing, the quality of healthcare and services has not improved significantly. Researchers, healthcare professionals, and other advocacy groups continue to push for an improved healthcare system in the United States with appropriate health services for all, and to do this, the healthcare system needs an accelerated transformation, which brings about quality care, proper information management, insurance for all, and equity to access (Dougherty & Conway, 2008). Dougherty and Conway (2008) proposed a model to transform the U.S. healthcare system, explaining how to deliver high-quality healthcare. Their plan outlines the activities, participants, investments, and fundamental shifts required to create and sustain a high-quality, patient-focused, healthcare system. Porter (2009) lists the following steps that must take place to improve the U.S. healthcare system:

1. Measurement and dissemination of health outcomes must be shared. 2. The delivery of prevention, wellness, screening, and routine health maintenance services must

be fundamentally restructured. 3. Care delivery must be reorganized around medical conditions. 4. A reimbursement program for healthcare professionals as incentives to achieve better

outcomes for patients should be introduced. 5. Providers must compete for patients based on the quality of the care provided. 6. All providers must establish electronic medical records. 7. Patients’ involvement in their health must improve and incentives for patient involvement

should be considered.

Porter explains that all items must happen simultaneously to build an effective healthcare system. Conway and Clancy (2009), in speaking of improving the healthcare system on the front line, emphasize the importance of improving measurements, adopting information technology, accelerating the production and use of requisite research, improving collaborations and networks, and increasing clinical training. Taking such action, Conway and Clancy claim, may significantly improve clinician engagement and patient care.

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CONCLUSION At this moment in history, healthcare is at the forefront of the public’s attention. As an item on the President’s platform, as the most popular topic on the news and radio, and as an issue greatly impacting individuals and employers, healthcare is an important topic, which is receiving attention from everyone. During this significant moment in the history of healthcare, nurses play an important role in providing quality healthcare, tracking patient progress, and being active members in healthcare reform. It is important that nurses are knowledgeable about health policy, politics, and healthcare reform because it will improve their understanding about where they work, the patients they care for, and government efforts that will impact both.

KEY CONCEPTS Because policy development and formulation is concerned with providing population-based interventions which will greatly impact the nation’s health, the political process has a close relationship with health policies. Making health policy takes great time, effort, and commitment. This process is presented as a dynamic and cyclic series of six events, namely, agenda-setting, policy formulation, policy adoption, policy implementation, policy assessment, and finally policy modification. When a policy is evaluated for its effectiveness, there is an interest in keeping the cost of a specific health program within reason, and it is critical to consider the overall costs and benefits of an existing program when a more efficient and effective service is identified and adopted. The U.S. healthcare system is a unique system of both independent and collaborative power and action by both federal and state governments. Healthcare issues of racial and ethnic minorities, low-income individuals, and the uninsured overlap. Community health agencies play an important role in providing access to healthcare for those who are underserved, whether from uninsured or low-income communities. The United States has an increasing healthcare professional immigration from other countries. There is an increasing need for a diverse workforce of healthcare providers who can provide culturally competent care for the growing minority population. The less diverse the workforce, the less representative and influential will be the impact of the healthcare providers on healthcare policies. Nursing has a rich history as a unique profession, with its own values, ethics, respect, integrity and responsibility. Nurses’ contributions to the policies are unlimited; there is a need for greater coordination of action to ensure that nursing is actively supported and involved in influencing and shaping health and healthcare policy. It is extremely difficult to evaluate the complexities of the quality of care for the U.S. population. U.S. policymakers have made the adoption of HIT a priority so that health records can be kept electronically, assisting patients, providers, and insurers. Because of the vast disparities in healthcare access and quality, President Obama made healthcare his top priority, promising affordable and adequate healthcare insurance for all Americans. Healthcare is closely linked with ethical issues and decisions and has implications for patients, providers, and healthcare leaders. Although most politicians agree a reform must take place, many cannot agree on what the change should look like. Consequently, healthcare reform in the United States has been a long political battle for quite some time. Research continues to be an influencing power by documenting the need for an accelerated reform in order to achieve quality care, proper information management, and insurance for all, and equity to access.

CRITICAL THINKING QUESTIONS

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1. Consider that you are a nurse working with a patient who is from a different cultural and ethnic background from your own. Explain how you could translate the concept of cultural competency into practice. Do not forget ethical considerations.

2. After reading this chapter, you have learned about the six stages of the process of policy. Give at least one example showing how nurses can be engaged in each stage of the process.

3. You have read a lot about President Obama’s Patient Protection and Affordable Care Act: a. What are the major milestones of this act that represent the healthcare reform? b. Explain how this act helps in delivering better healthcare services. c. Explain why this act has been considered a long political battle for a period of time.

4. You have learned about health information technology (HIT) in this chapter: a. Give a few examples for the application of HIT in the clinical practice. b. Explain the main barriers of using HIT in the healthcare system. c. How has the American Recovery and Reinvestment Act (ARRA) reinforced the use of HIT in different

healthcare settings? 5. How can research help in improving the U.S. healthcare system? 6. After carefully reading about Rice’s exploratory study regarding the U.S. healthcare system, summarize in

a short paragraph the major problems in this system. 7. Please visit this website https://www.healthypeople.gov/2020/topics-objectives and answer the following

questions: a. What is the role that the Healthy People 2020 initiative plays in healthcare reforms? b. What are the objectives that include professional nursing activities? c. How do you relate this to healthcare reforms and quality improvement?

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

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Chapter 4 Global Health: A Community Perspective Joyce Pulcini and Karen Dawn

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

It is health that is real wealth and not pieces of gold and silver. Mahatma Gandhi

Of all the forms of inequality, injustice in healthcare is the most shocking and inhumane. Martin Luther King Jr.

CHAPTER HIGHLIGHTS Definitions of global health and global burden of disease Indicators of health Health and human rights Factors that affect health globally Framework for improving world health Sustainable Development Goals

OBJECTIVES Identify critical determinants of global health and the intersection between health and the environment. Describe the approaches to achieving maximum health outcomes in poor countries and affluent countries. Define the concept of burden of disease, how it is measured, and the ultimate effect on a population’s health. Identify and explain the effects of political, economic, and sociodemographic factors on health. Describe the purpose of the Sustainable Development Goals and their future impact on improving global health. Describe key indicators of health that can be measured or used as benchmarks to examine the health outcomes of a population.

KEY TERMS Communicable disease: An illness caused by an infectious agent or its toxins that occurs

through the direct or indirect transmission of the infectious agent or its products from an

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infected individual or by an animal, vector, or the inanimate environment to a susceptible animal or human host (Centers for Disease Control and Prevention, 2010).

Demographic and epidemiologic transitions: Progressive improvement in health from a global perspective.

Determinants of health: Factors that affect outcomes of health status, such as physical environment, social environment, health behaviors, and individual health, as well as broader factors such as access to health services and overall health policies and interventions.

Global burden of disease: The importance of risks to health and their outcomes in different demographic populations and social settings.

Global health: “An area for study, research, or practice that places a priority on improving health and achieving equity for all people worldwide. Global health emphasizes transnational health issues, determinants, and solutions, involves many disciplines within and beyond the health sciences, and promotes interdisciplinary collaboration, and is a synthesis of population-based prevention with individual-level clinic care” (Koplan et al., 2009).

Health: A state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity.

Health indicators: Descriptors of the general health of a nation that are grouped into four categories: morbidity and mortality, risk factors, health service coverage, and health system resources.

Noncommunicable disease: Diseases that afflict a population which are chronic in nature and may be due to lifestyle changes, sometimes as a result of modernization of societies. Examples include cardiovascular diseases, cancers, diabetes, obesity, and chronic respiratory diseases.

Risk factors: Personal habits and behaviors, social, and environmental conditions, or inborn or inherited characteristics that are known to affect a health-related condition which could be alleviated or managed.

Public health: Ensuring that every person in the community has a standard of living adequate for the maintenance of health. This involves the science and art of preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts.

CASE STUDIES

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

CASE 1 Haweeyo is a 30-year-old woman living in extreme poverty just outside Mogadishu. She is pregnant by a man who sexually assaulted her several months ago. She reported the incident to the police but they did nothing. In her culture, pregnancy without marriage carries great stigma and shame. She and her family have become social outcasts in their community and are having difficulty finding work and paying for food. Haweeyo received threats of violence repeatedly by people in her community and was taken from her home and severely beaten 2 days ago. Haweeyo has received no prenatal care and did not seek treatment for her injuries because she feared she would be treated poorly by the health providers. A few hours after being attacked by her neighbors she went into early labor and her sister called the birth attendant. As her labor continued, the community health worker (CHW) birth attendant recognized the labor was complicated and needed to get Haweeyo to the hospital to deliver her baby. Her family did not have funds or transportation to get her to the city hospital. Haweeyo died in her own home a few hours later.

CASE 2 Vikram is a 68-year-old father of seven children, who shares a small home with his wife, three of his adult children and their families, his mother, and older brother in India. He is recently recovering from a third episode of diarrheal illness in the past 3 months. He experienced weight loss of almost 20 lb in 4 weeks, complained of feeling fatigued most of the time, shortness of breath, persistent

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cough, night sweats, and low-grade fever. Two years ago, he was diagnosed with tuberculosis. He took medications for a short time, but due to lack of finances and availability of the medications he stopped. Vikram visited the small health clinic where he was seen by the only medical practitioner in the village. With no x-ray facilities available, a TB skin test (TST) was performed and he was sent home. Three days later he returned to the clinic. The skin test was positive and TB was confirmed by a sputum smear test. While at the health clinic he was also tested for HIV, which was negative. He was started again on TB medications, but developed multidrug-resistant tuberculosis (MDR-TB) and subsequently his condition deteriorated.

e live in a global environment. Recent examples of how health in one region of the world affects other regions include both the Ebola epidemic and Zika infections. News of both of these infections have spread rapidly through world news and are

exacerbated by widespread global migration. What does it mean to be healthy in a global context? A person’s health status is highly

dependent on his or her living environment, social norms, gender, and age, specifically in low- resourced settings. Access to and utilization of healthcare is highly dependent on where you live in the world and the community definition of health. In addition, the health of individuals depends on the social and economic conditions in which they live. Many factors affect the health and well-being of individuals. This chapter explores an array of factors that affect health and the global environment.

DEFINITIONS OF HEALTH The World Health Organization (WHO) in 1947 defined health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” (WHO, 1947, p. 1). The WHO definition of health encompasses the highest level of health, involving self- actualization or reaching one’s true potential. The more specific concepts of public health or global health may be important when the concept of an individual’s health is considered. All are interrelated in a global context.

Winslow (1920), often called the father of public health, defined public health as “the science and art of preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts for the sanitation of the environment, the control of community infections, the education of the individual in principles of personal hygiene, the organization of medical and nursing service for the early diagnosis and preventive treatment of disease, and the development of the social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health” (p. 23). The identification of nursing in 1923 as a key participant in the social construct of health recognized the contribution that nurses could make to promote health and well-being of all humankind.

Dunn (1959) placed health on a continuum, ranging from premature death to wellness to high-level wellness, which can be equated to self-actualization. In this model, the environment (i.e., factors outside of the person) plays a major role in health (Fig. 4.1)

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FIGURE 4.1 The health grid, its axes and quadrants. (From Dunn, H. [1959]. High-level wellness for man and society. American Journal of Public Health, 49[6], 788.)

In her classic work, Smith (1981) identified four models of health:

1. Clinical model: elimination of disease or symptoms. Some people feel that they are well when they have no symptoms or diagnosed diseases and would not classify themselves as sick otherwise.

2. Role-performance model: health that involves a match between people and social roles. For example, some people, even if they have symptoms of disease, would classify themselves as unhealthy only if they could not fulfill their roles in life, such as parent or worker.

3. Adaptive model: health that involves adaptation to the environment. For example, some people consider health to be determined by their ability to adapt in the face of adversity or disease.

4. Eudaimonistic model: health that is the actualization or realization of human potential. In this model, for example, people would consider themselves to be healthy if they are functioning not only physically but also emotionally and socially. The WHO (1947) definition of health actually strives for this level of health.

Global health was defined by the Institute of Medicine (IOM, 1997) as “health problems, issues, and concerns that transcend national boundaries and may best be addressed by cooperative actions and solutions” (p. 2). Each of Smith’s four models can be viewed within the definition of the IOM and includes people’s definition of health based on their culture, role in life, and environmental resources. A person’s definition of health determines how and when he or she seeks assistance from the healthcare system and may ultimately affect the outcome of long-term health.

The evolution of the definition of health clearly shows an increased appreciation of the biophysical, sociodemographic, and environmental influences on individual, family, and community health. Health is a complex concept that can be conceptualized in many ways, from a broad to narrow disease-specific view. Further, complexity comes into play when the social, political, and economic conditions are factored into the equation.

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In each of these case studies, internal factors—the way a person views health—and external factors outside of the individual such as the environment, affect whether a person is viewed as healthy, unhealthy, or at risk. The way women view health, in particular pregnancy, can affect birth outcomes. Environment is key and ultimately changes the context in which health or illness conditions are experienced or played out. When dimensions of poverty, education, culture, lifestyle, norms, beliefs, and political and economic instability are added to the equation, it is possible to further understand the complexity of the concept of health and its determinants.

GLOBAL HEALTH CONCEPTS Determinants of Health Global health is a dynamic concept with many components. In examining this concept, several factors need to be considered. Skolnik (2016) identifies the key determinants of health, which encompass the following domains: (1) physical environment; (2) social environment; (3) health behaviors and coping skills; (4) access to health services; (5) healthy child development; and (6) employment and working conditions, in the context of the broader factors of access to health services, as well as health policies and interventions (p. 21).

Demographic and Epidemiologic Transitions

When it comes to global health, there is no “them”…only “us.” Global Health Council

Demographic and epidemiologic transitions refer to the improvement in global health indicators (WHO, 2013a). Changes in these demographic indicators signify improvement in health over time. In addition, specific indicators provide a unique picture of community health: life expectancy and morbidity and mortality, selected infectious diseases, health service coverage, health systems expenditure and inequities, and demographic and socioeconomic statistics (WHO, 2014a). They include many factors, such as age, gender, socioeconomic status, and disease prevalence, and taken together, they can portray the health of a community and identify areas in need of intervention.

In addition, these indicators are tracked by the demographic and health survey (DHS) program, which is conducted at the household level to evaluate the health of a nation (United States Agency for International Development, 2014). Every 3 to 4 years, a DHS is conducted to describe the health of a country and define specific demographics that can be compared to each other. These transitions are used as a measure of health improvement of a nation.

Demographic transitions may progress from low to high levels:

1. High fertility and high mortality, resulting in slow population growth 2. Improvement in hygiene and nutrition, leading to less infectious disease 3. Mortality declines, and later fertility declines 4. Elderly population increases

Epidemiologic transitions include the following:

1. High and fluctuating mortality, due to poor health, epidemics, and famine 2. Progressive declines in mortality, as epidemics become less frequent

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3. Further decline in mortality, increasing life expectancy, and predominance of noncommunicable diseases (NCDs)

As a country becomes more developed, levels of demographic or epidemiologic transitions shift upward. For example, as mortality rates decrease, more attention can be paid to increase the quality of life of all citizens, including the elderly. As the number of children involved in agrarian functions decreases and as the need for formal education increases, fertility rates tend to decrease. As more members of a population are educated, indicators of health, such as higher life expectancy and lower mortality rates, improve.

Global Burden of Disease

Every observer of human misery among the poor reports that disease plays the leading role. Fisher (1909, p. 124)

Global burden of disease (GBD) is the risks to health and health outcomes in different demographic populations and social settings related to a set of diseases and injuries. There are 18 components of GBD that are interrelated and create the changing picture of burden related to specific communities (Institute for Health Metrics and Evaluation, 2014). The largest study of these indicators was published in 2012, revealing that women and men are living longer but spending more time living with illness and injury (Horton, 2013). The collection of specific data related to risk factors, health indicators, and health outcomes of 291 diseases and injuries in 20 regions of the world determines the GBD (Murray et al., 2012). Indicators include lower respiratory tract infection, diarrheal disease, malaria, and protein malnutrition as well as road injuries and pollution (Institute of Health Metrics and Evaluation, 2014). Changes in these factors can identify areas of improvement or the need for intervention. The goal of analyzing these data is to summarize measures of a population’s health and to identify risk factors that affect health. The concept of disease burden first occurred in the early 1980s, when the World Bank signaled the need for a better understanding of disease control and mortality to set priorities for resource-limited countries. In an era of unmet needs, economic divisions, and health inequalities, the need for rigorous data for decision-making despite limited resources was, and still is, vital (Lopez, Mathers, Ezzati, Jamison, & Murray, 2006). Examining the effects of health indicators and risk factors on the overall health of a community can guide healthcare planners and providers in choosing those services and interventions that can improve health.

As health policymakers and governments better understood the impact of disease, the need for an analysis of the circumstances grew. In 1990, the World Bank commissioned the first study on disease burden (World Bank, 1993). In 1994, Jamison and Jardel (1994) incorporated the concept of cost–benefit analysis related to disease burden to assist countries in decision-making about health interventions. Murray and Lopez (1996) edited a publication called The Global Burden of Disease. All of these reports later influenced the ongoing analysis by the World Bank, as well as work by the Fogarty International Center at the U.S. National Institutes of Health and the Bill and Melinda Gates Foundation, to form the Disease Control Priorities Project (DCPP). The project’s purpose has been “to review, generate, and disseminate information that contributes to the scientific evidence base for improving population health in developing countries” (DCPP, 2008, p. 1). Murray and colleagues (2012) compared data on disease and injury from 1990 through 2010, providing a longitudinal assessment of effects of disease and injury on specific populations. Integrating collected health data, using evidence that supports the data, and applying to disease outcomes is paramount to improving global health.

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Noncommunicable Diseases In 2012, the World Health Assembly endorsed an important new health goal: to reduce avoidable mortality from noncommunicable diseases (NCDs) by 25% by 2025 (the 25 × 25 goal) (Alleyne et al., 2013). The Global Burden of Disease and Risk Factors study built upon earlier versions, providing a comprehensive analysis of the health of the world’s population, including health indicators for disease outcomes, as well as risk factors and monitoring strategies that can be used for program planning to improve health outcomes (Murray et al., 2012).

While communicable disease is still prevalent, 70% of all deaths globally are caused by NCDs. Four common behavioral risk factors that occur globally—tobacco use, excessive alcohol consumption, poor diet, and lack of physical activity—are associated with four health diseases— cardiovascular disease, cancer, chronic pulmonary disease, and diabetes that account for 80% of deaths from NCDs (Hunter & Reddy, 2013, WHO 2017a). Clearly, the leading causes of mortality and burden of disease worldwide have shifted from communicable to NCDs. This change represents an opportunity for communities to address behaviors that can affect overall health (Fig. 4.2). When examining the GBD chart, many diseases can be ameliorated through health promotion, education, and the provision of skilled healthcare (Box 4.1).

According to the WHO Global Status Report on Noncommunicable Diseases (2014b), of the 56 million global deaths in 2012, 38 million, or 68%, were due to NCDs, the most prominent of which were cardiovascular diseases, diabetes, cancers, and chronic respiratory diseases. Nearly 15 million of all deaths attributed to NCDs occur between the ages of 30 and 69 years and 80% of these deaths from NCDs occur in low- and middle-income countries (Lozano et al., 2012). The report states that, “almost three quarters of all NCD deaths (28 million), and 82% of the 16 million premature deaths, occur in low- and middle-income countries” (WHO, 2015, p 1). Low- income countries are mostly situated in middle Africa, but middle-income countries include most of Central and South America, Eastern Europe, and Asia. While NCDs are still not the most frequent causes of death in African nations, these diseases are rising rapidly and are projected to exceed communicable, maternal, perinatal, and nutritional diseases as the most common causes of death by 2030 (Southern African Development Community, 2012).

More than half of all cancer deaths occur in developing nations (Cancer Research U.K., 2014). NCDs also cause death at younger ages in low- and middle-income countries. For example, 29% of deaths due to NCDs in low- and middle-income countries occur among people under the age of 60, compared to 13% in high-income countries. A WHO report (2011) stated that the estimated percentage increase in cancer incidence by 2030, compared with 2008, will be greater in low-income (82%) and lower–middle-income countries (70%) compared with the upper–middle-income (58%) and high-income countries (40%).

Key factors in the rise of NCDs are similar in all countries, and the diseases are often preventable (Box 4.2). In low- and middle-income countries that are now seeing increases in the rate of NCDs, the process is accelerated by urbanization, culture change especially among the young, increasing sedentary lifestyles, and corporate marketing that targets these populations. One might see older populations still eating more healthy traditional foods, and younger populations lured in by fast food marketing, for example. Recommendations are being made, especially in low-resource settings, for increased surveillance and reporting of these diseases as well as increased efforts to educate the public on this important health area. NCDs play an important role not only on their effect on individuals but also on social, economic, and environmental factors that affect human development (Alleyne et al., 2013; WHO, 2017a).

An important factor in the increase in NCDs is also the aging of the global population. As we look to the future, the combination of aging and increased NCDs is likely to cause a higher disease burden.

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The Impact of Disease Burden The burden of disease is growing disproportionately in the world and is largely affected by climate, public policy, aging of the population, socioeconomic conditions, and risk factors (Fig. 4.3). Most of the countries burdened by disease have the least amount of human and economic capacity to effect change (Farmer, Furin, & Katz, 2004). Sub-Saharan Africa is unique in having an overwhelming share of the disease burden related to poverty and people living with HIV/AIDS (United Nations, 2012).

Women are disproportionately affected by the disease burden related to reproductive health and HIV infection (Hawkes & Buse, 2013). Globally, an estimated 830 women die daily from complications of childbirth (WHO, 2016a). Many of the complications resulting from childbirth can be prevented with the use of skilled midwives and nurses at birth. When a mother dies or is disabled, her children may be forced to live in poverty. Addressing the causes of these health discrepancies with education, specifically education for girls, and creating integrated health programs, such as HIV treatment and prenatal care, will improve the quality of care and thus decrease the disease burden (Potter et al., 2008; UNAIDs, 2017). Girls and young women aged 15 to 24 years are twice as likely to become infected with HIV and account for 22% of new HIV infections (United Nations AIDS, 2013). Women now comprise 51% of individuals infected with HIV worldwide (amfAR, 2016). Of adults living with HIV in sub-Saharan Africa, 58% are women, compared with 26% in North America. HIV/AIDS is the leading cause of death among women of reproductive age (aged 15 to 44) (amfAR, 2016).

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FIGURE 4.2 The leading causes of death worldwide. (Institute for Health Metrics and Evaluation. [2017]. University of Washington. Retrieved from https://vizhub.healthdata.org/gbd-compare.)

4.1 Top 10 Facts According to the Global Burden of Disease

Fact 1: Global average life expectancy increased by 5 years between 2000 and 2015, the fastest increase since the 1960s.

Fact 2: Globally, healthy life expectancy (HLE) at birth in 2015 was estimated at 63.1 years. Fact 3: In 2015, more than 16 000 children under age 5 died every day. Fact 4: 45% of deaths among children under age 5 occur during the first 4 weeks of life. Fact 5: In 2015, an estimated 2.6 million babies were stillborn. Fact 6: 1.3 million deaths in 2015 were attributable to hepatitis. Fact 7: Noncommunicable diseases (NCDs) caused 37% of deaths in low-income. Fact 8: Ischemic heart disease and stroke killed 15 million people in 2015. Fact 9: Diabetes is among the 10 leading causes of deaths and disability worldwide. Fact 10: Injuries claimed nearly 5 million lives in 2015.

Source: World Health Organization. (2017c). 10 Facts on the State of Global Disease. Retrieved from http://www.who.int/features/factfiles/global_burden/en.

4.2 Key Factors in the Rise of Noncommunicable Diseases

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Noncommunicable diseases (NCDs) kill 40 million people each year, equivalent to 70% of all deaths globally. Each year, 15 million people die from a NCD between the ages of 30 and 69 years; over 80% of these “premature” deaths occur in low- and middle-income countries. Cardiovascular diseases account for most NCD deaths, or 17.7 million people annually, followed by cancers (8.8 million), respiratory diseases (3.9 million), and diabetes (1.6 million). These four groups of diseases account for over 80% of all premature NCD deaths. Tobacco use, physical inactivity, the harmful use of alcohol, and unhealthy diets all increase the risk of dying from a NCD. Detection, screening, and treatment of NCDs, as well as palliative care, are key components of the response to NCDs.

Source: World Health Organization. (2017b). Global status report on non-communicable diseases. Retrieved from http://www.who.int/mediacentre/factsheets/fs355/en.

Children younger than 5 years who may be malnourished shoulder a significant portion of the disease burden. Nutrition is related to access to a food source and the quality of the food. In many countries, staple food such as rice, nshima, or millet, and other grain-based substances is abundant but lacks basic nutrients. Undernutrition and a diet of foods with poor nutritional content contribute to 45% of deaths in children younger than 5 years in developing countries (WHO, 2014c). Optimal breast-feeding could save more than 800,000 lives of children younger than 5 years each year. This primarily results from the lack of national infrastructure to adequately measure the effects of ill health on the entire country. Women are often essentially “invisible” to the healthcare system after childbirth. Compound this with poverty and lack of access, and women and children will remain in a state of poor health.

FIGURE 4.3 Global healthy life expectancy at birth. (World Health Organization [2016e]).

The community response to outcast Haweeyo and her family because of her pregnancy and unmarried status represents discrimination. As a woman, she suffers the triple stigma of being “immoral,” pregnant, and poor because the cultural norm in her country is to marry before conceiving a child. Why do you think stigma, shame, and social outcasting

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continue to be a challenge for women and their families in this region of the world? How might you explain the relationship between culture and perceived women’s role and behavior? As a nurse working in this community, what might be the best practice for intervening and preventing violence and death toward young girls and women who find themselves in a situation such as Haweeyo’s?

What Risk Factors Affect the Disease Burden? In a health context, risk factors are defined as personal habits and behaviors, environmental conditions, or inborn or inherited characteristics that are known to affect a health-related condition. Many of these can be reduced or prevented. Addressing risk factors and how they relate to the population can improve the health status of a nation. Risk factors occur in combination and change with age, creating different risks over a lifetime. Risk factor categories found to be associated with overall health include the following:

Childhood and maternal undernutrition: Underweight children and conditions related to iron, vitamin A, and zinc deficiencies contribute to poor health outcomes. Other nutrition-related risk factors and inactivity: Obesity and physical inactivity, coupled with hypertension and hyperlipidemia, affect adults as well as children worldwide. Addictive substances: Tobacco smoking, alcohol and illicit drug use affect the health of the world’s population. Sexual and reproductive health: Risk factors of unsafe sex and no use or ineffective use of contraception contribute to decreased health of women and children. Environmental risks: Unsafe drinking water, unsanitary conditions, poor hygiene, urban air pollution, and indoor smoke created by burning solid fuels, contribute to poor health.

What Can Nurses Do? The health of a nation is overwhelmingly affected by the presence of specific risk factors and the nation’s capacity to support and implement health programs that will affect the major causes of morbidity and mortality. Risk factors such as tobacco use, nutritional status, alcohol consumption, and condom use can be modified with educational interventions and have an effect on the overall quality of life (WHO, 2004). Nurses can have a profound effect on risk factors by playing a major role in health promotion and education. The quality of health service coverage, even in settings with few resources or ones where an extreme nursing shortage exists, can be improved by nurses who target health promotion issues within their community. One example is educating families on the daily use of insecticide-treated bed nets (ITNs) in regions where malaria is highly endemic, and use of artemisinin-based combination therapies (ACTs) in high- prevalence regions (WHO, 2013b). Artemisinin is a drug known for its ability to swiftly reduce the number of Plasmodium parasites in the blood of patients with malaria. The 2016 WHO Malaria Report (2016b) states that between 2010 and 2015, malaria incidence rates fell by 21% globally and in the WHO African Region. During this same period, malaria mortality rates fell by an estimated 29% globally and by 31% in the Region. During this same period, malaria mortality rates fell by an estimated 29% globally and by 31% in the African region. However, as cases of malaria have diminished, the use of ITNs has decreased. The public health sector needs to advocate that the ITNs are essential for all areas, and that they be retreated annually for efficacy. The Roll Back Malaria project of the WHO focuses on the community commitment to fight malaria (WHO, 2013b), and ITNs are one method of prevention. Promoting the proper use of ITNs would be an example of a program based on a specific demographic risk factor that nurses, as trustees of health, could promote.

Risk factors can be addressed both at the individual and the societal level. Often, the way in which various risk factors interact with one another, and the best approach to addressing each

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one, is not well understood or defined. If demographics and geographic patterns are applied to each of the risk categories, different patterns of need emerge. Using risk factors as a guide to which interventions will work (i.e., the package of interventions) greatly improves outcomes in specific communities. Removal of major risk factors, could improve healthy life expectancy worldwide.

Practice Point

Nurses can have a substantial effect on people’s health by focusing their teaching on modifiable risk factors such as changing lifestyle behaviors.

Health Indicators According to the WHO statistical information system, health indicators may be placed in four categories: morbidity and mortality, risk factors, health service coverage, and health system resources. Each category has a list of indicators and universal definitions. Morbidity and mortality are measured by life expectancy at birth and health-adjusted life expectancy (HALE) at birth. The effect of mortality on a population is reported as disability-adjusted life years (DALYs) (Box 4.3). These three indicators reflect the general health of a population. Secondary measures of mortality, such as maternal and neonatal rates, reflect at-risk groups that affect overall mortality. Risk factor reduction focuses on healthy nutrition, improving health behaviors, and ameliorating environmental factors such as clean water and burning solid fuels. Health service coverage data identify uptake of specific services known to improve or promote health and well-being, such as reproductive health services, infant and child health and immunization, HIV, and tuberculosis (TB) care. Health system resources focus on the capacity and supply of healthcare providers. These indicators in the aggregate provide valuable data that are used by health ministries and nongovernmental organizations (NGOs) as benchmarks for measuring target interventions.

4.3 Health Indicator Descriptions

Life expectancy at birth (years): average number of years a newborn is expected to live if the current mortality rates continue to apply

HALE (health-adjusted life expectancy at birth [years]): average number of years that a person can expect to live in “full health” by taking into account years lived in less than full health due to disease and/or injury

DALYs (disability-adjusted life years): quantifying the burden of disease to a healthy life. The loss of years related to burden of disease. The gap in years reflects the current state of health versus an optimum state of health of a nation.

Source: World Health Organization. (2014). Health statistics and health information systems. Retrieved from http://www.who.int/healthinfo/en.

Box 4.4 reflects the 10 highlights of the WHO Health Statistics Report for 2016 (WHO, 2016d). These highlights indicate that health discrepancies continue, and that interventions and benchmarks targeted at health indicators need to be based on the community-specific risk factors. In addition, these highlights suggest that global health continues to have an immense disease burden that is filled with opportunities for nurses to make a difference. Programs should focus on areas that have high impact on the overall health and well-being of the population they are intended to serve. The six lines of action (Box 4.5) of the WHO Health Statistics Report for

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2017 (WHO, 2017b) provide guidance in promoting health equity and sustainable development through 2030.

4.4 Ten Highlights of the 2016 WHO World Health Statistics Report

Every year:

303,000 women die due to complications of pregnancy and childbirth 5.9 million children die before their fifth birthday 2 million people are newly infected with HIV, and there are 9.6 million new TB cases and 214 million malaria cases 1.7 billion people need treatment for neglected tropical diseases more than 10 million people die before the age of 70 due to cardiovascular diseases and cancer 800,000 people commit suicide 1.25 million people die from road traffic injuries 4.3 million people die due to air pollution caused by cooking fuels 3 million people die due to outdoor pollution 475,000 people are murdered, 80% of them men

Source: World Health Organization (2016d). World Health Statistics 2016. Retrieved from http://www.who.int/mediacentre/news/releases/2016/health- inequalities-persist/en.

4.5 Six Lines of Action to Promote Health in the 2030 Agenda for Sustainable Development

1. Monitoring the health-related Sustainable Development Goals (SDGs) 2. Health system strengthening for universal health coverage 3. Health equity—leave no one behind 4. Sustainable health financing 5. Innovation, research and development 6. Intersectoral action for health

Source: World Health Statistics Report. (2017c). World Health Statistics Report 2017. Retrieved from http://apps.who.int/iris/bitstream/10665/255336/1/9789241565486-eng.pdf?ua=1.

Practice Point

Culturally appropriate, community-driven, and community-based programs are critical for eliminating disparities; strategies directed at individuals are not sufficient.

From what you know about global risk factors that affect burden of disease, in reviewing the highlights of the WHO report (2017c) what nursing interventions should be implemented to address improved health outcomes? What risk factors could be targeted that would address some of the issues highlighted within the report? For example, we know that unsafe sex practices is a major risk factor affecting reproductive health—maternal mortality is declining too slowly and cases of HIV infection are still on the rise in young women. What other factors would we need to know within a global setting before we could conduct a community needs assessment about unsafe sex practices? For example, how should we address unsafe sex practices for both men and women?

Statistics on population health indicators are used by governments and donor agencies.

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Health statistics will become vital to cost–benefit analysis for program development, with the shift in the developing world toward implementing a sector-wide approach program for health planning (WHO, 2008).

A sector-wide approach promotes the collective agreement of the government entity (e.g., a ministry of health), donor countries, and other key stakeholders in the community such as physician and nurse organizations, NGOs, and researchers. The process ensures that the government assumes leadership in developing a common policy and program for health, including monitoring arrangements and instituting more coordinated procedures for funding and procurement (WHO, 2013c). The challenge for ministries of health will be to administer, implement, and evaluate their annual healthcare goals and to work to identify ways and means to address the shortcomings that most affect the communities.

Evidence for Practice

Deaths from injuries and car accidents are about as prevalent as HIV/AIDS in the world. Bus accidents also cause many injuries in countries where safety laws are not well enforced. More than 90% of injury deaths occur in low- and middle-income countries, where preventive efforts are often nonexistent and healthcare systems are least prepared to meet the challenge, according to the WHO (2009b). What interventions can nurses implement that can reduce this problem?

Addressing the burden of highly infectious diseases such as TB is an urgent global health priority. TB is one of the 10 leading causes of death worldwide. In 2015 alone, an estimated 1.8 million people died from the disease, including 0.4 million with a dual diagnosis of TB and HIV. Despite a decrease in the incidence of the disease, approximately 10.4 million new cases were diagnosed in 2015 alone with most infections occurring among people living in crowded conditions in low-income countries. Treatment of TB involves following a strict drug regimen for several months, and completing the full course of treatment is critical. Unfortunately, failure to complete the drug regimen is very common, often attributed to cost and availability of medications. One of the consequences when patients stop taking their medications is the emergence of multidrug-resistant disease (MDR-TB). An estimated 480,000 people who started treatment developed multidrug-resistant TB (MDR-TB) in 2015. Ending the TB epidemic by 2030 is a key health target among the Sustainable Development Goals (SDGs) (WHO, 2017c).

As you reflect upon Vikram, what are some of the important preventive measures Vikram could have taken to reduce the risk of TB for himself and his family? What may have put Vikram at risk for MDR-TB? As a nurse, what are some of the important teaching points you should emphasize about taking TB medications? Why do you think Vikram was tested for HIV when he presented to the clinic with symptoms of TB?

Poverty and Risk Factors

Only when (and if) the “haves” develop genuine empathy for the “have-nots,” and come to acknowledge their own long-term interdependence with all other humans, will the global economy be improved to any significant advantage for the desperately poor. SR Benatar in PLOS Medicine (2005)

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Low- and middle-income countries have an increased burden of the risk factor of poverty. Extreme poverty—the inability to meet the basic needs of adequate nutrition, safe drinking water, basic education, and primary health services, and a livelihood that can generate the means to secure these basic needs—is the driving force behind increased mortality. Unlike those who are moderately and relatively poor, those who are extremely poor cannot access healthcare and are chronically hungry (Sachs, 2010, 2015). With a substantial segment of the world population existing on less than a dollar a day, the choices within the environment for sustenance create health risks. Nearly half the world’s population and about 81% of sub-Saharan African households rely on wood-based biomass energy (fuel wood and charcoal) for cooking (World Bank, 2011). Continuous smoke from burning air-polluting solid fuels affects the population’s health, and negatively impacts the economy. Attention to achieving sustainable energy sources, particularly in Africa, will help to alleviate poverty, improve healthcare status, and address ever- expanding greenhouse gas emissions (Venro, 2009). This continued reliance on air-polluting fuels, such as in China, affects the population’s health (which, in turn, affects their economic prospects).

Unclean water remains a major problem in reducing diarrheal illness and waterborne and water-related illnesses and their health consequences. Between 1990 and 2011, 1.9 million people gained access to improved sanitation facilities (United Nations, 2013a) and the proportion of people using an improved water source rose from 76% to 89%. Developing basic sanitation expectations for communities and decreasing reliance on traveling great distances to acquire water will improve health overall.

WOMEN, POVERTY, AND HEALTH

“There are two powers in the world; one is the sword and the other is the pen. There is a third power stronger than both, that of women.” Malala Yousafzai author of I Am Malala: The Girl Who Stood Up for Education and was Shot by the Taliban

Gender impacts health, both biologically and socially. The health of women and girls is affected by many social issues, particularly education. A lack of basic education worsens a female’s risk of poverty, which impacts childhood marriage, early childbirth, lack of birth control, and increased vulnerability to HIV/AIDS (Jackson, 2009; WHO, 2017b).

Some of the sociocultural factors that prevent women and girls from benefiting from quality health services and attaining the best possible level of health include:

unequal power relationships between men and women; social norms that decrease education and paid employment opportunities; an exclusive focus on women’s reproductive roles; and potential or actual experience of physical, sexual and emotional violence (WHO, 2017b).

Poverty is a barrier to health for both men and women, but it yields a higher burden on women and girls’ health.

The burden of disease associated with reproductive health affects the health indicators of a nation. Thompson (2007) described the deadly combination of poverty, the right to economic development, and the poor health of women as barriers to improving the health of the world’s families. If maternal and child healthcare is left unattended, the rates of maternal and neonatal mortality will rise and national development in those nations with the fewest resources will be limited. The continued low status of women, despite years of policy development, increases the risk of disease and disability. The power imbalances within households around the world affect

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the health of women and young girls. Maternal, newborn, and child health affect population mortality and health in profound

ways. An estimated 3 million unsafe abortions occur annually among girls and young women age 15 to 19 years (WHO, 2014d). Despite evidence of low-cost interventions that would improve reproductive health outcomes, scale-up for these interventions is lacking (Bhutta et al., 2008). The known interventions are focused on recognizing maternal and neonatal complications; procedures to prevent postpartum hemorrhage (PPH), such as active management of the third stage of labor; neonatal care at birth, such as drying the infant off and wrapping the infant immediately; and having a skilled provider examine the infant within 2 days of birth. Each of these interventions relies heavily on education of the mother and community and should be a primary focus of community-based programs to improve maternal and child health. As education increases in the community, evaluating the use of such interventions still remains low. Such low-cost, low-tech interventions can address the imbalances in maternal and child health, if used for every pregnancy and birth, and evaluated for quality of delivery and effectiveness. Refocusing efforts on the full cycle of quality improvement will greatly affect overall global health (Houweling et al., 2014).

In Case 1, Haweeyo benefited from the presence of an experienced CHW birth attendant and her ability to recognize the necessity for moving her to the hospital for advanced level of care for both mother and baby. As the nurse, you recognize gender differences and acceptable roles and behaviors for women are evident in this community. How might you intervene to reduce gender discrimination and violence based on culturally specific restrictive beliefs and taboo regarding women, moral behaviors, and role of women in a community? How might you help women like Haweeyo allay their fear of stigma and shame and become more aware of available services, transportation, and sensitive, caring providers who will care for her emotional and physical well-being?

SUSTAINABLE DEVELOPMENT GOALS

“Two years ago, world leaders adopted the ambitious 2030 Agenda for Sustainable Development, with 17 Sustainable Development Goals at its heart. The Agenda is our shared plan to transform the world in 15 years and, crucially, to build lives of dignity for all.” UN Secretary-General António Guterres

The Sustainable Development Goals (SDGs) were adopted by the United Nations in 2015 to replace the Millennium Development Goals (MDGs) (Fig. 4.4). The SDGs are a universal set of goals, targets, and indicators that the United Nations 191 member states are using to frame their agendas and political policies through 2030 (United Nations, 2017). The SDGs aim to address inequalities between nations, but also within nations. The SDGs contain 17 goals covering a broad range of sustainable development issues for the world. In addition to the overarching goals, there are targets within each goal for a total of 161 targets. Goal number 3: Good health and well-being for all, specifically addresses health.

The 17 SDGs:

1. End poverty in all its forms everywhere 2. End hunger, achieve food security and improved nutrition, and promote sustainable

agriculture 3. Ensure healthy lives and promote well-being for all at all ages

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4. Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all

5. Achieve gender equality and empower all women and girls 6. Ensure availability and sustainable management of water and sanitation for all 7. Ensure access to affordable, reliable, sustainable, and modern energy for all 8. Promote sustained, inclusive, and sustainable economic growth, full and productive

employment, and decent work for all 9. Build resilient infrastructure, promote inclusive and sustainable industrialization, and foster

innovation 10. Reduce inequality within and among countries 11. Make cities and human settlements inclusive, safe, resilient, and sustainable 12. Ensure sustainable consumption and production patterns 13. Take urgent action to combat climate change and its impacts 14. Conserve and sustainably use the oceans, seas, and marine resources for sustainable

development 15. Protect, restore, and promote sustainable use of terrestrial ecosystems, sustainably manage

forests, combat desertification and halt and reverse land degradation, and halt biodiversity loss

16. Promote peaceful and inclusive societies for sustainable development, provide access to justice for all and build effective, accountable, and inclusive institutions at all levels

17. Strengthen the means of implementation and revitalize the global partnership for sustainable development

FIGURE 4.4 United Nations Sustainable Development Goals. (WHO).

Over the past decade, significant improvements have occurred in global health outcomes, but it is important to note that health inequalities are prevalent throughout the globe. According to the International Counsel of Nurses (2017), the social determinants of health (SDH) are the conditions and systems that shape health throughout the life cycle. The SDH are the conditions

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in which people are born, grow, live, work, and age (Marmot, 2016). These circumstances are shaped by the distribution of money, power, and resources at the local, national, and global levels. Social factors, including education, employment status, income level, gender, and ethnicity have a direct influence on a person’s health. The SDH are mostly responsible for health inequities—the unfair and avoidable differences in health status seen within and between countries. Health equity and social determinants are acknowledged as an important component of the SDGs agenda and of the achievement of universal health coverage (UHC). To reduce health inequities, both SDH and UHC need to be addressed in an integrated and systematic manner (WHO, 2016c).

Evaluating the SDGs The United Nations has extensive and continuous targets for evaluating all 17 goals. The High- Level Political Forum (HLPF) has a central role in the follow-up and review of the 2030 Agenda and the 17 SDGs at the global level. The HLPF facilitates sharing successes, challenges, and lessons learned, and provides political leadership, guidance, and recommendations for follow- up. The HLPF also coordinates sustainable development policies, ensures that the 2030 Agenda remains relevant and ambitious, assesses progress, achievements, and challenges faced by developed and developing countries, and addresses emerging issues. A central feature of the HLPF is the voluntary national reviews (VNRs) that it receives from member states on their implementation of the 2030 Agenda and the SDGs. Regularly undertaken by both developed and developing countries, the VNRs provide a platform for partnerships between groups and stakeholders (United Nations, 2017). Global progress on meeting each SDG is summarized in Table 4.1. Progress on SDG #3 (health), is summarized in Box 4.6.

How Can Nurses Help Implement the STGs? Global health is encompassed in all the SDGs, and most prominently in SDG #3: Ensure healthy lives and promote well-being for all and all ages. Our nursing role directly impacts this SDG. While nurses seek to help people achieve their optimal health, our work frequently includes addressing the SDH and nurses understand the links between wider conditions on individual and population health. As nurses, we have a responsibility to care for our patients, communities, country, and the globe, by staying informed and continually educating ourselves on how to improve health for all. Suggestions on how to implement the SDGs from the International Council of Nursing (2017) include (1) becoming a leader and (2) raising your voice at the policy table. Becoming a leader involves working with groups within the healthcare system and larger community. Leadership includes both social responsibility and good citizenship, which connects to nurses’ professional and ethical responsibilities to improve health for all. According to the Institute of Medicine (2011), “a shift must take place in how nurses view their responsibility to those they care for; they must see themselves as full partners with other health professionals” to be effectively involved in improving overall health.

Evidence for Practice

The 2015 countdown report for maternal, newborn, and child survival outlines the progress that has been made in improving the lives of families. Yet more can be done with basic, low- cost interventions (United Nations, 2013b; WHO, 2012b). Sustaining focused interventions on early detection and treatment of diarrhea and pneumonia will decrease mortality (Walker

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et al., 2013). Four interventions known to affect both diarrhea and pneumonia include the following (Bhutta et al., 2013):

Breast-feeding. Not breast-feeding resulted in a 165% increased risk of acquiring diarrhea from 0 to 5 months of age (Lamberti, Walker, Noiman, Victora, & Black, 2011). Education on exclusive breast-feeding. Significant results, as high as 90%, were attributed to promotional interventions for children from 0 to 6 months of age (Bhutta et al., 2013). WASH interventions. Water, sanitation, and hygiene (WASH) interventions demonstrated a risk reduction of 17% with proper excreta disposal, and risk reductions of up to 48% with water and soap handwashing (Cairncross et al., 2010). Zinc supplementation. Supplementation resulted in a reduction in diarrhea and acute lower respiratory tract infection mortality (Yakoob et al., 2011). Postpartum hemorrhage. PPH is the leading cause of maternal death, claiming an estimated 140,000 lives in low-resource settings, with an additional 2 million women left to recover from anemia (Prata, Passano, Sreenivas, & Gerdts, 2010; Smith, Gubin, Holston, Fullerton, & Prata, 2013). The use of uterotonics such as oxytocin or misoprostol can have a profound effect on preventing and treating PPH. Several large randomized controlled trials (RCTs) have shown that the use of such medications will improve delivery of the placenta, decrease blood loss, and avert death and disability. Implementation of such treatments as a standard of care requires a reliable supply chain for medications and the support of nurse leaders to implement the procedures for every delivery, since we know that long labors and multiple gestations increase the risk for PPH, but many women with no risk factors suffer hemorrhage. Creating political will is important to improving health. Countries that improved care by strengthening their health system with education and deployment of midwives reduced their maternal mortality rate by 2% to 5% and will have a median drop of maternal mortality ratio by 63% over 20 years (Van Lerberghe et al., 2014). Countries with sustainable changes focused on improving access as close to the family as possible, scaling up birth care in line with the population, decreasing fees and financial barriers to care, and making quality care a priority. In countries where these four elements have been most successful, nurse midwifery has become more visible and accepted. Preterm birth and stillbirth have been neglected in improving child mortality (WHO, 2012a). Investing in low-cost interventions, such as universal kangaroo care, and high-cost interventions, such as corticosteroid injections, could save up to 950,000 infants per year. Education of skilled health personnel, specifically nurses and midwives, on tools to support preterm care and access to essential equipment and education can have a profound effect on neonatal survival. The global action report by WHO Born Too Soon (WHO, 2012a) outlines steps that can improve preterm birth and prevent causes of stillbirth, such as maternal malnutrition.

TABLE 4.1 Progress to Date: Sustainable Development Goals, 2017 Sustainable Development Goals Progress at Meeting Goal 1. End poverty in all its forms everywhere An estimated 767 million people lived below the extreme poverty

line in 2013, down from 1.7 billion people in 1999. This represents a reduction in the global rate of extreme poverty from 28% in 1999 to 11% in 2013.

2. End hunger, achieve food security and improved nutrition, and promote sustainable agriculture

The proportion of undernourished people worldwide declined from 15% in 2000–2002 to 11% in 2014–2016. Globally, approximately 793 million people were undernourished in 2014–2016, down from 930 million in 2000–2002.

3. Ensure healthy lives and promote well- See Box 4.6 for extensive progress at meeting this health goal.

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being for all at all ages 4. Ensure inclusive and equitable quality

education and promote lifelong learning opportunities for all

Despite gains in primary school enrollment between 2000 and 2014, 9% of primary school–aged children worldwide were out of school in 2014, with little progress since 2008.

5. Achieve gender equality and empower all women and girls

Women’s participation in national parliaments worldwide were 23% in 2017. In the majority of the 67 countries with data from 2009 to 2015, fewer than a third of senior- and middle-management positions were held by women.

6. Ensure availability and sustainable management of water and sanitation for all

In 2015, 5.2 billion people (71% of the global population) used a safely managed drinking water source located on premises, available when needed and free from contamination.

7. Ensure access to affordable, reliable, sustainable and modern energy for all

In 2014, 85% of the global population had access to electricity, up from 78% in 2000. However, 1.06 billion people still lived without this basic service

8. Promote sustained, inclusive and sustainable economic growth, full and productive employment, and decent work for all

The average annual growth rate of real gross domestic product (GDP) per capita expanded from 0.9% in 2005–2009 to 1.6% in 2010–2015. Real GDP growth in the least developed countries (LDCs) averaged 4.9% in 2010–2015, short of the target of at least 7% annually.

9. Build resilient infrastructure, promote inclusive and sustainable industrialization, and foster innovation

Global investment in research and development increased at an average annual rate of 4.5% between 2000 and 2014.

10. Reduce inequality within and among countries

In 49 of 83 countries with data from 2011–2015, the per capita incomes of the poorest 40% of the population grew more rapidly than the national average, leading to a reduction in income inequality.

11. Make cities and human settlements inclusive, safe, resilient, and sustainable

In 2014, nine in 10 people living in urban areas breathed air that did not meet the World Health Organization’s air quality guidelines value for particulate matter.

12. Ensure sustainable consumption and production patterns

Globally, the material footprint of human beings increased from 48.5 billion metric tons in 2000 to 69.3 billion metric tons in 2010. The material footprint per capita increased from 8 metric tons per person in 2000 to 10 metric tons per person in 2010.

13. Take urgent action to combat climate change and its impacts

As of 2017, 148 parties ratified the Paris Agreement.

14. Conserve and sustainably use the oceans, seas, and marine resources for sustainable development

Of the 63 large marine ecosystems, 16% are in the “high” or “highest” risk categories for coastal eutrophication (oxygen depletion leading to animal death). By 2050, it is estimated that coastal eutrophication will increase in 21% of large ecosystems.

15. Protect, restore and promote sustainable use of terrestrial ecosystems, sustainably manage forests, combat desertification and halt and reverse land degradation, and halt biodiversity loss

From 2010 to 2015, the annual net loss of forest area globally was less than half that of the 1990s. The proportion of land area covered by forest decreased from 32% in 1990 to 32% in 2010 and 31% in 2015.

16. Promote peaceful and inclusive societies for sustainable development, provide access to justice for all, and build effective, accountable, and inclusive institutions at all levels

Globally, the proportion of people held in detention without being tried or sentenced for a crime was 31% in 2013–2015.

17. Strengthen the means of implementation and revitalize the global partnership for sustainable development

In 2016, approximately 80% of the population in developed regions had internet access, compared to 40% in developing regions and 15% in LDCs.

Source: United Nations. (2017). Sustainable Development Goals Report 2017. Retrieved from https://unstats.un.org/sdgs/files/report/2017/TheSustainableDevelopmentGoalsReport2017.pdf.

4.6 Progress on SDG 3—Health

Goal 3 addresses all major health priorities and calls for improving reproductive, maternal and child health; ending communicable diseases; reducing noncommunicable diseases and other health hazards; and ensuring universal access to safe, effective, quality, and affordable medicines and vaccines as well as health coverage. Between 2000 and 2015, global health indicator changes included:

Maternal mortality ratio declined by 37%, and the under 5 mortality rate fell by 44%. However, 303,000 women died during pregnancy or childbirth and 5.9 million children under age 5 died worldwide in 2015; most from preventable causes.

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46% reduction in HIV incidence 17% decline in the incidence of tuberculosis 41% decrease in the incidence of malaria 21% drop in people requiring mass or individual treatment and care for neglected tropical diseases. The risk of dying between the ages of 30 and 70 from one of four main NCDs—cardiovascular disease, cancer, diabetes, or chronic respiratory disease—fell from 23% to 19% between 2000 and 2015, but not rapidly enough to meet the 2030 target. Nearly 800,000 suicides occurred worldwide in 2015, with men twice as likely to die by suicide as women. In 2013, approximately 1.25 million people died from road traffic injuries, an increase of 13% since 2000. Globally in 2012, household air pollution from cooking with unclean fuels and inefficient technologies led to an estimated 4.3 million deaths; another 3 million deaths were attributed to ambient air pollution from traffic, industrial sources, waste burning, and residential fuel combustion.

OTHER FACTORS THAT AFFECT GLOBAL HEALTH Economics and Politics The global environment is intricately intertwined with the economic and political status of a nation. As one area improves, so do others, and vice versa. It is known that health and education are clearly linked, in that the better educated the population is, the better the health of the population (Ross & Wu, 1995). Political and economic instability, which leads to poverty, is a major barrier to achieving health for a population. When economies and political systems are stable, the health of a population generally improves.

Over the past 60 years, the world economy has increased, and yet has spawned greater disparities. For example, the global economy increased sevenfold since 1950, whereas the disparity in gross domestic product between the 20 richest and 20 poorest nations more than doubled between 1960 and 1997 (British Medical Journal, 1999). Extreme poverty is decreasing in every region of the world, according to the 2017 Sustainable Development Goals Report of the United Nations. The proportion of people living on less than $1.25 a day fell from 43% in 1990 to 21% in 2010 (World Bank, 2014). An estimated 767 million people, or 10.7% of the population lived on less than $1.90 a day in 2013, with decreasing numbers of people living in conditions of extreme poverty. Yet living in poverty remains the driving economic condition that significantly affects health and well-being in sub-Saharan Africa and in southern Asia (United Nations, 2013a; World Bank, 2016).

The current economic and political instability of many parts of the world only exacerbates the difficulties for the world’s poor. The effects of a slowdown of the world economy on the incomes of other less wealthy nations have become evident. This ripple effect is felt by the poorest people of the world.

The first wealth is health. Ralph Waldo Emerson

Even with these enormous disparities in health, poor countries can learn to become more economically self-sufficient by producing enough basic commodities and foods for their population to survive, and also by producing specific goods for export that are not readily available in wealthier countries. Poor countries must grow staple foods that lead to nutritionally balanced diets for the local people. It is possible to achieve high levels of health even without high levels of income. Disparities between the wealthiest and poorest nations must be reduced; in the end, each individual is inextricably linked as the world quickly becomes a global community. Maintaining communities and honoring cultural norms and traditions can only help

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populations become more self-sufficient. It is inherently necessary for health planners to understand this basic fact.

In Case 2, consider some of the social and economic factors that may influence the health of Vikram and his family. How might access to healthcare services, education about prevention, and treatment of communicable diseases prevent transmission of TB from occurring in Vikram’s community and other rural, poorly resourced areas? How do diagnoses and treatments of communicable and infectious diseases differ both globally and culturally within different regions of the world?

Factors Associated With Healthcare Systems Healthcare systems differ in terms of the degree to which they can adequately serve the population and the degree to which they are centralized in the government. They range from national healthcare systems, such as those in the United Kingdom or Spain, to pluralistic free- market systems, such as those in the United States. National healthcare systems are highly regulated, tend to have salaried physicians and other providers, are funded by governments, and involve relatively high taxes. Free-market healthcare systems depend more on individual or employer and employee contributions than on taxes. In between these two extremes are the systems of various countries whose citizens have access to universal health insurance and pay higher taxes for these services, such as the Scandinavian countries of Denmark, Norway, and Sweden. Other health insurance funding methods include national health insurance programs with single-payer systems, such as those in Canada, and programs with multipayer health insurance systems that offer universal health insurance via sickness funds, such as those in Germany and France.

The U.S. system, which is often characterized as highly fragmented and segmented, depending on the individual’s insurance status or level of wealth, spends far more per capita on health than any other country in the world. Although the United States spends the most on healthcare per capita, it has the worst rating in preventable deaths (treatable cancer, diabetes, childhood infections/disease, and complications from surgery); it ranked last among 16 industrialized nations. From 1997–1998 to 2006–2007, the United States lowered its preventable mortality rate by only 20% compared to an average decrease of 31% in other nations (Nolte & McKee, 2011). The United States ranked last among 11 industrialized countries in access, administrative efficiency, equity, and healthcare outcomes in 2017 (Schneider et al., 2017). Figure 4.5 compares countries of the world on these measures (Schneider et al., 2017)

The United States passed the Patient Protection and Affordable Care Act in March 2010, a landmark national healthcare reform law that was expected to allow 94% of all Americans to obtain health insurance, reduce the growth in healthcare costs, and decrease the federal budget deficit by $143 billion over the next 10 years (Congressional Budget Office, 2010). This legislation has had many hurdles and had gradually increased the number of insured individuals in spite of opposition by many Americans and various states until 2017 when significant challenges occurred. So how does this translate to poorer countries with less wealth than the United States or Europe? Lessons learned from decades of work focusing on a specific disease of a population have provided data to suggest that focusing on the system may garner better health indexes for global health delivery (Kim, Farmer, & Porter, 2013). Care delivery value chains (CDVCs) targeted at a specific problem can create a system that engages all aspects of care toward one outcome. Creating a value-based delivery system which is focused on the value it achieves for the patient and society, and which emphasizes best practice and includes the need

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to understand the combined effect of interventions over a cycle of care, is an important aspect of CDVCs (Kim et al., 2013). The elements of the value chain include the following:

Monitoring and prevention Diagnosing Preparing Intervening Recovering and rehabilitation Monitoring and managing overall outcomes

Integrating this model into health systems may move health indexes to the next level. Strong healthcare systems are vital, yet they also need sustainable financial support. Some

countries are turning to insurance mechanisms. Smith and Sulzbach (2008) describe voluntary, nonprofit health insurance schemes, organized and managed at the community levels, that they call “community-based health insurance” (p. 2461). This concept is based on the principle of risk pooling and involves regular payments of a small premium in exchange for reducing direct payments at the point of service. These types of financing are also referred to as prepayment schemes, private prepaid programs, microinsurance, and mutual health organizations (Dror et al., 2016; Smith & Sulzbach, 2008). Although care in these poorer countries involves a completely different paradigm than in developed countries, lack of the greatest resource— healthcare providers—is one of the most compelling problems. Lack of financing either from the government or from the population further exacerbates this problem.

FIGURE 4.5 Healthcare System Performance Rankings. (Schneider, E., Sarnak, D., Squires, D., Shah, A., Doty, M. [2017]. Mirror, Mirror 2017: International comparison reflects flaws and opportunities for better U.S. healthcare. The Commonwealth Fund. Retrieved from http://www.commonwealthfund.org/∼/media/files/publications/fund- report/2017/jul/schneider_mirror_mirror_2017.pdf.)

Extreme shortages of healthcare workers are an endemic problem in developing countries, and yet again, these countries share the greatest burden of disease, spend the least on healthcare

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expenditures, and have the lowest number of healthcare workers. Fifty-seven countries, most of them in Africa and Asia, face a severe health workforce crisis. With most recent data available, the WHO (2006) estimated that at least 2,360,000 health service providers and 1,890,000 management support workers, or a total of 4,250,000 health workers, are needed to fill the gap. Without prompt action, the shortage will worsen, especially in the poorest countries. Sub- Saharan Africa, for example, had 11% of the world’s population and 24% of the GBD, and it manages with only 3% of the world’s health workers (WHO, 2006). The number of health workers is directly related to the health of global populations. Further, country-specific data can be found at the website of Global Atlas of the Health Workforce, WHO, Geneva: http://www.who.int/hrh/statistics/hwfstats/.

To add to this problem, many factors that affect the health of global populations are often beyond the control of individual people. Wars, political instability, famine, ecologic factors such as climate change and subsequent environmental disasters, and economic trends may lead members of the local health workforce (such as nurses and physicians) to move to highly developed countries where they can work in more favorable conditions.

What has occurred is a global shortage of nurses and physicians in areas of need, and workforce migration leading to a “brain drain” of workers moving from lesser-developed countries to more developed countries. In 2010, the WHO introduced the Global Code of Practice of the Recruitment of Health Personnel (WHO, 2010). The code promotes the ethical recruitment of personnel and provides a focus on health work force development and health systems sustainability, and strengthening local health systems. Table 4.2 lists the key facts related to health worker migration. The WHO (2011) assembly on strengthening nursing and midwifery supported a continued focus on including nursing and midwifery in health system planning and employment, and transforming education systems to meet the needs of each country. Gostin (2008) states that the factors contributing to a shortage of healthcare workers are globalization, which has increased over the past 20 to 30 years, and a decreased supply of healthcare workers along with an increased demand for well-trained workers. He says that this leads to a “push–pull” situation, in which healthcare workers are “pushed” from developing countries and “pulled” to developed countries with the promise of a brighter future. Factors leading to this problem include low wages, unsafe environments, the need for better living conditions and facilities, lack of opportunity to be promoted, and unusually heavy workloads and long working hours (Gostin, 2008). The WHO (2010) suggests that in-source countries need to consider better health workforce retention by focusing on maldistribution of nurses and quality of life. Health systems need to provide protection and better treatment of workers in general, as often there are poor working conditions and poor pay. Finally, in accordance with the WHO goal of improving nursing education, countries need to invest in improving the initial education and training of midwives so that they are better prepared as professional healthcare workers (WHO, 2009a). Because migration is a human right, the WHO supports destination or receiving countries to act as responsible global citizens in recruiting migrant workers. This includes building capacity in their own countries as well as treating expatriate workers with the same dignity and respect as all healthcare workers.

TABLE 4.2 Background on Health Workforce Shortage Globally, health workforce shortages are highest in sub-Saharan Africa, which bears 24% of the world’s disease burden but has only 3% of health workers and less than 1% of the world’s financial resources to respond to this burden (WHO, 2006).

Adding to the shortage and inequitable distribution of the health workforce, the past 20 years have seen an increase in international health worker migration, with patterns of migration becoming increasingly complex (Nair & Webster, 2013; Taylor & Dhillon, 2011). In this period, developed nations have become more and more reliant on international migrants to fill health workforce positions—including nursing assistants, nurses, physicians, and

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medical specialists.

With rising life expectancy and expanding elderly populations, this reliance is expected to continue.

Migration, undeveloped health systems, and poor wages and working conditions are some of the factors that impact limited health workers in countries with the poorest health indicators.

WHO estimates that the basic healthcare system of 57 countries is affected by shortage of human resources and about 1/3 of these countries are the emerging market economies (Nair & Webster, 2013).

Gostin (2008) does suggest an upside to migration for the worker and the community: workers who migrate also gain new skills in the receiving countries and can return to their native countries revitalized with education and new outlooks on solving the problems—in other words, “brain gain.” Those who leave may also come back with the skills to educate other workers. For example, nurses may return with advanced practice nursing skills and become educators in their respective countries.

When a country invests in its healthcare workers through improved training, improved working conditions, career ladders, and allocation of financial resources toward improving salaries and systems, workers are more likely to remain in that country. HIV protection and treatment, as well as plans for emergency preparedness, are paramount if workers are to feel safe in their environments. The “pull” to other countries is great, and healthcare workers must feel that their contribution is valued and that their future will be improved if they resist the perceived benefits of moving to more developed countries to live out their lives and careers.

ROLE OF NURSES The world is now a global village. Problems that affect people in other countries also affect people in their own countries. Nurses and community healthcare providers need to be knowledgeable about the needs of all people, as well as of their patients, in the global society. Knowledge of the goals for worldwide health can lead to new cooperative ventures and unique solutions using technology and knowledge transfer techniques. Do all citizens of the world deserve access to good health and a sense of well-being? It is expected that the answer to this question will be “yes,” but such a goal can be accomplished only through international cooperation, regardless of national boundaries. Larger questions of inequalities in wealth and resources must be addressed, and as a new generation of providers emerge, they may have the answers that have eluded societies before them.

Nurses are a major part of the solution to world health problems. The ability of nurses to assess patients and communities, set realistic goals, develop interventions partnered with local community resources, and continually evaluate progress toward meeting goals will move the global environment on a path toward improved health. Nurses’ enlightenment about global health issues will enable our valuable profession to be part of the solution toward a healthier global population.

KEY CONCEPTS Global health encompasses the behavioral and environmental risk factors of a community, which are influenced by politics, economics, and culture. Monitoring health indicators and ensuring the inclusion of vulnerable and invisible populations will improve packaged interventions to affect health outcomes. Global burden of disease is a term that reflects the health of a nation and the level of opportunity to improve

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health. The Sustainable Development Goals are a framework for achieving improved global health and outcomes. Nurses should participate in both policy and leadership working toward meeting the SDGs. The road map to achieving health relies on the participation of all individuals and nations to address the basic needs of clean drinking water, sanitation, and alleviating poverty. Education is the key to improving the community environment, which, in turn, will improve health. Health worker migration increases the burden of care for a society and results in the need to shift tasks primarily to nurses and community health workers.

CRITICAL THINKING QUESTIONS

1. Imagine the role that nurses can play in a more egalitarian world where all healthcare providers can contribute equally to the pressing global problems presented here. What are some of your proposed solutions?

2. How can nurses work within communities of interest to determine how the burden of disease is affected by poverty?

3. How can nurses influence the major risk factors related to maternal mortality and HIV? 4. What health factors can nurses address to work with young males of a community to improve overall

health?

COMMUNITY RESOURCES World Health Organization International Council of Nurses United Nations

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WEB RESOURCES

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Part 2 Evidence-Based Practice and Population Health

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Chapter 5 Frameworks for Health Promotion, Disease Prevention, and Risk Reduction Rosanna F. DeMarco and Judith Healey-Walsh

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

Perplexity is the beginning of knowledge. Khalil Gibran

In theory there’s no difference between theory and practice. In practice there is. Yogi Berra

If the facts don’t fit the theory, change the facts. Albert Einstein

CHAPTER HIGHLIGHTS Influences on health and well-being Role of the nurse as an interdisciplinary team member in health promotion and prevention Health promotion programs Epidemiologic models of health promotion and public health science Levels of prevention and pathogenesis Immunizations Screening Behavior change theories Ecologic model and women living with HIV/AIDS Health literacy Interactive health literacy and health education Critical health literacy and health promotion

OBJECTIVES Discuss the contribution of the Centers for Disease Control and Prevention to the health and well-being

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of people in the United States. Explain three levels of prevention in relation to levels of pathogenesis. Identify and define health behavior change models and their practical use in altering behavior to enhance health and well-being. Identify a multisystem prevention approach to people, families, and communities. Describe epidemiologic models of health promotion and modifiable risk reduction. Describe the relationship among health literacy, health education, and health promotion. Compare the three levels of health literacy: functional, interactive, and critical. Identify requisite health literacy knowledge and skills for self-management of health. Describe essential health literacy practices for community health nurses.

KEY TERMS Behavior change models: Models that assist clients, groups, and communities to redirect

activities toward health and wellness. Ecologic model: Model that considers intrapersonal attributes, interpersonal dynamics,

person/environment interactions, cultural beliefs, and attitudes. Health: A quality, an ability to adapt to change, or a resource to help cope with challenges and

processes of daily living. Health belief model: A behavior change model that considers the severity of the potential illness

or physical challenge, the level of conceivable susceptibility, the benefits of taking preventive action, and the challenges that may be faced in taking action toward the goal of health promotion.

Health literacy: The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate decisions.

Health literacy universal precautions: Practices that healthcare providers use to make all health information easier to understand, to confirm client–provider comprehension, and to reduce the difficulty of health-related tasks.

Health promotion: The process of enabling people to increase control over all modifiable determinants of health to improve their health and well-being.

Learning model: A behavior change model emphasizing reinforcement of social competence, problem solving, autonomy, and sense of purpose.

Modifiable risk: Susceptibility to disease or injury that can be controlled by individual people, families, or communities.

Motivational interviewing: Client-centered communication style for eliciting behavior change by helping clients and groups explore and resolve ambivalence to change.

Primary prevention: Maximizing health and wellness through strategies that are set in place before illness or injury is present.

Relapse prevention model: A change model that is used primarily to assist people struggling with relapse and recovery from substance use.

Risk reduction: Decreasing the chance of developing an illness, experiencing an injury, or being faced with chronic consequences of both.

Secondary prevention: Maximizing health and wellness through strategies set in place at the early and active chronic stages of illness and injury.

Social learning: A behavior change model that considers environmental influences, personal factors, and behavior as key components to change.

Social support: A component of change in which community members, friends, neighbors, and adjacent communities influence change by offering instrumental assistance, informational support, emotional support, and appraising support.

Tertiary prevention: Maximizing health and wellness through strategies that are set in place at the palliation and end stage of disease and injury trajectories.

Theory of reasoned action: A behavior model emphasizing that individual performance of a given behavior is primarily determined by a person’s intention to perform that behavior.

Transtheoretical model: Sequential approach to behavior change on the basis of process

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across stages and timely readiness of the learner. Well-being: A subjective perception of full functional ability as a human being.

CASE STUDIES

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

The following three case studies are examples of prevention research by the Centers for Disease Control and Prevention (CDC) to address community health risk reduction and health promotion initiatives in people of various ages. They illustrate how healthy behaviors and risk reduction can be addressed through culturally relevant avenues using both epidemiologic evidence and the behavior change models presented in this chapter. The key to success in promoting health and reducing risk in these cases is the thoughtful, planned building of coalitions among individuals, communities, and health professionals. For example, nurses who address a particular healthcare concern need to involve members of communities in identifying goals, objectives, and solutions that can affect lifelong health promotion. It is critical that the risk be modifiable (sometimes referred to as a “modifiable risk”), which means that individual people or groups can actually do something about the problem using social competence, problem solving, autonomy, and purpose.

CASE 1 At the CDC Prevention Research Centers’ (PRCs) annual program meeting, 300 participants received a bag that was a product of community prevention research. The PRC program purchased the bags from Threads of Hope, a small business developed by community partners and the Center for Health Promotion and Disease Prevention of the University of North Carolina at Chapel Hill, one of 33 CDC-funded PRCs. Threads of Hope is a spin-off of the center’s core research project, HOPE Works, which trains community facilitators to run support groups enabling women to help each other make health and lifestyle changes. The women, who are African American, Native American (Coharie tribe), Latina, or white, live in Sampson and Duplin Counties in eastern North Carolina, where unemployment has been high since the mid-1990s, when tobacco and textile production ceased in the area. At the time, the poverty rate was close to 20%.

Fifteen years of researcher–community collaboration in the area has indicated that income, education, occupation, and community factors are playing a greater role in health than individual health behaviors or access to healthcare. The economic depression contributed to a sense of hopelessness that made some women less motivated to address health behaviors. The women who participate in this community-owned business receive a living wage, training in textile production and business management, health insurance, a chance to pursue higher education, and access to health promotion interventions primarily concerning nutrition and physical activity (CDC, 2017a; HOPE (Health Opportunity, Partnerships, Empowerment) WORKS, 2017).

CASE 2 An organization known as Program to Encourage Active, Rewarding Lives for Seniors (PEARLS) was developed at the Health Promotion Research Center of the University of Washington to help combat depression in seniors. The CDC provided funding for this program, which lasts for six months and consists of eight in-home visits by a counselor.

Minor depression is characterized by loss of interest or pleasure in activities, and feelings of sadness or hopelessness. It strikes about 14% of seniors, many of whom are dealing with isolation, loss of friends and family, and debilitating chronic diseases. For example, seniors who have diabetes are more than twice as likely as other people of the same age to have depression. One client who had limited vision said, “I just can’t contribute anymore.” Another woman spent weeks lying hopelessly in bed after recovering from pneumonia. Counselors help clients identify and write down the factors contributing to their depression as well as develop and evaluate solutions. One counselor said, “…just like the cold or the flu has symptoms, so does depression.…There is a close connection between depression and unsolved problems. If the problem is, ‘I can’t do anything worthwhile,’ the goal can be, ‘Find something I can do on a small scale that will be beneficial to other people.’” Both the client with limited vision and the one recovering from pneumonia found help in PEARLS, which uses structured behavioral therapy and positive events to resolve depression. A counselor helped the woman with limited sight find ways to help others, such as

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knitting baby blankets and calling isolated people, which were activities suited to her skills, interests, and personality. Other components of PEARLS include scheduling social and physical activities and planning simple pleasures, such as taking a walk, calling a friend, or soaking in a hot bath.

In its 3-year study phase, PEARLS eliminated depression completely for more than a third of participants. Of seniors in a comparison group who received usual care, only 12% reportedly eliminated depression completely. PEARLS also reduced depressive symptoms by half for 43% of participants—with almost three times as many people achieving that result as in the comparison group. Investigators have also found that PEARLS reduces hospitalizations, for any reason, among participants. Researchers attribute the success of PEARLS to the behavioral therapy, which affects the same parts of the brain as some antidepressant drugs. Behavioral therapy can be more permanent than drugs, is less expensive, and can be used outside a clinical setting. Because the clients come up with solutions of their own, they feel capable of following through on them (CDC, 2015e).

CASE 3 A project called Planet Health, developed by the Prevention Resource Center on Nutrition and Physical Activity at Harvard University, combines important messages on nutrition and physical activity with four academic subjects in public schools: social studies, math, science, and language arts. Even though obesity affects many American children, officials still find they must eliminate health classes, nurses, and physical education from public schools because of tight budgets.

The Planet Health curriculum meets Massachusetts academic standards and includes lessons designed to fit into a teacher’s busy schedule. The program consists of 24 lessons a year, six in each of the four main subjects—language arts, math, science, and social studies—plus special activities for physical education classes. Planet Health also challenges students to turn off televisions. Harvard researchers have shown that television viewing is directly related to obesity. The curriculum encourages children to spend less time watching television, playing video games, or using the computer—to reduce their “screen time” to two hours or less per day. The curriculum also includes innovative exercises to learn more about food and the properties of food and styles of eating that make kids healthy.

In a two-year study at 10 middle schools, Planet Health reduced the amount of time boys and girls watched television and also lowered the prevalence of obesity among girls. According to another study, the program will save money for children later in life; for every dollar spent on the program in middle school, $1.20 in medical costs and lost wages will be saved by the time the children reach middle age. Blue Cross Blue Shield of Massachusetts picked up Planet Health as part of an overall school wellness program, and it is now used in more than 120 schools across the state. The YMCA has also started offering a version of Planet Health during after-school programs in Massachusetts. Since 2001, when the curriculum was put into book form, more than 4,000 copies have been sold. Researchers are working on a new edition that will add and update information about sugar-sweetened beverages, the different types of fats, and whole grains.

Researchers and administrators say Planet Health’s greatest success can be seen in the lifestyle changes it inspires—not just in the classroom, but in the community. Schools that use Planet Health have begun to hold fitness days for families, and teachers have started yoga classes for themselves (CDC, 2017f).

INTRODUCTION According to Glanz, Rimer, and Viswanath (2015), health is a quality, an ability to adapt to change, or a resource to cope with challenges and processes of daily living. Whether health is defined as an attribute that helps individuals, families, and communities navigate the stormy sea of life, or as an ideal state of physical, social, and mental well-being, the notion of health being the absence of disease is superseded by a complex relationship between health and a person’s sense of wellness. For example, it is true that people who make up neighborhoods, communities, and populations can die from lack of health, but they can die well (i.e., with a sense of well- being and at a high level of human functioning). This chapter explores models of health promotion through public health science, with specific emphasis on models of risk prevention and behavior change as vehicles to well-being. In this chapter, “disease” refers to illness or

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injury not just at the individual level, but also from the perspective of the larger community of people in neighborhoods, cities, states, countries, and the world. An important underpinning to every effort described in this chapter is the ethical imperative to address health as a proactive approach to wellness. The chapter ends with the discussion of an inclusive and integrative behavior change model that describes the need to consider multiple influences on positive health outcomes. This is in contrast to single-focused measures that have been used in the past to develop health promotion interventions and healthcare policy. The issue of African American women living with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) in the United States is used as an example of how a formidable infectious and communicable disease can be addressed using this model to identify key components that influence behavior change. It also illustrates how interdisciplinary teams that include nurses identify and foster health promotion and policy change.

Every human being is the author of his own health or disease. Buddha

HEALTH PROMOTION, DISEASE PREVENTION, AND RISK REDUCTION AS CORE ACTIVITIES OF PUBLIC HEALTH Health has different meanings to individuals, families, and communities. Nurses working with clients in communities with a focus on population-based health gain knowledge about subjective well-being by observing individuals, families, and communities who are directly participating in improving their health. Individuals and groups interact in partnership with public health professionals to enhance their well-being and maximize their progress toward health, rather than just avoid illness, such as in the case studies at the beginning of this chapter.

Improving health is a journey of discovery among health professionals, the science of public health (epidemiology), and people who are motivated to effect change across varied and complex influences on well-being. Ten key components of public health practice are central to keeping populations healthy and safe. Nurses promote health through prevention efforts by belonging to interdisciplinary teams that address the following core activities (American Public Health Association, 2017):

1. Providing essential input to interdisciplinary programs that monitor, anticipate, and respond to public health problems in population groups, regardless of which disease or public health threat is identified

2. Evaluating health trends and risk factors of population groups and helping to determine priorities for targeted interventions

3. Working with communities or specific population groups within the community to develop public policy and targeted health promotion and disease prevention activities

4. Participating in assessing and evaluating healthcare services to ensure that people are informed of available programs and services and are assisted in the utilization of available services

It is important to understand that promoting health and wellness behaviors in individuals as members of a group or population depends on addressing all 10 core activities of public health simultaneously as an integrated whole. Each of these areas is addressed throughout this chapter in more detail. In this chapter, health promotion is presented through frameworks or models that can direct nursing practice to (1) focus on how to approach this complex and almost

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overwhelming concept of health at the population level; (2) become knowledgeable about how and why behavior change needs to be addressed, related to disease prevention and health promotion, depending on levels of control over an outcome; and (3) devise creative, cost- effective interventions and policy changes related to levels of prevention.

HEALTHY PEOPLE INITIATIVES The Healthy People initiatives and Healthy People 2000, 2010, and 2020 (HP 2000, HP 2010, and HP 2020) are a set of health objectives established nationally to address keeping individuals, families, and populations safe and healthy (Koh, Blakey, & Roper, 2014). Chapter 4 discusses international approaches to public health issues on the global scale. In the United States, the CDC promotes health at the global level by promoting the sharing of knowledge, tools, and other resources as a global responsibility, as well as creating partnerships throughout the world through health promotion, health protection, and health diplomacy (CDC, 2017b). From a national perspective, HP 2020 is a guidepost for nurses and interdisciplinary teams in community and public health. HP 2020 has historic roots in efforts by the U.S. Surgeon General to establish a definitive plan for state and community organizations to address the health of citizens. The effort to establish measurable objectives was developed through a planned process that involves consulting healthcare experts locally and nationally, collecting data obtained from studies of population illness (morbidity, natural progression of disease and injury, and mortality patterns over time), engaging businesses in the process, and listening to the needs and barriers identified by citizens in the United States. HP 2020 is designed to achieve two primary goals: (1) to increase quality and years of healthy life and (2) to eliminate any barriers to accessing care, specifically through health disparities. Currently, 42 topic areas with congruent objectives and data are available for consideration. Of this current grouping, new seminal areas have been identified that include genomics, global health, healthcare-associated infections, LGBT (lesbian, gay, bisexual, and transgender) health, preparedness, and social determinants of health (HP 2020, 2017a). Box 5.1 lists all the new areas of interest in HP 2020. Please note that HP 2030 is on the way (HP 2020, Development of the National Health Promotion and Disease Prevention Objectives for 2030, 2017b).

Where would the first case study, about Threads of Hope, fit in terms of addressing HP 2020 indicators and focal areas? Identifying specific indicators and focal areas that support health promotion means very little unless professionals in community or public health practice, such as nurses, consider partnerships to be necessary in the promotion of community health. Do you think that Threads of Hope addresses a particular focal point that is missing from the HP 2020 project?

Knowing how to address the need for change and the actual change at a personal, family, and community level must be based on science—evidence based on rigorous understanding of a problem. Specific actions that can best achieve positive health outcomes can then be determined. Consideration must be given to realistic availability of solutions, cost and benefits, and the degree to which individual people will accept these approaches. It seems too simple to assume that promoting identified HP 2020 goals and objectives in tandem with known scientific methods will promote the health of the nation. Many complicated factors affect the process of educating the public about health, such as people’s knowledge of their risk of disease, subsequent health outcomes, and the personal or communal choice to be healthy. It is necessary to consider individual and family perspectives about health and wellness, as well as community

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definitions of these concepts.

5.1 Healthy People 2020 New Focal Areas

1. Adolescent health 2. Blood disorders and blood safety 3. Dementias, including Alzheimer disease 4. Early and middle childhood 5. Genomics 6. Global health 7. Healthcare-associated infections 8. Health-related quality of life and well-being 9. Lesbian, gay, bisexual, and transgender health

10. Older adults 11. Preparedness 12. Sleep health 13. Social determinants of health

Source: http://www.healthypeople.gov/2020/about/new2020.aspx.

Student Reflection

I will never forget giving a presentation to a group of men and women in a senior center as my first effort in trying to convince them that cholesterol was a silent killer. After sharing age- and education-specific information from the American Heart Association and the CDC demonstrating dietary and exercise choices to promote health, one man got up and said, “What difference does it make; we all are going to die from something and I would rather eat fried foods than not eat them.” Many people around him nodded their heads, and I realized that until people are convinced that scientific evidence applies to them and that their choices affect their personal well-being, family, and increasing costs in healthcare, we are stuck with lofty goals by tradition rather than through transformation into something new.

The role of the community and the public health nurse in promoting health encompasses advocacy, community organizing, health education, and political and social reform in collaboration with agencies and community members (Kulbok, Thatcher, Park, & Meszaros, 2012).

Thus, it is critical to seek out health promotion and behavior change models to provide direction in making health promotion, disease prevention, and risk reduction efforts meet the realities of communities and the agencies serving communities.

ROAD MAPS TO HEALTH PROMOTION Epidemiologic Model and Prevention Although illness care is a primary component of the art and science of nursing, health promotion and disease prevention are important, closely related public health efforts in achieving the goals of nursing care. “Health Promotion is the art and science of helping people discover the synergies between their core passions and optimal health, enhancing their motivation to strive for optimal health, and supporting them in changing their lifestyle to move toward a state of optimal health. Optimal health is a dynamic balance of physical, emotional, social, spiritual, and intellectual health. Lifestyle change can be facilitated through a combination of learning

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experiences that enhance awareness, increase motivation, and build skills and, most important, through the creation of opportunities that open access to environments that make positive health practices the easiest choice” (O’Donnell, 2009, p. 4).

In this chapter, the word “disability” is replaced with the words “physically challenged” or “differently abled” to emphasize that there is always “ability” to deal with structural and functional problems (Smeltzer, Robinson-Smith, Dolen, Duffin, & Al Maqbali, 2010).

Community health nurses are focused specifically on modifiable risks of acquiring disease. This requires nurses to analyze trends in risk surveillance data and consider the physical, emotional, and psychosocial challenges people face when confronting disease, physical stressors, and the possibility of premature death. Public health science uses in-depth processes of data collection across the natural history of disease to define trends, and in this way assists nurses and other public health officials in prioritizing the steps they need to take to minimize risk and improve the quality of care in populations.

Practice Point

The Morbidity and Mortality Weekly Report (MMWR), published weekly by the CDC and available online, contains useful public health information and guidelines that address trends in illness and disease. MMWR readership predominantly consists of physicians, nurses, public health practitioners, epidemiologists and other scientists, researchers, educators, and laboratory-oriented professionals. The data provided in the MMWR come from state health departments and compare morbidity and mortality rates annually. These records are very helpful to public health clinicians because they supply information that promotes a proactive approach to resource planning when the rates are increasing (CDC, 2017c).

Although the morbidity and mortality data reports are quantitative, it is important to understand that in most cases, perceptions of health or well-being on the part of individuals, families, and communities are subjective. The science of diagnosis and healthcare follow-up may be present, but it is the subjective perceptions of others that often determine a person’s willingness to participate in health promotion initiatives. For example, if people perceive that health or “low risk” means the absence of acute symptoms or the absence of disease, many of them may consider themselves healthy and in no need of making an effort toward health promotion. In fact, they could actually be living with real, chronic morbid or comorbid conditions such as diabetes, hypertension, congestive heart failure, or hepatitis C, or they may be at risk for acquiring these conditions.

Keeping in mind the subjectivity of wellness, how would you develop outreach in the PEARLS program to elderly members of the community who are isolated and may want to preserve their privacy?

What would be a convincing argument to make to women who are not involved in making bags with Threads of Hope? How could you convince them that doing so would actually be an act of health promotion and would have a positive effect on their well- being?

Health promotion is a strategy that is used in partnership with health professionals, individuals, and communities. It includes all three levels of disease prevention and has the potential to or can directly change health and well-being. Healthcare professionals or people in communities can institute these strategies. In reality, disease and physical challenges can occur

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at any time. In many cases, predictions made from statistical conclusions (probabilities) through the science of epidemiology are the basis for determining the possibility of getting a disease or becoming physically or emotionally challenged (see Chapters 6 and 7). Analysis of epidemiologic data occurs while health professionals consider what happens at the prepathogenic, early pathogenic, and late pathogenic phases of diseases and physical or emotional disorders. The basis of this scientific approach is the study of causal relationships that yield pathology. Epidemiologists make conclusions about the direction of further study by considering (1) relative risk of an agent causing a problem (e.g., smoking and lung cancer); (2) consistency (i.e., similar results across other studies); (3) exposure (i.e., correlation with a certain distinct pathologic condition, such as for asbestos and mesothelioma); (4) timing (i.e., cause and resulting condition both occurring within a short period of time, such as inhaled fumes and an asthma attack); and (5) plausibility (i.e., existence of a biologic process) (Wakeford, 2015).

The central idea here is to prevent illness and physical or emotional challenges from occurring. Or, if they do occur, the goal is to lessen their effects and enhance clients’ quality of life. The science of epidemiology helps health professionals such as nurses, and coalitions of interested citizens, develop interventions for the stages of illness or physical or emotional challenges, which enhance the quality of life of individuals and communities. In Figure 5.1, health and wellness change along a developmental timeline. After a disease or physical challenge is identified, it progresses and eventually becomes life threatening. Although this pattern appears to be linear, in reality the linearity is theoretical. Illness occurs erratically; there are times of stability and times of acute and stressful exacerbation (Yohannes et al., 2017). At each pathogenic level, health promotion is intimately linked to prevention.

FIGURE 5.1 Natural history of disease and levels of wellness/illness continuum.

Levels of Prevention Activities classified as “preventive” are directed at eradicating, eliminating, or reducing the impact of disease and injury on individuals and populations, thus promoting health instead of disease (Gasink & Lautenbach, 2008). Disease in this context refers to communicable and noncommunicable conditions. Examples of noncommunicable diseases (noninfectious diseases or physical or emotional challenges) are substance abuse, obesity, depression, or workplace injuries. Physical or emotional challenges, as well as genetic disorders, are conditions that are generally noncommunicable in nature but cause structural and functional changes that are not statistically normal in the general population. Some examples include glaucoma, scoliosis, Down syndrome, neurofibromatosis, hearing loss, and learning disabilities. Communicable diseases are caused by pathogens (e.g., viruses and bacteria) that multiply and enter hosts through a variety of mechanisms and influences. These diseases have the capacity to cause infections across living organisms, with life-threatening and potentially chronic effects. Examples include HIV, malaria, swine flu, and smallpox (Webber, 2016).

What type of diseases (communicable or noncommunicable) do the programs in each case study address? Could addressing noncommunicable diseases or physical or emotional challenges

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through these programs influence vulnerability or resistance to communicable diseases in these populations?

To understand specific health promotion approaches, nurses should think in terms of three levels: primary, secondary, and tertiary prevention. The individual person’s or the community’s state of health and well-being, as studied within the science of identification, description, and prediction of illness, serve as the basis for the levels.

Primary Prevention When an individual or a group is considered in good health and shows no signs or symptoms of disease or physical challenges, nurses in interdisciplinary teams and community partnerships are involved in primary prevention. They seek to maximize health and wellness, using a variety of strategies, at a time when they or the clients have some level of control over the trajectory of health and wellness. Examples of primary prevention include the use of seat belts, hand washing, proper preparation of food, exercise, and balanced nutrition (Box 5.2).

Surveillance of healthy populations is a continual, dynamic method of gathering data about the health of the general public for the purpose of primary prevention of illness. The CDC and individual states monitor emerging and endemic health hazards that occur in community settings on an ongoing basis. Data are systematically collected, analyzed, interpreted, and disseminated so that they can be used to develop activities and programs that will reduce morbidity and mortality and improve health. The functions of public health surveillance are described in Box 5.3. In addition, local surveillance of community populations can be obtained by using various records—from clinics, community health and visiting nurses, worker’s compensation settlements, personnel files, and the like.

5.2 Examples of Primary Prevention

Immunizations Driver’s safety classes Healthy water quality Healthy air quality Health education classes Improving safety designs of equipment Fire safety Decreasing exposure to sun Use of environmentally safe products Using seat belts Using earplugs and safety glasses

5.3 Functions of Public Health Surveillance

Estimating the impact of a disease or injury Portraying the natural history of a health condition Determining the distribution and spread of illness Generating hypotheses and stimulating research Evaluating prevention and control measures Facilitating planning for program activities Detecting outbreaks

Source: Centers for Disease Control and Prevention. (2004). Framework for evaluating public health surveillance systems for early detection of outbreaks. Morbidity and Mortality Weekly Report, 53(RR-05), 1–11.

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It is critical to understand that there are situations in which primary prevention is difficult to achieve at the individual or community level. Sometimes, even with professional support and healthcare information, clients are unable to avoid experiencing disease or physical challenges because the causative agents are “not modifiable,” for example, genetic conditions, unexpected tragedies (natural disasters such as floods or tornados), and situations in which there is no developmental control, such as the effect of secondhand smoke. These would be considered conditions for which primary prevention strategies are difficult to implement and not modifiable.

Great things are done by a series of small things brought together. Vincent Van Gogh

An important example of primary prevention is the availability and dispensing of vaccines developed to enhance the body’s ability to create antibodies to either live or attenuated antigens. This approach protects individuals and populations from getting communicable diseases or lessens the severity of the disease. Immunization with vaccines is an effective way to promote primary prevention. Nurses who actively participate in the immunization of children in well- child clinics, young adults in university health clinics, and adults in international travel clinics are promoting primary prevention of measles, human papillomavirus (American Cancer Society, 2017), and yellow fever, respectively. See Box 5.4 for a list of vaccine-preventable diseases (CDC, 2017g).

According to the CDC (2017g), immunity to a disease results from the presence of antibodies to that disease. Antibodies are proteins produced by the body to neutralize or destroy toxins or disease-carrying organisms, and they are disease-specific. For example, antibodies to measles protect a person who is exposed to measles but have no effect if the person is exposed to mumps. There are two types of immunity: active and passive.

5.4 Vaccine-Preventable Diseases

Anthrax Cervical cancer Diphtheria Hepatitis A Hepatitis B Haemophilus influenzae type b (Hib) Human papillomavirus (HPV) Influenza (flu) Japanese encephalitis Lyme disease Measles Meningococcal disease Monkeypox Mumps Pertussis (whooping cough) Pneumococcal pneumonia Poliomyelitis (polio) Rabies Rotavirus Rubella (German measles) Shingles (herpes zoster) Smallpox Tetanus (lockjaw)

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Tuberculosis Typhoid fever Varicella (chickenpox) Yellow fever

Active immunity results when exposure to a disease organism triggers the immune system to produce antibodies to that disease. Exposure to the disease organism can occur through infection with the actual live organism (resulting in natural immunity) or introduction of a dead or weakened form of the disease organism through vaccination (vaccine-induced immunity). Either way, if an immune person comes into contact with a disease, his or her immune system will recognize it and immediately produce the antibodies needed to fight it. Active immunity is long- lasting, sometimes lifelong.

Practice Point

It may be important for nurses working with clients older than 60 or in communities where chronic illnesses abound to consider the use of the vaccine against shingles. Shingles is a painful localized skin rash, often accompanied by blisters, caused by the varicella zoster virus (VZV), the same virus that causes chickenpox. Any person who has had chickenpox can develop shingles because VZV remains in the nerve cells of the body after the chickenpox infection clears and can reappear many years later. Shingles most commonly occurs in people 50 years of age or older, in those who have medical conditions that keep the immune system from working properly, or in those who receive immunosuppressive drugs. The vaccine against shingles is recommended by the Advisory Committee on Immunization Practices (ACIP) to reduce the risk of this condition and its associated pain in people 60 years of age or older. See http://www.cdc.gov/vaccines/vpd- vac/shingles/default.htm for further information.

Passive immunity results when a person is given antibodies to a disease rather than producing them through his or her own immune system. A newborn infant acquires passive immunity from its mother through the placenta. This type of immunity can also occur with the use of antibody-containing blood products such as immune globulin, which may be given when immediate protection from a specific disease is needed. This is the major advantage to passive immunity; protection is immediate, whereas active immunity takes time (usually several weeks) to develop. However, passive immunity lasts only for a few weeks or months. Only active immunity is long lasting. Herd immunity is a type of passive immunity; the presence of a large proportion of immune individuals in a community decreases the chances of contact between any infected people and susceptible individuals. An entire population need not be immune to prevent an epidemic of a disease. Herd immunity is often attributed to either antibody formation, which occurs when populations acquire an illness in a non–life-threatening form as a result of medical care interventions or reduced virulence, or to vaccination programs.

Secondary Prevention Secondary prevention is a planned effort to minimize the impact of a disease or injury once it is in effect. Secondary prevention is used at an early stage of pathogenesis or physical or emotional challenges. It includes, through the science of screening, initial recognition of the stage of an illness or physical challenge, which can progress to greater or lesser severity over time. The types of screening procedures and examples are found in Box 5.5.

Women diagnosed with HIV/AIDS and children who are identified as having scoliosis are

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examples of the need for secondary prevention. To screen effectively for the presence of these conditions, a test should be (1) cost-effective, meaning that the cost of producing and distributing the screening tool is justified by the positive effect on protecting the public; (2) easy to use; (3) available to large sectors of the population at risk; (4) sensitive and specific enough to identify true positives and true negatives; (5) backed by a healthcare infrastructure that can implement programs of care for people who have a verified risk of disease or physical challenge; and (6) acceptable to clients. Sensitivity and specificity are criteria used to measure how valid and reliable a screening test can be. Sensitivity measures the strength of a screening test’s ability to correctly identify people who have a disease or physical challenge. Specificity measures the strength of a screening test’s ability to correctly identify people who do not have a disease or physical challenge. In an ideal world, all screen tests should have both high sensitivity (100%) and high specificity (100%). The 100% level is approached but not met. Thus, confirmatory studies need to be undertaken to verify the presence of the disease. In the case of diseases that could be fatal, sensitivity is crucial (Box 5.6). For nurses participating in screening and delivering results of screening, it is most important to be aware of the test’s limitations of validity and reliability and to remember that serious economic costs to communities and health systems can be incurred when testing is not accurate. Nurses should also be aware of the psychological costs when a false-positive result occurs, which can create debilitating fear and anxiety. Calculation of sensitivity and specificity is discussed in Chapter 7.

5.5 Types and Examples of Screening Procedures

Mass screening: applied to entire populations

Blood lead level screening Papanicolaou (Pap) smears Phenylketonuria of newborns

Selective screening: performed for specific high-risk populations

Mammographies for young women at high risk for cancer Tuberculin tests for hospital employees Occupational diseases Exposure to radiation

Multiphasic screening: a variety of screening tests applied to the same population on the same occasion. Data can be used for establishing baseline data in a healthcare facility and for risk factor appraisal

Series of tests performed on a single blood sample Periodic surveillance of drug therapy Monitoring the stage of an illness Case finding: clinician’s search for illness as a part of a client’s periodic health examination Monitoring the health of individuals in a case load

Source: U.S. Preventive Services Task Force. (2002). Guide to clinical preventive services (3rd ed.). McLean, VA: International Medical Publishing.

5.6 Sensitivity and Specificity

Sensitivity = testing correctly to identify persons who have the disease/physical challenge High sensitivity: True positive (people who have the disease and test positive) Low sensitivity: False negative (people who have the disease but test negative [normal]) Specificity = testing to identify persons who do not have the disease High specificity: True negative (people who do not have the disease and test negative)

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Low specificity: False positive (people who do not have the disease but test positive [abnormal])

Student Reflection

I recently participated in an immersion trip to Central America as a nursing student. I kept asking questions to our guides about disease screening and secondary prevention related to breast cancer, HIV, human papillomavirus, cholesterol, and high blood pressure. In several instances, it was clear that no screening was being performed in some of the areas. I was upset that screening, which has been established as reputable and accurate, was not occurring—especially in population groups that suffered from poverty and suboptimal living situations (lack of running water, outdoor ditches for latrines, garbage dumps as housing, unavailable barrier protection with sexual intimacy). After discussions with local health officials, it was clear that the lack of health personnel to offer the screening, the cost of the necessary materials, and the severe lack of infrastructure to follow up if people tested “positive” meant that there could be no screening at all. This stunned me and allowed me to understand the economic and ethical considerations related to screening and secondary prevention.

For example, when a client is tested initially for HIV with the OraQuick HIV test for oral fluid, a test supported by the CDC based on many years of serum testing (CDC, 2017d), the healthcare team has a responsibility to verify these findings despite the high sensitivity and specificity of this test (99.3% and 99.8%, respectively). If a person tests positive for HIV, the initial result is confirmed by using an HIV antibody test known as the enzyme-linked immunosorbent assay (ELISA), which was developed in the 1980s (Homsy, Thomson- Honnebier, Cheng-Mayer, & Levy, 1988). After all confirmatory HIV testing has been completed and infectious disease experts, including physicians and nurses specializing in infectious disease, have reviewed the findings, these professionals may consider the client to be at the stage of illness early in the trajectory of pathogenesis. For example, the client may have a low viral load or absent viral load with a CD4 count greater than 200 cells/µL. This would mean that the client has the ability to fight infection and that replication of the virus is not high. Involving this client in medical care, with the support of infectious disease services such as housing, nutrition services, counseling, addiction recovery, financial support, and primary care services, offers him or her the potential to maintain health and wellness.

Some may question the use of the word “prevention” here, when indeed the person already has a confirmed diagnosis of HIV. In this context, secondary prevention means that efforts are being made to minimize (1) any further extension of the HIV illness to “full-blown” AIDS (CD4 count less than 200 cells/µL, with detectable viral loads); (2) the need to use antiretroviral medications, which have severe and debilitating side effects; (3) any exacerbation of other comorbidities that could affect HIV status, such as intravenous drug use; and (4) any possibility of communicating the virus to others. People living with HIV/AIDS need to have support to counter perceptions of stigma and discrimination that can lead to depression. Depression can be linked with decreased healthcare adherence, which can cause HIV to worsen and AIDS to develop. If these clients are sexually active and not using safe sex practices, which include not maintaining recovery from substance abuse and not using barrier protection, the virus will be spread to others and they, in turn, may become infected with another strain of the virus.

Is it possible to screen for the problems identified in the three case studies (depression, nutrition, and physical activity)? How would this screening occur? What resources would be used?

In a school screening program for idiopathic scoliosis, a school nurse may find that a child

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has an anatomical abnormality. Depending on the stage of the abnormality, the school nurse makes appropriate referrals on the basis of orthopedic and neurologic screening standards (Scoliosis Screening, 2017). Generally, scoliosis screening is conducted because of evidence- based predictions of development at a cross-section of time when identification of the problem is critical to timely interventions.

Sometimes, when screening is completed, the client’s level of disease or injury is found to be at a more advanced stage and is not considered to have been “caught early.” This is true for many women of color who are tested for HIV. History of intimate partner violence may inhibit personal motivation to receive care or may create situations in which the client may not be free to get care. Lack of healthcare insurance, mental health challenges, and active substance addictions can also cause women to delay testing for HIV. Subsequently, when they are diagnosed, they may be very ill, experiencing the life-threatening chronic and/or end stage of the illness called AIDS (Earnshaw, Smith, Chaudoir, Lee, & Copenhaver, 2012).

The U.S. government requires screenings for some conditions and not others. Some screenings are mandatory because of the physical and economic costs that may result if they are not performed (e.g., newborn screenings). On the other hand, some people see screenings as stigmatizing and may experience feeling of vulnerability or discrimination in a variety of ways (interpersonally, with regard to health insurance, and at work).

Tertiary Prevention Tertiary prevention is the long-term management and treatment of clients with chronic conditions, such as HIV/AIDS and cancer, so that quality of life is maintained, despite the fact that the condition will not improve and will most likely worsen. Tertiary prevention includes rehabilitation and palliative care. AIDS-related cancers such as lymphoma are not uncommon. In general, cancer is a life-threatening illness that may occur along with other conditions. Cardiovascular disease, diabetes, and pulmonary disease may be present as well and require clinicians such as nurses to plan clients’ cancer treatment, continue to assess HIV/AIDS disease progression, watch for opportunistic infections, and control pain or other side effects of the treatment. Care also includes supporting life choices that bring emotional comfort to clients such as family involvement, decreased isolation, supportive spiritual development, and organized help from communities.

Practice Point

Public health nurses should become familiar with those resources available to communities that can help address prevention at all levels. Local and state health departments have directories of both publicly and privately funded prevention support programs and services, and many hospital systems provide directories for clients to consider in their time of need. Finally, internet-based directories are being created to help citizens find a network of services in their community or region.

For example, nurses involved in cardiac care might do the following: Rather than envisioning end-stage cardiac rehabilitation as the focus of prevention after a cardiovascular event, or when cardiovascular disease is prominent in a community, they could think about approaches to prevention that are inclusive of all stages of health promotion and prevention. Many cardiovascular centers provide unique, prevention-as-treatment approaches for communities with high incidence and prevalence rates for heart disease or an unusual number of people who are at risk for developing heart disease. Interdisciplinary teams of clinicians, including nurses, offer clients and communities the strategies and tools necessary to reduce their

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risks. For example:

FIGURE 5.2 Natural history of disease, levels of wellness/illness, and levels of prevention continuum.

Primary prevention programs: Clients and families who are at risk for heart disease because of family history are treated. This level of prevention focuses on evaluation of personal risks in light of family history to help clients reach their heart health goals. Rehabilitation: Cardiac rehabilitation programs assist clients and families in recovery from heart attacks, angioplasty, and cardiac surgery and provide them with important information to make lifestyle changes to prevent recurrence. Associated comorbidities programs: Clients and families at risk for, or who already have, diabetes are assisted in weight loss and in managing other cardiac risk factors such as hypertension and high cholesterol. In addition, they are assisted in managing the combination of effects the illnesses have on daily life.

Therapies can include monitored exercise, stress management, yoga and meditation, nutrition counseling, smoking cessation, weight management, and stress testing.

In summary, prevention efforts are intended to decrease the physical, psychological, and economic costs of chronic, serious illness as well as physical and emotional challenges. Efforts to address these potential costs use an epidemiologic model of levels of prevention throughout the natural history of disease (prepathogenesis, early pathogenesis, and pathogenesis across time). These efforts include the use of immunizations, screening, and rehabilitation (see Figs. 5.1 and 5.2). Health promotion using this model is based on public health science and surveillance of trends related to diagnoses that are identified through sensitive and specific screening tests and the natural history of particular diseases. Nurses in public and community health practice, being advocates of decreasing risk in populations, use this model to care for individuals, groups, and communities through instrumental care or through health policy.

BEHAVIOR MODELS The focus of prevention efforts is the development of culturally relevant and gender-sensitive interventions that demonstrate positive outcomes in health and well-being. To promote health and well-being, one of the key approaches of primary, secondary, and tertiary prevention is a focused effort to change behaviors that have a negative impact on the natural history of disease and to promote behaviors that have a positive impact on the natural history of disease. Approaching individuals and groups about behavior change must incorporate knowledge of diverse client perspectives and include the use of counseling skills and motivational interviewing.

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Motivational interviewing, which was developed by Rollnick and Miller (1995), is defined as a “directive, client-centered communication style for eliciting behavior change by helping clients/[groups] to explore and resolve ambivalence” (Motivational Interviewing, 2017). It is a focused, goal-directed approach (Box 5.7). It originated with problem drinkers who presented themselves to clinicians; the drinkers needed help to change a behavior, although they wanted to continue it (ambivalence). To address behavior change using this method, the motivation comes from the client and is not imposed by a clinician. The client needs to resolve ambivalence to change a behavior with autonomy. Persuasion on the part of the clinician only intensifies resistance. The communication style is therefore one of directing the client to examine and resolve ambivalence. This method does not (1) argue with a group or community by insisting it has a problem that needs to change, (2) offer advice without actively encouraging group- identified choices, (3) give advice while the group is put in a passive role, (4) impose diagnostic labels, or (5) use coercive tactics. Motivational interviewing teaches all clinicians that making efforts to change behavior is based on a clinician–client exchange. Whether individuals or groups represent specific interests in communities, participation in decision making, informed consent, advocacy, and health literacy must be considered in using models of behavior change.

5.7 Actions Involved in Motivational Interviewing Behaviors for Clinicians

Seek to understand the person’s frame of reference through reflective listening. Express acceptance and affirmation. Elicit and select reinforcing motivational statements of problem recognition, concern, desire, intention,

and ability to change. Monitor the degree of readiness to change and ensure that resistance is not generated by clinician control. Affirm freedom of choice and direction.

Source: www.motivationalinterview.org/clinical/whatismi.html.

The quality of health at the individual, family, and community level is influenced by many factors. As discussed earlier, decreasing health disparities was an objective of HP 2010 and was identified as a key component in addressing barriers for some community dwellers who may desire to keep healthy and are ready to do so. So, despite the desire to change a behavior, there may be social, economic, or biologic nonmodifiable influences that prevent change. Behavior health models describe, explain, or predict prevention health behaviors. The models discussed here are available to help nurses consider creative methods of implementing the preventive measures identified earlier in this chapter. Although they appear to stand alone as unique and unrelated frameworks of behavior change, consideration of multiple influences cannot help but foster health, as in a “perfect world” (i.e., one in which nurses understand this concept and use all these methods together). The following section describes the theoretical frameworks of behavior change and many of the behavior change models that have been used to address health promotion and risk reduction (Glanz et al., 2015). This section ends by describing the ecologic model. The ecologic model is a model that considers multiple influences as a way to address complex behaviors to promote health at the individual, environmental, and policy level.

Learning Theories According to Skinner (1953), health behaviors are seen as incremental steps toward a final goal. In the so-called learning model, a goal is established and reinforced by the nurse, with rewards given for partial accomplishment, if necessary. Incremental increases are then made as the pattern of behavior is shaped toward a specific goal. Reinforcement is used as motivation to either continue or discontinue a behavior. This model uses extrinsic, or external, factors for

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reinforcement. Although extrinsic factors are successful in the adoption of initial behavior, intrinsic, or internal, factors are more effective in long-term adherence. Praise, encouragement, or prizes are examples of extrinsic rewards for the initial adoption of healthy behaviors. Feelings of accomplishment and changes in personal health habits are examples of intrinsic rewards that are often used in the long-term adoption of healthy behaviors.

A good example of the use of a classic learning model is the syndicated weight reduction program called Weight Watchers. Through the use of group encouragement, incremental weight loss is rewarded with public recognition and even a presented “ribbon” or “star” to indicate success. Intrinsic rewards, including the ability to show successful weight loss, as well as leadership opportunities within the program, can be helpful to people just beginning Weight Watchers, and have been documented within the past 10 years (Mitchell, Ellison, Hill, & Tsai, 2013).

Nurses in home care situations who work with clients with chronic illnesses, such as diabetes, congestive heart failure, and hypertension, have used the learning approach successfully while being actively involved in teaching and surveillance of client care. The difficulty with this approach is that there is a high level of expectation that intrinsic rewards will last over time, despite the influence of social norms and economic conditions. For example, in inner city and rural area communities, it is not uncommon to find a dearth of grocery stores, fresh fruit and vegetable stands, and farmer’s markets as options for purchasing low-calorie, low-fat, and low-cost healthy foods. Instead, small stores sell high-calorie, high-fat processed foods (Liu, Stephenson, Houlihan, & Gustafson, 2017). Thus, clients with diabetes may have received intrinsic and extrinsic rewards for glycemic control but have little opportunity for continuity given the economic and social choices available in their communities.

Anything that changes your values changes your behavior. George A. Sheehan

Evidence for Practice

Barch and colleagues (2017) explored how an important aspect of motivation in behavior is reinforcement learning that is implicit (outside of conscious awareness) or explicit (direct examples of rewards), as well as direct positive reinforcement or punishment. Motivational impairments are core features of a variety of types of psychopathology. Positive reinforcement is an important aspect of motivational function (learning about actions that lead to reward) and punishment (learning to avoid actions that lead to loss). In examining performance on tasks among individuals with schizophrenia, schizoaffective disorder, and bipolar disorder with psychosis, individuals with schizophrenia and schizoaffective disorder performed significantly worse than controls, but the individuals with bipolar disorder did not. Worse performance on an explicit reinforcement learning task, but not the implicit reinforcement learning task, was related to worse motivation and pleasure symptoms across all diagnostic categories. Performance on explicit reinforcement learning, but not implicit reinforcement learning, was related to working memory, which accounted for some of the diagnostic group differences.

Positive reinforcement has been used successfully in research studies to increase social behavior, improve cognitive and language skills, increase functional skills, and improve play skills. The questions that should be asked in reference to practices related to clients, groups, and communities are as follows:

How do I deal with challenging behaviors during an interaction? How do I structure care to facilitate appropriate behaviors? What strategies do I use to teach new behaviors?

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How am I currently using positive reinforcement in my practice? How can I use positive reinforcement more effectively in my practice?

Health Belief Model The health belief model, developed by Hochbaum (1956) and Rosenstock (1974), specifies that individual, family, or community health–related behavior depends on (1) the severity of the potential illness or physical challenge, (2) the level of conceivable susceptibility, (3) the benefits of taking preventive action, and (4) what stands in the way of taking action toward the goal of health promotion. This model uses cues as an important way to remind people of healthy behaviors and to promote these actions. Examples of this model include posting a note stating, “Don’t overdo it at dinner” (individual) or “Let’s try to do one thing tonight that is not related to a television set” (family), and placing a “Got Milk?” billboard in the neighborhood (community/population). Critical to this approach is the belief that the cue messages can be accomplished. If a community group does not believe that they can sustain a “walking” club in a safe section of a neighborhood, cues will not successfully encourage community members to follow a walking program. At the individual level, age-specific considerations are important. If people think they are healthy, they will not adhere to a preventive health program. Older people, who more readily see chronic illness and death as imminent, may become frightened with the prospect of susceptibility, while younger people often believe that they are invincible and impervious to illness and physical challenges.

Evidence for Practice

VanDyke and Shell (2017) explored the role of the health belief model in predicting breast cancer screening among women in rural Appalachia. Health beliefs (perceived susceptibility to breast cancer, severity of breast cancer, and benefits and barriers to screening) were used to predict health behavior through frequency of mammograms in a total of 170 women aged 18 to 78. Demographic characteristics, mammogram frequency, and perceived susceptibility, severity, and benefits and barriers to mammography were assessed. Findings included that women with objectively elevated risks for breast cancer (history of abnormal mammograms or family history of breast cancer) perceived themselves to be at higher risk for breast cancer, and those with a history of abnormal mammograms were more likely to receive mammograms regularly. Consistent with the health belief model, fewer perceived barriers to mammography predicted greater mammogram frequency. However, the model was not fully supported because perceived susceptibility, severity, and benefits to mammography did not predict mammogram frequency.

Student Reflection

My instructor in community health asked us to use the health belief model in caring for clients who were receiving care in a sexually transmitted infection (STI) clinic. He suggested that I show the clients some of the consequences of syphilis in particular (graphic pictures), because there had been a large increase in the incidence of the disease in the section of town where the clinic was situated. After I interviewed 10 different clients and really tried to increase their fear about the consequences of their actions, more than 50% stated that they never thought they would get an STI despite not using any precautions to reduce the

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chances of becoming infected. In fact, 30% of the clients revealed during assessment that this was their second or third diagnosis of syphilis. So, despite the severity of the results of the disease, other factors affected choices of risk about acquiring an STI. Some of those factors were alcohol abuse; inability to practice safe sex effectively; and trading unprotected sex for money, housing, and food.

Transtheoretical Model The transtheoretical model, developed by Prochaska and DiClemente (1983), is a sequential approach to behavior change that involves timely readiness of the learner. This model promotes change using a five-stage process; the stages are (1) precontemplation, (2) contemplation, (3) preparation, (4) action, and (5) maintenance. Experts believe that individuals, families, and communities progress through these stages in a back-and-forth manner, not in a linear fashion. For nurses, the key to this approach is developing interventions tailored to clients’ levels of readiness. For example, using this model to establish a twice-yearly blood pressure screening program in a community setting would require the following stages:

1. Precontemplation (no screening programs scheduled and no intention to schedule screening) 2. Contemplation (no screening programs scheduled but intent to start a program soon) 3. Preparation (no definite screening program but have taken steps to develop a program) 4. Action (a developed screening program and intent to sustain the program) 5. Maintenance (have had the program for some time and intend to continue) 6. Relapse (had a program, does not have a program currently but intends to be active with a

program soon)

Evidence for Practice

Owusu, Quinn, Wang, Aibangbee, and Mamudu (2017) analyzed data from 43,540 participants of the Global Adult Tobacco Survey in low- and middle-income countries because over 80% of active smokers live in these countries. Intentions to quit smoking were categorized into precontemplation (referent category), contemplation, and preparation stages based on the transtheoretical model. Approximately 82%, 14%, and 4% of the smokers were in precontemplation, contemplation, and preparation stages, respectively. Rural residents had increased odds of being in contemplation stage (OR = 1.41, 95% CI = 1.09–1.83) compared with urban residents. Compared to homes where smoking was allowed, smoke-free homes were associated with increased odds of contemplation (OR = 1.77, 95% CI = 1.41–2.23) and preparation (OR = 2.18, 95% CI = 1.78–2.66). Exposure to anti-smoking messages in more than one media channel was associated with increased odds of contemplation (OR = 1.60, 95% CI = 1.33–1.92) and preparation (OR = 1.73, 95% CI = 1.28–2.33) compared with no exposure to anti-smoking messages. The results suggest that anti-smoking media campaigns and smoke-free policies may promote intention to quit smoking. While these suggest the need for implementation of comprehensive anti-smoking campaigns and smoke-free policies, longitudinal studies are required to confirm these findings and to evaluate how intention to quit translates into quit attempts.

Theory of Reasoned Action The theory of reasoned action states that a person’s given behavior is primarily determined by his or her intention to perform that behavior (Fishbein & Ajzen, 1975). This intention is determined by the person’s attitude toward the behavior (beliefs about the outcomes of the

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behavior and value of these outcomes), and the influence of the person’s societal environment or subjective norm (beliefs about what others think the person should do). The ability to perform the behavior (a belief that it can be done) is the critical aspect of the change process. Social or subjective norms are significant, and the importance of abiding by these norms is reflected in what people expect of individuals, families, and communities. For example, healthcare practitioners may use this model in smoking cessation. If a client believes that he or she cannot give up the addiction, no social norm will influence the behavior change. Smokers may isolate themselves from others or from circumstances which might influence their belief in their ability to change. Thus, the notion of addictive behaviors being hidden to decrease social pressure is a formidable challenge when trying to encourage healthy behaviors. The theory of planned behavior (a theory that links attitudes with behavior) is aligned with the theory of reasoned action, which states that perceived control over skills is needed to perform a behavior. This is similar to Bandura’s concept of self-efficacy (the belief that one is capable of achieving a certain goal which may be a behavior).

Evidence for Practice

Kim, Darwish, Lee, and DeMarco (2017) used self-efficacy theory to create a community- engaged research protocol to help women living with HIV infection to quit smoking. Video conferencing to strengthen the belief that one can quit smoking was delivered on smart phones and was compared with telephone counseling. The counseling (video or phone) with actual treatment to quit (nicotine patches) were intended to be intervention components to help the women quit and sustain smoking cessation over time. Preliminary findings indicate that age predicts preference for phone call delivery of the intervention, thought to be chosen because of stigma related to smoking behavior.

Social Learning (Social Cognitive) Theory Social learning, or social cognitive, theory is a behavior change approach in which environmental influences, personal factors, and attributes of the behavior itself have an effect. Most importantly, a person must believe in his or her capability to perform the behavior (self- efficacy) as well as perceive an incentive to do so (positive expectations outweigh negative). The immediate or long-term benefits must be valued. Providing skill development by modeling desired behavior can increase self-efficacy (Bandura, 1986).

Evidence for Practice

Wieland and team (2016) studied U.S. immigrants with increasing cardiovascular risk because of barriers to physical activity and health diets. They developed a physical activity and nutrition intervention through a community-based participatory research approach where they developed and used a modular content manual based on social learning theory. Family health promoters from the participating communities (Hispanic, Somali, Sudanese) were trained to deliver the intervention using the modules through 12 home visits during the first six months and up to 12 phone calls during the second six months. Key measurements included accelerometer-based assessment of physical activity and 24-hour dietary recall. Secondary measures included biometrics and social learning theory–based instruments. Of 150 individuals that included adolescents and adults, moderate levels of self-efficacy and

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social support were reported for physical activity and nutrition. What is particularly relevant in this study is how the processes and products from this program may be relevant to other social learning communities aiming to reduce cardiovascular risk and negative health behaviors among immigrants and refugees.

Theories of Social Support Family members, friends, neighbors, and adjacent communities can influence change by offering social support—instrumental assistance, informational support, emotional support, and/or appraising support. An example of instrumental assistance is providing transportation to buy groceries or building a safe place to walk in a community. An example of informational support would be providing a community board with information on how to obtain assistance to clean a polluted pond. An example of emotional support is calling an isolated family that has lost a child to assist them in their bereavement. An example of appraising support is giving positive feedback about a new health skill (Berkman & Krishna, 2014). Although the literature suggests that social support is not equivalent to professional support, professionals can assist interested community members in organizing and developing social support opportunities that promote health in the community.

Evidence for Practice

Rackow, Sholz, and Hornung (2015) studied the concept of “enabling” in exercise where it was hypothesized that social support has an indirect association on exercise through self- regulation and self-efficacy. These researchers examined the effects of different kinds of social support (emotion and instrumental) on exercise not only through self-efficacy but also through self-monitoring and action planning. Using an eight-week online program, study participants were randomly assigned to an intervention or a control group. The intervention included exercising regularly with a new exercise companion (social support). The researchers found that received emotional social support predicted self-efficacy, self- monitoring, and action planning in the intervention group. No direct or indirect effect of received instrumental social support on exercise emerged. In the control group, neither emotional nor instrumental social support was associated with any of the selfevidence for the enabling hypothesis of received social support via self-efficacy on physical exercise in an intervention study. This study demonstrated the contribution of received emotional and instrumental social support in the context of the “enabling” hypothesis.

The Relapse Prevention Model The relapse prevention model has been used specifically with issues that relate to adherence. Relapse often occurs because of (1) negative emotional states; (2) lack of or limited coping skills; (3) decreased motivation; (4) stress; and (5) high-risk experiences. Taylor (2013) supports the idea that there are differences between a relapse and short lapse from healthy behavior and suggests that planning a strategy related to high-risk situations is critical for success, especially in the realm of harm reduction efforts. For example, communities interested in crime prevention and harm reduction may be aware that in certain months of the year, there is an increase in violent crime. They would then create a community campaign to promote nonviolence by increasing law enforcement presence and improving faith-based, school system, elder health, and neighborhood watch supports.

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Evidence for Practice

Luciano and colleagues (2014) studied strategies of people with co-occurring disorders such as severe mental and substance use disorders. Strategies for relapse prevention described by men with co-occurring disorders with one or more years of sobriety were identified by analyzing semi-structured interviews from a sample of 12 men with demographic and diagnostic clinical data. The men were receiving treatment in residential or outpatient care and were primarily Caucasian (91.7%) and unmarried (100%) with ages ranging from 23 to 42. The two most common psychiatric disorders were schizoaffective disorder (n = 4, 33.3%) and bipolar disorder (n = 4, 33.3%), while the two most commonly misused substances were alcohol and cannabis. Qualitative analyses showed that participants maintained sobriety for at least one year by building a supportive community, engaging in productive activities, and carefully monitoring their own attitudes toward substances, mental health, and responsibility. Alcoholics Anonymous might act as a catalyst for building skills. The researchers concluded that a variety of self-management strategies are used to prevent relapse—seeking support, activities, and a healthy lifestyle. The researchers identified a relapse prevention model from this work, in which social networks, role functioning, and self-monitoring and conceptualizing self-care are critical to extending periods of health and wellness.

The Ecologic Model The ecologic model stems from the original work of Bronfenbrenner (1979, 2004). This model is based on the belief that all processes occurring within individuals and their environment should be viewed as interdependent. It suggests that behavior change in individuals needs to be considered in a broader social context, including developmental history, psychological characteristics, interpersonal relationships, physical environment, and culture.

According to this model, behavior is a result of the knowledge, values, and beliefs of people, as well as numerous social influences. These social influences include relationships, social support networks, and community structure. According to the ecologic model, there are four levels of reciprocal influence, and it is necessary to consider all of these levels in order to change behavior. The four levels of influence, which may either promote risk or support protective factors, are (1) ontogenetic, (2) microsystem, (3) exosystem, and (4) macrocultural (Fig. 5.3) (El-Bassel et al., 2003). The influences represent biologic, environmental, and social influences as a dynamic and collective group of variables that need to be considered as a whole.

This model has been successfully used in health promotion and prevention research as a way to decrease barriers to mammography screening and safer sex practices (Eddy, Donahue, Webster, & Bjournstad, 2002; McLeroy, Bibeau, Steckler, & Glanz, 1988; Richards, Viadro, & Earp, 1998; Schaalma, Abraham, Gillmore, & Kok, 2004). Burke (2003) used the ecologic model to provide a better understanding of intrapersonal, interpersonal, and environmental factors associated with intimate partner violence in low-income communities. Others have used this model to identify individual and community resources, such as trust and partnership, to develop effective interventions for health access (Bhattacharya, 2003). El-Bassel and team (2003) used the ecologic model to study communication strategies for preventing HIV infection in African American and Latino heterosexual couples (n = 217).

USE OF THE ECOLOGIC MODEL: EVIDENCE FOR

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HEALTH PROMOTION INTERVENTION The ecologic model is an appropriate framework to help identify and measure complex processes at a variety of levels for women living with HIV/AIDS. It allows public health interdisciplinary teams to (1) emphasize the unique developmental nature of variables that influence behaviors; (2) use a multilayered understanding of influence on behaviors; and (3) test variables from each of the identified systems in the model to guide the assessment, development, implementation, and evaluation of targeted interventions. The following is an example of how public healthcare providers implement each of the systems in the model in order to develop appropriate health promotion interventions. The ecologic model is more inclusive than many of the theories of behavior change previously discussed. The references used include publications that are more than five years old, which indicates the historical development of evidence since the 1980s, when HIV was first identified in gay men in San Francisco, California.

FIGURE 5.3 Ecologic model.

Ontogenic System: Personal Factors Characteristics such as race, marital status, and level of education are predictors of effective HIV prevention strategies (Hodder et al., 2013). Three trends emerging from these studies are as follows: (1) black women with lower levels of education are less likely to use HIV prevention measures than other groups surveyed; (2) older women and women of color are less likely to use condoms; and (3) strong correlations exist between education level and AIDS-related knowledge. In research which explores sexual risk factors, intimate partner violence, and selected psychosocial illnesses (injection drug use, alcohol abuse, anxiety, depression, psychosis, and dementia), HIV-positive menopausal women without childbearing issues have been overlooked (Stockman et al., 2013). Regardless of gender, identity, race, or ethnicity, traumatic events, mental illness, distrust, and stigma have all been linked to poor adherence to health promotion and prevention efforts, and behaviors associated with increased HIV risk (Kalichman, Katner, Banas, & Kalichman, 2017). These factors are barriers to HIV prevention for black women, and the lack of economic opportunity means they must focus on immediate survival, restricting their choices. In spite of the help of public funding and support services, lack of adequate and sustaining income is formidable (Chandler, Ansley, Ross, & Morrison- Beedy, 2016).

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The relationship between trauma and HIV in African American–seropositive women and the contexts in which these risks occur are critical areas in need of understanding and successful intervention. Trauma, such as child sexual abuse, intimate partner violence, adult sexual abuse, and victimization from exposure to violent environments, contributes to behaviors associated with increased HIV risk and disease sequelae (Kalichman et al., 2017; Glover et al., 2010). “Research has shown that histories of physical and sexual trauma can affect the decisions women make with regard to risks for STIs and HIV, including the choice of partners and the ability to negotiate the use of barrier methods of protection” (Myers, Wyatt, Loeb, & Carmona, 2006, p. 401). In African American women, being a victim of violence increases depressive symptoms, decreases safe sex behaviors, increases the chance of becoming HIV-seropositive, and increases the chances of acquiring and being treated for an STI (Kalichman et al., 2017). Severe child sexual abuse is also associated with substance use and lower self-esteem (Willie, Overstreet, Sullivan, Sikkema, & Hansen, 2016).

In the health histories of aging African American women with no history of HIV, comorbid chronic conditions challenge self-care, especially when there is little or no social support (Willie et al., 2016). Risk-taking behaviors, such as having multiple sexual partners, unprotected sex, and drug and alcohol abuse greatly complicate HIV risk, HIV infection, and STIs when these behaviors are superimposed on chronic conditions such as hypertension, obesity, lupus, diabetes, and congestive heart failure. These behaviors continue to be major issues in prevention efforts (Buzi, Smith, Weinman, & Novello, 2013). Prevalence of hepatitis C virus is as high as 30% among those living with HIV and 90% if HIV was contracted through intravenous drug use. End-stage liver disease from hepatitis C virus is a major cause of death in people coinfected with HIV (HRSA, 2017). According to the CDC (2017c), the retrovirus responsible for HIV/AIDS targets the CD4+ T lymphocyte as a primary target, thus crippling a number of important immunologic functions. Progressive impairment of the immune response leads to susceptibility in a variety of opportunistic infections and chronic life-threatening conditions. Measurements of CD4+ T lymphocytes and the amount of HIV virus in the system (viral load in copies/mL), along with clinical manifestations of disease or infection, are used to guide clinical and therapeutic management of HIV-infected persons in the United States. Results of viral load assessments are used to make decisions regarding initiation of antiretroviral therapy and to determine whether current antiretroviral therapy is effective. These measures are critical in decreasing mortality and morbidity rates.

Microsystem: Relationship between Women and the Environment Disclosing one’s HIV status has been reported to increase feelings of shame and stigma, partner violence, rejection, depression, and high-risk sexual behavior (Herek, Gillis, & Cogan, 2009). Stigma is highly correlated with low self-image, depression, lack of social support, a lack of subjective social integration, and social conflict (Kalichman et al., 2017). Withdrawal from personal interaction as a way to reduce tension is part of stigmatization, and for persons living with HIV/AIDS who have strong histories of substance abuse, the temptation to fall out of recovery is profound (Logie & Gadalla, 2009). Poor self-image is linked to increased risk behaviors for HIV infection (Mahajan et al., 2008) and decreased disease adjustment, health promotion, self-advocacy, and self-efficacy for negotiating safe sex and safe sex practices (Herek et al., 2009). When women are empowered by HIV prevention efforts, they experience increased self-image, control over healthcare treatment decisions, self-efficacy, increased knowledge, and a positive sense of self as individuals and in relationships (Norris & DeMarco, 2005).

In non-HIV studies, such as breast cancer survivorship, self-image is related to relationship

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satisfaction and a positive feminine identity (Zimmermann, Scott, & Heinrichs, 2010). Self- image is a factor which affects risk behavior and perceptions of risk for unplanned pregnancies and is a predictor of the ability to negotiate safe sex behaviors (Zimmermann et al., 2010). In women, there is a relationship between poor self-image, depression, and lack of self-advocacy in sexual relationships (DeMarco, Johnsen, Fukuda, & Deffenbaugh, 2001). From a treatment perspective, depressive symptoms are underdiagnosed and are associated with lower medication adherence, risky behaviors, and poor health outcomes (Lennon, Huedo-Medina, Gerwien, & Johnson, 2012). Lack of adherence to antiretroviral medication schedules has an effect on CD4 and viral load counts (i.e., adherence slows the progression of HIV, thereby maintaining health and survivorship). Substance abuse (drugs and alcohol) in HIV-infected persons decreases the use of appropriate and needed healthcare interventions, and in addition, it decreases HIV prevention by increasing the likelihood of risky sexual behavior (Liebschutz, Geier, Horton, Chuang, & Samet, 2005).

Exosystem: Formal and Informal Social Structures Simoni, Walters, and Nero (2000) found that in women of African descent (black Hispanics, non-Hispanic blacks) living in New York City, disclosure of their HIV status to adult family members, friends, and coworkers was related to greater frequency of HIV-related social support but was not directly related to a decrease in depression or mood disturbance. During and after disclosure, social support was found to help with coping and improve psychological distress. Isolation, stigma, managing their medical care, and being a mother caused women to be unwilling to talk about their illness with their children, family, friends, and partners (DeMarco et al., 2001).

There is a strong connection between highly active antiretroviral therapy (HAART) and health. For poor women of color, adherence to medical protocols, which include HAART, and medical follow-up, as well as less high-risk behavior, is compromised by (1) believing that other people in their lives, specifically family and friends (children and sexual partners), come first; (2) subsisting on a low income, which affects resource allocation; (3) experiencing race discrimination, which magnifies the seropositive stigma; and (4) choosing to enter high-risk situations to obtain money (sex work) to change their circumstances. Many strategies are used to improve medication adherence, including counseling, support groups, educational information, telephone/computer-based feedback, improving motivation and self-efficacy, and directly observed therapy. Adherence may be improved with these strategies, but much needs to be understood within a particular group to determine their best use in a cost-effective manner (Haynes, Ackloo, & Sahota, 2008; Wolitski, Janssen, Onorato, Purcell, & Crepaz, 2005). However, despite the use of these methods, a proven method for implementing long-term behavior change remains unknown.

Social support includes relationships with family, friends, and community members. This is usually thought of as perceived social support; it represents the degree to which needs for relevant (or important) support are fulfilled by a person’s social network. High levels of depressive symptoms are related to lack of HIV social support from friends, relatives, partners, groups, and organizations. In contrast, increased social support improves self-esteem and mastery. Thus, interventions that include group support can benefit psychological health (Simoni, Huang, Goodry, & Montoya, 2005).

Psychosocial factors contribute to disease progression, which can be measured by CD4 and viral load levels. These levels are indirect measures of adherence to HIV medications (Ironson et al., 2005). Factors that support adherence to HIV treatment protocols include supportive family members and other emotional support, whereas barriers to adherence include stigma, feeling unloved, and relationship turbulence (Edwards, 2006).

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Macroculture: Values and Beliefs of Culture To reduce the spread of HIV/AIDS, women who are seropositive must reduce the number of instances when reinfection by other HIV strains may occur, and protect partners from the virus by increasing safe sex behaviors. Safer sex strategies, from adolescence and onward in sexual development, include assertiveness, self-advocacy to negotiate protection during intercourse, verbal strategies, avoidance of drugs and/or alcohol consumption before or during sex, and avoidance of contact with potentially infected body fluids (Buzi et al., 2013). Negotiated safer sex in adults has almost exclusively been associated with condom use (Widman, Carol, & Noar, 2013). Because of the belief that partners are not sexually active with others, heterosexual adults use condoms less often with primary or regular partners than with casual sexual partners (Widman et al., 2013). In addition, as mentioned earlier, many social and situational factors contribute to decreases in behavior that may prevent HIV in women, such as feeling intense stigma, victimization, substance abuse, mental health problems, and contracting other STIs (Crepaz et al., 2007; Mize, Robinson, Bockting, & Scheltema, 2002).

Gender roles in women and, in particular, the need to maintain connection in relationships at the cost of one’s own health are major issues for all women living with chronic diseases, but particularly for those who are HIV-positive (DeMarco & Johnsen, 2002, 2003; DeMarco, Lynch, & Board, 2002; DeMarco, Miller, Patsdaughter, Grindel, & Chisholm, 1998). Jack (1991, 1999) discussed the concept of silencing in the context of women’s experiences with relationships. Jack’s work is relevant today, since the experiences women have in relationships continue to be oriented toward understanding and defining themselves in the context of others. Jack supports the position that women’s relationships are influenced not only by biologic factors but also by psychosocial factors (Bancroft, 2002) and asserts “women’s orientation to relationships is the central component of female identity and emotional activity” (Jack, 1991, p. 3). This researcher’s extensive exploratory and longitudinal studies with diverse groups of women resulted in the development of the concept of “silencing the self” and the Silencing the Self Scale. This concept of “silencing the self” has been used to explain how gender roles negatively influence self-advocacy behaviors in women. Women tend to silence their voice in relationships in order to maintain connections with others, even if that means they will subsequently suffer physically, psychologically, or socially. According to Jack (1991), women are reinforced culturally to (1) care for others’ needs before their own, (2) abide by designated societal rules of behavior, (3) refrain from directly expressing their feelings and needs, and (4) outwardly maintain compliance, while feeling hostility inwardly because of their silencing behaviors. Silencing the self is relevant to the proposed study because it is a concept that is identified and understood in the context of relationships with others (i.e., a relational concept). The nature of intimate heterosexual relationships where seropositive safe sex occurs is an example of this relational context. Women living with HIV continue to be sexually active with men. Being quiet during times of sexual intimacy, rather than making direct requests and taking care of themselves, will not protect them against further strains of HIV and other STIs, and will infect others (DeMarco et al., 1998, 2001, 2002; DeMarco & Johnsen, 2002, 2003; DeMarco & Norris, 2004a, 2004b; Norris & DeMarco, 2004, 2005; Lanier & DeMarco, 2015).

HEALTH PROMOTION AND SECONDARY/TERTIARY PREVENTION FOR WOMEN LIVING WITH HIV/AIDS Using the ecologic model, the aim of any intervention to promote health and minimize the spread of HIV/AIDS requires the creative inclusion of a prevention initiative that is community- based, peer-led, and interdisciplinary. Advancing the scientific understanding of secondary HIV

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prevention (what is called positive prevention) and exploring ways to reduce behavioral risk in African American women may prevent further transmission of HIV and the serious negative psychological consequences of living with HIV disease. African American women experience disproportionate levels of (1) interpersonal mistrust and fear of disclosure because of the fear of stigma, (2) poor adherence to treatment and other health promotion and disease prevention efforts, (3) delay in seeking care related to mental health comorbidities and addiction recovery issues, and (4) compromised self-advocacy in sexual relationships. An innovative, culturally relevant, and gender-sensitive intervention that would address these barriers for women who are already disproportionately saddled with HIV/AIDS, racism, ageism, and poverty would be beneficial not only to them but also to their families and the communities in which they live. Ultimately, public health nurses would be trying to improve health outcomes for this underserved population of women.

Within the context of HIV physical care and efforts to decrease communicability using the ecologic model, consideration should be given to mental health symptoms, severity/frequency of the effects from significant trauma (PTSD), substance use, abuse, and addiction. In Table 5.1, the sectors of the model and areas that need to be considered to address prevention are shown as a process of collaboration between interdisciplinary teams, evidence, and real, population-based needs.

The previous sections of this chapter provided a theoretical grounding in varied frameworks, which can guide the planning, implementation, and evaluation of health promotion and disease prevention interventions and programs. In addition, empirical evidence of the use and effectiveness of the frameworks was discussed. The following sections explore the centrality of health literacy in its relationship with health education and health promotion.

TABLE 5.1 Ecologic Model with Health Promotion and Disease Prevention Considerations for African American Women Living with HIV

Ontogenetic System: Personal Factors

Microsystem: Relationship between the Individual and the Environment

Exosystem: Formal and Informal Social Structures

Macroculture: Values and Beliefs of Culture

Health history Physiologic indicators Comorbidities Mental health Age, education, marital

status, income, pregnancies, health history, sexual history, mental health symptoms

Effect of trauma CD4 count/viral load Sexually transmitted

infections

Relationships and influences in interactions in relationships

Stigma related to disclosure

Substance abuse/recovery Healthcare adherence Self-advocacy in sexual

relationships

Stressors or buffers that influence risky behaviors

Relationships with family, friends, community members

Healthcare adherence, substance use, self- advocacy in sexual relationships

Stigma

Culture of women Culture of African

American women Self-advocacy in sexual

relationships Stigma

Health literacy, health education, and health promotion are interrelated concepts, which individually and collectively have substantial effects on the health and well-being of individuals, families, and communities. Health literacy, health education, and health promotion seek to change knowledge, skills, attitudes, behavior, and social determinants to improve the health outcomes of individuals, families, and communities. Community and public health nurses are well-positioned to partner with individuals, families, and communities and to work collaboratively to initiate and maintain needed change. To be effective, nurses and their clients must understand health literacy and how the level impacts both access to healthcare and health outcomes. In addition, nurses must have skill in adapting health communication, health

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education, and health promotion strategies so that they can be clearly understood and acted upon by individuals, families, and communities at varied levels of health literacy.

The promise of health literacy is the promise of improved health. Pleasant et al., 2016

HEALTH LITERACY Origins of Health Literacy The concept of health literacy has evolved over the past two decades. Initial interest in health literacy stemmed from population studies of adult literacy. The 1992 National Adult Literacy Survey (NALS) conducted by the U.S. Department of Education revealed a surprisingly high prevalence of low literacy among the U.S. adult population (Weiss et al., 2005; Zarcadoolas, Pleasant, & Greer, 2009). This survey defined literacy as “the ability to use printed and written information to function in society, to achieve one’s goals, and to develop one’s knowledge and potential” (National Center for Education Statistics, 1993, p. 6). The survey categorized literacy into three general kinds of tasks: (1) prose tasks, which measure reading comprehension and ability to extract themes; (2) document tasks, which assess the ability of readers to interpret documents (consent forms, insurance forms); and (3) quantitative tasks, which assess the ability to work with numerical information embedded in written material (figure taxes, calculate calories on a nutrition checklist) (National Center for Education Statistics, 1993). As low literacy can negatively impact everyday functioning, questions were raised as to how low literacy might affect health and healthcare. Therefore, the concept of health literacy began getting attention in the 1990s.

The initial focus was on the content of health-related written materials, and the readability of that content. It was assumed at the time that most health consumers had the literacy skills to be able to read and understand materials disseminated by healthcare providers. However, multiple studies that examined the reading level and suitability of health materials across an array of health topics found repeatedly that the written materials exceeded the average reading ability of the public. For example, one out of five American adults read at the fifth grade level or below, and the average American adult reads at the eighth or ninth grade level, yet most healthcare materials are written at the 10th grade level (NPSF, 2018). This serious mismatch was found to contribute to inaccessibility of understandable health education and communication and to adverse events, compromising healthcare safety and quality.

In 2003 and most recently in 2016, the U.S. Department of Education, National Center for Education Statistics conducted the National Assessment of Adult Literacy (NAAL) and the Program for the International Assessment of Adult Competencies (PIAAC, 2016), which assessed the status of English adult literacy in the United States. For the first time, health literacy was included as a component of the larger assessment, providing the first nationally representative sample measuring the ability of the American public to read, understand, and apply health-related information (White, 2008). The results of this study provided insight into the levels of health literacy in the U.S. population. As community health nurses provide both individual and group health education and health promotion interventions, understanding the definitions and levels of health literacy is critical.

Definitions and Basic Level of Health Literacy The definition of health literacy has and continues to evolve (Cutilli & Bennett, 2009; Nuttbeam, 2000). Initially health literacy was viewed primarily as an individual’s ability to read health

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information. As the routes (verbal, written, media, internet) of health communication were viewed more broadly, the healthcare system became more complex, and the expectations for shared decision making (health consumer and health provider) and self-care increased, the definition of health literacy expanded (Cutilli & Bennett, 2009). Rather than just focusing on an individual’s ability to read health information, the Institute of Medicine (now the National Academies of Science) (2004) expanded the definition of health literacy to include, “The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate decisions” (p. 32). This is one of the most widely used definitions and, like others, considers the individual’s capacities, such as conceptual knowledge, and listening, speaking, numeracy, reading, and writing skills, along with abilities to access information and services, and uses all this information to make effective health-related decisions (Healthy People 2020, 2017a; IOM, 2004; Speros, 2006). Attention, although broadened beyond the written word, still was directed toward the abilities of the individual health consumer, and there was a widely held assumption that general literacy assured health literacy, and that most of the American public could understand basic health information as it was presented in health-related materials. This level of health literacy is referred to as functional health literacy, as it involves the basic level of reading and writing skills to obtain, understand, and apply information related to health risks, medication prescriptions, or access to health services (Nutbeam, 2000). The results of the NAAL were eye-opening, as it had a subsection specifically on health literacy, in demonstrating that health literacy was different than general literacy, and that proficiency in health literacy was very low in the U.S. population.

The 2003 NAAL study remains the only population-level study of health literacy and continues to be cited in the literature (National Center for Education Statistics, 2006). The health literacy tasks focused on the skills needed to address typical health-related materials, including insurance forms, medication labels, and pamphlets about specific diseases. The health-related tasks were divided among three principal healthcare domains: (a) clinical, (b) preventative, and (c) navigation of the healthcare system. The results showed that many U.S. adults struggle to understand healthcare information, with over one third (77 million people) at a basic or below basic health literacy level, who could therefore be confused about basic healthcare tasks such as how to take their medications by reading the label, how to follow a childhood immunization schedule by reading a standard chart, or how to understand critically important warnings on the label of an over-the-counter medication. Just over half demonstrated intermediate health literacy, whereby an individual could determine cause and effect, make simple inferences, and read instructions on a prescription label and determine what time to take the medication. Only 12% of Americans were proficient in health literacy, meaning that they could handle more complex health-related tasks, for example, using a table to calculate an employee’s share of health insurance costs for the year, or understanding a risk–benefit ratio. The results of the study also provided insights about risk factors for low health literacy and preferences for sources of health information. Other studies have identified an array of knowledge and skills that are related to health literacy (Speros, 2011).

Increasing Interest in Health Literacy Beyond the shocking prevalence of limited health literacy, three other factors fueled increasing interest in and study about health literacy: the risk factors contributing to low health literacy, the wide range of knowledge and skill required for proficient health literacy, and the relationship between health literacy and health outcomes. The increasing and ongoing study of health literacy revealed that limited health literacy can affect anyone and crosses gender, age, race, ethnicity, and socioeconomic status (IOM, 2004; Speros, 2011). However, beginning with the NAAL study and supported by subsequent studies, factors such as age, income, education, race,

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and linguistic ability were found to influence health literacy and contribute to health disparities (Rikard, Thompson, McKinney, & Beauchamp, 2016). Box 5.8 identifies the populations that have been found to be at the highest risk for limited health literacy.

Health literacy has been described as a state, not a trait, as it can be variable within the same individual, based on context (Berkman, Davis, & McCormack, 2010). The complexity of the task and the condition of the individual influence health literacy. Even adults with strong literacy skills can face health literacy challenges and feel overwhelmed, typically in situations when they (a) are not familiar with medical terms or how their body works, (b) have to interpret numbers or risks to make a healthcare decision, (c) are diagnosed with a serious illness and are scared or confused, or (d) have complex conditions that require complicated self-care. Therefore, health literacy is not a fixed characteristic but able to change during an individual’s lifespan, influenced by education, aging, culture, social interaction, life experiences, and specific context (IOM, 2004; Nutbeam, 2008).

Knowledge and Skills Related to Health Literacy Adults at the below basic level for health literacy were the least likely to use any written material to obtain information on health topics with 43% indicating that they used written information infrequently, far less than those at the intermediate or proficient level. Nonprint sources, including broadcast media, such as radio or television, were rated higher than any type of print source. The lower the health literacy level, the less apt the individual would be to use the internet as a source of health information. Only 15% of adults with below basic health literacy used the internet “some” or “ a lot” compared to 31% of adults with basic health literacy, 49% of adults with intermediate health literacy, and 62% of adults with proficient health literacy. This is an issue, as being computer-literate (able to operate and navigate a computer, portals with health information, and web-based health information) has been identified as one of the competencies for health literacy. Figure 5.4 illustrates the role of the community health nurse in educating an older adult in the use of computer technology to gain access to trustworthy health information. All adults, regardless of their health literacy skills, reported that they were more likely to get health information from nonprint sources, such as radio/television, friends/family, and most often health professionals (National Center for Education Statistics, 2006).

5.8 Populations at Risk for Low Health Literacy

Adults over 65 Individuals with limited education or low income Non-native speakers of English Racial and ethnic minorities Recent refugees and immigrants Adults with any type of disability, difficulty, or illness

Source: National Center for Education Statistics. (2006). The health literacy of America’s adults: Results from the 2003 national assessment of adult literacy. Washington, DC: U.S. Department of Education.

Further exploration of what constitutes health literacy has revealed that it requires broad knowledge and skills applied to a wide range of health topics, tasks, and situations. Beyond reading, health literacy involves a complex group of listening, computational, navigational, analytical, and decision-making skills, and the ability to apply these skills to varied health situations. Healthcare consumers need to be able to obtain, evaluate, and apply health-related information, which can require the use of technology. They need computational skills to calculate insurance premiums, deductibles, and copays, and analytical skills to make comparisons. For safe and accurate medication administration, the healthcare consumer must be

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able to read and interpret the prescription label or over-the-counter medication instructions and warnings, calculate or measure doses, understand the desired effect and potential side effects, obtain refills, and determine insurance medication benefit. Table 5.2 identifies the varied health literacy skills and tasks required for self-health management.

FIGURE 5.4 A community health nurse teaching an older adult how to navigate the web and find credible health information.

TABLE 5.2 Skills and Tasks Required for Health Literacy Aspects of Health Literacy Examples of Skills and Tasks Information-literate Reading ability

Comprehend complex health information Identify key information from dense text Understand directions for medication Understand nutrition labels Understand and follow directions for varied health-related procedures

and treatments Understand information to give informed consent Read and follow appointment slips Apply written information to make effective health-related decisions Find credible health-related information independently

Visually literate Understand and apply information from graphs, charts, diagrams, pictures, graphic instructions

Communication-literate Provide a health history Describe symptoms Ask and respond to health-related questions Listen and understand verbal instructions and teaching

Computationally literate Calculate doses Calculate calories within specialized diets Measure liquid medications Calculate deductibles, co-payments, and premium costs

Analytically literate Compare and analyze insurance costs and covered benefits Understand risk–benefit ratio of treatment options and health

promotion activities Interpret test results (blood glucose, peak flow results, etc.)

Computer-literate Operate a computer Navigate the internet Obtain, evaluate, and apply web-based health-related information Access and use personal information from a health portal

Source: Agency for Healthcare Research and Quality. (2010). Health literacy universal precautions tool-kit. AHRQ publication no. 10-0046-EF. Rockville, MD: AHRQ. Retrieved from http://www.ahrq.gov/qual/literacy/index.html; Institute of Medicine. (2004). Health literacy: A prescription to end confusion. Washington, DC: The National Academies Press; and Speros, C. (2011). Promoting health literacy: A nursing imperative. Nursing Clinics of North America, 46,

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321–333.

Health Outcomes Linked to Health Literacy Studies have shown that limited health literacy is associated with multiple suboptimal health outcomes. Adults with low health literacy have a higher risk and rate of hospitalization, and higher use of emergency room service (Baker et al., 2002; Schillinger, 2002). However, they are less likely to access preventative care, and had lower use of mammography and receipt of flu shots (IOM, 2004; White, Chen, & Atchison, 2008). Other problematic areas revealed that adults with low health literacy had less ability to interpret labels and health messages, and demonstrated poor ability in accurate self-administration of medications (Bennett et al., 2009). Among older adults, those with low health literacy presented lower overall health status and higher mortality (Baker et al., 2007). Patients with low health literacy and chronic diseases such as diabetes, asthma, or hypertension have less knowledge of their disease and its treatment and fewer correct self-management skills than literate patients (AHRQ, 2010a). Among primary care patients with type 2 diabetes, inadequate health literacy is independently associated with worse glycemic control and higher rates of retinopathy. Inadequate health literacy may contribute to the disproportionate burden of diabetes-related problems among disadvantaged populations (Schillinger, 2002).

In addition to the effects of low health literacy on the individual, there are economic consequences of low health literacy to society. Low health literacy is an enormous cost burden on the U.S. healthcare system. According to the report Low Health Literacy: Implications for National Health Policy, “low health literacy is a major source of economic inefficiency in the U.S. healthcare system” (Vernon, Trujillo, Rosenbaum, & DeBuono, 2007). Annual costs for individuals with low health literacy are four times higher than those with higher literacy skills. The annual cost of low health literacy to the U.S. economy was $106 billion to $238 billion (Vernon et al., 2007). This represents between 7% and 17% of all personal healthcare expenditures. Medical errors and behaviors labeled as noncompliant may be based on poor understanding of the healthcare information. Inpatient spending increases by approximately $993 for patients with limited health literacy (Howard, Gazmararian, & Parker, 2005). Improving health communication reduces healthcare costs and increases the quality of healthcare.

Expanding Responsibility for Health Literacy Low health literacy was initially viewed as an individual client’s deficit, that is, a client’s lack of knowledge and skills regarding health issues. The alarming prevalence of low health literacy and the concerning, varied, and serious negative health outcomes linked to limited health literacy drew increasing attention. It was evident that issues of health literacy went beyond reading written materials and individuals’ abilities. Health literacy began to be viewed as a systems problem within healthcare, reflecting the complexity of both the presentation of health information and navigation of the healthcare system (Parker & Ratzan, 2010; Rudd, 2010). It was becoming apparent that the healthcare consumer, healthcare provider, healthcare system, and government all have a role to play in addressing limited health literacy.

The Joint Commission (TJC), the major accrediting organization for healthcare organizations in the United States, recognizes the importance of health literacy and health communication as a critical component of patient safety and quality healthcare. TJC acknowledged the relationship among health literacy, health communication, and patient safety, stating in a 2007 report, “Health literacy issues and ineffective communications place patients at greater risk of preventable adverse events. If a patient does not understand the implications of her or his diagnosis and the importance of prevention and treatment plans, or cannot access healthcare services because of communications problems, an untoward event may occur” (TJC, 2007, p. 7).

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In addition, TJC’s accreditation standards “underscore the fundamental right and need for patients to receive information—both orally and written—about their care in a way in which they can understand this information” (TJC, 2007, p. 7). TJC called for more attention to the structure and function of the healthcare system and the manner in which it can be changed to “permit patients to receive more time, attention, education and understanding of their conditions and their care” (TJC, 2007, p. 49).

Three federal policy initiatives also addressed health literacy. The Affordable Care Act of 2010 addressed efforts to improve health literacy in two areas: (a) incorporating health literacy into professional training; and (b) requiring that the health plans and insurers provide consumers with clear, consistent, and comparable health information in a standardized summary of benefits and coverage template. The National Action Plan to Improve Health Literacy provided seven coordinated health literacy goals (Box 5.9) for the United States, based on the following two principles: (a) all people have the right to health information that helps them make informed decisions, and (b) health services should be delivered in ways that are understandable and lead to health longevity, and good quality of life (USDHHS, 2010). The Plain Writing Act of 2010 requires all new publications, forms, and publicly distributed documents from the federal government to be written in a clear, concise, and well-organized manner so that the public can understand and use them.

These notable reports and regulations have moved health literacy from a limited focus on an individual’s capacity to read and comprehend health information to a healthcare system’s issue related to the responsibilities of provider communication, and the challenges of navigating the complex system, and further to an issue of health policy and reform.

Practice Point

Health literacy influences the ability to understand, interpret, and act on health information.

5.9 The National Action Plan to Improve Health Literacy’s Seven Health Literacy Goals

1. Develop and disseminate health and safety information that is accurate, accessible, and actionable. 2. Promote changes in the healthcare system that improve health information, communication,

informed decision making, and access to health services. 3. Incorporate accurate, standards-based, and developmentally appropriate health and science

information and curricula in childcare and education through the university level. 4. Support and expand local efforts to provide adult education, English language instruction, and

culturally and linguistically appropriate health information services in the community. 5. Build partnerships, develop guidance, and change policies. 6. Increase basic research and development, implementation, and evaluation practices and

interventions to improve health literacy. 7. Increase the dissemination and use of evidence-based health literacy practices and interventions.

Source: U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2010). National action plan to improve health literacy. Washington, DC: Author. Retrieved from https://health.gov/communication/hlactionplan/pdf/Health_Literacy_Action_Plan.pdf.

HEALTH LITERACY AND HEALTH EDUCATION As further understanding of the impact of low health literacy emerged, efforts were directed at

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communication between healthcare providers and their clients, and clients’ ability to navigate the healthcare delivery system and more actively participate in self-care. Expectations in healthcare are changing and moving away from the healthcare provider as the expert and in charge of care. Health promotion and disease management are becoming more of a shared responsibility of the individual and the healthcare provider. In actuality, more and more is being expected of individuals and their informal family caregivers. If individuals are unable to understand what is taught or prescribed, then follow-through will be poor in relation to health behavior changes and the many tasks needed to manage chronic disease and to promote health. Consequently, another level of healthcare literacy, beyond functional health literacy, was proposed. Interactive health literacy refers to more advanced cognitive and social skills that empower an individual’s active participation in healthcare, promotes more shared decision making between the healthcare provider and their clients, and increased responsibility for self- care management of both disease and health promotion (Fernandez-Gutierrez, Bas-Sarmiento, Albar-Marin, Paloma-Castro, & Romero-Sanches, 2017; Nutbeam, 2000). Community health nurses provide health education and care coordination, and promote the client’s self- management of chronic conditions and health maintenance in many settings, including homes, schools, and ambulatory clinics. Therefore, nurses must have the knowledge and skill to assess and understand the health literacy levels of their clients in order to improve the safety and quality of the care they provide.

Health Literacy Competencies and Practices Useful in Health Education Health communication and health education seek to change knowledge, skill, and behavior, and ultimately to improve health and well-being. For change to occur, nurses and other healthcare providers must ensure that their oral and written health communication is presented in a manner that clients can comprehend and utilize. Addressing health literacy requires the use of clear and effective communication practices. Coleman, Hudson, and Pederson (2017) had 25 health literacy experts examine 32 previously identified health literacy and clear communication practices and competencies (knowledge, skills, and attitudes) (Coleman, Hudson, & Maine, 2013; Toronto, 2016; Toronto & Weatherford, 2015), and rank them in order from high to low importance. Consensus among the experts revealed a cluster of eight top-rated practices. Box 5.10 describes these practices, which provide guidance for healthcare providers in improving their health communication and health education strategies and outcomes. Toronto’s (2016) study of health literacy competencies for nurses examined knowledge, skills, and attitudes. The highest-rated knowledge competency focused on the importance of knowing that all individuals, regardless of their literacy level, prefer and benefit from clear, plain language communication. The most frequently identified skill related to the nurse’s ability to speak slowly and clearly. Regarding attitude, the findings emphasized the nurse’s understanding that you cannot tell who is at risk for low literacy by looking or even interacting with them. Therefore, nurses need to approach all health communication and education using health literacy universal precautions.

5.10 Eight Top-Rated Health Literacy Practices (Consensus From Experts)

1. In written and oral communication avoids using medical terminology, and when avoidable, clearly defines using lay terms

2. To assess understanding (knowledge) and ability (skill) and correct any misunderstandings of material taught/shared, uses a “teach-back” or “show-me” method

3. Invites questions from patients using a patient-centered approach (e.g., “what questions do you have”

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rather than “do you have any questions”) 4. Uses health literacy universal precautions method in written and oral communication with all patients 5. Uses a professional medical interpreter when communicating with a patient whose preferred language

is other than English 6. Partners with the patient from the outset of the encounter negotiating a mutual agenda 7. Prioritizes health messages/teaching with emphasis on one to three “need to know” or “need to do”

concepts during a clinical encounter 8. At the beginning of the clinical encounter asks the patient to share all of his or her concerns

Source: Coleman, C. A., Hudson, S., & Maine, L. L. (2013). Health literacy practices and educational competencies for health professionals: a consensus study. Journal of Health Communication, 18(Suppl 1), 82–102.

Health Literacy Universal Precautions As limited health literacy is so prevalent in the United States, is difficult to determine, and can vary based on the client’s current condition and the complexity of the health-related information or task, experts recommend that healthcare providers adopt the use of health literacy universal precautions, meaning that “healthcare providers make all health information easier to understand, confirm everyone’s comprehension, and reduce the difficulty of health-related tasks” (Liang & Brach, 2017, p. e216). Through the use of health literacy universal precautions, community health nurses can structure health communication and education to improve client understanding, informed decision-making, and ability to follow-through on a mutually established plan of care. Health literacy universal precautions promote specific strategies and practices that should be used with all clients to reduce the common mismatch that occurs between a clinician’s level of communication and a client’s level of comprehension. In fact, evidence shows that clients often misinterpret or do not understand much of the health information given to them by healthcare providers. This lack of understanding can lead to medication errors, poor self-management of chronic conditions, limited participation in health promotion activities, and adverse health outcomes (AHRQ, 2010a; Bennett et al., 2009).

ESTABLISHING A SUPPORTIVE LEARNING ENVIRONMENT No matter what the setting in which the community health nurse is providing health teaching, a supportive, shame-free learning environment in which clear communication is intentionally used must be established. The learning environment should foster clients as active partners in their healthcare, specifically by encouraging clients to ask questions. Clients may be embarrassed to ask questions, or not know how to express their question, particularly when the nurse appears pressed for time or unsupportive. Asking “What questions do you have?” communicates to the client an expectation that they should have questions and will more likely encourage questions, rather than saying “Do you have any questions?” which typically leads to a “no” answer by clients even if they do have questions. In addition, the nurse can support client questioning by (a) making it clear that the nurse has time and wants to address questions; (b) sitting at the same level as the client (not standing); (c) looking at the client, listening attentively, and not interrupting; (d) helping the client to prioritize his or her questions; and (e) encouraging the client to write down questions before interactions with any healthcare provider (primary care provider, specialist, pharmacist) (AHRQ, 2010b).

EFFECTIVE QUESTIONING An effective tool for community health nurses to teach clients is the Ask Me 3 Good Questions for Good Health developed by the National Patient Safety Foundation (now available through the Institute for Healthcare Improvement). Community health nurses should teach these three questions to their clients, and encourage them to ask these questions every time they meet with a healthcare provider. The questions are:

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What is my main problem? What do I need to do? Why is it important for me to do this?

Ask Me 3 can provide a useful guide for clients, encouraging them to speak up and ask questions. These three questions are useful in focusing important conversations; making all clinical encounters and health education sessions interactive can increase understanding for both the provider and the client. Clients are more apt to follow a plan of care if they understand what the problem is, specifically what they need to do, and the rationale for the actions advised. However, community health nurses can also use it to structure how they share information with clients to ensure that the answers to the three questions are provided in the course of the conversation.

EVIDENCE-BASED HEALTH LITERACY UNIVERSAL PRECAUTIONS The Agency for Healthcare Research and Quality has developed a Health Literacy Universal Precautions Toolkit (https://www.ahrq.gov/professionals/quality-patient-safety/quality- resources/tools/literacy-toolkit/index.html) that provides evidence-based guidance to improve health communication between healthcare providers and clients at all levels of health literacy. The toolkit includes 21 tools and 30 resources addressing four domains that are essential for the promotion of health literacy: (a) spoken communication, (b) written communication, (c) self- management and empowerment, and (d) supportive services.

Research has demonstrated that for spoken language, the healthcare provider should avoid medical jargon; use simple, clear, lay terms; speak clearly and slowly; and listen attentively. The amount of information should be limited with no more than four main messages all focusing on the desired behaviors and actions, which are repeated and reinforced during the session. Most people prefer clear communication using simple words and short sentences, covering the essential, need-to-know information. Using pictures or other visuals and everyday examples to supplement the teaching is effective (Speros, 2011).

Written health education materials should also use simple terms, active voice, and short sentences. They should be easy to read, using bulleted lists, beginning with the most important information first and limiting the amount of information. Headings and subheadings are useful in separating and introducing new information. Pictures and graphic illustrations are helpful in improving understanding and retaining information (Speros, 2011).

The focus of health communication and education should be on moving the client to well- informed, self-care management of all aspects of their health, including management of illnesses and preventative and health promoting activities. Promoting clients as active partners in their healthcare decisions and management supports client empowerment.

Table 5.3 summarizes health literacy universal precautions evidence-based practices. Studies have shown that 40% to 80% of the medical information patients receive is forgotten

immediately and nearly half of the information retained is incorrect (Kessels, 2003). It cannot be assumed that what the nurse has taught has been understood by the client and that the client can act on it. Therefore, another important health literacy–health education related tool is using the teach-back method every time the nurse shares health-related information with a client. The purpose of this teach-back technique is to ensure that the nurse has explained the information clearly and that the client has accurately understood the information. The nurse asks clients to explain in their own words what they have been taught, what they need to know, and what they need to do. If a client is unable to teach back the information, the nurse would explain the information again, reassess, and repeat the process until the client can demonstrate understanding. A variation of the teach-back method is the show-me method, wherein the nurse has the client demonstrate a skill, such as blood glucose monitoring or medication administration, so that the nurse and client are confident in the client’s ability to perform the

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skill at home. Effectiveness of the teach-back technique has been shown to improve client– provider communication, client follow-through on plans of care, and client health outcomes (Sudore & Schillinger, 2009). Clients who understand their personal health information make fewer mistakes and demonstrate greater follow-through with instructions. Health literacy can be improved through intentional provision of information, effective communication, and structured education.

TABLE 5.3 Health Literacy Universal Precautions Practices in Health Communication and Education

Health Literacy Domain Practices Written communication Use plain, simple words

Avoid medical jargon Write at the fifth grade level Use short sentences Use bulleted lists Use active voice Focus on no more than four key points Begin with most important point Use headings and subheadings to separate information Chunk similar information Use white space and reasonable font size Add pictures graphic illustrations to illustrate information Summarize key points at the beginning and the end

Spoken communication Establish a shame-free learning environment Show respect and a helpful, caring attitude Face the client Speak slowly, clearly Use simple, everyday language, avoiding medical jargon Encourage questions Teach clients to use Ask Me 3 Repeat and review key points Use written information, pictures, videos, and other visual aids to

reinforce spoken communication Use teach-back and show-me methods to verify comprehension Summarize at the end

Source: Agency for Healthcare Research and Quality (AHRQ). (2010). Health literacy universal precautions tool-kit. AHRQ publication no. 10-0046-EF. Rockville, MD: AHRQ. Retrieved from http://www.ahrq.gov/qual/literacy/index.html; Speros, C. (2011). Promoting health literacy: A nursing imperative. Nursing Clinics of North America, 46, 321–333.

Evidence for Practice

Bailey and team (2016) completed a mixed-methods study to determine if a health literacy universal precautions approach resulted in similar or different satisfaction levels among low and high health literacy participants. This study was part of a larger research project that tested the effectiveness of SIPsmartER, a six-month behavioral intervention designed using a health literacy universal precaution approach. The intervention was directed at reducing the sugar-sweetened beverage (SSB) intake in a population of rural-dwelling, low socioeconomic adults. The intervention was comprised of several health education components including 3 small group classes, one live teach-back call, 11 interactive voice response (IVR) calls, personal action planning, and self-monitoring (SSB) logs. The researchers analyzed the program’s interview-administered summative evaluation, which was completed by 105 participants (68 identified as high and 37 low health-literate).

Overall results demonstrated no significant differences in the satisfaction of each of the interventions components and that participants with low and high health literacy benefitted from and were satisfied with an intervention designed using health literacy universal precautions. Quantitative data revealed that each component was positively evaluated. The

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small group classes received the highest rating and were chosen as the most motivating by both groups. A higher number of low health literacy participants liked the content and length of the IVR system as compared to the high health literacy participants. The IVR calls reviewed and reinforced information from the small group sessions and may have been more beneficial to the low health literacy participants; however, the completion rate of the IVR calls was the same for both groups. Qualitative findings indicated more likes than dislikes in both groups.

HEALTHY PEOPLE 2020 AND HEALTH LITERACY Healthy People 2020 acknowledges the relationship among health literacy, health communication, and health outcomes. Health communication objectives were identified to improve population health outcomes and healthcare quality and to achieve health equity. The objectives proposed that improvements in health communication will provide accurate, understandable, actionable, tailored health information that will contribute to improved health literacy, which should support better health outcomes.

Two overarching health communication objectives identified in HP 2020 are: a. Improve the health literacy of the population b. Increased proportion of persons who report that their healthcare providers have satisfactory

communication skills

5.11 Healthy People 2020: Health Communication Objectives

Increase the proportion of persons who report that their healthcare providers always explained things so they could understand them. Increase the proportion of persons who report that their healthcare provideres always gave them easy-to-understand instructions about what to do to take care of their illness or health conditions. Increase the proportion of persons who report that their healthcare provider always asked them to describe how they will follow the instructions. Increase the proportion of persons who report that their healthcare providers always involved them in decisions about their healthcare as much as they wanted.

Source: Healthy People 2020. (2017a). 2020 Topics and objectives. Retrieved from https://www.healthypeople.gov/2020/topics-objectives.

Improved health literacy can empower individuals to assume more responsibility for their health and actively participate in better informed, shared decision making with their healthcare providers. The health communication sub-objectives measure an increase in the evidence-based practices outlined in health literacy universal precautions (Box 5.11).

Evidence for Practice

Improving health literacy is a goal included in the U.S. Department Health and Human Services’ national health promotion and disease prevention initiative, Healthy People 2020 (USDHHS, 2010). To track progress in the adoption of health literacy universal precautions, Healthy People 2020 selected measures of three health literacy strategies: (1) providing easy-to-understand instructions about what to do for self-management of an illness or health condition; (2) asking patients to describe in their own words, how they will follow the instructions (teach-back method); and (3) offering assistance in completing a form. Liang and Brach (2017) used data from the Agency for Healthcare Research and Quality’s Medical Expenditure Panel Survey (MEPS)— Household Component, which tracks progress in Healthy People 2020 healthy literacy measures to examine the extent of health

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providers’ use of recommended health literacy universal precautions. The findings, which analyzed changes from 2011 to 2014, did reveal an improvement in each measure. Seventy percent of adults reported always receiving easy-to-understand instructions (increased from 64% in 2011), 29% (up from 24% in 2011) reported that their providers always asked them to explain how they will follow the instructions, and 17% (up from 14% in 2011) were offered assistance in completing a form.

Practice Point

Improved health literacy should be a goal of health education and health promotion.

Health communication, health literacy, and health education can be more than the sum of their parts. By working together we can progress farther to improve individual and community health. Allen et al., 2017

HEALTH LITERACY AND HEALTH PROMOTION Both in practice and research, the focus of health literacy has been on individual abilities in basic functional literacy and interactive literacy, and health communication between clients and healthcare providers. Attention has been on the effect of low health literacy and the implementation of practices to alleviate the potential negative outcomes. Health literacy researchers and experts have suggested an additional perspective that views health literacy as an asset, which can increase through health education and health promotion (Pleasant et al., 2015). Low health literacy is linked to poor health outcomes and health disparities, while strong health literacy is connected to improved health outcomes. It has been suggested that improving health literacy could contribute to decreasing health disparities. To improve health literacy, health providers and consumers need to look beyond individual health literacy capacities and health providers’ health literacy competencies, to necessary system’s level changes in the social, economic, and environmental context (Allen, Auld, Logan, Henry Montes, & Rosen, 2017; Chinn, 2011; Rudd, 2015). In its landmark report, Health Literacy: A Prescription to End Confusion (IOM, 2004), the Institute of Medicine noted “improving individual health literacy requires great effort from the public health and healthcare systems, the education system, and society overall” (IOM, 2004, p. xiv). To realize the broader goal of improving health literacy across populations requires a larger effort, one that addresses health literacy at the community and population levels. This requires broadening definitions and another level of health literacy that are closely related to health promotion and public health, which address the social determinants of health and health disparities.

The following three expanded definitions of health literacy recognize the relationships among health literacy, health promotion, and public health. According to the World Health Organization’s (WHO) definition, health literacy “represents the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health. By improving people’s access to health information and their capacity to use it effectively, health literacy is critical to empowerment” (WHO, 2018b). Sørensen and colleagues (2012) also included health promotion in their enhanced definition, “Health literacy is linked to literacy and entails people’s knowledge, motivation, and competences to access, understand, appraise, and apply health information in order to make judgments and take decisions in everyday life concerning

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healthcare, disease prevention and health promotion to maintain or improve quality of life during the life course” (p. 3). In these expanded definitions, health literacy is viewed as an asset, an outcome of health promotion efforts, and as having both personal and social benefits. Advanced cognitive skills include critical thinking, analysis, decision making, and problem solving in a health-related context. These cognitive skills are combined with social skills of communication and questioning to empower individuals to improve their personal health status and the health of the communities in which they live (Crondahl & Karlsson, 2016).

Freedman and colleagues (2009) broadened the definition of health literacy to include a focus on public health and the community, “The degree to which individuals and groups can obtain, process, understand, evaluate and act upon information needed to make public health decisions that benefit the community” (p. 448). The authors propose that in addition to individual-level health literacy efforts, equal attention should be given to literacy about public health with more emphasis on primary prevention and population health. Health literacy is not just a personal resource; higher levels of health literacy within populations, such as public health literacy, yield social benefits, for example, by mobilizing communities to address the social, economic, and environmental determinants of health, which can be the root causes of health illiteracy. An emphasis on community recognizes that individuals and families are embedded in environmental and sociocultural contexts. This understanding supports the perspective that health literacy is a collaborative responsibility among individuals, communities, the healthcare system, the government, and other related societal institutions, to promote health and reduce health disparities among individuals, families, communities, and societies (Rudd, 2015).

Critical Health Literacy Critical health literacy reflects elements of the above definitions. This level of health literacy requires more advanced cognitive skills, coupled with social skills that can “be applied to critically analyse (sic) information, and to use information to exert greater control over life events and situations” (Nutbeam, 2000, p. 264). Chinn’s (2011) concept analysis of critical health literacy revealed three domains, including (a) critical appraisal of information, (b) understanding the social determinants of health, and (c) collective action. Similarly, Nutbeam (2000, 2008) asserts that critical literacy requires individual and collective action to understand and address the social, economic, and environmental determinants of health. People with critical health literacy can change general and organizational practices related to health, and communicate with leaders and politicians to realize changes they consider important. The author suggests a strong relationship between health promotion and health literacy. Nutbeam (2000) references the WHO’s (1986) Ottawa Charter for Health Promotion’s influence on defining health promotion, “as public health action directed toward improving people’s control over all modifiable determinants of health” (p. 261). Concern is not only for personal behaviors and lifestyle, but also for living and working conditions and public policy, all of which influence public health.

International Health Promotion Efforts Supporting Critical Health Literacy The United Nations ECOSOC Ministerial Declaration of 2009 provided a clear mandate for action: “We stress that health literacy is an important factor in ensuring significant health outcomes and in this regard, call for the development of appropriate action plans to promote health literacy. Indeed, knowledge and understanding remain powerful tools in health promotion” (WHO, 2016). Improving health literacy in populations provides the foundation for self and community empowerment, whereby individuals are enabled to assume an active role in

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improving their own health, and coalitions form to promote community action for health, and to move local, state, and national governments to meet their obligations in addressing public health issues.

Health Promotion and the Social Determinants of Health The Ottawa Charter for Health Promotion is an international agreement signed at the First International Conference on Health Promotion, organized by the WHO and held in Ottawa, Canada, in November 1986. The charter defines health promotion as “the process of enabling people to increase control over, and to improve, their health. It moves beyond a focus on individual behaviour (sic) and toward a wide range of social and environmental interventions” (WHO/Ottawa Charter for Health Promotion, 1986; WHO/Health Promotion, 2018). Health promotion seeks to both support individuals to assume responsibility for their own health and to work to create an environment in which they can be successful. It involves motivation and self- efficacy, community empowerment, and health-promoting political and social activism. Good health is a major resource for personal, family, community, social, and economic development and has an essential impact on the quality of life. Political, economic, social, cultural, environmental, behavioral, and biologic factors can either foster or limit health. Most communication and health education interventions remain focused on personal health and lifestyles. There is a real need to develop, implement, and evaluate interventions to improve knowledge, understanding and capacity to act on social, economic, and environmental determinants of health, thus developing individual and community empowerment. Public health literacy is as much citizen-based as it is expert-driven, and it can take multiple forms from voting to organizing grassroots initiatives to establishing healthy policies and structures.

The Ottawa charter identified five action areas for health promotion, which remain relevant today:

Build healthy public policies: Health promotion goes beyond healthcare. Health and health consequences should be considered in all public policies, including non-health sectors. Create supportive environments: Health is strongly affected by environmental factors. The environments in which people live, work, learn, and play must be structured to promote health and well-being. Strengthen community action: Community empowerment in health promotion activities must be emphasized. Community stakeholders need to be involved in all areas of community action including setting priorities, making decisions, and planning, implementing, and evaluation strategies to improve health. Develop personal skills: Health education is a component of health promotion that supports the acquisition of knowledge and skills required for self-management of health, informed decision-making, and participation in community action. Reorient health services: Responsibility for health is shared among individuals, community groups, health professionals and service institutions, and governments. Healthcare needs to move beyond its focus on illness and clinical interventions and services, toward a health promotion direction that embraces broader social, economic, cultural, political, and physical environmental factors that exert a strong influence on health.

As community health nurses focus on the multiple determinants of health, stressing the crucial social factors, and emphasize health promotion and disease prevention, they are well positioned to support the development of critical health literacy and community empowerment. The five action areas emphasized by the Ottawa Charter provide guidance for community health nurses as they develop individual and community-based health promotion activities, form community health action coalitions, and support efforts to address health in all public policies and create environments where healthy choices are accessible by all.

Health literacy at the community level has many implications regarding daily decisions

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about health promotion and disease prevention, not only for individuals, but decisions for and by the family and community units. Community-based health literacy interventions have been defined as “Any purposeful, organized activity to help a group of people find, understand, use, or communicate about health information, services, or issues for themselves or their communities” (National Academies of Sciences, Engineering and Medicine, 2018, p. 8). Health literacy in the community setting has profound influence on an individual’s and community’s ability to engage in negotiations, decision making, activism, and community level empowerment and development focused on health (Batterham, Hawkins, Collins, Buchbinder, & Osborne, 2016).

Practice Point

Health literacy, including all three levels (functional, interactive, and critical), is an asset that improves individual, family, and community health, and has the potential to reduce health inequities.

Evidence for Practice

Low health literacy among Korean American women has been identified as a significant barrier to their participation in breast and cervical cancer screening. Han and colleagues (2017) tested a community health worker (CHW)–led health literacy intervention on mammogram and Papanicolaou test screening among Korean American women. The authors used a cluster randomized control design to compare a CHW-led health literacy intervention with an educational control group. Participants had to be Korean American women aged 21 to 65, who were able to read and write in either English or Korean, and had not had a mammogram or Pap test in the past 24 months. Trained CHWs from 23 ethnic churches recruited the study sample of 560 women (intervention n = 278 and control n = 282). The control group received publicly available educational breast and cervical cancer brochures. The intervention group received an educational brochure tailored specifically to their risk factors. After receiving this, they received a two-hour health literacy training facilitated by the trained CHW, within a small group community-based setting. The training introduced key medical terms, and allowed practice of phrases in English and role play of a typical screening process. In addition, participants received practice reading and interpreting appointment slips and instructions, and guidance on how to effectively navigate the healthcare system screening process.

At the end of the small group meeting, participants received a DVD and guidebook that reinforced all aspects of the class. For six months, the CHWs initiated monthly calls to reinforce the knowledge and skill gained in the health literacy session, and assist with any navigational barriers. The researchers assessed self-report of mammogram and Pap test utilization at baseline, and medical record review at three- and six-month intervals. At six months, 56.1% and 54.5%, respectively, of those in the intervention group had received a mammogram and Pap test compared with 10.0% and 9.2%, respectively, of women in the control group. Having read all of the intervention materials was an important factor, as completing a screening test doubled for both cancers when a participant had read all materials compared to a participant who read only some or none. The CHW-led health literacy intervention was successful in promoting mammogram and Pap test screening among Korean American women, which could contribute to decreasing existing cancer health disparities among this population. In addition, the findings support the importance of transforming the design of health literacy training from a knowledge-based to a skills- building and empowerment focus.

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ROLE OF NURSES This chapter addresses real examples of how nurses, as part of an interdisciplinary team, can be involved in fundamental prevention and health promotion efforts. After using public health science and evidence to identify risk, the focus of prevention and health promotion can proceed using culturally relevant, sensitive, ethical, and creative ways to motivate others to consider health and wellness as individuals, groups, and communities. Historical behavior change theories are examples of how health science has developed in using psychology, sociology, anthropology, and ethical perspectives to advance efforts at the national level and beyond. Although primary prevention in particular is often overlooked as a critical component to health and wellness when it comes to resource allocation in the U.S. health system, in truth it is one of the most influential areas where nurses as teachers can make a difference in people’s lives.

In addition, the chapter explores the relationship among health literacy, health education, and health promotion, areas of healthcare in which community health nurses have a central role and responsibility. Understanding the complexities of health literacy is a core responsibility. Community health nurses need to integrate health literacy universal precautions best practices into their health education and health promotion interventions to improve health outcomes. Knowledge of the three levels of health literacy—functional, interactive, and critical—allows the community health nurse to intervene at the individual, provider, and community level.

KEY CONCEPTS National goals and directives to maintain the health of individuals, families, and communities are important road maps for healthcare professionals. Three levels of prevention assist health professionals to advance quality of life and health through the natural history of disease and disability. Identifying modifiable risk and using health promotion models to address change in behaviors, beliefs, attitudes, and intentions can significantly increase the health of individuals, families, and communities. Health literacy involves three levels: functional, interactive, and critical, all of which must be addressed to improve individual and public health. Health literacy, health education, and health promotion are interrelated and collectively work to support health self-management, effective provider–client communication and collaboration, and community engagement and activism to address the social determinants of health.

CRITICAL THINKING QUESTIONS

1. What does it mean to be healthy and well when diagnosed with multiple sclerosis? 2. Name community indicators that would demonstrate health and wellness for a particular geographic area. 3. What are the responsibilities of community and public health nurses in promoting health and decreasing

illness and injury in populations, families, and individuals? 4. Identify five key influences on health and wellness in the United States. 5. If national health policies are identified but cannot be funded because of national fiscal deficits, how would

community/public health nurses initiate support for these policies? 6. Choose a data-based publication that represents each level of prevention and take a position about which

level is the most complex to put into action for advancing health and wellness. 7. Critique behavior change from the perspective of measuring the change after a health promotion

intervention has been implemented (e.g., teaching communities to decrease saturated fat in their diet and to exercise more).

8. Evaluate the written teaching materials used at your clinical placement. Do they reflect the use of health

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literacy universal precautions? If not, take one and revise it using the universal precautions practices. 9. Reflect on your spoken communication with clients. Do you consider health literacy issues? List five ways

that you can use health literacy universal precautions in your spoken communication and then practice them at clinical and evaluate your competence.

COMMUNITY RESOURCES State and local departments of health (divisions of maternal and child health, communicable disease, occupational health, addictions, gerontology) YMCA/YWCA programs Gyms/athletic complexes State and local police departments Parks and recreation departments Places where blood pressure equipment is sold or screenings are available (local retail stores) School systems (school nurse associations) Local restaurants Air and water control areas Primary care physician and advanced nurse practices Dentists Elder services

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Chapter 6 Epidemiology: The Science of Prevention Patrice Nicholas and Patricia Lussier-Duynstee

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

There are in fact two things, science and opinion, the former begets knowledge, the latter ignorance.

Hippocrates

Science is organized common sense, where many a beautiful theory was killed by an ugly fact. Thomas Huxley

Get your facts first, then you can distort them as you please. Mark Twain

CHAPTER HIGHLIGHTS Defining epidemiology Development of epidemiology as a science Epidemiologic conceptual frameworks Applying epidemiologic principles in practice Assessment of health needs and assets Using assessment data for planning and implementing interventions Promoting healthy lifestyles Preventing and controlling outbreaks Contributing to a safe and healthy environment Evaluating the effectiveness of health services

OBJECTIVES Trace the origins of epidemiology. Comprehend the basic principles and scope of epidemiology. Contrast three epidemiologic conceptual models. Apply principles of epidemiology to Healthy People 2020. Relate the problem-solving process to both the epidemiologic process and the nursing process. Apply epidemiologic principles to the practice of public health nursing.

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KEY TERMS Epidemic: An outbreak that occurs when there is an increased incidence of a disease beyond

that which is normally found in the population. Epidemiologic triad: Model based on the belief that health status is determined by the

interaction of the characteristics of the host, agent, and environment. Epidemiology: Study of the distribution and determinants of states of health and illness in

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

Natural history: Course of a disease or condition from the onset to resolution. Outbreak: Epidemic usually limited to a localized increase in the incidence of the illness. Rate: Primary measurement used to describe either the occurrence or the existence of a specific

state of health or illness. Risk: Probability or likelihood that a disease or illness will occur in a group of people who

presently do not have the problem. Risk factor: Characteristics or events that have been shown to increase the probability that a

specific disease or illness will develop. Web of causation: Epidemiologic model that strongly emphasizes the concept of multiple

causation while de-emphasizing the role of agents in explaining illness. Wheel of causation: Epidemiologic model that de-emphasizes the agent as the sole cause of

disease while emphasizing the interplay of physical, biologic, and social environments.

CASE STUDY

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

In 2011, there were an estimated 782,500 gang members in the United States. In 2012, an increase brought the known total to 850,000, with an estimated 30,700 gangs, up from 29,900 in 2011. Gang members often come from socially and economically disadvantaged communities. In 2012, cities with populations of 50,000 or more had a prevalence of 85.6 as compared to suburban counties at 49.5, smaller cities at 25.4, and rural counties at 16.0. Gang members commit a disproportionate amount of violence and crime compared with youths not involved in gangs. Gang members are also more likely to use drugs and alcohol, as well as engage in unsafe sex. As a result, youths who belong to gangs can be considered a vulnerable population at increased risk for negative health outcomes. Public health nurses in large cities have developed programs that target youths in gangs. These nurses represent local healthcare facilities, community service agencies, churches, schools, businesses, and other neighborhood groups focusing on increasing access to expanded community health services, promoting healthy living behaviors and fostering a positive community environment. Healthy People 2020 (Centers for Disease Control and Prevention [CDC], 2010a) objectives include decreasing the proportion of secondary school students who report the presence of youth gangs at school during the school year with a baseline of 12.4% and a target of 10.4%.

(2012 National Youth Gang Survey; Healthy People 2020)

Katie, a public health nurse in Los Angeles, has developed a partnership with a local police department juvenile diversion program that offers a delinquency prevention program to young people from 13 to 18 years of age. These young people have been arrested for nonviolent offenses, such as possession of drugs, burglary, theft, joy riding, and vandalism. Some of these young people are gang members, and others are at risk for joining gangs because they come from neighborhoods with long histories of gang activity. Katie’s responsibilities are to lead interactive three-hour sessions that primarily focus on health-related issues for the youths. She identifies three topics for discussion: (1) major causes of morbidity and mortality in youth, (2) major health issues common in a particular age group, and (3) risk prevention and health promotion (adapted from Sanders, Schneiderman, Loken, Lankenau, & Bloom, 2009).

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L ike other types of modern science, epidemiology arose from building blocks constructedby ancient civilizations. Humans have experienced disease for as long as they haveexisted, and in the early days, attempts that people made to understand the onset of disease and to prevent its occurrence were crude. People perceived health as something holy, and healers looked to the spiritual world to protect health and prolong life. People often considered disease and disability as a great curse and a divine punishment, and they believed that amulets, totems, charms, and rituals prevented all sorts of evils. However, early cave dwellers experimented with medicinal plants and became adept at treating some illnesses. These discoveries were primarily a direct result of trial-and-error observations, enhanced by doses of curiosity, common sense, and chance.

For thousands of years, the practice of healing slowly developed as humans observed that more and more herbal remedies and therapeutic treatments had beneficial results. Some cultures, such as in Egypt, had an extensive repertoire of treatments. More than 700 remedies existed for ailments resulting from crocodile bites to infections following childbirth. Practitioners at that time reduced dislocations, aligned and immobilized fractures, and applied hot and cold treatments to reduce inflammation. People recognized and understood differences in individual constitutions and observed that many diseases were contagious in nature. Interestingly, they conceptualized the influence of the environment on the occurrence of disease. However, priests and religious healers kept most of this knowledge secret.

Hippocrates of Cos (460 to 370 bc), considered the father of modern medicine, was the first person to record these secrets in writing. In a textbook of medicine that was used for centuries, he recorded the belief that external factors in the environment were a cause of illness in humans. He wrote of the effects of seasons, winds, and water, as well as the characteristics of the ground. He encouraged healers to observe what are known today as lifestyle patterns: “what are their pursuits, whether they are fond of drinking and eating to excess, and given to indolence, or are fond of exercise and labor” (Hippocrates, 1938). Hippocrates also wrote On Air, Waters and Places, a book that provided details on the relationship between humans and the environment. Experts now consider this book as a milestone in the development of the science of epidemiology, illustrating the connection between human life and the environment. However, people overlooked this concept for centuries, and it was not seriously considered again until investigators in the late 19th century developed the science of bacteriology.

Men and women today still search for reasons for their illnesses, and many still perceive illness as a punishment for sins. However, the wealth of scientific knowledge developed within the last 160 years has permitted the understanding of the complexities of the human body and the effects of internal and external stressors. This knowledge has provided the means for preventing and modifying illness and repairing disabilities. Much of this knowledge has been gained through the extension of the observations of the past to the rigorous study of specific illnesses or disabilities in large groups of people.

DEFINING EPIDEMIOLOGY Early attempts to understand illness and disease focused on studying the experiences of individual people. Today, clinicians consider these case reports or case studies. Studying individual experiences is invaluable for forming ideas, or hypotheses, about possible causes of specific diseases. However, studying individual people may not provide accurate information about the characteristics of the disease being investigated, because individual experiences with a disease may vary. Also, examining the experiences of individual persons does not provide

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evidence of causality (see Chapter 8). To gather more accurate information about disease, studying groups of people is essential.

An example is the relationship between smoking and lung cancer that experts statistically determined in the 20th century. Without studying the experiences of groups of people, they may never have identified this relationship. Some smokers never develop lung cancer, and some nonsmokers do develop lung cancer. However, epidemiologists Doll and Hill, in the 1950s, demonstrated the relationship between lung cancer and smoking by comparing a group of people with lung cancer to a group of people without lung cancer. They discovered that the people with lung cancer had smoked significantly more cigarettes than those without lung cancer (Doll & Hill, 1950). Further epidemiologic research studies provided more evidence of a causal link between smoking cigarettes and lung cancer.

Unfortunately, after 50 years, smoking is still a cause of significant illness and death throughout the world. In the United States alone, in 2015, 15.1% of all adults were identified as smokers, as defined by smoking every day. The percentage is even greater in American Indians/Alaska Natives, multiple race individuals, and non-Hispanic Blacks (CDC, 2016).

Epidemiology as the science of prevention emerged from the rigorous study of disease and illness in groups of people. Epidemiology is defined as the study of the distribution and determinants of states of health and illness in human populations. States of health and illness include health, disease, morbidity, injuries, disability, and mortality. The goals of epidemiology are to prevent or limit the consequences of illness and disability in humans, as well as to maximize their state of health (Harkness, 1995). The word epidemiology is derived from the word epidemic in the Greek language: epi—upon, demo—people, and logos—thought. In epidemiology, the community replaces the individual client as the primary focus of concern (Mausner & Kramer, 1985).

The science of epidemiology has been traditionally associated with infectious disease. Many of the techniques used in epidemiologic investigations were developed when cholera was killing much of the population of Europe. Therefore, early epidemiologic attempts to control and prevent infectious disease involved altering the characteristics of the agent, the host, and the environment (see Chapter 14).

The scope of epidemiology has expanded and shifted substantially. Primarily as a result of improved public health practices in the early 20th century, life expectancy in the United States, the United Kingdom, and European countries, as well as in other developed countries, rose. With it, a change in the patterns of disease occurred. No longer are infectious diseases the leading causes of death; the morbidity and mortality from noninfectious diseases and chronic degenerative conditions have increased (Table 6.1). Advancing technology in the 20th century made everyday life increasingly complex. There were unparalleled changes in diagnostic practices and therapeutic methods, resulting in expanded strategies for the prevention and control of disease. A focus on maintenance of wellness evolved.

All truths are easy to understand once they are discovered—the point is to discover them. Galileo Galilei

Investigators now use epidemiologic techniques to study all aspects of health, including factors that keep people well. Chronic disease, psychosocial problems, occupational injuries, environmental effects, and the planning and evaluation of health services are but a few of the disciplines that have been enhanced by using principles of epidemiology. Today, epidemiology is both a research methodology used to study states of health and illness and a body of knowledge that results from the study of a specific state of health or illness. When using epidemiology as a research methodology, the calculation of rates is the primary measurement used to describe either the occurrence or the existence of a specific state of health or illness (see

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Chapter 7).

How can Katie use these principles of epidemiology, both as a research method and as a body of knowledge, in her preparation for the three-hour sessions? How does her knowledge interface with Healthy People 2020 (CDC, 2010a) data?

TABLE 6.1 Comparison of the Leading Causes of Death in the United States, 1900 and 2010

1900a 2010b

1. Major cardiovascular–renal disease 2. Influenza and pneumonia 3. Tuberculosis 4. Gastritis, duodenitis, enteritis, and colitis 5. Accidents 6. Malignant neoplasms 7. Diphtheria 8. Typhoid and paratyphoid fever 9. Measles

10. Cirrhosis of the liver

1. Heart disease 2. Malignant neoplasms (cancer) 3. Chronic lower respiratory diseases 4. Cerebrovascular diseases (stroke) 5. Unintentional injuries 6. Alzheimer disease 7. Diabetes mellitus 8. Nephritis, nephritic syndrome, and nephrosis 9. Influenza and pneumonia

10. Suicide

aUnited States Census Bureau. (1975). Historical statistics of the United States, colonial times to 1970, bicentennial edition, Part 2. Washington, DC. bCenters for Disease Control and Prevention. Health, United States, 2013. Retrieved from http://www.cdc.gov/nchs/hus.htm.

DEVELOPMENT OF EPIDEMIOLOGY AS A SCIENCE John Graunt and the Bills of Mortality The study of illness in groups of people developed gradually. One of the first people to study patterns of disease in populations was a London haberdasher, John Graunt. In 1662, he analyzed the weekly reports of births and deaths in London; his analyses were the precursor of modern vital statistics. Graunt found that more male infants were born than female infants and that more men died than women. He also observed that infant mortality was high, and he noted that seasonal variations occurred in deaths.

Through his analysis of the Bills of Mortality, Graunt developed a better understanding of diseases and conditions that led to death. He published his observations and findings in Natural and Political Observations Made Upon the Bills of Mortality. Graunt added an essential step in the development of epidemiology as a science. He developed a new logic of statistical inference, demonstrating that examining routinely collected data from groups of people would yield clues to human illness. His publication can be found online.

Two centuries passed before William Farr expanded Graunt’s work. In the meantime, James Lind instituted the precursor of the clinical trial when he compared responses to dietary treatments for scurvy, and Percivall Pott observed cancer of the scrotum in English chimney sweeps, hypothesizing that soot was the cause. Edward Jenner performed the first successful vaccination against smallpox with the liquid from a cowpox pustule, resulting in the vaccination of more than 100,000 people in England within three years. These accomplishments in the 18th century linked specific diseases with the characteristics of groups of people and documented the effects of various treatments. Table 6.2 summarizes the milestones in the evolution of epidemiology from 460 bc through the 20th century.

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William Farr, Registrar General In 1839, William Farr was appointed to the new Office of the Registrar General for England and Wales. Farr set up a system for the consistent collection of the numbers and causes of deaths. With these data, he was able to compare the death rates of workers in various occupations, the differences in mortality according to gender, and the effect of imprisonment on mortality. He also discovered an inverse relationship: deaths from cholera decreased with an increase in elevation above sea level (Farr, 1852).

Farr and his predecessors contributed significantly to the understanding of the distribution of illness and death. As one of the first epidemiologists, he recognized (1) the value of a precise definition of both the illness and the population at risk for the illness, (2) the importance of using appropriate comparison groups, and (3) that factors such as age, health status, and environmental exposure can confound statistical results.

TABLE 6.2 Selected Milestones in the Evolution of Epidemiology Time Person Accomplishment or Event 460–377 BC Hippocrates of Cos First to record the relationship of the external environment to the

health of individuals. Considered the first epidemiologist. ca. 81 AD Aretaeus, the

Cappadocian Described pulmonary tuberculosis in detail.

129 Claudius Galen Described the four humors and introduced many drugs derived from plants. First to describe smallpox.

500 Susruta Brahmin physician who associated malaria with the mosquito. 850 Rhazes Arab physician who wrote al-Hawi, papers that incorporated all

known medical, anatomical, and pharmacologic knowledge of the time. Differentiated smallpox from measles.

1347 Italian 40-day ban on travel and trade was established to control bubonic plague. Quarantine comes from the Italian word quarentina, meaning 40 days.

1589 Thomas Moffet First description of living organisms causing disease: lice, fleas, and scabies mites.

1662 John Graunt London haberdasher who analyzed weekly reports of births and deaths. Found infant mortality was high and deaths varied according to seasons.

1683 Anton van Leeuwenhoek

Used a microscope to observe and describe “animalcules” from pond water and human saliva.

1701 Nicolas Andry French surgeon who proposed that infection by germs was a cause of disease.

1747 James Lind Observed and compared responses to dietary treatments for scurvy —the first evidence of a clinical trial. Recommended preventive techniques for typhus.

1760 Daniel Bernoulli Demonstrated that smallpox conferred lifelong immunity through the use of the first life table techniques.

1775 Percivall Pott Observed that many English chimney sweeps developed cancer of the scrotum; hypothesized that exposure to soot was the cause.

1779 Johann Peter Frank German who wrote A System of a Complete Medical Policy, the first book about public health.

1798 Edward Jenner Discovered the first vaccination against smallpox with cowpox pustule liquid. Within three years, 100,000 people in England were vaccinated.

1800 William Cruikshank Scottish surgeon who used chlorine to purify water. 1836 Pierre-Charles-

Alexandre Louis Conducted observational studies demonstrating the ineffectiveness

of bloodletting. Emphasized statistics. 1840–1860s William Farr First Registrar General in England. Considered father of modern

statistics. Developed mortality surveillance systems and addressed basic epidemiologic concepts. Pioneered public health reforms.

1846 Peter Ludvig Panum Danish physician who described the epidemiology of measles and the mechanism for spread of disease.

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1847 Ignaz Semmelweis Hungarian obstetrician who demonstrated that mortality from puerperal fever could be dramatically reduced if doctors washed their hands.

ca. 1850 Jean Baptiste Emile Vidal

French dermatologist responsible for the introduction of an efficient sewage system in Paris.

ca. 1854 John Snow Performed epidemiologic research on transmission of cholera using natural experiments, mapping, and rates. Removed London’s Broad Street drinking water pump handle to stop the spread of cholera.

1854 Florence Nightingale Initiated sanitary reforms in the Crimean War and demonstrated that preventable or contagious diseases were the primary cause of mortality. Later used statistics to improve public health in England. Considered the founder of the nursing profession.

ca. 1860 John Parkin English surgeon who used charcoal filters to purify water in an attempt to prevent the spread of cholera.

1860–1880s Louis Pasteur Developed pasteurization. Suggested that living organisms called “germs” caused infectious diseases.

1864 Contagious Diseases Act passed in England to combat the spread of venereal disease.

1865–1880s Robert Koch German who discovered the causal agents for anthrax, cholera, and tuberculosis. Developed criteria for identifying cause. Won Nobel Prize for bacteriology in 1905.

1866 Joseph Lister Developed a carbolic acid spray for surgical disinfections. 1921 Johns Hopkins University established the first academic program in

epidemiology. 1927 Wade Hampton Frost Developed cohort analysis of mortality data and developed life

tables. Credited for moving epidemiology from a descriptive to an analytical discipline.

1930 National Institutes of Health established in the United States. 1946 U.S. Communicable Disease Center was established. Now Centers

for Disease Control and Prevention (CDC). 1948 Framingham cohort study of cardiovascular disease initiated. 1950s Richard Doll and A.

Bradford Hill English researchers who conducted the landmark studies on the

relationship between smoking and lung cancer. Second half of the

20th century Chronic degenerative diseases replaced infectious diseases as

leading causes of death worldwide.

Sources: Lee, H. S. J. (2002). Dates in infectious diseases: A chronological record of progress in infectious diseases over the last millennium. New York: Parthenon Publishing Group.; Timmreck, T. C. (2002). An introduction to epidemiology. Boston, MA: Jones and Bartlett; and Lilienfeld, D. E., & Stolley, P. D. (1994). Foundations of epidemiology. New York: Oxford University Press.

John Snow and the Broad Street Pump Perhaps the best known epidemiologist of the 19th century was John Snow, a contemporary of William Farr. He was a British physician who used population data and his own observations to investigate the epidemic of cholera that occurred from 1848 through 1854. He observed that deaths from cholera were particularly high in the parts of London supplied by two water companies the Lambeth Company and the Southward and Vauxhall Company.

Sewage heavily polluted a section of the Thames River, and interwoven water mains piped untreated water into the homes of two thirds of London’s residents. Houses on the same street received water from different companies. Sometime between 1849 and 1854, the Lambeth Company changed its water source to a less contaminated location upstream. During a particularly bad cholera outbreak from 1853 to 1854, Snow demonstrated through calculation of death rates from cholera that the disease decreased in those areas supplied by the Lambeth Company but remained the same in those areas supplied by the Southward and Vauxhall Company (Table 6.3).

TABLE 6.3 Death Rates From Cholera by Water Company, London, 1853– 1854

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Water Company Population, 1851 Cholera Deaths Deaths/100,000 Southwark and Vauxhall 167,654 192 114 Both companies 301,149 182 60 Lambeth 14,632 0 0

Source: Snow, J. (1855). On the mode of communication of cholera. London: John Churchill. Retrieved from http://www.ph.ucla.edu/epi/snow/snowbook.html.

The most severe outbreak during this time was in the area of Broad Street, Golden Square, where people obtained their water from a local pump. More than 500 people died from cholera within 10 days. Believing that the water delivered by the pump was responsible for the cases of cholera, Snow removed the handle, and the number of cases immediately declined. However, there also were a number of other factors that contributed to this event, for example, an exodus of the population to other locations. Nonetheless, he is credited for “staying the epidemic,” and a pump now has been erected in his honor on the corner of Broad Street in Soho.

Snow, during his investigations, mapped the areas where cholera occurred, developed rates as an objective measure to compare populations, made use of the natural experiment provided by the unusual pattern of water mains, and found evidence for the cause of cholera. These were outstanding accomplishments in an era that preceded bacteriology. He published his findings in On the Mode of Communication of Cholera (Snow, 1855). The entire document is available online.

Florence Nightingale, Nurse and Epidemiologist Florence Nightingale, the daughter of a wealthy Englishman, was also a contemporary of William Farr and John Snow. She devoted her life to the prevention of needless illness and death. She used compelling statistics to bring about healthcare reforms, both during the Crimean War and later in her English homeland. Also, she is credited with founding the profession of nursing.

Prior to leading a group of nurses to aid the British soldiers in the Crimean War, Nightingale was superintendent of a London hospital. There she supervised nurses, the operation of the physical plant, and the purity of the medicines. In 1854, she and a group of carefully chosen nurses and servants joined the troops in Scutari, in the Crimea. She was appalled by the conditions of the hospital barracks. Rats and fleas infested buildings, facilities were overcrowded, linen was filthy, essential supplies were missing, and an open sewer ran underneath the barracks. The soldiers suffered not only from wounds, but also from dysentery, malnutrition, frostbite, cholera, typhus, and scurvy. The mortality rate for the soldiers was 42.7% (Cohen, 1984).

Using carefully gathered data that were unique at the time, Nightingale documented the results of her sanitary reforms. The polar area diagram she designed (Fig. 6.1) illustrates the needless deaths in the military hospitals during the Crimean War. Deaths peaked in January 1855. During that month, 83 soldiers died from wounds, but 2,700 died from infectious diseases. If the dead soldiers had not been replaced, infectious diseases would have wiped out the entire army. By the end of the war, the death rate in British soldiers in the Crimea was less than that of the troops at home (Cohen, 1984).

With the help of William Farr, Nightingale continued documenting events after the war that were associated with poor sanitary conditions. She compared mortality in civilians with that in soldiers and found that in peacetime, the soldiers in England had a mortality rate nearly twice that of civilian males. Nightingale asked for and received a formal investigation of military healthcare, and eventually, the government implemented her sanitary reforms. She studied the health of soldiers in India, the mortality in British hospitals, and the mortality following surgery. Throughout her career, she experimented with graphs and diagrams that everyone could

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understand and tried to introduce statistics into higher education. As a pioneering epidemiologist, she effectively demonstrated that statistics provide an organized way of learning from experience.

FIGURE 6.1 Florence Nightingale’s polar area diagram illustrating the extent of needless deaths in British military hospitals during the Crimean War, April 1854 to March 1855. The blue wedges measured from the center of the circle represent area for area the deaths from preventable zymotic diseases, the red wedges measured from the center the deaths from wounds, and the black wedges measured from the center the deaths from all other causes. The black lines across the red triangles in September and November 1854 mark the boundaries of the deaths from all other causes during those months. In October 1854, the black area coincides with the red. The entire areas may be compared by following the blue, the red, and the black lines enclosing them. (From Aiken, L. [1988]. Assuring the delivery of quality patient care. State of the Science Invitational Conference, Nursing resources and the delivery of patient care [NIH Publication No. 89–3008, pp. 3–10]. Washington, DC: U.S. Department of Health and Human Services, Public Health Service; Cohen, I. B. [1984]. Florence Nightingale. Scientific American, 250[3], 129.)

EPIDEMIOLOGIC MODELS Epidemiologic Triad The epidemiologic triad is the classic model based on the belief that health status is determined by the interaction of the characteristics of the host, agent, and environment, not by any single factor. The host is the client whose health status is the concern, whether it is a person, a family, a group of high-risk people, or the community as a whole. Agents are an element or force that under proper conditions can initiate or perpetuate a health problem. Environment refers to the context within which the agent and host interact (Fig. 6.2).

Host factors, sometimes called intrinsic factors, include both variable (modifiable) and

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absolute (nonmodifiable) factors. Age, race, and genetic makeup are examples of absolute, or nonmodifiable, factors. Lifestyle, exercise level, nutrition, health knowledge, and motivation for achieving optimal wellness are examples of host factors that are variable, or modifiable.

Agents can be classified into five groups. These agents may be physical, such as heat and trauma; chemical, such as pollutants, medications, and drugs; nutritional, such as the absence or excess of water, vitamins, fats, proteins, and carbohydrates; psychosocial, such as stress, social isolation, and social support; and biologic, such as bacteria, viruses, arthropods, toxins, and conditions that interfere with the normal function of the body.

Environmental factors are frequently divided into three categories: biologic, physical, and social. The biologic environment is composed of plants, animals, and the toxins they produce; this includes pathogenic microorganisms, vectors that carry the infectious agents, and the reservoirs where infectious agents are normally found. The physical environment includes light, heat, air, atmospheric pressure, radiation, geologic factors, and the structures in the environment. The social environment includes culture, technology, educational opportunities, political systems, demographic characteristics, sociologic factors, and economic and legal systems.

The Wheel of Causation Many diseases, illnesses, and conditions have multiple or no discernible agents, or the agent may be a part of the environment. An alternate model is conceptualized as a wheel, with a circle as the genetic core of the host, surrounded by a larger, segmented wheel representing the biologic, physical, and social environments (Fig. 6.3). The wheel of causation de-emphasizes the agent as the sole cause of disease, whereas it emphasizes the interplay of physical, biologic, and social environments. Interaction between the host and environment, with or without an identifiable agent, remains the major determinant of health status in all epidemiologic models.

FIGURE 6.2 The epidemiologic triad.

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FIGURE 6.3 The wheel of causation.

The Web of Causation The web of causation is an epidemiologic model that strongly emphasizes the concept of multiple causation while de-emphasizing the role of agents in explaining illness. At the time of development, there was a need to create a model that would help describe the multiple factors underlying chronic illnesses. These causal webs are more focused and realistic, and they may be as intricate and complex as needed. In this model, it is necessary to identify all possible antecedent factors that could influence the development or prevention of a particular health condition. Each factor is perceived as a link in multiple interrelated chains. By making the pathways explicit in a web of causation, a diagram deepens understanding and provides a framework for statistical analysis. It also serves as a valuable practical guide. Direct and indirect factors can be identified that can be changed or modified to improve health. Not only does it provide multiple entry points for intervention, but it also has the capacity to demonstrate the interrelationship of different factors. These can include both unpredicted and possibly undesirable side effects. Public health professionals use web of causation models such as this to design methods that interrupt the chain of events that lead to adverse states of health. Figure 6.4 exemplifies a classic web of causation that identifies multiple ways to reduce health problems, in this case drug use and abuse in adolescents.

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FIGURE 6.4 The web of causation for drug use. (Used with permission from Duncan, D. F., & Petrosa, R. [1999]. Social and community factors associated with drug use and abuse among adolescents. In T. P. Gullotta, G. R. Adams, & R. Montemayor (Eds.). Substance misuse in adolescence (pp. 56–91). Thousand Oaks, CA: Sage Publications.)

Natural History of Disease In 1958, Leavell and Clark developed a conceptual model for the natural history of any disease affecting humans (Leavell & Clark, 1965). This groundbreaking model integrated the pathogenesis of an illness with primary, secondary, and tertiary prevention measures (Fig. 6.5). The initial interactions between the agent, host, and environment occur during the prepathogenesis period. Primary prevention measures specific to the disease can be implemented at this stage to prevent its onset in a population of well people. The period of pathogenesis begins when there are biologic, psychological, or other responses within the host. Secondary prevention measures focus on early diagnosis and prompt treatment. This can limit resulting disabilities when implemented during the early stages of the disease. Tertiary prevention follows with rehabilitation measures that enable the individual to function at his or her maximum capability. This model, used widely in practice, is discussed in more detail in Chapter 5 (see Fig. 5.2).

Every human being is the author of his own health or disease. Buddha

APPLYING EPIDEMIOLOGIC PRINCIPLES IN PRACTICE The epidemiologic process and the nursing process are both derived from the problem-solving process that provides a framework for gathering data about health problems, analyzing the

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information, generating diagnoses or hypotheses, planning for resolution, implementing plans of action, and evaluating results (Table 6.4). The focus of the nursing process is on caring for the client within his or her family, whereas the focus of the epidemiologic process is on caring for the population of the community as a whole. Whether caring for the individual or the members of a community, nurses need access to data, abstract critical thinking skills, and complex reasoning abilities.

Assessment of Health Needs and Assets Community and public health nurses assess both health needs and health assets for individual people within their environment and for the population within the community as a whole. Both the individual and the community are considered clients.

FIGURE 6.5 Leavell and Clark’s natural history of any disease affecting humans. (From Leavell, H. R. & Clark, E. G. (1979). Preventive medicine for the doctor in his community: An epidemiological approach. Malabar, FL: Krieger Publishing Company.)

Individual Assessment Providing personal healthcare services to individual persons is a cornerstone of nursing practice. Community health and public health nurses often provide direct health services, including

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preventive services, to high-risk, displaced, and vulnerable populations. The nurse is usually the first person to systematically observe the individual person, either in the home, clinic, parish, or healthcare facility. The public health nurse takes a nursing history, performs a physical assessment, and makes both objective and subjective observations about the condition of the person. He or she establishes where the person is in relation to the full spectrum of health and identifies the person’s assets as well as needs. Assets include strengths and resources of the client such as general state of health, prior use of healthcare services, health behaviors, lifestyle, motivation, and other factors. This information establishes the database about the client. The planning process and the interventions that are subsequently implemented are based on this assessment. Also, the database becomes a baseline for measuring the outcomes of care.

TABLE 6.4 Similarities Between the Nursing Process and the Epidemiologic Process

Nursing Process, Client Based Epidemiologic Process, Population Based Assessment

An individual client database is established Data are interpreted

Data are gathered from reliable sources Nature, extent, and scope of problem are defined Problem described by person, place, and time

Diagnosis Healthcare needs and assets are identified Goals and objectives for care are established

Tentative hypothesis is formulated Data analyzed to test the hypothesis

Planning Processes for achieving goals are selected Plans are made for control and prevention of the

condition or event

Implementation Actions initiated to achieve goals Actions are initiated to implement the plan

Evaluation

Extent of goal achievement is determined Actions are evaluated and report is prepared Further research is conducted if necessary

Considering the goals of the delinquency prevention program, what information does Katie need to gather from her group of young people? How could she access this information?

Practice Point

You have to ask the right questions to gather the information (data) you need.

Nurses use the information that epidemiologic research has established when performing most client assessments, although they may not be aware that they are doing so. For example, a common process is to assess individuals for risk factors that have been associated with a disease or illness through epidemiologic research. Risk refers to the probability or likelihood that a disease or illness will occur in a group of people who presently do not have the problem. Risk factors are those characteristics or events that have been shown to increase the probability that a

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specific disease or illness will develop. Some risk factors are modifiable, and others such as age are not. For example, epidemiologic research has established that certain risk factors, such as a sedentary lifestyle, obesity, increased cholesterol, hypertension, and smoking, are associated with cardiovascular disease. These risk factors are now a part of the epidemiologic body of knowledge, or the epidemiology, of heart disease. As a result, several health appraisal approaches are now commonly used to profile client risk.

What factors increase the risk of negative health outcomes for youths in gangs?

Epidemiologic research has also established the natural history of most illnesses. This refers to the course of a disease or condition from onset to resolution. It includes (1) pathologic onset stage, (2) the presymptomatic stage, and (3) the manifestation of clinical disease (Leavell & Clark, 1965). Through the individual assessment process, the nurse can begin to determine the stage of the illness in question. Cues identified at the initial assessment may indicate whether primary, secondary, or tertiary prevention interventions would be most appropriate.

Evidence for Practice

Decline in the physical functioning of the elderly is of concern worldwide. Chen, Chang, and Lan (2015) conducted a study that evaluated the association between changes in physical functioning and a variety of other factors in an older population in Taiwan. The data of 907 participants were derived from the Functioning and Aging Study conducted in Taipei between 2005 and 2009.

Functional status was assessed using activities of daily living, instrumental activities of daily living and mobility tasks, and classification as being normal, with mild disability, moderate disability, and severe disability.

The proportion of elderly participants with normal function decreased with time throughout the study period. Risk factors, both modifiable and nonmodifiable, that were associated with changes in physical functioning included the following:

Age Living arrangements, social support Self-rated health Stroke Diabetes Parkinson disease Osteoporosis Depression Cognition Vision History of fracture and falls Incontinence of urine and feces Physical activity Body mass index (BMI), short physical performance

Researchers conclude that older persons with stroke, Parkinson disease, diabetes, osteoporosis, geriatric conditions, and poor short physical performance would benefit the most from prevention measures for functional decline. Older people not living with spouses, with poor self-rated health, with low social support, who are malnourished and live a

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sedentary lifestyle might also benefit from interventions protecting against functional decline. All public health nurses can assess their elderly clients and plan interventions that will protect them from excessive decline in the ability to function well in their daily lives.

Community Assessment Conceptualizing the community as a client is difficult for the individual-oriented nurse. Assessing the health needs and assets of a community involves creating a comprehensive community profile or database. The individual nurse may be solely responsible for the assessment, but usually he or she contributes to the assessment as a member of a team. Epidemiologic statistical methods, such as calculation of rates, are used in this process (see Chapter 7). A detailed discussion of community assessment is found in Chapter 11.

Epidemiologists gather available demographic data that provide information about the age and sex distribution, socioeconomic characteristics, and cultural and ethnic distributions. They access vital statistics, including applicable epidemiologic morbidity and mortality rates. Additional data can be obtained from community members or community groups. Information about the accessibility and availability of healthcare services, such as health manpower, may or may not be community assets. To obtain information about health beliefs, norms, values, goals, perceived needs, and health practices, healthcare workers may use focus groups, interviews or observation, or surveys. Nurses may participate in field-testing new tools for data collection.

After epidemiologists collect the data, they synthesize and analyze the information and generate a list of community health needs and assets. Identifying patterns of disease, illness, and injuries detects trends that form the rationale for program development. Critical thinking skills are essential for the appropriate analysis of this information. Finally, it is necessary to set goals and objectives to address high-priority problems.

Practice Point

A thorough and accurate client database, whether that of individuals, groups, or the community, provides the evidence and rationale for your interventions.

To understand the scope of the health problems facing the young people who were enrolled in the delinquency prevention program, a community assessment should be considered. What information does Katie need to gather, and where would she find that information?

Student Reflection

Although my nursing program focused a lot on research findings, particularly in writing assignments, I did not fully understand the impact that statistics can make in nursing until I had my community practicum in a local women’s health center. When I arrived there, the staff was talking about a violent episode that had occurred the previous week. Everyone seemed to think that there was more violence in the community than there should be, and that we needed to know more about it.

My preceptor was a program developer, and the women at the center asked her if they needed a violence prevention program. One of my first assignments was to find out just how

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much and what types of violence had occurred in the last year. The first thing my preceptor suggested was to go online and look at websites for various states and towns. I was amazed at how much information was available. For example, I found out that the rates of homicide, assaults, and rapes in our town were greater than the average for both the state and the nation. Also, I found out that 45% of the poor, young males from minority groups were in jail for crimes of violence! I learned that most violence occurs between people who know each other, and that violence is related to substance abuse. I presented my information to the staff, and they all decided to have my preceptor contact other community agencies and the local college to form a coalition to address violence. I attended the first meeting, and people tossed around lots of ideas. They decided to look into a 24/7 free telephone line to give people support in a crisis, increase housing for women suffering from domestic violence, and consider a number of initiatives for youth in the town.

This experience taught me several things.

Lots of information is available about health problems in a community. New ideas require presentation of supportive data. Involving other interested communities can enhance whatever is planned to reduce health problems. One person’s efforts can really make a difference.

Using Assessment Data for Planning and Implementing Interventions The individual or community client database, much of which has been gathered using epidemiologic methods, provides the rationale for planning and implementing interventions. It is possible to use the epidemiologic body of knowledge that describes the natural progression of specific diseases or illnesses to target ways to break the problem cycle once it has been identified. An intervention plan outlines the goals, objectives, and strategies for achieving the interventions and provides completion dates for their accomplishment. The type of health problem, the readiness of the individual or community to address the problem, the availability of health services, the nurse’s role, the characteristics of social change, and other related factors influence successful implementation.

Three goals for the delinquency prevention program are presented at the beginning of this chapter. Write an objective for each goal.

Promoting Healthy Lifestyles Every phase of public health nursing involves the provision of health education whenever the opportunity arises. Lifestyle patterns are modifiable, and nurses can help make the public aware of the benefits of preventive health through use of the media and meeting with individuals and community groups.

Following the landmark epidemiologic studies of smoking and lung cancer in the 1950s, the general public gradually recognized that personal behaviors such as smoking were risk factors for the leading conditions causing morbidity and mortality in the United States and other countries. In 1984, the CDC and the U.S. state health departments collaboratively established the Behavioral Risk Factor Surveillance System (BRFSS). The goal of this surveillance system is to collect, analyze, and interpret specific behavioral risk factor data that can be used to plan,

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implement, and monitor health promotion and disease prevention programs. The BRFSS gathers information about health behaviors, such as lack of physical activity,

obesity, and safety belt use, primarily by telephone calls. It also gathers data about preventive health services, such as screening for breast and cervical cancer and elevated blood cholesterol. The BRFSS used these epidemiologic statistics when national objectives were established for Healthy People 2000, Healthy People 2010, and Healthy People 2020. Healthy People 2020, developed by the U.S. Department of Health and Human Services, sets behavioral objectives to be achieved over the second decade of the 21st century. Experts developed these objectives through a broad consultation process, built on the best scientific knowledge and designed to measure programs over time. Along with the BRFSS data, Healthy People 2020 serves as the basis for the development of state and community plans to improve the health of their populations. Each state collects statistics for the BRFSS, and thus these data are available for nurses to access when planning educational programs for primary prevention.

Dietary factors are associated with 4 out of the 10 leading causes of death: heart disease, some types of cancer, stroke, and type 2 diabetes. Obesity rates have doubled in adults and tripled in children and adolescents over the last two decades. The data are alarming (CDC, 2015).

The prevalence in the United States between 2011 and 2014 is as follows: 36.5% of adults aged 20 years and older were obese 20.5% of adolescents aged 12 to 19 years were obese 17.5% of children aged 6 to 11 years were obese 8.9% of children aged 2 to 5 years were obese

These are significant increases in obesity as compared to the period of 1999–2000. The estimated cost of these diet-related conditions is more than $123 billion annually in

medical expenses. Including lost productivity in these statistics adds billions more (CDC, 2010b). The BRFSS data dramatically demonstrate the significant increase in the prevalence of overweight people in the United States (Fig. 6.6). Using these data, Healthy People 2020 identified overweight and obesity as a major health issue in the United States. Sex and ethnicity are also important factors in the development of obesity (Fig. 6.7). Overweight is most prevalent in African American and Hispanic females. If nurses find that such statistics apply to the members of their own community, they can initiate programs to address the problem.

The burden of food-related ill health measured in terms of mortality and morbidity is similar to that attributable to smoking. The cost is twice the amount attributable to car, train, and other accidents, and more than twice that attributable to smoking. The vast majority of the burden is attributable to unhealthy diets rather than to food-borne diseases (Rayner & Scarborough, 2005).

Practice Point

Use statistics to demonstrate the need for program development and community interventions.

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FIGURE 6.6 Changes in prevalence of obesity among U.S. adults. Note that the data are for ages 18 years and over, based on self-reported weight and height via telephone interview. Obesity is defined as body mass index ≥30. (From National Health and Nutrition Examination Survey, NCHS, CDC; BRFSS, 2012.)

FIGURE 6.7 Age-adjusted prevalence of obesity among adults aged 20 and over, by race/ethnicity: United States, January to June 2013. Note that data are age adjusted to the 2000

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standard population. Obesity is defined as body mass index ≥30. (Retrieved from www.cdc.gov/nchs/data/nhis/earlyrelease/earlyrelease201312_06.pdf.)

Evidence for Practice

Healthier food access in schools is a major objective of Healthy People 2020. To accomplish this goal, the United States has invested heavily in actions to prevent youth obesity by promoting healthy eating and physical activity. With support from the CDC, the Communities Putting Prevention to Work (CPPW) obesity prevention program was initiated in King County, Washington, during 2010 and 2012 (CDC, 2014). Components of the robust obesity prevention program included the following:

Implementation of nutrition standards for school meals Student-led healthy eating and active living promotional campaigns Farm to school initiatives High-quality physical education Nutrition and culinary training for school cafeteria staff Participation in community health coalitions

The CPPW focused on low-income school districts and communities, since community health assessment data indicated that the prevalence of obesity, poor nutrition, and physical inactivity was disproportionately high relative to higher-income communities. Data were obtained from a school-based survey analogous to the national Youth Risk Behavior Survey. The Washington State Department of Health used self-reported height and weight from the survey to calculate BMI. The survey response rates ranged from 63% to 71%, resulting in approximately 34,000 respondents per survey year, for the project group, and 61% to 67% for the rest of the population of Kings County and the state of Washington resulting in approximately 18,500 respondents per survey year.

Results indicated a statistically significant 17% decline in youth obesity after implementation of CPPW school districts, but not in non-CPPW districts. Also, there was a statistically significant reduction in youth obesity in Kings County when compared with the rest of the state of Washington.

These findings suggest that focused, multifaceted, and comprehensive policy, systems, and environmental change interventions located in each community can reduce obesity in youth. Continued community level interventions such as these have the potential to meet the CDC’s obesity prevention priority as one of its 10 “winnable battles.”

Preventing and Controlling Outbreaks The investigation of an epidemic or outbreak is an example of the epidemiologic process in action. Epidemics occur when there is an increased incidence of a disease or event beyond that which is normally found in the population. Although the term outbreak is often used synonymously with epidemic, outbreaks are usually limited to a localized increase in the incidence of the illness. The steps of investigating an outbreak are presented in Box 6.1. A detailed description of outbreak investigations is found in Chapter 14.

6.1 How to Investigate an Outbreak

Establish the existence of the outbreak. Describe the outbreak according to person, place, and time. Formulate and test hypotheses as to the most probable causative factors. Implement a plan for control of the outbreak and prevention of further outbreaks.

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Evaluate results, prepare reports, and conduct further research if necessary.

Public health nurses may be involved in any of the steps of the outbreak investigation. The nurse’s role varies with the workplace. Generally, nurses are involved in education of the public, mobilization of community resources, and implementing regulatory and control measures.

Practice Point

When you are investigating unusual events, determine whether the incidence is greater than what normally would occur at that time and place.

What types of outbreaks may occur during the delinquency prevention program?

Contributing to a Safe and Healthy Environment Individual and community risk assessments should include detection of real or potential threats from the environment. Environment includes physical, biologic, social, cultural, or any other external factors that can influence the health status of individuals or populations. The principles of epidemiology, normally used in investigating disease and illness, can be applied to the human effects of natural disasters such as hurricanes and earthquakes, as well as to industrial disasters such as injuries, air pollution, nuclear accidents, and release of toxic chemicals.

Practice Point

Evaluate your community, and subsets of the community, for potential environmental hazards.

When healthcare professionals gather demographic data, vital statistics, and epidemiologic morbidity and mortality statistics, they should also consult environmental health sources. Using detailed individual or community client databases, nurses then have the potential to link environmental exposure to illness and disease. Nurses often provide case management for both communicable and chronic illnesses that result from environmental exposure. Nurses also may be risk consultants, communicators, and educators, working with community groups, agencies, and industry to protect the health of their workers.

What are the environmental risks for the group of delinquent youth? How would Katie address these in her sessions with the youth?

The World Health Organization (WHO), the National Institute for Occupational Safety and Health (NIOSH) in the United States, and other international and national agencies review existing knowledge about chemicals, radiation, and other environmental hazards that have

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immediate and long-term effects on health, and issue reports concerning environmental health criteria. See Chapter 19 for detailed information regarding environmental assessment.

Evaluating the Effectiveness of Health Services Public health professionals who collect epidemiologic data during assessments and use them for establishing the need for health programs can also use them to evaluate those services. Evaluation requires a systematic and objective process that determines the relevance, effectiveness, and impact of the health service. Creating objectives that are measurable assists in this process. Nurses should continuously monitor the health status indicators in the community, especially for vulnerable populations. Age-specific mortality rates, low birth rates, infant mortality rates, health services utilization, and other indexes specific to the characteristics of the community are examples (see Chapter 7). This information assists in identifying gaps and detecting emerging problems early so that appropriate responses can be facilitated. In addition, nurses and other healthcare professionals can also use epidemiologic principles to develop surveys to gather specific information from targeted populations such as child care centers or the population of census tracts that may be at high risk.

The primary way to demonstrate prevention or control of a health problem is to compare epidemiologic statistics before and after the implementation of the health service. Planning and evaluation are continuous processes. As new data become available, modification in health services may be necessary, and those modifications require evaluation.

Practice Point

Use your program objectives to evaluate your interventions.

Outline an evaluation program for the delinquent youth prevention program discussed in the case at the beginning of this chapter.

KEY CONCEPTS Early attempts at understanding the reasons for disease were primarily a direct result of trial-and-error observations of individual people. Study of illness and causes of death in groups of people began in the 17th century. Founders of epidemiology as the science of preventive medicine included John Graunt, William Farr, John Snow, and Florence Nightingale. Epidemiology is defined as the study of the distribution and determinants of the states of health and illness in human populations, with the goal of preventing or limiting consequences and maximizing states of health. Individual and community assessments, using epidemiologic principles, form the database that provides the evidence and rationale for interventions. Promoting healthy lifestyles uses epidemiologic data such as that found in the BRFSS. The U.S. publication Healthy People 2020 defines measurable objectives to be achieved over the second decade of the 21st century. Nurses, in their care of individual and community clients, have the potential to link environmental exposure

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to illness and disease. Epidemiologic data, collected during assessments that establish the need for health programs, are also used to evaluate those services.

CRITICAL THINKING QUESTIONS

1. Jeff is 11 years old and slightly overweight. His father is a truck driver who was recently diagnosed with type 2 diabetes. His mother is a licensed practical nurse at the local hospital. At a recent health science fair at his school, a student-led screening clinic documented Jeff’s blood pressure at 140/92 mm Hg. a. Is Jeff at risk? If so, for what? b. Utilizing the Guidelines for High Blood Pressure in Adults (American College of Cardiology, 2017), what

is Jeff’s future risk from adolescence through adulthood? c. What other data do you need? d. How does epidemiologic data define hypertension in a child of Jeff’s age? e. What recommendations would you make? f. Are there health promotion activities that you would recommend?

2. Look through several major newspapers for articles containing health statistics. a. What are the implications of these statistics for your community? b. What further data would you obtain to document the problem in your community?

3. Go to the CDC website www.cdc.gov. Pick a topic to explore. Show how epidemiologic information has been used to describe the topic.

4. Explore the website “Violence Prevention” (http://www.cdc.gov/ViolencePrevention/pub/PreventingYV.html). Identify at least one activity that Katie could use to meet each of the goals of her program.

REFERENCES American College of Cardiology. (2017). 2017 Guideline for high blood pressure in adults. Retrieved from

http://www.acc.org/latest-in-cardiology/ten-points-to-remember/2017/11/09/11/41/2017-guideline-for- high-blood-pressure-in-adults

Centers for Disease Control and Prevention. (2010a). Healthy people 2020. Retrieved from https://www.healthypeople.gov/2020/About-Healthy-People

Centers for Disease Control and Prevention. (2010b). National health priorities, reducing obesity, heart disease, cancer, diabetes and other diet and inactivity related diseases, costs, and disabilities. Retrieved from http://www.cdc.gov/nccdphp/dnpao/index.html

Centers for Disease Control and Prevention. (2014). Declines in student obesity prevalence associated with a prevention initiative—King County, Washington, 2012. Morbidity and Mortality Weekly Reports, 63(07), 155–157.

Centers for Disease Control and Prevention. (2015). Prevalence of obesity among adults and youth: United States, 2011–2014. Retrieved from https://www.cdc.gov/nchs/data/databriefs/db219.pdf

Centers for Disease Control and Prevention. (2016). Current cigarette smoking among adults—United States, 2005–2015. Morbidity and Mortality Weekly Report, 65(44), 1205–1211. Retrieved from https://www.cdc.gov/mmwr/volumes/65/wr/mm6544a2.htm

Chen, C. M., Chang, W. C., & Lan, T. Y. (2015). Identifying factors associated with changes in physical functioning in an older population. Geriatrics and Gerontology International, 15(2), 156–164.

Cohen, I. B. (1984). Florence Nightingale. Scientific American, 250(3), 128–137. Doll, R., & Hill, A. B. (1950). Smoking and carcinoma of the lung; preliminary report. British Medical

Journal, 2(4682), 739–748. Farr, W. (1852). Influence of elevation on the fatality of cholera. Journal of the Statistical Society of

London, 1(2), 155–183. Harkness, G. A. (1995). Epidemiology in nursing practice. St. Louis, MO: Mosby. Hippocrates. (1938). On airs, waters, and places [400 BC]: Translated and republished. Medical Classics,

3, 19–42.

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Leavell, H. R., & Clark, E. G. (1965). Preventive medicine for the doctor in his community: An epidemiologic approach (p. 21). New York: McGraw-Hill.

Mausner, J. S., & Kramer, S. (1985). Epidemiology—An introductory text (2nd ed.). Philadelphia, PA: W. B. Saunders.

Rayner, M., & Scarborough, P. (2005). The burden of food related ill health in the UK. Journal of Epidemiology and Community Health, 59(12), 1054–1057.

Sanders, B., Schneiderman, J. U., Loken, A., Lankenau, S. E., & Bloom, J. J. (2009). Gang youth as a vulnerable population for nursing intervention. Public Health Nursing, 26(4), 346–352.

Snow, J. (1855). On the mode of communication of cholera. London: John Churchill. Retrieved from http://www.ph.ucla.edu/epi/snow/snowbook.html

WEB RESOURCES

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

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Chapter 7 Describing Health Conditions: Understanding and Using Rates Patrice Nicholas and Patricia Lussier-Duynstee

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

Perplexity is the beginning of knowledge. Khalil Gibran

There are three kinds of epidemiologists: those who can count and those who can’t. Anonymous

Prejudice is a great time saver. You can form opinions without having to get the facts. E.B. White, author

CHAPTER HIGHLIGHTS Concept and calculation of rates Crude, specific, and adjusted rates Incidence and prevalence rates Sensitivity and specificity calculations

OBJECTIVES Describe the primary method used to measure the existence of states of health or illness in a population during a given time period. Explain the formula and rules for calculation of a rate. Differentiate between crude and adjusted rates. Contrast incidence rates and prevalence rates. Discuss the use of specific rates when describing characteristics of person, place, and time. Differentiate between incidence density, incidence rates, and relative risk ratio. Discuss differences between the sensitivity and specificity of tests. Using examples, interpret the relevance of the use of rates in nursing practice.

KEY TERMS

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Adjusted rate: Statistical procedure that removes the effects of differences in the composition of a population, such as age, when comparing one to another.

Attack rate: An incidence or occurrence rate. Attributable risk: The difference between the incidence rates in an exposed and an unexposed

group of people. Case fatality rate: Calculated by dividing the number of deaths from a specific disease by the

number of people living with that disease during the year, and multiplying by 100. Cause-specific mortality rate: The probability of death from a specific cause. Crude rate: Measurement of the occurrence of the health problem or condition being

investigated in the entire population. Demographic data: The study of the size, distribution, and characteristics of human populations. Epidemic curve: A graph that plots the distribution of cases by the time of onset of the disease. Epidemiologic descriptive studies: Research studies designed to acquire more information

about the occurrence and distribution of states of health, such as characteristics of person, place, and time.

Incidence density: Use of a person-time denominator in the calculation of rates; a person-day reflects one person at risk for 1 day, and a person-year represents one person at risk for 1 year.

Incidence rate: Measure of the probability that people without a certain condition will develop that condition over a period of time.

Long-term change: Fluctuations in time surrounding health problems that extend over decades, reflecting gradual changes.

Morbidity: A departure from a state of physiologic or psychological well-being. Mortality rate: The probability of death from any cause among the entire population within a

given time frame. Period prevalence: A prevalence rate that indicates the existence of a condition during an

interval of time, often a year. Periodic change: Seasonal or cyclic fluctuations in time surrounding health problems. Point prevalence: A prevalence rate that indicates the existence of a condition at a specific point

in time. Populations at risk: Groups of people who have specific characteristics, or risk factors, that

increase the probability of developing health problems. Prevalence rate: Measures the number of people in a given population who have an existing

condition at a given point in time. Proportion: A type of ratio that includes the quantity in the numerator as a part of the

denominator. Proportional mortality ratio: A ratio that compares deaths from a specific illness with deaths

from all other causes. Rate: The primary measurement used to describe the occurrence (quantity) of a state of health in

a specific group of people in a given time period. Ratio: A fraction that represents the relationship between two numbers. Relative risk ratio: The ratio of the incidence rate in the exposed group and the incidence rate in

the nonexposed group. Sensitivity: Ability of a test to correctly identify people who have a health problem; the probability

of testing positive if the health problem is truly present. Short-term change: Variations measured in hours, days, weeks, or months; commonly found in

outbreaks of infectious disease. Specific rates: Detailed rates that are calculated using the number of people in the smaller

subgroups of the population in the denominator. Often, people are divided into subgroups by age and sex, although any characteristic can be used.

Specificity: Ability of a test to correctly identify people who do not have a health problem; the probability of testing negative if the health problem is truly absent.

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T

CASE STUDY

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

The Visiting Nurse Association serving two rural counties in Florida has received a grant from the United States Office of Minority Health for a human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) prevention outreach program targeted toward the two counties’ large African American population. The counties are adjacent to each other and have a combined population of 312,838 people. The number of African American people in the two counties is 57,875, or 18.5% of the population.

Lindsay is on the team that developed the program grant, and she is now the program director. She and the team members develop a HIV/AIDS outreach survey, a yes-or-no checklist that serves as a data collection form. Demographic information will be collected at the end of the interview. Outreach workers from the African American community are hired to interview people on the street and in their homes following a week-long training session on HIV/AIDS and methods of establishing rapport (adapted and updated from [Brown & Brown, 2003])

Data from a recent survey in seven African countries found that in 2016, an estimated 1.5 million females aged 15 to 24 years were living with HIV infection in Eastern and Southern Africa, where the prevalence of HIV infection among adolescent girls and young women (3.4%) is more than double that for males in the same age range (1.6%) (Brown et al., 2018). Consider the questions on the HIV/AIDS Outreach Survey below for both of these HIV surveys.

HIV/AIDS OUTREACH SURVEY FORM 1. Do you know about HIV/AIDS? 2. Are you doing anything to protect yourself from HIV? 3. Have you used drugs? 4. Have you been tested for HIV? 5. Modes of HIV transmission reviewed? 6. Risk factors reviewed? 7. Discussed HIV risk reduction?

a. Correct condom use b. Monogamous partners c. Reduce number of partners d. Cleanliness of equipment

8. Literature given? 9. Condoms given?

10. Is subject male or female? Comments: _____________________

o understand the extent of a state of health, whether it is a disease, disability, or factors that keep people well, it is necessary to describe the magnitude or frequency of the condition. Since people differ in terms of health, it is important to know how they differ.

By looking at the frequency of the condition in groups of people who either have or do not have the problem under investigation, it can be determined who is at risk or not at risk for that condition. Using this technique, descriptive epidemiology can demonstrate the seriousness of the problem, determine the characteristics of the people it affects, and identify where and when it occurs. It can also provide data, or clues, that suggest how the condition evolves and why the condition exists. This information can indicate which people are likely to develop certain health problems; what diseases, disabilities, or needs they have; how these health problems are distributed within the community; and what kind of health services are needed. The use of

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existing resources in a community can then be determined and programs planned to address the needs.

Using the information about the frequency and distribution of a condition, nurses and other healthcare professionals can examine the characteristics of groups of people in the community, or within institutions, who are most likely to develop health problems. These groups are considered to be populations at risk. Knowledge about the population at risk and risk factors can be also used to set priorities for the development of strategies to meet emerging health needs and for expansion or change in programs or services that are directed toward secondary or tertiary prevention.

The process of using epidemiologic techniques to generate a knowledge base about a specific health problem and plan for its control and prevention is best illustrated by cardiovascular disease. The knowledge gained from the study of populations at risk and identification of predisposing risk factors has been the foundation for the primary, secondary, and tertiary prevention strategies used widely today. Since the initial development of objectives in the earlier reports on Healthy People 2000 and 2010, Healthy People 2020 (CDC, 2010a) has strengthened the focus on health promotion activities in the United States. With a vision based on developing a society in which all people live long, healthy lives, its mission is to identify nationwide health improvement priorities; increase public awareness and understanding of the determinants of health, disease, and disability and the opportunities for progress; provide measurable objectives and goals that are applicable at the national, state, and local levels; engage multiple sectors to take actions to strengthen policies and improve practices that are driven by the best available evidence and knowledge; and identify critical research, evaluation, and data collection needs.

The overarching goals of Healthy People 2020 (CDC, 2010a) are: Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death Achieve health equity, eliminate disparities, and improve the health of all groups Create social and physical environments that promote good health for all Promote quality of life, healthy development, and healthy behaviors across all life stages

Although most epidemiologic studies have focused on disease and disability, it should be emphasized that this process can also be used to study states of wellness. For example, studies of the factors that are associated with healthy, community-dwelling elderly people can lead to the implementation of strategies to enhance wellness in the elderly population.

To demonstrate that African American people are a population at risk, Lindsay examines Florida statistics. She finds that since the epidemic began, a cumulative total of 107,980 cases of HIV/AIDS have been diagnosed in Florida. Nearly half (48.7%) of these cases have occurred in African American people.

Make a list of other information that Lindsay needs to understand the scope of the HIV/AIDS problem in the two counties.

UNDERSTANDING AND USING RATES Although the most basic measure of frequency involves counting the number of affected people, this may result in misleading impressions and usually is of limited use. A higher number of cases in one group of people versus another may mean that the number of susceptible people in that group is greater or that the counting took place over a longer period of time. To provide

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more valid descriptions of the frequency of various states of health, it is necessary to use ratios, proportions, and rates.

However, there are some statistics that are impressive even if they involve counting (or estimating) just the number of affected people. For example, Figure 7.1 illustrates the 10 leading causes of death in the world in 2015. The figure shows that ischemic heart disease and stroke caused 15 million deaths. Chronic obstructive pulmonary disease caused 3.2 million deaths, lung cancer 1.7 million deaths, and diabetes 1.6 million, an increase from 1 million in 2000 (World Health Organization [WHO], 2015).

A ratio is a fraction that represents the relationship between two numbers. It is the value obtained by dividing one quantity by another quantity. People (or things) counted in the numerator are not counted in the denominator. For example, the number of boys (160) in an elementary school could be contrasted with the number of girls (80) in that school using a ratio (160/80 = 2/1 = twice as many boys as girls).

A proportion is a type of ratio that includes the quantity in the numerator as a part of the denominator; it is the relationship of a part to the whole. Dividing the number of boys by the total number of children in the school results in a proportion (160 divided by 240 = 0.67; 67% of the students are boys).

The rate is the primary measurement used to describe the occurrence (frequency or quantity) of a state of health in a specific group of people in a given time period. It is a proportion that includes the factor of time. Therefore, rates are the best indicators of the risk (probability) that a specific disease, condition, or event will occur. The rules for calculation of rates are outlined in Box 7.1. Rates are used to quantify either the occurrence (incidence) or the existence (prevalence) of states of health or illness. Using rates rather than counting cases takes both the size of the population at risk and the time frame into account.

Not everything that counts can be counted, and not everything that can be counted counts. Albert Einstein

For example, suppose it is necessary to compare 2,250 cases of H1N1 influenza diagnosed in February in Lake County having a population of 104,000 with 10,500 cases of H1N1 influenza diagnosed in February in Barnes County having a population of 950,000. If only the frequency count is examined, Barnes County has the greatest number of people with the flu, and therefore, it could be concluded that Barnes County has the greater community problem. However, it is not appropriate to compare the raw numbers alone; more cases would be expected in a county with more residents. Indeed, the calculation of rates in Table 7.1 indicates that Lake County had the most severe outbreak of the illness in February.

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FIGURE 7.1 The 10 leading causes of death in the world (WHO, 2015). (Available from http://www.who.int/mediacentre/factsheets/fs310/en.)

7.1 How to Calculate Rates

1. All of the events being measured should be included in the numerator. 2. Everyone included in the denominator should be at risk for the event in the numerator. For example,

it would be inappropriate to include males in the denominator when calculating a rate for ovarian cancer because no males are at risk for the illness.

3. A specific period of time for the observations must be clearly indicated. This can range from a single point in time to several years, depending on the type of rate that is being calculated.

4. A rate is a fraction or a proportion; therefore, it is necessary to multiply by a base, usually a multiple of 10, to make the rates understandable. This removes the decimal points and makes the comparison of rates easier to interpret. Any base multiple of 10 may be chosen that results in a rate above the value of 1. For large populations, 100,000 is often used. For smaller populations, 100 is often used, and the rate can then be expressed as a percentage.

5. Formula for calculation:

Practice Point

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When assessing the extent of a health problem in a community at a given time, the number of cases should be counted, the number of people in the population should be obtained, and a rate should be calculated.

Crude Rates Crude rates are general or summary rates that measure the occurrence of the condition being investigated in the entire population. Calculation of these rates usually involves averaging the population numbers at the beginning and end of the year, and that number is used in the denominator. However, smaller groups within the entire population (subgroups) may differ significantly with regard to their risk of developing the condition, and thus, calculating only crude rates may obscure important information. For example, the formula for a crude birth rate has the entire population in its denominator. Births can occur only to females who are of childbearing age; therefore, the total population may not be an ideal denominator.

There are 2,150 people living with HIV/AIDS this year in two Florida counties. What is the crude rate of the HIV/AIDS burden in these two counties?

Adjusted Rates There is often a need to remove the effects of differences in the composition of a population when comparing one with another. For example, an investigator may want to compare two or more groups knowing that they differ in terms of a characteristic, such as age, that may influence the results. The process of adjusting rates controls for these differences. Although age adjustment and other types of adjusted rates are artificial, they provide a valid way to compare two populations without the confounding variable (such as age) affecting the results.

As an example, Figure 7.2 illustrates age-adjusted death rates by race, Hispanic origin, state, and territory: United States and U.S.-dependent areas, average annual 1979 to 1981, 1989 to 1991, and 2013 to 2015 (Centers for Disease Control and Prevention [CDC], 2016).

Age-adjusted rates are meaningful only as a comparison and should not be used if an accurate description of a population is desired and not a comparison of populations. It is also possible to adjust rates to remove other variables, such as race or occupation, that are confounding an investigation.

Incidence Rates An incidence rate (also an occurrence or attack rate) is a measure of the probability that people without a certain condition will develop the condition over a period of time, often a year. It measures the pace at which new illnesses, such as H1N1 influenza, occur in a previously disease-free group of people. The general rules that apply to rates also apply to calculation of incidence rates (see Box 7.1). However, only the new cases that have occurred in the designated time period are counted and placed in the numerator. Common incidence rates and ratios that provide indexes of the health of a community are presented in Table 7.2.

TABLE 7.1 Calculation of Rates of H1N1 Influenza in Lake and Barnes Counties

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FIGURE 7.2 Age-adjusted death rates, by race, Hispanic origin, state, and territory: United States and U.S. dependent areas, average annual 1979–1981, 1989–1991, and 2013–2015 (CDC, 2016). (Available from https://www.cdc.gov/nchs/data/hus/2016/016.pdf.)

Determination of the date of onset is required for studies of incidence. For acute conditions, this can be quickly established. H1N1 influenza is an acute, time-limited condition; thus, the data in Table 7.1 result in incidence or occurrence rates. For other conditions such as cancer or depression, it may be difficult to determine the time of onset. In this case, an event that can be verified, such as the date of diagnosis, is considered as the time of onset.

Lindsay finds that 384 new cases of HIV infection were diagnosed in the two counties within the past year. What is the incidence rate? Contrast this incidence rate with: (1) the crude rate of the HIV/AIDS burden calculated above; and (2) the incidence rate in the United States of 83.7 new HIV infections per 100,000 in 1 year. Interpret the results.

Prevalence Rates Both incidence rates and prevalence rates can be measures of morbidity—a departure from a state of physiologic or psychological well-being. Prevalence rates measure the number of people in a given population who have a specific existing condition at a given point in time. The general rules that apply to rates also apply to calculation of prevalence rates (see Box 7.1). However, both new cases and existing cases (old and new cases) are counted in the designated time period and placed in the numerator.

There are two types of prevalence rates. Period prevalence indicates the existence of a condition during a period or an interval of time. Point prevalence refers to the existence of a

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condition at a specific point in time and provides a picture of an existing situation for a group of people. If the time frame is not given, point prevalence is inferred. Point prevalence does not have to be expressed in calendar time; it can refer to an event that happens to different people at different times. For example, it could refer to the day of discharge from an institution for a group of people or a specific day of attendance at a screening clinic.

Prevalence is influenced by two factors: the number of people who have developed the condition in the past and the duration of their illness. The longer the duration of a condition, the higher the prevalence rate. This is best illustrated with chronic diseases. Even if the incidence rate is low, the prevalence rate may be high. For instance, there are many more existing cases of cancer in a community than are indicated by examining the number of new cases of cancer.

Prevalence statistics are very important in identifying public health problems that exist in a community. They are particularly useful to health planning professionals because they measure the burden of a condition or illness in a community. This information documents the need for developing programs such as the initiation of primary, secondary, or tertiary prevention strategies for people at risk. Also, these data provide the rationale for modification of facilities and hiring staff to meet the requirements of the community.

TABLE 7.2 Incidence Rates and Ratios That Provide Indexes of the Health of a Community

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Evidence for Practice

Researchers at the Centers for Disease Control and Prevention (CDC, 2010b) used the results of the Oregon Healthy Teens Survey, which had questioned eighth-grade students to determine the demographic characteristics and risk factors for participation in the “choking game.” This is an activity where youths become “high” by cutting off blood and oxygen to the brain with a belt, towel, rope, or other item. Evaluation of earlier studies had indicated that youths experiencing peer rejection or other disruptive factors are more likely to participate in strangulation activities.

This investigation (CDC, 2010b) reported prevalence rates as percentages because the base multiplier for calculation of the rates was 100. A total of 36.2% of the youths had heard of the choking game, 30.4% had heard of someone participating, and 5.7% had taken part themselves. Risk factors included substance use and mental health factors, such as depression. Youths with these factors had the highest participation rate (15.8%) and were approximately nine times more likely to participate. Of those who reported only substance use and no mental health factors, the participation rate was 7.9%, and of those who reported only mental health factors and no substance use, the participation rate was 4%. In students with no reported risk factors, the participation rate was 1.7%.

Public health surveillance of these strangulation activities in youths should be expanded to understand the frequency of the risk and the motives and circumstances surrounding participation. Along with parents and educators, nurses, counselors, and others who work with youths should be aware of strangulation activities and their serious health effects. They should watch for signs of participation in strangulation activities, especially in youths with suspected substance use or mental health risk factors. Three quarters of parents responding reported being familiar with the choking game, but considerably fewer (20%) reported having talked to their children about this activity. Ninety-six percent of parents reported knowing that unintentional death was a potential risk and 90% believe information about this activity should be included in school health curricula (Bernacki & Davies, 2012). In addition, this report indicated the importance parents’ perspectives on the topic of the prevention of the choking. The association between participation in strangulation activities and other sensation-seeking behaviors or mental health risk factors suggests that effective methods for substance use prevention might serve as models for effective prevention strategies. However, prevention methods for this activity should be tested before being incorporated into general use. For example, an unintended consequence of prevention methods may be increased youth participation in the choking game. Effective prevention methods could be incorporated into existing substance use and mental health screening instruments, curricula, or related public health tools (CDC, 2010b).

SPECIFIC RATES: DESCRIBING BY PERSON, PLACE, AND TIME Specific rates are more detailed rates and are calculated using the number of people in the smaller subgroups of the population in the denominator. Often, people are divided into subgroups by age and sex, although any characteristic can be used. The frequency and severity of most illnesses vary according to age more than any other personal characteristic.

When investigating the distribution and the determinants of a health condition, one of the first steps is to use statistics to find out who is experiencing the condition (person), where it is occurring (place), and when it appears (time). This information about the distribution of the condition is an essential step in the identification of high-risk groups and in the search for possible solutions.

There are three ways of examining descriptive information that can be helpful in developing

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plausible explanations (hypotheses) for the occurrence of the condition under study. First, look for differences in frequency of characteristics between groups; second, look for areas of agreement where factors are identified that are occurring frequently; and third, look for variations in the data that may present clues for control and prevention of the condition. Rates are usually used in this process, and it is often helpful to use graphs or charts to depict the results.

If you can’t explain it simply, you don’t understand it well enough. Albert Einstein

Person: Who Within any general population, whether it consists of members of a neighborhood, the clients in a community clinic, or the residents in an assisted living facility, there are differences among the individual people. These differences are genetic, biologic, behavioral, and socioeconomic. Because of these variations, specific incidence and prevalence rates should be calculated according to these specific characteristics. Statistics of this type that are gathered to describe populations are referred to as demographic data, or the study of the size, distribution, and characteristics of human populations.

Two characteristics are considered routine descriptors of a person: age and sex. Most health problems vary in both frequency and severity by age, and many are sex-specific. Therefore, morbidity and mortality rates for almost all health conditions vary by age or sex. Because of this, age- and sex-specific incidence and prevalence rates should be calculated whenever describing a problem.

Practice Point

Age is the most important characteristic to address when describing the state of people’s health; it is directly associated with risk for illness or disability.

The CDC has used specific incidence rates in its surveillance of injuries in the United States (CDC 2014a). Figure 7.3 shows the percentage distribution of injury episodes by place of occurrence in 2010. As can be expected, 47% of the nonfatal, medically attended injury episodes took place in or around the home. Nearly 40% of these injuries occurred while a person was engaged in leisure activities, including sports (CDC, 2012). Figure 7.3 shows percentages; however, these are also rates with a multiplier of 100. Knowing what an injured person was doing and where his or her injury occurred is very important for designing prevention programs.

Figure 7.4 presents an example of specific prevalence rates for adults aged more than 45 years who need help with routine activities, by age group and selected race or ethnicity. Again, this example shows rates expressed as percentages; examining this figure shows that needing help with routine activities increased steadily with age for all racial/ethnic groups. Non-Hispanic blacks were more likely to need help with routine activities compared with Hispanics and non- Hispanic whites for those aged 45 to 74 years. Among adults aged 45 to 54, Hispanics were least likely to need help with routine activities. However, the pattern changes among adults aged 75 years and over. Hispanics and non-Hispanic blacks were both more likely to need help with routine activities than non-Hispanic whites. Studying figures such as this one can give public health practitioners data that is needed to institute primary, secondary, and tertiary interventions to enhance the health of these groups (CDC, 2013).

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FIGURE 7.3 Percentage distribution of injury episodes, by place of occurrence: United States, 2010. (Source: National Health Interview Survey, 2010. Available from http://www.cdc.gov/nchs/data/factsheets/factsheet_injury.htm.)

FIGURE 7.4 Percentage of adults aged greater than or equal to 45 years who need help with routine activities by age group and selected race/ethnicity—National Health Interview Survey, United States, 2011. (Available from https://www.cdc.gov/nchs/data/series/sr_10/sr10_255.pdf.)

Facts are stubborn, but statistics are more pliable. Mark Twain

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Place: Where Examining the differences in the rates of illness or disability and determining where they are highest or lowest assists in determining health needs, planning prevention and control measures, and allocating resources. Natural boundaries, political boundaries, and environmental characteristics are taken into consideration in this process.

Variations in incidence and prevalence rates can be examined by continent, nation, states, city, census tract, city block, or other geographic area. Differences between urban and rural areas or among smaller localities may be helpful in investigating specific health needs for communities. Place of occurrence is almost always examined when investigating outbreaks, both in the community and within institutions. Rates can be compared among institutions, among units in a single institution, or among different groups within any healthcare facility. This information indicates where prevention and control measures and health resources should be concentrated to decrease incidence and prevalence of a particular problem.

FIGURE 7.5 Number of laboratory-confirmed cases (n = 135) of Salmonella typhimurium infection with the outbreak strain, involving pet turtles in the United States, March 13 through November 17, 2008. (Data from Centers for Disease Control and Prevention. [2010]. Multistate outbreak of human Salmonella typhimurium infections associated with pet turtle exposure—United States, 2008. Morbidity and Mortality Weekly Report, 59[07], 191–196. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5907a2.htm.)

Evidence for Practice

The CDC monitored the 2015–2017 outbreak of salmonella related to exposure to pet guinea pigs, the fourth such outbreak since 2006 (CDC, 2018). A total of nine cases have occurred in eight states and the District of Columbia, but many more unreported illnesses likely occurred. This is similar to the 2008 outbreak, demonstrated in Figure 7.5, which caused a multistate outbreak of salmonella related to exposure to pet turtles (CDC, 2010c). In this third outbreak in 2015–2017, a total of 135 cases occurred in 25 states and the

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District of Columbia. Figure 7.5 shows the distribution of the confirmed cases by state. The first known (index) case was a 2-year-old girl who was brought to a physician’s office in Philadelphia after 3 days of diarrhea and fever. Salmonella typhimurium was isolated from her stool specimen. Three weeks earlier, the family had purchased two pet turtles with shell lengths less than 4 in from a street vendor. Within weeks, more clients in Pennsylvania were diagnosed with the same strain of the organism, and matching isolates had been found in cases from 10 states. Most ill people reported exposure to turtles with shell lengths less than 4 in that had been acquired from flea markets, street vendors, and souvenir shops. It is important to note that small turtles pose a greater risk to young children because they are perceived as safe pets, but are small enough to be placed in the mouth or handled inappropriately.

Investigation of the salmonella outbreak documented that young children without direct turtle exposure are at risk for turtle-associated salmonellosis through person-to-person transmission in child care settings. This investigation reinforced the need for continuing the existing prevention and control measures. Increasing enforcement of the existing local, state, and federal regulations against the sale of small turtles, increasing penalties for illegal sales, and enacting more state and local laws regulating the sale of small turtles could enhance federal prevention efforts and facilitate a more rapid public health response (CDC, 2010d).

Time: When Variations in time can be short-term, periodic, or long-term. Short-term changes are measured in hours, days, weeks, or months. They are commonly found in outbreaks of infectious disease. Figure 7.6 illustrates an epidemic curve created from study of an outbreak of mumps that occurred from June 2009 to January 2010 in New York and New Jersey. Cases of reported confirmed or probably mumps (n = 1,494) are shown by week of illness onset and age group during the outbreak. At the time of the report, local transmission continued to occur (CDC, 2010e).

More recently, reports on an increase in newborn microcephaly in northeast Brazil demonstrated an emerging epidemic of the Zika virus. Infants born with a small head, measured by circumference, and those whose head circumference fails to increase in infancy have a condition called microcephaly (WHO, 2016). This is a rarity and usually occurs in one case among several thousand births. The outcome of microcephaly is severe, with physical and learning disabilities occurring.

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FIGURE 7.6 Number (n = 1,494) of reported confirmed or probable mumps cases, by week of illness onset and age group in New York and New Jersey, June 2009 through January 2010. (Data from Centers for Disease Control and Prevention. [2010]. Update: Mumps outbreak—New York and New Jersey, June 2009–January 2010. Morbidity and Mortality Weekly Report, 59[05], 125–129. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5905a1.htm.)

TABLE 7.3 Zika Information From Brazil: Date, Total Cases, Locations, and Deaths

Date Total # Cases

Locations Reported Deaths

As of October 2015 Increase # cases

Northeastern Brazil 0

As of 17 November 2015

399 Northeastern Brazil Seven states

0

As of 21 November 2015

739 Northeastern Brazil Nine states

1

As of 05 December 2015

1761 Nationally across 42 municipalities across 14 federal units The Northeastern region continued to report the highest

number

19

As of 02 January 2016 3,174 Nationally across 684 municipalities of 21 federal units. The Northeastern region continued to report the highest number of suspected cases

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Source: World Health Organization. (2017). Microcephaly Brazil. Retrieved from http://www.who.int/csr/don/8-january-2016-brazil-microcephaly/en.

In 2016, the Ministry of Health of Brazil reported to the World Health Organization (WHO, 2017) the data shown in Table 7.3.

In response to this emerging data, the World Health Organization and Brazilian public health

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agencies responded with an increase in vector prevention and control (WHO, 2017). Periodic changes may be seasonal or cyclic. For example, respiratory diseases are more

common in winter and spring, and infectious hepatitis increases in incidence every 7 to 9 years. Figure 7.7 shows the percentage of all deaths attributed to pneumonia and influenza for 122 cities in the United States between 2009 and 2013. The seasonal variation in death rates reflects the seasonal variation in respiratory infections. When studying these mortality statistics, it is possible to compare the percentage of all deaths attributable to pneumonia and influenza with a seasonal baseline and epidemic threshold value calculated for each week. An increase of 1.645 standard deviations above the seasonal baseline deaths is the “epidemic threshold.” This is the point at which the observed proportion of deaths attributed to pneumonia or influenza is significantly higher than would be expected at that time of the year. Long-term changes extend over decades and reflect gradual changes. An interesting example follows the tracking of West Nile virus infection, a disease that is transmitted by a mosquito vector. Figure 7.8 follows the progression of the illness from one state to another after it was first reported in New York in 1999. This figure combines variation in both place and time over a period of 15 years (CDC, 2014b).

FIGURE 7.7 Pneumonia and influenza mortality for 122 U.S. cities: Week ending March 8, 2014. (Available at http://www.cdc.gov/flu/weekly.)

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FIGURE 7.8 Average annual incidence of West Nile virus neuroinvasive disease reported to CDC by state, 1999 to 2012. (Source: ArboNET, Arboviral Diseases Branch, Centers for Disease Control and Prevention. Retrieved from http://www.cdc.gov/westnile/statsMaps/cumMapsData.html.)

Figure 7.9 shows that variations in trends of the mortality of various cancers can be seen when examined over many years. Overall, the age-adjusted cancer rates between 1930 and 2010 have fluctuated but are decreasing slowly. Cancer of the lung and bronchus leads all cancers as the cause of mortality in both men and women. It is interesting to note that the mortality rate for cancer of the stomach has decreased steadily since 1930, that cancer of the lung rose steadily until the 1990s, and that cancer of the colon and rectum continues to decrease (American Cancer Society, 2018). This is likely a result of primary prevention measures such as education and increased awareness as well as secondary prevention measures such as colonoscopy screening.

TYPES OF INCIDENCE RATES Mortality Rates Mortality rates or death rates are common incidence rates that are calculated for public health purposes. Crude mortality rates indicate the probability of death from any cause among the entire population in a designated geographic area. Cause-specific (disease-specific) mortality rates indicate the probability of death from a specific cause; the number of deaths from a specific disease is divided by the number of people in the population at midyear and multiplied by 100,000. In calculating the case fatality rate, the number of people with a specific disease such as lung cancer becomes the subgroup being studied out of the entire population in a designated geographic area. For example, the case fatality rate is calculated by dividing the number of deaths from lung cancer by the number of people living with lung cancer during the year, and multiplying by 100. Further breakdown into specific subgroups might involve age, sex, occupation, tobacco use, or other characteristics for calculation of mortality rates.

It is possible to confuse the proportional mortality ratio (PMR) with the cause-specific mortality rate. The PMR compares deaths from a specific illness to deaths from all other causes; it reflects the proportion of deaths due to a specific cause. The PMR is not a rate. The denominator includes all deaths within a given time period rather than the entire population under study. In contrast, the cause-specific mortality rates indicate the risk of death from a specific disease for a given living population. Both the PMR and cause-specific mortality rates should be calculated when death statistics are being examined for public health purposes.

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Incidence Density When there are unequal periods of observation for study subjects, it may be necessary to use a person-time denominator in the calculation of incidence rates. This technique provides a measure of incidence density. In healthcare, people often enter a study period at different times and therefore contribute unequal periods of time to the study. To identify the precise period of observation for each person and weigh that period of observation properly in calculating rates, a person-time unit, such as person-day or person-year, can be constructed. A person-day represents one person at risk for 1 day, and a person-year represents one person at risk for 1 year. Incidence density can be calculated as:

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FIGURE 7.9 A: Age-adjusted cancer death rates, males by site, United States, 1930 to 2010. B: Age-adjusted cancer death rates, females by site, United States, 1930 to 2010. Rates are per 100,000 age-adjusted to the 2000 U.S. standard population. (Data from American Cancer Society. [2018]. Cancer Facts & Figures 2018. Atlanta: American Cancer Society. Retrieved from https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual- cancer-facts-and-figures/2018/incidence-and-mortality-rates-for-selected-cancers-by-race-and- ethnicity-us-2010-2015.pdf.)

TABLE 7.4 Incidence Rates of Institution-Associated Pneumonia in an Acute and Long-Term Care Setting

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Table 7.4 demonstrates the difference between the calculation of crude incidence rates and incidence density in a study that examined the development of hospital- and institution- associated pneumonia in both an acute care facility and a long-term care facility. These incidence data illustrate the need to calculate and compare both crude incidence and incidence density rates when comparing different settings with varying lengths of stay. In this example, the incidence rate in long-term care was almost five times that of the acute care setting. However, when the researchers included client days in the denominator, the acute care setting reflected twice the incidence density of the long-term care setting. More clients contributed shorter periods of time in the acute care setting, whereas there was relatively little turnover in residents in the long-term care setting.

Measures of incidence density can account for those persons who die, those who are lost to follow-up, or those who have acquired the illness and are therefore not at risk for the entire study period. Normally, it is assumed that the risk of acquiring the illness is constant throughout the entire period of the study.

Attributable Risk Attributable risk is the difference between the incidence rates in an exposed group of people and an unexposed group of people. It measures the risk of a condition occurring in an exposed group that is attributable to a specific exposure but not to other factors. In almost any health- related event, some risk occurs normally in a population without a specific exposure. In calculating attributable risk, the risk of the event that would have occurred under normal circumstances is subtracted from the risk of the event in the exposed group:

Relative Risk Ratio Incidence rates indicate the occurrence of a health-related event in a population in a given period of time. It is an indicator of the probability that people without a specific condition will develop the condition within a designated period of time. Therefore, it is a measure of the risk of developing the condition. Often, incidence rates for groups exposed to a certain risk factor are compared with the incidence rates for people who are not exposed. This procedure results in a relative risk ratio. It is a ratio of the incidence rate in the exposed group and the incidence rate in the nonexposed group.

A relative risk of 1.0 indicates that the risk is equal for both groups, and conversely, a relative risk greater than 1.0 indicates that the risk is greater in the exposed group. For example, a relative risk of 6.0 can be interpreted to mean that people who are exposed to a disease are six times more likely to develop it. The CDC used this technique to develop an educational chart for use in HIV prevention programs (Fig. 7.10). This chart shows how the relative risk for transmission from a person living with HIV to a person without the infection varies according to

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sexual activity and condom use. For example, it is possible to contrast insertive oral sex while using a condom, which has a low risk for HIV transmission, with receptive anal sex without a condom, which is 2,000 times more risky. This kind of information regarding HIV transmission can influence decisions about sexual activity and condom use (CDC, 2007).

A relative risk less than 1.0 indicates that the risk is less in the exposed group; the factor in question may possibly protect against the condition under study. Although this finding is not very common, it may signify that further study is warranted. Statistical tests, such as the calculation of the chi-square statistic, are used to determine whether the relative risk ratios are different from those that would be expected by chance. In this way, the statistical significance of the findings can be established.

SENSITIVITY AND SPECIFICITY Sensitivity and specificity are statistical measures that evaluate the validity and reliability of a test. Sensitivity is the ability of the test to identify correctly people who have the health problem under study. It is the probability of testing positive if the health problem is truly present. Specificity is the ability of the test to correctly identify people who do not have the health problem. It is the probability of testing negative if the health problem is truly absent. Increasing the sensitivity of a test causes a decrease in specificity, and conversely, increasing the specificity of a test decreases sensitivity. The formulas for calculation of sensitivity and specificity are found in Box 7.2. To obtain sensitivity and specificity values, it is necessary to perform research studies that obtain the values of screening tests and then determine whether the health problem truly exists in each subject.

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FIGURE 7.10 Relative risk for transmission from a person living with HIV. (Data from CDC. Relative risk for transmission from a person living with HIV. Retrieved from http://www.cdc.gov/hiv/topics/treatment/PIC/pdf/chart.pdf.)

In an ideal situation, a screening test is able to identify the presence or absence of a health problem correctly in every person screened with a sensitivity and specificity of 100%. However, this is almost impossible to achieve in actual practice. One way to address this problem is to use several screening tests to make health decisions.

7.2 How to Calculate Sensitivity and Specificity

Before screening projects are undertaken, it is important to determine carefully the screening levels or test values. Much depends on the consequences of leaving some cases undetected (false negatives) or classifying healthy people as having a health problem (false positives). When the disease being studied is rare, the specificity of a test is rarely high enough to give an adequate positive predictive value. Only the sensitivity of a test is useful in the case of a rare disease. The choice of screening levels is subjective and based on the severity of the disease, cost, time

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factors, advantages of early treatment, and other screening criteria.

The outreach program promotes HIV testing in the African American population. Lindsay examines the types of tests available and finds that rapid, same-day testing has a high sensitivity and specificity. She reviews the below example to understand what this means.

This is perhaps best illustrated by example. Imagine a population of 100,000 people, of whom 10,000 are actually HIV-infected and 90,000 HIV-uninfected. The goal of a screening procedure would be to correctly identify all 10,000—and only those 10,000— HIV-positive individuals. A test with 99% sensitivity would correctly identify 9,900 of the 10,000 infected individuals (99%). One hundred infected people would test falsely negative (a false-negative rate of 1%).

If the same test procedure had a specificity of 90% (an unrealistically low value used to simplify this example), it would correctly identify 90% (81,000) of the HIV-uninfected individuals as HIV-negative. However, 9,000 HIV-uninfected persons would test falsely positive (a false-positive, http://www.aidsmap.com/Sensitivity-and- specificity/page/1322984/ rate of 9,000/90,000=10%). Box 7.2 for the equations used to calculate sensitivity and specificity.

USE OF RATES IN DESCRIPTIVE RESEARCH STUDIES Epidemiologic descriptive studies include the descriptions of health conditions, case reports, and correlational studies. Descriptive studies are very useful in describing the characteristics of disease occurrence and in generating hypotheses for further study. They are the first studies to be performed in investigating the determinants of a health problem and are essential in determining the rationale for an experimental or intervention study.

Researchers design descriptive studies to acquire more information about the occurrence of health problems or, alternatively, the factors that keep people well. The specific rates calculated in these studies describe people who have or do not have the health problem in terms of person, place, and time. These studies provide a picture of the events as they naturally occur. Therefore, this type of data is very helpful for nurses involved in health planning or administration in both community and institutional settings. Knowledge of people who are the most or least susceptible to a health problem can help when deciding to implement programs for prevention or control of health problems and to allocate resources.

Lindsay develops a plan to evaluate the effectiveness of the outreach program. Using the HIV/AIDS Outreach Survey, decide what statistics should be calculated for each of the 10 questions. Include the calculation of both general (crude) rates and specific rates where appropriate.

KEY CONCEPTS Measuring the magnitude or frequency of a state of health determines the characteristics of those who are at high risk. Epidemiologic descriptive studies have determined measurable risk factors for major illnesses. Calculation of rates provides the best indicators of the probability that a specific state of health will occur.

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Indexes of the health of a community, region, or country include comparisons of general mortality rates and maternal infant rates. A variety of rates can be calculated according to need, including incidence, prevalence, adjusted, and specific rates. Specific rates calculated by person, place, and time provide the best description of a health condition. Prevalence is influenced by the number of people who have developed the condition in the past and the duration of their illness. Prevalence rates provide essential data for implementing prevention measures. Before screening projects are undertaken, the sensitivity and specificity of screening levels or test values should be carefully reviewed.

CRITICAL THINKING QUESTIONS

1. Between January 1 and December 31, 35 new cases of tuberculosis were diagnosed in a city. There were a total of 300 active cases among the population of 400,000 on December 31 of that year. Twenty deaths from tuberculosis were recorded during the 1-year period. a. What was the incidence rate per 100,000 people for tuberculosis during the year? b. What was the prevalence rate of tuberculosis per 100,000 on December 31? c. What is the cause-specific death rate per 100,000 for tuberculosis during the year?

2. A recent report from a state health department included a map indicating the distribution and number of rabid animals for each of the 167 towns in the state between January 1 and October 31. What type of information about the occurrence of rabies does this report include? Why were rates not calculated? How might this information be used to control rabies?

3. A community nurse uncovers the following statistics regarding HIV infection in African Americans in two rural counties in the United States: a. What is the incidence rate in black males and black females per 10,000 people in the 1-year period? b. What is the prevalence rate in black males and black females per 10,000 people in the 1-year period? c. Interpret the incidence and prevalence rates. Which statistics provide the best information to use for

program planning? d. What population group should be targeted for the HIV/AIDS outreach program? Why?

New HIV Infection Living With HIV Population Total Males 150 838 29,560 Females 234 1,312 28,315 African American population 384 2,150 57,875

REFERENCES American Cancer Society. (2018). Cancer facts & figures 2018. Atlanta: American Cancer Society.

Retrieved from https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and- statistics/annual-cancer-facts-and-figures/2018/incidence-and-mortality-rates-for-selected-cancers-by- race-and-ethnicity-us-2010-2015.pdf.

Bernacki, J. M., & Davies, W. H. (2012). Prevention of the Choking Game: parent perspectives. Journal of Injury and Violence Research, 4(2), 73.

Brown, E. J., & Brown, J. S. (2003). HIV prevention outreach in black communities of three rural North Florida counties. Public Health Nursing, 20(3), 204–210.

Brown, K., Williams, D. B., Kinchen, S., Saito, S., Radin, E. Patel, H.,…Voetsch, A. C. (2018). Status of HIV epidemic control among adolescent girls and young women aged 15–24 years—Seven African countries (2015-2017). Morbidity and Mortality Weekly, 67(1), 29–32.

Centers for Disease Control and Prevention. (2007). Relative risk for transmission from a person living with HIV. Retrieved from http://www.cdc.gov/hiv/topics/treatment/PIC/pdf/chart.pdf.

Centers for Disease Control and Prevention. (2010a). Healthy People 2020. Retrieved from https://www.healthypeople.gov/.

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Centers for Disease Control and Prevention. (2010b). “Choking game” awareness and participation among 8th graders—Oregon, 2008. Morbidity and Mortality Weekly Report, 59(1), 1–5.

Centers for Disease Control and Prevention. (2010c). Multistate outbreak of human Salmonella typhimurium infections associated with pet turtle exposure—United States, 2008. Morbidity and Mortality Weekly Report, 59(7), 191–196.

Centers for Disease Control and Prevention. (2010d). Multistate outbreak of human Salmonella typhimurium infections associated with pet turtle exposure—United States, 2008. Morbidity and Mortality Weekly Report, MMWR News Synopsis. Retrieved from https://www.cdc.gov/media/mmwrnews/2010/n100225.htm.

Centers for Disease Control and Prevention. (2010e). Update: Mumps outbreak—New York and New Jersey, June 2009–January 2010. Morbidity and Mortality Weekly Report, 59(5), 125–129. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5905a1.htm.

Centers for Disease Control and Prevention. (2012) NCHS fact sheet: NCHS data on injuries. Retrieved from http://www.cdc.gov/nchs/data/factsheets/factsheet_injury.htm.

Centers for Disease Control and Prevention. (2013). QuickStats: Percentage of adults aged ≥45 years who need help with routine activities by age group and selected race/ethnicity—National Health Interview Survey, United States, 2011. Morbidity and Mortality Weekly Report, 62(33), 683. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6233a7.htm?s.

Centers for Disease Control and Prevention. (2014a). NCHS data on injuries: NCHS fact sheet. Retrieved from http://www.cdc.gov/nchs/data/factsheets/factsheet_injury.htm.

Centers for Disease Control and Prevention. (2014b). West Nile virus disease cases and deaths reported to CDC by year and clinical presentation, 1999–2012. Final cumulative maps & data for 1999–2012. Retrieved from http://www.cdc.gov/westnile/statsMaps/cumMapsData.html.

Centers for Disease Control and Prevention (CDC). (2016). Age-adjusted death rates, by race, Hispanic origin, state, and territory. Retrieved from https://www.cdc.gov/nchs/data/hus/2016/016.pdf.

Centers for Disease Control and Prevention. (2018). Multistate outbreak of salmonella enteritidis infections linked to pet guinea pigs. Retrieved from https://www.cdc.gov/salmonella/guinea-pigs-03-18/index.html.

World Health Organization. (2015). The top 10 causes of death. Retrieved from http://www.who.int/mediacentre/factsheets/fs310/en/.

World Health Organization. (2016). Microcephaly. Retrieved from http://www.who.int/mediacentre/factsheets/microcephaly/en/.

World Health Organization. (2017). Microcephaly Brazil. Retrieved from http://www.who.int/csr/don/8- january-2016-brazil-microcephaly/en/.

WEB RESOURCES

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

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Chapter 8 Gathering Evidence for Public Health Practice Barbara A. Goldrick

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

Of course we don’t know what we’re doing, that’s why it’s called research. Albert Einstein

1. Statistical significance is not the same thing as practical importance. 2. The more complex the test required to show statistical significance, the less

important to an individual the association is likely to be. 3. The word “significant” without the prefix “statistical” is usually a coward’s way of

implying “important” without mathematical evidence. Cowden’s Three Rules of Statistics; John M. Cowden, English epidemiologist

People commonly use statistics like a drunk uses a lamppost: for support rather than for illumination. Mark Twain

CHAPTER HIGHLIGHTS Epidemiologic/public health research defined Observational studies: Descriptive versus analytical research Strengths and limitations of epidemiologic research methodology Applying epidemiologic research to public health nursing practice

OBJECTIVES Describe the difference between descriptive and analytical research. Discuss the strengths and weaknesses of retrospective, prospective, case–control, and experimental designs. Generate research questions related to problems identified in community and public health nursing practice.

KEY TERMS

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Analytical study: Investigation that uses comparisons between groups to determine the role of various risk factors in causing the problem.

Association: Statistical relationship between two or more events, characteristics, or other variables.

Case–control study: Observational analytic study that enrolls one group of persons with a certain health problem (case patients) and a group of persons without the health problem (control subjects). It compares differences in exposures, behaviors, and other characteristics to identify and quantify associations, test hypotheses, and identify causes.

Case study: Research method that involves an in-depth analysis of an individual, group, or institution.

Causality: Relationship between two variables in which the presence or absence of one variable (the “cause”) determines the presence or absence of the other (the “effect”).

Clinical trial: Experimental study in which the investigator specifies the type of exposure for each study participant and then follows each person’s health status to determine the effects of the exposure.

Cohort study: Observational analytic study in which enrollment is based on status of exposure to a certain factor or membership in a certain group.

Controls: Subjects in an experiment who do not receive the “treatment” and provide baseline data against which the effects of the treatment can be measured.

Cross-sectional study: Study in which a sample of persons from a population is enrolled and their exposures and health outcomes are measured simultaneously.

Demographic variables: Characteristics or attributes that are collected to describe the sample. Dependent variable: The response, behavior, or outcome presumed to be affected by the

independent variable(s). Descriptive study: Study in which information is collected to characterize and summarize a

health event or problem. Epidemiologic research: The study of the distribution and determinants of health conditions or

events among populations. The studies may be descriptive or analytic. Extraneous variables: Variables outside of the study that can affect (confound) the

measurement and relationship among study variables. These can be intrinsic to the subjects (e.g., stress) and/or external factors (e.g., environment). Randomization is the most effective method to control for extraneous variables in study subjects. Control over variables external to the study generally take place in an artificial environment such as a laboratory setting.

Hypothesis: Statement of the expected outcome between two or more variables in a specific population.

Independent variable: The treatment or experimental activity that is manipulated by the researcher to test its effect on the dependent variable.

Intervention study: Investigation designed to test a hypothesized relationship by modifying an identified factor in a population. Studies may be therapeutic (clinical) or preventive.

Null hypothesis: Statement that there is no difference between/among the variables under study.

Observational study: Study in which the investigator observes rather than influences exposure and disease among participants.

Odds ratio (OR): Measure of association used in comparative studies, particularly case–control studies, which quantifies the association between an exposure and a health outcome.

p value: In statistical testing, the probability that the obtained results are not due to chance alone. Generally, the significance level set by the researcher is less than or equal to 0.05.

Preventive trial: Study in which the investigator provides a specific preventive measure to the group under study and follows the group to determine the effects of the intervention.

Prospective study: Analytic study in which participants are enrolled before the health outcome of interest has occurred.

Quasi-experimental study: Study with limited control where the subjects cannot be randomly assigned to an intervention. However, the researcher can still manipulate the dependent variable.

Relationship: See association; the two terms are often used interchangeably.

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Relative risk (RR): Ratio of the risk of disease or death among those exposed to the risk among the unexposed; synonymous with risk ratio.

Retrospective study: Analytic study in which participants are enrolled after the health outcome of interest has occurred.

Sample: Selected subset of a population; a sample can be random or nonrandom and representative or nonrepresentative.

Survey research: Systematic canvassing of persons to collect information, often from a representative sample of the population. Studies may use questionnaires and/or interviews to collect data.

Therapeutic trial: Clinical trial in which the investigator provides a specific intervention/treatment (therapy) to the group under study and follows the group to determine the effects of the treatment.

Type I error: An error created by rejecting the null hypothesis when it is true; that is, a difference is seen to exist when in fact it does not.

Type II error: An error created by accepting the null hypothesis when it is false; that is, it is concluded that no difference exists when in fact it does.

Variables: Qualities or characteristics of persons, things, or situations that change and can be manipulated or measured in research. Extraneous variables can affect the measurement and relationship among study variables.

CASE STUDIES

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

CASE 1 A Healthy People 2020 goal is to increase the proportion of adults aged 65 years and older who are vaccinated against pneumococcal disease, which is caused by Streptococcus pneumoniae, to at least 90% (USDHHS, 2010). However, data from the Centers for Disease Control and Prevention (CDC)/National Center for Health Statistics (NCHS) found that only 61% of persons 65 years of age or older had ever received pneumococcal polysaccharide vaccine in 2014 (CDC, NCHS, 2014b).

A group of community health nurses learn that their state is not on target to meet the Healthy People 2020 objective to increase the proportion of persons aged 65 years or older vaccinated against pneumococcal disease to 90% (USDHHS, 2010). In addition, the state health department has reported the occurrence of four cases of multidrug-resistant S. pneumoniae in the state within the past several months.

CASE 2 In 2014 the World Health Organization (WHO) updated its 2011 report and confirmed that noncommunicable diseases (NCDs) are still the leading cause of mortality worldwide. Cardiovascular diseases account for most NCD deaths, at 17.7 million people annually, followed by cancers (8.8 million), respiratory diseases (3.9 million), and diabetes (1.6 million). These four groups of diseases account for 81% of all NCD deaths and share four common risk factors:

Physical inactivity Tobacco use Poor diets Harmful use of alcohol

Seventeen million people die from a NCD before the age of 70, with 87% of these “premature” deaths occurring in low- and middle-income countries (WHO, 2014).

n Chapter 6, epidemiology was defined as the study of the distribution and determinants of states of health and illness in human populations. This information provides the data necessary to

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I justify the establishment of health services designed to maintain and improve health.

Epidemiologic surveillance is then conducted to monitor and evaluate these health services. The purposes of epidemiologic research, on the other hand, are to: (1) identify community/public health problems; and (2) describe natural history and etiology of diseases.

Community/public health nurses use a variety of epidemiologic research methods to generate new knowledge and provide evidence for best practice. As can be seen in Figure 8.1, the epidemiologic research cycle includes both experimental or intervention studies and observational studies.

OBSERVATIONAL STUDIES Observational studies may be either descriptive or analytical. In descriptive studies, the researcher collects information to characterize and summarize the health event or problem when little is known about the phenomenon. Descriptive studies provide the foundation for the development and testing of hypotheses.

As can be seen in see Figure 8.1, observational studies can be hypothesis-generating and hypothesis-testing studies. Hypothesis-generating research includes case studies and cross- sectional studies. Hypothesis-testing studies, on the other hand, include analytical studies that test the relationship between two or more variables in a specified population (see further discussion below).

FIGURE 8.1 Epidemiologic study cycle.

In analytical studies, the researcher relies on comparisons between groups to determine the role of various risk factors in causing the problem.

Descriptive Studies Descriptive studies are fundamental to public health research and practice (CDC, 2012a). Descriptive research identifies the characteristics of individuals, situations, or groups and the frequency with which certain phenomena (risks) occur (Gray, Grove, & Sutherland, 2017). The concept of risk was defined in Chapter 6 as it relates to person, place, and time. Therefore, descriptive studies, which are frequently used in public health, are designed to acquire more information about characteristics of health (or disease) as they pertain to person, place, and time. People in the study population will all have some characteristic in common; therefore, some

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restrictions to this broad definition must be made. For example, research is limited to considering people of the same age range, sex, or geographic location.

Many descriptive studies are observational; that is, no intervention or treatment is included. However, descriptive studies provide the foundation for the development and testing of hypotheses.

If it looks like a duck, and quacks like a duck, we have at least to consider the possibility that we have a small aquatic bird of the family Anatidae on our hands. Douglas Adams, science fiction writer

Case Studies Case studies involve an in-depth analysis of an individual, group, or social institution (Gray, Grove, & Sutherland, 2017). In epidemiologic and public health research, the case study often is the first clue that a problem may exist. A case series is a group of people with the same, or similar, illness or injury and with the same, or similar, factors that may be importantly related to the disease or injury. A historic example of a case series was the first cases of young men who presented with Kaposi sarcoma and Pneumocystis carinii pneumonia in California and New York in the early 1980s. What these young men had in common was having sex with other men. In June 1981, the CDC published the first report about AIDS in the United States, which alerted the medical and public health communities 4 months before the first peer-reviewed article on the subject of AIDS was published. For more information on the history of HIV/AIDS, see the CDC website at http://www.cdc.gov/hiv/topics/basic/#origin and AVERT website at http://www.avert.org/history-aids-1986.htm.

Survey Research Another method used in public health to collect data is survey research. Survey research focuses on the collection of information regarding the status quo of some situations by questionnaire or by interviews with a sample of respondents (Gray, Grove, & Sutherland, 2017). The main principle of survey research is that the sample of respondents must represent the population from which it was drawn.

An example of survey research was conducted by nurse researchers using existing data from a larger study. The purpose of the study was to determine the predictors of smokers’ participation in a smoking cessation program among patients with head and neck cancer from three Veterans Affairs medical centers. All participants who agreed to participate (N = 136) had smoked within the past 6 months and were classified as currently smoking, having quit in the past month, or having quit in the past 6 months. The dependent variable for the analysis was the smoker’s participation (yes/no) in the smoking cessation program (intervention). The major independent variables of interest included perceived difficulty in quitting, health behaviors (smoking and problem drinking), clinical characteristics (depression and cancer site and stage), and demographic variables.

More than half of the participants believed it would be very to extremely difficult to quit smoking. More than 60% were currently smoking and were smoking a pack a day or less. The remaining 40% of participants had quit smoking within the past 1 to 6 months. Significant associations were found between participation in the smoking-cessation program and high perception that it would be difficult to quit, miles traveled to the clinic, and hospital site (p < 0.05). No significant associations were found between participation status and alcohol use problems, greater symptoms of depression, time since diagnosis, age, or educational level.

The authors cited several limitations to the study. Although depressive symptoms and alcohol use were measured by a validated screener, they were not confirmed by a medical

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evaluation, which may have resulted in an overestimation of drinking problems and depressive symptoms. Despite the researchers’ efforts to recruit from three Veterans Affairs medical centers with a large number of minorities, the sample was predominantly white. The original sample included 286 patients with approximately equal numbers of participants and nonparticipants; however, only 136 (48%) agreed to participate. Therefore, some of the studied variables may have reached significance had the sample size been larger (Duffy et al., 2010).

Another example of survey research is the National High Blood Pressure Education Program, coordinated by the National Heart, Lung and Blood Institute (NHLBI) of the National Institutes of Health. Established in 1972, the program has succeeded in increasing awareness, prevention, treatment, and control of hypertension. Considerable success has been achieved in the National High Blood Pressure Education Program. The last hypertension guidelines published by NHLBI Joint National Committee (JNC) on Blood Pressure in Adults was in 2014 (James et al., 2014). However, in 2017, the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines developed new high blood pressure clinical practice guidelines, which update prior JNC reports (Whelton, P. K., et al., 2017). The 2017 hypertension guidelines, presented in Table 8.1, used an evidence-based approach to the management of hypertension in adults. Table 8.2 outlines the 2013 American Heart Association/American College of Cardiologists recommendations for lifestyle management to lower blood pressure and cardiovascular risk (Eckel et al., 2014).

TABLE 8.1 2017 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adultsa

BP Category SBP DBP Normal <120 mm Hg and <80 mm Hg Elevated 120–129 mm Hg and <80 mm Hg Hypertension Stage 1 130–139 mm Hg or 80–89 mm Hg Stage 2 ≥140 mm Hg or ≥90 mm Hg

aIndividuals with SBP and DBP in 2 categories should be designated to the higher BP category. BP indicates blood pressure (based on an average of ≥2 careful readings obtained on ≥2 occasions); DBP, diastolic blood pressure; SBP, systolic blood pressure; mm Hg, millimeters of mercury. Source: Whelton, P. K., et al. (2017). ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. Hypertension, 70(5), 1–283. Retrieved November 30, 2017 from http://hyper.ahajournals.org/content/guidelines2017.

Evidence for Practice

Hepatitis C virus (HCV) infection is the most common bloodborne infection in the United States. According to a 2015 study, it is estimated that 3 to 4 million people are currently infected with hepatitis C in the United States. Based on the CDC data, an additional 800,000 individuals are estimated to be infected each year (CDC, 2018).

More than 75% of adults infected with HCV are baby boomers (those born from 1945 to 1965). It is believed that most boomers became infected in the 1970s and 1980s when rates of hepatitis C were the highest. People with hepatitis C can live for decades without symptoms, and approximately half are unaware that they were infected with HCV many years ago (CDC, 2018).

The following persons are known to be at increased risk for HCV infection and should be tested:

Current or former injection drug users, including those who injected only once many years ago

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Recipients of clotting factor concentrates made before 1987, when more advanced methods for manufacturing those products were developed Recipients of blood transfusions or solid organ transplants before July 1992, when better testing of blood donors became available Chronic hemodialysis patients Persons with known exposures to HCV, such as healthcare workers after needlesticks involving HCV-positive blood, recipients of blood or organs from a donor who tested HCV- positive Persons with HIV infection Have persistently abnormal alanine aminotransferase levels (ALT) Children born to HCV-positive mothers (CDC, 2018)

Who should be tested for HCV? One-time HCV testing is recommended for adults born from 1945 through 1965 (without prior ascertainment of HCV risk factors and regardless of country of birth).

There is no vaccine against HCV infection, but research into the development of a vaccine is under way.

The Food and Drug Administration (FDA) has approved several antiviral drugs to treat chronic HCV infection. These medications have proven efficacy when used as a component of a combination antiviral regimen to treat HCV-infected adults with compensated liver disease, cirrhosis, HIV co-infection, and hepatocellular carcinoma awaiting liver transplant (CDC, 2018).

Guidance for hepatitis C treatment in adults is changing constantly with the advent of new therapies and other developments. The Infectious Diseases Society of America (IDSA) and American Association for the Study of Liver Diseases (AASLD), in collaboration with the International Antiviral Society–USA (IAS–USA), developed a web-based process for the rapid formulation and dissemination of evidence-based, expert-developed recommendations (CDC, 2018). For the latest published recommendations for testing, managing, and treating hepatitis C, see their website at http://www.hcvguidelines.org.

TABLE 8.2 Recommendations for Lifestyle Management to Lower Blood Pressure

Recommendations NHLB Strength of Evidence

Diet 1. Consume a dietary pattern that emphasizes intake of

vegetables, fruits, and whole grains

Strong

2. Include low-fat dairy products, poultry, fish, legumes,

nontropical vegetable oils and nuts

Strong

3. Limit intake of sweets, sugar-sweetened beverages and

red meats

Strong

4. Achieve this by following the USDA food pattern, or the

ADA diet

Strong

5. Lower sodium intake to 1,500 mg/day

Moderate

6. Combine the DASH dietary pattern with lower sodium

intake

Strong

Physical Activity

Engage in aerobic physical activity three to four times a week, lasting on average 40 minutes, and involves moderate-to-vigorous physical activity

Moderate

Adapted from Eckel, R. H., Jakicic, J. M., Ard, J. D., de Jesus, J. M., Houston Miller, N., Hubbard, V. S.,…Tomaselli, G. F. (2014). 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: A report of the American College of Cardiology/American Heart Association task force on practice

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guidelines. Circulation, 129(25 suppl 2), S76–S99. Retrieved July 10, 2017, from http://circ.ahajournals.org/content/129/25_suppl_2/S76.

Cross-Sectional Studies Cross-sectional studies (prevalence studies) are another example of public health survey research. In this type of study, the population to be studied is defined, and data are collected from members of the group about their disease and exposure status. The data represent a point in time; therefore, they provide a “snapshot” of the population. Cross-sectional studies are good for examining the relationship between a variable and a disease/condition but not for determining cause and effect, which requires the collection of data over time. Cross-sectional studies may be designed to gather data from two or more groups with different characteristics or with different exposure risk.

An example of cross-sectional studies is the Behavioral Risk Factor Surveillance System (BRFSS) established by the CDC in the early 1980s when scientific research clearly indicated that personal health behaviors played a major role in premature morbidity and mortality. The BRFSS is an efficient method that takes a cross-section of the population at a single point in time and monitors the prevalence of the major behavioral risks in adults associated with premature morbidity and mortality at the state level. These data are useful for planning, initiating, supporting, and evaluating health promotion and disease prevention programs. Several states use these data to determine progress toward achievement of Healthy People 2020 objectives (USDHHS, 2010). For more information on the BRFSS, see the CDC’s BRFSS website at http://www.cdc.gov/brfss/.

TABLE 8.3 Assessment of Selected Healthy People 2020 Objectives, 2014 Objective Year 2014 (%) Target 2020 (%) Reduce the proportion of adults (aged ≥18 years) who are obese 28.9 30 Increase the proportion of adults (aged ≥18 years) who engage in

leisure-time physical activity 47.5 47.9

Reduce cigarette smoking by adults (aged ≥18 years) 17.0 12 Increase the proportion of adults (aged ≥65 years) who are

vaccinated annually against influenza 70.1 90

Increase the proportion of adults (aged ≥65 years) who are vaccinated against pneumococcal disease

61.3 90

Sources: Centers for Disease Control and Prevention, National Center for Health Statistics. (2014). Health, United States, 2014. Retrieved July 14, 2017, from https://www.cdc.gov/nchs/data/hus/hus14_inbrief.pdf.; U.S. Department of Health and Human Services. Healthy People 2020. Retrieved July 14, 2014, from http://www.healthypeople.gov/2020/topicsobjectives2020/default.aspx.

Table 8.3 outlines an assessment of how progress was being made on selective objectives of Healthy People 2020 in 2014. These data are based on the CDC National Center for Health Statistics (NCHS) 2014 (CDC, NCHS, 2014b). As can be seen in see Table 8.3, the prevalence of obesity among U.S. adults aged 18 and over was lower than the 2020 objective for obesity in this age group. Also, the percentage of adults (18 years and older) who had participated in federal guidelines for physical activity in 2014 was closer to the 2020 target of 47.9%. However, the percentage of adults who were current smokers in 2014 was more than the targeted 12% by 2020 (USDHHS, 2010).

Healthy People 2020 targets to increase influenza and pneumococcal vaccination in adults, which had been retained from Healthy People 2010, still had not been met as of 2014 (CDC, NCHS, 2014b). The percentage of adults aged 65 and older who had received influenza and pneumococcal vaccinations in 2014 remained well below the targets of 90%, respectively. It will be interesting to see how many of the objectives proposed for Healthy People 2020 are met by the target date (USDHHS, 2010).

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Case 1: In an attempt to increase the number of people aged 65 years or older who are vaccinated against pneumococcal disease, the community health nurses in Case 1 decide to conduct the following: An assessment of baseline knowledge, attitudes, and practices among healthcare providers in the community regarding pneumococcal vaccination to identify barriers to providing pneumococcal vaccination An assessment of baseline knowledge, attitudes, and beliefs among community residents aged 65 years or older to determine barriers to receiving pneumococcal vaccination 1. What research method could the nurses use to perform these assessments? 2. How would you go about gathering the data for these assessments?

Analytical Studies As can be seen in Figure 8.2, research study designs are on a continuum, ranging from strongest to weakest designs.

There are two general types of nonexperimental designs used in epidemiologic studies: cohort (prospective) studies and case–control (retrospective) studies. These nonexperimental studies may be “weaker” on the continuum; however, they can lead to hypothesis testing based on established associations (correlations).

The research design continuum in Figure 8.2 is designed to be used as a tool to help researchers, practitioners, and policymakers better understand best available research evidence. On a practical level, the continuum can be used to help practitioners and policymakers make decisions about which prevention strategies to adopt in their communities. It also can be used by researchers and practitioners to identify which aspects of a prevention program, practice, or policy can be improved to better demonstrate the evidence of its effectiveness.

Cohort Studies Cohort studies, sometimes referred to as longitudinal studies, are prospective studies that monitor subjects over time to find associations between risk factors and health outcomes (Porta, 2014). Although they are stronger in design methodology than are case–control studies when well executed (see later discussion), cohort studies also are more expensive. In their simplest form, a sample (cohort) of subjects who are exposed to the risk factor(s) is matched with a sample of subjects not exposed to the risk factor(s). Some prospective studies, such as the Framingham Heart Study, which were designed to estimate the lifetime risk of coronary heart disease, lasted for decades. Many recommended public health guidelines for BP, total cholesterol, and low-density lipoprotein cholesterol resulted from the Framingham Heart Study (Shortreed, Peeters, & Forbes, 2013).

Practice Point

A biased sample will result in a biased study with biased results. Randomization is crucial to obtaining a representative sample. The larger the sample, the greater the chances of a true representation of the population.

The advantages of cohort studies are that they minimize selection bias, a threat to internal

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validity, and provide preliminary evidence of the incidence of a risk factor with which the relative risk (RR) can be established. Internal validity is the degree to which the effects detected in a study are real rather than from confounding or extraneous variables (Gray, Grove, & Sutherland, 2017). See Box 8.1 for threats to internal validity.

Relative risk is defined as the ratio of disease incidence (or death) in an exposed population to that in an unexposed population. The assumption is that the underlying risk without the exposure is the same in both groups:

Relative risk is a ratio ranging from zero to infinity that indicates the strength of the association between the risk factor and the outcome. It is calculated by dividing the risk in the group exposed to a risk factor by the risk in the unexposed group.

An RR significantly greater than 1 (statistically) indicates that the exposure is associated with increased risk of disease. An RR significantly less than 1 (statistically) indicates that the exposure is associated with decreased risk of disease; that is, the exposure is protective. An RR not significantly different from 1 (statistically) indicates that there is no association between the exposure and the risk of disease (Washington State University, n.d.).

FIGURE 8.2 Research design continuum.

8.1 Threats to Internal Validity

History: Refers to events that are occurring during the study, which could influence participants’ responses to the intervention.

Maturation: Refers to unplanned and unrecognized changes in the participants that could affect the findings of the study, such as fatigue, hunger, or increased knowledge.

Testing: Refers to the effect of multiple measurements of participants’ responses that could influence the participants’ responses thereby altering the outcome of the study.

Selection: Refers to the process by which participants are selected and grouped for a study. This threat is more likely to occur when randomization is not possible.

Instrumentation: Refers to changes in the measurement instrument used in the study, which result in inconsistent data collection.

Mortality: Refers to loss of subjects from the study. When those who drop out of the study differ significantly from those who remain in the study, and if there is a difference in those who remain in experimental and control groups, the outcome of the study would be affected.

Source: Gray, J. R., Grove, S. K., & Sutherland, S. (2017). Burns and Grove’s the practice of nursing research: Appraisal, synthesis, and generation of evidence (8th ed.). St. Louis, MO: Elsevier.

Epidemiologic cohort studies are developed to examine causality among variables in illnesses. Causal associations found in this manner are known as inferred causality. Repeated, multiple studies strengthen the causal link. This strategy may not be as powerful as experimental

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designs; however, in many epidemiologic studies, a true experimental study would not be ethical. For example, a researcher would not deliberately expose one group to an infectious microorganism to study its effect. An important finding of inferred causality came from the well-known cohort study, the Harvard Nurses’ Health Study, which has followed female registered nurses from 14 states since 1976. A 1994 landmark study established an association between breast cancer and long-time use of hormone replacement therapy (Colditz et al., 1995). The Nurses’ Health Study, considered the “grandmother” of women’s health studies, is the world’s largest, longest-running study of women’s health. The study, which is now in its third phase (Nurses’ Health Study 3, n.d.), has also provided other valuable information on women’s health (e.g., increased dietary calcium intake does not protect against fractures of the hip and wrist among postmenopausal women; birth control pills do not increase the risk of heart disease among nonsmoking women). More information on the Harvard Nurses’ Health Study can be found at http://www.channing.harvard.edu/nhs/.

Cohort studies attempt to find cause-and-effect relationships; however, to find statistically meaningful data (i.e., causality), a large number of cases are needed. There may also be threats to internal validity due to loss of subjects from the study (mortality). Nonetheless, data from cohort studies may be used as the basis for hypotheses generation for stronger experimental studies, such as randomized controlled trials (CDC, 2012a). The five criteria listed in Box 8.2, which are based on the historical Bradford Hill criteria (1965) have been used in assessing the quality of research evidence and include considerations arising to establish a cause-and-effect relationship.

8.2 Criteria for Causality

The relationship must be clear (strength of association). Observation of the association must be repeatable in different populations at different times

(consistency). The cause must precede the effect (temporality). The explanation must make sense biologically (plausibility). There must be a dose–response relationship (biological gradient).

Source: Adapted from Hill, A. B. (1965). The environment and disease: Association or causation. Proceedings of the Royal Society of Medicine, 58(5), 295–300.

To every complex question there is a simple answer…and it is wrong. H. L. Mencken, writer and wit

Case–Control Studies Case–control studies, also known as retrospective studies, work backward from the effect to the suspected cause (Porta, 2014). Subjects are selected on the basis of the presence or absence of the disease or outcome in question: one group of people (case subjects) with the health problem and another group without the health problem (controls). The two groups are then compared to determine the presence of specific exposures or risk factors.

For example, diethylstilbestrol (DES) was thought to be a safe and effective way to prevent miscarriages or premature deliveries. It has been estimated that between 5 and 10 million people were exposed to DES in the United States between 1938 and 1971. However, landmark case- controlled epidemiologic studies have found health risks associated with DES in women for whom it was prescribed during pregnancy and the offspring born of those pregnancies (DES sons and daughters). DES daughters and sons are defined as women or men who were exposed to DES in utero. Research has confirmed that daughters of mothers who took DES are at risk for clear cell adenocarcinoma, a rare kind of vaginal and cervical cancer that may affect females

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from their early teens to their 40s. Studies have also demonstrated that sons of mothers who took DES are at risk for epididymal cysts and other genital abnormalities, including testicular hypoplasia, cryptorchidism, and microphallus (CDC, 2012b).

In addition, research is underway to determine whether the offspring of sons and daughters of mothers who took DES might have health effects related to DES exposure. These grandchildren of women prescribed DES during pregnancy are sometimes called the “third generation” (CDC, 2012b). More detailed information about DES can be found at the CDC website DES Update Home at http://www.cdc.gov/des/hcp/nurses/index.html.

The relationship between exposure and outcome in a case–control study is quantified by calculating the odds ratio (OR). The OR is an estimate of RR that is interpreted in the same manner as RR. When a disease is relatively rare (e.g., a cumulative annual incidence of less than 5% in the unexposed population), the OR is similar to the RR. Otherwise, the OR overestimates RR. An OR significantly greater than 1 (statistically) indicates that the exposure is associated with increased risk of disease, and an OR not significantly different from 1 statistically indicates there is no association between the exposure and the risk of disease (CDC, 2012a).

Case–control studies have several advantages: they (1) allow for the examination of multiple exposures for a single outcome; (2) are suitable for studying rare diseases and those with long latency periods; (3) require fewer case subjects; and (4) generally are quicker and less expensive to conduct than cohort studies, making them well suited for an outbreak investigation (see Chapter 14). They have several disadvantages: (1) they are not appropriate for studying rare exposures, (2) they are subject to bias because of the method used to select controls, and (3) they do not allow the direct measure of the incidence of disease. Also, because they look backward, case–control studies may create uncertainty about the temporal relationship between exposure and disease (CDC, 2012a).

INTERVENTION (EXPERIMENTAL) STUDIES True experiments that control all factors other than the one under investigation are rare when studying human populations. Many studies, although experimental in design, are not able to either randomize selection of subjects or exert the same degree of control of the study variables that would be found in true experimental studies. Manipulation of the independent variable occurs, but it may not be possible to control influencing or confounding factors.

Case 2: Data from the 2016 National Health and Nutrition Examination Survey indicate that adults aged 20 years and older in the United States had at least one of the following preventable cardiovascular disease risk factors: obesity, diabetes, or smoking. For 2016, 30.6% of U.S. adults aged 20 and over were obese. Also, in 2016, 9.4% of adults aged 18 and over have been diagnosed with diabetes. The prevalence of current cigarette smoking among U.S. adults declined from 24.7% in 1997 to 15.8% in 2016. However, the percentage of adults aged 18 and over who were current cigarette smokers was still higher than the 12% target for 2020 (CDC, 2016). The incidence of heart disease is increased in persons who are overweight or obese (BMI >25), while high blood pressure is twice as common in adults who are obese than in those who are a healthy weight. And obesity is associated with elevated triglycerides, diabetes, and decreased HDL cholesterol (USDHHS, 2013).

The Framingham Heart Study estimated the lifetime risks for cardiovascular disease, which account for most noncommunicable diseases worldwide, at 17.7 million (WHO, 2014). 1. What type of epidemiologic study was conducted in the Framingham Heart Study?

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2. What does a “more-than-twofold increase in RR for cardiovascular disease” mean?

Student Reflection

Public health practitioners strive for comprehensiveness in characterizing an epidemiologic event, whether it be a pandemic of influenza or mammograms to detect early breast cancer. Descriptive epidemiology covers time, place, and person.

The 5Ws in descriptive epidemiologic research include:

What: health issue of concern Who: person Where: place When: time Why/how: causes, risk factors, modes of transmission

In epidemiologic research public health professionals tend to use synonyms for the 5Ws: diagnosis or health event (what); person (who); place (where); time (when); and causes, risk factors, and modes of transmission (why/how). Community and public health nurses reviewing and/or conducting research should keep these five essential components of a study in mind.

Adapted from CDC. (2012a). Principles of epidemiology in public health practice. 3rd ed. Retrieved July 6, 2017 from, https://www.cdc.gov/ophss/csels/dsepd/ss1978/index.html.

Practice Point

When gathering evidence for practice, nurses should consider the strength of the evidence as follows: High: There are consistent results from good-quality studies. Further research is very unlikely

to change the conclusions. Moderate: Findings supported, but further research could change the conclusions. Low: There are very few studies, or the existing studies are flawed. Insufficient: Research is either unavailable or does not permit estimation of a treatment

effect.

Source: Agency for Healthcare Research and Quality. (2012). Treatment to prevent osteoporotic fractures: An update. Retrieved July 14, 2017, from http://www.effectivehealthcare.ahrq.gov/ehc/products/160/1048/lbd_clin_fin_to_post.pdf.

Intervention studies in public health are categorized as preventive trials and therapeutic trials, and both can be either quasi-experimental studies or true experimental studies. Quasi- experimental study designs are weaker because assignment of subjects into groups is not randomized, the researcher is unable to manipulate the variable under study (see Fig. 8.2), or because of situations where it may be unethical or impractical to randomize subjects. The quasi- experimental design is used in preventive trials that focus on primary prevention (i.e., during the prepathogenesis stage to reduce the incidence of disease).

Preventive Trials An example of a preventive trial using a quasi-experimental design is a study of a school district participating in a smoking prevention program. The sample is divided into two groups: some schools receive a health education program on smoking (“treatment”), and the others

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receive nothing (“control”). The two groups are then assessed for the incidence of smoking at 3 months, 6 months, and 1 year following the program. In this case, assignment to the treatment and comparison groups was not randomized; therefore, it is considered a quasi-experimental study. The greatest strengths of quasi-experimental studies are their practicality, feasibility, and, to some extent, their generalizability (external validity) to similar groups. External validity is the degree to which the results of a study can be generalized to other settings or samples other than the ones studied (Gray, Grove, & Sutherland, 2017). Box 8.3 for threats to external validity.

When a quasi-experimental design is used, control over other factors (confounding variables) may result in statistical differences due to competing hypotheses (type I error) or result in no statistical difference when it does exist (type II error). Also, if a quasi-experimental design is used, it cannot be assumed that the treatment and control groups were equal. However, the design can be made stronger by pretesting both groups before the intervention. If both groups respond similarly on the pretest, then information obtained after the intervention can be assumed to be the result of the intervention (Gray, Grove, & Sutherland, 2017).

8.3 Common Threats to External Validity

Reactivity: Also known as the “Hawthorne effect;” this threat occurs when participants behave in a certain way because they know they are being studied, affecting the generalizability of the findings.

Novelty: Occurs when a new intervention affects the outcome of the study because of either enthusiasm or skepticism by the researchers or the participants.

Experimenter/participant effect: Occurs when the researcher or subject has preconceived expectations of the intervention, resulting in bias and affecting generalizability of the findings.

Interaction of selection and intervention: Occurs when subjects willing to participate in the study are not representative of the target population, thus limiting the generalizability of the results.

Interaction of setting and intervention: Occurs when the characteristics of the study setting influence the outcome of the study, limiting the generalizability of the findings to other settings.

Interaction of history and intervention: Occurs when the circumstances (history) of the study influence the results of the study, and decrease the generalizability of the findings.

Source: Gray J. R., Grove, S. K., & Sutherland, S. (2017). Burns and Grove’s the practice of nursing research: Appraisal, synthesis, and generation of evidence (8th ed.). St. Louis, MO: Elsevier.

Practice Point

Although statistical analysis is beyond the scope of this text, it is important to know that the sample size in intervention trials should be large enough for adequate statistical power to prevent a type II error. In addition, the researcher should set the expected statistical p value, generally at 0.05, to ensure that the study results are not due to chance alone and to avoid committing a type I error.

A type I error occurs when the null hypothesis (Ho, a theory that has been put forward, either because it is believed to be true or because it is to be used as a basis for argument) is rejected when it is true. A type II error occurs when one accepts the null hypothesis when it is false (i.e., the alternative hypothesis [Ha] is true). For example, in a clinical trial of a new drug, the null hypothesis might be that the new drug is no better than the current drug. The null hypothesis and alternative hypothesis, respectively, would be: Ho: there is no difference between the two drugs. Ha: there is a difference between the two drugs.

From error to error, one discovers the entire truth. Sigmund Freud

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Evidence for Practice

Falling is a significant problem among community-living older adults in the United States. Liu and Frank (2010) examined 19 published longitudinal studies that studied the effects of the Chinese art of Tai Chi on reducing the risk of falling among the elderly through regular exercise. They found that Tai Chi exercise duration of 12 weeks or longer, with frequencies of twice a week or more, and session lengths of at least 45 minutes had the following outcomes: reduced fear of falling, increased single-leg stance, decreased rate of falling, increased flexibility, and improved walking. The authors concluded that Tai Chi could be an economic and effective exercise program for improving balance and balance confidence in older adults.

Properly executed experimental studies provide the strongest empirical evidence. The hallmark of the experimental study is random assignment of subjects to treatment (intervention) and control groups, which controls for potential unknown extraneous (confounding) variables. Randomization also provides a better foundation for statistical procedures to prevent type I and type II errors than do observational and quasi-experimental studies. The research continuum in Figure 8.2 indicates that experimental study designs are the strongest because they control for all factors except that which is under investigation. The “gold standard” for experimental studies is the prospective, double-blind, placebo control group design, also referred to as clinical trials or therapeutic trials. In double-blind experimental studies, neither the researchers nor the subjects are aware to which group they are randomly assigned.

Therapeutic Trials Therapeutic trials are based on secondary prevention, which focuses on limiting the spread of disease (see Chapter 14), and where the treatment (independent variable) is manipulated by the researcher. For example, the 1994 landmark study conducted between 1991 and 1993 enrolled 477 HIV-infected pregnant women between 14 and 34 weeks of gestation. In this double-blind, placebo-controlled, randomized therapeutic trial, the women were stratified according to gestational age (14 to 26 weeks or greater than 26 weeks) and were randomly assigned to receive either zidovudine (AZT) or placebo. There were no significant differences between the characteristics of the AZT group and the placebo (control) group (Connor et al., 1994).

The AZT regimen consisted of antepartum AZT (100 mg orally five times daily) plus intrapartum AZT (administered intravenously every hour until delivery), as well as AZT for the newborn beginning 8 to 12 hours after birth (2 mg/kg orally every 6 hours for 6 weeks). During the study period, 409 women gave birth to a total of 415 live infants. The infants were evaluated by cultures and HIV serologic tests both at birth and at several weekly intervals until 78 weeks of age. At the 18-month analysis for AZT efficacy, there was a two-thirds reduction (67%) in the risk of HIV transmission from mother to infant in the AZT group. Because of these rather dramatic findings, the study was halted, and all mothers were given AZT (Connor et al., 1994). Recent studies of antiretroviral prophylaxis in the prevention of mother-to-child HIV transmission have found similar results (Sturt, Dokubo, & Sint, 2010; Tudor-Car et al., 2013).

The U.S. Public Health Service Task Force recommends the use of antiretroviral therapy to reduce perinatal HIV transmission, universal prenatal HIV counseling, and HIV testing with consent for all pregnant women in the United States. As a result, the number of HIV-infected infants born each year in the United States has decreased from approximately 1,750 (in the mid- 1990s) to approximately 143 in 2010 (CDC, 2013). For more information regarding the prevention of maternal–child transmission of HIV, see CDC, Eliminating Perinatal HIV

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Transmission at http://www.cdc.gov/primarycare/materials/hivtransmission/. In both preventive trials and therapeutic trials, planning includes sample selection, protocol

methodology, data collection, and data analysis. Sample selection is taken from the target population, the population to which the results of the intervention are applicable. In the Connor and colleagues (1994) AZT trial described above, the target population was HIV-infected pregnant women. The sample consisted of HIV-infected pregnant women who were randomly assigned to the treatment (AZT) group or the placebo (control) group. The study was a double- blind study, in which neither the researchers nor the participants knew who was receiving AZT treatment until the study was ended. A double-blind study is one method to prevent observation