Home visiting assignment

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For this activity, you will select either an older adult or pregnant/post-partum mom and infant
individual/family to complete your 3 virtual or in-person home visits. To ensure timely completion of
conducting the home visits, it is important to identify an individual and schedule these visits early in the
semester. The three home visits are summarized below:

PART I
Foundational Concepts

for Public Health
Nursing Practice

1 Introduction to Public Health Nursing Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

2 Evidence-Based Public Health Nursing Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

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AN: 1917387 ; Patricia M. Schoon, Carolyn M. Porta, Marjorie A. Schaffer.; Population-Based Public Health Clinical Manual, Third Edition: The Henry Street Model
for Nurses
Account: s4200124.main.ehost

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3

‘‘

’’

CHAPTER

1Introduction to Public
Health Nursing Practice

n Patricia M. Schoon
with Marjorie A. Schaffer and Jill Timm

Abby will soon be starting her public health nursing clinical and is struggling with the idea of practicing
nursing outside the hospital. She is talking about public health clinicals with Alberto and Sia at lunch.
“I can’t imagine myself out in someone’s home, or in a school, or in a community center or public health
agency. I’m not sure I know what I’m supposed to do. I also wonder how I will be respected without scrubs
or my uniform. Is it really true that one of the most important skills in public health is listening and that
sometimes that is all that you do? I feel like I should be doing something more.”

Alberto responds, “My friend, Zack, had public health last semester. He said that it was interesting to
consider listening as its own intervention. It was hard to not jump in and ‘teach’ immediately. He often
wanted to do more. After a while, he started to get comfortable and also started to understand the benefits
of really trying to understand the perspectives of clients in the community.”

Sia comments, “I worry about all of this too. I was talking with Jen, a friend of mine who took public
health last year. She said that on her first home visit, she went with her public health nursing preceptor.
This gave her a chance to get a sense for the family’s needs and possible interventions.”

Abby says, “I am really worried about being out alone. I wonder what the neighborhood where my
family lives will be like and whether I will be safe.”

Sia states, “I’m also curious about the various public health nursing roles that we may be able to
observe or do. It seems like the field is so broad and there are so many things to consider.”

ABBY’S NOTEBOOK

USEFUL DEFINITIONS

Client: A client (syn. patient) is the individual/family, community, population or subpopulation, or system that is
the public health nurse’s focus of care.

Community: A community can refer to (a) a group of people or a population group, (b) a physical place and time
in which the population lives and works, or (c) a cultural group that has shared beliefs, values, institutions, and
social systems (Dreher, Shapiro, & Asselin, 2006, p. 23).

Health Determinants: Health determinants are factors that influence the health of individuals, families, and
populations. Health determinants can potentially have a positive (protective factors) or negative (risk factors)
influence on health.

Health Status: Health status refers to the level of health or illness and is the outcome of the interaction of the
multiple health determinants. Health status indicators, also called global measures of population health, include
birth, longevity, and death rates (mortality); illness (morbidity) patterns; perception of wellness and life satisfac-
tion; level of independence; and functional ability.

(continues)

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4 PART I  n  Foundational Concepts for Public Health Nursing Practice

USEFUL DEFINITIONS (continued)

Holistic Nursing: Holistic nursing is defined as “all nursing practice that has healing the whole person as its goal
and honors relation-centered care and the interconnectedness of self, others, nature, and spirituality; focuses on
protecting, promoting health and wellness…” (Dossey & Keegan, 2016, p. 3).

Levels of Prevention: The levels of prevention comprise a health-intervention framework applied to the stages of
health and disease for individuals and groups (Leavell & Clark, 1958; Stanhope & Lancaster, 2008). The levels of
prevention are (a) primary—the prevention of disease and promotion of health; (b) secondary—early diagnosis
and treatment; and (c) tertiary— limiting of negative effects of disease and restoring of function.

Population: A population is defined as the “total number of people living in a specific geographic area.”
A subpopulation (syn. group or aggregate) “consist[s] of people experiencing a specific health condition;
engaging in behaviors that have potential to negatively affect health; or sharing a common risk factor or risk
exposure, or experiencing an emerging health threat or risk” (American Nurses Association [ANA], 2013, p. 3).

Population-Based Practice: Population-based practice focuses on the population as a whole to determine its
priority needs (Minnesota Department of Health [MDH], 2001).

Public Health: Public health refers to all organized measures (whether public or private) to prevent disease,
promote health, and prolong life among the population as a whole (World Health Organization [WHO], n.d.).

Public Health Nursing: Public health nursing is the practice of promoting and protecting the health of popula-
tions using knowledge from nursing, social, and public health sciences. Public health nursing is a specialty prac-
tice within nursing and public health. It focuses on improving population health by emphasizing prevention and
attending to multiple determinants of health. Often used interchangeably with community health nursing, this
nursing practice includes advocacy, policy development, and planning, which addresses issues of social justice
(American Public Health Association [APHA], Public Health Nursing Section, 2013, p. 1).

Social Determinants of Health: The social determinants of health are the conditions in which people are born,
grow, live, work, and age. The distribution of money, power, and resources at the global, national, and local levels
shape these circumstances. The social determinants of health are mostly responsible for health inequities—
the unfair and avoidable differences in health status seen within and between countries (Modified from
WHO, 2013).

System: A system is an institution or organization that exists within one or multiple communities.

ABBY’S NOTEBOOK

Practicing Nursing Where We All Live
Public health nursing care is provided to individu-
als, families, communities, and populations through a
population-based lens that enables nurses to view their cli-
ents within the context of the community in which they and
their clients live . All aspects of the client’s life are considered
as public health nurses (PHNs) carry out the nursing pro-
cess . PHNs practice in their communities, where they can
make a difference in the lives of their families, the people
they serve, and their communities on a daily basis .

As you practice nursing in a variety of clinical settings,
you will become aware that the health of people in your
families, neighborhoods, and communities affects every-
one in the community both socially and economically .
As you read this chapter, consider the concepts presented
from both your personal and professional perspectives . As
nurses, you are all citizens of the world and have civic and

professional responsibilities to promote health and provide
for a safe environment .

In the case study at the beginning of the chapter, Abby
and her friends are concerned about providing nursing
care in the community . It is difficult for nursing students
to think about practicing nursing outside the acute and
long-term care settings . Many of the skills that nursing stu-
dents learn in the acute or long-term care setting (e .g ., IV
therapy, medication administration, tube care) are part of
the delegated medical functions of nursing practice, which,
by necessity, are priorities when caring for acutely ill, frail,
and elderly individuals . In the community setting, most of
what PHNs do is part of the independent practice of nursing
(e .g ., teaching, counseling, coordinating care), as the focus
of public health nursing practice is primary prevention .
Components of public health nursing can be practiced in
any setting, although they are most often practiced in the

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5CHAPTER 1  n  Introduction to Public Health Nursing Practice

whole to determine the community’s priority health needs
(Minnesota Department of Health [MDH], Public Health
Nursing Section, 2000, 2001; MDH, Center for Public Health
Nursing, 2003) . PHNs in a variety of work settings can carry
out population-based practice . To be population based, pub-
lic health nursing practice should meet five criteria:

1. Focus on entire populations possessing similar health
concerns or characteristics

2. Be guided by an assessment of population health
status that is determined through a community
health assessment process

3. Consider the broad determinants of health
4. Consider all levels of prevention, with a preference

for primary prevention
5. Consider all levels of practice (individual/ family,

community, system) (MDH, 2001, pp . 2–3;
MDH, 2003)

PHNs work in homes, clinics, schools, jails, businesses,
religious organizations, homeless shelters, camps, hospitals,
visiting nurse associations, health departments, and Indian
reservations . Public health nursing is defined by its goals,
not by its setting . Although public health nursing is con-
sidered a specialty area of practice, its standards include
expectations for entry-level baccalaureate nursing gradu-
ates . Even at the entry level, PHNs are expected to function
as change agents and to help shape the healthcare system
to meet the public health needs of the 21st century . This
leadership expectation for public health nursing practice is
implicit in the American Nurses Association’s Public Health
Nursing: Scope and Standards of Practice (ANA, 2013) . The
American Public Health Association (APHA) definition of
public health nursing, “the practice of promoting and pro-
tecting the health of populations using knowledge from
nursing, social, and public health sciences” (APHA, 2013,
p .  2), implies the importance of the scientific knowledge
base for PHN practice .

community . Not all nursing practiced in the community
can be described as public health nursing . For example,
home care and hospice care, both very important areas of
nursing, are practiced in the community and exhibit com-
ponents of public health nursing but are not traditionally
categorized as public health nursing . As you work through
this book and engage in nursing activities, think about how
you are integrating the components of public health nursing
into your nursing practice . Also, think about how you prac-
tice nursing where you live and what your civic and pro-
fessional responsibilities are to promote the health of your
community .

Public Health
The practice of public health nursing includes components
of public health and is a part of the broader field of public
health . It is important to understand the nature and scope
of public health practice . Public health practice focuses on
protecting and promoting the health of entire populations .
This practice includes the prevention of disease and injury
and the promotion of the social conditions and lifestyles
that maintain health and prolong life .

Public health professionals monitor and diagnose the
health concerns of entire communities and promote healthy
practices and behaviors to ensure that populations stay
healthy . The World Health Organization uses the term
“global public health” to recognize that, as a result of glo-
balization, forces that affect public health can and do come
from outside state boundaries . Responding to public health
issues now requires paying attention to cross-border health
risks, including access to dangerous products and environ-
mental change (WHO, n .d .) . PHNs need to take a global
perspective about the nature of population health threats
and issues when practicing in the community .

Public Health Nursing
Public health nursing combines the theory and practice
of nursing and public health . Public health nursing, like
nursing practice everywhere, involves the interaction of the
nurse and client; the health of the client; the influence of the
home, healthcare, and community environment; and the
nursing care provided . One of the unique features of pub-
lic health nursing is that the client can be an individual or
family, a group of people, or a whole community . The client
could also be a system within the community (e .g ., a school,
church, or community health or social service agency) .
PHNs work to improve population health at the local, state,
national, and international levels (ANA, 2013; APHA, 2013) .
Public health nursing goals are to promote and preserve
the health of populations and the public, prevent disease
and disability, and protect the health of the community as
a whole .

Public health nursing practice is considered population-
based because it starts by focusing on the population as a

Definition of Public Health Nursing Practice

Up to this point in your nursing education, you have focused
on nursing care of individuals and families. Public health
nursing is population based and focuses on population
health. “Public health nursing is the practice of promoting
and protecting the health of populations using knowledge
from nursing, social, and public health sciences. Public
health nursing is a specialty practice within nursing and
public health. It focuses on improving population health by
emphasizing prevention, and attending to multiple deter-
minants of health” (APHA, 2013, p. 1). While public health
nursing practices include primary, secondary, and tertiary
prevention, the focus is on primary prevention.

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6 PART I  n  Foundational Concepts for Public Health Nursing Practice

in 1881 (Kulbok, Thatcher, Park, & Meszaros, 2012; Kub,
Kulbok, & Glick, 2015; see Figure 1 .1) . PHNs saw themselves
not only as caregivers but also as advocates for those living
in unhealthy conditions and experiencing unmet health-
care needs . Care of the ill soon expanded to care of those
at risk for poor health and to populations and entire com-
munities . Disease prevention and health promotion for vul-
nerable or at-risk populations in diverse settings became a
second focus .

Until the late 1960s, PHNs working for governmental
public health agencies generally provided services to two
at-risk populations: mothers and children, and adults living
at home with chronic diseases and disabilities . When Medi-
care legislation was enacted in 1966, home care became a
covered service, and private agencies began to offer home
care services (see Chapter 7) . Many public health agencies
renewed their commitment to the goals of health promotion,
disease prevention, and protection and risk reduction, and
they stopped providing home care to adults with chronic
diseases and disabilities . PHNs increased their efforts to
address the social determinants of health, which are dis-
cussed later in this chapter . Today, public health nurses
often work with community groups as well as individuals
and families . Community engagement, population-based
advocacy, collaboration with other community agencies
and groups, and community organizing are all part of the
scope of practice of public health nurses (see Chapters 2, 5,
and 10) . At the same time, nurses practicing in a variety of
non-traditional public health settings (e .g ., home care, hos-
pice, faith-based nursing, institutional and insurance care
coordination and care management, etc .) use public health
nursing principles and public health interventions in their
practice .

Emerging threats to public health require a dramatic shift
in the focus of healthcare, public health, and public health
nursing . ANA (2013, p . 2) has identified six 21st- century
threats that form a context for the current and future direc-
tions of public health nursing practice:

1. Reemergence of communicable disease and increas-
ing incidence of drug-resistant organisms

2. Environmental hazards
3. Physical or civic barriers to healthy lifestyles (e .g .,

food “deserts”)
4. Overall concern about the structure and function of

the healthcare system
5. Challenges imposed by the presence of modern

public health epidemics, such as pandemic influenza,
obesity, and tobacco-related diseases and deaths

6. Global and emerging crises with increased opportu-
nities for exposure to multiple health threats

Nursing continues to expand its leadership role in
healthcare in all settings, but in public health nursing, that
leadership role often takes place in the community, includ-
ing in the public policy–making arena (ANA, 2003, 2013) .

As students, you have already learned about nursing
core concepts that also shape public health nursing, which
include (Keller, Strohschein, & Schaffer, 2011):
n Care and compassion
n Holistic and relationship-centered practice
n Sensitivity to vulnerable populations
n Independent nursing practice

This book also introduces you to additional public health
core concepts that shape public health nursing, which
include (Keller et al ., 2011):
n Social justice
n Population focus
n Reliance on epidemiology
n Health promotion and prevention
n The greater good
n Long-term commitment to community

Evolution of Public Health Nursing
In this chapter, you will read about how nurses practice pub-
lic health nursing in the community, and you will consider
how important nurses are to the health of communities at
the local, national, and international levels . It is important
to mention two key founders of public health nursing . Since
the time of Florence Nightingale, the first public health
nurse, nurses have always been essential participants in
improving and maintaining the health of individuals, fami-
lies, and communities . Nightingale, who started her nursing
career in 1850, provided leadership for the health of vulner-
able populations by advocating for changes in the organiza-
tions and communities that were responsible for providing
healthcare (Selanders & Crane, 2012) . Nightingale focused
on managing the environment of those who needed care,
whether it was on the Crimean War battlefields or work-
ing with the London poor . Her concerns about the impact
environmental conditions had on health and her work to
advocate for healthful environments is as relevant today as
it was in the 1800s (Davies, 2012) . Lillian Wald, the founder
of modern-day public health nursing, founded the Henry
Street Settlement in 1893 to provide nursing services to the
indigent citizens of New York . In 1903, Wald, in collabo-
ration with Metropolitan Life, started the first insurance
reimbursement for nurse home visiting and demonstrated
its effectiveness (Abrams, 2008; Buhler-Wilkerson, 1993) .
The Henry Street Settlement House continues to provide
health and social services today .

Public health nursing in the United States developed out
of a need to provide nursing services to individuals and
families who had unmet health needs, and started with
Clara Barton, who founded the American Red Cross as a
response to the needs of injured and ill Civil War soldiers

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7CHAPTER 1  n  Introduction to Public Health Nursing Practice

‘‘

’’

Cornerstones of Public Health Nursing
The Cornerstones of Public Health Nursing (Minnesota
Department of Health [MDH], Center for Public Health
Nursing, 2007) provide the foundation for population-based
nursing practice (Keller et al ., 2011) . The Cornerstones reflect
the values and beliefs that guide public health nursing prac-
tice, and they are also closely related to the ANA Principles
of Public Health Nursing Practice (ANA, 2013), as repre-
sented in Table 1 .1 .

These Cornerstones are reflected in PHNs’ daily practice
when they:
n Organize their workload and schedule based on priority

health needs of clients and community
n Take time to establish trust when visiting families in

their homes
n Carry out holistic assessments of individuals and

families within the context of culture, ethnicity, and
communities

n Use evidence-based practice from nursing and pub-
lic health sciences to select appropriate and effective
interventions

n Collaborate with other members of the healthcare team
n Make critical decisions about the needs of their clients

and the selection, implementation, and evaluation of
interventions based on their professional knowledge and
professional licensure

A key principle to keep in mind is that PHNs must place
more importance on goals related to the public good than
goals for the benefit of individuals in the social and eco-
nomic systems (see Chapter 13 for a discussion of social jus-
tice and Chapter 14 for a discussion of public health nursing
leadership) .

“I still don’t really understand how we are going to factor in
community or environmental needs when we are working
with individuals.” Albert sighs.

Sia responds, “What I remember from our public health
theory class this morning is that even though we are meet-
ing people in their homes, we have to take into account the
home environment and the community. Our instructor
also talked about public health nurses having a responsibil-
ity to improve the health of the public at the local, national,
and international levels. She mentioned that this idea can
be overwhelming for nursing students and suggested that
we focus on what we could do to improve the health of indi-
viduals and families as a way to help improve the health of
our community. She used the term ‘glocal,’ which means to
think global, but act local.”

Abby adds, “Maybe we should read more about this in
our textbook and look at some of the websites suggested.”

“Good idea,” says Sia.

FIGURE 1.1 Public Health Nursing in the United States
Sources: Abrams, 2008; Buhler-Wilkerson, 1993; Kub, Kulbok, & Glick, 2015;

Visiting Nurses Association of Western New York, n.d.

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8 PART I  n  Foundational Concepts for Public Health Nursing Practice

‘‘

’’

and developmental delays. Abby’s PHN preceptor modifies
her home-visiting plan for the day so that she can make
an initial visit to this family at the local family homeless
shelter. The family speaks Spanish but the PHN does not, so
she arranges for an interpreter to accompany them on the
visit to this family. The PHN has Abby gather information
about local homeless shelters and food banks to take to the
visit and has her get some bus passes for the family to use
when they go to different agencies to apply for assistance.
The PHN also brings along important phone numbers so
that she can assist the family with follow-up regarding their
application for cash assistance. After her busy day with her
PHN preceptor, Abby discusses her visit to the homeless
family with Alberto and Sia that evening. Their instructor
has challenged them to identify the Cornerstones of Public
Health Nursing found in their clinical visits that day.

Activity
Keep a log of your nursing activities. Reflect on how you have 
demonstrated the cornerstones of public health nursing in your 
clinical activities.

Abby is spending the day with her PHN preceptor. Her pre-
ceptor receives a referral to visit a family who just moved
into the community and is homeless. The PHN knows
that a health priority for her community and agency is to
improve the health of homeless populations, particularly
those in the population with young children. Recent data on
the health needs of her county demonstrate that young chil-
dren in homeless families have higher rates of malnutrition

TABLE 1.1 Cornerstones of Public Health Nursing and Related ANA Principles of PHN Practice

Cornerstones of Public Health Nursing ANA Principles of Public Health Nursing Practice

Focuses on the health of entire populations The client or unit of care is the population .

Reflects community priorities and needs The primary obligation is to achieve the greatest good for the greatest
number of people or the population as a whole (also related to the
social justice cornerstone) .

Establishes caring relationships with communities,
systems, individuals, and families

NA

Is grounded in social justice, compassion, sensitivity to
diversity, and respect for the worth of all people, especially
the vulnerable

A public health nurse is obligated to actively identify and reach out to
all who might benefit from a specific activity or service .

Encompasses mental, physical, emotional, social, spiritual,
and environmental aspects of health

Public health nursing focuses on strategies that create healthy envi-
ronmental, social, and economic conditions in which populations
may thrive .

Promotes health through strategies driven by
epidemiological evidence

Optimal use of available resources and creation of new evidence-
based strategies is necessary to ensure the best overall improvement
in the health of the population .

Primary prevention is the priority in selecting appropriate activities .

Collaborates with community resources to achieve those
strategies but can and will work alone if necessary

Public health nurses collaborate with the client as an equal partner .

Collaboration with other professions, populations, organizations, and
stakeholder groups is the most effective way to promote and protect
the health of the people .

Derives its authority for independent action from the
Nurse Practice Act

NA

Sources for Cornerstones: Keller et al ., 2011; MDH, Center for Public Health Nursing, 2007
Source for ANA Principles: ANA, 2013, pp . 8–9

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9CHAPTER 1  n  Introduction to Public Health Nursing Practice

Holistic Foundations of
Public Health Nursing
Public health nursing and holistic nursing practice have
common roots . Florence Nightingale, who believed in care
that focused on unity, wellness, and the interrelationship of
human beings and their environment, is considered to be
one of the first holistic nurses . She is known for her global
vision, leadership, and advocacy (Beck, 2010; Dossey &
Keegan, 2016; Selanders & Crane, 2012) . Lillian Wald was
as concerned about the health of the indigent of New York
as she was about their social welfare, the tenement envi-
ronment in which they lived, and the cultural and political
environment that needed to change in order to improve the
health of her clients and her community (Buhler- Wilkerson,
1993) . Both Nightingale’s and Ward’s nursing practices have
informed contemporary holistic public health nursing
practice .

A contemporary nursing theory that reflects the synthe-
sis of nursing and public health and reflects holistic pub-
lic health nursing practice is Watson’s Theory of Human
Caring, in which the nurse and the client exist within a
caring-healing environment . Watson was greatly influenced
by the practice of Florence Nightingale and built upon Night-
ingale’s work in emphasizing the “curative factors” of dis-
ease and illness, embracing the wholeness of the individual .
The Theory of Human Caring reflects an expansive sharing
process that changes the self, others, the culture, and the

environment; respects the beliefs of others; and recognizes
and is open to unexpected life events (Parker & Smith, 2010;
Watson, 2008, p . 34, 2010) . Some of the public health nursing
theoretical perspectives that you will find in later chapters
reflect this synthesis of public health nursing and holistic
nursing into holistic public health nursing practice .

Scope and Standards of
Public Health Nursing Practice
All professional nurses, regardless of their clinical areas of
practice, have a scope of practice . A scope of practice refers
to the boundaries of safe and ethical practice (see Chapter 6
for a discussion of the scope of practice of public health
nursing) and depends on four components: educational
preparation, credentials, state licensure law, and clinical or
employer role description . A PHN’s job description is a good
measure of the nurse’s scope of practice .

Professional nurses are also guided by standards of prac-
tice developed by their professional nursing organizations .
One nationally accepted set of standards for public health
nursing is the American Nurses Association (ANA) publi-
cation Public Health Nursing: Scope and Standards of Prac-
tice (2013); Table 1 .2 lists these standards . Specific criteria
for operationalizing these standards and measuring perfor-
mance are included in the publication .

TABLE 1.2 Standards of Public Health Nursing Practice and Professional Performance

Standards of Public Health Nursing Practice

Standard 1. Assessment: The public health nurse collects comprehensive data pertinent to the health status of populations .

Standard 2. Population Diagnosis and Priorities: The public health nurse analyzes the assessment data to determine the diagnosis
or issues .

Standard 3. Outcomes Identification: The public health nurse identifies expected outcomes for a plan specific to the population or
issues .

Standard 4. Planning: The public health nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes .

Standard 5. Implementation: The public health nurse implements the identified plan .

Standard 5A. Coordination of Care: The public health nurse coordinates care delivery .

Standard 5B. Health Teaching and Health Promotion: The public health nurse employs multiple strategies to promote health and a
safe environment .

Standard 5C. Consultation: The public health nurse provides consultation to influence the identified plan, enhance the abilities of
others, and effect change .

Standard 5D. Prescriptive Authority: Not applicable .

Standard 5E. Regulatory Activities: The public health nurse participates in the application of public health laws, regulations,
and policies .

Standard 6. Evaluation: The public health nurse evaluates progress toward the attainment of outcomes .

Standard 7. Ethics: The public health nurse practices ethically .

(continues)

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10 PART I  n  Foundational Concepts for Public Health Nursing Practice

Standards of Professional Performance

Standard 8: Education: The public health nurse attains knowledge and competence that reflect current nursing practice .

Standard 9. Evidence-based Practice & Research: The public health nurse integrates evidence and research findings into practice .

Standard 10. Quality of Practice: The public health nurse contributes to quality nursing practice .

Standard 11. Communication: The public health nurse communicates effectively in a variety of formats in all areas of practice .

Standard 12. Leadership: The public health nurse demonstrates leadership in the professional practice setting and the profession .

Standard 13. Collaboration: The public health nurse collaborates with the population and others in the conduct of nursing practice .

Standard 14. Professional Practice Evaluation: The public health nurse evaluates her or his own nursing practice in relation to
professional practice standards and guidelines, relevant statutes, rules, and regulations .

Standard 15. Resource Utilization: The public health nurse utilizes appropriate resources to plan and provide nursing and public
health services that are safe, effective, and financially responsible .

Standard 16. Environmental Health: The public health nurse practices in an environmentally safe, fair, and just manner .

Standard 17. Advocacy: The public health nurse advocates for the protection of the health, safety, and rights of the population .

Source: American Nurses Association, 2013, pp . 28–64

TABLE 1.2 Standards of Public Health Nursing Practice and Professional Performance (continued)

Activity
n Review your preceptor’s job description with your preceptor. 

n Share the list of the ANA practice standards for public 
health nursing. 

n Discuss how your preceptor’s job description and nursing 
practice incorporate specific ANA standards. 

Global Nature of Public Health Nursing
Public health nurses are citizens of the world as well as
their own communities . Travel, communication technol-
ogy, immigration patterns, the global spread of disease, and
the universality of the social determinants of health in all
geographic areas and cultures have changed the nature of
public health nursing practice .

In 2015, the United Nations (UN) General Assembly
adopted resolution 70/1. Transforming Our World: The 2030
Agenda for Sustainable Development (2015) . This resolution
addresses the social determinants of health at a global level
and sets out an action plan for people, the planet, prosper-
ity, peace, and partnership . This action plan identifies 17
Sustainable Development Goals (SDGs) . These goals, repre-
sented by the following set of icons (see Figure 1 .2), provide
a framework for the public health nursing practice wherever
PHNs practice . Examples of how SDGs are addressed will
be highlighted throughout the chapters of this book .

EVIDENCE EXAMPLE 1.1
Health in All Policies

In 2017, an International Health in All Policies Conference
was convened in Adelaide, Australia to strategize over how
to make progress in achieving the SDGs. A major outcome
of the conference was Health in All Policies: Governance, Part-
nerships and the Sustainable Development Agenda, Adelaide
Statement II on Health in All Policies 2017.
The statement stresses that:

n “Health is a political choice, and as such any political,
economic, social and ecological decision has health and
equity impacts. Mayors play a critical role in agenda
2030 and health.

n The SDGs are indivisible and universal and should not
be addressed in silos but rather through taking into
consideration their interconnectedness.

n The transformative strategies for implementing the
SDGs require joint action and policy coherence through
the various levels of the government. Thus, health
literacy is critical to good governance” (WHO, 2017).

As nurses who care about the social environment in
which you and the populations you serve live, you need to
consider how your nursing practice fits into both the SDGs
and the Health in All Policies approach within your local,
national, and global communities .

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11CHAPTER 1  n  Introduction to Public Health Nursing Practice

Ethnic diversity in the community requires a complex ethi-
cal framework that includes the complementary approaches
of rule ethics, virtue ethics, and feminist ethics (Racher,
2007; Volbrecht, 2002) .

Rule ethics uses a framework of guiding principles
for decision-making (Racher, 2007) . Examples of rules
or principles include autonomy, beneficence (promoting
good), nonmaleficence (preventing harm), justice, loyalty,
truth-telling, and respect (Aiken, 2004; Beauchamp & Chil-
dress, 1979; Purtilo, 2005; Scoville Walker, 2004) . Rule eth-
ics is based on a biomedical model of decision-making .

In contrast, virtue ethics is based on good character
(Racher, 2007) . One’s actions are evaluated in the context
of one’s community . Examples of nursing virtues include
compassion, honesty, courage, justice, self-confidence, resil-
ience, practical reasoning, and integrity (Volbrecht, 2002) .

Feminist ethics focuses on building relationships and
reducing oppression in society (Volbrecht, 2002) . Key values
in a feminist ethics approach are inclusion, diversity, partic-
ipation, empowerment, social justice, advocacy, and inter-
dependence (Racher, 2007) . Table 1 .3 provides additional
explanations about these three ethical approaches .

This three-pronged ethical approach is used throughout
the book to highlight ethical concerns and principles related
to specific public health nursing competencies .

Ethical Framework for
Public Health Nursing
The ever-changing healthcare environment, complex health-
care systems, and technological changes require a dual
approach according to Ivanov and Oden (2013) . They recom-
mend that PHNs employ a rights-based approach consistent
with the Universal Declaration of Human Rights passed by
the United Nations (UN) in 1948 (United Nations, 1948) and
an ethical approach based on ethical standards for nursing
practice published by the American Nurses Association . The
International Council of Nurses (ICN), in its position state-
ment on Nurses and Human Rights (2011; p . 1), states that “all
human rights are interdependent and indivisible and that
individuals’ health and wellbeing can be harmed when their
human rights in any category are violated .”

Other authors propose a complementary ethical frame-
work that addresses the diversity of client populations and
settings . PHNs might experience ethical problems when
they have to consider the impact or benefits and burdens
of their decisions on multiple clients, population groups,
and communities (Racher, 2007) . Culturally diverse soci-
eties and communities might have moral standards differ-
ent from each other’s and from those of the PHNs, which
could lead to conflicts between the PHNs and clients .

FIGURE 1.2 UN Sustainable Development Goals With Icons
Source: United Nations General Assembly, 2015

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12 PART I  n  Foundational Concepts for Public Health Nursing Practice

’’

‘‘

The Cornerstones, health determinants framework, and
levels of prevention are included in this chapter . The pub-
lic health nursing process and Public Health Intervention
Wheel are discussed in Chapter 2 . In the United States,
PHNs and other public health professionals who work for
governmental public health agencies have a scope of prac-
tice that is based on identified core public health functions
and the essential services of public health (IOM, 1988) . Chap-
ter 7 discusses the responsibility and accountability of PHNs
who work in governmental agencies .

“Well, this is all very interesting. But I still don’t have a clue
how I am actually going to practice public health nursing,”
Albert sighs.

Sia responds, “I’m realizing that there are a variety of
roles in public health nursing. Some PHNs might spend
their time working with individual families, but they still
have to consider global impacts on health. Our instruc-
tor told us we would be practicing at the individual/fam-
ily level of practice during most of our clinical time. But, I
know we still need to consider how basic human rights are
impacted by public health nursing work. There are a lot of
good internet videos on human rights. I suppose we could
look at them. And there is additional information in the
textbook itself.”

Abby states, “Great! But I think I want to spend more
time actually doing something. I am going to spend a day
with my preceptor tomorrow. Maybe I can apply some of
what I have read and watched on the web.”

Practicing Public Health Nursing
As a student, you will probably be spending most of your
clinical hours working with individuals and families . How-
ever, the role of the PHN is broader; PHNs also spend time
working with community groups and other members of the
community team . Public health nursing is carried out at
different levels of practice within society: individual/family,
community, and systems (MDH, 2001, pp . 4–5) .

Individual/Family Level of Practice
PHNs work with individuals and families to promote health
and reduce risks . The family is the essential unit of all com-
munities and societies . A family is defined as a social unit
of two or more people who identify themselves as a fam-
ily, share emotional bonds, and carry out the functions of a
family, including managing healthcare (Clark, 2008; Fried-
man, Bowden, & Jones, 2003; Martin, 2005) .

PHNs work with individuals and families in many differ-
ent community settings (see Chapter 3 for information on

TABLE 1.3 Ethical Framework for
Public Health Nursing Practice

Rule Ethics
n Rule ethics defines rules or principles that are based on

perceptions of fairness .
n Ethical principles are standards of conduct that guide

behavior and specify moral duties and obligations
(Racher, 2007) .

n Community rights might be given priority over individual
rights in some situations .

n Resources are given based on need and thus might be
distributed unequally (distributive justice) .

n Those who have been unfairly burdened or harmed are
compensated (compensatory justice) .

Virtue Ethics
n Virtue ethics identifies characteristics of the individual

(moral agent) and that person’s intentions and behaviors .
n An individual is responsible for developing good character

and good community (Volbrecht, 2002) .
n This type of ethics provides the foundation for professional

ethics, which specifies professional values and virtues .

Feminist Ethics
n A core ideal is achieving social justice; feminist ethics

applies social justice and distributive justice to social struc-
tures and context .

n This ethical approach focuses on characteristics of rela-
tionships, strengthens relationships and connectedness,
eliminates oppression, and realigns power imbalances .

n Feminist ethics is committed to restructuring relation-
ships, social practices, and institutions so that people can
live freer and fuller lives (Volbrecht, 2002) .

Key Components of
Public Health Nursing
The key components of public health nursing practice dis-
cussed in this book include:
n Cornerstones of Public Health Nursing (MDH, 2007)
n Core public health functions and essential services of

public health (IOM, 1988)
n The standards of public health nursing practice

(ANA, 2013)
n Health determinants framework (U .S . Department of

Health and Human Services [U .S . DHHS], n .d .-b)
n Levels of prevention (Leavell & Clark, 1958; Stanhope

& Lancaster, 2008)
n Public health nursing process (ANA, 2013; MDH, 2001)
n Public Health Intervention Wheel (MDH, 2001)

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13CHAPTER 1  n  Introduction to Public Health Nursing Practice

PHNs practice at the systems level when they work with
providers and professionals like teachers, social workers,
nurses, doctors, government officials, and members of the
business community working for different agencies . If you
are working with members of systems to help these systems
adapt or change their values, health beliefs, or the way they
conduct their business (behaviors) so that they can improve
their capacity to meet the health needs of those they serve,
then you are working at the systems level of practice .

The Relationships Between
Individuals/Families, Communities,
and Systems
Individuals, families, and systems are best understood
within the context of the community in which you live .
Individuals and families interact with, and are influenced
by, their social and physical environments and the systems
that influence their health . For example, families living in
an inner-city neighborhood might not have access to a gro-
cery store with fresh fruits and vegetables or transportation
to the store . The neighborhood’s characteristics influence
family access to quality food and their nutritional well-
being . Figure 1 .3 shows an example of the interrelationships
among families, communities, and systems .

home visiting and family assessment) . Working with fam-
ilies in the community helps you understand the diverse
socioeconomic, cultural, and environmental factors that
influence the health, wellness, and disease of individuals
and families . If you are working with an individual or fam-
ily to help them adapt or change their values, health beliefs,
or behaviors to improve their health status, then you are
working at the individual/family level of practice .

Community Level of Practice
We tend to think of a community as a geographic place, but
a community may refer to any group of people who share
common values, culture, characteristics, and goals, whether
they live in a specific geographical locale or are separated
by distance (Skemp, Dreher, & Lehmann, 2016) . Commu-
nities are composed of people, organizations, and social
patterns of behavior . If you are working with members of
the community to help the community adapt or change its
values, health beliefs, or behaviors to improve the members’
health status, then you are working at the community level
of practice .

PHNs work with two types of populations in the commu-
nity: populations of interest and populations at risk (MDH,
2001, p . 2) . Table 1 .4 defines and provides examples of these
populations .

Systems Level of Practice
A system is an institution or organization that exists within
one or multiple communities . Key systems include health-
care systems, public health systems, schools, churches, gov-
ernment agencies, nonprofit organizations, and businesses .

TABLE 1.4 Populations Served by
Public Health Nurses

Population Examples

Population of Interest:
Population who is
essentially healthy but
could improve factors
that promote or protect
health (MDH, 2001)

n Families who live in urban
areas with little opportunity
for exercise because of lack
of parks, playgrounds, or
bike paths

n College students who have
increased stress because of
study needs and college debts
and are looking for ways to
reduce their stress level

Population at Risk:
Population with a
common identified risk
factor or risk exposure
that poses a threat to
health (MDH, 2001)

n Children who are not immu-
nized for major childhood
illnesses, such as measles and
chickenpox

n Older members of a church
congregation who live alone
and are at risk for falls

FIGURE 1.3 Interrelationships of Families, Communities,  
and Systems

Individual/Family—
No access to grocery store
with fresh fruit and vegetables;
no transportation to
supermarket 5 miles away

Community—
No community
action plan
exists to bring
supermarket
or community
market to
inner-city
neighborhood

System—
No for-profit grocery store
chain wants to locate in
inner-city neighborhood

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14 PART I  n  Foundational Concepts for Public Health Nursing Practice

To make a difference for these families and others in
their inner-city neighborhood, PHNs might carry out the
following interventions:

n Refer families who are eligible for food benefits and
nutrition services to Women, Infants, and Children
(WIC)—individual/family level of practice .

n Work with a community action council to make its
members aware of problems in their inner-city neigh-
borhood and assist them with taking action to obtain
bus service from the neighborhood to a shopping center
or supermarket—community level of practice .

n Help form a coalition of nonprofit organizations and
businesses to bring a cooperative store or other full-
service grocery store to the neighborhood—systems
level of practice .

Table 1 .5 summarizes the three levels of PHN practice
and provides examples of how public health nursing is car-
ried out at these levels . These are all actions that you as a stu-
dent or a newly practicing public health nurse can also take .

TABLE 1.5 Levels of Public Health Nursing Practice

Individual/Family Level Examples

“Population-based, individual-focused practice changes knowl-
edge, attitudes, beliefs, practices, and behaviors of individuals .
This practice level is directed at individuals, alone or as part of
a family, class, or group . Individuals receive services because
they are identified as belonging to a population at-risk” (MDH,
2001, p . 5) .

n Make home visits to newborns and their parents .
n Teach hand-washing to a first-grade class .
n Assess for the presence of lead-based paint in a home with

preschool children .
n Develop a fall-prevention plan for an elderly person living

alone .

Community Level Examples

“Population-based, community-focused practice changes com-
munity norms, community attitudes, community awareness,
community practices, and community behaviors . They [PHNs]
are directed toward entire populations within the community
or occasionally toward target groups within those populations .
Community-focused practice is measured in terms of what pro-
portion of the population actually changes” (MDH, 2001, p . 4) .

n Write a letter to the editor of a local paper to stress the
value of home visits to parents of newborns .

n Create a billboard about the hazards of lead-based paint .
n Participate in a community “town hall” meeting to make

the community aware of safety hazards for elderly people
living alone .

Systems Level Examples

“Population-based, systems-focused practice changes organiza-
tions, policies, laws, and power structures . The focus is not directly
on individuals and communities but on the systems that impact
health . Changing systems is often a more effective and long-lasting
way to impact population health than requiring change from every
single individual in a community” (MDH, 2001, pp . 4–5) .

n Meet with legislators to advocate for reimbursement for
home visits with families of newborns .

n Develop a hand-washing program at an elementary school .
n Teach real-estate agents how to recognize lead-based paint

in a home .
n Develop a fall-prevention protocol for nurses working with

the elderly in the community .

Health Determinants
Public health nurses consider the multiple factors that
determine the health of their clients . Health determinants
are factors that influence the health of individuals, families,
and populations . Health determinants can have a positive or
negative influence on health . Table 1 .6 presents examples of
protective and risk factors at all three levels of practice for
communicable disease in childhood:
n Protective factors are health determinants that pro-

tect a person from illness or assist in improving the
person’s health .

n Risk factors are health determinants that contribute
to the potential for illness to occur or to a decrease in
health or well-being .

Just as holistic nursing practice focuses on the whole,
public health nursing focuses on the whole by identifying
all of the factors that influence the health of individuals,
families, and communities . To ignore this wholeness of the
living condition is to ignore many factors that impact health
and the ability of public health nurses to promote health .
Biological, behavioral, and environmental factors interact

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15CHAPTER 1  n  Introduction to Public Health Nursing Practice

TABLE 1.6 Protective and Risk Factors for Childhood Communicable Diseases

Protective Factors by Level of Practice

Individual/Family Level
n Family has insurance that covers

immunizations .
n Children are up to date on

immunizations .
n Parents teach children proper

hand-washing and the benefits of
covering their mouths when coughing .

Community Level
n 95% of children in the community are

immunized (herd immunity) .
n Community billboards urge parents to

immunize their children .
n Low-density housing or single-

dwelling homes reduce contact
between infected and noninfected
children .

Systems
n Immunizations are available at public

health clinics, pharmacies, and medi-
cal clinics .

n Free or low-cost immunizations are
available to the uninsured .

n Childcare center has effective infection
prevention and control practices .

Risk Factors by Level of Practice

Individual/Family Level
n Family is uninsured .
n Family members are not aware of the

need for immunizations .
n Parents are not aware of how to pre-

vent the spread of infectious diseases .

Community Level
n 45% of children in the community are

immunized (no herd immunity) .
n Some community groups oppose

childhood immunizations .
n Many high-density housing and apart-

ment complexes in the community
place people living close together at
greater risk .

Systems
n Immunizations are not available at the

public health clinic .
n Funding for low-cost immunizations

for the uninsured is lacking .
n School district does not track students’

immunization records .

and contribute to the health and illness of individuals, fam-
ilies, and populations (ANA, 2013; Marmot & Wilkinson,
1999; Zahner & Block, 2006) . Individuals and families are
able to influence or control some of their biological and
many of their behavioral health determinants but are not
able to control many of the physical and social environmen-
tal determinants of health that occur at the community and
systems levels . Health determinants shaped by social, eco-
nomic, and political forces, including systems put in place to
deal with illness, are called the social determinants of health .
(See Chapter 13 for further discussion on the social determi-
nants of health .) These social determinants of health affect
population health in all nations of the world .

The social determinants of health are the conditions in
which people are born, grow, live, work, and age . These cir-
cumstances are shaped by the distribution of money, power,
and resources at global, national, and local levels . The social
determinants of health are mostly responsible for health
inequities—the unfair and avoidable differences in health
status seen within and between countries (WHO, 2013) .

Health Status
PHNs use the community assessment process and public
health nursing process (see Chapter 3) to determine the
health statuses of individuals, families, communities, and

populations . Health status refers to the level of health or ill-
ness and is the outcome of the interaction of the multiple
health determinants . Health status indicators are frequently
represented by statistical measures, such as rates and per-
centages . Some common examples of population health
status indicators are teen pregnancy rates, percentage of
low-birthweight babies, neonatal mortality rates, percentage
of malnutrition in a group, and obesity rates . Rates and per-
centages of various population groups can be compared to
determine similarities or differences in the health status of
those groups . Health status comparisons can also be applied
at an individual level, such as identifying a child with mal-
nutrition as having a lower level of health than a child who is
not malnourished . Health status comparisons allow PHNs
to determine their priorities for actions with specific indi-
viduals, families, communities, and populations . Figure 1 .4
illustrates a health determinants model .

All of the Healthy People 2020 health determinants,
including access to healthcare, are represented in Fig-
ure 1 .4 (U .S . DHHS, n .d .-b) . This model represents a holistic
approach to assessment of the protective and risk factors
that determine health status in individuals, families, and
communities . Health determinants, including protective
and risk factors, exist at individual/family, community,
and systems levels, so nursing interventions should address
health determinants at all levels as needed . PHNs can use
this holistic approach to organize and identify the complex
contributors to the health status of specific individuals,

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16 PART I  n  Foundational Concepts for Public Health Nursing Practice

families, and populations and to develop interventions
to improve health . PHNs collaborate with their clients by
building and strengthening their protective factors and
helping them reduce their risk factors . The social determi-
nants of health that play a significant role in health dispari-
ties are discussed in Chapter 13 .

Activity
Review the following Health Determinants Analysis Case Study:

n Identify the health status indicators for this community.

n Identify health determinants, including protective and 
risk factors that contribute to the health status of this 
community. 

n Determine how you would work with community members to 
build on their protective factors and reduce their risk factors.

CASE STUDY
Health Determinants Analysis

A community assessment in a small rural community determines 
that  more  than  one-third  of  the  adult  residents  are  overweight 
or obese. The assessment reveals that 40% of the adults in this 
community  report  that  they  have  high  cholesterol,  and  30% 
report that they have high blood pressure. The majority of adults 
admit  to  eating  out  at  fast-food  restaurants  at  least  five  times 
a  week.  This  community  contains  many  fast-food  restaurants, 
and the most common foods sold in them are high in fat, sodium, 
sugar, and calories. This community has few outdoor recreational 
sites, such as bike and walking paths, and the county board has 
voted  against  increasing  tax  levies  to  provide  those paths.  The 
local hospital does provide evening and weekend health educa-
tion classes on modifying diet and exercise to lead a healthier life. 
A  coalition  of  healthcare  clinics,  the  public  health  agency,  and 
local businesses  is working on a plan  to  increase healthy  living 
resources in the community.

FIGURE 1.4 A Health Determinants Model for Individuals/Families, Communities, and Populations

Health Status
Levels of Health and/or Illness

Morbidity Rates (illness)
Mortality Rates (death)
Levels of Independence

Life Satisfaction
Comparisons with Others

• biological factors
• physical characteristics
• genetic factors
• health conditions

Biology

Behaviors
• health-seeking actions
• health-limiting actions
• lifestyle patterns
• socioeconomic status
• family, work, and

community roles
• levels of coping and

resilience
• language and literacy
• health literacy

Social Environment
• culture
• government
• education
• commerce
• religion
• health systems
• media
• social & economic

patterns Access to Healthcare

Physical Environment
• geography
• climate
• weather
• natural resources
• agriculture
• urban versus rural
• natural versus

built environment

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17CHAPTER 1  n  Introduction to Public Health Nursing Practice

‘‘

’’

Levels of Prevention
The levels of prevention (primary, secondary, and tertiary)
provide a framework for health-promotion and disease-
prevention efforts in the stages of the natural history of dis-
ease (Leavell & Clark, 1958; Stanhope & Lancaster, 2008) .
The health-promotion progression from primary to sec-
ondary to tertiary prevention provides a framework for
population-based public health nursing interventions at all
levels of public health nursing practice (MDH, 2001; Skemp
et al ., 2016) . It is important to determine the health status
of individuals/families, communities, and populations and
to determine the level of prevention for specific health con-
cerns to implement the appropriate interventions . Figure 1 .5
provides an overview of the stages of health, the levels of
prevention, and intervention approaches .

Although the focus of public health nursing is primary
prevention, public health nursing practice encompasses
all three levels . In contrast, within the hospital setting,
the focus of most nursing care is on ill patients and their
family members, and nurses more often provide secondary
and tertiary prevention but may also provide some primary
prevention . Table 1 .7 shows the definition of each level with
examples .

healthypeople.gov

Healthy
People

  Healthy People, a program of the U.S.  
  Department of Health and Human Services,  
  has established science-based benchmarks 
and 10-year national objectives for improving the health of all 
Americans. Healthy People 2020 is the third set of national 
health priorities identified over the last 3 decades. Its vision is “a 
society in which all people live long healthy lives” (U.S. DHHS, 
n.d.-b, p. 1). The mission and goals are displayed in Table 1.8. 
This national program seeks to involve all Americans by encour-
aging community and organizational collaboration, empowering 
individuals to make informed health decisions, and measuring 
the outcomes of prevention activities (U.S. DHHS, n.d.-b). 

“Okay! Now I understand why public health nurses do what
they do, but I am still not clear about what I am supposed
to do!” Albert states in an exasperated tone of voice.

Sia responds, “I guess we have to assess our clients’
health status, identify their health determinants, and
develop a plan of care that builds on their protective factors
and reduces their risk factors. Now it makes sense that we
would be mostly listening, teaching, and counseling. Did
you know that the words listen and silent have the same
letters? I guess we need to use silence to listen to our clients!”

Abby states, “I really like all the secondary and tertiary
prevention interventions that I do in the hospital setting, so
I am afraid I am going to get bored working in the commu-
nity. I can only sit and listen for so long. I like action!”

Albert reflects, “Primary prevention doesn’t have to
mean you are not doing anything. Just because there isn’t
already an illness or disease doesn’t mean there isn’t work
to do. Primary prevention is the way that we can identify
health determinants and make an impact. Our instructor
says we can apply public health nursing in any nursing
practice setting. Maybe I will think about how I can use
everything I learn in my community clinical in my hospital
practice. But, who knows, maybe I will decide to become a
public health nurse!”

Sia asks, “I understand what we are supposed to focus
on when we work with individuals and families, but I am
not sure how identifying their health statuses and health
needs fits in with the concept of population-based practice.
I guess I need to talk to my preceptor about how our home
visits fit in with the priority health needs of our community.
How do I know whether what we are doing reflects what the
community really wants public health nurses to do?”

FIGURE 1.5 Stages of Health and Disease and Levels of Prevention

Key
Interventions

Health
Promotion and

Prevention

Screening,
Diagnosis, and

Treatment

Rehabilitation,
Remediation,
Maintenance

Level of
Prevention

Primary Secondary Tertiary

Stage
of Health

Healthy Early Disease
or Injury

Chronic
Disease

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18 PART I  n  Foundational Concepts for Public Health Nursing Practice

TABLE 1.7 Prevention Continuum With Public Health Nursing Examples

Definitions Examples

Primary prevention promotes health and protects against
threats to it . It is designed to keep problems from occur-
ring in the first place . It promotes resiliency and protective
factors or reduces susceptibility and exposure to risk factors .
Primary prevention occurs before a problem develops . It
targets populations that are essentially well .

PHN Antepartal home visit:
n Teaching parents the importance of taking a newborn home from

the hospital in an approved car seat
n Providing parents with information about approved car seats

PHN Postpartum home visit:
n Checking the car seat to determine that it is correctly installed
n Monitoring the parents’ use of car seat

Secondary prevention detects and treats problems in their
early stages . It keeps problems from causing serious or
long-term effects or from affecting others . It identifies risks
or hazards and modifies, removes, or treats them before a
problem becomes more serious . Secondary prevention is
implemented after a problem has begun, possibly before
signs and symptoms appear . It targets populations that
share common risk factors .

PHN at WIC Clinic:
n Using a growth chart to plot children’s heights and weights
n Identifying children who are outside established norms
n Referring parents and children who are above 95th percentile or

below 5th percentile to a primary care provider for assessment
and to a nutritionist for nutritional education and counseling

Tertiary prevention limits further negative effects from a
problem and aims to keep existing problems from getting
worse . Tertiary prevention is implemented after a disease
or injury has occurred . It alleviates the effects of disease
and injury and restores individuals to their optimal levels
of functioning . It targets populations that have experienced
disease or injury .

School Nurse
Beginning of the school year:

n Identifying students with asthma and obtaining asthma plans
n Working with teaching staff to reduce environmental asthma

triggers in the school building

During the school year:
n Monitoring students with asthma for adherence to their asthma

plans and their health status
n Providing nebulizer treatments in the health office

Source: Modified from MDH, 2001, p . 4

TABLE 1.8 Healthy People 2020 Mission and Goals

Mission—Healthy People 2020 strives to: Overarching Goals

n Identify nationwide health-improvement priorities
n Increase public awareness and understanding of the

determinants of health, disease, and disability and
opportunities for progress

n Provide measurable objectives and goals that are
applicable at the national, state, and local levels

n Engage multiple sectors to take action to strengthen
policies and improve practices that are driven by the best
available evidence and knowledge

n Identify critical research, evaluation, and data- collection
needs

n Attain high-quality, longer lives free of preventable disease,
disability, injury, and premature death

n Achieve health equity, eliminate disparities, and improve the
health of groups

n Create social and physical environments that promote good
health for all

n Promote quality of life, healthy development, and healthy
behaviors across all life stages

Source: U .S . DHHS, n .d .-b

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19CHAPTER 1  n  Introduction to Public Health Nursing Practice

BSN Preparation
The need for nurses to be prepared to both work in the
community and have the ability to practice entry-level pub-
lic health nursing has become more urgent as healthcare
moves from the acute care setting to the community and
new models of healthcare and nursing practice emerge . The
challenge of practicing in the community is influenced by
the persistence of health disparities among all age groups
and diverse populations, the aging of the population, and
the continuous increase in healthcare costs . In addition,
healthcare needs and diseases are not isolated by geographic
boundaries but evolve within a global environment . Recog-
nition of the need for nurses to have the ability to improve
the health of populations by taking leadership roles within
the healthcare system and in their communities and by
partnering with other health professionals and community
leaders has resulted in a renewed commitment to increase
the proportion of nurses with baccalaureate degrees and
to enrich the baccalaureate nursing curriculum to prepare
nurses for the challenges that face them (Education Com-
mittee of the Association of Community Health Nurse
Educators [ACHNE], 2010; Institute of Medicine [IOM],
2011; Robert Wood Johnson Foundation, 2013) . ACHNE has
identified 15 basic core knowledge competencies for bacca-
laureate nursing graduates that should be included in the
baccalaureate nursing curriculum (2010):
n Communication
n Epidemiology and biostatistics
n Community/population assessment
n Community/population planning
n Policy development
n Assurance
n Health promotion and risk reduction
n Illness and disease management
n Information and healthcare technology
n Environmental health
n Global health
n Human diversity
n Ethics and social justice
n Coordination and care management
n Emergency preparedness, response, and recovery

Activity
n Which knowledge areas have you already studied?

n What are your knowledge and competency goals for your 
public health nursing clinical?

A set of national health priorities titled Leading Health
Indicators (LHIs) is included in Healthy People 2020 (U .S .
DHHS, n .d . -a) . They include 42 health outcomes orga-
nized into 12 health topics . These priorities reflect the great-
est unmet national health needs based on an analysis of
Healthy People 2010 health outcome data . The 12 health top-
ics are listed in the following “Leading Health Indicators”
box . A mid-course review of progress toward achieving the
42 health indicators shows that 21% of the targets have been
achieved and 19% are improving while 11% are getting worse
(U .S . DHHS, 2017) .

OnlineActivity
    Go to the Healthy People webpage (http:// 
www.healthypeople.gov) and search for the LHIs. 

n Read about one of the LHI health outcomes that 
interests you. 

n Find the Healthy People 2010 statistical data that measured 
the achievement of that outcome.

n What is the goal for the Healthy People 2020 outcome? 
Which statistic would demonstrate improvement of that 
outcome?

Activity
n Explore the community health priorities of your state or local 

health department. Compare them with the LHIs.

n Identify programs or activities in your clinical agency that are 
related to the LHIs. 

n Discuss with your preceptor how nurses are involved in these 
programs or activities.

n Consider how you might become involved as a citizen or 
as a nurse in working on one of the LHI priorities in your 
community.

Leading Health Indicators, Healthy People 2020

n Access to Health Services

n Clinical Preventive Services

n Environmental Quality

n Injury and Violence

n Maternal, Infant, and Child Health

n Mental Health

n Nutrition, Physical Activity, and Obesity

n Oral Health

n Reproductive and Sexual Health

n Social Determinants

n Substance Abuse

n Tobacco

Sources: National Center for Health Statistics, 2012; U .S . DHHS, n .d .-a

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20 PART I  n  Foundational Concepts for Public Health Nursing Practice

Entry-Level Population-Based Public
Health Nursing Competencies
This chapter has given you a lot to think about . Now it is
time to focus on the entry-level public health nursing com-
petencies that you can work to develop in your community
clinical . This book is going to help you focus on the entry-
level competencies expected of baccalaureate nursing grad-
uates and novice nurses entering public health nursing .

Henry Street Entry-Level PHN Competencies
The Henry Street Consortium (HSC) entry-level population-
based public health nursing competencies, initially pub-
lished in 2003 and updated in 2017, are intended for
baccalaureate nursing graduates and novice public health
nurses (Henry Street Consortium, 2017; Schaffer et al ., 2011) .
These 12 competencies are consistent with national bench-
mark standards for entry-level public health nursing (ANA,
2013; Quad Council of Public Health Nursing Organiza-
tions, 2011) . (See Table 1 .9 .) A consortium of practicing pub-
lic health nurses and educators developed these simplified
entry-level standards to facilitate the teaching and learning
of public health nursing knowledge and skills in the clinical
setting (Schaffer et al ., 2011) .

This list presents each competency in broad statements
that are not measurable by themselves . A more complete
outline of each of the HSC competencies, which provides
measures of how to evaluate PHN achievement of each
competency, is found in Appendix A . Chapters 3 to 14 each
cover one of the 12 competencies and provide specific evi-
dence about best practices for each competency . As you read
this book, you will learn how you might meet these entry-
level competencies in your public health clinical learning
activities .

Activity
n Review the competencies and their related activities in 

Appendix A. Make a list of activities within each compe-
tency that you would like to practice during your community 
clinical. 

n Talk with your preceptor about how you might practice these 
public health nursing activities. 

TABLE 1.9 Henry Street Consortium
Entry-Level Population-Based Public Health
Nursing Competencies

Entry-Level Population-Based Public Health Nursing
Competencies

For the New Graduate or Novice Public Health Nurse

1 . Applies the public health nursing process to communities,
systems, individuals, and families

2 . Utilizes basic epidemiological (the incidence, distribution,
and control of disease in a population) principles in public
health nursing practice

3 . Utilizes the principles and science of environmental
health to promote safe and sustainable environments for
individuals/families, systems, and communities

4 . Practices within the auspices of the Nurse Practice Act

5 . Works within the responsibility and authority of the
governmental public health system

6 . Utilizes collaboration to achieve public health goals

7 . Effectively communicates with communities, systems,
individuals, families, and colleagues

8 . Establishes and maintains caring relationships with
communities, systems, individuals, and families

9 . Incorporates mental, physical, emotional, social, and
spiritual aspects of health into assessment, planning,
implementation, and evaluation

10 . Demonstrates nonjudgmental/unconditional acceptance
of people different from self

11 . Shows evidence of commitment to social justice, the
greater good, and the public health principles

12 . Demonstrates leadership in public health nursing with
communities, systems, individuals, and families

Source: Henry Street Consortium, 2017

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21CHAPTER 1  n  Introduction to Public Health Nursing Practice

n Primary prevention is the focus of public health nurs-
ing, but PHNs also provide secondary and tertiary
prevention interventions .

n PHNs work at all three levels of practice: individual/
family, community, and systems .

n Emerging threats and challenges in health and health-
care require changes in and leadership from public
health nursing .

n The HSC Entry-Level Public Health Nursing competen-
cies, based on accepted national standards, provide a
guide for baccalaureate nursing students to achieve the
expected outcomes of baccalaureate nursing education .

KEY POINTS

n Public health nursing combines the theory and practice
of nursing and public health . It is a required component
of baccalaureate nursing education .

n Public health nursing practice is guided by the national
scope of practice standards .

n The goal of public health and public health nursing is to
improve the health of the public at the local, national,
and international levels .

n The Cornerstones of Public Health explain the beliefs
and values of the clinical specialty of public health
nursing practice .

n Public health nursing practice is population-based,
focusing on the priority health needs of populations .

‘‘

’’

REFLECTIVE PRACTICE

Alberto takes a deep breath, closes his eyes as if in deep
thought, and says to Abby and Sia, “Let’s see if I have this
straight. Public health nursing is part of my professional
nursing practice. It can be practiced anywhere, because
public health nursing is shaped by its goal, not by its set-
ting, but it is most often practiced in the community. The
goal of public health nursing is to improve the health of the
public, the health of the communities in which we live. The
client in public health nursing may be an individual, a fam-
ily, the community, or a population within the community.
To improve and protect the public’s health, I need to assess
the health status and identify the health determinants that
affect the health status of individuals, families, communi-
ties, and populations. Then I need to intervene by helping
my clients build on their protective factors and reduce their
risk factors. The interventions I will use most often are
teaching and counseling, but we will learn about more inter-
ventions as we read this book and complete our community
clinical. When I practice in the community, I will probably

be partnering with other members of the healthcare team
as well as community members. I need to demonstrate a
set of entry-level public health nursing competencies to
successfully complete my baccalaureate nursing education.
The Henry Street Consortium Population-Based Public
Health Nursing Competencies focus on what I should be
learning and practicing in my public health clinical activi-
ties. Whew! Do I have that right?”

Abby and Sia respond, “Yes. You’ve got it! You get an ‘A’
for the course!”

1. Think about what Alberto, Abby, and Sia have learned
about public health nursing from their observations
and discussions with their preceptors .

2. How will you analyze what you observe about public
health nursing during your clinical experience?

3. How would you describe public health nursing prac-
tices you observe in your clinical to your classmates?

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22 PART I  n  Foundational Concepts for Public Health Nursing Practice

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25

‘‘

’’

CHAPTER

2Evidence-Based Public
Health Nursing Practice

n  Patricia M. Schoon and Marjorie A. Schaffer 
with Stephanie Rivery

Abby is talking with Jaime, an RN who has returned to school to get his baccalaureate nursing
degree. She is struggling to understand the three levels of public health nursing practice. Abby
asks, “How do you use the nursing process in your hospital work? Did you ever think you could
use it for more than the patients you are caring for?”

Jaime replies, “It still seems kind of strange to me. But I am a member of the Quality Improve-
ment Team. We just finished an audit to look at the incidence of patient falls to find out whether
our unit is meeting the goals set by the hospital to reduce the patient fall rate. Our patient fall rate
is still higher than the goal set by the hospital, so we decided that we need to hold an in-service on
assessing patients for their fall risk and the different protocols we can use to reduce the number of
patient falls. So, I guess if we think of my unit as a community, we are using the nursing process
at more than one level.”

Abby ponders, “I guess I can kind of see that you are using the nursing process to assess the
fall rate. The idea of using the nursing process at the systems level still seems very strange to me.”

Jaime thinks about the idea of nursing at the systems level and finally says, “Maybe if I think
of the nursing staff on my unit as part of the hospital system, then Quality Improvement Team
members can assess what they know about fall risk and prevention and design a program just for
our staff members to improve their skills in that area. What do you think?”

Abby sighs, “I kind of understand how I can use nursing process to assess the health needs of
individuals, families, and communities, but I can’t think how I would assess the health status of
a system. Do systems have a health status?” Abby muses, “If a system, like a public health agency,
doesn’t have enough money to provide the health services that the community needs, then I guess
it wouldn’t be very healthy.”

Jaime says thoughtfully, “Maybe we need to look at a community’s health needs and determine
whether specific community systems, such as hospitals, schools, educational systems, and public
health agencies, have the resources to meet the priority needs of their community. If they don’t
have the resources, then maybe we can plan interventions to help them get the resources or services
they need.”

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26 PART I  n  Foundational Concepts for Public Health Nursing Practice

’’

‘‘

The application of the nursing process to all three levels of
practice is discussed in Chapter 3.

An easy way to remember the level of practice is to ask
yourself, “Whose knowledge, beliefs, behaviors, and values
am I trying to modify?” For example, if you are teaching
a group of first grade students how to wash their hands,
even though they are in a group, your intention is to modify
the handwashing behaviors of the individual students. So,
you are intervening at the individual/family level of prac-
tice. If you taught the first-grade teachers how to monitor
the handwashing behaviors of their students, you would be
intervening at the systems level of practice. If you handed
out a flyer on the reasons for handwashing and the cor-
rect handwashing procedure at a county fair, you would be
intervening with the community level, hoping to change
community norms for handwashing, not the behaviors of
specific individuals.

Abby comments, “My PHN preceptor told me that we are
going to make a joint visit with the social worker to a family
where a baby has failure to thrive. My preceptor is going
to focus on assessing the health status of the baby, and the
social worker is going to focus on the family support system
and resources in the community for the mother. It will be
interesting to see how they work together.”

Jaime responds, “I am going to an interdisciplinary
child protection team meeting with my preceptor. It is a
county-wide team made up of police, social workers, law-
yers, and public health nurses. It seems like my preceptor is
always working with other people.”

Abby concurs, “It really does seem that PHNs work with
lots of other disciplines. My preceptor says that is the best
way to deal with community-wide health problems.”

Several years ago, a nursing student about to graduate
reflected on what she had learned. She said, “I get it. Nursing
is about critical thinking!” Nursing is a knowledge profes-
sion. That means nurses think before they do (assessment
and planning), while they do (modifying interventions),
and after they do (evaluation). This chapter explains how
to apply the nursing process to public health nursing prac-
tice and to identify and use interventions that support pub-
lic health practice goals. You will learn how to apply what
you already know about evidence-based nursing practice to
your public health nursing practice. PHNs are accountable
to their clients and to the public for practicing effectively
and efficiently to achieve the best outcomes using the least
amount of resources. This chapter discusses how PHNs use
best practice information to improve their clients’ health.

The Public Health Nursing Process
The public health nursing process integrates concepts of
nursing and public health. The steps of the nursing process
are the same: assessment, diagnosis, planning, implemen-
tation, and evaluation. However, the public health nursing
process expands the nursing process in that PHNs focus
their assessment and interventions on three different levels
of practice: individuals and families, communities, and sys-
tems (MDH, 2001). Refer to Chapter 1 for a description of the
three levels of PHN practice. Critical thinking throughout
the PHN process is essential in identifying and modifying
the complex determinants of health that influence the health
status of individuals, families, and communities. This appli-
cation of the nursing process is reflected in the American
Nurses Association’s (ANA’s) Public Health Nursing: Scope
and Standards of Practice (2013), as illustrated in Figure 2.1.

ABBY’S NOTEBOOK

USEFUL DEFINITIONS

Evidence-Based Practice: “A problem-solving approach to clinical decision-making within a healthcare orga-
nization. EBP integrates the best available scientific evidence with the best available experiential (patient and
practitioner) evidence” (Dang & Dearholt, 2018, p. 4).

Evidence-Based Public Health: Making decisions on the best information available and creating interventions
based on that evidence (Barr-Walker, 2017).

Public Health Interventions: Actions that PHNs take on behalf of individuals, families, systems, and communi-
ties to improve or protect their health status (Minnesota Department of Health [MDH Center for Public Health
Nursing], 2001); public health nurses (PHNs) commonly practice all 17 interventions.

Public Health Nursing Process: Integration of concepts of public health, community, and all three levels of the
PHN practice (i.e., individual, community, and systems) into the nursing process (Minnesota Department of
Health [MDH], Center for Public Health Nursing, 2003).

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27CHAPTER 2  n  Evidence-Based Public Health Nursing Practice

These interventions are organized in the Public Health
Intervention Wheel illustrated in Figure 2.2. The Public
Health Intervention Wheel is evidence-based and represents
what PHNs do (Keller et al., 2004). PHNs often use more
than one intervention at more than one level of practice
(individual and family, community, or system) to influence
the multiple health risks affecting individuals, families, and
populations.

The 17 interventions are divided into five wedges with
three or four interventions in each wedge. Each group of
wedges reflects a cluster of interventions. The cluster of
interventions within each wedge often occurs either con-
currently or consecutively. The five wedges (also depicted in
specific colors) include the following interventions:

n Wedge 1 (pink): Surveillance, disease and health event
investigation, outreach, and screening (case finding is
the individual level for this wedge)

n Wedge 2 (green): Referral and follow-up, case manage-
ment, and delegation

n Wedge 3 (blue): Health teaching, counseling, and
consultation

n Wedge 4 (orange): Collaboration, coalition building,
and community organizing (no individual level for
coalition building and community organizing)

n Wedge 5 (yellow): Advocacy, social marketing, policy
development, and enforcement

The three inner circles, called segments, represent the
three levels of public health nursing practice (individual/
family, community, and systems). All but three interventions
are carried out at all three levels of practice. Case finding is
only carried out at the individual/family level of practice, so
it is placed inside the individual/family circle in the wheel
diagram. Community organizing and coalition formation
are practiced at the community and systems levels but not
at the individual/family level. Sixteen of the interventions
are independent nursing actions that can be practiced under
your state’s Nurse Practice Act without medical orders. The
seventeenth intervention, delegated functions, can include
medical functions delegated by a medical professional, such
as immunizations. Nursing activities that the PHN delegates
to another health team member, such as vision and hearing
screening, are part of the independent practice of nursing
and usually reflect one of the other PHN interventions.

Definitions and examples of the 17 population-based
public health interventions are outlined in Table 2.1. Inter-
ventions are organized within the five wedges on the Public
Health Intervention Wheel. Nursing students could do all
the intervention examples in the table.

The Public Health Intervention Wheel has been dissemi-
nated to public health nursing students, PHNs, other public
health professionals, and health departments nationally and
internationally. The Wheel is used as a framework for teach-
ing; a guide for planning, documentation, and evaluation in
public health practice; and a model for research on interven-
tion use and effectiveness.

PHNs often work with people in other professions as well
as community members to achieve public health goals. (See
Chapter 8 for a discussion of interprofessional collabora-
tion.) Many of the interventions that PHNs use are also used
by other professionals in the community.

Public Health Intervention Wheel
The Public Health Intervention Wheel is a major concep-
tual model in public health nursing (Keller, Strohschein,
Lia-Hoagberg, & Schaffer, 1998, 2004; Bigbee & Issel, 2012).
Concepts in the Public Health Intervention Wheel include:
population-focus, three levels of practice, three levels of pre-
vention, and 17 interventions that define the shared practice
of public health nursing. Research supporting the use and
effectiveness of many of the interventions in this model are
found in this book. This model is supported by evidence
from literature and validated by more than 200 public
health nurses from a variety of practice settings.

Public health interventions are actions that PHNs take
on behalf of individuals, families, systems, and commu-
nities to improve or protect their health status (MDH,
2001). The Public Health Intervention Wheel identifies 17
population-based interventions specific to public health
practice that are found at three levels: individual/family,
community, and systems (Keller et al., 1998, 2004; MDH,
2001). Because PHN practice occurs at three levels, interven-
tions must also be implemented at all three levels.

FIGURE 2.1 Nursing Process at Three Levels of Public Health 
Nursing Practice

Community

System

Individual/
Family

Planning

Im
plem

entation

D
ia

gn
os

is

Ev
aluation Assessment

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28 PART I  n  Foundational Concepts for Public Health Nursing Practice

TABLE 2.1 Public Health Nursing Interventions at All Three Levels of Practice

PHN Intervention
Definition

PHN Intervention
Examples

Surveillance (Wedge 1 – Pink)
Surveillance describes and monitors health events
through ongoing and systematic collection, analysis, and
interpretation of health data for the purpose of planning,
implementing, and evaluating public health interventions
(MDH, 2001, p. 13).

n Investigate and report the incidence and prevalence of sexually
transmitted infections in the local teen population (community
level).

n Work with a school nurse at an elementary school to develop a
tracking program to identify the incidence and prevalence of
student-on-student bullying before and after the implementation of
an anti-bullying curriculum (systems level).

Disease & Health Event Investigation (Wedge 1 – Pink)
Disease and other health event investigation systemati-
cally gathers and analyzes data regarding threats to the
health of populations, ascertains the source of the threat,
identifies cases and others at-risk, and determines control
measures (p. 29).

n Identify and follow up on cases of sexually transmitted infection in
a high school population to identify sources of infection and provide
treatment (individual/family level).

n Gather information about radon levels in your community and
determine high-risk geographical areas (community level).

FIGURE 2.2 Public Health Intervention Wheel 
Source: MDH, Center for Public Health Nursing (2001)

Case Finding

Population-Based

Population-Based

Population-Based

Individual-Focused

Community-Focused

Systems-Focused

Surveillance
Disease &Health EventInvestigation

Outreach

Screening
R

eferral &

Follow
-U

p

Ca
se

M
an

ag
em

en
t

Dele
gate

d

Fu
nct

io
ns

Health

Teaching

Counseling

Consultation

Collaboration

Coalition

Building
C

om
m

unity

O
rganizing

A
dv

oc
ac

y

Socia
l

M
ark

etin
g

Policy

Development &

Enforcement

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29CHAPTER 2  n  Evidence-Based Public Health Nursing Practice

PHN Intervention
Definition

PHN Intervention
Examples

Outreach (Wedge 1 – Pink)
Outreach locates populations of interest or populations
at risk and provides information about the nature of the
concern, what can be done about it, and how services can
be obtained (p. 41).

n Interview people at a family homeless shelter to determine who
needs information about the location of local food shelves and WIC
clinics (individual/family level).

n Develop brochures for local grocery stores to hand out about nutri-
tional needs for children and the location of local food shelves and
WIC clinics (systems level).

Case Finding (Wedge 1 – Pink)
Case finding locates individuals and families with identi-
fied risk factors and connects them to resources (p. 55).

n Identify new immigrants from southeast Asia who might be at risk
for tuberculosis (TB) (individual/family level).

n Give at-risk immigrants information on where to receive TB
screening (individual/family level).

Screening (Wedge 1 – Pink)
Screening identifies individuals with unrecognized
health risk factors or asymptomatic disease conditions in
populations (p. 63).

n Conduct blood pressure screening for African-American males
( community level)

n Organize a blood pressure screening clinic at a community center
( systems level)

Referral & Follow-up (Wedge 2 – Green)
Referral and follow-up assists individuals, families,
groups, organizations, and communities to utilize
necessary resources to prevent or resolve problems or
concerns (p. 79).

n Give an elderly person who is homebound information about how
to contact a local Meals on Wheels program and then contact the
individual a week later to see if he or she has successfully reached
the Meals on Wheels program (individual/family level).

n Work with Emergency Department (ED) nurses and home visiting
nurses to develop and use a referral process for elderly individuals
seen in the ED that need home healthcare services (systems level).

Case Management (Wedge 2 – Green)
Case management optimizes self-care capabilities of
individuals and families and the capacity of systems and
communities to coordinate and provide services (p. 93).

n Work with parents of a newborn with Down’s Syndrome to iden-
tify services in their community that they can use to help them
( individual/family level).

n Work with a PHN and school nurse to coordinate in-home and
school health services for children with severe developmental delays
(systems level).

Delegated Functions (Wedge 2 – Green)
Delegated functions are direct care tasks a registered
professional nurse carries out under the authority of
a healthcare practitioner, as allowed by law. Delegated
functions also include any direct care tasks a registered
professional nurse entrusts to other appropriate person-
nel to perform (p. 113).

n Provide immunizations at a community flu clinic under standing
orders from medical personnel (individual/family and systems
levels).

n Direct a peer counselor to work with a new diabetic to organize a
grocery list and menu plans (individual/family level).

Health Teaching (Wedge 3 – Blue)
Health teaching communicates facts, ideas, and skills
that change knowledge, attitudes, values, beliefs, behav-
iors, and practices and skills of individuals, families,
systems, and/or communities (p. 121).

n Teach a class for teen moms about how to care for new baby
( individual/family level).

n Develop a program on childcare for new moms at a local high school
(systems level).

(continues)

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30 PART I  n  Foundational Concepts for Public Health Nursing Practice

PHN Intervention
Definition

PHN Intervention
Examples

Counseling (Wedge 3 – Blue)
Counseling establishes an interpersonal relationship with
a community, system, family, or individual intended to
increase or enhance their capacity for self-care and cop-
ing. Counseling engages the community, system, family,
or individual at an emotional level (p. 151).

n Provide support for parents who are coping with providing care for
their dying child at home (individual/family level).

n Provide crisis management services to a community that has just
experienced a devastating tornado (community level).

Consultation (Wedge 3 – Blue)
Consultation seeks information and generates optional
solutions to perceived problems or issues through
interactive problem-solving with a community, system,
family or individual. The community, system, family or
individual selects and acts on the option best meeting the
circumstances (p. 165).

n Help a recently divorced father who has custody of his two children
to problem solve balancing parenting and work responsibilities
(individual/family level).

n Consult with a peer-counseling group for diabetes management
to help them develop strategies for working with individuals with
diabetes in their community (community level).

Collaboration (Wedge 4 – Orange)
Collaboration commits two or more persons or organiza-
tions to achieving a common goal through enhancing the
capacity of one or more of them to promote and protect
health (p. 177).

n Partner with the nurse and social worker in an adolescent correction
facility in developing a program to help inmates maintain con-
tact with caring individuals in their family or friendship network
( systems level).

n Work with the county parks and playground department and local
young parents group to develop a plan to provide more bike and
walking paths for family use (community and systems level).

Coalition Building (Wedge 4 – Orange)
Coalition building promotes and develops alliances
among organizations or constituencies for a common
purpose. It builds linkages, solves problems, and/or
enhances local leadership to address health concerns
(p. 211).

n Develop an alliance between local environmental groups, waste
management, and recycling organizations to improve community
recycling (community level).

n Establish a network of agencies to work together to develop a
community disaster plan (systems level).

Community Organizing (Wedge 4 – Orange)
Community organizing helps community groups identify
common problems or goals, mobilize resources, and
develop and implement strategies for reaching the goals
they collectively have set (p. 235).

n Organize a group of renters from several low-income housing devel-
opments to work together to improve the safety of their buildings
(community level).

n Help organize a group of low-income housing services organiza-
tions, community homeless shelters, and county human services
to develop strategies to provide a more streamlined program for
placing homeless people in affordable housing (systems level).

Advocacy (Wedge 5 – Yellow)
Advocacy pleads someone’s cause or acts on someone’s
behalf, with a focus on developing the community, sys-
tem, individual, or family’s capacity to plead their own
cause or act on their own behalf (p. 263).

n Help a client file an appeal for an insurance denial for home-care
services when the client meets eligibility criteria stated in insurance
policy (individual/family level).

n Lobby legislators for support of community mental health programs
(systems level).

Social Marketing (Wedge 5 – Yellow)
Social marketing utilizes commercial marketing princi-
ples and technologies for programs designed to influence
the knowledge, attitudes, values, beliefs, behaviors, and
practices of the population of interest (p. 285).

n Create a video for teen parents on how to help their infants and
toddlers meet developmental milestones (individual/family level).

n Participate in a televised panel discussion about the effects of drug
and alcohol use during pregnancy on the fetus (community level).

TABLE 2.1 Public Health Nursing Interventions at All Three Levels of Practice (continued)

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31CHAPTER 2  n  Evidence-Based Public Health Nursing Practice

PHN Intervention
Definition

PHN Intervention
Examples

Policy Development & Enforcement (Wedge 5 – Yellow)
Policy development places health issues on decision-
makers’ agendas, acquires a plan of resolution, and
determines needed resources. Policy development results
in laws, rules and regulations, ordinances, and policies.
Policy enforcement compels others to comply with the
laws, rules, regulations, ordinances, and policies created
in conjunction with policy development (p. 313).

n Participate on a county task force to revise county human services
guidelines for mandating reporting of suspected child abuse or
neglect (systems level).

n Talk to a church group about the need to support a bill for commu-
nity nutrition programs for children living in poverty (community
level).

Source: Definitions from MDH, Center for Public Health Nursing (2001)

EVIDENCE EXAMPLE 2.1
Public Health Intervention Wheel

n Over 600 school nurses (SNs), members of the National
Association of School Nurses (NASN), completed an
electronic survey on using public health interventions in
their practice as defined by the Public Health Intervention
Wheel. Most SNs (67%) were not familiar with the Wheel;
however, participants identified interventions that were
consistent with the Wheel. They used screening, referral
and follow-up, case management, and health teaching
more often than other interventions. In estimates of
time spent at specific practices levels, SN practice was
primarily at the individual level (65%). They also provided
community-level interventions 22% of their time and
systems-level interventions 14% of their time. SNs can use
the Wheel to document and explain the interventions they
provide in school nursing practice to address the health of
school populations (Schaffer, Anderson, & Rising, 2016).

n A qualitative study explored how school nurses (n = 43)
understood and used the interventions from Public Health
Intervention Wheel. Data were analyzed from six focus
groups conducted across the state of Minnesota. Ns rep-
resented urban, suburban, and rural schools. The SN prac-
tice stories included all interventions and levels of practice

except for case management and delegation at the com-
munity level. The highest number of practice examples
were for health teaching, case finding, and referral and
follow-up, all at the individual level. The practice stories
provide examples of how SNs can extend their practice to
community and systems levels and affirm school nursing
as a population-focused practice (Anderson et al., 2018).

n McDonald and colleagues (2015) replicated the process
of identifying and defining public health interventions
from the Wheel in the context of public health nursing
in Ireland. Public health nursing leaders in Ireland con-
ducted a literature review and hosted discussions on each
intervention wedge at the 2011 Institute of Community
Health Nursing conference. The aim was to promote
visibility of the PHN role and build a common language
to describe interventions. A key theme of practice stories
was the importance of building trusting relationships with
individuals and communities to support interventions.
The Population Health Interest Group (2013) pub-
lished practice stories from Irish nurses for each of the
17 interventions.

‘‘

’’

Jaime says, “I am going to a meeting with my PHN precep-
tor this afternoon about how the different county agencies
and the school district are working together as a team to try
to reduce smoking among high school students. I guess that
would be an example of collaboration, but I am not sure
which level of practice that would be.”

Abby ponders, “I think maybe when PHNs work with
agencies and school districts, they are practicing at the sys-
tems level. If they use an intervention like social market-
ing to let teens know about the availability of a smoking

cessation program at their school, then they would be prac-
ticing at the community level.”

Jaime responds, “Teens at risk for smoking are a vul-
nerable population within the community, and PHNs
work with populations within the community. If the team’s
goal is to change the smoking behaviors of individual high
school students, even if they were part of a group and PHNs
carried out some health teaching in the classroom, I guess
those actions would be at the individual/family level. This
gets kind of confusing at times.”

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32 PART I  n  Foundational Concepts for Public Health Nursing Practice

PHNs take a comprehensive approach to dealing with
public health problems in the community. They use mul-
tiple interventions to achieve primary, secondary, and ter-
tiary prevention goals and, when possible, work with other
members of the interdisciplinary team and members of the
community. Table 2.2 outlines how primary, secondary, and
tertiary interventions might be employed at all three levels
of practice to reduce tobacco use in teens. (See Chapter 1 for
a discussion of primary, secondary, and tertiary prevention.)

Evidence-Based Practice
Public health organizations are expected to use evidence-
based approaches in decision-making and in taking actions
based on population-based evidence (Lovelace et al., 2015).
This evidence-based public health approach means that
PHNs use the best information available to create new inter-
ventions (Barr-Walker, 2017). This evidence-based decision
process includes (Brownson, Fielding, & Maylahn, 2009,
p. 177):
n Using the best available scientific evidence
n Systematically using data and information systems

TABLE 2.2 Three Levels of PHN Practice and Three Levels of Prevention With Public Health
Interventions to Reduce Tobacco Use in Teens

Individual/Family Level of Practice

Primary Prevention Secondary Prevention Tertiary Prevention

Health Teaching
n Conduct classroom teaching on the

dangers of tobacco use and strategies
to avoid it.

Case Finding, Referral, and Follow-Up
n Assess the health behaviors, including

tobacco use, of individual students.
n Identify students at risk for tobacco

use and those already using tobacco.
n Refer students who smoke to the

school smoking prevention and
cessation team.

n Follow up with the school nurse.

Case Management and Collaboration
n The school nurse, physical education

teacher, and school psychologist team
up to work with teens using tobacco
and to monitor and implement a
smoking cessation program.

Community Level of Practice

Social Marketing and Outreach
n Staff a teen booth at the county fair

and hand out brochures on the hazards
of tobacco use and available tobacco
prevention and cessation programs.

Screening, Referral, and Follow-Up
n Hold health-behaviors screening,

including tobacco use, for teens and
young adults at the county fair.

Case Management and Social Marketing
n Create a social networking site to

empower teens and for teens to
provide peer support for smoking
cessation.

Systems Level of Practice

Health Teaching/Provider Education
n Develop and present a program to

teachers and school staff about the
hazards of tobacco use and available
smoking prevention and cessation
programs.

Screening, Referral, and Follow-Up
n Develop a health-behaviors screen-

ing, referral, and follow-up program
for middle school and high school
students.

Case Management and Collaboration
n Develop a case management protocol

for the school smoking prevention and
cessation interdisciplinary team.

n Applying program planning frameworks
n Engaging the community in assessment and

decision-making
n Conducting sound evaluation
n Disseminating findings

Public health nurses’ practice is expected to be evidence-
based. This evidence-based approach means that PHNs use
a problem-solving approach to find the best available sci-
entific evidence and the best available experiential evidence
and then integrate this evidence into their practice (Dang &
Dearholt, 2018, p. 4).

The search for credible evidence includes knowledge
gleaned from both research and nonresearch. The lev-
els of evidence at the core of the Johns Hopkins Nursing
Evidence-Based Practice Model (JHNEBP) include research
and nonresearch evidence. There are five levels of evidence
(see Table 2.3). You will find examples from all levels of evi-
dence in the remaining chapters of this book. Although the
levels of evidence are presented in a hierarchical manner in
Table 2.3, this table does not mean that lower levels of evi-
dence should be discounted or that randomized controlled
trials (RCTs) in experimental research should be considered
the only credible or most meaningful forms of evidence

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33CHAPTER 2  n  Evidence-Based Public Health Nursing Practice

TABLE 2.3 Best Practices in Public Health Nursing by Level of Evidence

Evidence Level Definition Examples

Level I:

Experimental study, randomized controlled
trials (RCTs)

Explanatory mixed methods design

The Nurse Family Partnership involving intensive structured home visiting by
PHNs reduces repeat childbirths, improves the stability of partner relation-
ships, facilitates children’s academic adjustment to elementary school, and
reduces childhood mortality from preventable causes (Kitzman et al., 2010;
Olds et al., 2004; Olds et al., 2007; Olds et al., 2010).

Level I:

Systematic reviews of RCTs, with or without
meta-analysis

Professional organizations publish systematic reviews of medical and nursing
research
n The Cochrane Database of Systematic Reviews, published online by the

Cochrane Collaboration.
n Worldviews on Evidence-Based Nursing, a peer-reviewed journal published

by Sigma Theta Tau International.
n The Joanna Briggs Institute provides an online listing of systematic reviews

and meta-analysis specific to nursing practice. Systematic reviews of non-
RCT research may be either Level II or Level III evidence.

Level II:

Quasi-experimental study

Explanatory mixed-method design

Systematic review of a combination of RCTs and
quasi-experimental studies or quasi-experimental
studies only

A prospective cohort study evaluated the impact of breastmilk expression in
early postpartum period on breastfeeding duration (Jiang et al., 2015).

Level III:

Nonexperimental study

Systematic reviews of combination of RCTs,
quasi- experimental, and nonexperimental
studies

A descriptive study identified four significant predictors of breastfeeding
attitudes: age, gender, number of breastfeeding observations in childhood, and
breastfeeding beliefs (Vari et al., 2013).

A systematic review using CINAHL (Cumulative Index to Nursing and Allied
Health Literature), PubMed, and Cochrane Library databases identified bar-
riers to breastfeeding in the WIC population to make recommendations for
guidelines for WIC clients (Hedberg, 2013).

Level IV:

Opinion of respected authorities and nationally
recognized expert committees or consensus
panels based on scientific evidence
n Clinical practice guidelines
n Consensus panels/position statements

ANA. (2013). Public Health Nursing: Scope and Standards of Practice (2nd ed.)

Quad Council of Public Health Nursing Organizations. (2011).
The Quad Council competencies for public health nurses

Centers for Disease Control and Prevention. (2017). Immunization Schedules

Level V:

Based on experiential and nonresearch evidence
n Integrative reviews
n Literature reviews
n Quality improvement, program, or financial

evaluation
n Case reports
n Opinion of nationally recognized expert(s)

based on experiential evidence

The Best Start program supporting area-based interventions to increase breast-
feeding was evaluated. Area-based interventions and community partnerships
were found to have a positive influence on breastfeeding rates (Kelaher, Dunt,
Feldman, Nolan, & Raban, 2009).

Source: Definitions of Levels of Evidence from Dang & Dearholt, 2018, Appendix D, pp. 278–279

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34 PART I  n  Foundational Concepts for Public Health Nursing Practice

‘‘
in public health. It is important to thoughtfully consider
and analyze information from all levels of evidence. For
example, the use of qualitative research, particularly when
studying culture and ethnicity, has led to significant under-
standing of how diverse populations and people view them-
selves and the world around them.

Experiential evidence that may be found in IV and V
evidence levels includes clinical expertise and client’s pref-
erences and values. PHNs know that evidence-based inter-
ventions found in the scientific literature need to fit the
demographics and cultural diversity of their clients at the
individual/family and community levels of practice in order
to be consistent with ethical holistic nursing practice (see
Figure 2.3).

These three interrelated elements occur within the con-
text of the community—where public health nurses are
expected to be lifelong learners who take the initiative to
engage with their community to explore the life experi-
ences, health status, and health determinants of diverse
populations. The information PHNs gather about the indi-
viduals/families and communities they serve leads them to

question how they can positively impact the health of these
individuals/families and communities.

Public health nurses use critical thinking in applying a
deliberative process for identifying and implementing best
practices in a timely manner. The Johns Hopkins Nursing
Evidence-Based Practice Model (JHNEBP) includes three
essential components: inquiry, practice, and learning (Dang
& Dearholt, 2018):
n Inquiry: To question, examine, and collect information

about an issue or problem (p. 36)
n Practice: Reflects on the translation of what nurses

know to what they do (p. 36)
n Learning: A change in the way nurses think and

behave

The movement from inquiry to learning is represented
by the JHNEBP PET Process (see Figure 2.4). This process
is a group effort within or across organizations. In public
health, the team could be formed from members of a spe-
cific organization or be an interprofessional team at the
community level with key stakeholders and community
members involved. The practice team identifies the practice
issue, defines and refines the practice question, searches for
and evaluates the evidence, and determines which evidence
can and should be translated into new or revised practices
in the workplace.

Abby wonders how PHNs know what to do when they work
with their clients. She says, “The PHNs keep talking about
evidence-based practice, but I am not sure exactly what
that is.”

Jaime responds, “Today, my PHN preceptor and I made
a home visit to an elderly woman who lives alone. We did
a fall risk assessment and a home safety check. I asked the
PHN how she selected which risk assessment and home
safety assessment tools to use. She told me that a committee
of PHNs reviewed journal articles to find research reports
on which assessment tools were effective for determining
fall risks in older adults. They also looked at which home
safety tools had been developed specifically for frail older
adults living at home. Then they piloted the home safety
assessment tools themselves and picked the tool that best fit
what their PHNs needed to know about the home environ-
ment and what the elderly adults preferred. I think this is
the way you do evidence-based practice, but I need to read
more about it.”

Abby comments, “One of the PHNs at my agency went
to a fall prevention workshop given by an occupational
therapist and a physical therapist at the local hospital.
They taught the workshop participants how to screen
older adults for fall risk and which types of interventions
would help reduce fall risks, such as using assistive devices,
installing good lighting, removing slippery rugs, and wear-
ing nonskid slippers. Do you think this information could

FIGURE 2.3 Best Practice Approach to Evidence-Based 
Practice in Public Health Nursing
Sources: Based on work by Keller & Strohschein, 2009; Melnyk &
Fineout-Overholt, 2014

Credible evidence

Client
preference
and values

Clinical
expertise

FIGURE 2.4 JHNEBP PET Process
Source: Used with permission: Dang & Dearholt, 2018, p. 4

Practice
Question

Evidence Translation

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35CHAPTER 2  n  Evidence-Based Public Health Nursing Practice

’’

be considered evidence-based? The two therapists said they
were reporting on what they had found worked best with
their patients.”

Jaime says, “I guess we could review the material on
evidence-based practice in our textbooks and then talk
more to our PHN preceptors.”

“Good idea,” says Abby. “Let’s do it. We can also do a
search using CINAHL to see if there are any studies that
support what the PHN learned at the workshop. Do you
think this information about effective interventions will be
easy to find? What is an effective intervention anyway?”

Effective interventions fit your client’s situation and pref-
erences and result in the desired outcomes. Using inter-
ventions that are known to be effective is important. PHNs
have carried out research to demonstrate the effectiveness

of many interventions provided to individuals, families,
and communities. However, it is not always easy to find sci-
entific literature on the effectiveness of PHN interventions
(Swider, Levin, & Reising, 2017). Although research for
evidence-based practice might be limited in public health
nursing, PHNs should refer to it whenever it exists (Keller &
Strohschein, 2009, from Brownson, Baker, Leet, & Gillespie,
2002). PHNs are accountable to their clients (individuals/
families, communities, and systems) and to the public to
determine the effectiveness of an intervention and to justify
the use of resources. Your own experiences as a nursing stu-
dent can also guide your choices of which interventions you
can carry out effectively. You can use the evidence-based
public health approach—making decisions on the best
information available and creating interventions based on
that evidence (Barr-Walker, 2017). Table 2.4 includes recent
studies that demonstrate effective public health nursing
interventions.

TABLE 2.4 Effectiveness of Selected Public Health Nursing Interventions

Individual/Family Level

Intervention Results

Case management Decreased difficulty and dependence for meal preparation, telephone use, shopping, and ordinary house-
work (Instrumental Activities of Daily Living) were found for elders receiving home visiting in compari-
son with usual care (Li, Liebel, & Friedman, 2013). [Level I]

Case finding
Case management
Health teaching
Consultation
counseling

Significantly higher scores on overall healthy eating and healthy eating subdimensions (i.e., food selection,
preparation, and consumption) were found in elders 60 years and over in comparison to control group
(Meethien, Pothiban, Ostwald, Sucamvang, & Panuthai, 2011). [Level I]

Counseling Socially withdrawn students showed an increase in self-efficacy after participation in group-based coun-
seling interventions led by school nurses (Kvarme et al., 2010). [Level II]

Counseling
Health teaching
Referral and follow-up

Low-income, first-time mothers who participated in the Nurse–Family Partnership (NFP) home visiting
program had more beneficial breastfeeding and immunization outcomes compared to similar clients not
in the program (Thorland, Currie, Wiegand, Walsh, & Mader, 2017). [Level III]

Community Level

Surveillance In response to an online survey of PHNs in 29 states, PHNs reported they conducted ongoing surveillance
for tuberculosis, vaccine-preventable diseases, sexually transmitted diseases, pediculosis, foodborne dis-
eases, and elevated blood lead levels in their communities (Schaffer, Keller, & Reckinger, 2015). [Level III]

Coalition building School nurses participated in an interfaith coalition to respond to youth suicide in the community
(Anderson et al., 2017). [Level III]

Systems Level

Consultation
Screening

A maternal and child health nurse screening program for mothers experiencing domestic violence
(nurse-designed model) increased safety planning among postpartum women (Taft et al., 2015). [Level I]

Collaboration
Outreach

School nurses collaborated with a hospital and a school of nursing to develop and implement an
injury-prevention curriculum for helmet safety in elementary schools. Students from the intervention
group reported increased helmet use after intervention in comparison with the control group (Adams,
Drake, Dang, & Le-Hinds, 2014). [Level II]

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36 PART I  n  Foundational Concepts for Public Health Nursing Practice

‘‘
’’

Evidence-based practice (EBP)—and nursing interven-
tions—should be both effective and efficient. PHNs use the
evidence-based public health approach and consider all
evidence-based information, including the experiences of
experts. Because resources are limited in both healthcare
and public health, PHNs also need to consider the efficiency
of interventions. Efficient interventions require the least
amount of resources and achieve the desired outcomes in
the shortest period of time.

Evidence-based practice supports efficacy (the ability
to reach a desired result); efficiency (the achievement of a
desired result with minimum expense, time, and effort); and
effectiveness (the ability to produce a desired result). Addi-
tionally, EBP weighs risks, benefits, and costs against a back-
drop of patient preferences (Dang & Dearholt, 2018, p. 4).

Jaime voices his concern that if he knew from the literature
that an intervention was known to achieve a desired out-
come, he might use it even if he did not know if it would
be effective. “How do I know if it is going to work with a
specific client?”

Abby responds, “Well you can ask your preceptor what
type of interventions have worked in the past with your
client. You could also ask the client if he wants to try it.”

Before using an intervention, look at the literature or
consult with expert PHNs to identify specific interventions
that can best meet your clients’ unique needs and charac-
teristics. You also want to consider if the intervention is a
good use of your time and resources and the client’s time
and energy. Questions you can ask to determine effective-
ness and efficiency are listed in Table 2.5.

healthypeople.gov

Healthy 
People

   Healthy People 2020 identified 11 Leading  
  Health Indicators (LHIs) as priority health  
  concerns, including Nutrition, Physical 
Activity, and Obesity. Go to the Healthy People 2020 website, 
click “Leading Health Indicators,” and then click “Nutrition, 
Physical Activity, and Obesity.” Read about the most recent 
data and population disparities on nutrition, physical activity, 
and obesity. Look for the links to the science-based Dietary
Guidelines for Americans and the Physical Activity Guidelines. 
What evidence do you find that supports a healthy eating and 
physical activity program for you and your family? 

Just because “best practice” evidence is available does not
mean that it will be adopted and used. To create a supportive
evidence-based practice environment, three strategies are
necessary: establishing the EBP culture, building the capac-
ity for EBP, and ensuring sustainability (Dang & Dearholt,
2018, p. 19). A strategic plan and committed leadership are
necessary to develop the organizational resources and sup-
port for a sustainable evidence-based practice culture. Staff

TABLE 2.5 Analyzing Effectiveness and
Efficiency of Interventions

Determining
Intervention
Effectiveness

Determining
Intervention
Efficiency

n Is the intervention
culturally and develop-
mentally congruent with
the client’s status and
situation?

n Is the intervention
acceptable to the client?

n Does the outcome of the
intervention demonstrate
improvement of the
client’s health status?

n What are the costs of the
intervention (money, time,
people involved, and other
resources) for the PHN,
the other members of the
health team, the agencies
involved, and the client?

n Are the costs of imple-
menting the intervention
justified by the health
benefits for the client and
the community?

needs include continuing education on evidence-based
practice as well as initiatives to be implemented. Resources
such as Internet access to useful databases and journals,
evidence-based organizational mentors, and reimbursable
time facilitate integration of evidence into practice.

This chapter presents an overview of evidence-based prac-
tice relevant to public health nursing practice. The term best
practices is often used synonymously with evidence-based
practice. A few points are helpful to keep in mind as you
think about and use evidence of “best practices” in your
community health clinical:
n Experimental research using RCTs is considered uneth-

ical when placing an individual in a control group that
denies that individual treatment or interventions are
already demonstrated to be effective.

n Public health/community health nursing agencies may
be carrying out quasi- and nonexperimental research to
determine the effectiveness of their programs and inter-
ventions. These activities may be a component of their
ongoing quality improvement programs. Sometimes
students participate in these research studies. If you are
asked to participate, ask to see any informed consent or
ethical guidelines that your agency is using.

n The policies and procedures of your public health/
community agency and the professional practice stan-
dards guiding PHN practice may be considered clinical
guidelines. Progress reports and annual agency reports
may be considered organizational experiences.

n The knowledge and experiences of your preceptor and
other PHN agency staff will be reflected in the practice
you observe and the mentoring you receive. These repre-
sent expert opinions and clinical expertise.

n Clinical experiences may include both participant
and nonparticipant observation. When you reflect on
your observations of your preceptor or other public

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37CHAPTER 2  n  Evidence-Based Public Health Nursing Practice

health/community health nurses interacting with clients
by using PHN interventions, you are demonstrating
nonparticipant observation. When you use these inter-
ventions yourself and reflect on your practice, you are
demonstrating participant observation. Both types of
experiences add to your clinical expertise.

n Community assessments that are carried out in collabo-
ration with community members and client satisfaction
surveys provide evidence of consumer preferences. See
Chapter 3, Competency #1, for information on commu-
nity assessments.

Database and Internet Searches
The sources of evidence must be as credible as the evidence
itself. That is why PHNs search scientific databases. The
online databases that provide the most relevant journal
articles for nursing are CINAHL and PubMed. CINAHL is
a proprietary database hosted by EBSCO, which means it
is privately owned and available to members of subscribing
institutions who pay a fee for remote access. PubMed is an
open-source database that is free to the public. Other cred-
ible sources include websites maintained by professional
organizations and service providers and governmental web-
sites, such as those run by the National Institutes of Health
(NIH), the U.S. Surgeon General, and the Centers for Disease

Control and Prevention (CDC). The Cochrane Library is an
international database of systematic reviews owned by the
Cochrane Collaboration and is an open-source database
that is free to use. The CDC Stacks, an excellent source for
public health information, is a free digital repository of pub-
lications produced by the CDC.

The NIH provides guidelines for evaluating web-based
health resources that can help you determine whether the
website resource you have found is credible. One example
of a credible website is a government program that reviews
maternal-child health home visiting program effectiveness,
called Home Visiting Evidence of Effectiveness (HOMVEE).
This website includes discussion of models and programs,
whether they meet Department of Health and Human Ser-
vices (DHHS) criteria, their target populations, and whether
research shows positive effectiveness (U.S. Department of
Health and Human Services, n.d.).

The goal of evidence-based practice is not to generate new
knowledge, but to improve practice. Baccalaureate nursing
graduates are expected to be able to find and use best prac-
tice evidence to improve their nursing practice. Hopp & Rit-
tenmeyer (2012, p. 84) identify a five-step process known as
the “5 A’s.” This process works well for students and PHNs
alike and can be used when students partner with public
health nurses during their clinical learning activities in
public health. Table 2.6 outlines a process for public health
nursing students to carry out the “5 A’s.”

TABLE 2.6 Using the 5 A’s for Evidence-Based Practice in Student Clinical Learning Activities

The 5 A’s Students Using the 5 A’s with Community Partners

Ask: To find the right answer, you
need to ask the right question.

n Work with PHNs or other community partners to identify a public health practice issue
about a specific health concern with a specific population and a related knowledge gap
about current best practices.

n Work with PHNs or other community partners to create a specific practice question.
n Identify reasonable client outcomes that you wish to achieve with modified or new best

practice evidence.

Acquire: Search for the answer by
exploring all levels of evidence.

n Work with reference librarian, instructor, and community partners to identify credible
data sources for all five levels of evidence.

n Identify appropriate databases to search and keywords for search.
n Work with instructor and community partners to identify evidence from nonscientific

literature (e.g., credible websites, professional organizations, agency reports, etc.).
n Conduct key informant interviews.
n Conduct search, preferably for the past 5 years (or 10 years if there is little published

information for the past 5 years).

Appraise: Critically evaluate
the evidence and select the “best
practice evidence.”

n Work with fellow students, instructors, and interprofessional teams to critically review
the evidence and determine what evidence answers your practice question and is applica-
ble to the client population.

n Work with community partners to consult practice experts to determine which interven-
tions fit what the experts know about the population and health concern.

n Work with key community stakeholders to determine population preferences and values.

(continues)

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38 PART I  n  Foundational Concepts for Public Health Nursing Practice

Evidence of Best Practices
PHNs need to be critical consumers of public health and
nursing research. They must use a deliberative problem-
solving approach when making decisions about which
evidence in the literature is strong enough to support a
change in practice (Poe & White, 2010). However, public
health providers often do not have adequate knowledge
about evidence-based practice or the tools and resources
to research current evidence-based best practices (Barr-
Walker, 2017). In addition, published evidence in scientific
journals is limited, and many of the sources used are from
health-related statistics, government reports, and organiza-
tional or professional guidelines.

Much of the evidence for effective public health nursing
comes from Evidence-Based Practice Levels III, IV, and V. It
is often not ethical, possible, or practical to randomly place
people in an experimental or a control group, especially if
placement in either group could have a negative effect on
an individual’s health or well-being. An increasing body of
qualitative research in public health nursing exists. Under-
standing the context of the family, culture, and commu-
nity; the meaning of events; and the impact of these factors
on the clients’ health behaviors and health status is often
best achieved through the use of qualitative research meth-
ods. Public health nurses also learn a great deal from their
practice experiences and those of their colleagues. This
evidence-based information or practice-based knowledge
helps public health nurses translate evidence into practice
in specific clinical care settings (Barr-Walker, 2017). Case
study examples can be found in the literature, shared at
professional conferences, or reported on the Internet. These
anecdotal reports are also part of the practice evidence of
public health nursing.

Framing Your Evidence-Based Practice  
With the “5 A’s”
One of the most difficult skills is knowing how to initiate
the evidence-based practice process in a clinical setting. It is
time to return to the “5 A’s” discussed earlier in the chapter

(Hopp & Rittenmeyer, 2012): ask, acquire, appraise, apply,
and assess.

Ask
When you explore the scientific literature for best practice
evidence, it is helpful to first identify your clinical ques-
tion so that you are focused in your search. One helpful
way to frame your clinical practice question is to use the
PICOT approach by identifying the patient population (P),
the intervention of interest (I), the comparison interven-
tion (C), the outcome (O), and the timeframe (T) (Stillwell,
Fineout-Overholt, Melnyk, & Williamson, 2010). For exam-
ple, if you wanted to research the effectiveness of teaching
parents about the “Back to Sleep” program to reduce the risk
of Sudden Infant Death Syndrome (SIDS), you might frame
your PICOT question as outlined in Table 2.7.

The “T” in PICOT may not be necessary to include when
reviewing the literature, but it may be helpful to include the
time element when you plan how and when you are going to
evaluate the outcome of the intervention you have selected
to implement in your clinical setting. Once you find a set of
articles that report on the effectiveness of the intervention
you are interested in, it is time to review them to determine
their usefulness.

Acquire
After writing your PICOT question, you can identify the
keywords in the sentence. A helpful way to identify key-
words is to create a PCO Table (Population, Content, Out-
comes). Table 2.8 demonstrates that using a PCO Table helps
you to identify six keywords or phrases. If you have access
to a reference librarian, you can take your keywords to the
librarian who can then help you create your online literature
strategy and identify the databases to search (Butler, Hall, &
Copnell, 2016). Complete your search using your keywords.

Appraise
The next step is to compare and contrast the studies and
reports you have appraised. Select the best studies or reports
with the most credible evidence that fits your clinical

The 5 A’s Students Using the 5 A’s with Community Partners

Apply: Make the evidence action-
able by using the evidence to
change your practice.

n Report credible evidence from all five levels to community partners.
n Make recommendations for change in practice or new interventions.
n Collaborate with community partners on modifications of current interventions or

development of new interventions.
n Partner with your PHN preceptor to implement the intervention if possible.

Assess: Evaluate the outcomes
of the change in practice in your
clinical setting.

n Identify how and when the client outcomes will be evaluated and determine the
effectiveness and efficiency of the modified or new intervention.

TABLE 2.6 Using the 5 A’s for Evidence-Based Practice in Student Clinical Learning Activities (continued)

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39CHAPTER 2  n  Evidence-Based Public Health Nursing Practice

‘‘

’’
situation and addresses your specific question. Think about
how you would present your findings and recommendations
to the PHNs and team you are working with.

Apply
Once you have completed the first three steps and have iden-
tified a best practice intervention, begin working with your
clinical team to translate or apply the evidence into clinical
practice. Before you implement a change in your practice or
your clinical team’s practice, you need to think about how
you will evaluate the effectiveness of the change. Identify
the outcome you would like to achieve.

Assess
The timeframe for assessment of client outcomes after imple-
menting the new intervention will depend on the urgency to

determine efficacy of an intervention as well as a realistic
expectation as to when effectiveness can be evaluated. For
example, if you implemented a community-wide campaign
to increase the flu vaccine in September to decrease the inci-
dence of influenza in the fall, you would probably compare
the incidence of influenza this fall to last fall in December. If
you were evaluating the effectiveness of the “Back to Sleep”
program, you might choose a 6-month timeframe to evalu-
ate the outcome of the program.

It would be important to evaluate both the effectiveness
and the efficiency of the intervention from a cost-benefit
perspective, which would be based on the quality of life as
well as the financial and human resource costs involved.
This is not always easy to do. For example, if the “Back to
Sleep” program reduced the incidence of crib death by one
infant in a 3-month period, would any of your community
partners consider the program effective and efficient?

Jaime comments, “I think I am going to do my intervention
paper on ways to reduce smoking in high school students.
I have to start looking for evidence-based practice articles.
I wonder how I should go about that.”

Abby says, “I have been working with the college refer-
ence librarian to research my topic. She suggested that I
use three databases: CINAHL, PubMed, and the Cochrane
Database of Systematic Reviews. I have found a few good
articles in each database.”

Jaime responds, “Great! I will try those databases, too! I
know that both PubMed and the Cochrane Database are in
the public domain and free to users. CINAHL is privately
owned, and organizations have to pay for employees to
use it. I don’t think my hospital has a contract to access
CINAHL.”

Abby concludes, “Don’t forget to write your PICOT
question first!”

Translating Evidence Into Practice
One of the most difficult skills is knowing how to initiate
the evidence-based practice process in a clinical setting
and to translate best practice evidence into practice, which
means that you use the best practice evidence to evaluate
and update how you practice nursing. PHNs need to make
sure that their recommendations for change in practice are
based on the best evidence and are appropriate and feasible
for their client populations, their agencies, and their com-
munities. Support and funding for PHN practice depends
on documentation and dissemination of evidence that PHN
practice makes a positive difference in the health of its com-
munities. Evidence Example 2.2 shows step-by-step how to
use an evidence-based practice approach to find best prac-
tice evidence.

TABLE 2.7 The PICOT Approach to
Clinical Problem Solving

PICOT Question
Elements Examples

P = Patient population

I = Intervention of interest

C = Comparison interven-
tion of interest

O = Outcome(s) of interest

T = Time it takes the inter-
vention to achieve outcomes

P = Infants at risk for SIDS

I = Teach parents to place
infants on backs to sleep
using “Back to Sleep”
program

C = No purposeful teaching
about safe sleeping position
of infants

O = Percentage of babies
sleeping on back

T = Evaluate at 6 weeks and
3 months

PICOT Question: Will infants (P) whose parents are taught
to place them on their backs to sleep using a “Back to
Sleep” program (I) as opposed to no purposeful teaching
about safe sleeping positions for infants (C) be sleeping on
their backs (O) at 6 weeks and 3 months after receiving the
intervention (T)?

TABLE 2.8 Finding Keywords Using PCO

PCO Elements Examples

P = Patient Population P = Infants at risk for SIDS,
parents, caretakers

C = Context C = Teaching safe sleeping positions

O = Outcome O = Sleeping on back

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40 PART I  n  Foundational Concepts for Public Health Nursing Practice

EVIDENCE EXAMPLE 2.2
Searching for Best Practice Evidence on Optimal Breastfeeding Initiation  
and Translating the Evidence Into Practice

Breastfeeding is initiated in the setting where delivery occurs.
Often that is the hospital. Many new mothers are sent home
from the hospital within 24 hours of delivery. So, it is import-
ant for PHNs to know the best practice evidence to share with
their antepartum clients about what breastfeeding approaches
work best and then to support those practices during the
postpartum period. Public health nurses need to work with
their nursing partners in the hospital setting to prepare their
clients for breastfeeding, advocate for the preferences of the
new mothers with their acute care colleagues, and provide for
a seamless transition in the breastfeeding routine when the
mother returns home through coordination and case manage-
ment interventions. In this example, nurses in a birthing center
searched for best practice evidence for initiation of breast-
feeding immediately after birth. The following example shows
how the “5 A’s” and the PICOT process were used to identify
best practice evidence and translate it into practice. The ques-
tion was whether it was best practice to use a breast pump to
support breastfeeding in the first 72 hours postpartum.

Ask
A PICO(T) question was developed to frame the question to
guide the literature search:

P = Efficacy of use of breast pump in early postpar-
tum period to promote exclusive breastfeeding with
mother’s milk

I = Electric breast pump after breastfeeding during first
24–48 hours

C = Breastfeeding on-demand during first 24–48 hours

O = Baby fed exclusively with mother’s own breastmilk

T = 6 weeks postpartum

The question: Does use of an electric breast pump after
breastfeeding versus breastfeeding on-demand during the
first 24–48 hours postpartum increase the likelihood a baby
will be exclusively fed with a mother’s own breastmilk at
6 weeks postpartum?

Acquire
Ovid Medline, CINAHL, PubMed, and Google Scholar were
searched using a variety of search terms. Although 23 articles
were found, only 3 of these articles addressed the PICOT ques-
tion and the actual practice question.

Appraise
The literature reviewed suggested that while it remains unclear
if pumping has any immediate impact on breastfeeding initia-
tion and milk supply, using a breast pump in the first days and
weeks postpartum is associated with a shorter breastfeeding

duration (Chapman, Young, Ferris, & Perez-Escamilla, 2001;
Felice, Cassano, & Rasmussen, 2016; Jiang et al., 2015).
Other important evidence was identified:

Anticipating return to work and suboptimal long-term lac-
tation support systems increased women’s dependence on
expressing breastmilk with a pump (Chapman et al., 2001;
Felice et al., 2016; Jiang et al., 2015).

Hand expression is more effective at expressing colos-
trum (first days’ breastmilk supply) than an electric pump
( Flaherman et al., 2013).

Developing the nurse-family relationship fosters an
empowering environment where the family can experience
growth and develop the skills needed to achieve successful
infant feeding patterns, including direct breastfeeding and
expressing breastmilk (Raile Alligood, 2010).

After reviewing the scientific evidence, the nursing team at
the birthing center considered the other two evidence com-
ponents: the practice and procedures of the birthing center
and the preferences of the new mothers. The context of the
relationship between the mother and the nursing staff was
considered. The nurses’ caring interaction was considered as
necessary as the evidence-based knowledge to facilitate suc-
cessful breastfeeding initiation.

Apply
Supporting Breastfeeding Guidelines were developed and
implemented based on the evidence. The nurse in the birthing
center who initiated the quality improvement process changed
jobs and became a clinical coordinator in a public health nurs-
ing agency. She was able to share the best practice evidence
about the initiation of breastfeeding with the public health
nursing staff.

Assess
At the birthing center, the new guideline was instituted and
evaluated at both the systems and the individual/family
practice levels. Nursing staff completed a nursing practice
survey before and after implementation of the new guide-
lines. The purpose was to measure the accuracy with which
nurses were able to determine the appropriate interventions
needed to support lactation (when and when not to use an
electric pump) and their confidence levels of decision-making
regarding when to utilize the breast pump to support lactation.
The individual-level change was measured through a patient
survey completed at discharge. The survey measured the
breastfeeding mothers’ confidence levels of continuing their
breastfeeding plan of care when returning home and their per-
ception of nursing support received for their individual infant
feeding goals.

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41CHAPTER 2  n  Evidence-Based Public Health Nursing Practice

‘‘

’’

Jamie is continuing to work on his evidence-based practice
search on how to reduce smoking in high school students.

Abby changed her topic. With her PHN preceptor, she
has been co-visiting a first-time mom who has postpartum
depression. The PHN is visiting the mom twice weekly, and
the PHN has asked Abby to research best practices in work-
ing with moms with postpartum depression. Abby is going
to develop her PICOT question, create her PCO Table, and
then consult with her instructor and the reference librarian
on how to go about searching for the best practice evidence.
She is excited to be able to partner with her PHN preceptor
to find the most up-to-date best practice evidence to present
to the Family Health Team.

If you follow through on the steps outlined in this chapter
for researching best practices and taking steps to translate
this evidence into your nursing practice, you will be prac-
ticing nursing from an evidence-based practice framework.
As a professional, you are accountable for your own nursing
practice, so you need to be aware of and use best practices.
You will find that this book presents many levels of evidence
to justify using specific interventions.

ACTIVITY
Imagine that you are the nurse who changed jobs from the  
birthing center to the public health agency.

n How would you use this best practice breastfeeding  
initiation evidence?

n What would you want to know about the public health  
nurses and their antepartum and postpartum clients?

n How would you develop your PICOT question? 

n How might you partner with the staff to carry out the  
“5 A’s” process? 

The evidence-based practice approach does not always
entail a simple, concise process. However, through the use
of various levels of evidence, clinical expertise, local con-
text, and client preference, best practice interventions can
be developed and implemented to promote and protect the
health of individuals, systems, and populations.

n All five levels of evidence are used to identify best
practices.

n Evidence-based practice is a deliberative process start-
ing with a practice question, followed by an appraisal
of the evidence, and then a change in practice based on
credible evidence.

n Using the “5 A’s” and PICOT provides a structure for
practicing from an evidence-based foundation.

KEY POINTS

n The public health nursing process guides the PHN’s
actions.

n PHNs work at all three levels of practice (individual/
family, community, and systems).

n PHNs carry out 17 interventions unique to public health
nursing; 16 of these interventions are practiced inde-
pendently as part of professional nursing practice.

n Public health nursing practice is evidence-based.

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42 PART I  n  Foundational Concepts for Public Health Nursing Practice

REFLECTIVE PRACTICE

 1.  What do you think are the major differences between
the nursing process and the public health nursing
process?

l What will you do differently when following the
public health nursing process?

l How will your knowledge about the determinants of
health guide you in your assessments and interven-
tions at the three levels of practice: individual/family,
community, and systems?

 2.  Which other disciplines will you work with most often
in your public health clinical?

l What additional information do you need to know
about the other health disciplines?

l How will you find out the information that you need?
 3.  Which public health nursing interventions have you

used in previous clinical experiences?
l How will you carry out these interventions in your

public health clinical?
l How will this experience be the same or different

from what you have done before?

 4.  Have you used an evidence-based practice approach in
other nursing clinical experiences?

l What have you learned in reading this chapter that
you did not know before?

l How will your past experiences and your new knowl-
edge help you practice evidence-based public health
nursing?

 5.  Which types of best practice evidence related to a PHN
intervention would you like to explore?

l What is your PICOT question?
l How do you frame this as a PICOT statement?
 6.  Refer to the Cornerstones of Public Health Nursing in

Chapter 1. Which of the Cornerstones support the use
of evidence-based practice in public health nursing?

APPLICATION OF EVIDENCE

How would you work with your PHN preceptor to identify
an intervention that the staff would like to have researched
to identify any new best practice recommendations?

When you search for best practice evidence, how would
you implement the following steps?
n Determine which databases to use in your search.
n Carry out your literature search. Obtain help from the

reference librarian if you are having difficulty with your
keyword search.

n Select three to five journal articles to review. You may
use articles that represent different levels of evidence.

How would you carry out the following steps to analyze the
evidence?
n Compare and contrast the articles you have appraised.

Are their findings and recommendations similar or
different?

n Identify the articles that have the most credible evidence
that best fits your clinical situation.

n What format would you use to report your
evidence-based finding to the PHN staff?

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PART II
Entry-Level Population-Based

Public Health Nursing
Competencies

3 COMPETENCY 1: Applies the Public Health Nursing Process to Communities, Systems,
Individuals, and Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

4 COMPETENCY 2: Utilizes Basic Epidemiological (The Incidence, Distribution, and
Control of Disease in a Population) Principles in Public Health Nursing Practice . . . . . . . . . . . . . . . 75

5 COMPETENCY 3: Utilizes the Principles and Science of Environmental Health to Promote
Safe and Sustainable Environments for Individuals/Families, Systems, and Communities . . . . . . . 95

6 COMPETENCY 4: Practices Within the Auspices of the Nurse Practice Act . . . . . . . . . . . . . . . . . . . . 127
7 COMPETENCY 5: Works Within the Responsibility and Authority of the Governmental

Public Health System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
8 COMPETENCY 6: Utilizes Collaboration to Achieve Public Health Goals . . . . . . . . . . . . . . . . . . . . . 167
9 COMPETENCY 7: Effectively Communicates With Communities, Systems, Individuals,

Families, and Colleagues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
10 COMPETENCY 8: Establishes and Maintains Caring Relationships With Communities,

Systems, Individuals, and Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
11 COMPETENCY 9: Incorporates Mental, Physical, Emotional, Social, and Spiritual Aspects

of Health Into Assessment, Planning, Implementation, and Evaluation . . . . . . . . . . . . . . . . . . . . . . . 221
12 COMPETENCY 10: Demonstrates Nonjudgmental/ Unconditional Acceptance of People

Different From Self . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
13 COMPETENCY 11: Shows Evidence of Commitment to Social Justice, the Greater Good,

and the Public Health Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251
14 COMPETENCY 12: Demonstrates Leadership in Public Health Nursing With Communities,

Systems, Individuals, and Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279
15 Putting It All Together: What It Means to Be a Public Health Nurse . . . . . . . . . . . . . . . . . . . . . . . . . . 301

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AN: 1917387 ; Patricia M. Schoon, Carolyn M. Porta, Marjorie A. Schaffer.; Population-Based Public Health Clinical Manual, Third Edition: The Henry Street Model
for Nurses
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47

‘‘

’’

CHAPTER

3
COMPETENCY #1
Applies the Public Health Nursing
Process to Communities, Systems,
Individuals, and Families

n Patricia M. Schoon
with Karen S. Martin, Kelly Krumwiede, and Noreen Kleinfehn-Wald

Kristi is listening to Beth, her public health nurse (PHN) preceptor, tell her about the client they are about
to visit for the first time. The local public health agency received a maternal child health visit referral
from a local OB/GYN for a 16-year-old, 20-weeks-gestation primipara. The client, Sara, has been diag-
nosed with anemia and is underweight with poor weight gain. Sara is single and living with her mother,
mother’s boyfriend, and two younger siblings. Sara and her family are uncomfortable with the idea of a
public health nurse who works for the government visiting them in their home.

Beth says, “Well, I think the first thing we do is go and visit them. We need to get them to trust us if we
are to help them.”

Kristi responds, “I have never visited a pregnant teenager or her family in their home. I don’t think I
will feel comfortable. Will the family be okay with me there?”

Beth responds, “I asked Sara’s mother if you could covisit with me and she was okay with that. We
will ask Sara and her mother what their health concerns and goals are and talk with them about how to
arrange our visits and what we can do to help Sara. We will open a case file on Sara and begin to do a
family assessment. You can observe and listen on this visit and take a more active part in future visits.”

Kristi says, “That sounds good to me!”
As they walk to Beth’s car she mentions, “We can start to do a windshield survey on our way to Sara’s

home as part of the community assessment that you and your student work group are going to do of the
local community.”

Kristi responds, “Great. I just happen to have my camera with me.”

KRISTI’S NOTEBOOK
COMPETENCY #1 Applies the Public Health Nursing Process to Communities, Systems, Individuals, and Families

(continues)

A. Identifies the population(s) for which the PHN is accountable

B. Assesses the health status of communities, systems, individuals, and families

1) Uses a health and social determinants framework to determine risk factors and protective factors that
lead to health and illness in communities, systems, individuals, and families

2) Identifies relevant and appropriate data and information sources for the populations to which the PHN is
accountable

a. Familiar with data used in the health department

b. Familiar with data in the programs in which the PHN works

3) Works in partnership with communities, systems, individuals, or families to attach meaning to collected
quantitative and qualitative data

4) Works in partnership with communities, systems, individuals, and families to establish priorities

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48 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

KRISTI’S NOTEBOOK
COMPETENCY #1 (continued)

C. Creates public health strength, risk and asset-based diagnoses for communities, systems, individuals,
and families

D. In partnership with communities, systems, individuals, and families, develops a plan based on priorities
(including nursing care plans for individuals/families)

1) Selects desired outcomes that are measurable, meaningful, and manageable

2) Selects public health interventions that

a. Are supported by current literature as evidence-based

b. Reduce health determinant risk factors and strengthen health determinant protective factors

c. Have the greatest potential for improving the health of the population

d. Respect and are consistent with the culture and ethnic beliefs of the community

e. Are consistent with professional standards, the Nurse Practice Act, existing laws, ordinances, and
policies

3) Selects level(s) of intervention (community, systems, individuals, and families)

4) Selects level(s) of prevention (primary, secondary, tertiary)

E. Implements the plan with communities, systems, individuals, and families

1) Works in partnership with communities, systems, individuals, and families to implement public health
interventions

2) Utilizes best practices when implementing the public health nursing intervention

F. Evaluates

1) Measures outcomes of public health nursing interventions using evidence-based methods and tools

2) Documents public health nursing process by completing forms, records, and charts for communities,
systems, individuals, and families

3) Uses information technology to collect, document, analyze, store, and retrieve the health status of
communities, systems, individuals, and families

Source: Henry Street Consortium, 2017

USEFUL DEFINITIONS

Community: Refers to (a) a group of people or population group; (b) a physical place and time in which the
population lives and works; or (c) a cultural group that has shared beliefs, values, institutions, and social systems
(Skemp, Dreher, & Asselin, 2006, p. 23).

Community Assessment: The process of systematically collecting information about a community’s structure,
processes, and dynamics, its physical and social environment, its populations, and its level of health and wellness
to determine its strengths, its resources, its populations of interest and populations at risk, its health needs, and
its health priorities.

Electronic Health Records (EHRs): “Longitudinal collection of clinical and demographic client-specific data that
are stored in a computer-readable format” (Martin, 2005, p. 461).

Family: A family is defined as a social unit of two or more people who identify themselves as a family, share
emotional bonds, and carry out the functions of a family including managing healthcare (Clark, 2008; Friedman,
Bowden, & Jones, 2003; Martin, 2005), and family is “a group of individuals who are bound by strong emotional
ties, a sense of belonging, and a passion for being involved in one another’s lives” (Wright & Bell, 2009, p. 46).

Family Assessment: The process of systematically collecting information about clients’ family structure, pro-
cesses, and dynamics; their physical and social environments; and their levels of health and illness to determine
their strengths, resources, health needs, and health priorities.

Health Status Indicators: Measures of the level of health or illness of an individual/family, community, or popu-
lation, such as incidence or prevalence of disease, birth and death rates, level of independence, life satisfaction,
and quality of life.

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49CHAPTER 3  n  Competency #1

of the students, a recent immigrant, said she thought these
families were fairly well off—they had housing, food, and
were safe in their homes . The country she had emigrated
from was in turmoil . She had seen family members mur-
dered, their cattle slaughtered, homes burned, and people
without food or clothing . These people, she thought, had
truly stressful lives . The other students reflected on her com-
ments and came to realize that people view the world from
their own experiences . Understanding and appreciating the
lived experiences of people is important . Knowing about
and understanding each other helps promote the oppor-
tunity for people to work together in a mutually respectful
manner that can build on each other’s strengths .

PHNs work in partnership with individuals, families,
and communities . Partnerships are mutual relationships
based on trust . PHNs establish trust with individuals, fam-
ilies, and communities by respecting their rights to make
their own health decisions and by adapting the nursing
practice to fit the lived experiences and daily lives of those
individuals, families, and communities . PHNs direct their
efforts to meet the priority health needs their clients iden-
tify . Public health nursing practice includes the “3 E’s”:

n Egalitarian (equal) relationships with individuals,
families, and communities

n Enhancement of individual, family, and community
strengths, resilience, and resources

n Empowerment of individuals, families, and com-
munities to advocate for and manage their own
healthcare needs

Thinking and Doing Population Health—
Nursing Process Leads the Way
PHNs work with individuals and families wherever they
find them in the community and in whatever condition
they find them . The priority for public health nursing is
health promotion and disease prevention, but PHNs also
work with individuals and families who have chronic health
conditions to help them achieve their health potential and,
whenever possible, manage their own lives and healthcare
needs . They need to discover their clients’ potential for self-
care and wellness to help them reach that potential . PHNs
use a strengths-based approach when using the public health
nursing process . Because their clients live in the commu-
nity, PHNs need to find out as much as they can about the
community’s support systems, resources, and resource gaps .

Partnering With Individuals,
Families, and Communities
PHNs need to understand the story, the context of the lives
of the people in the community in which they work . PHNs
must know and understand the history, culture, and life-
style of individuals, families, populations, and the entire
community . For example, in a post-clinical seminar, stu-
dents were discussing the stresses and crises of the families
they were visiting . They stated that they did not understand
how these families could function with so much stress . One

Omaha System: “Research-based approach to practice, documentation, and information management that
incorporates the Problem Classification Scheme, Intervention Scheme, and Problem Rating Scale for Outcomes”
(Martin, 2005, p. 463).

Population: The “total number of people living in a specific geographic area”; subpopulations (syn. groups or
aggregates) “consisting of people experiencing a specific health condition, engaging in behaviors that have
potential to negatively affect health, sharing a common risk factor or risk exposure, or experiencing an emerging
health threat or risk” (American Nurses Association [ANA], 2013, p. 3).

Priority Setting: Organizing health concerns by hazard level so that health risks that place individuals/families,
communities, or populations at greater risk are dealt with first.

Public Health Informatics: Public health informatics is the systematic application of information, computer
science, and technology to public health practice, research, and learning (Centers for Disease Control and
Prevention [CDC], n.d.-b).

Public Health Nursing Process: Integrates concepts of public health, community, and all three levels of PHN
practice (i.e., individual/family, community, system) into the nursing process (i.e., assessment, diagnosis,
planning, implementation, and evaluation) (Minnesota Department of Health [MDH], Center for Public Health
Nursing Practice, 2003).

System: An organization or institution that is part of the social environmental determinant of health
(i.e., healthcare, education, commerce, religion, government).

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50 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

third-party payers and accreditors require health depart-
ments to provide evidence that their programs result in
improved client outcomes . Aggregate data are a powerful
tool to demonstrate the value of agency programs and can
be shared with the public, be used to obtain grants and other
funds, and be incorporated into quality improvement and
program evaluation reports . Examples of reports generated
by various agencies are found at www .omahasystem .org/
links .html .

Data Collection, Data Management,
and the Public Health Nursing Process
Data compose the engine that drives the problem-solving
process in nursing practice . Data are used to determine
the health of populations and sub-populations in order to
influence health priorities, health policy, and programs that
promote the health and safety of communities and their pop-
ulations (Allen, Soderberg, Laventure, 2017; Nelson & Stag-
gers, 2018) . A continuum of population data is used by public
health agencies to improve the health of their communities
(see Figure 3 .1) . Accurate and consistent population data can
be transformed to information, which leads to population
health knowledge, and then to wisdom in order to design
public health interventions to create healthier communities .

Therefore, you need to have a system and process for
data collection and management in place at the beginning
of the nursing process . For this reason, we discuss data in
this chapter before we discuss the components of the public
health nursing process . Many public health and community
agencies use electronic health records (EHRs) and auto-
mated health information systems (HIS) . EHRs and HISs
provide ways to collect, store, analyze, and share informa-
tion . Community and population data can be gathered from
a variety of primary (data collected by individuals carrying
out assessment) and secondary (data collected and published
by others) sources .

Although more than one HIS exists, a system created for
public health nursing is useful as an example . The Omaha
System, a standardized terminology initially developed for
use in the community, provides a problem-solving approach
based on the nursing process (see Figure 3 .2) . The Omaha
System is the foundation of the HIS that interprofessional
team members at many health departments and other
community provider sites regularly use to collect, docu-
ment, and analyze individual, family, and population clin-
ical data . The Omaha System allows PHNs to collect and
record their own evidence-based practice data, analyze the
data, and generate meaningful information that can be used
to improve the quality of the care they provide . By using
this approach, PHNs operationalize the data-information-
knowledge- wisdom continuum (Allen et al ., 2017; Martin,
2005; Nelson & Staggers, 2018) . They can tell their data- and
evidence-driven stories about the individuals, families, and
communities they serve . More than 22,000 interprofes-
sional clinicians use the Omaha System globally (Omaha
System, 2017) .

The adoption of EHRs by healthcare providers, includ-
ing health departments, is increasing very rapidly (Amer-
ican Nurses Association [ANA], 2015; Martin, Monsen, &
Bowles, 2011; Office of the National Coordinator for Health
Information Technology, 2017; Omaha System, 2017) .

When health departments use EHRs based on the
Omaha System accurately and consistently, they can aggre-
gate individual and family data into larger data sets so that
patterns can be identified within populations . Increasingly,

FIGURE 3.1 Transforming Data to Practice
Source: Allen et al., 2017; adapted by LaVenture, 2008

PUBLIC HEALTH PRACTICE

HEALTHIER C MMUNITIES

LE
V

EL
O

F
V

A
LU

E

DATA

INFORMATION

KNOWLEDGE

WISDOM

PRACTICE

FIGURE 3.2 Omaha System Model of the Problem-Solving 
Process
Source: Martin, 2005, p. 7, used with permission

INDIVIDUAL,
FAMILY, OR

COMMUNITY

Evaluate
problem
outcome

Collect
and assess

data

Plan
and

intervene

Identify
admission
problem

rating

Identify
interim/
dismissal
problem

rating

State
problem

PRACTITIONER–CLIENT RELATIONSHIP

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51CHAPTER 3  n  Competency #1

‘‘

’’

communities)—The Problem Classification Scheme is a
hierarchy of terms that includes domains; individual-,
family-, and community-centered problems; modifiers;
and signs/symptoms .

n Intervention Scheme (plans, pathways, care activities,
and service delivery terms to improve safety, qual-
ity, and effectiveness)—The Intervention Scheme is a
hierarchy of terms that includes categories, targets, and
client-specific information .

n Problem Rating Scale for Outcomes (evaluation that pro-
vides usable information for measuring and reporting
client progress and change across time)—The Problem
Rating Scale for Outcomes consists of Knowledge,
Behavior, and Status concepts and Likert-type rating
scales . Evidence Example 3 .2 showcases a case study of
the Omaha System used to tell the story of a nurse-client
interaction .

See Appendix B for additional Omaha System resources .

Kristi has just finished reading about the Omaha System.
Her PHN preceptor, Beth, tells her that the public health
nursing agency uses the Omaha System, and Beth wants
Kristi to have a basic understanding of the Omaha System
before she and Beth chart on any of the clients they visit.
Beth gives Kristi the case study about Anna to read to help
her understand the system. Beth asks Kristi if what she
read made sense.

Kristi reflects: “I expected to be confused about the
Omaha System, but the case study helped a lot. I could see the
how the nurse assessed Anna and provided nursing services
to her. She could use the Problem Rating Scale for Outcomes
to evaluate Anna’s progress when she returns for another
visit. I can see that using this system helps nurses measure
the impact of their care and report how nursing care makes
a difference. The one concern I have is that my instructor
stresses the importance of using a strengths-based approach
and the Omaha System always uses the term ‘problems.’”

Beth comments: “I had the same concern when I started
using the Omaha System, but my supervisor pointed me to
the literature on how ‘problem’ is actually defined in the
Omaha System. Here is the definition of problem that I
found: ‘Unique client concerns, needs, strengths, issues, foci,
or conditions that affect any aspect of the client’s well- being;
nursing diagnosis stated from the client’s perspective’* Also,
I found that the term ‘problem’ can be considered neutral,
not negative, so a problem in the Omaha System can also be
used as part of a strengths-based approach.**

Kristi responds: “That makes me more comfortable.
I am going to share with my classmates that the Omaha
System term ‘problem’ can be used from a strengths-based
perspective.”
* Source: Martin, 2005, p . 465
** Source: Monsen, Vanderboom et al ., 2017

Omaha System terms are used in documentation at
the point of care (i .e ., the time and place that care occurs) .
Because the terms of the Omaha System are not complex
and the structure is relatively simple, nonhealthcare pro-
fessionals can understand it . Clinicians see and use point-
of-care terminologies in their EHRs . In 2014, Minnesota
became the first state to recommend that American Nurses
Association recognized point-of-care terminologies be
included in all EHRs (ANA, 2015; Minnesota Department of
Health [MDH], 2015) . Prior to that, Minnesota Department
of Health staff conducted a survey and found that 96 .5% of
community agencies in all counties used the Omaha System
(Omaha System, 2017) .

The Omaha System enables healthcare providers to ana-
lyze and exchange client-centered coded data that can be
transformed to information, the first two stages of the data-
to-wisdom continuum . The Omaha System was designed to
be used by interprofessional clinicians to guide their prac-
tice and document and communicate information about
clients from admission to discharge . It exists in the public
domain (no fee or license) and is intended for use across
the continuum of care nationally and globally . It is based
on a conceptual model that reflects the pivotal position of
the individual, family, and community as client; interpro-
fessional partnerships; and the value of the problem-solving
approach . The Omaha System encourages critical thinking,
enhances communication, and operationalizes the nursing
process . The problem-solving approach complements the
strengths-based approach that focuses on building devel-
opmental assets and increasing the health of youth and
communities (Martin, 2005; Monsen, Vanderboom, Olson,
Larson, & Holland, 2017; Omaha System, 2017) . The Omaha
System consists of three components:
n Problem Classification Scheme (client-centered

assessment that engages individuals, families, and

EVIDENCE EXAMPLE 3.1
The Omaha System

The Omaha System was developed by the Visiting Nurse
Association of Omaha (Nebraska) and seven test sites to
enhance practice, documentation, and information man-
agement. Four federally funded research studies were
conducted between 1975 and 1993 that validated appro-
priateness and effectiveness of the terminology. DeLanne
Simmons, chief executive officer, envisioned a computer-
ized management information system that incorporated an
integrated, valid, and reliable clinical information system
focused on clients who received services, not on the nurses
and other interprofessional team members who provided
the services (Martin, 2005; Martin et al., 2011; Omaha Sys-
tem, 2017). More than 400 articles, chapters, and books
have been published about the Omaha System; the Listserv
has more than 3,000 members located in the U.S. and 22
other countries (Omaha System, 2017).

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52 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

EVIDENCE EXAMPLE 3.2
Omaha System Case Study

Anna K.: Older woman who had a chronic cardiac condition
and attended a screening clinic

First Visit/Encounter Data
Public health nurses at the Dakota County Public Health
Department (Minnesota) developed health clinics for senior
citizens. The clinics offered screening for health concerns, par-
ticularly hypertension, heart disease, and depression; accurate
health information for prevention and treatment; and outreach
and referral coordination for home care, equipment, medical
assistance, and other community services. Because inter-
action time was limited, the nurses developed standardized
protocols and forms based on the Omaha System to increase
the efficiency and effectiveness of assessment, interventions,
and documentation. When new clients visited the clinics, the
nurses considered four problems, Communication with com-
munity resources, Mental health, Circulation, and Medication
regimen. If those problems did not reflect clients’ presenting
data, the nurses selected and documented other pertinent
problems, interventions, and outcome ratings.
When Anna K. came to the senior clinic for the first time,
she reported that she had a history of dizziness and high blood
pressure, but could not recall previous readings. When the
nurse checked her vital signs, her blood pressure was 152/86
sitting and 154/82 standing; her pulse was 60 and regular. Her
weight was 138 pounds, appropriate for her reported height.
They talked about hypertension, blood pressure guidelines,
the Circulation protocol, and Anna’s data. The nurse suggested
strategies to increase Anna’s safety when she was dizzy. The
nurse recorded Anna’s vital signs on a health card, gave the
card to her, and suggested that she have her blood pressure
re-checked monthly and recorded on the card. She asked her
to show the card to her doctor during future appointments.
Anna said she took two “heart” pills fairly regularly. She
agreed to bring them with her when she returned to the Senior
Clinic the following week so she and the nurse could discuss
them. The nurse planned to use the Medication regimen pro-
tocol if appropriate, and record them on Anna’s health card.

Anna’s Answers: Transforming the Story into the Omaha
System assessment, services, and evaluation terms

Domain: Physiological

Problem: Circulation (high priority problem)

Problem Classification Scheme
Modifiers: Individual and Actual
Signs/Symptoms of Actual:

n syncopal-fainting episodes/dizziness

n abnormal blood pressure reading

Intervention Scheme
Category: Teaching, Guidance, and Counseling
Targets and client specific information:

n anatomy/physiology (circulatory system)

n mobility/transfers (avoid falls)

n signs/symptoms-physical (importance of vital signs,
when to notify physician, dizziness)

Category: Case Management
Targets and client specific information:

n continuity of care (show doctor her health card with
monthly blood pressure checks)

Category: Surveillance
Targets and client specific information:

n medical/dental care (schedule and go to appointments)

n signs/symptoms-physical (vital signs, circulatory status,
weight, blood pressure)

Problem Rating Scale for Outcomes
Knowledge: 2—minimal knowledge (some information about
normal/abnormal blood pressure readings but not impact on
health; did not know previous readings)

Behavior: 4—usually appropriate behavior (usually took
medications, has blood pressure checked periodically, seeks
healthcare)

Status: 3—moderate symptoms (blood pressure exceeded
expected range for non-diabetic client)

Elizabeth A. Vance, BSN, RN, PHN
RN Primary Care
Allina Health Clinics Division
Minneapolis, Minnesota

Carol A. Fish, MS, RN, PHN
Supervisor, Social Services Department
Dakota County Public Health Department
West St. Paul, Minnesota

Source: Vance & Fish, 2017 Omaha System case study . Personal correspondence from Karen S . Martin, Martin Associates, Omaha, NE . December 8, 2017 .

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53CHAPTER 3  n  Competency #1

Home Visiting and the Nursing Process
PHNs carry out assessments as part of the nursing process
most often in a community setting, such as a home, a school,
or a clinic . Most of the information is gathered through
observation and listening . When in the home setting, PHNs
are guests of the family members and need to follow their
lead regarding communication methods; timing, length,
and place of visit; and roles of the nurse and family mem-
bers . To assess the family, PHNs must first establish a trust-
ing relationship with family members based on mutual
respect and understanding (Eriksson & Nilsson, 2008;
Martin, 2005; McCann & Baker, 2001) . Answering ques-
tions about personal family matters and health situations
requires families to disclose information they generally do
not share with strangers, so the development of a trusting
relationship needs to precede or occur simultaneously with
the interviewing process . Andrew Gardner (2010) found
that one way to engage clients and help them feel comfort-
able was to start by being open and friendly; this approach

seems obvious but can be challenging for nurses who are
learning to be professional while maintaining boundaries
and creating an environment conducive to effective nurs-
ing practice . An appropriate level of openness certainly can
facilitate a connection and mutual understanding, but this
is sometimes a difficult balancing act, as friendship often
occurs within the professional context of the nurse-client
relationship . The initial visit to a family is critical in estab-
lishing the nurse-client trust relationship (see Evidence
Example 3 .3) .

Home visiting programs may include one or more vis-
its to a client . PHNs follow some families for months and
years, depending on their health risks and needs . So you
should not feel as though you have to get everything done
in one visit . Table 3 .1 demonstrates how a PHN would use
the nursing process in making a series of home visits . The
orientation phase takes one to three visits on average . The
working phase might require multiple visits over a period of
months or years .

EVIDENCE EXAMPLE 3.3
Public Health Nurses’ Views of a Good First Meeting

Swedish researchers used focus groups to determine what
public health nurses believed constituted a good first home
visit with parents of newborns (Jansson, Petersson, & Uden,
2001). A good first visit is considered key to developing an
effective relationship with parents. Three criteria were identi-
fied (Jansson et al., 2001):

1. Creating trust through good contact/reciprocal relation-
ships; listening; being a guest; having an equal role with
parents; and having time, privacy, and peace and quiet

2. Creating a picture of the family’s life situation by getting
a holistic impression of the family, seeing them in their
home environment, getting a picture of what the clients
are like, and taking in, consciously and unconsciously, the
mood and a variety of information about the family

3. Creating a supportive climate by confirming and affirming
parents’ feelings, abilities, and responsibilities and increas-
ing their responsibilities while providing a safety net of
services until family is able to manage on its own

TABLE 3.1 How the Nursing Process Occurs in Home Visits

Home-Visiting Components Nursing Process

Orientation Phase
n Introduction
n Determine purpose of visit and visit activities with client
n Engage in social conversation
n Assessment
n Identify and state client’s problems

Assessment and Diagnosis
n Individual/family and community assessment
n Strengths-based assessment—protective factors identified
n Resources identified
n Health risks and active health problems identified
n Unmet health needs identified

Working Phase: Identification
n Client asks questions and identifies nurse as someone who

can help .
n Client identifies problems .
n Nurse provides health teaching, support and counseling,

follow-up assessment, referral, and advocacy .

Planning and Implementation
n Mutual planning, priority-setting, goal-setting
n Interventions often used include teaching, guidance, and

counseling; treatments and procedures; case management;
surveillance, advocacy, referral, and follow-up .

(continues)

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54 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

Home-Visiting Components Nursing Process

Working Phase: Mutual Relationship
n Client uses nurse as resource and accesses community

resources .
n Nurse engages client in mutual problem solving .

Implementation
n Interventions often used are teaching, guidance, and

counseling; treatments and procedures; case management;
surveillance; collaboration; and consultation .

Resolution and Termination
n Problems are solved or ongoing but stable .
n Client becomes independent of nurse or continues to

need support .
n Relationship ends when client no longer needs nurse or no

longer participates in plan (moves or refuses participation
in plan or visits) .

Evaluation
n Evaluation of Knowledge, Behavior, and Status outcomes:

outcomes met, partially met, or not met
n Replan—change in goals, outcomes, or interventions
n New priorities or emerging problems identified and nursing

process continued

Sources: Phases adapted from McNaughton, 2005; Omaha System terms from Martin, 2005; and interventions from Minnesota Department of Health, 2001

TABLE 3.1 How the Nursing Process Occurs in Home Visits (continued)

PHNs carry equipment they need to complete assess-
ments on individual family members . For example, common
equipment used on maternal/child health visits includes a
baby scale, blood pressure cuffs, a stethoscope, paper tape
measures, disposable thermometers, developmental screen-
ing tools, growth grids, and a thermometer for determining
the temperature of bath water .

PHNs carry smartphones, laptops, and other electronic
devices to stay in contact with others, access information,
and enter family data into EHRs during their home visits .
Many PHNs use automated guidelines or clinical path-
ways specific to individual client and family situations . For
example, public health agencies have screening, assessment,
and monitoring databases for newborns, infants, children,
antepartum, postpartum, and family clients . PHNs collect
admitting data on each client during their initial visits to
their clients . They monitor and record health changes at
each visit .

Public Health Nursing Assessment
Public health nursing assessment is a systematic, deliber-
ative, and holistic process of collecting data about a client
(individual, family, community, or system) that leads to an
understanding of the client’s health determinants, health
status, and priority health concerns and needs, as shown
in Figure 3 .3 . PHNs also need to carry out strengths-based
assessments so that intervention plans for health concerns
and problems are based on the clients’ abilities to manage
their own healthcare needs . Strengths-based assessments
identify clients’ abilities, resources, and resilience as well as
health needs (Monsen, Vanderboom et al ., 2017) .

FIGURE 3.3 How PHNs Collect Data About Individuals, 
Communities, and Systems

Individual/Family
• Family assessment
• Family health goals

Community
• Strength-based
assessment
• Health assessment and
intervention process

• MAP-IT
• Windshield
survey

System
• Community health priorities
• Community action plan
• Community intervention plan

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55CHAPTER 3  n  Competency #1

‘‘

’’

Individual/Family Level of Practice
The family is the focus of care when PHNs work at the
individual/family level of practice . The family is the pri-
mary unit of society and is responsible for carrying out the
functions that allow family members to survive and thrive .
In a health sense, the family is a unit of care allowing the
nurse to simultaneously focus on the individual, the family,
and the health issue (Hunt, 2013) . Families come in many
shapes and sizes and in different stages of development .
Family composition is varied and changeable in contempo-
rary society (Kaakinen, Coehlo, Steele, & Robinson, 2018) .
A family is “a group of individuals who are bound by strong
emotional ties, a sense of belonging, and a passion for being
involved in one another’s lives” (Wright & Bell, 2009, p . 46) .

The experience of illness or a health concern is felt by not
just the individual but also by larger systems including fam-
ily members and the community (Marshall, Bell, & Moules,
2010) . Family-focused care has the potential to empower
vulnerable and at-risk families (Rossiter, Fowler, Hopwood,
Lee, & Dunston, 2011) . Family assessment is a holistic pro-
cess in which all the factors that influence a family’s level
of health and wellness are considered . Specifically, a family
unit assessment includes collecting data on the individual,
family, household, and community to identify resources,
strengths, and risks (Meiers, 2016; Meiers, Krumwiede,
Denham, & Bell, 2016) . In addition to considering individ-
ual human development stages, PHNs consider the family’s
stage of development . Transitions between the stages involve
rearrangement of relationships . Although it is important to
note that this is a very traditional model for married fam-
ilies with children and would need to be adapted to a vari-
ety of diverse family structures, Carter and McGoldrick’s
(2005) Family Life Cycle model highlights the development
of the family system over time:
n Leaving home as single young adults
n Joining of families through marriage: the new couple
n Families with young children
n Families with adolescents
n Launching children and moving on
n Families in later life

Each stage is associated with tasks that will foster each
member’s development . Sara’s family falls in the “families
with adolescents” stage . One unique aspect to this stage is
that the parents face a transition with both the adolescent in
terms of growing independence and the adolescent’s aging
grandparents . This stage requires the family to alter its
parent-child relationship to accommodate the adolescent’s
growing independence and autonomy . This awareness of the
family’s stage of development can be helpful for PHNs in
understanding potential family conflict as they are work-
ing through the stages . Table 3 .2 outlines the components
of family assessment typically included in a comprehensive
family assessment using the Healthy People 2020 Health
Determinants Framework .

Beth and Kristi make their first visit to Sara. Her mother,
Patricia, introduces herself at the beginning of the visit and
states that she hopes the public health nurse can straighten
out her daughter and help her daughter understand the
poor choice she made in getting pregnant at such a young
age. She is concerned because Sara is missing so much
school. Sara has poor eye contact with Beth and her mother.
Beth focuses on Sara and asks her what she would like help
with for the rest of her pregnancy. Sara responds that she
is very tired and feels uncomfortable with all of her body
changes that are now becoming visible. She is afraid of how
the other students at school will treat her.

Beth tells Sara and Patricia that she would like to get a
good sense of the family before she begins any work with
Sara. Beth asks if she can visit again next week to finish the
family assessment she was able to start today. Before Beth
and Kristi leave, Beth collects information from Sara so a
case file can be opened. Beth then asks Sara if Kristi can
check her height and weight to get some basic information.
Sara agrees. Kristi finds that Sara weighs 100 lb. and her
height is 5’3″.

After the visit, Kristi writes in her public health nursing
clinical journal. She thinks about what phases of the home
visiting occurred during this first visit. She also analyzes
the visit and asks herself the question, “Was this a good
first visit?” Kristi also reviews the holistic family assess-
ment framework that she and Sara will be using during the
second home visit.

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56 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

’’

‘‘During the second home visit, Kristi works with Beth to
complete the family assessment. She constructs a genogram
with Sara and her mother and they notice that Patricia
and Sara’s grandmother have a history of preterm labor.
During the visit, Jimmy, Patricia’s boyfriend, comes home
early from work and Sara’s sisters, Tara and Kara, 9-year
old twins, come home from school. The home becomes loud
and there are lots of interruptions during the early part of

the visit. Beth asks Patricia if they can continue the visit in
the kitchen and asks the twins to stay in the living room.
Jimmy decides he will take a nap. The visit continues unin-
terrupted. By the end of the visit, information about the
family health determinants of biology and behaviors have
been collected. When Kristi completes her weekly clinical
journal, she organizes the family data by health determi-
nant categories.

Table 3 .3 is what Kristi recorded .

TABLE 3.2 Holistic Family Assessment Framework

Framework Factors

Family Biological and
Genetic Factors

n Age
n Sex or gender identify
n Three-generation genogram
n Family-identified ethnicity
n Health status

Family Behavioral Factors n Lifestyle and daily patterns including nutrition, sleep, exercise, and recreation
n Housing and living arrangements
n Social support/ecomap
n Family and community roles
n Education, employment
n Socioeconomic status (income, poverty)
n Cultural patterns, religious affiliations
n Language and health literacy
n Health-seeking and health-limiting behaviors
n Patterns of coping and resilience
n Patterns of conformity and nonconformity

Physical Environment
Factors

n Home environment (use a home safety checklist appropriate to family members’ age,
development, and physical and cognitive abilities)

n Immediate neighborhood (observations, walkability, windshield surveys)
n Natural physical environment and weather
n Built environment, including safety
n Maintenance of sidewalks, roads, pedestrian crossing
n Transportation
n Adequate recreational resources
n Access to shopping centers
n Accessible healthcare—see the 5 A’s of accessible healthcare in the community-assessment guide
n Potential or actual environmental hazards such as pollution of air, water, food, or soil

Social Environment
Factors (i.e., social
actions, patterns, systems,
healthcare access)

n Availability of health and social services resources
n Availability of quality schools and daycare
n Availability of fire and police
n Employment opportunities
n Mass media and library availability
n Cultural and social patterns of community, including potential exposure to violence
n Governmental services
n Business community and working conditions

Data Analysis Summary of the family assessment including:
n Major family protective factors, major family risk factors
n Statement of family resilience and ability to manage own healthcare
n Family’s priority health problems or concerns and health goals

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57CHAPTER 3  n  Competency #1

TABLE 3.3 Sara’s Family Assessment: Individual/Family Health Determinants

Biological and Genetic Health Determinant Factors

Sara: is 16 years old, 20 weeks gestation, primipara, on a prenatal vitamin, diagnosed with anemia, and underweight with poor
weight gain . She and her family are Caucasian .

Patricia: mother, is 34 years old taking hydrochlorothiazide 12 .5 mg daily for hypertension .

Jimmy: mother’s live-in boyfriend, is 37 years old and has no health conditions .

Siblings: Tara and Kara are 9-year-old twins; both females have attention deficit hyperactivity disorder (ADHD) and take
Adderall XR 1 .25 mg daily . Immunizations are up to date .

Extended family: Sara’s grandparents, Patricia’s parents, live on a farm house 30 miles away . Grandmother, 55 years old, has
hypertension . Grandfather, 57 years old, has type II diabetes .

Samuel: Sara’s boyfriend, is 17 years old, Hispanic, and has no known health conditions .

Behavioral Factors

Socioeconomic Status: Sara is a full-time high school student in 10th grade, unemployed, and with no income . Patricia is a full-time
factory worker and Jimmy is a full-time welder . Both have high school diplomas . Tara and Kara are full-time elementary school
students . Samuel, Sara’s boyfriend, is a full-time 11th-grade student and works part time at a restaurant . Although the family does
not live in poverty, their income is low and they struggle to pay their monthly bills . Patricia has family health insurance and Jimmy
has his own insurance .

Cultural and Religious Affiliation: All family members were born in the United States and are Catholic . The family attends church
most Sundays .

Family Developmental Stage: families with adolescents’ developmental stage (Carter & McGoldrick, 2005)

Family Roles and Function: Patricia takes on leadership and organizer role in the home and schedules Sara’s prenatal check-
ups . Patricia makes the decisions and Jimmy pays the bills and fixes the house . Sara babysits the twins but lacks knowledge of the
difference between being an older sibling and being a parent . Patricia is tired, stressed, guilty for not being available for the family,
and upset that Jimmy is not helping more at home . Samuel doesn’t come over much anymore because Patricia and Jimmy are not
very welcoming .

Family Lifestyle Patterns (disrupted by health concerns): The family is struggling to manage schedules . Sara has been missing
school due to fatigue and does not want anyone to know she is pregnant . Patricia and Jimmy leave for work at 6:00 a .m ., so Sara
routinely takes care of the twins in the morning . Lately, Sara hasn’t been helping the twins get ready for school or to the bus on time .
Patricia has been contacted by both schools due to Sara’s multiple absences and Tara and Kara’s tardiness . Patricia has been working
overtime to pay for Sara’s prenatal care costs . Due to the stress of Sara’s pregnancy and working overtime, the house is messy, meals
are not being made or eaten together, and the twins are not taking their ADHD medication as prescribed .

Ecomap Summary: The family has close relationships with their neighbors and church . The twins’ relationship with their school is
strained due to tardiness . Sara also has a strained relationship with her school and misses Samuel and her friends . She would like to
find a peer support group for pregnant and parenting teens but cannot find one .

Health seeking behaviors: Prior to the recent family disruptions, the family had healthy eating patterns, including eating supper
together . They enjoyed weekly family bike riding . The twins and sometimes Sara got at least 8 hours of sleep most nights . No one in
the family smokes; Sara does not use alcohol or other drugs .

Health Limiting Behaviors: The family lacks time to prepare and share meals and to go bike-riding . The twins often miss their daily
ADHD medications . Sara feels like she is getting fat due to pregnancy, so she eats only one meal a day, typically a peanut butter and
jelly sandwich, chips, and a soda and ice cream as a bedtime snack .

Family Resilience and Coping Patterns: Patricia stated she and her girls are strong and that Jimmy makes the family even stron-
ger . Patricia went through a difficult divorce and feels her family is stronger because of the experience . Patricia and the girls talked
through the experience; they “stuck together .” They have a positive outlook and pray together . Sara’s pregnancy has been stressful
for the family . Sara is scared to give birth and depends on her mom being strong . “She has always been my rock and now I am scared
because my mom is so disappointed in me . We don’t talk anymore; she just yells at me all the time .”

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58 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

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’’

‘‘

’’

Beth and Kristi decide that Kristi could return for a third
family visit to complete the home and neighborhood por-
tions of the family assessment if Sara and her mother are
okay with this. Beth phones Patricia and gets permission
for Kristi to visit. After the visit, Kristi records the data on
the physical and social environmental health determinants
in her clinical journal. Kristi believes that she and Beth
have now completed the Orientation Phase of family visit-
ing. She will confirm this with Beth.

Table 3 .4 shows the notes that Kristi wrote after her visit .

Kristi goes to meet with Beth at the office before their next
scheduled home visit with Sara and her family. Beth and
Kristi review the data analysis of the family assessment and
the summary of the family strengths and risk factors and
identifies what she thinks are the family’s health problems
and priorities.

Beth comments, “It is difficult to focus on the family as
a whole when we opened the case on Sara and now we are
assessing and planning on intervening with the family as a
whole. You did a good job focusing on the family as a unit
and putting Sara in the center of that family.”

Establishing Family Health Goals
The PHN continues the nursing process by moving into iden-
tification of the individual’s or family’s health priorities and
mutual goal-setting . PHNs employ mutual problem-solving
strategies with clients to foster self- efficacy . When working
with families in the community, the PHN partners with the
families in determining priorities, establishing goals, and
developing an intervention plan . The plan should be con-
gruent with and integrated into the family’s culture, life-
style, and daily routine and be within the family’s potential
to achieve . The plan should enhance the family’s potential
for self-care and autonomy . The family care plan should be
realistic, understandable, measurable, behavioral, achiev-
able, and time-limited so that the effectiveness of the plan
and the nursing interventions can be determined . It is pos-
sible to develop and measure Knowledge, Behavior, and
Status outcomes for a family using the Omaha System Prob-
lem Classification Scheme .

TABLE 3.4 Sara’s Family Assessment: Physical and Social Environmental Health Determinants

Physical Environment Health Determinant Factors (Natural and Built Environment)

The family lives together in a 3-bedroom, 1-bath rambler in need of repairs in a low-income neighborhood . The twins share a room .
The home safety checklist findings included: presence of smoke detectors, carbon monoxide detectors, and good lighting through-
out . Cleaning products are in an unlocked cupboard under the sink . This will present a safety hazard for the new baby . Their
neighborhood has sidewalks and is well lit . Traffic is light . There is a grocery store, a farmer’s market, and a park nearby . The family
medical clinic is 5 miles from their home .

Social Environment Health Determinant Factors

The family feels that they live in a good neighborhood and good community . The neighborhood has a neighborhood watch commit-
tee and a few retired neighbors have a Safe Home sign in their window, which means that any child who needs help can go to those
homes . The local schools have good teachers and are safe . Patricia and Sara are relieved that a PHN can come to see Sara at home .
The PHN is working with the school nurse and social worker to plan for Sara’s return to school once she has the baby . There is no
peer support program for pregnant and parenting teens at the school . The City Council has recently started a marketing program to
attract new businesses, which will give Patricia and Jimmy opportunities for better jobs .

Data Analysis—Summary of Family Assessment

Family Strengths (Protective Factors): The family has a good history of resilience and healthy family roles and functions . The
family has good community support systems . Patricia and Jimmy expressed the desire to support Sara in her pregnancy . Sara plans
to complete high school and go to college; she does not use substances such as tobacco, drugs, or alcohol . The family is working with
the PHN, school nurse, and social worker to help Sara achieve her goals .

Family Risk Factors: Sara’s unexpected pregnancy has placed a stress on the family functions that has resulted in interruptions in
some family processes . Key areas for improvement are meal preparation, Sara’s difficulty with caretaking the twins in the morning,
and Sara’s poor eating habits . The family history of preterm labor is an added risk factor for Sara’s pregnancy . Sara has experience
caring for her younger siblings and has a desire to learn about prenatal care; however, she has a lack of knowledge about pregnancy
and caring for an infant . The relationship between Patricia and Sara is strained, and Sara does not feel she is receiving the support
she needs from her mother . The relationship between Samuel and the family is strained . The twins are not receiving their daily
ADHD medications and are often tardy at school, while Sara has frequent absences from her school .

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59CHAPTER 3  n  Competency #1

TABLE 3.5 Sara’s Pregnancy and Family Stress in the Omaha System

DOMAIN: Physiological DOMAIN: Psychosocial

PROBLEM: Pregnancy (high-priority problem)
Modifiers: Individual and Actual

Signs/Symptoms of Actual
n Difficulty with prenatal exercise/rest/diet/behaviors
n Difficulty coping with body changes
n Inadequate social support

Problem Rating Scale for Outcomes

Knowledge: 2—Minimal knowledge (interested in information
about appropriate rest, exercise, and diet patterns)
Behavior: 1—Not appropriate behavior (no prenatal care; high-
risk behaviors)
Status: 1—Extreme signs/symptoms (anemia and is underweight
with poor weight gain)

PROBLEM: Interpersonal Relationship
Modifiers: Family and Actual

Signs/Symptoms of Actual:
n Difficulty establishing/maintaining relationships
n Incongruent values/goals/expectations/schedules
n Prolonged, unrelieved tension

Knowledge: 3—Basic knowledge (describes importance of
positive communication but not methods)
Behavior: 3—Inconsistently appropriate behavior (great
decrease in number and increase in length of relationships,
increase in repairing relationship)
Status: 2—Severe symptoms (limited, brief communication
and interaction, often tense)

’’‘‘

‘‘

’’

Kristi and Beth carry out a home visit with Sara and her
family to identify the family’s priority health goals. During
the visit, they work collaboratively with the family to iden-
tify two family health goals and then translate them into
the Omaha System Problems.

• Goal One: Have a healthy baby to add to the
family → Problem: Pregnancy.

• Goal Two: Work on supporting each other by
improving their relationships and communications
and get back into a scheduled routine → Problem:
Interpersonal Relationship.

Kristi and Beth return to the office to input the family
data for their family health goals using the Omaha System
Problem Classification Scheme. In order to measure health
outcome improvements over the time of the home visiting,
Beth assigns a Knowledge, Behavior, and Status (KBS) rat-
ing starting for the primary family health problems.

Kristi’s KBS rating for Sara and her family is shown in
Table 3 .5 .

Beth says, “The next step will be to develop care plans.”
Kristi states, “I just reviewed Anna’s case study and the
Intervention Scheme. Was that a care plan?”

Beth suggests, “The Omaha System Intervention Scheme
is used to describe care plans and services. For simplic-
ity, Anna’s case study documents services so readers can
‘match’ the services to the text in Anna’s story. Why don’t
you take the next half hour and go online to the Omaha Sys-
tem Community of Practice (http://omahasystemmn.org/
data.php)? Watch ‘An Introduction to the Omaha System’

and ‘How to Read an Omaha System Pathway.’ You will see
that the term ‘pathway’ is used to suggest various Interven-
tion Scheme categories, targets, and client-specific infor-
mation for specific problems. Then we can work together
to develop pathways for the Pregnancy and Interpersonal
relationship problems.”

Kristi responds, “That sounds like a great idea. I am
concerned though that Sara has a lot of other health prob-
lems related to her pregnancy: her eating habits and not
gaining any weight, anxiety, isolation from her friends and
her boyfriend, Samuel. The list goes on and on! When will
we deal with those issues?”

Beth responds, “With home visiting, we take things
one small step at a time. We are still in the Identification
Phase of the Home Visiting Process. As we work with Sara
and her family, we will deal with all of these issues using
many interventions. Once we have developed a working
relationship with the family we will move into the Mutual
Relationship Phase. Then we will be able to have more of a
consultative relationship and help them connect with com-
munity resources and decide how they want to manage the
challenges of the birth of Sara’s baby.”

Health teaching, counseling, consultation, and case
management are interventions commonly used to build on
and enhance the families’ strengths and encourage them to
manage their healthcare . PHNs use advocacy to facilitate
the individual’s and family’s ability to access health and
social resources . They also use advocacy when populations
are found to be at risk for a specific health hazard .

Whether individuals live alone or with others, the same
family functions are relevant . If you are working with an
individual who lives alone or whose extended family lives

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60 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

‘‘

’’

elsewhere, you still need to use the same family assess-
ment approach . Sometimes a complete family assessment is
not needed or impossible to collect . In that case, the PHN
would select the assessment components that relate to the
specific family health problem or priority concern . It would
be important to include the following components in this
focused family assessment: the health problem or issue and
the related risk factors and protective factors, the family goal
related to the health problem or concern, necessary access to
health and social services, and the family’s ability to manage
healthcare needs and resources .

Community Level of Practice
PHNs assess communities to determine their levels of health
and wellness . These assessments are carried out in partner-
ship with the community . Many geographic communities,
such as cities, counties, and states, conduct a community
assessment on a periodic basis . They do this to monitor
changing health conditions of the populations in their com-
munities and to establish community priorities for health
goals, funding, and actions . The governmental agencies
conducting the assessment partner with other community
organizations and members to ensure that the diversity of
the community and all points of view are reflected in the
assessment . PHNs are part of the team that collects and
analyzes the community data .

It is important to conduct a strengths-based assessment
as part of the community-assessment process . PHNs work
to enhance community strengths so that communities can
be as independent as possible in solving their own health-
care problems and managing their own healthcare needs .
See Chapter 8 for a discussion of the formation of com-
munity partnerships and building on community assets
to strengthen the community’s ability to manage its own
healthcare needs .

The population data collected in public health includes
population health status, health differences or health status
gaps between populations (health disparities), and health
determinants (causes of health and illness within the popu-
lation) . Population health status data, also known as global
health status measures, are the “vital signs” of the popula-
tion . These global health measures include:
n Mortality (death rates) data
n Life Expectancy (average years lived for someone born

in a specific year)
n Years of Potential Life Lost (life expectancy–age of

death = YPLL)

n Morbidity (illness rates) data
n Health behaviors data (e .g ., smoking, exercise, obesity,

use of seatbelts)
n Health and life satisfaction data (how satisfied one is

with current health and lifestyle)
n Functional health data (ability to live independently

and manage own healthcare needs)

Kristi is just starting her community-assessment proj-
ect with three of her classmates. They are conducting an
aggregate assessment (focusing on a specific portion of the
population). Because of the home visits to Sara and her
family, Kristi is interested in looking at the needs of preg-
nant and parenting teens and identifying existing resources
and resource gaps. She finds out that Sara’s mother’s church
is considering starting an outreach program for pregnant
and parenting teens. She asks Beth what information the
health department might have to help her and the church
members decide what to do. Did the PHNs have any data
that would help?

Beth responds, “The public health department carries
out a community assessment every five years to determine
the priority health problems of the people living in the com-
munity. We want to know what the major health needs are
and which needs are met and which are unmet. We also
look at the assets or resources of the community to deter-
mine the community’s capacity to manage its own health-
care needs and solve its own problems. Then we prioritize
and decide which services to offer, what the funding should
be, and how to allocate resources to our different programs.
During the last community-assessment process, we found
out that while our teen pregnancy rate had decreased,
we still did not have the outreach and health promotion
services to meet their needs. One area we identified as a
priority was peer support groups for pregnant and parent-
ing teens. Many of our public health nurses provide health
teaching and case management interventions for pregnant
and parenting teens in the home, and they found that
until the teens return to school, they are quite isolated. We
aren’t sure if this is affecting their ability to parent their
newborns. So, we are in the process of using Omaha System
data to see if there are services we need to provide. When
you organize your aggregate assessment, you should con-
sider looking at what other churches and community orga-
nizations are doing or if they have the resources to develop
new programs.”

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61CHAPTER 3  n  Competency #1

Community Health Assessment
and Intervention Process
Community assessment and intervention is an inclusive
process that involves all relevant stakeholders such as health
and social services providers, spokespeople for the commu-
nity and its sub-populations, and key decision-makers in the
community . The MAP-IT 5-step process (see Figure 3 .4) is a
Healthy People 2020 tool that helps people unite to improve
the health of their communities (CDC, n .d .-a) . It may be

used as a community-assessment tool and as a commu-
nity planning process tool . MAP-IT resources are found at
http://www .healthypeople .gov/2020/implement/MapIt .aspx .

Before starting the data-collection process, an assess-
ment tool must be selected or developed . The community-
assessment tool presented in Table 3 .6 is based on the
determinants of health (see Chapter 1) . The community-
assessment project you participate in as a student may
include many of these components . Remember that all data
sources, both primary and secondary, must be documented .

TABLE 3.6 Community-Assessment Guide

Part I: Defining Target Population

n Entire Population of a Geographic Area: Population by census track, community, county, state, country
n Sub-Population or Aggregate: Population who share common character (i .e ., ethnic, cultural or religious group, age or

developmental stage, common health risk [potential or actual])
n Population of Interest: Population who is essentially healthy but could improve factors that promote or protect health

(MDH, 2001)
n Population at Risk: Population with a common identified risk factor or risk exposure that poses a threat to health (MDH, 2001)

Part II: Identifying Population Health Status

Levels of Health and Illness
n Birth and Death (Mortality) Rates
n Accidents and Injuries: accidental, intentional, homicide, and suicide
n Communicable and Infectious Disease Incidence and Prevalence Rates
n Acute and Chronic Disease Rates (physical, mental)

Health Risk Behaviors (may also be listed under Behavioral Health Determinants)
n Rates of smoking or chewing, drinking, drug use, obesity, drinking and driving, sexual behaviors and unprotected sex, use of

seatbelts and helmets, interpersonal abuse, participation in antisocial or illegal behaviors

Levels of Independence by age, gender, health status, socioeconomic status

Levels of Life Satisfaction by age, gender, health status, socioeconomic status

(continues)

FIGURE 3.4 Community Planning Process: MAP-IT
Source: Adapted from MAP-IT (CDC, n.d.-a)

Mobilize key people
& organizations

Identify roles
& responsibilities

Form coalition

MOBILIZE

Assess needs
and assets

Start collecting
community data

Work together
as coalition to
set priorities

ASSESS

Develop goals
and objectives

Decide how to
measure progress

& success

Consider
intervention points

where & when
change can occur

PLAN

Create detailed
work plan

Develop a
communication

plan

Identify a single
point of contact to

manage project

IMPLEMENT

Plan regular
evaluations to
measure and

track progress
over time

Share progress
and success

TRACK

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62 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

Part III: Assessing Population Determinants of Health

Population Biological and Genetic Factors
n Population at last census and population changes in last decade
n Demographics: Age, gender, race, and ethnicity (may use population pyramids)
n Physical characteristics
n Genetic factors
n Health conditions: Acute and chronic

Physical Environment Factors
n Natural Environment: Geography, climate, weather, air and water and other natural resources, agriculture, animal life, urban,

rural, suburban
n Built Environment: Infrastructure of community (roads, bridges, transportation, public spaces, and recreational areas), public,

and governmental buildings; housing stock and density; industries and workplaces; educational and religious facilities; health-
care facilities; shopping and entertainment; accessibility; and environmental adaptation

Social Environmental Factors: Social Actions and Social Patterns

Population Behavioral Patterns
n History of the community
n Social, economic, and political

patterns
n Socioeconomic status (income,

poverty), education, employment,
and work patterns

n Housing and living arrangements
n Lifestyle patterns
n Cultural patterns, diversity, and

religious affiliations
n Community roles and engagement
n Language
n Health insurance
n Health literacy
n Health-seeking behaviors
n Health-limiting behaviors
n Patterns of coping and resilience
n Patterns of conformity and

nonconformity

Community Systems (Institutions)
n Cultural and ethnic organizations
n Education (public, private, religious)
n Commerce and job opportunities
n Media and forms of communication

including mail delivery, phone, radio,
television, and Internet

n Libraries and public information
n Governmental systems and services:

public health and social services;
police and protective services;
environmental services (water, air
quality, sanitation, waste management,
recycling services, vector control);
emergency preparedness and response

n Laws, regulations, ordinances
n Community safety net programs

( public and private)
n Community support systems

(formal and informal)
n Community networks, coalitions
n Health services and health services

access (physical, mental, chemical,
dental, pharmaceutical)

Access to Healthcare

Assessing the “7 A’s of Access”

(Truglio-Londrigan & Lewenson, 2013,
p . 93)

1 . Is the individual, family, or population
aware of its needs and the services
available in the community?

2 . Can the individual, family, or pop-
ulation gain access to the services it
needs?

3 . Are services available and convenient
for the individual, family, or popu-
lation in terms of time, location, and
place for use?

4 . How affordable are the services for
the individual, family, or population?

5 . Are the services acceptable to the
individual, family, or population in
terms of choice, satisfaction, and
congruency with cultural values and
beliefs?

6 . How appropriate are the services for
the individual, family, or population?

7 . Are the services adequate in terms of
quantity or degree for the individual,
family, or population?

Part IV: Analysis of Population Health Data

n Summarize the population demographics and health status
n Summarize the physical and social environmental factors
n Identify the major protective factors for population health
n Identify the major risk factors for population health
n Identify the key health disparities within the population as a whole and between sub-groups

TABLE 3.6 Community-Assessment Guide (continued)

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63CHAPTER 3  n  Competency #1

Windshield Survey
The windshield survey is a first look at a community through
a car’s windshield . Observers are asked to use their senses
(sight, hearing, and smell) to learn about a community as
they drive, walk, or use public transportation to get around
the community . They then make observations about the
physical and social environments and the natural and built
environments . The windshield survey is sometimes referred
to as a familiarization survey because it helps establish the
community context of care for PHNs . It can also be an initial

step to a more comprehensive community assessment by
raising awareness of issues for further exploration . Table 3 .7
includes a list of questions you might ask yourself to help
guide your windshield survey and analyze your findings .

Other types of windshield surveys may also be carried
out, such as environmental hazard surveys (see Chapter 5)
and walkability surveys to assess areas not accessible by car
such as sidewalks, paths, parks, playgrounds, campuses,
and malls .

TABLE 3.7 Windshield Survey—Snapshot of Community Assessment

Windshield Survey

The first steps of a windshield survey require identifying the community boundaries and determining whether you will conduct the
survey by car, by public transportation, or partially on foot to determine feasibility of your possible travel routes . It is best to con-
duct the survey in pairs or as a group . As you drive or ride through the community, pay careful attention to as many characteristics
of the community as possible . You may wish to take photos or videotape your windshield survey . Make sure that you are only taking
photos of people in public places . Be sensitive to the privacy of others; avoid taking pictures of people where they could be identified .

n Which resources/assets do you see available in the community? Resources may include libraries, clinics, thriving local
businesses, and other features that may provide support to community members .

n Which types of services for families do you see in the community?
n Are there other organizations, such as youth centers, churches, or Head Start programs that might provide activities for

children/families?
n Where do people live in the community? Is the housing primarily single-family housing or apartments? What is the condition

of the housing?
n What types of jobs are available in the community? Would these jobs likely be held by people in the area?
n Where do people shop? Which types of stores are available: locally owned or chain stores?
n How do people get around in the community? Is public transportation available?
n What do you notice about ethnic diversity in the community? Which age range seems predominant?
n What is the geographic environment? Which types of opportunities are available for exercise? Are parks available? Is there

green space?
n Which options are available for eating out?
n What did you learn about the health status of population groups in the community that augments published population

health data?
n Where can people go for healthcare services?
n Based on your observations, what would you identify as assets in this community?
n Overall, how did you feel about being in the community (e .g ., safe, comfortable, uneasy)?

Reflection and Analysis Questions
n What is the story of each photo you have taken? What do the photos tell you about the life and health of the community?
n What are the community’s outstanding assets? Is there a relationship between these assets and the health of the community?
n What appear to be the community’s major challenges? Is there a relationship between these challenges and the health of

the community?
n What do you see as the most striking characteristic about the community? Would this characteristic influence your approach

to providing care to the community?
n What did you find to be the most unexpected? Would the unexpected be an asset or a challenge to providing care to the

community?

Source: Modified from Hargate, 2013

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64 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

‘‘

’’

PHN Assessment at the
Systems Level of Practice
Systems are part of the social environmental category of
health determinants . Systems can be assessed to determine
their ability to respond to public health priorities in the
community . Systems that PHNs interact with on an ongo-
ing basis include healthcare systems; public and govern-
mental agencies; schools and school systems; community
health and social service agencies; local and state govern-
ments, including elected and appointed officials; insurance
companies; and faith-based organizations . PHNs assess
systems to identify the extent to which they can meet com-
munity health needs and, if gaps exist, to identify the addi-
tional resources that are needed . Kristi’s discussion about
the local Catholic church, the Salvation Army, and county
public health nurses working together demonstrates how
public-private partnerships can often fill the gap when one
organization cannot meet the need alone .

Kristi and her fellow students find that two organizations
in the community are interested in developing some out-
reach services to pregnant and parenting teens: a local
Catholic church and the Salvation Army. She asks her PHN
preceptor if two such different organizations might be able
to work together.

Beth advises, “You might want to divide your group of
four students into two and ask each pair to assess one of
the organizations. You would want to look at their values,
goals, resources, and willingness to work with each other.

If you find common ground based on an interest in help-
ing pregnant and parenting teens, then you can arrange a
meeting of the two organizations. You could let them know
that the PHNs in our agency would be willing to help them.”

Kristi responds, “Wow! We might be able to do some-
thing valuable for the community while we are carrying out
our clinical assignment. I am going to call my classmates
and set up a meeting to get started. Thanks.”

Identifying Community Health Priorities
PHNs employed in governmental public health agencies
are accountable to the public for the health priorities they
select, the populations they serve, and the services they pro-
vide (see Chapter 7) . PHNs consciously make the connec-
tion between the health needs of the community as a whole
and the health needs of individuals and families within the
community . The priority health needs identified through
the community-assessment process help PHNs determine
the most vulnerable and underserved populations in their
communities and target those with greatest need for services .

PHNs also identify health priorities in the community
by determining health and illness patterns among their
individual clients and families by aggregating data on all
the families whom their agency serves . PHNs look at mul-
tiple interacting health determinants, including the social
determinants of health, to identify population health pat-
terns and causes when working with individual clients
and community partners (Monsen, Swenson, & Kerr, 2016;
Monsen, Brandt et al ., 2017; Monsen, Swenson, Klotzbach,
Mathiason, & Johnson, 2017) . PHNs also conduct research
to identify health concerns in known vulnerable popula-
tions . For example, a study of early care and education pro-
grams identified the following health needs of the centers
and enrolled children: hygiene and hand-washing; sanita-
tion and disinfection; supervision; and safety of indoor and
outdoor equipment (Alkon, Rose, Wolff, Kotch, & Aronson,
2016) . PHNs can determine community health priorities by
reviewing the community-assessment data to determine
which health problems have the greatest potential for harm
and have effective interventions . Questions to consider
when establishing health priorities are listed in Table 3 .8 .

PHNs are ever-vigilant community watchers who are
often the first to notice when a new health concern emerges
or when a service gaps exists in the community . An exam-
ple of a health concern identified by a PHN intake nurse,
explored by agency staff, and taken to a group of commu-
nity partners for a systems-level intervention is found in
Evidence Example 3 .5 .

EVIDENCE EXAMPLE 3.4
Windshield Survey

A total of 284 windshield surveys were carried out by
nursing students in Mexico, New Zealand, Norway,
Turkey, and the United States. The Omaha System Prob-
lem Classification Scheme was used to evaluate the wind-
shield survey data. The students were able to input the
community-assessment data into electronic records using
an online checklist of 11 Omaha System problems. This
framework for collecting and analyzing community data
was found to be an effective teaching-learning tool for
students.

Source: Kerr et al ., 2016

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65CHAPTER 3  n  Competency #1

TABLE 3.8 Determining Community
Health Priorities

1 . What is the incidence and prevalence of major diseases,
health risk behaviors, and health concerns in the com-
munity (e .g ., heart disease, teen pregnancy, drinking
and driving, smoking, depression, influenza)?

2 . What are the major causes of death and disability in the
community (e .g ., heart attacks, stroke, cancer, demen-
tia, car accidents, and homicide)?

3 . Which populations in the community are most affected
by these health problems (health disparities)?

4 . What are the major health risks in the community
(e .g ., obesity, air pollution, homes with lead-based
paint, seasonal flooding, homelessness, lack of health
insurance)? Consider level of risk and proportion of
population affected . What are the key social determi-
nants of health affecting vulnerable populations in the
community?

5 . Which health needs are met by community resources?

6 . Which health needs are not met?

7 . Are affordable and effective interventions available for
these health needs?

8 . Who is responsible for meeting these health needs?

9 . Rank order priorities by level of risk or hazard to
community population or sub-populations .

Decline in Child Mortality

GOAL 3 Significant progress has been made in reducing child mortality. In 2015, the mortality rate for
children under age 5 worldwide was 43 deaths per 1,000 live births—a 44% reduction since 2000. This
translates to 5.9 million under-5 deaths in 2015, down from 9.8 million in 2000. But despite progress in
every region, wide disparities persist. Sub-Saharan Africa continues to have the highest under-5 mortal-
ity rate, with 84 deaths per 1,000 live births in 2015—about twice the global average.
Children are most vulnerable in the first 28 days of life (the neonatal period). To reduce child deaths
even further, greater attention must be focused on this crucial period, where progress has not been as
rapid. In 2015, the global neonatal mortality rate was 19 deaths per 1,000 live births, a 37% reduction

since 2000. This means that, in 2015, about 2.7 million children died in the first month of life. Neonatal mortality remains highest
in Central and Southern Asia and in sub-Saharan Africa: 29 deaths per 1,000 live births in 2015 in both regions.
The share of newborn deaths in all under-5 deaths grew from 40% in 2000 to 45% in 2015, due to the slower pace of progress
among newborns. It is estimated that 40% of neonatal deaths could be prevented by providing high-quality care for both mother
and baby around the time of birth (United Nations, n.d.).

EVIDENCE EXAMPLE 3.5
Determining Population Needs in a
Rural/Suburban County

The intake nurse at the public health agency was respon-
sible for logging referrals and conversations of significant
public health concern. The agency she worked at was small
and lacked an on-site physician or walk-in clinic services.
It was a 50-mile drive to the larger metropolitan commu-
nity where low-cost clinics were available. An analysis of
the monthly logs included calls from uninsured adults with
a variety of acute and chronic healthcare conditions. The
intake nurse found a trend of increasing numbers of working
adults lacking access to care. She compiled a brief report
summarizing two months of log entries and presented it to
her public health director. At the next community partner
committee meeting with local medical clinics and hospi-
tals, the director shared the intake nurse’s report. After
consulting with other community partners, the committee
proposed establishing a nursing center. The hospital agreed
to fund the part-time center staffed by a PHN for one after-
noon a week for two years. Services focused on screening,
referrals, and health promotion. A review of client data after
several months identified a need for limited physician ser-
vices. A local medical clinic offered to see patients referred
by the nursing center free of charge. Another healthcare
provider purchased a mobile health unit to do mammog-
raphy outreach. The committee worked with this provider
to use the mobile unit to visit several community sites on
a monthly basis. These services were the direct result of
systems-level collaboration and advocacy for those lacking
access to healthcare.

Source: Kleinfehn-Wald, 2010

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66 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

Public health diagnoses for populations are often written
as population risk diagnoses . The traditional risk diagno-
ses have four components: health risk, population at-risk,
modifiable risk factors, and bio-statistical data . This tradi-
tional population risk diagnosis has been modified to create
an asset-based risk diagnosis by adding the component of
modifiable protective factors (see Table 3 .9) . This approach
helps to build on existing community resources and involve
community members when creating an intervention plan .

If you wish to write an asset-based public health risk
diagnosis using the Omaha System taxonomy, you would
include Domain, Problem, and Signs/Symptoms in the
health risk area and could use the KBS ratings as a way to
measure outcomes . The category of Problem as discussed in
Chapter 2 may also be used to identify strengths .

Public Health Nursing Community Action Plan
When the PHN is working with the community, the plan-
ning process and intervention process involves an interpro-
fessional team and key community members . After the team

has established priorities and formulated clear statements
of the health priorities to be addressed, it is time to deter-
mine goals . Community goals are based on community
values, beliefs, and the willingness of community members
and elected and appointed officials to make changes; the
resources available; and a consensus of what is achievable
in the given time frame . Specific outcomes are then estab-
lished . An example of a goal and an outcome for a commu-
nity follow (sometimes the words goal and outcome are used
interchangeably):
n Goal: Reduce obesity in our community
n Outcome: Reduce obesity in adults in our community

by 10% by 2020

Population Health Goals
The United States has established population health goals
each decade since 1990 . The purpose of the goals is to
encourage communities to work together to improve the
health of their citizens and to empower individuals to make
better health decisions (U .S . Department of Health and
Human Services [U .S . DHHS], 2010) . These measurable out-
comes, called health status indicators, are determined by
reviewing existing population health outcomes, comparing
specific population outcomes with outcomes from other
populations, and analyzing evidence from the literature on
acceptable outcomes . They are time-specific and stated as a
percent . For example, scientific evidence suggests that obe-
sity is a risk factor for many diseases, so reduction of obesity
in adults within the U .S . population by 2020 would be a pos-
itive health outcome . Healthy People 2020 was based in part
on the level of achievement of Healthy People 2010 goals
(Reinberg, 2010; U .S . Department of Health and Human
Services [U .S . DHHS], 2010) . Healthy People 2030 will be
based on the population progress toward achievement of
Healthy People 2020 goals . Evidence Example 3 .6 illustrates
the ongoing monitoring of level of achievement of Healthy
People 2020 goals .

TABLE 3.9 Asset-Based Public Health
Population Risk Diagnosis

Components Example

Health risk Increased risk of infection (pertussis)

Population at risk Among nonimmunized or partially
immunized infants and children in
(specify geographic area, community,
or county)

Modifiable risk
factors

Related to contact with non-
immunized children and adults who
may have pertussis, health beliefs
opposing childhood immunizations,
knowledge deficit about benefits of
immunization, lack of access to health
resources

Modifiable
Protective Factors

Related to increased funding for
outreach and immunizations to at-risk
populations through the public health
department, coalition with local
religious organizations and safety net
organizations to immunize children .

Bio-statistical data
(for geographic
area, community,
city, county, state,
national)

As evidenced by lack of herd immu-
nity (80–90% immunization) in
preschool population (state immuni-
zation rate) in (geographic area or city,
county, state, country) with (insert
number of cases) reported cases of
pertussis in the last month in infants
and children ages (insert age range) .

EVIDENCE EXAMPLE 3.6
Healthy People 2020 Goals

A mid-decade review of progress toward Healthy People
2020 goals identified that Healthy People 2020 goals
would be more modest than the 2010 goals. Only 19% of
Healthy People 2010 goals were met, and progress was
made on only 52% of them. Some, like obesity, had become
worse since 2000. U.S. obesity rates increased from 25%
to 34% between 2000 and 2010 (Reinberg, 2010), and the
prevalence of obesity in the U.S. was 35.6% between 2011
and 2014 (CDC, 2015).

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67CHAPTER 3  n  Competency #1

n Systems Level: Consult with schools to increase the
physical activities of students within the curriculum .

n Individual/family Level: Provide health education and
counseling to children and families to empower them to
develop healthier lifestyles .

The Public Health Nursing
Community Intervention Plan
PHNs work collaboratively with multiple community part-
ners to establish population health goals and to develop
intervention plans . These plans need to be consistent with
the demography, culture, and health status of the target
population and be in language that is clear to interprofes-
sional partners and the community . It may be more appro-
priate to label the plan a population health plan rather than
a nursing care plan . However, the framework of the public
health nursing process can be used effectively with interpro-
fessional as well as lay groups . Public health interventions
for population health:
n Modify the health determinant risk factors that are

causing the population health problems or disparities by
weakening or eliminating the risk factors

n Modify health determinant protective factors that will
improve the ability of at-risk and vulnerable populations
to better manage their own healthcare

Online Activity
    Go to Healthy People 2020 and study a goal of interest  
to you. 

n Identify an objective and then click “National Snapshots”  
to see how progress has been made on that goal. 

n Go to the “Interventions & Resources” tab to find evidence  
of interventions that have been effective in working to 
achieve this goal. 

Public health nurses and other public health profession-
als use Healthy People goals as well as their community-
assessment data to establish organizational and program
goals for their communities and the clients they serve . The
focus in Public Health is primary prevention; however,
PHNs will include secondary and tertiary prevention goals
when appropriate to meet unmet community needs . PHNs
often work at more than one level of practice simultane-
ously . For example, if there is a primary prevention goal to
reduce childhood obesity, the PHNs might do the following .
n Community Level: Collaborate with local television

stations to have a media campaign to increase commu-
nity level of awareness for the need to increase children’s
activity levels and to develop more afterschool sports
and activity programs for children .

THEORY APPLICATION
Population-Based Models for PHN Interventions and Outcomes

Twelve conceptual models of population-based PHN interven-
tions and outcomes published between 1981 and 2003 were
identified and compared (Bigbee & Issel, 2012). Four of the
twelve models are very consistent with the PHN community

assessment and intervention model presented in this chapter.
The following table demonstrates how these models reflect
essential components of this book’s population-based PHN
intervention plan.

Model Major Components PHN Concepts

PHN Conceptual Model (White, 1982) Determinants of health impacted by
nursing process at individual/family,
and population levels

PHN process, levels of practice, deter-
minants of health, PHN interventions,
outcomes

Community as Partner Model
(Anderson & McFarlane, 1988, 2011)

Based on Neuman’s systems model and
includes assessment wheel and inter-
ventions based on Intervention Wheel

PHN process, levels of prevention,
PH interventions from the Intervention
Wheel, outcomes

Public Health Intervention Model
(Keller-Olson et al ., 1998)

Population-based model including 17
interventions at individual, commu-
nity, and systems levels

Population focus, levels of practice,
interventions, interprofessional aspects

LA Public Health Nursing Practice
Model–LA Model (Smith &
Bazini-Barakat, 2003)

Population-based model using nursing
process to address health indicators
using Intervention Wheel

PHN process, population focus,
levels of practice, interventions
from Intervention Wheel, outcomes,
interprofessional aspects, client
participation

Source: Abstracted from Bigbee & Issel, 2012

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68 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

‘‘

’’

The Public Health Nursing Community Intervention
Plan includes the following components:
n Public health asset-based population risk diagnosis
n Population health goal and level of prevention focus
n Client focus: individual/family, community, system
n SMART behavioral outcomes that are measurable and

attainable and understandable to the family . SMART
outcomes are:

l Specific: What needs to be accomplished?
l Measurable: How will the nurse, client, and family

know the goal has been met?
l Attainable: Can the goal be met with the resources

available?
l Realistic: Does the client (and family) have the physi-

cal, emotional, and mental capacity to meet the goal?
l Time-Bound: When will the goal be achieved?
n Evidence-Based Public Health Interventions: Pub-

lic Health Intervention Wheel (Keller, Strohschein,
Lia-Hoagberg, & Schaffer, 2004; refer to Chapter 2) or
Omaha System (Omaha System, 2017) interventions may
be used . Include the intervention, the strategy or process
to be used, and the provider(s) of the intervention

n Evidence-Based Rationale for each intervention:
Include the scientific rationale with citations as well as
population preferences

n Evaluation of Outcomes: Use quantitative measures to
determine the progress made toward achievement of the
outcome . These measures to be used should be selected
during the planning process .

EVIDENCE EXAMPLE 3.7
Evaluation of a Home Visiting Program for Pregnant and Parenting Teens

After interventions are implemented, it is necessary to assess
the effectiveness of the program and the progress of the target
population toward goal and outcome achievement.
Four commonly used public health evaluation methods
identified by Spiegelman (2016) are:

n Feasibility evaluation: Assess whether something will
work and be effective in the “real world”

n Impact evaluation: Assess the efficacy and effectiveness
of an intervention on health outcomes

n Program evaluation: Assess a program’s processes to
improve them (quality improvement approach)

n Comparative effectiveness: Assess and compare
interventions to see which work best for whom, in what
situations, and from a cost-effectiveness perspective

The Pregnant and Parenting Teen program, discussed in
Evidence Example 3.8, demonstrates the effectiveness of
using all four of these evaluation methods.

Implementing population-based interventions in a com-
munity often includes collaborative efforts of many provid-
ers, organizations, and community members . Usually, a core
team develops the implementation plan timeline and selects
or designs public health intervention strategies . For exam-
ple, if social marketing is selected for a program to encour-
age parents to have their children immunized, potential
strategies could be billboards, development of online and
printed media, and radio and television adds or other forms
of media . It would be important to know when the best time
(i .e ., window of opportunity) would be to start a social mar-
keting campaign and where (before school starts in the fall,
during spring preschool enrollment, etc .) .

Kristi and her classmates complete an assessment of the
sub-population of pregnant and parenting teens in their
community and identify an unmet need for a pregnant
and parenting peer support group. They work with a
group of local churches and the Salvation Army to plan
a community-wide outreach effort with the Salvation
Army for the meeting site. The church groups and local
high school are ready to start recruiting teen participants.
They work with Kristi’s preceptor, Beth, to identify the best
time to recruit teens and start the program. They decide to
recruit teens at the time the pregnancy is confirmed, and
decide that the beginning of the next school year is a good
time to launch the program.

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69CHAPTER 3  n  Competency #1

‘‘

’’

‘‘

’’

Kristi asks her neighbor, a county commissioner, if she
would help to find funds for the pregnant and parenting
teen peer support group that will be held at the Salvation
Army. The group needs funding for transportation for the
teens and their babies to attend a support group meeting
once a week for 6 months. The commissioner asked Kristi
if she has data to support the need for transportation ser-
vices. Kristi assures her that she does. There are 20 teens
interested in joining such a group, and only two of them
have transportation. Although the local bus service has a
stop only a block away from the Salvation Army, only five
of the girls are on a bus line. That leaves 13 teens without
transportation. In addition, the PHNs have assessed all the
teens and have data that support the need for socialization
and peer group support for these pregnant and parenting
teens. The commissioner is not sure if these teens can make
a commitment to attend the group or if attending the group
would really make a difference. Kristi tells the commis-
sioner that PHNs from the county are going to be group
facilitators and would be using the Problem Rating Scale
for Outcomes to determine if the outreach and counseling
efforts are effective. Of course, she has to explain to the
commissioner what the Problem Rating Scale for Outcomes
is! The commissioner asks Kristi and her classmates to
come to a council meeting to present their proposal. Kristi
says they can do that and she will also ask her PHN precep-
tor to come to the meeting.

EVIDENCE EXAMPLE 3.8
PHN Home Visiting Program for Pregnant and Parenting Teens

A visiting nurse association created and implemented a Preg-
nant and Parenting Teen Program to promote family and child
health and family self-sufficiency for teen moms 19 years
of age or younger. The pillars of the program are: a trusting
relationship between the PHN and the teen; outreach and
coordination with schools, clinics, and human service agen-
cies; a comprehensive and intensive maternal mental health
curriculum; and community support and caring by provision
of needed resources. A comprehensive evaluation of the pro-
gram’s effectiveness and client outcomes’s success was com-
pleted after two years (Schaffer, Goodhue, Stennes, & Lanigan,
2012). Key outcomes presented by four public health evalua-
tion methods follow.

n Feasibility evaluation: 78% of the teens referred to the
program accepted the services.

n Impact evaluation: 76% of teens with 10 or more visits
continued or graduated high school compared to 56% of
teens who received 9 visits or less; 97% were up-to-date
on well-child check-ups; 95% were up-to-date on immuni-
zations; and 96% had healthy birth weight babies.

n Program evaluation: 69% referred to community
resources; 47% received needed resources.

n Comparative effectiveness: Teens with 10 or more visits
were more successful in achieving expected outcomes
than teens who had 9 or fewer visits.

Ethical Application
Community assessment and program evaluation involves
collecting data on individuals . These data are then aggre-
gated to provide for confidentiality and anonymity . How-
ever, when the group size is small or the members of the
group are easily identified, ethical issues related to privacy
rights can arise .

Kristi is concerned because there are only 20 teens who will
be participating in the initial pregnant and parenting teen
peer support program. Most of these teens are well known
in the community. She is worried that when the program
evaluation occurs, the teens will be evaluated as individu-
als. Even though their outcome data will be aggregated, it
will be difficult to provide for anonymity if there is a need
to present program outcomes to the county commissioners.

Use the ethical framework in Table 3 .10 to determine how
you would use ethical principles to make decisions about
this ethical problem .

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70 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

TABLE 3.10 Ethical Application of the Nursing Process in Public Health Nursing

Ethical Perspective Application

Rule Ethics
(principles)

n Respect the rights of individuals related to privacy, autonomy, and self-determination .
n Critique selected actions and interventions for possible unintended harmful consequences that might

occur for diverse populations in a community .
n Select interventions that promote justice through reducing health disparities .

Virtue Ethics
(character)

n Maintain the dignity and confidentiality of individuals, families, populations, and communities when
assessing their health needs .

n Be honest in communicating the purpose of selected interventions to individuals, families,
populations, and communities .

n Be an advocate for assessing the public health needs of vulnerable populations .

Feminist Ethics
(reducing oppression)

n Include voices of vulnerable populations in community assessments and in setting priorities for action .
n Emphasize the contribution of the assets that communities and diverse populations bring to resolving

public health concerns .

Table based on work by Volbrecht (2002) and Racher (2007)

n PHNs use public health nursing interventions to provide
nursing services to individuals, families, communities,
and systems .

n PHNs use EHRs and HIS to assist them in assessing and
monitoring their clients’ health status, evaluating their
clients’ progress, and determining the effectiveness of
interventions and programs . The Omaha System is the
only ANA-recognized standardized terminology that
has integrated those components .

KEY POINTS

n PHNs are accountable to the individuals and families
they serve, and the communities in which they live
and work, to take action to maintain or improve their
health status .

n PHNs work in partnership with individuals, families,
communities, and systems .

n The public health nursing process is used to assess and
intervene with individuals, families, communities, and
systems .

n PHNs collect demographic and health determinant data
when carrying out family and community assessments .

REFLECTIVE PRACTICE

It is difficult for public health nursing students to adapt to
providing nursing care in the unstructured environment
of the home and community . When students are in family
homes, they are visitors in someone else’s personal space .
Visits often do not go as planned . It takes time to develop
trust with family members who may initially be uncom-
fortable with a nurse in their home . Think about Kristi’s co-
visits with her PHN preceptor Beth to Sara, the pregnant
teen, and her mother and then the individual visit Kristi
made to complete the home environmental assessment . If
you were making that visit alone as Kristi was, consider how
you would carry out the home environmental assessment
with Sara and her mother .
n How would you prepare for the visit? What would you

wear? Do you think you should phone Patricia or Sara
to confirm the visit?

n How would you introduce yourself to Sara and her
mother and review the purpose of the visit?

n This is your first visit alone with Sara and her mother .
Think about what makes a good first visit . What would
you want to do to make your visit a good one?

n When you carry out the home environmental assess-
ment, you will probably be going into some private areas
of the home . What can you do to make Sara, her mother,
and yourself comfortable in these private spaces?

n What will you do if you are told you cannot go into
certain rooms?

n Will you share your assessment of the family home
environment as you conduct the assessment, or will you
wait until the end of the visit?

n How will you end the visit with Sara and her mother?

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71CHAPTER 3  n  Competency #1

Centers for Disease Control and Prevention . (n .d .-a) . MAP-IT:
A guide to using Healthy People 2020 in your community.
Retrieved from http://www .healthypeople .gov/2020/
implement/MapIt .aspx

Centers for Disease Control and Prevention . (n .d .-b) . Public health
101 series: Introduction to public health informatics. Retrieved
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introduction-to-public-health-informatics .pdf

Centers for Disease Control and Prevention . (2015) . Prevalence of
obesity among adults and youth: US 2011–2014. Retrieved from
https://www .cdc .gov/nchs/data/databriefs/db219 .pdf

Clark, M . J . (2008) . Community health nursing. Upper Saddle
River, NJ: Pearson/Prentice Hall .

Eriksson, I ., & Nilsson, K . (2008) . Preconditions needed for estab-
lishing a trusting relationship during health counseling—An
interview study . Journal of Clinical Nursing, 17(17), 2352–2359 .

Friedman, M . M ., Bowden, V . R ., & Jones, E . (2003) . Family
nursing: Research, theory, and practice (5th ed .) . Hoboken, NJ:
Pearson Education, Inc .

Gardner, A . (2010) . Therapeutic friendliness and the development
of therapeutic leverage by mental health nurses in community
rehabilitation settings . Contemporary Nurse, 34(2), 140–148 .

Hargate, C . (2013) . Survey. Unpublished manuscript, Bethel
University, St . Paul, MN .

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APPLICATION OF EVIDENCE

Think about the community assessment you and your class-
mates are going to complete . You are interested in deter-
mining the need for and the resources for a teen pregnant
and parenting peer support group . Your assessment is going
to be assessing a sub-group of the community (i .e ., aggre-
gate), so you need to think about whom you will want to
work with and what data you need to collect .

Review Figure 3 .4 (Community Planning Process:
MAP-IT):

1. How would you use this tool to plan a community
assessment?

2. How would you carry out the community assessment?
3. When you develop your intervention plan, you need

to consider your “window of opportunity” for imple-
mentation . How would you find your “window of
opportunity”?

4. The implementation phase requires a detailed work
plan . What would you include in your work plan?

5. The tracking phase includes measuring the effective-
ness of your intervention plan . How would you mea-
sure the effectiveness of your plan?

6. Review Evidence Example 3 .7 . What type of evaluation
would you want to include? What measures might
you use?

Review the Community-Assessment Guide . This is an
aggregate assessment . You do not have to collect all of the
community data . Think about what you need:

1. What community demographic data would you want
to collect?

2. What biological and genetic health determinant data
would you want to collect?

3. What physical environmental health determinant data
would you need?

4. What social environmental health determinant data
would be most important?

5. How would you collect information about healthcare
access?

6. Once you have all of your data collected, how would
you analyze it?

7. What would be effective methods to communicate
your community-assessment data to others?

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72 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

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Monsen, K . A ., Brandt, J . K ., Brueshoff, B ., Chi, C . L ., Mathiason,
M . A ., Swenson, S . M ., & Thorson, D . R . (2017) . Social determi-
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Monsen, K . A ., Swenson, S . M ., Klotzbach, L ., Mathiason, M . A .,
& Johnson, K . E . (2017) . Empirical evaluation of change in
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Monsen, K . A ., Vanderboom, C . E ., Olson, K . S ., Larson, M . E .,
& Holland, D . E . (2017) . Care coordination from a strengths
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Racher, F . (2007) . The evolution of ethics for community practice .
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75

‘‘

’’

CHAPTER

4
COMPETENCY #2
Utilizes Basic Epidemiological (The
Incidence, Distribution, and Control of
Disease in a Population) Principles in
Public Health Nursing Practice

n   Carolyn M. Porta 
with Noreen Kleinfehn-Wald, Linda J. W. Anderson, and Madeleine Kerr

Elizabeth has worked as a public health nurse (PHN) doing home visits on the maternal child health
team for approximately a year. One day as she is having lunch with her co-workers, someone mentions
that an outbreak of pertussis had occurred in an adjacent county. In fact, there are 42 cases! Two days
later, Elizabeth’s supervisor asks whether she can help the Disease Prevention & Control (DP & C) team
investigate 10 probable cases of pertussis.

DP & C nurses operate the immunization clinic and work with infectious disease issues, such as tuber-
culosis. Other than these activities, Elizabeth knows very little of what their day-to-day work is like.
Her supervisor explains that disease investigation is case management work. She will most likely not be
required to do any additional home visits. (Sometimes follow-up visits are necessary when it is difficult to
locate people.) She will need to plan on a limited amount of time to place phone calls, review records, and
work with community partners, such as school nurses. Elizabeth agrees to take the additional assignment
and arranges to receive orientation from the lead nurse. During this briefing, the lead nurse explains
the state’s data-privacy laws, the state health department’s infectious disease reporting requirements for
pertussis, and the report form that needs to be completed by the healthcare provider or the lab associated
with the clinic for each suspect or confirmed case. This is a lot of new information!

ELIZABETH’S NOTEBOOK
COMPETENCY #2 Utilizes Basic Epidemiological (The Incidence, Distribution,  
and Control of Disease in a Population) Principles in Public Health Nursing Practice

A. Understands the relationship between community assessment and health promotion/disease prevention
programs, especially the populations and programs with which the PHN works

B. Understands the relationships between risk/protective factors and health issues

C. Obtains and interprets information regarding risks and benefits to the community

D. Applies an epidemiological framework when assessing and intervening with communities, systems,
individuals, and families

Source: Henry Street Consortium, 2017
(continues)

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76 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

USEFUL DEFINITIONS

Agent: The primary cause of the health-related condition. Agents are most often classified into six main types:
physical agents, chemical agents, nutritive agents, infectious agents, genetic agents, and psychological agents
(Valanis, 1999). [Note that the term infectious agent has been replaced with causative factors (Merrill,
2017, p. 11).]

Communicability: The ability of a disease to be transmitted from one person to the next; communicability is
determined by how likely a pathogen or agent is to be transmitted from a diseased or infected person who is not
immune and is susceptible (Merrill, 2017, p. 43).

Environment: Reflects the aggregate of those external conditions and influences affecting the life and develop-
ment of an organism . . . physical, chemical, biological, and social factors that affect the health status of people
(Merrill, 2017, p. 214); factors external to the human or animal that cause or allow transmission (p. 8).

Epidemic: Occurrence of cases of an illness, specific health-related behavior, or other health-related events
clearly in excess of normal expectancy in a community or region (Merrill, 2017, p. 5).

Epidemiological Triangle: Shows the interaction and interdependence of the agent, host, environment, and time
(Merrill, 2017, p. 8).

Epidemiology: The study of the distribution and determinants of health-related states or events in human
populations and the application of this study to the prevention and control of health problems (Stedman’s
Medical Dictionary for the Health Professions and Nursing (5th ed.) in Merrill, 2017, p. 2).

Herd Immunity: Resistance a population has to the invasion and spread of an infectious disease. Herd immunity
is accomplished when the number of susceptible people is reduced and the number of protected or non-
susceptible people dominates the herd (population); provides barriers to direct transmission of the disease;
occurs when 85% level of immunity exists (Merrill, 2017, p. 53).

Host: The human being affected by the particular condition under investigation. Factors that the host brings
to the triangle include intrinsic factors (age, gender, race, etc.), physical and psychological factors, and the
presence or absence of immunity (Clark, 2008). Host can be a human or animal that is susceptible to disease
(Merrill, 2017, p. 8).

Immunity: The state of nonsusceptibility to a disease or condition. Types include (a) active immunity, where the
host is exposed to the antigen through having the disease or via immunization; and (b) passive immunity, where
antibodies are provided to the host via immune globulin or mother-to-fetus transfer across the placenta—
passive immunity is short-lived (Merrill, 2017, p. 52).

Incidence: The number of individuals who develop the disease over a defined period of time (Le, 2001) or the
number of new cases of a particular health-related state or event reported over a specific period of time
(Merrill, 2017, p. 74).

Life Course Epidemiology: The study of long-term effects on later health or the risk of disease due to physi-
cal or social exposures during gestation, childhood, adolescence, young adulthood, and later adult life (Kuh,
Ben-Shlomo, Lynch, Hallqvist, & Power, 2003, p. 778).

Prevalence: The presence of a disease or health condition in a given population at a given point in time divided
by the number of persons in that population (Friis, 2018, p. 64).

Protective Factor: Health determinants that protect one from illness or assist in improving health
(see Chapter 1).

Risk Factor: A condition that is associated with the increased probability of a health-related state or event
(Merrill, 2017, p. 3). Risk factors are also health determinants (see Chapter 1).

Surveillance: The ongoing systematic collection, analysis, interpretation, and dissemination of health-related
data to improve the health of populations (Centers for Disease Control and Prevention [CDC], 2001). Public
health surveillance is the systematic ongoing collection, analysis, interpretation, and dissemination of health
data (Merrill, 2017, p. 112).

ELIZABETH’S NOTEBOOK  (continued)

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77CHAPTER 4  n  Competency #2

n Which interventions can reduce the spread of this
occurrence/disease?

n Will I be working at the individual/family, community,
or systems level?

n Do I need to consider any ethical issues?
n How will I know whether the interventions are effective?
n What could have prevented this outcome?

At its core, epidemiology is the study of solving
mysteries—of understanding where and to what extent
diseases, events, and behaviors are influencing the health
of populations. Epidemiology is more than simply under-
standing what is going on. It also involves acting on what
you learn to prevent or control problems. Similarly, a PHN
should be committed not only to understanding what is con-
tributing to a problem and the extent of the problem but also
to identifying and implementing disease prevention and
health promotion strategies. In fact, this use of core epide-
miological tools—namely, mathematics and data analysis—
contributed to advancing the role and view of nursing in
the 19th century (Earl, 2009). See Evidence Example 4.1 to
examine how Lillian Wald and Florence Nightingale used
data gathering and analysis to understand and address key
health problems. By doing so, they advanced the profession
of nursing beyond what had, up until that time, been a fairly
ill-considered occupation.

Using Data to Solve Health
and Disease Mysteries
Nurses often want to know why something happens or does
not happen. This inquisitive nature is useful when nurses
are working to prevent something from happening or to
intervene before something gets worse. In some situations,
if questions are not asked, credible solutions might be over-
looked, and health outcomes might not be optimal. In a
worst-case scenario, lives might be lost or seriously harmed
if the status quo is maintained and curious questions are
not asked and acted upon. At the foundation of effective
population-based public health nursing is the science of epi-
demiology. Epidemiology guides the questions that PHNs
ask and the steps that they take to find answers and solu-
tions. Following is a list of questions nurses ask or should
ask regularly:
n When did the problem start (end, worsen, improve)?
n What has contributed to the change? Triggered a

response?
n Why have x, y, z not improved?
n How did this occur?
n Who should be involved to contribute to the solution?
n Where are available resources to aid in addressing this

situation?

EVIDENCE EXAMPLE 4.1
Origins of Epidemiology and Nursing

Catherine Earl (2009) has written a fascinating and thorough
historical article that describes the influence of epidemiol-
ogy in the developing role of public health nursing. Beginning
in the early 19th century, Earl presents a summary of history
that reminds the reader of how far nursing and science have
come in the past 200 years. Not that long ago, diseases were
addressed solely within the individual, with little appreciation
given for trends among the group or population. Advances
in mathematical theories caused a shift, notably when Pierre
Charles Alexandre Louis, a leading 19th-century physician,
declared that the practice of bloodletting (often with the help
of leeches) was ineffective and used statistics to support his
claims. It is intriguing that, according to Earl, the use of quan-
titative methods was not well supported at that time and was
poorly understood. In the 21st century, quantitative analyses
are core to randomized controlled trials (RCTs), which are con-
sidered the gold standard for establishing evidence.
Lillian Wald used this advance in health and science to sup-
port her work with families in New York. She advocated for
nurses to live and work near and among those they were also
serving. She used numbers to support her need for resources,
including the number of nurses. Her successes are many, and
they are in part based on her foresight and wisdom in rec-
ognizing the need for data to accomplish goals and meet the

health and social needs of society. Earl summarizes well the
contribution PHNs—led by Lillian Wald—made in addressing
tuberculosis, because they collected and reported critical data:
“Nurses’ involvement in the care of TB [tuberculosis] patients
in 1914 was considered a major advancement in the use of sta-
tistical methods, because nurses became involved in improv-
ing health through their role as data collectors” (p. 262).
Florence Nightingale, considered by many to be the first
biostatistician and the first epidemiologist, also used data to
support her efforts to address health and sanitation. In her era,
it was not common for women to be educated, yet her father
encouraged her to learn varied subjects, including mathe-
matics. As a result, Nightingale had skills that enabled her to
identify causes of problems and to intervene not only to heal
or cure but also to prevent. As Earl states, “With an epidemi-
ological perspective and further discussions of mortality and
morbidity rates and the importance of sanitary conditions as
described by Florence Nightingale, the first preventorium, a
program established to save children, was designed for the
prevention, not the treatment, of TB” (p. 263). Both Lillian
Wald and Florence Nightingale contributed to a significant
shift from solely focusing on treatment to also concentrating
on prevention, which today is also a primary focus of PHNs all
over the world.

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78 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

’’

‘‘

Although most PHNs are not epidemiologists, many
activities that PHNs engage in parallel the work of epide-
miologists. Often, epidemiologists work at the systems level
of a healthcare facility or state health department and are
responsible for the data collection, analysis, and program
development related to a particular health/medical issue.
Conversely, PHNs are frequently found in the grassroots
level of healthcare, working with local vulnerable popula-
tions and community partners, interpreting and promot-
ing the recommendations, protocols, and policies that have
been developed by an authoritative body. See Table 4.1 for a
sample list of activities that an epidemiologist often engages
in, and note the similarities to many public health nursing
activities and interventions.

Elizabeth realizes she needs to have a better understand-
ing of terms that she is reading as she investigates state
and county reports about infectious disease threats in her
community. She is getting confused by the different labels
for cases and isn’t exactly clear on the difference between
quarantine and isolation. She finds the following defini-
tions that provide clarity and adds them to her notebook:

✔ Case: Person or population identified as having a particular
disease, disorder, injury, or condition (Merrill, 2017, p. 7)

l Primary case: The first disease case in the population (p. 7)

l Index case: The first disease case brought to the attention
of the epidemiologist (p. 7)

l Secondary case: Persons who have become infected and ill
after contact with a primary case (p. 7)

✔ Incubation period: Time interval between the invasion by
an infectious agent and the appearance of the first signs or
symptoms (Friis, 2018, p. 284)

✔ Isolation: Persons who have a communicable disease are kept
away from other persons for a period of time that corre-
sponds generally to the interval when the disease is commu-
nicable (Friis, 2018, p. 284)

✔ Quarantine: Persons, animals, or objects that have been
exposed to a contagious disease are kept away from other
persons for a specified period of time (adapted from Merrill,
2017, p. 57)

Historically, nurses participated in epidemiological inves-
tigations to determine the cause of a recurring problem, such
as cholera outbreaks. As part of that process, nurses realized
very early on that numerous risk factors often contributed to
the spread of disease. This realization led to creative inter-
ventions that had multiple components to aid those already
sick or affected and to prevent others from becoming sick.
Quarantine (i.e., separation of an exposed individual from
the rest of the community) laws are a good example of a spe-
cific effort to contain the spread of disease in the absence
of other strategies. Interestingly, quarantine strategies are
still used today, because some infectious viruses can spread

TABLE 4.1 Alignment of Epidemiologist
Activities With PHN Intervention Wheel

Epidemiologist
Activities

Public Health Nursing
Activities and
Interventions

Identifying risk factors for
disease, injury, and death

Disease and Health Event
Investigation

Describing the natural
history of disease

Health Teaching

Identifying individuals and
populations at greatest risk
for disease

Outreach

Screening

Referral and Follow-Up

Advocacy

Case Management

Identifying where the public
health problem is greatest

Surveillance

Disease and Health Event
Investigation

Monitoring diseases and
other health-related events
over time

Surveillance

Evaluating the efficacy and
effectiveness of prevention
and treatment programs

A key part of the nursing
process, but not a specific
component of the interven-
tion wheel

Providing information useful
in health planning and
decision-making for estab-
lishing health programs with
appropriate boundaries

Consultation

Collaboration

Community Organizing

Policy Development and
Enforcement

Assisting in carrying out
public health programs

Most interventions on the
Public Health Intervention
Wheel

Serving as a resource Consultation

Communicating health
information

Outreach

Health Teaching

Social Marketing

Consultation

Source: Adapted from Merrill, 2017

during an incubation period before symptoms are present.
Examples of such illnesses in the 21st century include per-
tussis, chicken pox, measles, Ebola, avian influenza, and
seasonal flu. When an individual is diagnosed with pertus-
sis and other family members have been exposed, the per-
tussis case is strongly encouraged to stay isolated from the

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79CHAPTER 4  n  Competency #2

home environment remains unchanged, the child’s recov-
ery might not be maintained. In this case, the nurse might
link the family to resources such as financial heat assistance,
food banks, food stamps, etc. The nurse might begin to cre-
ate long-term solutions by helping adult family members to
explore financial management strategies as well as possi-
bilities for higher-paying employment or more affordable,
reliable housing. Finally, the nurse might advocate for leg-
islation that prohibits companies or landlords from turning
off heat sources during cold winter months. Nurses encoun-
ter numerous possible mechanisms for influence when they
face a problem that might appear to have a simple solution
but often requires complex intervention approaches to keep
that problem from recurring.

Understands the Relationship Between
Community Assessment and Health
Promotion and Disease Prevention
Programs, Especially the Populations and
Programs With Which the PHN Works
Many public health agencies and community organizations
use community assessments to prioritize their resources
and subsequent programs and services. Fundamental to the
community assessment is the understanding of the inci-
dence and distribution of disease in the community. The
PHN might begin by reviewing the birth and death (mor-
tality) data available through the state department of health.
Morbidity (illness/disease/injury not resulting in death)
data can also be reviewed to determine trends in reportable
diseases (such as tuberculosis or sexually transmitted infec-
tions) or conditions such as cancers or motor vehicle fatali-
ties. A comprehensive review of data sources generally leads
and directs the community assessment process.

A variety of other strategies (e.g., needs assessment via
focus groups or key-informant interviews, windshield
survey) can be used to expand the community assess-
ment. (See Chapter 3 for more information on community
assessment.) PHNs work collaboratively in conducting
assessments and using the resulting data for informing pri-
orities and actions. Although it might be natural to focus on
needs because the nurse is trying to address a problem, it is
extremely valuable to take an asset-based approach toward
the issue (Lind & Smith, 2008). An asset-based approach
ensures that the assessment includes documentation of
existing or potential strengths. In this way, the possible
problem-solving strategies will ideally build on identified
strengths and assets. If nurses focus only on problems, they
might reach a solution that consists of outside resources
rather than builds on what is available. Asset-based per-
spectives inherently encourage capacity building as well as
self-care among individuals and families, communities, and
populations. (See Chapter 8 for discussion of incorporating
community assets.)

broader community until five days of antibiotic treatment
have been completed. During the Sudden Acute Respira-
tory Syndrome (SARS) event in 2002 and 2003, quarantine
of exposed individuals was key to containing the epidemic.
Individuals placed under quarantine were monitored twice
daily by public health workers until the SARS incubation
period was completed. Although quarantines are not always
enforced as they were years ago and in the SARS event, they
can be effective when they are followed and when individu-
als and families adhere to the restrictions.

More broadly, Lillian Wald offers a great example of a
PHN using a variety of intervention tools to address uncon-
trolled disease and unnecessary deaths in New York City
tenements, as shown in Figure 4.1. At the individual level,
she provided direct care for sick individuals in crowded
apartments. At the community level, she organized com-
munity care for neighborhood children in need of a place
to engage in physical activity. At the systems level, she advo-
cated for programs that would meet the needs of many (e.g.,
welfare, food accessibility, child labor laws).

Today’s PHN needs a repertoire of intervention strat-
egies so that when health improves, it can be maintained
over time—which is sometimes hard to do, especially in
the presence of poor health determinants. For example, if
a child recovers from an illness that worsened as a result
of malnourishment and lack of warmth, but the family

FIGURE 4.1 How Lillian Wald Practiced the  
Individual/Community/System Approach to Healthcare

Individual/Family
Provided direct care
for sick individuals

Community
Organized community
care for neighborhood
children

System
Advocated for programs to
meet the needs of many
(welfare, food accessibility,
child labor laws)

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80 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

’’

‘‘ because of fear, and without a known cause, they had little
confidence that the disease could be stopped or prevented.
John Snow created a map that began to identify where the
deaths from cholera were occurring across London. This
now-famous map (see Figure 4.2) yielded some clues for
Snow, because he managed to visualize the areas where
the deaths were most heavily concentrated. He suspected
a water source, so to prohibit people from accessing this
source of “risk,” he removed the water pump handle:

1854: Physician John Snow convinces a London local
council to remove the handle from a pump in Soho. A
deadly cholera epidemic in the neighborhood comes to
an end immediately, though perhaps serendipitously.
Snow maps the outbreak to prove his point… and
launches modern epidemiology (Alfred, 2009, p. 1).

In the 21st century, PHNs continue to solve mysteries in
identifying and eliminating health risks, and although con-
ditions have improved in many parts of the world, reducing
the risks from unsanitary conditions, these improvements
are not universal. Consider the following observation:

The 2010 cholera epidemic in Haiti (and the 2017 chol-
era outbreak that persists in Yemen) reminds us that
cholera remains a deadly disease, not all that differ-
ent from the time of John Snow. While Snow debated
the appropriateness of the germ theory versus the
miasmatic theory for the cause of the disease, cur-
rent scientists are focusing on different, but related,
hypotheses (University of California, Los Angeles
[UCLA], 2010, p. 1).

Elizabeth looks at the faxed pertussis report she has been
given on 11-year-old Billy Johnson. Information includes
Billy’s birth date, address, phone number, and laboratory
results, which are positive for pertussis. Next, Elizabeth
looks up Billy in the computerized state immunization
registry. She sees that he was vaccinated with five doses of
DTaP vaccine, the last of which was administered at 5 years
of age. Elizabeth recognizes that the immunity provided by
the vaccine has possibly waned.

Activity
Reflect on the following questions:

n What has Elizabeth discovered so far? 

n What are her next steps? 

Understands the Relationships
Between Risk and Protective Factors,
and Health Issues
No better classic example of understanding the relation-
ship between a risk factor and a health issue exists than
that of John Snow in mid-1800s London (Alfred, 2009). For
unknown reasons, many people in London began to suffer
and die as a result of cholera. People were fleeing the city

FIGURE 4.2 A Map Detailing Cholera Deaths in 1800s London; the Beginning of Epidemiology
Source: Alfred, 2009

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81CHAPTER 4  n  Competency #2

‘‘

Indeed, it is true that more than a century since Snow’s
solved mystery, PHNs continue to seek clear answers and
solutions regarding the risks and diseases that are present in
public health settings across the globe. In the United States,
PHNs face complex challenges in meeting the needs of indi-
viduals, families, communities, and populations. Nurses
need to identify risk and protective factors at multiple influ-
encing levels. For example, a nurse might be working with
a child recently diagnosed with asthma. The nurse needs to
identify risk factors in the family environment that might
be triggers for asthma episodes. Similarly, the nurse needs
to assess for protective factors in the family, such as parental
commitment to preventing episodes, which is an import-
ant asset the nurse can support with education and related
tools. The nurse might want to go further and explore the
neighborhood environment, including collaborating with
school personnel, for possible risks or protections influenc-
ing the child.

It can take time to carefully and thoroughly assess risk
and protective factors using a strengths-based approach.
Usually, the time is well spent because the PHN will have
a very clear picture of available assets as well as deficits
to address when intervening on a particular health issue.
Doing this proactively is a critical part of health promotion.
Conducting assessments of risk and protective factors after
a health issue has become apparent is important to mini-
mize the effect of the health problem and to encourage pos-
itive intervention results. PHNs continually reassess for risk
and protective factors, because these factors can be tempo-
ral; one day a risk might exist (e.g., lack of health insurance
coverage), but the following week the family might have new
health insurance coverage. PHNs commit to efforts that
routinely assess, intervene, evaluate, and reassess.

A PHN also stays informed about emerging diseases and
pandemic threats. For example, during 2015 pertussis cases
decreased by 37% compared with 2014. See Table 4.2 for
states that had the highest reported rates of pertussis in 2015.
The majority of deaths continue to occur among infants
younger than 3 months of age, and the incidence rate of per-
tussis among infants exceeds that of all other age groups.
The Centers for Disease Control again observed increased

TABLE 4.2 States With Incidence of Pertussis the Same or Higher Than the National Incidence
During 2015, Which Is 6.5/100,000 Persons

Nebraska 27.2 Oregon 14.6 Minnesota 10.9

Montana 22.3 Kansas 14.5 California 9.2

Maine 21.1 Alaska 14.2 Arizona 8.5

Washington 19.3 Wisconsin 13.1 Vermont 7.8

Colorado 16.7 Idaho 11.7 Pennsylvania 6.9

Utah 16.6 New Mexico 11.6

Source: 2015 Final Pertussis Surveillance Report, Centers for Disease Control and Prevention [CDC], 2015

rates in adolescents ages 13–15 as well as in 16-year-olds.
In the case of pertussis, the PHN would recognize pertus-
sis vaccination as a protective factor. Lack of vaccination,
waning immunity from vaccination, and posing immune-
compromising conditions would be risk factors.

Elizabeth prepares to call Billy’s parents. She places the pro-
tocol nearby and has her report form ready. Billy’s mother
answers the phone, and Elizabeth introduces herself as a
PHN who works with infectious diseases. She explains how
she has obtained a pertussis report on Billy and inquires
whether his mother has about 15 minutes to speak with her.
Billy’s mother states that she operates an in-home daycare,
but most of the children have not yet arrived.

Elizabeth mentally notes this information about the
daycare and then explains that the purpose of the call is
to identify what can be done to prevent the spread of the
disease. Elizabeth starts with what she thinks is the most
logical question—when did this cough start? Billy’s mother
recalls that he started coughing on September 17 and had
a paroxysmal cough without a whooping sound. He occa-
sionally coughed so hard that he vomited. About 1 week
before his cough started, he had a low-grade fever and a
runny nose.

Because his cough was not getting any better, his mother
brought Billy to the clinic on September 26. Billy did not
have pneumonia or any other complications of pertussis. He
was given azithromycin antibiotic and is now on his third
day of a 5-day course of treatment. Elizabeth jots down a
note that states the period of infectivity started about Sep-
tember 10, or about a week before the cough started.

Next Elizabeth asks how many other family members
are in the home. Billy lives with his parents and has no
siblings. Neither parent has been coughing. Elizabeth dis-
cusses with his mother the public health recommendation
that other household members take a preventive course of
antibiotics. She agrees to call the clinic for prescriptions.

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82 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

’’

a PHN might be interested in exploring trends related to
tuberculosis cases in the community over the past 5 years—
that is, the nurse is doing surveillance of TB in the juris-
diction (see Figure 4.3). The data in a graph form provide
a snapshot of how the number of cases is increasing, main-
taining, or decreasing. In the tuberculosis example, it is
apparent that active TB cases are progressively increasing,
whereas latent TB cases can dramatically decrease, increase,
and then stabilize. This information might lead the PHN to
ask questions about pulmonary versus nonpulmonary TB
or population changes in the community and explore spe-
cific intervention strategies to reduce the number of active
TB cases over the next few years.

healthypeople.gov

Healthy 
People

  The Healthy People 2020 website offers  
  opportunities to explore the uses of data in  
  public health. On the website, click “Data 
Search.” From here, you can do a data search on a public health 
topic of interest to you. Select the health topic and then limit 
your search by a variety of factors, such as sex, age, race/ 
ethnicity, and geographic location. The results are presented 
using the Healthy People 2020 indicators (goals/markers) and 
show trends over the past few years. What do you observe in 
the data you explore? How might these data be useful to a PHN 
engaged in health promotion?

Data Trend per 100,000 in a Graph
Similarly, a PHN might examine the trend of chlamydia
cases over a period of five years. Rather than looking at
the raw number of cases (as in the tuberculosis example),
the PHN might prefer to examine the rate of cases, which
is always based on a ratio or number of cases per 100,000
persons. The raw case number in the tuberculosis exam-
ple does not give a picture of how serious the problem is,

To further assess for close contacts, Elizabeth asks
questions about Billy’s school. Billy told his mother “a lot
of kids” were coughing in his classroom. Elizabeth states
that she will talk to the school nurse about sending a noti-
fication letter to the parents of the students in Billy’s class-
room; Elizabeth is careful to inform the mother that Billy
will not be identified in the letter. Elizabeth explains that
she will also be working with the school to identify children
who sit adjacent to Billy, as they might also need preventive
antibiotics.

Obtains and Interprets Information
Regarding Risks and Benefits to
the Community
PHNs need to know how to find and use data. Data drive
so much of what PHNs do. In fact, PHNs determine health
priorities by using data to identify key problem areas or con-
cerns. PHNs also use data to evaluate whether interventions
or programs are successful in reducing the risks or health
problems in a local community. Unfortunately, data are not
always easy to interpret or understand; data are often pre-
sented in such formats as tables, figures or graphs, or raw
numbers. They might be posed as percentages or risk ratios.
Although in-depth knowledge of data, formulas, and calcu-
lations is not necessary for entry-level PHNs, some aware-
ness of how to read data and data types is useful.

Data Trend in a Graph
Often, data are presented over time by using graphs to show
what is happening in a community with respect to a par-
ticular health problem or population trend. For example,

FIGURE 4.3 Sample Trend of Active and Latent Tuberculosis Cases in a Community

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83CHAPTER 4  n  Competency #2

because the graph does not indicate how many people are
in the community. For example, if the community popu-
lation count were 100 and there were 50 cases of latent TB,
the PHN would be much more concerned than if there were
50 cases in a community population of 100,000. In the chla-
mydia example, the rate of cases appears to be increasing,
from around 340 per 100,000 in year 1 to nearly 428 per
100,000 in year 5 (see Figure 4.4). This increase is concerning
by itself, but the PHN might want to compare the rate in one
community with the rate in another community. Compar-
ing rates in different communities or populations provides
the PHN with perspective about the relative severity of the
disease incidence or prevalence and helps determine how to
prioritize efforts to prevent the spread of chlamydia.

Evidence Example 4.2 discusses using data regard-
ing incidence rates to identify a problem and evaluate the
impact of a system-wide intervention—in this case the rate
of tuberculosis among correctional system inmates.

Data Comparison Between State  
and National Sources
Comparing health and disease trends across communities
can be challenging and create turmoil if it is not done care-
fully. No community wants to appear worse than another
when it comes to a health problem or condition. On the other
hand, if resources are scarce, a community might want to
justify acquiring greater access to available resources. Care-
ful comparison of data within and across communities is
vital to ensure that public health priorities are appropriate
and that the chosen resource allocation is warranted. Com-
parison is useful because it can bring understanding of the
severity or scope of a problem, especially if policymakers
are unaware of the problem or not convinced that it requires
attention.

EVIDENCE EXAMPLE 4.2
Use of Epidemiological Tuberculosis Data to Inform 
a New York State Corrections Intervention

In a study addressing tuberculosis, data were used to inform
strategies to prevent increases of tuberculosis among
inmates in the New York State Corrections system (Klopf,
1998). Data indicated that the incidence of tuberculosis
had increased over a 6-year period from 43 per 100,000
to 225 per 100,000, a serious problem that warranted
intervention. Collaboratively, people from corrections, the
local department of health, and the parole division devel-
oped a comprehensive TB control program that focused on
the prevention and containment of disease. Importantly,
they implemented a nurse-led case management program,
using infection control nurses to carefully monitor and
intervene on active and suspected TB cases. The program
was truly comprehensive, including policies, development
of a TB registry, surveillance, detection, and case man-
agement involving preventive and directly observed ther-
apy among the inmates. The staff and inmates received
education regarding testing, diagnoses, disease process,
and treatment. It is believed that this comprehensive pro-
gram contributed to the reduced incidence of TB. Six years
later, the rate decreased from 225 per 100,000 to 61 per
100,000—a 73% reduction! The data informed the need
for an intervention that relied heavily on nurses. The data
also demonstrated, in part, the impact of the intervention
program, showing a significant reduction in the new cases
of TB among New York’s inmates.

FIGURE 4.4 Chlamydia Example of Case Rate per 100,000 Over 5 Years

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84 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

different timeframes, and it’s good to note when discrepan-
cies exist. In Figures 4.5 and 4.6, both MDH and CDC data
are reported for 2015, which offers a useful comparison. An
effective PHN tries to find the most comparable data possi-
ble but does point out discrepancies when comparisons are
made between incomparable data. Using data that are not
a perfect match is not wrong, but these differences must be
identified so that people can make informed decisions based
on the existing data. It might not be true that people can
make data say exactly what they want them to say, but it
certainly is possible to inadvertently or purposefully present
data in ways that might not be entirely accurate. Therefore,
PHNs need to spend time practicing how to present data in
meaningful, representative ways, and, equally vital, they
need to have the ability to interpret and critique any data
that are presented to them.

Data Comparison Between National  
and Global Sources
To understand the context from which a client originates, a
PHN may be interested in disease incidence in other parts
of the world. The earlier PHN who graphed active TB cases
against latent TB cases may have found increasing numbers
of families from several parts of the world now living in her
community. Reviewing information from the World Health
Organization (WHO) will inform her of the distribution
of TB elsewhere. This information can then be applied to
determine communicable disease risk related to immigra-
tion patterns in her community.

Data as Population Trends
Equally valuable are data that demonstrate population
trends. These are most commonly presented in the form of
a population pyramid, which at a glance provides a picture
of population growth (see Figure 4.7). In this figure, the age
distribution of people in the U.S. is portrayed. Compared
with other years, one can visually see changing trends in
population age distribution. This could be valuable to
determining priorities for PHN interventions, particularly

A good example of this scenario is Lyme disease, which
is contracted through exposure to ticks. Lyme disease cases
between 1996 and 2016 have varied from 252 to 1,431 cases
in Minnesota and have steadily increased since 2002 (see
Figure 4.5). However, without being able to compare these
numbers to those of another state, it is difficult to determine
whether the problem is serious or relatively consistent with
national trends. The PHN investigating this issue might
look beyond state-level data to what is occurring nationally.
Review of national data provided by the CDC demonstrates
that Minnesota has one of the highest density areas of Lyme
disease, second only to states along the East Coast (see
Figure 4.6). The data in Figure 4.6 are from a Geographic
Information System (GIS) wherein a dot is placed within the
county of residence for each confirmed case of Lyme disease.
GIS is an example of a mapping tool that PHNs may use for
surveillance. (See “Innovative Data Collection: Maps and
Apps,” for more GIS information.) These data would sup-
port efforts by PHNs to bring attention to the problem and
to invest in preventive messages for Minnesotans regarding
the spread of Lyme disease.

Often data are not easily and perfectly comparable
between sources due to different years of reported data or

EVIDENCE EXAMPLE 4.3
Comparing Virtual and Outpatient Tuberculosis 
Clinic Models of Care

In a recent study, the use of a virtual public health clinic was
compared with a traditional outpatient clinic for managing
tuberculosis in a Canadian province (Long, Heffernan, Gao,
Egedahl, & Talbot, 2015). The TB prevention and care model
was delivered through one virtual and two outpatient clin-
ics, which were subsequently assessed on 28 performance
indicators. Overall, one clinic type did not demonstrate
superiority to the other, which is promising for virtual or
tele-health models of healthcare delivery and management
for challenging public health concerns such as TB.

Addressing Asthma to Improve Health in Cities

GOAL 11 Nurses are on the front line globally for addressing asthma, which is the most common
chronic condition among children that can have long-term consequences when left undiagnosed and
undertreated. Nurses in Iceland and the United States developed an International School Nurse Care
Coordination Model that informs strategies addressing asthma at both the student and the school
levels, including symptom management, care coordination within and outside the school setting, and
broader educational strategies (Garwick et al., 2015). Collaborative efforts such as this offer promise of
achieving this SDG by recognizing where global challenges might be met with similar strategic models.

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85CHAPTER 4  n  Competency #2

FIGURE 4.6 Reported Cases of Lyme Disease—United States, 2016 
Source: Centers for Disease Control and Prevention [CDC], 2016

FIGURE 4.5 Reported Cases of Lyme Disease in Minnesota, 1996–2016 (n = 17,744)
Source: Minnesota Department of Health [MDH], 2016

Reported Cases of Lyme Disease
in Minnesota by Year, 1996–2016 (n = 17,744)

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86 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

be interested in more in-depth statistical comparisons and
analysis, such as chi-square analysis. PHNs might not rou-
tinely calculate these numbers, but they often read and ana-
lyze research that includes reported rates, risk ratios, odds
ratios, chi-squares, and levels of significance (i.e., p < .001
or p < .05). It is beyond the scope of this book to completely
explain how to calculate each of these, but it is useful for
PHNs to have an awareness of what the numbers mean and
how to appropriately interpret them.

Table 4.3 shows an example of data used to calculate odds
and an OR. This ratio is useful in identifying the odds of con-
tracting the disease, given the presence or absence of a risk
factor. The formula for calculating the OR is (a/c) / (b/d) =
ad/bc. Specifically, the odds of contracting the disease in the
presence of the risk factor is calculated by dividing the num-
ber of people with the disease and the risk by the number of
people without the disease but with the risk (i.e., 75/25, or 3).
Similarly, the odds of contracting the disease but not having
the risk factor can be calculated 2/98, or 0.0204. The OR is
calculated by dividing the odds with the risk factor by the
odds without the risk factor (3/0.0204), or 147. In this exam-
ple, someone with the risk factor is 147 times more likely to
contract the disease than someone without the risk factor. A
PHN with this information needs to make decisions on how
to act based on many factors. For example, even though the
OR is so high, the disease might not be life threatening, or

when resources are limited. Population data are important
because they offer a glimpse into the big picture of how peo-
ple are distributed, but the data by themselves might not be
sufficient to guide intervention decisions or justify program
budget priorities.

Data as Risk Ratios and Odds Ratios
Another very common tool used to examine the data regard-
ing risks and health outcomes is a 2×2 table (see Table 4.3).
This table aids in understanding how a disease is distributed
in a population based on the presence or absence of a risk fac-
tor. From this table, a PHN can calculate the rate of disease
in each group; the risk ratio (RR: the rate of disease for those
with the risk behavior divided by the rate of disease for those
without the risk behavior); and the odds ratio (OR), which
is regularly used to describe the likelihood of contracting a
disease for someone with the risk factor compared to some-
one without. In the example shown in Table 4.3, the rate of
disease for the “Yes” risk behavior group is 0.75 (75/100),
and the rate of disease for the “No” risk behavior group is
0.02 (2/100). Already a relationship between the risk behav-
ior and the disease seems obvious given the raw rates (0.75
versus 0.02). Taking this a step further, you can calculate
the RR (0.75/0.02 = 37.5). PHNs do not often use the RR by
itself, but it is an important calculation for those who might

FIGURE 4.7 Population Pyramid of United States—2016
Source: Central Intelligence Agency: The World Factbook, 2016

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87CHAPTER 4  n  Competency #2

Innovative Data Collection:  
Examples of Maps and Apps
Data are typically collected through surveillance systems
at the local, state, or national levels. Sometimes healthcare
professionals provide the data, and other times individuals,
families, or communities are surveyed. PHNs need to be
aware of the variety of tools used to collect epidemiologi-
cal data, because they might participate in data collection,
interpretation, or dissemination. A Geographic Informa-
tion System (GIS) is an example of a tool growing in pop-
ularity in the field of public health. Technological advances
make it possible for local PHNs (and the general public) to
access GIS data and contribute to mapping efforts readily
via smartphones, tablets, and laptops.

GIS tools can yield data useful to a neighborhood, com-
munity, state, or country in advancing public health pri-
orities. The County Health Rankings & Roadmaps provide
an annual check-up of the health of each county in the U.S.
(County Health Rankings & Roadmaps, 2012). This publica-
tion shows that some places are doing very well, while oth-
ers have room for improvement. Figure 4.8 shows maps that
provide insights about health outcomes and health factors
in Minnesota, with healthier counties depicted in lighter
colors. See Figure 4.8, County Health Rankings & Road-
maps; and Figure 4.9, a sample interactive GIS map from
the California Department of Public Health that addresses
nutrition, from www.cnngis.org.

TABLE 4.3 Association Between
Risk Factor and Disease

Disease

Risk Factor Yes No Total

Yes a c a + c

No b d b + d

Total a + b c + d a + b + c + d

Disease

Risk Factor Yes No Total

Yes 75 25 100

No 2 98 100

Total 77 123 200

the risk factor might not be common. The risk factor might
easily be eliminated with an intervention, or the risk factor
might not be easily identified, making it difficult to inter-
vene. PHNs need to consider numerous factors when data
are interpreted and then acted upon. PHNs have an import-
ant role in helping interpret data so that they are not used
inappropriately to justify action or inaction.

FIGURE 4.8 County Health Rankings & Roadmaps: Minnesota 
Source: County Health Rankings & Roadmaps, 2018

2018 Health Factors: Minnesota2018 Health Outcomes: Minnesota

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88 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

n Federal Emergency Management Agency (FEMA)
Geoplatform (at http://fema.maps.arcgis.com/
home/index.html) provides geospatial data and
analytics for emergency management (see also
www.geoplatform.gov)

n FEMA Geospatial Coordination Mapping
and Data (see https://data.femadata.com/
NationalDisasters/HurricaneHarvey/Documents/
Geospatial%20Coordination%20Call%20Notes/
for Hurricane Harvey examples)

n American Red Cross Online Mapping provides infor-
mation about open shelters and ongoing storm data (see
http://arc-nhq-gis.maps.arcgis.com/home/index.html)

n National Oceanic and Atmospheric Administration
NowCOAST provides real-time coastal observations,
warnings, and forecasts (see https://nowcoast.noaa.gov/)

n Ushahidi crowdsource mapping was used to aid
in response and recovery efforts (see https://
irmamiami.ushahidi.io/views/map) including oil
spill tracking after Hurricane Harvey (see https://
skytruth.ushahidi.io/views/map)

GIS data are also being used to carefully examine
community-level assets and risks related to public health
problems such as obesity prevention. For example, GIS data
can aid in understanding how communities compare in
terms of access to full-scale grocery stores, corner supermar-
kets, gas stations, and liquor stores. Additionally, GIS data
can indicate the location of parks and transpose (e.g., over-
lay) violent crime data, which might provide insights into
why youth in certain neighborhoods are reporting higher
levels of physical activity than youth in other neighborhoods.

In emergency situations, GIS programs are playing a cru-
cial role. In Haiti in 2010, a GIS program was used within
the first few hours after the earthquake to update a base-
line map of Haiti. People on the ground used OpenStreet-
Map, a GIS crowdsourced mapping program, to modify the
existing map in real time, thereby facilitating rescue efforts.
The pre-earthquake terrain maps that existed were not very
helpful, but the real-time maps provided valuable support to
search-and-rescue teams. Since then, the use of GIS to map
disaster events and response has dramatically increased.
Consider just a few of the following GIS resources that were
available and used in 2017 to aid in addressing hurricanes
(Harvey, Irma, Matthew, and others):

FIGURE 4.9 Sample GIS Map Viewer: Network for a Healthy California

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89CHAPTER 4  n  Competency #2

Mapping is also being used to monitor and visualize
outbreaks across the globe (see http://www.healthmap.org/
en/) and can be valuable historically to review an outbreak,
such as the 2014 Ebola outbreak (see https://www.cdc.gov/
vhf/ebola/outbreaks/2014-west-africa/distribution-map.
html). The data behind the mapping are useful not only in
the real-time incidents that require response and interven-
tion, but also in the future, as scientists use data to develop
algorithms that could help to predict future outbreaks. With
public health professionals questioning when, not if, the
next worldwide outbreak or pandemic threat might occur,
the ability to see and process a large amount of real-time
data, and historic data, is very important.

Consider learning about the Global Health Security
Agenda (see https://www.ghsagenda.org/) to “advance a
world safe and secure from infectious disease threats, to
bring together nations from all over the world to make new,
concrete commitments, and to elevate global health security
as a national leaders-level priority” (Global Health Secu-
rity Agenda [GHSA], 2017, para. 1). This initiative is exten-
sive, promoting efforts that engage global partners, local
government, universities, those already in the workforce,
and those who are about to graduate and enter the public
health workforce as public health nurses, veterinarians, and
environmental health professionals. Examples of these ini-
tiatives are found online: One Health Workforce at https://
medium.com/one-health-workforce and PREDICT at http://
www.vetmed.ucdavis.edu/ohi/predict/.

In addition to broad use of mapping data in public health,
there are real-time data collection strategies being used
to more quickly and more thoroughly understand public
health problems and to more efficiently deliver public health
interventions. Consider the extensive and overwhelming
availability of smartphone apps designed to help individu-
als manage their health, quit an unhealthy behavior, begin a

healthy one, and track every step along the way. Visit an app
store and do a search for a common public health challenge
you might address as a PHN working with individuals or
families. You will find dozens, if not hundreds, of possible
tools. Of value are articles that summarize the benefits and
challenges of these apps, as well as websites that offer rank-
ings and scores to help potential users consider the right app
for them. An example is provided for mental health apps
at https://adaa.org/finding-help/mobile-apps. Not every sit-
uation warrants use of an app (or a map), and it is really
important for PHNs to understand this. Just because a tech-
nological tool exists does not inherently mean it should be
used. PHNs need to consider the challenge being addressed,
the stakeholders, the benefits or challenges associated with
the technological solution, and then make an informed
decision about using it.

Applies an Epidemiological Framework
When Assessing and Intervening With
Communities, Systems, Individuals,
and Families
How a PHN comes to understand a problem and its possible
causes and solutions is somewhat dependent on the frame-
work that the PHN uses. The epidemiological triangle has
traditionally been used to understand disease transmission.
This triangle consists of identifying a host system affected
by the condition, an agent that causes the condition, and the

EVIDENCE EXAMPLE 4.4
Using Big Data to Inform PHN  
Home Visiting Interventions

There is so much data generated in every home visit, and
over time and across visits, the data repository grows and
becomes a valuable source of broad information. PHNs
have traditionally provided the data, offering rich chart-
ing and thorough details for each home visit, but now
PHNs are using these data to understand patterns and
inform interventions to a much greater extent. Monsen
et al. (2017) analyzed data from 4,263 women who had
received home visits, examining social and behavioral
determinants of health as well as outcomes following the
home visits. Analyses demonstrated that minority women
showed greater improvements following the interventions
and revealed the value of using big data to begin to unravel
intervention elements and intervention outcomes.

EVIDENCE EXAMPLE 4.5
Screening for Neurodevelopmental Delays in  
Four Communities in Mexico and Cuba 

Cuban and Mexican PHNs used a newly developed com-
puterized evaluation instrument to assess and compare
the prevalence of neurodevelopmental problems in three
areas: language/communication, psychomotor, and hear-
ing/vision (Guadarrama-Celaya et al., 2012). Four hun-
dred children ages 1 to 5 years were screened using the
Neuropediatric Development (NPED) screening tool in
urban and suburban cities in Cuba and Mexico. Results
demonstrated failures in all communities (e.g., 2.3% vision,
16.5% language) and differences by country (e.g., higher
failures rate for hearing in Cuban communities). Results
also demonstrated successful use of this computerized
Spanish-language tool for broad community assessment
of key neurodevelopmental problems among children at
important stages of development. This tool can facilitate
earlier identification and intervention so that long-term
neurodevelopmental problems can be avoided as children
develop.

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90 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

the web design to identify all the factors influencing the cen-
ter of the web (i.e., the disease, such as cardiovascular disease
or asthma, or the social health problem, such as teen preg-
nancy). After you have drawn the web, you are faced with a
dilemma—specifically, which related thread to address first.
How do you decide whether to prioritize a biological-related
factor or a social-based factor? The web might help identify
numerous potential causes, contributors, and influences,
yet the model by itself does not yield readily apparent strat-
egies or solutions. More than 10 years ago, Nancy Krieger
(1997) identified these criticisms of the web framework and
proposed an ecosocial framework for developing epidemio-
logical theories about public health problems and possible
solutions. The central question answered using an ecosocial
framework is, “Who and what is responsible for population
patterns of health, disease, and well-being, as manifested in
present, past, and changing social inequalities in health?”
(Krieger, 2001a, p. 694).

A shift in thinking about traditional epidemiology mod-
els has occurred, with growing recognition of the impor-
tance of social epidemiology, the field that acknowledges
and seeks to address the complex combination of biological
and social factors influencing health and well-being. Social
epidemiology was initially defined in the 1950s but has in
more recent decades grown in popularity and use among
public health professionals (Krieger, 2001b, 2012). PHNs
need to be aware of the trends in public health as well as
the theories that guide understanding of the “risk-asset-
problem-intervention” relationships in public health.

environment that contributes to the condition. Host consid-
erations include genetics; inherent characteristics, such as
age and gender; acquired characteristics, such as immune
status; and lifestyle factors. Agents are typically categorized
as infectious, chemical, or physical agents. Environmental
factors might include a variety of physical, social, and eco-
nomic factors. Interactions between these three elements
of the triangle are examined to determine how diseases are
transmitted and how intervention strategies can be targeted
to stop or prevent transmission of the health conditions.
Using influenza as an example of the three triangle compo-
nents, the host would be the individual susceptible to the flu,
the agent is the influenza virus, and the environment might
be the physical apartment that is overcrowded and under-
heated (Clark, 2008).

This model has been adapted to consider more complex
scenarios that might be contributing to disease or illness
(see Figure 4.10). It is an important adaptation, because for
most health problems that PHNs address, the contributing
factors are complex and multifaceted. Illnesses result not
merely from a simple transmission in the right time and
place but also because of factors not easily controlled or
resolved (e.g., poverty, inadequate housing, food shortages).

For many in public health, complex contributing factors
to poor health or well-being have been informed by such
models as the web of causation. The name itself implies
greater complexity than the epidemiological triangle, yet
this model is also not perfect. For example, imagine a spider
web (where the name is drawn from) and how you might use

FIGURE 4.10 Epidemiological Triangle in the 21st Century
Source: Merrill, 2017, p. 11

Environment
Behavior and culture,
physiological factors,

ecological factors

Causative Factors
Biological (infectious agents),
chemical (drugs, acids, alkali,
heavy metals, poisons, some

enzymes), physical (excessive
heat, cold, noise, radiation,

collisions, injuries, etc.)

Group or Population
Age, gender, ethnicity, religion, customs,

occupation, heredity, marital status,
family background, previous diseases

Time

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91CHAPTER 4  n  Competency #2

’’

‘‘

Permanente (see https://www.cdc.gov/violenceprevention/
acestudy/index.html) have been done, showing the strong—
and in some cases, predictive—relationship between expo-
sure to these risks in childhood and poor outcomes in
young adulthood and adulthood (Holman et al., 2016; Wolff,
Baglivio, & Piquero, 2015).

The life course perspective views health not in stages
separate from each other (infancy, early childhood, adoles-
cence, adulthood) but as a continuum. As Krieger (2001a,
p.  695) describes, “Life course perspective refers to how
health status at any given age, for a given birth cohort,
reflects not only contemporary conditions but embod-
iment of prior living circumstances.” A classic life course
study was the research on the effects of the 1944–1945 Dutch
famine that linked malnutrition with subsequent effects on
human development and mental performance (Stein, Susser,
Saenger, & Marolla, 1975). Throughout the life course con-
tinuum, biological, behavioral, environmental, psycholog-
ical, and social factors dynamically interact, contributing
to one’s health. As Matthias Richter (2010, p. 458) summa-
rizes, “This perspective was truly helpful to contribute to a
better understanding of biological, behavioural and social
influences—from gestation to death—for health as well as
health inequalities.”

The next area for Elizabeth to assess for close contacts is
the in-home daycare. Billy’s mother states that they have a
split-entry home and that the lower level is for the licensed
daycare. On a normal day, she has five children who stay
until 5:30 p.m. In addition, a set of 1-year-old twin girls
stay until approximately 11:00 p.m. Billy’s mother indicates
that since Billy has been ill, he has stayed only on the upper
level, away from most of the lower-level childcare children.
However, the situation with the twins is different: Billy eats
supper with them and plays with them until bedtime. The
twins have been exposed to pertussis and, according to
the definition in the protocol, are considered face-to-face
contacts.

Elizabeth asks whether the twins’ parents have been told
about Billy’s pertussis. The mother states that she has not
told them because she is concerned about losing her clients
and income. Elizabeth explains that the public health rec-
ommendation is that the twins receive preventive antibiot-
ics because of their close contact with Billy. Billy’s mother
agrees to notify the twins’ parents by passing out to all par-
ents a standardized notification letter from the PHN.

Public health nursing is grounded in the science of
epidemiology. On numerous levels, epidemiological data
help describe the scope of a problem, prioritize interven-
tion strategies, and evaluate outcomes or trends over time.
Data are presented and collected using many different for-
mats; nurses need the skills to interpret and critique these
data, regardless of how they are presented. PHNs also use

Nursing practice should always be informed by theory.
It is relatively easy in nursing practice to get caught up in
the tasks one has to do and to forget, at times, to take a step
back, reflect, and consider why something is being done a
certain way or why certain events are occurring. Theories
are always advancing, and an effective PHN strives not only
to use theory but also to keep up with theoretical ideas that
guide and inform practice and the care of individuals, fam-
ilies, communities, and populations. Epidemiology is an
ideal example of the value and importance of theory as a
guide for understanding and intervening in extremely com-
plex societal health problems and conditions.

Another important theoretical framework in public
health that PHNs should be aware of is referred to as life
course epidemiology. Historically, as the focus of epidemiol-
ogy shifted from infectious disease to chronic illness in the
mid–20th century, new and expanded paradigms emerged
to better recognize and understand the antecedents and
causes of chronic diseases. Consider adverse childhood
experiences (ACEs); these are now commonly understood
as important life events that can have physical and men-
tal health effects that persist into adulthood (Felitti et al.,
1998). ACEs include a range of experiences, but most com-
mon are those that children experience directly (e.g., sex-
ual abuse, emotional abuse, physical abuse), and through
exposure in the home (e.g., parental substance use or incar-
ceration, parental mental health problems, parental abuse,
parental divorce or separation). Numerous studies since
the original ACEs Study conducted by the CDC and Kaiser

THEORY APPLICATION
Ecosocial Theory

Krieger’s ecosocial theory offers an integrated framework
that considers pathways of public health problems in the
context of life course (e.g., from infancy to older adulthood),
and ecological layers (e.g., individual, family, community,
system, etc.). Critical to the theory is the explanatory man-
ner in which complex, intersectional risks and protections
can be considered when examining a public health or social
problem (see Krieger, 2012, p. 938, for a modeling of the
framework applied to racism, for example). Krieger states
that the ecosocial theory is a tool that:

fosters analysis of current and changing population
patterns of health, disease, and well-being in rela-
tion to each level of biological, ecological and social
organization (e.g., cell, organ, organism/individual,
family, community, population, society, ecosystem)
as manifested at each and every scale, whether rel-
atively small and fast (e.g., enzyme catalysis) or rel-
atively large and slow (e.g., infection and renewal
of the pool of susceptible for a specified infectious
disease) (Krieger, 2001b, p. 671).

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92 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

epidemiological theories to inform actions and priorities for
addressing public health problems. PHNs need to use and
contribute to the development of theories that recognize the
social complexities influencing public health problems in
the 21st century.

Ethical Considerations
As seen in the narrative woven throughout this chapter, the
daycare provider was concerned about a loss of income and
her reputation as a provider. Many times, PHNs confront
challenging situations in their practice. For example, report-
ing a nuisance house situation to the city building inspector
might prompt the eviction of a renter or harassment from
a landlord. Although they are trying to protect children
living in less than desirable circumstances, PHNs’ actions

TABLE 4.4 Ethical Action in Using Epidemiological Principles in Public Health Nursing

Ethical Perspective Application

Rule Ethics (principles) n PHNs should use epidemiology to assess and develop interventions that promote beneficence.
n PHNs can support the autonomy of those they are working with, even when uncomfortable

changes are needed to minimize the spread of disease.

Virtue Ethics (character) n PHNs need to demonstrate respect for individuals, families, and communities when suggesting
promotion or prevention strategies; this can be challenging but necessary, especially when some
might refuse to adhere to the actions being recommended.

n PHNs should be persistent in understanding the complexity of factors contributing to a problem
so that potential solutions are comprehensive and yield lasting changes.

Feminist Ethics
(reducing oppression)

n PHNs can advocate for system-level changes that promote the well-being of those who often feel
they have no voice (e.g., tenants who are unable to ask a landlord to maintain heat levels during
the winter).

n PHNs should explore societal changes that can improve the underlying environment for people,
such as increasing the minimum-wage law so that families have additional resources to sustain
and promote health.

might have unintended consequences for entire families.
Similarly, interventions focused on reducing the expo-

sure to lead paint in older homes might be embarrassing
or financially difficult. Although the health department
might offer a free home/environmental inspection for the
detection of lead paint, this activity might force families
to temporarily leave their homes, which some may per-
ceive as an invasion of privacy. Moving in with relatives for
a day might be embarrassing for some; for others, staying
in a hotel might be beyond the family budget. Some health
departments offer a free service to abate lead in a home if the
family has not done so. Although this solution is helpful in
covering up a lead source, the repainting services are often
spotty and unsightly in appearance. The benefits of reduc-
ing lead exposure to children must be weighed against the
other consequences for the family. See Table 4.4 for ethical
perspectives and applications relevant to epidemiological
principles in public health nursing.

n Epidemiological data, including prevalence and inci-
dence data, help set national and local public health
priorities.

n PHNs can and should use epidemiological data to
advocate for health promotion priorities in their areas
of influence.

KEY POINTS

n Epidemiology is an important foundation to the work
of PHNs.

n There is a growing shift from traditional epidemiologi-
cal models toward more complex models that consider
social influences on health, such as a social epidemio-
logical model.

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93CHAPTER 4  n  Competency #2

Clark, M. (2008). Community health nursing: Advocacy for popula-
tion health (5th ed.). Upper Saddle River, NJ: Pearson Education.

County Health Rankings & Roadmaps. (2012). Minnesota. Univer-
sity of Wisconsin Population Health Institute. Retrieved from
http://www.countyhealthrankings.org/app/minnesota/2018/
overview

Earl, C. (2009). Medical history and epidemiology: Their contri-
bution to the development of public health nursing. Nursing
Outlook, 57(5), 257–265.

Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz,
A. M., Edwards, V., & Koss, M. P. (1998). Relationship of child-
hood abuse and household dysfunction to many of the leading
causes of death in adults: The Adverse Childhood Experiences
(ACE) study. American Journal of Preventive Medicine, 14(4),
245–258.

Friis, R. H. (2018). Epidemiology 101 (2nd ed.). Burlington, MA:
Jones & Bartlett

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Centers for Disease Control and Prevention. (2001). Updated
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Centers for Disease Control and Prevention. (2015). 2015 Final
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library/publications/resources/the-world-factbook/geos/us.html

REFLECTIVE PRACTICE

Investigating outbreak possibilities can be challenging, but
it can also present opportunities to practice great commu-
nication skills. Elizabeth handled a situation that could have
been extremely difficult in a professional, thoughtful man-
ner. She asked the right questions and managed to express
concern rather than judgment. By building a good relation-
ship right away, Elizabeth received honest responses from
the childcare provider, and together they determined who
had been exposed and an appropriate course of action.

 1.  What do you imagine will be some follow-up steps that
Elizabeth will take in this situation?

 2.  How can Elizabeth be a resource for the childcare pro-
vider if her clients grow angry when they are informed
about the possible exposure?

 3.  Who might be additional partners to Elizabeth within
the health department as she follows this case until it
is resolved?

 4.  How might Elizabeth address an ethical issue, such
as whether some of the exposed refuse preventive
treatment?

 5.  How will Elizabeth know whether this case investiga-
tion has been successful? What will be important for
Elizabeth to document?

 6.  How will the numbers that Elizabeth has collected
as part of this investigation be useful to others at her
local health department? At the state level? At the
national level?

 7.  How might Elizabeth use each of the Cornerstones
of Public Health Nursing (see Chapter 1) in this case
investigation?

APPLICATION OF EVIDENCE

 1.  What are some ways you can use the ecosocial theory
to examine contributing and influencing factors on
complex public health problems in the United States in
the 21st century, such as obesity or the opioid epidemic?

 2.  Examine the different types of data presented in this
chapter (e.g., rates, maps) and identify when you might
use one type of data more than another type.

 3.  As a PHN working in a community, identify three to
five sources of state- or federal-level data you would
want to use in demonstrating how your community
issues compare to others.

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94 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

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M. A., Swenson, S. M., & Thorson, D. R. (2017). Social determi-
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Richter, M. (2010). It does take two to tango! On the need for
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Garwick, A. W., Svavarsdóttir, E. K., Seppelt, A. M., Looman,
W. S., Anderson, L. S., & Örlygsdóttir, B. (2015). Development
of an International School Nurse Asthma Care Coordination
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Guadarrama-Celaya, F., Otero-Ojeda, G. A., Pliego-Rivero, F. B.,
Porcayo-Mercado, M., Ricardo-Garcell, J., & Perez-Abalo, M. C.
(2012). Screening of neurodevelopmental delays in four commu-
nities of Mexico and Cuba. Public Health Nursing, 29(2), 105–115.

Henry Street Consortium. (2017). Entry-level population-based
public health nursing competencies. St. Paul, MN: Author.
Retrieved from http://www.henrystreetconsortium.org

Holman, D., Ports, K., Buchanan, N., Hawkins, N., Merrick,
M., Metzler, M., & Trivers, K. (2016). The association between
adverse childhood experiences and risk of cancer in adulthood:
A systematic review of the literature. Pediatrics, 138(Suppl. 1),
S81–S91.

Klopf, L. (1998). Tuberculosis control in the New York State
Department of Correctional Services: A case management
approach. American Journal of Infection Control, 26(5), 534–538.

Krieger, N. (1997). Epidemiology and the web of causation: Has
anyone seen the spider? Social Science and Medicine, 39(7),
887–903.

Krieger, N. (2001a). A glossary for social epidemiology. Journal of
Epidemiology and Community Health, 55(10), 693–700.

Krieger, N. (2001b). Theories for social epidemiology in the 21st
century: An ecosocial perspective. International Journal of
Epidemiology, 30(4), 668–677.

Krieger, N. (2012). Methods for the scientific study of discrimina-
tion and health: An ecosocial approach. American Journal of
Public Health, 102(5), 936–945.

Kuh, D., Ben-Shlomo, Y., Lynch, J., Hallqvist, J., & Power, C.
(2003). Life course epidemiology. Journal of Epidemiology and
Community Health, 57(10), 778–783.

Le, C. T. (2001). Health and numbers: A problem-based introduction
to biostatistics (2nd ed.). New York, NY: Wiley-Liss.

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95

CHAPTER

5
COMPETENCY #3
Utilizes the Principles and Science of
Environmental Health to Promote Safe and
Sustainable Environments for Individuals/
Families, Systems, and Communities

n  Patricia M. Schoon 
with Noreen Kleinfehn-Wald, Carolyn M. Porta, and Stacie O’Leary

‘‘

’’

Jeff, Gena, Max, and Dana are working with Candace, the school nurse, at an environmental mag-
net elementary school. Candace tells them that she has documented an increase in asthma attacks and
asthma-related absences since the beginning of the flu season a month ago. She asks the students to do
an assessment, kind of like a modified community assessment, to identify the potential causes of the
increased incidence. The students are having a meeting to discuss how to organize their assessment.

Jeff states, “I think we need to research all of the causes of asthma and asthma attacks and what might
place these students at risk for increased attacks.”

Gena responds, “This is going to be complicated. My niece has asthma and my sister is always looking
for asthma triggers. My sister also recently met with the school nurse to develop an asthma action plan to
use at school. There are so many risk factors.”

Dana comments, “I don’t know much about environmental health. I think I want to do some reading
about what it is and what environmental health has to do with nursing.”

Max responds, “I agree with Dana. When I think of environmental health and nursing I think of how
we dispose of hazardous waste materials in the hospital. There is also the climate change issue, but I don’t
know what this has to do with nursing. I need to figure out where asthma triggers fit in all of this.”

Gena reflects, “Besides this community assessment, we are all making home visits with a public health
nurse [PHN]. Maybe some of what we learn will help us with our assessment of the families we are visiting
and with the interventions we do with our PHN preceptors.”

The students review the environmental health PHN competencies they will be developing as they com-
plete this project. Jeff starts a to-do list and writes a list of definitions the group will need as they research
their topic from an environmental perspective.

JEFF’S NOTEBOOK
COMPETENCY #3 Utilizes the Principles and Science of Environmental Health to Promote Safe  
and Sustainable Environments for Individuals/Families, Systems, and Communities

A. Promotes environments that facilitate holistic well-being and health, healing, and healthy lifestyles for
individuals/families, systems, and communities

1) Assesses environmental risk factors and protective factors for individuals/families, systems, and
communities

2) Engages in actions to reduce environmental risk factors and strengthen protective factors for
individuals/families, systems, and communities

3) Takes actions to reduce and manage harmful waste products from individuals/families, systems,
and communities

4) Evaluates the outcomes of actions to promote healthy environments
(continues)

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96 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

B. Seeks to protect individuals/families, systems, and communities from environmental hazards

1) Educates individuals, families, systems, and communities about environmental hazards and harmful
lifestyle factors

2) Recommends modifications in home, neighborhood, workplace, and community environments to
increase safety for individuals and families across the life span

3) Supports right-to-know legislation and regulations that protect and inform the public about hazardous
products

C. Considers the diverse values, beliefs, cultures, and circumstances of individuals/families and populations
when recommending and implementing healthy environmental interventions

1) Is attentive to diverse lifestyle factors and assesses potential health and safety risks related to them

2) Accepts and supports diversity in environmental lifestyle factors

3) Makes referrals when appropriate to governmental agencies when harmful environmental lifestyle
factors place children and vulnerable adults at risk

D. Promotes stewardship of the environment at local, national, and international levels

1) Advocates for sustainable natural and built environments

2) Advocates for environmental justice for vulnerable and under-represented populations

3) Supports policies that promote safe and sustainable natural and built environments and water and
food systems

Source: Henry Street Consortium, 2017

USEFUL DEFINITIONS

Built Environment: Includes products, structures, buildings, or transportation created or modified by
human beings.

Environment: “Reflects the aggregate of those external conditions and influences affecting the life and develop-
ment of an organism… physical, chemical, biological, and social factors that affect the health status of people”
(Merrill, 2017, p. 214); “factors external to the human or animal that cause or allow transmission” (p. 8).

Environmental Health: “Environmental health comprises those aspects of human health, including quality of
life, that are determined by physical, chemical, biological, social, and psychosocial factors in the environment.
It also refers to the theory and practice of assessing, correcting, controlling, and preventing those factors in the
environment that can potentially affect adversely the health of present and future generations.”—draft defini-
tion developed at a WHO consultation in Sofia, Bulgaria, 1993 (U.S. Department of Health and Human Services
[U.S. DHHS] Environmental Health Policy Committee, Risk Communication and Education Subcommittee, 1998).

Environmental Stewardship: The responsibility for environmental quality shared by all those whose actions
affect the environment (Environmental Protection Agency Environmental Action Council, 2005).

Exposure: A three-phase process: “1) contact is between a target and one or more agents in the same
environment; 2) agent accesses target by one or more routes of entry; and 3) the agent enters the target by
crossing a barrier or boundary” (Thompson & Schwartz Barcott, 2017, p. 1315).

Hazard: Ability of an environmental agent to do harm.

Natural Environment: Includes the physical environment (e.g., air, water, land, soil, plants, weather, climate)
and biological and chemical entities that exist in the environment.

Planetary Health: The achievement of the highest attainable standard of health, well-being, and equity world-
wide through judicious attention to the human systems—political, economic, and social—that shape the future
of humanity, and the Earth’s natural systems that define the safe environmental limits within which humanity
can flourish. Planetary health is the health of human civilization and the state of the natural systems on which it
depends (Lancet Commission, 2015; Whitmee et al., 2015).

JEFF’S NOTEBOOK
COMPETENCY #3 (continued)

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97CHAPTER 5  n  Competency #3

and morbidity is referred to as the global disease burden, as
illustrated in the following quotation:

Twenty-three percent of global deaths and 22% of
global disability adjusted life years were attributable
to environmental risks in 2012… The global disease
burden attributable to the environment is now domi-
nated by noncommunicable diseases. Susceptible ages
are children under five and adults between 50 and 75
years (Prüss-Ustün et al., 2017).

Responses to environmental health challenges involve
efforts to eliminate or weaken the hazard, reduce the poten-
tial for exposure to the hazard, and mitigate the effects of
the exposure.

History of U.S. Environmental Health Movement
The contemporary environmental health movement in the
United States began with the 1962 publication of the book
Silent Spring, written by Rachel Carson, a marine biologist.
She published her research on chemical pesticides, which
resulted in the government banning the agricultural pesti-
cide DDT, a synthetic aromatic hydrocarbon (U.S. Fish and
Wildlife Service, 2012).

From 1942 to 1953, a chemical company dumped chem-
ical hazardous waste into Love Canal, an aborted Niagara
River canal project that ran through a 15-acre working-class
neighborhood (Kleiman, 2017). In the 1970s, investigative
reporters revealed a cluster of illnesses including epilepsy,
asthma, migraines, and nephrosis, as well as abnormally
high rates of birth defects and miscarriages occurring in
families that lived near Love Canal. Contaminated water
was found in the basements and yards of residents as well
as in the school playground built over the canal. Activist
women, mostly mothers in the Love Canal neighborhood,
tried to get the New York State government to take action,
but it did not. Between 1978 and 1981, 939 families were
relocated by the federal government. This tragedy mobi-
lized concerned citizens nationwide to lobby Congress
to act to make businesses responsible for cleanup of toxic

What Is Environmental Health?
When you think of the environment, what comes to your
mind? The first things that probably come to mind are the
physical locations in which you spend your daily life, such
as your home, neighborhood, parks, and open green spaces.
When you consider the health of the environment, you
must pay attention to both the seen (e.g., air, water, land)
and the unseen (e.g., microscopic pollutants) as well as the
social factors, including individual and societal behaviors,
that shape the world. A holistic definition of environmental
health would include physical, chemical, biological, social,
and behavioral factors that influence the environment. A
thorough understanding of environmental health requires
looking beyond the factors that compose “environment”
and determining whether it is healthy or unhealthy. You
need to also carefully consider the interactive effects, and
you need to further analyze the role of human behavior and
response to the environment that is consequently shaping
the world and impacting health.

Challenges of Environmental Health
In this chapter, you will read about both the immediate and
the long-term challenges of environmental health, ranging
from the hazards and exposures that you encounter on a
daily basis to the broader encompassing global challenges
of climate change. Public health nurses (PHNs) give atten-
tion to the immediate environmental risks faced by individ-
uals, families, and communities, such as the availability of
clean water, healthy food, and safe home and community
environments. In many parts of the world there are threats
to health related to the presence and disposal of biological
and chemical hazards. These environmental challenges to
health are substantial and necessitate action to mitigate
them and promote health and well-being. Exposure to envi-
ronmental hazards poses significant threats to health that
include acute illness, infectious and chronic diseases, and
premature deaths (i.e., those occurring before expected life
span). The impact of environmental hazards on mortality

Precautionary Principle: When an activity raises threats of harm to human health or the environment, precau-
tionary measures should be taken even if some cause and effect relationships are not fully established scien-
tifically. In this context, the proponent of an activity, rather than the public, should bear the burden of proof
(Chaudry, 2008).

Risk: The likelihood of harm occurring once an individual is exposed to a hazard (United Nations [UN], 2015).

Social Environment: Social interactions, behaviors, norms, institutions, and access to healthcare.

Sustainable Community: A sustainable community is one that is economically, environmentally, and
socially healthy and resilient. It meets challenges through integrated solutions, rather than through frag-
mented approaches that meet one of those goals at the expense of the others (Institute for Sustainable
Communities, n.d.).

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98 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

environmental health as a core function of nursing practice
in all clinical practice areas and not just the province of
nurses who specialize in environmental health (IOM, 1995).
The IOM also identified the importance of using the pop-
ulation-based public health nursing approach for environ-
mental health issues and the need to prepare more nurses at
the baccalaureate level so that the nursing profession would
have greater capacity to address the environmental health
concerns of populations as well as individuals. In 2007,
the American Nurses Association (ANA), recognizing the
importance of environmental health as a core component of
the scope of practice of professional nursing, published the
ANA’s Principles of Environmental Health for Nursing Prac-
tice with Implementation Strategies (see Table 5.1).

A coalition of U.S.-based nurses created the Alliance of
Nurses for Healthy Environments (ANHE) in 2008 (ANHE,
2017). This alliance has published standards for environ-
mental health nursing, developed an online free eBook,
Environmental Health in Nursing (2016), maintains a listing
of environmental hazards (see https://envirn.org/) and has

waste dumps that they created. In 1980, Congress passed
The Superfund Bill (i.e., Comprehensive Environmental
Response, Compensation, and Liability Act). These citizen
actions were the beginning of a grassroots environmental
movement that continues to the present day.

Environmental Health—
At the Core of Nursing Practice
PHNs are concerned about how the environment affects
individuals, families, and the community/society at large.
They consider the ongoing interactions between their clients
and the environment and the cumulative effects of envi-
ronmental hazards on health status. PHNs assess both the
protective and the risk factors of the natural and the built
physical environment and take actions to reduce environ-
mental risk factors to improve the health status of individu-
als, families, and communities.

Since the time of Florence Nightingale, nurses have iden-
tified the relationship between the environment and health
outcomes. In Notes on Nursing, Nightingale lists five things
that must be present to have a healthy home; although gen-
erated in the 19th century, they remain relevant to the 21st
century: pure air, pure water, efficient drainage, cleanliness,
and light (Nightingale, 1860). Nightingale was responsi-
ble for applying principles of cleanliness in the care of the
injured during war, which likely resulted in numerous
saved lives.

Clara Barton, trained as a teacher and not a nurse, pro-
vided nursing care to Union soldiers during the Civil War
and was officially named head nurse for one of General Ben-
jamin Butler’s units in 1864. Her experience in the Civil War
began her long history of helping those in need in times of
conflict and disaster. Barton was instrumental in starting
the American Red Cross in 1881 and was president of the
Red Cross until 1904. She then started National First Aid
Association of America; the organization’s priority was
emergency preparedness (Michaels, 2015).

Years later, Lillian Wald, recognized as the first public
health nurse in the U.S., worked to improve horrifically
overcrowded and infested housing conditions in New York
City. She believed that the crowded and dismal living con-
ditions of immigrants and children on the Lower East Side
of New York resulted in poor health outcomes and began
providing nursing services in peoples’ homes. She used her
societal position to lobby for safe spaces for children to play
in New York City, and helped to establish the first parks and
playgrounds for children in the 20th century (Filiaci, n.d.).
Wald founded the Henry Street Settlement in 1893 and led
that organization until 1933, providing health and social
services to people who suffered health consequences for the
environmental health condition of their place of residence
(Henry Street Settlement, 2017).

The Institute of Medicine’s (IOM) 1995 landmark pub-
lication, Nursing, Health, and the Environment, addressed

TABLE 5.1 ANA’s Principles of
Environmental Health for Nursing Practice

1. Knowledge of environmental health concepts is essential
to nursing practice.

2. The Precautionary Principle guides nurses in their practice
to use products and practices that do not harm human
health or the environment and to take preventive action in
the face of uncertainty.

3. Nurses have a right to work in an environment that is safe
and healthy.

4. Healthy environments are sustained through multi-
disciplinary collaboration.

5. Choices of materials, products, technology, and practices
in the environment that impact nursing practice are based
on the best evidence available.

6. Approaches to promoting a healthy environment respect
the diverse values, beliefs, cultures, and circumstances of
patients and their families.

7. Nurses participate in assessing the quality of the environ-
ment in which they practice and live.

8. Nurses, other health care workers, patients, and commu-
nities have the right to know relevant and timely informa-
tion about the potentially harmful products, chemicals,
pollutants, and hazards to which they are exposed.

9. Nurses participate in research of best practices that
promote a safe and healthy environment.

10. Nurses must be supported in advocating for and imple-
menting environmental health principles in nursing
practice.

Source: ANA, 2007, p. 16

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99CHAPTER 5  n  Competency #3

decisions about actions you should take. For example, long
before the causal relationship between the ultraviolet rays of
the sun and skin cancer was known, people took precautions
about time spent in the sun to avoid sunburn. The acronym
ACT serves as a critical-thinking approach to known and
potential environmental hazards, including those that pose
both immediate and long-term actual and potential risks:

A. Assessment: Assess environmental hazards and
health risks.

C. Critical thinking: Reflect on the consequences of
these risks and how best to mitigate or eliminate
them in the short and long term. Consider the sus-
tainability of interventions and the evidence base for
their likely success.

T. Take Actions: Know best practices to reduce envi-
ronmental hazards and risks, and apply them.
Consider PHN interventions at the individual/family,
community, and systems levels of PHN practice.

Environmental Health—
The Role of the PHN
The role of the PHN in environmental health is dependent in
part on the employment location of the PHN, the structure
of the public health agency, and existing laws and regula-
tions. Some agencies include an environment health section,
and some employ a single environmental health special-
ist or a sanitarian. Agencies provide services for building
code compliance, solid waste disposal, and hazardous waste
removal. If there is a sanitarian on staff, the PHN may serve
as a consultant to the sanitarian or work with those cases
that need long-term follow-up due to a medical or health
impact. In agencies where there is not a sanitarian, PHNs
may do the environmental risk assessment themselves.

PHNs often collaborate with human service providers
working in child protection or with vulnerable adults. The
PHN might accompany a social worker to a home to assess
safety conditions or might request a social worker to inter-
vene after doing an initial home visit. Family lifestyle pat-
terns are diverse, so it is important to consider whether the
differences in conditions are benign or harmful to family
members. The PHN might need to make a determination as
to whether the conditions are significant enough to warrant
removal or temporary relocation of an individual. The PHN
may also be involved in a plan to improve the livability of
a dwelling. Some environmental situations, such as hoard-
ing, can be very complex and could involve social workers,
mental health professionals, law enforcement, and others to
address the situation.

Existing laws and ordinances greatly shape the role of
the PHN in addressing environmental hazards or risks. For
example, a state law or local ordinance may designate a pub-
lic health inspection. If such is the case, then there is usu-
ally a process to give legal orders to abate a situation, and a

workgroups for education, research, practice, and policy/
advocacy. ANHE has identified ten reasons why it is import-
ant and appropriate for nurses to be involved in environ-
mental health (see Table 5.2).

The Precautionary Principle
PHNs take actions to prevent harm to their clients. How-
ever, the cause-effect relationship between some environ-
mental hazards or potential hazards is not always clear.
PHNs use the Precautionary Principle to guide their actions
in protecting themselves and their families, clients, and
community. The following definition provides guidelines
for applying the Precautionary Principle to nursing actions.

When an activity raises threats of harm to human
health or the environment, precautionary measures
should be taken even if some cause and effect rela-
tionships are not fully established scientifically. In
this context the proponent of an activity, rather than
the public, should bear the burden of proof. The pro-
cess of applying the Precautionary Principle must be
open, informed, and democratic and must include
potentially affected parties. It must also involve an
examination of the full range of alternatives, includ-
ing no action (Science and Environmental Health
Network, 1998).

Using the Precautionary Principle makes good sense.
Start by considering what you can do in your home, neigh-
borhood, and workplace to reduce exposure to hazards.
You can also look at correlation and make common sense

TABLE 5.2 Top Ten Reasons That Nurses
and Environmental Health Go Together

n Nurses provide healing and safe environments for people.
n Nurses are trusted sources of information.
n Nurses are the largest healthcare occupation.
n Nurses work with persons from a variety of cultures.
n Nurses effect decisions in their own homes, work settings,

and communities.
n Nurses are good sources of information for policymakers.
n Nurses translate scientific health literature to make it

understandable.
n Nurses with advanced degrees are engaged in research

about the environment and health.
n Health organizations recognize nurses’ roles in

environmental health.
n Nursing education and standards of nursing practice

require that nurses know how to reduce exposures to
environmental health hazards.

Source: ANHE, 2016, p. 2

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100 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

‘‘

’’

Online Activity
    Help Max and Jeff research environmental asthma 
triggers. Here are a few online resources for you to use. Refer 
to the information on the following websites and make a list of 
environmental asthma triggers. 

n Environmental Health in Nursing, an open-source text-
book, written by members of the Alliance of Nurses for 
Healthy Environments at https://envirn.org/wp-content/
uploads/2017/03/Environmental-Health-in-Nursing.pdf 

n Environmental Triggers of Asthma at https:// 
www.atsdr.cdc.gov/csem/csem.asp?csem=32&po=6

n Asthma and Allergies and Their Environmental Triggers  
at https://kids.niehs.nih.gov/topics/pollution/ 
asthma-and-allergies/index.htm

n Childhood Asthma at http://asthmaandallergies.org/
asthma-allergies/childhood-asthma/

Individual/Family Level of Practice
This section focuses on identifying key environmental haz-
ards that have a direct effect on individuals and families and
strategies for how to prevent or mitigate the exposures and
their effects. A few hazards often encountered by PHNs in
their personal lives and daily work are discussed. Five com-
mon types of environmental hazards are found in the home,
in the workplace, and in schools:
n Chemical: Medications; illegal drugs; pesticides; form-

aldehyde (found in almost all new products containing
glue); volatile organic compounds (VOCs) found in
household products such as paints, varnishes, wax,
mothballs, many cleaning and disinfecting products,
personal hygiene products, and cosmetics; and indus-
trial chemicals used in cars and in the workplace

n Physical: Radon, radiation, weather, sound, vibration,
impact

n Mechanical: Pressure, ergonomics, confined space,
repetitive motion

n Biological: Bacteria, viruses, parasites, mold, allergens,
pet dander

n Sociocultural: Violence and war, interpersonal abuse,
institutionalized racism

The impact of the exposure to human beings and ani-
mals is often multifaceted and might have immediate, short-
term, or long-term influence. The three-phase process of
exposure includes: 1) exposure of the target host with one
or more environmental agents; 2) ability of the agent to
access one or more routes of entry in the target host; and,
3) entry of the agent into the target host by crossing a barrier
or boundary (Thompson & Schwartz Barcott, 2017, p. 1315).

process to follow in the event the property owner does not
comply. The PHN may be involved in tracking the progress
made or consulting with the local court system if there is
noncompliance. Some states legally designate local public
health to be the final authority on cleanup of methamphet-
amine houses (homes that have been contaminated because
of the presence of a meth lab). Often public health nurses
need to be fluent on issues related to lease agreements,
tenant rights, and accessing low-cost legal assistance as they
provide counsel to vulnerable clients.

Nurses also need to advocate with medical providers and
insurance companies to provide equipment that reduces the
risks of those with chronic disease who are exposed to envi-
ronmental hazards in the home. For example, home care
nurses who have clients with respiratory conditions may
need to advocate for air purifiers to improve the quality of
indoor air. PHNs may also be the advocate for those living
in sub-standard housing or in areas where there are sig-
nificant outdoor environmental hazards. There is a known
disparity in the availability of healthy homes and healthy
living environments, which has a disparate impact on the
poor and minorities (U.S. DHHS, 2009). PHNs may need
to advocate with policymakers to improve the opportuni-
ties for disadvantaged populations to have access to healthy
homes and neighborhoods.

Jeff and Max have been thinking about the role of the nurse
in environmental health. They feel overwhelmed. They
talk with Gena and Dana, who have just made their first
home visit with a public health nurse. Dana made a home
visit to a young woman who is pregnant and was worried
about environmental exposures she might have had that
could harm her baby. During a visit to a young family with
a child with asthma, Gena found out that the family has
bedbugs.

Dana reflects, “What we are learning in our home vis-
iting experiences about environmental health can help us
determine what environmental factors we need to consider
when looking for the causes of increased asthma attacks. I
think we need to look at the physical environment both at
home and at school to see what the risks are. Let’s focus on
the students’ homes and their families. We need to look for
the asthma triggers.”

Gena reminds them, “We also need to think about the
school environment—both the physical and the social
aspects. We need to find out what the school staff know
about asthma triggers and what they are doing that pro-
tects the children with asthma.”

Max states, “I am going to research environmental
asthma triggers.”

Jeff responds, “We need to find more resources.”

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Public/Community Health
and Nursing Practice

CARING FOR POPULATIONS

SECOND EDITION

7711_FM_i-xviii 21/08/19 11:08 AM Page i

Public/Community Health
and Nursing Practice

CARING FOR POPULATIONS

SECOND EDITION

Christine L. Savage, PhD, RN, FAAN
Professor Emerita

Johns Hopkins University School of Nursing
Baltimore, Maryland

7711_FM_i-xviii 21/08/19 11:08 AM Page iii

F. A. Davis Company
1915 Arch Street
Philadelphia, PA 19103
www.fadavis.com

Copyright © 2020 by F. A. Davis Company

Copyright © 2020, 2016 by F. A. Davis Company. All rights reserved. This book is protected by copyright. No part of it may
be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying,
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Library of Congress Cataloging-in-Publication Data

Names: Savage, Christine L., author.
Title: Public/community health and nursing practice : caring for populations

/ Christine L. Savage.
Other titles: Public health science and nursing practice
Description: 2nd edition. | Philadelphia : F.A. Davis Company, [2020] |

Preceded by: Public health science and nursing practice / Christine L.
Savage, Joan E. Kub, Sara L. Groves, 2016. | Includes bibliographical
references and index.

Identifiers: LCCN 2019007149 (print) | LCCN 2019008721 (ebook) | ISBN
9780803699878 (ebook) | ISBN 9780803677111 (pbk.)

Subjects: | MESH: Public Health Nursing | Community Health Nursing | Health
Planning | Population Characteristics

Classification: LCC RT97 (ebook) | LCC RT97 (print) | NLM WY 108 | DDC
610.73/4—dc23

LC record available at https://lccn.loc.gov/2019007149

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for users of the Transactional Reporting Service is: 978-0-8036-7711-1/19 0 + $.25.

7711_FM_i-xviii 21/08/19 11:08 AM Page iv

To my husband, Joe, for all his love and support.

7711_FM_i-xviii 21/08/19 11:08 AM Page v

Preface

The World Health Organization (WHO) partnered with
the International Council of Nursing and began the
Nursing Now campaign that “… aims to improve health
by raising the profile and status of nursing worldwide”
(WHO, 2018). They recognized that nurses provide care
essential to the optimizing of health for individuals, fam-
ilies and communities. Health occurs from the cellular
to the global level; thus nurses must have knowledge re-
lated to health across this continuum. Nursing education
often begins with understanding health at the cellular
level through courses related to pathophysiology and
physical assessment. Building on this knowledge, this
text covers health, disease, and injury within the context
of the world we live in. No matter what settings nurses
work in, they apply public health science on a daily basis
to prevent disease, reduce mortality and morbidity in
those who are ill, and contribute to the health of the com-
munities we serve. Our goal with this book is to lead you
on the journey of discovering how the public health sci-
ences are an integral part of nursing practice and how
nurses implement effective public health interventions.

About This Book
This book presents public health in a way that captures
the adventure of tackling health from a community- and
population-based perspective. Public health helps us to
answer the question, “Why is this happening?” and to im-
plement interventions that improve the health of popu-
lations. Public health issues are usually messy real-world
problems that do not always have obvious solutions. You
will learn through the examples provided how to gather
the needed information to understand important health
issues, especially those included in Healthy People. You
will have an opportunity to explore population-level,
evidence-based interventions and learn how to evaluate
the effectiveness of those interventions. We aim to pro-
vide you with the knowledge to achieve the competencies
in public health you increasingly need as a professional
nurse across multiple settings. You will be provided with
numerous examples of how public health nurses integrate
nursing and public health, with a focus on promoting the
health of populations.

The application of public health knowledge in the
provision of care and the prevention of disease is not
new to the nursing profession. Florence Nightingale is
often viewed as the first nurse epidemiologist because of
her work in the Crimean War. She applied public health
science to nursing practice in a way that saved lives and
improved outcomes, both in the context of war and back
in England, with the development of professional nurs-
ing in hospital and home settings. As nurses practicing
in the 21st century, we follow in her footsteps. Consider
nurses working in primary care with mothers and chil-
dren or those working in low-income countries facing
epidemics of tuberculosis and HIV/AIDS. How does
knowledge of public health science enhance our ability
to address these complex health issues? Before we can
improve health outcomes, we must understand the nat-
ural history of disease, the social context in which these
health issues arise, and the resources critical to address-
ing all of the barriers to care. Knowledge of public health
and how it applies to nursing practice has taken on in-
creased importance as we move from a fee-for-service
model of care to a health-care system that rewards pre-
vention of disease.

Nurses must know how to apply the basics of the pub-
lic health sciences such as epidemiology, social and be-
havioral sciences, and environmental health. They must
also meet the Quad Council generalist core competencies
such as community assessment, health planning, and
health policy. To help you to do that, we have employed
a problem-based learning approach to the presentation
of the material in this book so that you can apply the
principles of public health to real-life nursing settings.

Throughout the book, case studies demonstrate how
the application of the public health sciences and public
health practice to nursing practice is essential to the pro-
motion of health and the prevention of disease. At times,
the focus will be on solving health-related mysteries and
how that leads to the implementation of interventions to
address the health problems at the population level. At
other times, the focus will be on the application of the
public health sciences to the development and imple-
mentation of evidence-based, population-level interven-
tions aimed at addressing the health issue.

vii

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Although there have been significant improvements
in health during the past 100 years, achieving our
stated health goals, whether it be Healthy People goals
and objectives or global goals, continues to be a chal-
lenge. The ability of each individual, family, and com-
munity to lead a healthy and productive life involves
an interaction among ourselves, our environment, and
the communities in which we live. Understanding
the multiple determinants of health, including social
determinants that significantly influence health dispar-
ities and health inequities, is an essential skill for
nurses. The public health sciences help us understand
the complexity of the interaction of external and inter-
nal forces that shape our health. The premise of this
book is that all nurses require adequate knowledge of
the public health sciences and how to apply it to nurs-
ing practice across all settings and populations. With
this knowledge, we can truly contribute to the building
of a healthy world.

Organization of the Text
The philosophical approach to this text is that all profes-
sional nurses incorporate population-level interventions
no matter what the setting. We include not only chapters
on the traditional public health settings such as the public
health department and school health, but also chapters
on acute and primary care settings. The book uses a con-
structivist learning approach by which the learner con-
structs her or his own knowledge. Thus, the content is
delivered by applying the information within the context
of the real world.

This text uses a problem-based learning approach so
that the student can apply the content to nursing prac-
tice. It is organized into three units. Unit I, Basis for
Public Health Nursing Knowledge and Skills, covers the
essential knowledge based in the public health sciences
and core public health nursing competencies needed to
solve health problems and implement evidenced-based
interventions at the population level. This unit provides
the basic public health knowledge needed by all gener-
alist nurses. The content covered in these chapters is
applied across the next two units of the book. Unit II,
Community Health Across Populations: Public Health
Issues, covers health issues that span populations and
settings including communicable and noncommunica-
ble disease, health disparity, behavioral health, and
global health. Unit III, Public Health Planning, covers
the settings in which nurses practice, public health
policy, and disaster management.

Understanding health within the context of commu-
nity includes understanding the role of culture. To help
underscore the importance of culture, it has been inte-
grated across each of the chapters rather than have a
stand-alone chapter dedicated to culture. In each chapter
there is a callout box related to the role of culture specific
to the subject of that chapter.

Global health is the other concept now integrated
across all of the chapters. In earlier public health textbooks,
the term most often used was ‘international health’. As it
became clearer that the health of one nation does not
occur in a vacuum, but rather contributes to the health of
the globe, global health became the accepted term. To truly
adhere to the concept that health is global across all set-
tings, we have included a cellular to global box in every
chapter relevant to the content in that chapter. As nurses
dedicated to optimizing health for all, visualizing health
within a global context will help us join with the WHO in
promoting nursing as a true force in health.

Key Features
t CASE STUDIES
Throughout the book, the student will find case studies
embedded in the chapters that provide essential content
within the context of actual nursing practice. This ap-
proach begins with the issue and walks the reader through
the process of deciding how best to address the problem
presented. In some of the cases presented, the object is to
solve the mystery (Solving the Mystery), such as the case
in Chapter 8 that walks through how to solve the mystery
of why people are presenting at the emergency depart-
ment with severe gastrointestinal symptoms. Other cases
(Applying Public Health Science) describe how nurses
apply the public health sciences, such as epidemiology, to
help develop and implement evidence-based interven-
tions at the population level. There is a standard case
study at the end of selected chapters. For instructors, there
is online access on the DavisPlus website for the book to
a problem-based learning exercise that can be used to fur-
ther apply the content presented in the chapter.

n HEALTHY PEOPLE
Healthy People is referenced throughout, including
Healthy People 2020 and information on Healthy People
2030 available prior to publication. Boxes are included
that present the Healthy People 2020 objectives and the
midcourse reviews on progress towards meeting those
objectives.

viii Preface

7711_FM_i-xviii 21/08/19 11:08 AM Page viii

n EVIDENCE-BASED PRACTICE
BOXES

Evidence-Based Practice (EBP) boxes illustrate how re-
search and its resulting evidence can support and inform
public health nursing practice. Cutting-edge EBP is a
strong underpinning of the book as a whole.

LEARNING OUTCOMES AND KEY TERMS

Each chapter begins with Learning Outcomes and a list
of Key Terms that appear in boldface and color at first
mention in a chapter.

Teaching/Learning Package
Instructor Resources
Instructor Resources on DavisPlus include the following:

• NCLEX-Style Test Bank
• PowerPoint Presentations
• Instructor’s Guide with PBL exercises

• Problem-Based Learning PowerPoint Presentation
• Case Study Instructor’s Guides for end-of-chapter

case studies
• QSEN Crosswalk
• Quad Council Competencies
• Simulation Experiences

Student Resources
Student Resources on DavisPlus include the following:

• Student Quiz Bank
• Student Guide to Problem-Based Learning
• List of Web Resources
• QSEN Crosswalk
• Quad Council Competencies

We hope you will enjoy this book and, most of all,
we hope as nurses you will always care for the health
of populations no matter the setting, thus increasing
the contribution of nursing to the goal of optimal
health for all.

Preface ix

7711_FM_i-xviii 21/08/19 11:08 AM Page ix

Contributors

Laurie Abbott, PhD, RN, PHNA-BC
Assistant Professor

Florida State University College of Nursing
Tallahassee, Florida

Chapter 13

Kathleen Ballman, DNP, APRN, ACNP-BC, CEN
Associate Professor of Clinical Nursing, Coordinator,
Coordinator of Adult-Gerontology Acute Care
Programs

University of Cincinnati, College of Nursing
Cincinnati, Ohio

Chapter 14

Derryl E. Block, PhD, MPH, MSN, RN
Dean, College of Health and Human Sciences

Northern Illinois University
DeKalb, Illinois

Chapter 21

Susan Bulecza, DNP, RN, PHCNS-BC
State Public Health Nursing Director

Florida Department of Health
Tallahassee, Florida

Chapter 13

Deborah Busch, DNP, RN, CPNP-PC, IBCLC
Assistant Professor

Johns Hopkins School of Nursing
Baltimore, Maryland

Chapter 17

Amanda Choflet, DNP, RN, OCN
Director of Nursing, Johns Hopkins Medicine
Department of Radiation Oncology & Molecular
Radiation Sciences

Baltimore, Maryland
Chapter 11

Christine Colella, DNP, APRN-CNP, FAANP
Professor, Executive Director of Graduate Programs

University of Cincinnati, College of Nursing
Cincinnati, Ohio

Chapter 15

Joanne Flagg, DNP, CRNP, IBCLC, FAAN
Assistant Professor, Director MSN Programs

Johns Hopkins School of Nursing
Baltimore, Maryland

Chapter 17

Gordon Gillespie, PhD, DNP, RN, PHCNS-BC, CEN,
CPEN, FAEN, FAAN
Professor, Associate Dean for Research, Deputy
Director Occupational Health Nursing Program

University of Cincinnati
Cincinnati, Ohio

Chapters 5, 20, & 22

Bryan R. Hansen, PhD, RN, APRN-CNS, ACNS-BC
Assistant Professor

Johns Hopkins School of Nursing
Baltimore, Maryland

Chapter 10

Barbara B. Little, DNP, MPH, RN, PHNA-BC, CNE
Senior Teaching Faculty

Florida State University
Tallahassee, Florida

Chapter 13

Minhui Liu, RN, PhD
Post-doctoral

Johns Hopkins University School of Nursing
Baltimore, Maryland

Chapter 19

Donna Mazyck, MS, RN, NCSN, CAE
Executive Director

National Association of School Nurse
Silver Spring, Maryland

Chapter 18

Paula V. Nersesian, RN, MPH, PhD
Assistant Professor

Johns Hopkins University School of Nursing
Baltimore, Maryland

Chapter 16

xi

7711_FM_i-xviii 21/08/19 11:08 AM Page xi

Michael Sanchez, DNP, ARNP, NP-C, FNP-BC,
AAHIVS
Assistant Professor

Johns Hopkins School of Nursing
Baltimore, Maryland

Chapters 8 & 11

Phyllis Sharps, RN, PhD, FAAN
Professor
Associate Dean for Community Programs
and Initiatives

Johns Hopkins University School of Nursing
Baltimore, Maryland

Chapter 17

Christine Vandenhouten, PhD, RN, APHN-BC
Associate Professor (Nursing & MSHWM Programs
Chair of Nursing and Health Studies, Director
of BSN-LINC

University of Wisconsin, Green Bay Professional
Program in Nursing
Green Bay, Wisconsin

Chapter 21

Erin Rachel Whitehouse, RN, MPH, PhD
Epidemic Intelligence Service Officer at Centers
for Disease Control and Prevention

Atlanta, Georgia
Chapter 3

Erin M. Wright, DNP, CNM, APHN-BC
Assistant Professor

Johns Hopkins School of Nursing
Baltimore, Maryland

Chapter 17

Contributors to Previous Edition

Sheila Fitzgerald, PhD

Sara Groves, RN, MPH, MSN, PhD

Joan Kub, PhD, MA, PHCNS-BC, FAAN

William A. Mase, Dr.PH, MPH, MA

Mary R. Nicholson, RN, BSN, MSN CIC

xii Contributors

7711_FM_i-xviii 21/08/19 11:08 AM Page xii

Reviewers

Kathleen Keough Adee, MSN, DNP, RN
Associate Professor

Salem State University
Salem, Massachusetts

Lynn P. Blanchette, RN, PhD, PHNA-BC
Associate Dean, Assistant Professor

Rhode Island College School of Nursing
Providence, Rhode Island

Dia Campbell-Detrixhe, PhD, RN, FNGNA, CNE,
FCN
Associate Professor of Nursing

Oklahoma City University Kramer School of Nursing
Oklahoma City, Oklahoma

Kathie DeMuth, MSN, RN
Assistant Professor

Bellin College
Green Bay, Wisconsin

Bonnie Jerome-D’Emilia, RN, MPH, PhD
Associate Professor

Rutgers University School of Nursing-Camden
Camden, New Jersey

Vicky P. Kent, PhD, RN, CNE
Clinical Associate Professor

Towson University
Towson, Maryland

Kimberly Lacey, DNSc, RN, MSN, CNE
Assistant Professor

Southern Connecticut State University
New Haven, Connecticut

Charlene Niemi, PhD, RN, PHN, CNE
Assistant Professor

California State University Channel Islands
Camarillo, California

Phoebe Ann Pollitt, PhD, RN, MA
Associate Professor of Nursing

Appalachian State University
Boone, North Carolina

Lisa Quinn, PhD, CRNP, MSN
Associate Professor of Nursing

Gannon University
Erie, Pennsylvania

Delbert Martin Raymond III, BSN, MS, PhD
Professor

Eastern Michigan University
Ypsilanti, Michigan

Meredith Scannell, PhD, MSN, MPH, CNM,
SANE, CEN
Nursing Faculty

Institute of Health Professions
Charlestown, Massachusetts

Elizabeth Stallings, RN, BSN, MA, DmH
Assistant Professor

Felician University
Lodi, New Jersey

xiii

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Acknowledgments

This book exists because of the wonderful students I have had over the years and their
dedication to improving the health of individuals, families, and communities. Their
thirst for knowledge fed my own. I am grateful to my colleagues who I have had the
privilege to work with over my nursing career, with a very special thanks to those who
contributed to the writing of this book. I would also like to thank Jeannine Carrado,
Elizabeth Hart, and Terri Allen at F. A. Davis for their support and guidance throughout
the writing of this book. Improving the health of communities thrives on respectful and
thoughtful collaboration between many different people, and so does the writing of a
text book.

xv

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Table of Contents

Unit I n Basis for Public Health Nursing Knowledge and Skills 1

Chapter 1 Public Health and Nursing Practice 1
Chapter 2 Optimizing Population Health 23
Chapter 3 Epidemiology and Nursing Practice 55
Chapter 4 Introduction to Community Assessment 77
Chapter 5 Health Program Planning 107
Chapter 6 Environmental Health 128

Unit II n Community Health Across Populations: Public Health Issues 157

Chapter 7 Health Disparities and Vulnerable Populations 157
Chapter 8 Communicable Diseases 191
Chapter 9 Noncommunicable Diseases 218
Chapter 10 Mental Health 239
Chapter 11 Substance Use and the Health of Communities 256
Chapter 12 Injury and Violence 283

Unit III n Public Health Planning 313

Chapter 13 Health Planning for Local Public Health Departments 313
Chapter 14 Health Planning for Acute Care Settings 343
Chapter 15 Health Planning for Primary Care Settings 372
Chapter 16 Health Planning with Rural and Urban Communities 398
Chapter 17 Health Planning for Maternal-Infant and Child Health Settings 420
Chapter 18 Health Planning for School Settings 447
Chapter 19 Health Planning for Older Adults 479
Chapter 20 Health Planning for Occupational and Environmental Health 509
Chapter 21 Health Planning, Public Health Policy, and Finance 537
Chapter 22 Health Planning for Emergency Preparedness and Disaster Management 569

Index 607

xvii

7711_FM_i-xviii 21/08/19 11:08 AM Page xvii

1

Basis for Public Health Nursing
Knowledge and Skills

Chapter 1

Public Health and Nursing Practice
Christine Savage, Joan Kub, and Sara Groves

LEARNING OUTCOMES

After reading the chapter, the student will be able to:

KEY TERMS

1. Identify how public health plays a central role in the
practice of nursing across settings and specialties.

2. Describe public health in terms of current frameworks,
community partnerships, and the concept of population
health.

3. Investigate determinants of health within the context of
culture.

4. Explore the connection between environment, resource
availability, and health.

5. Identify the key roles and responsibilities of public health
nurses (PHNs).

6. Identify the formal organization of public health services
from a global to local level.

Aggregate
Assessment
Assurance
Community
Core functions
Cultural competency
Cultural humility
Cultural lenses
Culture

Determinants of
health

Diversity
Ethnicity
Global health
Globalization
Health
High-income countries

(HICs)

Life expectancy
Low-income countries

(LICs)
Lower middle-income

countries (LMICs)
Policy development
Population health
Population-focused

care

Public health
Public health nursing
Public health science
Race
Upper middle-income

countries (UMICs)

n Introduction
Every day the media presents us with riveting stories: “The
flu season—the worst in a decade,” “Flint’s water supply
contaminated with high levels of lead,” “School shooting
leaves 17 dead,” “Hurricane Maria leaves 80% of Puerto
Rico without power and water,” “Zika virus results in con-
genital brain damage,” “The homicide rate in Chicago rises,”
“More than 80 dead from the Camp Fire in California.” All
of these stories reflect the connections among the health of
individuals and families, the communities they live in, the

quality of the public health infrastructure, and population-
level events such as disasters (natural and manmade), com-
municable diseases (CDs), and violence. As nurses, we
provide care directly to individuals and families within
the context of the communities we serve. That context
encompasses diverse and unifying cultures, demographics,
geography, infrastructure, resources, and the vulnerability
of certain members of the community. That is why under-
standing health from a cellular to global level requires
a sound grounding in public health science, a central
component of nursing science and practice.

U N I T I

7711_Ch01_001-022 23/08/19 10:19 AM Page 1

As nurses, we apply public health science daily. Ob-
vious examples include infection control nurses, school
nurses, and nurses in the public health department.
Nurses working in an acute care setting also apply public
health science when using protective equipment and
caring for a patient in isolation to prevent transmission
of a CD. Public health science applies to every setting
where nurses work; understanding public health and the
science behind it is a core competency of professional

nursing. It is expected that upon graduation an entry-
level nurse will be able to integrate knowledge from pub-
lic health into their nursing practice. Nurses must apply
the nursing process and incorporate knowledge of the
ecological and social determinants of health as they care
for individuals and families, and by extension commu-
nities and populations. Finally, they are expected to be
able to evaluate health within a global context and
demonstrate cultural humility in the care of individuals,
families, communities, and populations.1 According to
the American Nurses Association’s (ANA) Scope and
Standards, the importance of public health is clear.2
Other competencies grounded in public health include
infection control (Chapter 8), emergency preparedness
and disaster management (Chapter 22), environmental
health (Chapter 6), and a basic understanding of epi-
demiology (Chapter 3).

Public Health Science and Practice
What exactly is public health science? Public health sci-
ence is the scientific foundation of public health practice
and brings together other sciences including environ-
mental science, epidemiology, biostatistics, biomedical
sciences, and the social and behavioral sciences.3,4

Thus, public health science, as a combination of sev-
eral other sciences, allows us to tackle health problems
using a wide range of knowledge. We apply the results of
public health science to deal with health problems on a
regular basis. For example, the evidence that underlies
the reliability and validity of screening and diagnostic
test results comes from the analysis of population-level
data using the science of epidemiology. Public health sci-
ence also provides the tools needed to try and solve a
problem in the community or in a geographical area.

When confronted with a health problem, health care
providers begin with the question “What can we do
about it?” This requires an examination of the underlying
risks and protective factors related to the health problem,
both individual and population based. Based on this type
of examination, lead experts in nursing used a population
health framework to develop a conceptual model of nurs-
ing that reflects the shift from a concentration on indi-
vidual health alone to an understanding that health
occurs within the context of a population and factors that
support or undermine the health of the population as a
whole.5 Understanding the factors that contribute to
health, both negative and positive, from both a popula-
tion and an individual/family perspective allows us to de-
velop nursing interventions that incorporate the full
continuum of health from individuals to populations,

2 U N I T I n Basis for Public Health Nursing Knowledge and Skills

n CELLULAR TO GLOBAL
Health Across the Continuum

The health of individuals occurs across a continuum
from the cellular level to the global level. When we
care for individuals and their families, understanding
the context of their health is vital to the promotion of
optimum health. For example, a person with type 2 dia-
betes who is seeking care may or may not have access
to the needed resources depending on what exists in
their community as well as their own financial status.
Providing care to that person requires use of pre-
scribed medication, encouragement to exercise, and
encouragement to maintain a healthy diet. As you
learned in pathophysiology, type 2 diabetes occurs at
the cellular-level, but external factors may increase the
risk for being diagnosed with the disease. In addition,
the community in which a person lives, both locally
and at the state level, has an impact on their ability to
pay for medications, to have access to safe areas for
exercise, and to obtain affordable fresh food.

Likewise, individual health at the cellular level de-
pends on the health of the Earth from a global level.
Optimal health requires access to basic resources
such as potable water, a secure food supply, sanitation,
and adequate shelter. Events at the global level such
as climate change can result in the inability to obtain
these needed resources. For example, following the
2018 Camp Fire in California, which was associated
with climate change, many people lost their homes.
Outbreaks of communicable diseases (see Chapter 8)
in one part of the world can spread and affect many
other parts of the world, such as the Zika virus
outbreak in the summer of 2016. Natural disasters
often have far-reaching effects such as the tsunami
of 2004 that resulted in deaths and injury across
multiple countries including Indonesia, India, Malaysia,
Myanmar, Thailand, Sri Lanka, and the Maldives. Thus,
all disease and injury occur within the context of the
health of the community and the globe.

7711_Ch01_001-022 23/08/19 10:19 AM Page 2

and, it is hoped, to contribute with each intervention to
the goal of the World Health Organization (WHO), the
public health arm of the United Nations (UN): “… to
build a better, healthier future for people all over the
world.”6

According to Issel,7 individuals do not achieve health
through uninformed, individualistic actions. Instead, in-
dividual health occurs within the surrounding context of
the population and the environment. Therefore, all
nurses need skills and knowledge related to their pa-
tients’ informed actions within the context of the health
of their community. During the last century and into the
21st century, public health science has been the backbone
of the nursing interventions we provide to individuals,
families, and communities. Standard care, such as flu
vaccinations, lead poisoning screening, and prevention
programs, comes from work done using the principles
of public health science. As nurses, we must be suffi-
ciently competent to understand the basics of this science
and apply it daily in our care. After all, it is our heritage.
The modern founder of our profession, Florence
Nightingale, was an early pioneer in epidemiology and
public health science.

Although public health has contributed significantly
to the health of the nation over the past century, it is
often difficult to define. In 1920, a respected public health
figure, C.E.A. Winslow, defined public health as:

… the science and art of preventing disease, prolonging life
and promoting health and efficiency through organized
community effort for the sanitation of the environment,
the control of communicable infections, the education of
the individual in personal hygiene, the organization of
medical and nursing services for the early diagnosis and
preventive treatment of disease, and for the development
of the social machinery to insure everyone a standard of
living adequate for the maintenance of health, so organiz-
ing these benefits as to enable every citizen to realize his
birth right of health and longevity.3

Winslow’s definition reflects what public health is, the
scientific basis of public health, and what it does, and it
remains relevant to this day.4

In 1988, the Institute of Medicine (IOM), now known
as the Health and Medicine Division (HMD) of the
National Academies of Sciences, Engineering, and Med-
icine, in its report The Future of Public Health, added
clarity to the term by defining public health as what so-
ciety does collectively to assure the conditions for people
to be healthy.8 It identified three core functions that en-
compass the purpose of public health: (1) assessment,
(2) policy development, and (3) assurance. Assessment

focuses on the systematic collection, analysis, and mon-
itoring of health problems and needs. Policy develop-
ment refers to using scientific knowledge to develop
comprehensive public health policies. Assurance relates
to assuring constituents that public health agencies pro-
vide services necessary to achieve agreed-upon goals.

In 1994, the Public Health Functions Steering Com-
mittee, a group of public and private partners, added fur-
ther clarification to the definition by establishing a list of
essential services (Chapter 13). The committee developed
the list of essential services through a consensus process
with federal agencies and major national public health
agencies (see Box 1-1). 9

Although the government is likely to play a leadership
role in ensuring that essential services are provided, pub-
lic, private, and voluntary organizations are also needed
to provide a healthy environment and are a part of
the public health system. In a 2012 report by the IOM,
experts concluded that “… funding for governmental

C H A P T E R 1 n Public Health and Nursing Practice 3

The 10 essential public health services provide the
framework for the National Public Health Performance
Standards Program (NPHPSP). Because the strength
of a public health system rests on its capacity to effec-
tively deliver the 10 Essential Public Health Services,
the NPHPSP instruments for health systems assess how
well they perform the following:

1. Monitor health status to identify community health
problems.

2. Diagnose and investigate health problems and health
hazards in the community.

3. Inform, educate, and empower people about health
issues.

4. Mobilize community partnerships to identify and
solve health problems.

5. Develop policies and plans that support individual
and community health efforts.

6. Enforce laws and regulations that protect health and
ensure safety.

7. Link people to needed personal health services and
assure the provision of health care when otherwise
unavailable.

8. Assure a competent public health and personal
health-care workforce.

9. Evaluate effectiveness, accessibility, and quality of
personal and population-based health services.

10. Research for new insights and innovative solutions to
health problems.

BOX 1–1 n Ten Essential Public Health Services

Source: (9)

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public health is inadequate, unstable, and unsustain-
able.”10 Thus the promotion of population level health
requires a comprehensive public health infrastructure.
According to Healthy People 2020 (HP 2020) the three
essential infrastructure components include a capable
and qualified workforce, up-to-date data and informa-
tion systems, and public health agencies capable of
assessing and responding to public health needs (see
Box 1-2). 11

Public Health Frameworks: Challenges
and Trends
Public health in the 21st century is facing new challenges
and trends that are likely to demand different frameworks
for its practice. Over the past 2 decades, numerous events
both here in the U.S, and globally have brought this fact
to the forefront including the attacks of September 11,
2001; numerous hurricanes; mass shootings; emerging
CDs such as Ebola and the Zika virus; and massive
migrations of populations due to war. These events have
brought recognition to alarming public health concerns
related to both manmade and natural disasters. These
events result in disease, death, displacement of commu-
nities, and serious damage to essential public health
infrastructures.

To better understand the impact of both natural and
manmade disasters, it is helpful to revisit Hurricane

Katrina, which savaged the Gulf Coast of the United
States in the summer of 2005. A horrified TV audience
watched news stories detailing the collapse of the emer-
gency systems in New Orleans. This collapse left people
to suffer and die, not only from the destruction of the
hurricane, but also from a lack of water, food, sanitation,
and medical attention. The aftermath of Katrina and
the attacks of September 11, 2001, highlighted the need
to strengthen the public health infrastructure, with an
increasing emphasis on disaster preparedness and emer-
gency response. Unfortunately, responses to natural
disasters continue to challenge the United States as
exemplified by Hurricane Maria and the devastation
to Puerto Rico, and Hurricane Harvey in Houston,
Texas, both in 2017. Full restoration of power and access
to food and potable water remained a challenge in
Puerto Rico long after the hurricane was over. Individ-
ual health requires essential services at the population
level including adequate sanitation, potable water, and
power. Understanding the interaction among cultural
considerations, the economy of a country, and public
health infrastructure is essential to promotion of health
and adequate response to disasters and subsequent
threats to health.

Any disaster can quickly escalate from direct injuries
and deaths to indirect illness and risk of mortality be-
cause of the destruction of the public health infrastruc-
ture and the lack of public health resources especially for
vulnerable populations. CD outbreaks challenge com-
munities to respond in a way that provides care for those
with the disease as well as protection for those who are
in danger of getting the disease. Care for those with long
term noncommunicable disease (NCD) requires access
to care and to environments that support healthy living.
Across the continuum from cellular to global, public
health systems are a key component in the promotion of
health and adequate care for those with disease. How-
ever, much of the emerging threats to population health
are tied to increasing globalization.

Globalization is “the process of increasing economic,
political, and social independence and integration as cap-
ital, goods, persons, concepts, images, ideas, and values
cross state boundaries.”12 It is associated with increased
travel, trade, economic growth, and diffusion of technol-
ogy, resulting sometimes in greater disparities between
rich and poor, environmental degradation, and food
security issues. It has also resulted in greater distribution
of products such as tobacco or alcohol. With globaliza-
tion, there is also an emergence and re-emergence of
CDs, including Zika, human immunodeficiency virus
(HIV), acquired immunodeficiency syndrome (AIDS),

4 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Public health infrastructure is fundamental to the provi-
sion and execution of public health services at all levels.
A strong infrastructure provides the capacity to prepare
for and respond to both acute (emergency) and chronic
(ongoing) threats to the nation’s health. Infrastructure is
the foundation for planning, delivering, and evaluating
public health. Public health infrastructure includes three
key components that enable a public health organization
at the federal, tribal, state, or local level to deliver public
health services. These components are:

A capable and qualified workforce
Up-to-date data and information systems
Public health agencies capable of assessing and respond-

ing to public health needs

These components are necessary to fulfill the previ-
ously discussed 10 Essential Public Health Services.

BOX 1–2 n Healthy People 2020: Public Health
Infrastructure

Source: (11)

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severe acute respiratory syndrome (SARS), hepatitis,
malaria, diphtheria, cholera, measles, and Ebola virus.
Planning for CD outbreaks, including pandemics, may
require new ethical frameworks to guide decision making
regarding appropriate action with limited resources.13

Despite climate change, wars, terrorism, and other
challenges, population health at the global level is
improving. Infrastructure, educational opportunities,
and a growing global economy are some of the factors
that contribute to this improvement. According to global
data made available through the “Our World in Data”
Web site, run by Oxford University economist Max
Weber, fewer people are experiencing poverty, life ex-
pectancy is up, and more people have access to electricity
and drinking water.14 Some interesting statistics using
these data demonstrate the positive news related to global
improvements in indicators of a healthy life. In the 1950s,
more than 60% of the world’s population was illiterate;
today, only 14.7% are illiterate.15 In 1980, 44% of the
world’s population lived in extreme poverty, which is
living with less than $1.90 USD per day. The 2015 pro-
jections bring that down to just 9.6%.16 Another common
indicator of the health of a community is access to
potable water. According to Richie and Roser, access to
potable water also rose from 76% in 1990 to 91% in
2015.17 A key measure of the health of populations is life
expectancy, which is the average number of years a per-
son born in a given country would live if mortality rates
at each age were to remain constant in the future. The
WHO reported a 5-year rise in the global average life
expectancy to 71.4 years (73.8 years for females and
69.1 years for males) between 2000 and 2015. According
to the WHO this was the fastest increase since the 1960s.18

Another challenge facing public health is the advance-
ment of scientific and medical technologies that pose
ethical questions.13 The increasing use of genomics, for
example, raises questions of how to protect against
discrimination. Another challenge is aging and increas-
ing diversity within populations. With aging, comes an
increase in persons living with NCDs and CDs that re-
quire long-term care. Examples of disease that require
long-term care include diabetes and HIV. In addition,
some long-term diseases and health concerns relate to
lifestyle choices such as smoking and poor nutrition. In
1926, Winslow discussed the need for new methods to
address heart disease, respiratory diseases, and cancer.19

We still need frameworks to help improve NCD and
CD outcomes and, from a global perspective, to address
how international collective action becomes essential
to combating preventable risk factors associated with
development of disease such as the tobacco epidemic.20,21

Emerging Public Health Frameworks
In 2003, the IOM (now HMD) produced The Future of
the Public’s Health in the Twenty-First Century as an
update of the 1988 IOM report.22 The new report pre-
sented the ecological model as the basis not only for un-
derstanding health in populations but also for assuring
conditions in which populations can be healthy. The
committee built on an ecological model created by
Dahlgren and Whitehead,23 and based its model on the
assumption that health is influenced at several levels:
individuals, families, communities, organizations, and
social systems (Fig. 1-1). The model is also based on the
assumptions that:

• There are multiple determinants of health.
• A population and environmental approach is critical.
• Linkages and relationships among the levels are

important.
• Multiple strategies by multiple sectors are needed to

achieve desired outcomes.24

Conventional public health models such as the epi-
demiological model of the agent, host, and environment
(Chapter 3) are grounded in the ecological model. How-
ever, the ecological model reflects a deeper understand-
ing of the role not only of the physical environment but
also of the conditions in the social environment creating
poor health, referred to as an “upstream” approach.10,21,24

C H A P T E R 1 n Public Health and Nursing Practice 5

Individual

Relationship

Community

Societal

Figure 1-1 The Social-Ecological Model. (Adapted by
CTLT by Dahlgren and Whitehead, 1991; Worthman, 1999)

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Upstream refers to determinants of health that are some-
what removed from the more “downstream” biological
and behavioral bases for disease. These upstream deter-
minants include social relations, neighborhoods and
communities, institutions, and social and economic poli-
cies (see Chapter 2).24

Community Partnerships
One of the recommendations of the 2003 IOM report
was to increase multisectored engagement in partner-
ships with the community. In 2016, the National Acad-
emy of Sciences published a detailed report Communities
in Action: Pathways to Health Equity that addresses the
importance of community-level efforts aimed at improv-
ing health.25 In the past, the community’s role in health
programs had often been that of a passive recipient, ben-
eficiary, or research subject, with the active work carried
out by public health experts. There is now a growing
commitment to collaboration in promoting the health of
communities and populations. Evidence shows that such
efforts increase effectiveness and productivity, empower
the participants, strengthen social engagement, and
ensure accountability.25, 26

Population Health and Population-
Focused Care
According to Caldwell,27 a population is a mass of peo-
ple that make up a definable unit to which measurements
pertain. The WHO defined health as “the state of com-
plete physical, mental, and social well-being, and not
merely the absence of disease or infirmity.”28 However,
population health is more than just a combination of
these two terms, because it requires an understanding of
all the factors listed in the ecological model that con-
tribute to the health of a population.

Much of the curricular content in nursing programs
pertains to acquiring the knowledge and skill the nurse
needs to deliver nursing care to individuals. When nurses
deliver care to an individual, the outcomes of interest are
at the individual level. The goal is to implement nursing
interventions that contribute to the individual’s ability
to achieve a maximum health state. However, achieving
a complete state of health and well-being usually extends
beyond the interventions that nurses and other health-
care professionals provide on an individual level during
a single episode of care. A state of health and well-being
requires meeting an individual’s mental, social, and eco-
nomic needs as well as their immediate health needs. To
take in this wider scope of influences on the person’s
health, the nurse must consider the individual as a part

of a greater whole, which includes the individual’s inter-
actions with other individuals and groups. This requires
placing the individual within his or her socioecological
context.

With individuals, nurses always start their care with
an assessment. This requires knowledge of the biomed-
ical, social, and psychological sciences. When providing
population-focused care, nurses need a basic knowledge
of the different scientific disciplines that make up public
health science. When nurses assess a community and/or
a population, they use their knowledge of epidemiology
and biostatistics to help identify priority health issues
at the population level. Some terms relevant to a discus-
sion of public health—aggregate, population, and
community—are sometimes used interchangeably, but
there are differences among them (see Box 1-3 for

6 U N I T I n Basis for Public Health Nursing Knowledge and Skills

For this book, these terms are defined within the context
of public health building on standard dictionary defini-
tions and definitions used in the literature.

Aggregate: In public health, this term represents individual
units brought together into a whole or a sum of those
individuals. In public health science, the term aggregate
often refers to the unit of analysis, that is, at what level
the health-care provider analyzes and reports data.

Population: Refers to a larger group whose members
may or may not interact with one another but who
share at least one characteristic such as age, gender,
ethnicity, residence, or a shared health issue such as
HIV/AIDS or breast cancer. The common denomina-
tor or shared characteristic may or may not be a
shared geography or other link recognized by the
individuals within that population. For example, peo-
ple with type 2 diabetes admitted to a hospital form a
population but do not share a specific culture or place
of residence and may not recognize themselves as
part of this population. In many situations, the terms
aggregate and population are used interchangeably.

Community: Refers to a group of individuals living within
the same geographical area, such as a town or a
neighborhood, or a group of individuals who share
some other common denominator, such as ethnicity
or religious orientation. In contrast to aggregates and
population, individuals within the community recog-
nize their membership in the community based on
social interaction and establishment of ties to other
members in the community, and often join collective
decision making.

BOX 1–3 n Definitions for Aggregate, Population,
and Community

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detailed definitions).29,30 All of these interventions,
grounded in public health science, when framed beyond
the individual ultimately improve the health of aggre-
gates, populations, and communities.

Determinants of Health and Cultural
Context
Determinants of health include a range of personal, so-
cial, economic, and environmental factors.31 Before de-
veloping an intervention to improve health outcomes in
a population, a nurse must first identify these determi-
nants of health. MacDonald explained that earlier models
related to population health were built on the assump-
tion that patterns of disease and health occur through a
complex interrelationship between risk and protective
factors.32 This resulted in a focus on biological and be-
havioral risk factors that require changes at the individ-
ual level. Multiple examples exist of health promotion
activities that focus on changing individual behavior to
reduce risk, such as smoking cessation, healthy eating,
and increased exercise. Some success has occurred with
this approach. However, there have also been successful
efforts at the macrosocioecological level. These interven-
tions focus on population behavioral change that then
trickles down to the individual. Population behavioral
change addresses risk factors that affect the whole popu-
lation, such as provision of potable water to prevent
cholera. The underlying assumption is that the popula-
tion level of risk affects health outcomes independent of
individual/family-level risk factors.

Take, for example, lung cancer. One of the well-
documented determinants of this disease is the use of to-
bacco. Efforts to reduce this risk factor focus on changing
individual behavior. Theories have emerged that help to
explain behavior, such as the Transtheoretical Model of
Change.33 This model theory helps a health-care provider
determine in what stage of change a person is and helps
the provider put together a plan of care that fits the indi-
vidual’s readiness to quit smoking. Many of the inroads
made in tobacco use cessation in this country began with
a broader population health approach, including media
campaigns related to smoking cessation and governmen-
tal nonsmoking policies that resulted in a cultural shift
within our society. Once researchers made the case for
the hazards of secondary smoke, tolerance of smoking
within the community dramatically decreased. The pop-
ulation’s exposure to tobacco smoke has decreased be-
cause the cultural view of tobacco use has changed. An
increasingly negative perception of smoking has also in-
creased the willingness of communities to implement

policies that reduce the community’s risk. A cultural shift
reducing tolerance of smoking in public places and
increasing the ostracism experienced by smokers has
reduced the prevalence of smoking. Healthy behaviors
remain a key issue in the health of populations. Taking a
population approach allows for elevation of behavioral
changes from the individual/family level to the popula-
tion level.

Serious disparities in health exist at the global level,
which can be seen by comparing life expectancies between
high-income countries and low-income countries. For ex-
ample, the estimated life expectancy in 2017 in Monaco
was 89.4 years, whereas in Chad it was 50.6 years. The U.S.
was ranked 43 with a life expectancy of 80.0 years.34 To
address these disparities, public health as a science has
shifted from focusing on dramatic cases to focusing on
existing disparities and addressing the underlying social
determinants of health, such as poverty.35

Cultural Context, Diversity, and Health
Understanding the determinants of health begins with
the cultural context and the diversity of populations
across the globe. Diversity reflects the fact that groups
and individuals are not all the same but differ in relation
to culture, ethnicity, and race. Culture as defined in the
Merriam Webster Dictionary as “… the customary be-
liefs, social forms, and material traits of a racial, religious,
or social group; also: the characteristic features of every-
day existence (such as diversions or a way of life) shared
by people in a place or time.”36

C H A P T E R 1 n Public Health and Nursing Practice 7

n CULTURAL CONTEXT
AND NURSING CARE

Knowledge and understanding of the cultural context
of persons constitutes a key aspect in the development
of effective nursing interventions. This context includes
many aspects of life that affect the health of individuals,
such as food preferences, gender roles, birthing prac-
tices, language, and spiritual beliefs to name a few.
Spector equated culture to a set of luggage that a
person carries that contains such things as beliefs,
habits, norms, customs, and rituals that are handed
down from one generation to the next through both
verbal and nonverbal communication. Spector goes on
to state, “All facets of human behavior can be inter-
preted through the lens of culture.”37 Thus, nurses
must have an appreciation for cultures represented
within the population they are caring for while ac-
knowledging and understanding their own cultural
views of the world, also known as cultural lenses.

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Ethnicity, Race, and Culture
Having clear definitions of race and ethnicity helps in the
understanding of what is meant by cultural context. Race
and ethnicity are often used interchangeably but are
actually different constructs. Multiple definitions exist
for ethnicity. Commonalities across definitions include
shared geographical origin, language or dialect, religious
faith, folklore, food preferences, and culture. O’Neill38

included physical characteristics as well and suggested
that we use ethnicity in two distinct ways: to classify peo-
ple who may have no specific cultural traditions in com-
mon into a loose group, and to classify groups that have
a shared language and cultural traditions. For example,
to classify an ethnic group under the name Native Amer-
ican results in grouping together people who are actually
diverse in both culture and language. However, if the eth-
nic group is a specific Native American tribe, such as the
Navajo, then the group does share specific cultural tra-
ditions, beliefs, and language that may not be shared with
other Native American tribes such as the Inuit. There-
fore, care is required when using the term ethnicity be-
cause of the variation in its use. Identifying the ethnicity
of a group of people, which only considers broad shared
characteristics, may miss key cultural differences within
the group.

Geographical differences also play a part in diversity
across groups and can result in shared cultural traditions
that extend across ethnic groups within that geograph-
ical region. In the United States, cultural differences
exist among specific regions, such as New England, the
South, and the West Coast. These three regions differ in
dialect, accepted protocol for social interactions, and
food preferences.

Race categorizes groups of people based on superficial
criteria such as skin color, physical characteristics, and
parentage. In the United States, we continue to use racial
categories; these are increasingly less accurate as ethnic
groups become less defined. The U.S. Census Bureau
acknowledges that the use of racial categories is limited,
especially because some people may classify themselves
as belonging to more than one category.39,40 As the field
of genetics grows, so does the evidence that there is no
scientific basis for placing an individual into one racial
group. In a classic article in Newsweek, “What Color Is
Black?” Morganthau challenged the myth of race and
concluded that it is not a legitimate method for classify-
ing groups of people. Scientists found that people with
very dissimilar racial characteristics such as skin color
and facial features were in some cases more closely
related genetically than groups with similar skin color.41

However, race continues to be used to identify groups.

Traditionally, scientists report epidemiological data
using racial categories as a means of identifying disparity
between racial groups, especially in relation to health
outcomes and access to care. The U.S. 2010 Census
shows that the ability to group people using racial cate-
gories is increasingly difficult as these categories expand
to include individuals who identify themselves as biracial
and multiracial.

Understanding diversity in a population enhances the
process of partnering with communities and improves
the likelihood of the potential success of an intervention.
By contrast, if a nurse plans an intervention without tak-
ing into account the cultural and ethnic diversity within
the population, violation of ethnic and cultural values or
beliefs can lead to failure to achieve the goals of the
intervention. If the nurse only views an intervention
through his or her cultural lens, and if that lens differs
from those who will receive the intervention, then a key
piece is missing. Does the population view the interven-
tion as culturally relevant? Is the desired health outcome
valued? For example, if a nurse develops an intervention
aimed at increasing the number of women who breast-
feed their infants, the first step is to evaluate the cultural
view of breastfeeding. If the target population includes
all the women giving birth at a large urban hospital, the
population is probably diverse and may include cultures
with different practices related to breastfeeding. If
the nurse fails to acknowledge this fact and incorporate
possible cultural differences into the assessment and
planning stage (Chapters 4 and 5), the intervention may
not succeed with women who have specific cultural
beliefs surrounding breastfeeding.

Respecting culture and diversity when planning
population level interventions requires the inclusion of
the community members as partners in the process.
Interventions planned for communities rather than with
communities ignore the point made by Murphy that
communities interpret their own health. In addition,
Murphy stated that communities themselves can come
up with ways to improve their health. From a population
health perspective, collaboration and community partic-
ipation are essential when developing interventions.42

Engagement with the community can occur only within
the context of culture and ethnic heritage and the com-
munity’s own perception of what constitutes optimal
health.

Cultural Competency and Cultural Humility
Cultural competency is a core aspect of care for health-
care providers. It is traditionally defined as the attitudes,
knowledge, and skills the health-care provider uses to

8 U N I T I n Basis for Public Health Nursing Knowledge and Skills

7711_Ch01_001-022 23/08/19 10:19 AM Page 8

provide quality care to culturally diverse populations. It
requires an understanding and capacity to provide care
in a diverse environment. This implies an endpoint of
acquired knowledge related to the culture of others.
Cultural humility, conversely, acknowledges that the
understanding of the multitude of diverse cultures in the
world today may be too big a task. Cultural humility is
an understanding that self-awareness about one’s own
culture is an ongoing process, and an acknowledgment
that we must approach others as equals, with respect
for their prevailing beliefs and cultural norms.43 One is
not exclusive of the other. Cultural competence is the
standard to help guide the delivery of health care to in-
dividuals and to populations, whereas cultural humility
is the underlying quality needed to truly implement
interventions to improve health in partnership with
communities and populations.

Developing cultural humility takes self-reflection. This
provides an essential beginning point for nurses to de-
velop the insight and knowledge needed to provide care
to those who differ culturally from themselves. How do
nurses create health-care environments that are safe and
welcoming for clients and patients from all backgrounds?
The first step in this process for individual nurses should
be a cultural self-assessment. Cultural self-assessment
involves a critical reflection of one’s own viewpoints,
experiences, attitudes, values, and beliefs. When one can
honestly identify learned stereotypes and ethnocentric
attitudes, enlightenment can occur. Nurses cannot begin
to effectively consider the cultural context while provid-
ing care without first exploring their own cultures using
basic questions (Box 1-4).

Creating a culturally welcoming health-care environ-
ment requires purposeful action by health-care providers.
This necessitates commitment to principles and practices
on all levels that support inclusion. These principles and
practices should be a part of the systemic workings of
health-care organizations. There should be visible and tan-
gible signs of culturally welcoming health-care environ-
ments. However, more important are nurses who provide
care that is inclusionary and culturally appropriate.

Environment and Resource Availability
The environment is another factor that affects health
(see Chapter 6). Availability of clean air, abundant
and potable water, and adequate food supplies all affect
the health of an environment. For much of humankind’s
existence, the health of a population was concerned
with the short-term survival of that population and cen-
tered on food sources, predators, and pestilence. This
changed dramatically during the industrial revolution

as populations moved from rural communities to urban
areas. As large groups of people congregated in these
urban areas, new issues arose related to sanitation, food
supplies, and water. Communities with fewer resources
and inadequate infrastructure to provide these essential
components of a healthy life are at greater risk for
disease. Poor sanitation and lack of potable water sig-
nificantly increase the possibility of the spread of CDs.
For example, in April of 2015, Uganda experienced a
typhoid epidemic. As you can see in Figure 1-2, there
are serious environmental risks to children and an
increased risk for contaminated water sources.

Epidemiology, the study of the occurrence of disease
in humans, identifies environment as a key factor con-
tributing to morbidity and mortality (see Chapter 3).
Epidemiology emerged in the 19th century in response
to these new challenges brought by the industrial revo-
lution. Though early epidemiologists did not understand
that microscopic pathogens caused disease (the germ
theory), they firmly established the role that environment
plays in the health of humans. Efforts during the last half
of the 19th century and into the 20th century focused
on the introduction of sanitary measures, including
management of sewage and providing clean water and
adequate ventilation.32

John Snow was an epidemiologist who first studied as-
pects of the environment related to sanitation (see Chap-
ter 3). He conducted a classic investigation of a cholera

C H A P T E R 1 n Public Health and Nursing Practice 9

The following questions can be used to guide cultural
self-reflection:

• Where did I grow up? How did this environment influ-
ence my worldview (country, region, rural, urban)?

• What values were emphasized in my family of origin?
• Who were the people most influential to me in

shaping my worldview?
• Who were the people within my circle of friends and

acquaintances during my years of growing up? How did
they differ from me?

• What privileges did I enjoy while growing up?
• What are some of the key experiences that have

shaped my view of the world and the people in it?
• What are my religious beliefs, if any?
• What are the values and morals that I adhere to?
• What does “good health” mean to me? How do I

obtain and maintain good health?
• How do I view those individuals whose values differ

from my own?

BOX 1–4 n Personal Cultural Assessment

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outbreak in the Soho area of London in 1854.44 Snow
mapped out cholera deaths block by block and found
that they clustered around the Broad Street pump, lead-
ing him to conclude that the pump was the source of the
contamination. He even examined the water under a
microscope and identified “white, flocculent particles”
that he thought were the causative agents. Though other
authorities dismissed his evidence of a microscopic
agent, he convinced others of the link between the
disease and the water pump. He was successful in getting
the water company to change the pump handle.55

Snow’s work brought attention to the importance of safe
water. The measures taken did not require a change in
individual behavior but rather a change in how the water
company delivered water to the populace.

Initial public health efforts focused on the develop-
ment of a public health infrastructure related to sanita-
tion and delivery of safe water supplies. In the late 19th
and early 20th centuries, large metropolitan municipal-
ities initiated the development of underground sewerage
systems and water pipes that are still in service today. The
implementation of similar systems in smaller towns and
rural areas occurred later, with outhouses still in use in
the 1950s. In the United States, long before antibiotics
were available, addressing these sanitation and safe water
issues directly reduced the spread of CDs such as infan-
tile diarrhea and cholera. In undeveloped countries with-
out this public health infrastructure, these two diseases
continue to contribute to the morbidity and mortality of
their populations.

To survive, humans need adequate water and food
supplies, shelter from the elements, and protection from

pestilence and disease. In modern developed societies,
geopolitical groups come together to supply adequate
potable water and sewerage. Agricultural businesses pro-
vide food. In most developed societies, most individuals
and families have the means to purchase adequate shelter
and the health care needed to protect them from both
CDs and NCDs. In some societies, government-based
programs provide the means for obtaining health-care
resources aimed at protection from pestilence and dis-
ease, and in other societies individuals purchase the
health care either directly or indirectly through health
insurance. Governments and individuals need adequate
money to provide these resources; thus, obtaining
adequate resources to promote the health of a population
depends on that population’s economic health. When
the economy is healthy, the majority of the population
generally has access to adequate water, food, and shelter.
However, an economy in jeopardy may result in a
reduced ability to meet these basic needs. In all societies,
nurses must be aware of the environment in which the
patient resides. Does the patient live in a community
with a healthful environment? Is there adequate, safe,
and usable water? Is food available, affordable, and
nutritionally beneficial? Is the economy strong enough
to provide access to health-care resources? Environment
is one of the main determinants of health for individuals,
populations, and the communities they live in.

Public Health as a Component of Nursing
Practice Across Settings and Specialties
Nursing practice requires the application of knowledge
from multiple sciences, including public health. Health
is not just a result of individual factors such as biology,
genetics, and behavior; it is also a product of an indi-
vidual’s social, cultural, and ecological environment.
To meet our obligation to maximize health on all levels,
we must incorporate public health science into our
nursing care.

Public Health Science and Nursing Practice
In 2010, the IOM (now HMD) published a report on the
future of nursing.45 The stated goal was to have 80% of
all registered nurses prepared at the baccalaureate of
science in nursing (BSN) level or higher. The rationale
for this goal was that BSN programs emphasize liberal
arts, advanced sciences, and nursing coursework across
a wide range of settings, along with leadership develop-
ment and exposure to community and public health
competencies. In addition, the authors emphasized that

10 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Figure 1-2 Children in Uganda during typhoid out-
break. (Courtesy of the CDC/Jennifer Murphy)

7711_Ch01_001-022 23/08/19 10:19 AM Page 10

entry-level nurses need to be able to transition smoothly
from their academic preparation to a range of practice
environments, with an increased emphasis on commu-
nity and public health settings.45

Population-Focused Care Across Settings
and Nursing Specialties
Nurses provide population-focused care every day, in
every setting. For a staff nurse working in an urban hos-
pital, the population of interest is the patients who come
to that hospital for care. The population may include var-
ious subpopulations based on shared geographical resi-
dence, age group, primary diagnosis, culture, and ethnic
group. Staff nurses in an acute or community-based set-
ting take care of patients on an individual level, often
serving as the member of the health-care team that de-
livers the interventions and evaluates the effectiveness of
those interventions. Nurses actively participate in re-
viewing how well the team is delivering care to the pa-
tient population as a whole. Over time, the health-care
team begins to group patients based on diagnosis or
other identifying characteristics to provide better care.
This may occur when nurses are engaged in performance
improvement activities, the development of a care map,
or in response to changes in the population.

Across settings and specialties, nurses work to success-
fully answer the “who, what, when, where, why, and how”
of health problems within the context of populations.
Providing individual care alone after disease has occurred
is an essential part of what nurses do. In a sense, all nurses
are Public Health Nurses (PHN) because our mandate is
not only to provide state-of-the-art care to individuals but
also to safeguard the public’s health and actively partici-
pate in optimizing health for all populations.

Public Health Nursing as a Specialty
Public health nursing is the practice of promoting and
protecting the health of populations using knowledge
from nursing, social, and public health sciences. Public
health nursing is a specialty practice within nursing and
public health. It focuses on improving population health
by emphasizing prevention and attending to multiple de-
terminants of health. Often used interchangeably with
community health nursing, this nursing practice includes
advocacy, policy development, and planning, which ad-
dresses issues of social justice. With a multi-level view of
health, public health nursing action occurs through com-
munity applications of theory, evidence, and a commit-
ment to health equity. In addition to what is put forward
in this definition, public health nursing practice is guided

by the ANA Public Health Nursing: Scope and Standards
of Practice and the Quad Council of Public Health Nurs-
ing Organizations’ Core Competencies for Public Health
Nurses.46

Public health nursing is different from other nursing
specialties because of its focus on eight principles
outlined in an unpublished white paper by the Quad
Council in 199747 and cited in the Public Health Nursing:
Scope and Standards of Practice.48 (See Box 1-5.) These
principles define the client of public health nursing as the
population and further delineate processes and strategies
used by PHNs.

Public Health Nursing as a Core Component
of Nursing History
The roots of public health nursing lie in the work of
women who provided comfort, care, and healing to indi-
viduals during the Middle Ages. During that time, nuns,
deaconesses, and women of religious orders provided
comfort and care to the sick in their homes.49 The imme-
diate precursor to public health nursing was district
nursing, which began in England. William Rathbone
employed a nurse to care for his wife during her terminal
illness and after this experience realized that home visiting
to the sick poor could benefit society. This resulted in the

C H A P T E R 1 n Public Health and Nursing Practice 11

1. The client or unit of care is the population.
2. The primary obligation is to achieve the greatest good

for the greatest number of people or population as a
whole.

3. The processes used by PHNs include working with
the client as an equal partner.

4. PRIMARY prevention is the priority in selecting appro-
priate activities.

5. Public health nursing focuses on strategies that create
healthy environmental, social, and economic condi-
tions in which populations may thrive.

6. A PHN is obligated to actively identify and reach out
to all who might benefit from a specific activity or
service.

7. Use of available resources must be optimal to assure
the best overall improvement in the health of the
population.

8. Collaboration with a variety of other professions,
populations, organizations, and other stakeholder
groups is the most effective way to promote and
protect the health of the people.

BOX 1–5 n The Eight Principles of Public Health
Nursing

Source: (1)

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development of district nursing, under which towns were
divided into districts, and health visitors provided nursing
care and education to the sick poor within those districts.
In 1861, Rathbone wrote Florence Nightingale to request
the development of a training school for both infirmary
and district nursing, which eventually resulted in trained
nurses in 18 districts of Liverpool.53 Public health nursing
owes much of its early development to Florence Nightin-
gale. She was concerned about the care of the sick poor
and the quality of their homes and workhouses. She is also
widely known for her work during the Crimean War,
during which she kept impeccable statistical records on
the living conditions of the soldiers and on the presence
of disease. She is also known for her promotion of health
reform.50,51

Beginnings of Public Health Nursing
in the United States
Public health nursing in the United States evolved from
district nursing in England. In 1877, the New York City
Mission hired Francis Root to make home visits to the
sick. Other sites followed suit, and visiting nurse associ-
ations were set up in Buffalo (1885), Boston (1886), and
Philadelphia (1886). Trained nurses cared for the sick
poor and provided instruction on improving the clean-
liness of their homes. Originally these associations bore
the name District Nursing Services, with the Boston
association referred to as the Boston Instructive District
Nursing Association. Eventually they all changed their
names to Visiting Nurse Associations.52

In 1893, Lillian Wald and Mary Brewster established
a district nursing service called the Henry Street Settle-
ment on the Lower East Side of New York and coined the
term public health nurse.53 In her work, Wald emphasized
the role that social and economic problems played in
illness and developed unique programs to address the
health needs of the immigrant population. During the
early part of the 20th century, poverty was increasingly
seen as a cause of social problems and poor health in com-
munities. Wald believed that environmental and social
conditions were the causes of ill health and poverty.54,55

For Lillian Wald and her colleagues, efforts of social re-
form were focused on civil rights for minorities, voting
rights for women, the prevention of war, child labor laws,
and improving unsafe working conditions.55

Public Health Nursing in the 20th Century
Wald’s accomplishments were the background for the
development of the public health nursing specialty. Pub-
lic health efforts in the early part of the 20th century
made great strides in reducing disease, especially due to

advances related to the provision of potable water, regu-
lations around food and milk supply, removal of garbage,
and disposal of sewage. However, authorities realized
that they needed to implement other programs to work
on improving health education among those most at risk,
especially the poor. PHNs filled this need and provided
care to the sick while educating families on personal
hygiene and healthy practices.55 The visiting nurse move-
ment, with a focus on caring for the sick poor, joined
forces with public health to focus on prevention. Accord-
ing to Buhler-Wilkerson, “By 1910, the majority of
the large urban visiting nurse associations had initiated
preventive programs for school children, infants, moth-
ers, and patients with tuberculosis.”56

Public health nursing continued to grow with the
expansion of the federal government. The Social Security
Act of 1935 provided funding for expanded opportuni-
ties in health protection and promotion, resulting in the
employment of PHNs, increased education for nurses in
public health, the establishment of health services, and
research. World War II increased the need for nurses
both for the war effort and at home. PHNs also played
a role in surveillance and treatment of CDs such as
tuberculosis and Hanson’s disease, also known as lep-
rosy. As seen in the photo in Figure 1-3, taken in 1950,
PHNs worked with other nurses caring for the patients
receiving care for CDs.

The 1960s and 1970s saw the implementation of neigh-
borhood health centers, maternal-child health programs,
and Head Start programs. By the 1980s, however, there
was another shift in funding to more acute services, med-
ical procedures, and long-term care. The use of health
maintenance organizations (HMOs) was encouraged. By

12 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Figure 1-3 Public Health Nurses in the 1950s. (Courtesy
of the CDC/Elizabeth Schexnyder, National Hansen’s Disease
Museum, Curator)

7711_Ch01_001-022 23/08/19 10:19 AM Page 12

the latter part of the 1980s, public health as a focus had
declined and the percentage of PHNs working as govern-
ment employees had dropped.

Public Health Nursing in the 21st Century
In this century, the move toward population health and
the need for more services to communities outside of
traditional hospital settings has the potential to increase
the demand for PHNs. Currently, PHNs work in a wide
variety of settings. Some are based in schools, commu-
nity clinics, local health departments, and visiting nurse
associations. PHNs also work at the national level in the
United States Public Health Service, a branch of the
armed services in the U.S. (Fig. 1-4).

Based on a report completed by the Health Resources
and Services Administration on the registered nurse pop-
ulation in the United States, in 2017, 61% of nurses work
in hospital settings, 18% work in primary care, 5% work
in government, 7% in extended care facilities, and 3% in
education.57 If the predictions of Ezekiel J. Emanuel, vice
provost of the University of Pennsylvania Hospital, are
correct, hospitals will continue to downsize as health care

moves out into the community and individual homes.58

This may require an increase in the number of practicing
PHNs. This will also increase the need for all nurses to
have sufficient knowledge and skills to provide care
across the continuum from individuals to populations
within the context of community.

Public Health Nursing Scope and Standards
of Practice
The Public Health Nursing: Scope and Standards of
Practice outlines the expectations of the professional
role of the PHN and sets the framework for public
health nursing practice in the 21st century.1 As with the
other nursing specialties’ scope and standards, these are
based on the nursing scope and standards established
by the ANA.1,2

Public Health Nursing Standards
Included in the 11 Standards of Professional Performance
for Public Health Nursing (see Box 1-6)1 are six standards
of practice that describe a competent level of care using
the nursing process: (1) Assessment, (2) Population
Diagnosis and Priorities, (3) Outcomes Identification,
(4) Planning, (5) Implementation, and (6) Evaluation.
Specific standards related to implementation include the
coordination of care, health teaching, and health promo-
tion, consultation, and regulatory activities. These stan-
dards of practice are differentiated for the PHN and the
advanced PHN.

Public Health Nursing Competencies
The Scope and Standards of Practice delineates compe-
tencies for practice based on the ANA nursing frame-
work assuring that public health nursing fits as a
recognized nursing specialty. In addition, the Council of
Linkages Between Academia and Public Health Practice,
a coalition of organizations concerned with the public
health workforce, produced a document in 2001 that has
been used as a framework for the development of addi-
tional public health nursing competencies. The 2018 re-
vised version of the PHN Core Competencies includes
eight domains (Box 1-7) and incorporates three tiers of
practice: Basic or generalist (Tier 1); Specialist or mid-
level (Tier 2); and Executive and/or multisystem level
(Tier 3).59 These tiers reflect the different levels of respon-
sibility for those working in public health.60

Public Health Nursing Roles
and Responsibilities
There are roles and responsibilities specific to public
health nursing practice built on nursing practice for all

C H A P T E R 1 n Public Health and Nursing Practice 13

Figure 1-4 United States Public Health Service Nurse at
a blood pressure clinic. (Courtesy of the CDC/Nasheka Powell)

7711_Ch01_001-022 23/08/19 10:19 AM Page 13

14 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Standard 1. ASSESSMENT

The PHN collects comprehensive data pertinent to the
health status of populations.

Standard 2. DIAGNOSIS

The PHN analyzes the assessment data to determine the
diagnoses or issues.

Standard 3. OUTCOMES IDENTIFICATION

The PHN identifies expected outcomes for a plan specific
to the population or situation.

Standard 4. PLANNING

The PHN develops a plan that prescribes strategies and
alternatives to attain expected outcomes.

Standard 5. IMPLEMENTATION

The PHN implements the identified plan.

Standard 5A. COORDINATION OF CARE

The PHN coordinates care delivery.

Standard 5B. HEALTH TEACHING AND HEALTH
PROMOTION

The PHN employs multiple strategies to promote health
and a safe environment.

Standard 5C. CONSULTATION

The PHN provides consultation to influence the identi-
fied plan, enhance the abilities of others, and effect
change.

Standard 5D. PRESCRIPTIVE AUTHORITY

The advanced practice registered nurse practicing in the
public health setting uses prescriptive authority, proce-
dures, referrals, treatments, and therapies in accordance
with state and federal laws and regulations.

Standard 5E. REGULATORY ACTIVITIES

The PHN participates in applications of public health laws,
regulations, and policies.

Standard 6. EVALUATION

The PHN evaluates progress toward attainment of
outcomes.

Standard 7. ETHICS

The PHN practices ethically.

Standard 8. EDUCATION

The PHN attains knowledge and competence that reflect
current nursing practice.

Standard 9. EVIDENCE-BASED PRACTICE AND
RESEARCH

The PHN integrates evidence and research findings into
practice.

Standard 10. QUALITY OF PRACTICE

The PHN contributes to quality nursing practice.

Standard 11. COMMUNICATION

The PHN communicates effectively in a variety of formats
in all areas of practice.

Standard 12. LEADERSHIP

The PHN demonstrates leadership in the professional
practice setting and the profession.

Standard 13. COLLABORATION

The PHN collaborates with the population, and others in
the conduct of nursing practice.

Standard 14. PROFESSIONAL PRACTICE
EVALUATION

The PHN evaluates her or his own nursing practice in
relation to professional practice standards and guide-
lines, relevant statutes, rules, and regulations.

Standard 15. RESOURCE UTILIZATION

The PHN utilizes appropriate resources to plan and
provide nursing and public health services that are safe,
effective, and financially responsible.

Standard 16. ENVIRONMENTAL HEALTH

The PHN practices in an environmentally safe, fair, and just
manner.

Standard 17. ADVOCACY

The PHN advocates for the protection of the health,
safety, and rights of the population.

BOX 1–6 n Standards of Public Health Nursing Practice

Source: (1)

7711_Ch01_001-022 23/08/19 10:19 AM Page 14

specialties. They are in alignment with the Scope and
Standards of Nursing Practice in general and build in the
care of communities and populations.

Coordination, Consultation, and Leadership: A PHN
is responsible for coordinating programs, services, and
other activities to implement an identified plan.46 A PHN
acts as a consultant when he or she works with commu-
nity organizations or groups to develop a local health fair
or provide the latest information about a CD outbreak
to the community. At a more complex level, Advanced
Public Health Nurses (APHN) act as consultants when
providing expert testimony to the federal or state gov-
ernments about a health promotion program. As leaders,
PHNs can serve in coalition-building efforts around a
health issue such as teen smoking prevention or opioid
overdose prevention.

Advocacy: Advocacy refers to the responsibility of
PHNs to speak for populations and communities that
lack the resources to be heard.1 Assisting families living
in poverty to access appropriate services is one example
of an important role of PHNs. Another example of ad-
vocacy is engaging in strategies to affect policy at the
local, state, or national level.

Health Education and Health Promotion: The
PHN selects teaching and learning methods to help com-
munities address health issues, presenting the informa-
tion in a culturally competent manner, implementing the
health education program in partnership with the com-
munity, and evaluating the effectiveness of the program
by collecting feedback from participants.

Regulatory Activities: Since the beginning of public
health nursing, health policy has been an important
aspect of practice. Responsibilities include identifying,
interpreting, and implementing public health laws, reg-
ulations, and policies.1 Activities include monitoring and
inspecting regulated entities such as nursing homes. It

also includes educating the public on relevant laws, reg-
ulations, and policies.

Ongoing Education and Practice Evaluation:
PHNs are responsible for maintaining and enhancing
their knowledge and skills necessary to promote popu-
lation health. This requires PHNs to take the initiative to
seek experiences that develop and maintain their com-
petence as PHNs. Thus, as with nurses in other settings,
PHNs must engage in self-evaluation, seek feedback
about performance, and implement plans for accom-
plishing their own goals and work plans.

Professional Relationships and Collaboration:
Effective partnerships with communities and stakehold-
ers provide the mechanism for moving the public
health agenda forward.1 For example, nurses working in
health departments often join with other human service
providers to develop effective programs aimed at ad-
dressing a health issue of mutual concern such as the
opioid epidemic. PHNs seek collegial partnerships with
peers, students, and colleagues as a means of enhancing
public health interventions.

Public Health Nursing Ethics
The principles guiding any ethical discourse in nursing
include autonomy, dignity, and rights of individuals.
The same is true for public health nursing. Assuring
confidentiality and applying ethical standards are critical
in advocating for health and social policy.60,61 Equally
important to any discussion of public health ethics is the
fact that public health is concerned with the public good,
which can override individual rights.62 This is evident in
the enforcement of laws that are aimed at the whole
population (e.g., immunizations, disease reporting, or
quarantines). Underlying public health ethics is the con-
cept of social justice defined as: “… acting in accordance
with fair treatment regardless of economic status, race,
ethnicity, citizenship, disability, or sexual orientation.”1

This includes the eradication of poverty and illiteracy,
the establishment of sound environmental policy, and
equality of opportunity for healthy personal and social
development.1

Global Health
Global health is “the collaborative transnational research
and action for promoting health for all.”63 This definition
aligns with the WHO classic definition of health: “a state
of complete physical, mental, and social well-being
and not merely the absence of disease or infirmity.”64

The constitution of the WHO further recognizes “the

C H A P T E R 1 n Public Health and Nursing Practice 15

1. Assessment and analytical skills
2. Policy development/program planning skills
3. Communication skills
4. Cultural competency skills
5. Community dimensions of practice skills
6. Public health science skills
7. Financial planning, evaluation and management skills
8. Leadership and systems thinking skills

BOX 1–7 n PHN Core Competencies includes
Eight Domains

Source: (60)

7711_Ch01_001-022 23/08/19 10:19 AM Page 15

enjoyment of the highest attainable standard of health …
as one of the fundamental rights of every human
being.”65 The WHO recognizes that nurses play a large
role in the promotion of global health. In February of
2018, the WHO launched a new global campaign, called
Nursing Now, to “… empower and support nurses in
meeting 21st century health challenges.”66

One of the variables associated with differences
among countries is their economic well-being. The terms
most often used to differentiate countries based on
country-level income data are high-income countries
(HICs), upper middle-income countries (UMICs),
lower middle income countries (LMICs), and low-
income countries (LICs). These terms replace the earlier
terms of developed and developing countries. The World
Bank classifies countries based on current economic
ranges of the annual per capita gross national income
(GNI). In 2016, a LIC was a country with a per capita
GNI equal to or less than U.S. $1,005; LMIC’s per capita
GNI ranged from U.S. $1,006 to $3,955; UMIC’s per
capita GNI ranged from $3,956 to $12,235; and an
HIC’s per capita GNI was equal to or greater than U.S.
$12,236.67 From a global health perspective, a major con-
cern is the growing disparity between the two lower
groups (LIC and LMIC) and the two higher groups
(HIC and UMIC). Previously, international health-care
workers in LICs and LMICs looked for solutions to
health care within the country or collaborated with
one other country. The key conceptual change in global
health over the past 2 decades is the recognition of
the interdependence of countries; the interdependence
of the health of people in all countries; and the interde-
pendence of the policies, economics, and values that arise
related to health.68 The 2018 WHO launch of “Nursing
Now” with the stated purpose “… to empower and sup-
port nurses in meeting 21st century health challenges”
showcases this conceptual change.66

An example of global efforts to assist countries
with fewer resources to improve health is the effort to
improve access to vaccines for common childhood
illnesses. For example, in 2008 the Cairo M/R Catch-Up
Campaign was initiated (Fig. 1-5), a national supple-
mental immunization activity in Egypt. Another exam-
ple, in 2018, is the plan by the Bill and Melinda Gates
Foundation to pay off the $76 million debt that Nigeria
owes Japan for their program to eradicate polio. These
efforts demonstrate the importance of health of children
as a primary focus of health at the global level. World-
wide in 2016, the number of children under the age
of 5 who died was 5.6 million, down from 6.6 million
children in 2012 and a sharp decrease from 1990 when

the total number of deaths was 12.4 million.69 Despite
these gains, efforts continue to help lower the number
as most of the deaths are preventable.

Public Health Organizations and Management:
Global to Local
Public health organizations constitute an essential
part of improving health from the cellular to the global
level. These organizations provide essential public health
services such as conducting surveillance, responding to
CD outbreaks and disasters, and evaluating the evidence
to make recommendations for action. In addition, these
organizations set goals related to the improvement of
health such as the UN’s Sustainable Development Goals
(SDGs).70

World Health Organization
The WHO, established in 1948, is the world health
authority under the auspices of the UN. Their “… primary
role is to direct and coordinate international health

16 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Figure 1-5 Vaccinating children for measles and rubella
in Egypt. (Courtesy of the CDC/Carlos Alonso)

7711_Ch01_001-022 23/08/19 10:19 AM Page 16

within the United Nations’ system.”64 Their stated areas
of work include health systems, promoting health
through the life-course, NCD, CD, and corporate serv-
ices.76 Based in Geneva, the WHO employs 7,000 people
working in 150 country offices, 6 regional offices, and at
the central headquarters.64

In 1978, the WHO held a conference in Alma-Ata
(now Almaty), Kazakhstan, that supported the resolu-
tion that primary health care was the means for attaining
health for all. At the beginning of the first decade in
the 21st century, a new model emerged of integrated
services that respond to multiple threats to health. The
WHO has expanded to include emergency response and
disaster preparedness initiatives (see Chapter 22). An-
other key initiative was the institution of International
Health Regulations (IHRs) that countries must follow
in response to disease outbreaks and to increase the abil-
ity of the WHO to respond to public health emergencies
brought on by natural or manmade disasters.64 The
WHO continues to set global population heath goals
and tracks the attainment of these goals. The current
SDGs built on the Millennial Development Goals
(MDGs) that ended in 2015. There are 17 goals with a
target date of 2030 and, unlike the MDGs, the goals
apply to all countries, and there is no distinction be-
tween LIC and other countries (Box 1-8). The stated
purpose of the SDGs is to “… end poverty, protect the
planet, and ensure prosperity for all.”70

National Health Organizations
Individual countries have their own national organiza-
tions dedicated to the promotion of health and the pro-
tection of their populations. They coordinate with the
WHO and, as evidenced by the new interdependency
framework mentioned earlier, often work together to ad-
dress threats to heath. Some countries, including the
U.S., have public health departments, also known as
boards of public health. Even though these governmental
bodies do not encompass the entirety of the field of pub-
lic health, they are key to providing infrastructure as well
as oversight of the health of populations.

The U.S. Constitution provides for a two-layer pub-
lic health system composed of the federal level and the
state level. However, the Constitution did not make any
specific provisions for the management of public health
issues at the federal level, therefore, public health man-
agement now comes under state authority.30 After rat-
ification of the 14th Amendment, states were required
to provide protections to their own citizens, which
helped to legalize activities of local health departments
to take such actions as imposing quarantines.

Centers for Disease Control and Prevention
The CDC, founded in 1946, grew out of the wartime
effort related to malaria control. In the beginning, the
CDC employed approximately 400 people, including en-
gineers and entomologists (scientists who study insects).
Only seven employees functioned as medical officers.71

The work of the CDC contributed to the 10 great public
health achievements over the past century (Box 1-9).72

These included immunizations, fluoridation of water,
and workplace safety. The implementation of childhood
vaccination programs resulted in the eradication of
smallpox and the banishment of mumps and chickenpox
from schools in the United States.79 Without an active
public health infrastructure, the marked increases in life
expectancy in the 20th century would not have occurred.

Activities of the CDC: From this humble beginning,
the CDC has grown into one of the major operating
components of the Department of Health and Human

C H A P T E R 1 n Public Health and Nursing Practice 17

According to the United Nations, “The SDGs build
on the success of the Millennium Development Goals
(MDGs) and aim to go further to end all forms of
poverty. The new Goals are unique in that they call for
action by all countries, poor, rich and middle-income to
promote prosperity while protecting the planet. They
recognize that ending poverty must go hand-in-hand with
strategies that build economic growth and addresses a
range of social needs including education, health, social
protection, and job opportunities, while tackling climate
change and environmental protection.”70

The 17 sustainable goals include:

1. No poverty
2. Zero hunger
3. Good health and well-being
4. Quality education
5. Gender equality
6. Clean water and sanitation
7. Affordable and clean energy
8. Decent work and economic growth
9. Industry, innovation, and infrastructure

10. Reduced inequalities
11. Sustainable cities and communities
12. Responsible production and consumption
13. Climate action
14. Life below water
15. Life on land
16. Peace, justice, and strong institutions
17. Partnerships for the goals

BOX 1–8 n United Nations’ Sustainable
Development Goals

Source: (70)

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Services (DHHS). The scope of the agency’s efforts includes
the prevention and control of CDs and NCDs, injuries,
workplace hazards, disabilities, and environmental health
threats. In addition to health promotion and protection,
the agency also conducts research and maintains a national
surveillance system. It also responds to health emergencies
and provides support for outbreak investigations.73 Ac-
cording to the CDC, it is distinguished from its peer agen-
cies for two reasons: the application of research findings to
people’s daily lives and its response to health emergencies.74

The CDC collaborates with state and local health de-
partments in relation to disease and injury surveillance
and outbreak investigations, including bioterrorism. It
sets standards for the implementation of disease preven-
tion strategies and is the repository for health statistics.
Health statistics are available to health providers, health
departments, and the public.74 Web sites of interest to
nurses needing population level information include
CDC WONDER, FASTSTATS, and VITALSTATS (see
Box 1-10 for details).

Healthy People: Every decade Healthy People releases
a set of goals and health topics with specific objectives
aimed at improving health across the life span. As the tar-
get date of 2020 approached, the CDC and the USDHHS
worked on the development of the next iteration of
Healthy People, HP 2030 (see Box 1-11).73

18 U N I T I n Basis for Public Health Nursing Knowledge and Skills

1. Immunizations
2. Motor vehicle safety
3. Workplace safety
4. Control of communicable diseases
5. Declines in deaths from health disease and stroke
6. Safer and healthier foods
7. Healthier mothers and babies
8. Family planning
9. Fluoridation of drinking water

10. Tobacco as a health hazard

BOX 1–9 n Top 10 Public Health Achievements

Source: (79)

CDC WONDER provides online data sources (AIDS
public use data, births, cancer statistics); environment
(daily air temperature, land service temperatures,
fine particulate matter, sunlight, and precipitation);
mortality (detailed mortality, infant deaths, online
tuberculosis information systems); population (bridged
population, census); sexually transmitted morbidity;
and vaccine adverse event reporting.

Source: http://wonder.cdc.gov/.
FASTSTATS provides statistics on topics of public health

importance.
Source: http://www.cdc.gov/nchs/fastats/.
VITAL STATISTICS ONLINE DATA PORTAL is a

Web site that provides users with the ability to access
vital statistics, specifically birth and mortality data.
Source: https://www.cdc.gov/nchs/data_access/
vitalstatsonline.htm.

BOX 1–10 n Centers for Disease Control
and Prevention Web Resources

n HEALTHY PEOPLE 2030
Proposed Framework

For 2030, there are five overreaching goals and a plan
of action for reaching those goals.

Vision: “Where we are headed”

A society in which all people achieve their full potential
for health and well-being across the life span.

Mission: “Why we are here”

To promote and evaluate the Nation’s efforts to im-
prove the health and well-being of its people.

Overarching Goals: “What we plan to achieve”

• Attain healthy, purposeful lives and well-being.
• Attain health literacy, achieve health equity, eliminate

disparities, and improve the health and well-being of
all populations.

• Create social and physical environments that pro-
mote attaining full potential for health and well-being
for all.

• Promote healthy development, healthy behaviors,
and well-being across all life stages.

• Engage with stakeholders and key constituents across
multiple sectors to act and design policies that im-
prove the health and well-being of all populations.65

Public health systems are commonly defined as “all
public, private, and voluntary entities that contribute to
the delivery of essential public health services within a
jurisdiction.” This means that all entities’ contributions
to the health and well-being of the community or state
are recognized in assessing the provision of public health
services.72 As noted earlier, the CDC laid out 10 essential
public health services (see Box 1-1) that help guide all
public health organizations in the United States.9 These

7711_Ch01_001-022 23/08/19 10:19 AM Page 18

functions and services directly relate to the ability of
a public health department to address CDs, eliminate
environmental hazards, prevent injuries, promote
healthy behaviors, respond to disasters, and assure qual-
ity and accessibility of health services.72 The CDC col-
laborates with state and local health departments, as well
as public health entities across the world, especially the
WHO. Globally it has personnel stationed in 25 foreign
countries.

State Public Health Departments
States independently decide how they will structure their
local and state health departments (see Chapter 13). Vari-
ations exist across states in relation to the organization
and management of formal public health systems. The
variation stems, in part, from how the state government
has directed the establishment of public health boards or
departments and from the variation in state jurisdictional
structure. For example, some states such as Pennsylvania
use a town/city (municipality), township, or county sys-
tem, and other states such as Massachusetts divide their
entire state into municipalities. Finally, some states such
as Alaska have territories as well as municipalities because
they have smaller populations spread across a larger land

mass. States with sovereign Native American nations
within their borders add an additional layer to the struc-
turing of their state level public health department.

Local Public Health Departments
The basic mandate of the local public health department
is to protect the health of the citizens residing in their
county, municipality, township, or territory. However,
how public health departments implement this protec-
tion varies across states (see Chapter 13). This results in
variability in the services offered and the public health
activities of the local health departments. As a result of
federal mandates, public health departments uniformly
perform certain activities. These include surveillance,
outbreak investigation, and quarantine as well as man-
dated reporting of specific diseases and cause of death to
state health departments and the CDC. This allows the
federal government to track the incidence and prevalence
of disease from a national perspective. Local health de-
partments are essential to the health of communities and
provide the day-to-day services required to assure safe
environments and the provision of essential public health
services (see Chapter 13) with state departments and fed-
eral health organizations.

C H A P T E R 1 n Public Health and Nursing Practice 19

Overarching Goals
• Attain healthy, thriving lives and well-being, free of pre-

ventable disease, disability, injury, and premature death.
• Eliminate health disparities, achieve health equity, and

attain health literacy to improve the health and well-
being of all.

• Create social, physical, and economic environments that
promote attaining full potential for health and well-being
for all.

• Promote healthy development, healthy behaviors, and
well-being across all life stages.

• Engage leadership, key constituents, and the public
across multiple sectors to take action and design
policies that improve the health and well-being of all.

Plan of Action
• Set national goals and measurable objectives to guide

evidence-based policies, programs, and other actions to
improve health and well-being.

• Provide data that is accurate, timely, accessible, and
can drive targeted actions to address regions and

populations with poor health or at high risk for poor
health in the future.

• Foster impact through public and private efforts to im-
prove health and well-being for people of all ages and
the communities in which they live.

• Provide tools for the public, programs, policy makers,
and others to evaluate progress toward improving health
and well-being.

• Share and support the implementation of evidence-
based programs and policies that are replicable, scalable,
and sustainable.

• Report biennially on progress throughout the decade
from 2020 to 2030.

• Stimulate research and innovation toward meeting
Healthy People 2030 goals and highlight critical research,
data, and evaluation needs.

• Facilitate development and availability of affordable
means of health promotion, disease prevention, and
treatment.

BOX 1–11 n Healthy People 2030 Goals and Action Plan

7711_Ch01_001-022 23/08/19 10:19 AM Page 19

n Summary Points
• Public health is a core component of nursing knowl-

edge and competency across settings and specialties.
• The goal of nursing is to help people achieve optimal

health, which ultimately requires understanding the
health of populations and communities due to the
intricate interplay between individuals, families, and
the communities in which they live.

• Public health science encompasses efforts to improve
the health of populations from the cellular to the
global level.

• Public health provides us with the means to build a
healthy environment and respond to threats to our
health from nature and from humans.

• Public Health Nursing is a recognized specialty at the
generalist and advanced level with specific scope and
standards of practice.

• Formal structures from the global to local level exist
to promote health, reduce risk, and protect popula-
tions from threats to health.

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20 U N I T I n Basis for Public Health Nursing Knowledge and Skills

t THE CASE OF THE PARASITE ON
THE PLAYGROUND

In 2018, the New York Times published an article
related to roundworms, genus Toxocara, found in the
intestines of cats and dogs that are shed in the feces.1
The CDC estimated that about 5% of the U.S. popula-
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who live below the poverty line (10%) and for African
Americans (7%).1,2 The difference in prevalence appears
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regular veterinary care. Based on a recent survey of
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Suggested prompts for discussion:

1. Review the CDC Web site on Toxocara. What
interventions are needed at the individual level
versus the community level?

2. What knowledge does a nurse need to set up
interventions to prevent this disease?

3. What is the role of individual health care providers,
health care organizations, and public health depart-
ments. Who else might play a role?

4. How does this issue depict the role of the social
determinants of health in the spread of disease?

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73. Centers for Disease Control and Prevention, Office of Public
Health Preparedness and Response. (2013). Funding and
guidance for state and local health departments. Retrieved
from http://www.cdc.gov/phpr/coopagreement.htm.

74. Centers for Disease Control and Prevention. (2014).
About CDC: Mission goal and pledge. Retrieved from
http://www.cdc.gov/about/organization/mission.htm.

22 U N I T I n Basis for Public Health Nursing Knowledge and Skills

7711_Ch01_001-022 23/08/19 10:19 AM Page 22

23

KEY TERMS

Attributable risk
Behavioral prevention
Clinical prevention
Downstream approach
Ecological determinants of

health
Environmental prevention
Health education
Health literacy

Health prevention
Health promotion
Health protection
Indicated prevention
Intervention Wheel
Multiphasic screening
Natural history of disease
Population attributable

risk (PAR)

Prevalence
Prevalence pot
Prevented fraction
Prevention
Primary prevention
Reliability
Risk reduction
Secondary prevention
Selective prevention

Sensitivity
Social determinants of

health
Specificity
Tertiary prevention
Universal prevention
Upstream approach
Validity
Yield

n Introduction
The proposed vision of Healthy People 2030 (HP 2030)
is that of “A society in which all people achieve their
full potential for health and well-being across the life
span.” The mission is “To promote and evaluate the
nation’s efforts to improve the health and well-being of
its people.”1 Thus, the health of populations takes center
stage in the effort to achieve the vision of reaching the
full health potential for all. The major objective of nurs-
ing practice is to provide interventions to individuals,
families, communities, and populations aimed at ad-
dressing disease and optimizing health. This requires
implementing multiple levels of prevention along the
entire spectrum of health and disease. To provide the
best possible care requires not only an understanding of
the pathophysiology of disease but also of the concepts
of health promotion, risk reduction, and the underlying

frameworks of prevention that help guide nursing inter-
ventions. These frameworks are not unique to nursing
and, for the most part, come from the public health
sciences.

In 2018, the New York Times published an op-ed
article by Pagan Kennedy who explained that, although
there are things individuals can do to improve their
health, there are things that remain outside of our control
such as bad genes, unintentional injuries, and environ-
mental risk factors. She stated that, “It’s the decisions that
we make as a collective that matter more than any choice
we make on our own.”2 In other words, the effects of
the environment and genes can override what we do at
the individual behavioral level. Making our collective de-
cisions as a society about our environment is perhaps
more important than our individual decisions about our
behavior. Kennedy uses examples of experts in healthy
living who nevertheless died early despite adherence to

Chapter 2

Optimizing Population Health
Christine Savage and Sara Groves

LEARNING OUTCOMES

After reading the chapter, the student will be able to:
1. Apply the concept of population health to nursing

practice.
2. Describe current public health frameworks that guide

prevention efforts from a local to a global perspective.
3. Apply public health prevention frameworks to specific

diseases.
4. Compare and contrast different levels of health

promotion, protection, and risk reduction interventions.

5. Identify health education strategies and chronic disease
self-management within the context of prevention
frameworks.

6. Describe components of screening from a population
and individual perspective.

7. Identify public health methods used to evaluate the
outcome and impact of population-based prevention
interventions.

7711_Ch02_023-054 23/08/19 10:21 AM Page 23

a healthy diet and exercise. It is often factors outside our
individual control that contribute to early death.

To be effective as nurses, with the understanding that
our collective decisions as a society impact our health, we
need basic knowledge and skills at the population health
level as well as at the individual level to provide expert
care to individuals and their families. As evidenced by the
launch of the Nursing Now campaign in February of
2018, nurses are key to reaching the goals set by the World
Health Organization (WHO) as well as the proposed
HP 2030 goals. Nursing Now represents a collaborative
effort by the WHO and the International Council of
Nurses “… to improve health globally by raising the pro-
file and status of nurses worldwide – influencing policy-
makers and supporting nurses themselves to lead, learn,
and build a global movement.”3

As a profession, nursing contributes substantially to
the health of populations. In turn, healthier populations
lead to more robust communities and societies. To achieve
the proposed HP 2030 overarching goals (see Chapter 1),
HP published the proposed framework for these goals
that includes foundational principles that clearly link the
health of populations to a well-functioning society.

The proposed goals and foundational framework for
HP 2030 align well with those of the United Nations’
(UN) Sustainable Development Goals (SDGs) (Box 2-1)
that focus on sustaining and developing healthy
environments. In particular, goal three of the SDGs is
to “… ensure healthy lives and promote well-being
for all at all ages.”4 All of this requires a population
level perspective and encompasses more than treating
or preventing disease. It requires promotion of a healthy

24 U N I T I n Basis for Public Health Nursing Knowledge and Skills

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

nutrition, and promote sustainable agriculture.
Goal 3. Ensure healthy lives and promote well-being for

all at all ages.
Goal 4. Ensure inclusive and equitable quality education

and promote lifelong learning opportunities for all.
Goal 5. Achieve gender equality and empower all

women and girls.
Goal 6. Ensure availability and sustainable management of

water and sanitation for all.
Goal 7. Ensure access to affordable, reliable, sustainable,

and modern energy for all.
Goal 8. Promote sustained, inclusive, and sustainable

economic growth, full and productive employment,
and decent work for all.

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

Goal 10. Reduce inequality within and among countries.
Goal 11. Make cities and human settlements inclusive,

safe, resilient, and sustainable.
Goal 12. Ensure sustainable consumption and production

patterns.
Goal 13. Take urgent action to combat climate change

and its impacts.*
Goal 14. Conserve and sustainably use the oceans, seas,

and marine resources for sustainable development.
Goal 15. Protect, restore and promote sustainable use

of terrestrial ecosystems, sustainably manage forests,
combat desertification, and halt and reverse land
degradation and biodiversity loss.

Goal 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.

Goal 17. Strengthen the means of implementation and
revitalize the Global Partnership for Sustainable
Development.

BOX 2–1 n Sustainable Developmental Goals

Source: (4)
*Acknowledging that the UN’s Framework Convention on Climate Change is

the primary international, intergovernmental forum for negotiating the global
response to climate change.

n HEALTHY PEOPLE 2030
Foundational Principles: “What Guides
Our Actions”

Note: Foundational Principles explain the thinking that
guides decisions about Healthy People 2030.

• Health and well-being of the population and communi-
ties are essential to a fully functioning, equitable society.

• Achieving the full potential for health and well-being
for all provides valuable benefits to society, including
lower health-care costs and more prosperous and
engaged individuals and communities.

• Achieving health and well-being requires eliminating
health disparities, achieving health equity, and
attaining health literacy.

• Healthy physical, social, and economic environments
strengthen the potential to achieve health and
well-being.

• Promoting and achieving the nation’s health and well-
being is a shared responsibility distributed among all
stakeholders at the national, state, and local levels,
including the public, profit, and not-for-profit sectors.

• Working to attain the full potential for health and well-
being of the population is a component of decision
making and policy formulation across all sectors.

• Investing to maximize health and well-being for the
nation is a critical and efficient use of resources.1

7711_Ch02_023-054 23/08/19 10:21 AM Page 24

access to healthier foods in 2014.6 Although this initiative
is not currently active, the framework provides a way to
visualize the interaction between the elements that con-
tribute to the health of populations.

Increasing the number of healthy persons at all stages
of their life across the globe requires purposeful and well-
planned prevention on the part of nurses across the con-
tinuum of prevention. The full scope of interventions
includes those aimed at health promotion, risk reduc-
tion, and disease prevention. Specific population health
interventions done routinely by nurses include screen-
ing, health education, and evaluation of the effectiveness
of disease and injury prevention programs.

Population Health Promotion, Health
Protection, and Risk Reduction
The social ecological model of health has been used in
the public health field for the last 3 decades and clearly
demonstrates that health occurs from the cellular to
global level (Chapter 1, Fig. 1-1). It provides a basis for
understanding health promotion and prevention efforts
key to the achievement of the HP Goals and the SDGs
through an inclusion of both the physical and social
environments as key components of health.7,8 More
recently some authors have suggested turning the model
inside out, “… placing health-related and other social
policies and environments at the center.”9 Turning it
inside out places the focus on community context as
a means for fostering health policy and environmental
development.9 Either way, the model emphasizes the
interaction among communities, policy, and environ-
ment and their role in the health of individuals and their
families.

The social environmental determinants of health are
different from the individual-level biological and behav-
ioral determinants of health that are the usual focus of
health prevention interventions. The use of the ecological
model within the context of health promotion, health
protection, and risk reduction requires the inclusion
of social relations, neighborhoods and communities, in-
stitutions, and social and economic policies in the devel-
opment of prevention strategies.

Health Promotion, Risk Reduction,
and Health Protection
Health promotion-related interventions are an essential
component of nursing practice and occur from the in-
dividual to the population level. Authors use various
terms in relation to reducing the occurrence or severity
of disease in a population and enhancing the capacity of

environment, ending poverty and hunger, and increas-
ing access to education.4 It also requires development
of partnerships within nations and across the globe to
promote a healthy world.

In the U.S., over the past 2 decades, health care has
taken on a central role at the federal policy level. Follow-
ing the passage of the Affordable Care Act (ACA), the
National Prevention Council released a comprehensive
plan, the purpose of which was to increase the number
of Americans who are healthy at every stage of life.5 It in-
cluded four broad strategic directions fundamental to
this prevention strategy: (1) building healthy and safe
community efforts; (2) expanding quality preventive
services in both clinical and community settings; (3) em-
powering people to make healthy choices; and (4) elim-
inating health disparities (Fig. 2-1). There were seven
priorities: (1) tobacco-free living, (2) preventing drug
abuse and excessive alcohol abuse, (3) healthy eating,
(4) active living, (5) injury- and violence-free living,
(6) reproductive and sexual health, and (7) mental and
emotional well-being.5 The National Prevention Council,
per the ACA, was required to provide the president with
an annual report until 2015. The last report covered ad-
vances made including increasing the number of colleges
with tobacco-free campuses, improving school nutrition,
increasing supports for breast feeding, and increasing

C H A P T E R 2 n Optimizing Population Health 25

Figure 2-1 National Prevention Strategy Priorities.
(From National Prevention Council, 2012.)

7711_Ch02_023-054 23/08/19 10:21 AM Page 25

a population to achieve optimal health. These terms
include health promotion, risk reduction, and health
protection. The WHO’s definition of health promotion
is: “… the process of enabling people to increase control
over, and to improve, their health. It moves beyond a
focus on individual behaviour towards a wide range of
social and environmental interventions.”10 Risk reduc-
tion refers to actions taken to reduce adverse outcomes
such as the use of a condom to reduce the risk of trans-
mission of a communicable disease (CD). Another term
used in conjunction with risk reduction is health pro-
tection, which puts the emphasis on increasing the per-
son’s ability to protect against disease. An example of a
health promotion intervention is the institution of an
exercise program in an elementary school; an example
of a health protection, risk reduction program is a
vaccination outreach program. The first intervention
promotes a healthy behavior and the second increases
the ability of the immune system to protect against a
communicable agent, thus reducing risk.

Health promotion often focuses on interventions
aimed at helping patients increase healthy behaviors,
such as a healthy diet and exercise, and reduce unhealthy
behaviors, such as tobacco use or at-risk alcohol use.
In 2008, Michael O’Donnell, editor-in-chief emeritus of
the Journal of Health Promotion, stated that health pro-
motion is both a science and an art that helps people
change their lifestyles to achieve optimal health.11 From
O’Donnell’s perspective, health promotion remains
rooted in individual behavioral change. However, exam-
ined from a broader perspective and following the
WHO definition, health promotion encompasses
activities taken to promote health that require changes
other than behavioral changes, such as facilitating the
individuals’ ability to improve the health of their envi-
ronment and increase their access to resources needed
to promote health, such as good nutrition or a safe place
to exercise.

The socioecological model provides the basis of eco-
logical health promotion that expands on O’Donnell’s
individual approach to health promotion by taking into
account social and ecological determinants of health
using an upstream approach. Ecological determinants
of health include “… potable water and sanitation, af-
fordable and clean energy, climate action, life below
water, and life on land.”12 Social determinants of health,
according to the WHO “… are the conditions in which
people are born, grow, live, work, and age. These circum-
stances are shaped by the distribution of money, power,
and resources at global, national, and local levels. The
social determinants of health are mostly responsible for

health inequities—the unfair and avoidable differences
in health status seen within and between countries.”13 To
achieve optimal health for all, educational, policy, eco-
nomic, and environmental strategies are used to increase
access to needed resources as well as interventions aimed
at health promotion and protection.14 Nurses support
this goal of achieving optimal health for all not only
through the delivery of care to individuals, families, and
communities but also through advocacy and active in-
volvement in policy development, implementation, and
evaluation (see Chapter 21).

Health Promotion
Health promotion at the individual and family level
helps people make lifestyle changes aimed at achieving
optimal health. These prevention interventions are
implemented in various ways and often focus on behav-
ioral change. In relation to obesity, health promotion ac-
tivities focus on diet and exercise. Health-care providers
deliver these interventions to individuals in their care.
These interventions are also delivered to populations via
health education programs, media campaigns, or in the
workplace. The goal of these health promotion programs
is to achieve change at the individual level based on the
biological and behavioral issues related to developing
disease due to obesity. The assumption is that the pro-
motion of healthy behaviors will reduce risk and thereby
reduce the prevalence of morbidity and mortality related
to obesity.

The ecological model allows us to expand on this
approach to health promotion by incorporating what is
referred to as an upstream approach in contrast to a
downstream approach to these efforts.14 An upstream
approach focuses on eliminating the factors that increase
risk to a population’s health. In contrast, a downstream
approach represents actions taken after disease or injury
has occurred. These two terms are important in under-
standing health promotion efforts today. Upstream rep-
resents a macro approach to addressing health whereas
downstream takes a more micro approach with a focus
on illness care. Both are needed to adequately address
health issues in the population.15 Take obesity as an ex-
ample. With a downstream approach, a health-care
provider may focus primarily on nutritional health
teaching based on nutritional patterns, portions, and
choices without taking into consideration the environ-
mental factors influencing choices within a community.
If there are no supermarkets within a community, it is
difficult to make healthy choices. In contrast to a down-
stream approach, an upstream approach to obesity might
include interventions focused on agriculture subsidies,

26 U N I T I n Basis for Public Health Nursing Knowledge and Skills

7711_Ch02_023-054 23/08/19 10:21 AM Page 26

transportation policies, and urban zoning. It might also
involve interventions restricting television advertising of
food to children, creating national nutrition standards
for meals served in childcare settings, or working with
the private sector to introduce healthier options in
restaurants and local markets

An upstream approach to health promotion related to
the obesity epidemic examines the environmental factors
that contribute to the epidemic and institutes prevention
interventions that target environmental change. Using
the first and third strategic directions of the National
Prevention Strategy as examples, this can occur through
empowering community members to initiate and imple-
ment the changes to create a healthy community. For
example, to promote healthy eating behaviors in chil-
dren, a school system in Kentucky took action and elim-
inated all fried foods that had been offered on the school
menu. Other communities have eliminated all vending
machines in schools that offer unhealthy beverages and
food. The National School Lunch Program supports in-
cluding larger portions of fruits and vegetables, less
sodium, and no trans fats. It also places a cap on the num-
ber of calories for the school lunch at 650 for grades K
through 5, 700 calories for grades 6 through 8, and
850 calories for grades 9 through 12. Milk can be at most
1% fat, and flavored milk must be fat-free although there
are flexibilities allowed to help provide more local con-
trol.16,17 Such an approach to health promotion requires
that the planners for the health promotion intervention
take into account the context of the healthy behavior they
hope the population will adopt. If the focus is only on
having the schoolchildren change their eating habits
without taking into account the food available to them
in their total environment, then that kind of health
promotion program will likely fail.

Health Protection and Risk Reduction
In contrast to health promotion, which focuses on the
promotion of a healthy lifestyle and environment,
health protection/risk reduction interventions protect
the individual from disease by reducing risk. These
terms are often used interchangeably, but are in actu-
ality distinct. A good example of health protection is
the use of vaccines. When an individual is vaccinated,
the body develops immunity to the infectious agent and
is therefore protected from the disease. The use of a
vaccine has reduced the risk of developing disease. Risk
reduction, conversely, encompasses more than biolog-
ical protection. It can involve removing risk from the
environment or reducing the level of risk, for example,
by reducing hazardous chemical emissions produced at

industrial plants. Health protection and risk reduction
activities are an important component of our national
effort to prevent disease.

Much of the health protection and risk reduction
activities currently used in our health-care system focus
on influencing behavioral change at the individual level.
The focus is to have individuals adopt protective health
activities, even if the prevention program is offered to
groups or populations. For example, policies related to
the recommended childhood vaccines are population
based and aimed at reducing risk for the development
of childhood CDs. However, the actual delivery of the
vaccine requires an individual response.

Risk reduction and health promotion must take into
account the broader concept of risk for development of
disease by incorporating environmental and social risk
factors associated with the development of disease that
may not be amenable through individual-level interven-
tions. For example, protection from lead poisoning re-
quires an environmental approach aimed at eradicating
lead paint in the environment. The risk factor, lead paint,
cannot be eliminated solely at the individual level and
often requires a system or community approach related
to allocation of funds, development of public policy, and
follow-through with the removal of lead paint from older
buildings in the community.

Prevention Frameworks
Prevention is a word used often in health care, but what
does it mean and how does it work? From a simplistic
standpoint, prevention refers to stopping something from
happening. From a health perspective, health prevention
refers to the prevention not only of disease and injury
but also to the slowing of the progression of the disease.
It also refers to the prevention of the sequelae of diseases
and injury, such as the prevention of blindness related
to type 1 diabetes. Health prevention is accomplished
through the institution of public health policies, health
programs, and practices with the goal of improving the
health of populations, thus reducing the risk for disease,
injury, and subsequent disability and/or premature death.

Health promotion and protection are fundamental
concepts for nursing practice and are based on preven-
tion frameworks in use in the public health field.18,19 Pre-
vention frameworks help nurses shape prevention
interventions within a particular context. In the summer
of 2016, a major public health issue was the Zika virus
epidemic. Preventing the spread of the disease was the
main focus of the public health interventions taken by
the Centers for Disease Control and Prevention (CDC)

C H A P T E R 2 n Optimizing Population Health 27

7711_Ch02_023-054 23/08/19 10:21 AM Page 27

and the WHO. These activities included behavioral,
environmental, and clinical interventions. People were
asked to modify their behavior by utilizing insect repellent
and avoiding unprotected sexual intercourse with a
person who had been exposed. Governments worked to
reduce the mosquito population through sprays, and
travel alerts were put in place. How do these interventions
relate to the natural history of disease, and how do they
fit into current public health prevention frameworks?

Natural History of Disease
An understanding of the natural history of disease is an
essential basis for the discussion of current prevention
frameworks that follows. The natural history of disease
provides the foundation for the public health frameworks
currently in use, especially the most widely used frame-
work of primary, secondary, and tertiary prevention.
The natural history of disease depicts the continuum of
disease from the disease-free state to resolution. The four
stages are (1) susceptibility; (2) the subclinical phase after
exposure when pathological changes are occurring with-
out the person being aware of them; (3) clinical disease
with the development of symptoms; and (4) the resolu-
tion phase in which the final outcomes are cure, disability,
or death.20,21 The subclinical phase is also sometimes
referred to as the incubation period for CDs and latency
period for noncommunicable illness (Fig. 2-2).

This traditional presentation of the natural history of
disease with four stages initially appears linear. For some
diseases such as influenza, this linear model works well.
In some disease processes, an individual may go from a
subclinical stage to a clinical stage and then back to a sub-
clinical stage. For example, in human immunodeficiency
virus (HIV) infection, during the initial subclinical stage
an infected individual has no clinical symptoms that meet
the criteria for a diagnosis of acquired immunodeficiency

syndrome (AIDS). As the infection progresses, the person
may develop one or more clinical diagnoses, thus placing
the individual in the clinical stage of the disease. However,
with the treatments now available for treating AIDS, an
individual may recover from a clinical episode and return
to being asymptomatic, but there has been no resolution
of the disease; instead, that individual has reverted to a
subclinical stage.

Figure 2-2 also depicts the outcome of a particular
disease. Following the development of clinical disease, an
individual recovers completely (cure), is disabled by the
disease (disability), or dies. Some diseases, both commu-
nicable and noncommunicable, have no endpoint except
death. HIV/AIDS is an example of a CD with no cure.
Those who become infected will remain infected for the
rest of their lives. An example of a noncommunicable
disease (NCD) without a cure is type 1 diabetes. A person
diagnosed with this type of diabetes does not at some point
in time revert to producing insulin at normal levels.

To further illustrate, examine the prevalence of a
disease and the prevalence pot. Prevalence is basically
the number of total cases of disease (numerator) divided
by the total number of people in the population (denom-
inator) and reflects the total number of cases of a disease
in a given population. A prevalence pot is a way of
depicting the total number of cases of the disease in
the population that takes into account issues related to
duration of the disease and the incidence of the disease
(Fig. 2-3). For some CDs with a short incubation period
such as influenza, cases rapidly move in and out of the
prevalence pot, but for long-term chronic diseases with
no known cure, the prevalence pot can grow over time
(e.g., HIV infection). If the definition of a case is infection
with the HIV virus, then individuals who are subclinical
and those who have evidence of clinical illness that meets
the criteria for an AIDS diagnosis would all be in the

28 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Stage of Recovery,
Disability, or Death

Stage of
Clinical Disease

Stage of
Subclinical Disease

Stage of
Susceptibility

Pathological
ChangesExposure

Onset of
Symptoms

Usual Time
of Diagnosis

Figure 2-2 The natural
history of disease timeline.
(From Centers for Disease
Control and Prevention. (1992).
Principles of epidemiology (2nd ed.).
Atlanta, GA: U.S. Department
of Health and Human Services.
Retrieved from http://www.cdc.
gov/osels/scientific_edu/ss1978/
lesson1/Section9.html.)

7711_Ch02_023-054 23/08/19 10:21 AM Page 28

prevalence pot. During the early years of the AIDS epi-
demic, there were few treatment options. Once diag-
nosed, an individual often died within a short period of
time. As treatment has improved and the survival rate
for those infected with HIV has greatly increased, the
number of AIDS-associated deaths has declined. How-
ever, the HIV/AIDS prevalence pot has grown, because
the only way out of the prevalence pot is through death.
In developing countries where treatment for HIV/AIDS
is less available, the prevalence pot has not grown as rap-
idly, even with a higher number of cases, because the life
span of those with HIV/AIDS remains short.

Mapping out a disease using the natural history of dis-
ease model helps to identify where on the continuum
prevention efforts are needed. The prevalence pot helps
identify those health conditions that may have an in-
creasing number of cases over time if the development
of new cases is not prevented. In the case of seasonal flu,
laying out the natural history of the strain of flu appear-
ing in a given year helps to determine where the primary
focus should be. In the beginning of the fall in most years,
the majority of the U.S. population does not have in-
fluenza. As the next few months progress, more and
more people usually become infected, and some die.
Based on the severity of the flu epidemic nationwide,
large-scale prevention efforts may be instituted. In 2009,
during the H1N1 flu outbreak, efforts focused on vacci-
nating populations at greatest risk, in that case pregnant
women, children, and older adults, resulting in a focus
on those without disease at highest risk for mortality.22

This was important due to the shortage of vaccines avail-
able. Those who were most vulnerable got priority for
receiving the vaccine. The H1N1 virus is now a regular

human flu virus. Based on the 2009 pandemic and data
from subsequent years, the CDC updated its warnings
related to populations that were most vulnerable.
The most vulnerable populations now include children
under the age of 5, pregnant women, older adults, Native
Americans, and Native Alaskans. 23

How does the natural history of the disease and the
prevalence pot help public health officials focus on inter-
ventions? In the case of flu epidemics, the incubation
period, that is, the time interval between infection and
the first clinical signs of disease (Chapter 8), is short, with
those infected rapidly developing symptoms. In addition,
the course of the disease is also short. People with in-
fluenza are able to infect others from 1 day before getting
sick to 5 to 7 days after getting sick. Those who become
infected with a flu virus rapidly develop clinical symp-
toms including fever, cough, and in some cases gastroin-
testinal symptoms. New cases that enter the prevalence
pot usually leave the pot within 7 days. Most recover
completely, some experience long-term effects such as
coma and/or respiratory problems, and some die.

Using the natural history of disease model, the nurse
can lay out the progression of influenza (see Fig. 2-2).
The preclinical phase is very short (1 to 2 days), and there
are no interventions available that would prevent the
progression from this phase to clinical disease. Once the
patient is in the clinical phase, there are limited options
for intervention because the causative agent, the flu virus,
does not respond to antibiotics. However, early recogni-
tion in vulnerable patients, such as older adults, and
treatment with antiviral medication may help to reduce
the risk of complications and adverse consequences.

Because of the limited ability of antiviral medication
to prevent adverse consequences in at-risk populations
and the short period of time between phases, the best
approach is to focus on preventing disease from occur-
ring in the first place. The natural history of influenza
provides the basis for the nationwide public focus on pri-
mary prevention through the development, distribution,
and administration of flu vaccines with the hope of keep-
ing the majority of the population disease-free because
of the limited ability to provide effective secondary or
tertiary prevention interventions.

The natural history of a disease also allows the nurse
to identify who is at greatest risk for developing the
disease. For influenza, early evaluation of the prevalence
of the disease by age groups helps to establish who is
most likely to become ill. In the case of the 2009 H1N1
flu pandemic, the CDC concluded that there was a
greater disease burden on those under the age of 25.22

Unlike in other flu outbreaks, those who were younger,

C H A P T E R 2 n Optimizing Population Health 29

Figure 2-3 The prevalence pot.

Death

Leaving the pot

New Cases
People newly

diagnosed

The
Prevalence Pot:

Total Current
Cases

All people with
the disease

Entering the pot

Disability

Cure

7711_Ch02_023-054 23/08/19 10:21 AM Page 29

immune compromised, or pregnant were at increased
risk of death. This led to the speculation that the virus
was related to earlier strains, and those in late adulthood
had immunity due to earlier exposure. Thus, the older
members of the population had natural biological pro-
tection, whereas those under the age of 60 did not. With
limited vaccine available in the fall of 2009, decisions
were made to provide the vaccine to those at highest
risk. This included pregnant women, household and
caregiver contacts of children younger than 6 months of
age, health-care and emergency medical services person-
nel, people from 6 months through 24 years of age,
and people aged 25 through 64 years who had medical
conditions associated with a higher risk of influenza
complications.

The natural history of disease for type 1 diabetes is quite
different from H1N1 flu. The etiology, or cause, of type 1
diabetes is genetic rather than infectious. Although there
is no known prevention for type 1 diabetes, early detection
during stage one can lead to early diagnosis and treatment.
However, identifying the disease early will not prevent the
development of clinical disease, which lasts for a lifetime
because the body is unable to produce insulin. There is no
cure. This puts the majority of the focus on treatment of
the patient in the clinical stage to prevent premature death
and disability. Another key distinction between the natural
history of these two diseases is that influenza is population
based, that is, the disease spreads from one person to
another. Interventions are required to protect the entire
population at risk. By contrast, a disease such as type 1
diabetes is individual based, and the risk is usually tied to
a genetic trait passed down in families.

Public Health Prevention Frameworks
The natural history of a disease and the difference be-
tween population-based risks and individual-based risks
form the basis for two main prevention frameworks used
in public health science. The first framework is the tra-
ditional public health prevention model of primary, sec-
ondary, and tertiary prevention.21 The second is the
framework of universal, selected, and indicated preven-
tion based on work done by Gordon and put forth by the
Health and Medicine Division (HMD) of the National
Academies of Sciences, Engineering, and Medicine (for-
merly known as the IOM). 24 Both use a health promotion
and health protection approach, and employ the three
types of interventions—clinical, behavioral, and environ-
mental. The best place to start is with the traditional pri-
mary, secondary, and tertiary prevention model, because
it has been in use since the 1950s, and the newer IOM
framework was not used widely until it was mandated by

the Centers for Substance Abuse Prevention (CSAP), a
branch of the U.S. Federal Substance Abuse and Mental
Health Service Administration (SAMHSA), in 2004.25

Levels of Prevention
The traditional public health approach to prevention
focuses on health prevention based on the natural his-
tory of disease and includes three levels of prevention—
primary, secondary, and tertiary. Primary prevention
interventions are conducted to prevent development of
disease or injury in those who are currently healthy.21

The focus is usually on people at risk for developing the
disease or injury but may take a population approach
such as recommendations that all persons be vaccinated
against the flu. Activities include promoting healthy
behaviors and building the ability of populations and
individuals within that population to protect themselves
against disease. Many health policies are aimed at
primary prevention such as banning smoking in public
places, which is aimed at reducing the development of
diseases secondary to exposure to second-hand smoke.
The goal is to reduce risk factors for a health problem.
If the risk for developing disease or sustaining an injury
can be reduced, then the incidence (occurrence of new
cases) of a disease will be reduced. Secondary preven-
tion interventions include those aimed at early detection
and initiation of treatment for disease, thus reducing
disease-associated morbidity and mortality.21 If early
intervention results in cure from the disease, with or
without disability, screening can contribute to the reduc-
tion of the prevalence of a disease (total number of new
and old cases), thereby reducing the size of the preva-
lence pot. Secondary prevention can include screening
or case finding in CD outbreaks by seeking contacts of
people already ill. The focus of tertiary prevention is the
prevention of disability and premature death and, when
indicated, the initiation of rehabilitation for those diag-
nosed with disease.21 It includes interventions aimed at
preventing secondary complications related to disease
such as the prevention of bedsores.

Primary Prevention: Primary prevention is a central
part of nursing practice. Nurses engage in the delivery of
primary prevention across settings, including the acute
care setting where, on first glance, it looks as though the
nurse is only providing tertiary prevention interventions.
Because this approach is based on the natural history of
disease, what types of primary prevention does a nurse
provide in an acute care setting when every patient ad-
mitted has a diagnosis of clinical disease? A prime exam-
ple is the activities nurses do to prevent hospital-acquired
infections. All nurses must follow hospital policy related

30 U N I T I n Basis for Public Health Nursing Knowledge and Skills

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to the use of personal protective equipment, isolation
precautions, and personal hygiene. These activities pre-
vent the spread of infection from a patient with disease
to patients or health-care workers without disease.
Nurses also participate in primary prevention from a
health protection perspective. All nurses must comply
with hospital policy related to vaccinations. In this way
the members of the health-care workforce who are free
of disease take steps to build their immunity to disease,
thus preventing the spread of disease to patients and
fellow workers who are free of disease. All these activities
are population based.

Nurses also apply the principles of primary prevention
on an individual level through health education, vacci-
nation, and other activities aimed at promoting and
protecting the health of their patients and increasing
the patients’ ability to protect themselves from disease.
Patients receiving nursing care in acute care settings
who are receiving care for one clinical disease may be at
increased risk for other disease or injury. Nurses often
include primary prevention in their plan of care, such as
altering the environment to prevent falls and teaching
basic fall prevention strategies to patients and their
families that can be implemented on discharge. Health
education begins with primary prevention, teaching
patients to reduce risk for disease (e.g., teaching patients
to increase exercise, reduce caloric intake, and perform
proper hand hygiene). Nurses working in the community
provide primary prevention by providing health educa-
tion, promoting breastfeeding, and working with com-
munities to reduce hazards such as lead paint.

During epidemics and pandemics, countries depend
on nurses as frontline workers in nationwide primary
prevention efforts to reduce the incidence of the disease
and prevent premature death. Public health departments
across the country often mobilize nurses and student
nurses to administer the vaccines at schools, health clin-
ics, and other community settings. Because of the need
for nurses to deliver the vaccine to large groups of at-risk
individuals, nurses and other health-care providers are
often the first to receive the vaccine when it becomes
available. Primary prevention is an essential part of pro-
viding nursing care to individuals and populations across
all settings.

Secondary Prevention: Nurses also regularly partic-
ipate in secondary prevention interventions in all set-
tings. Screening is one aspect of secondary prevention
and is an essential component of the nursing assessment
focused on early detection of problems in asymptomatic
individuals who already have certain risk factors. Screen-
ing also targets conditions that are not yet clinically

apparent for purposes of earlier detection. Early treat-
ment reduces risk for further morbidity and for mortal-
ity. In acute, community, and long-term care settings,
nurses regularly screen patients of all ages for the possible
existence of a number of conditions. Screening for
developmental delays is an example of secondary pre-
vention in children, whereas encouraging mammograms
is an example of a secondary prevention intervention for
adults. The goal of mammograms is to detect early stage
breast cancer. Some activities done by nurses can serve
as both secondary prevention and tertiary prevention.
For example, the simple taking of blood pressures at a
blood pressure clinic held in a local senior center is a type
of screening when conducted with older adults who have
not been identified previously as having hypertension.
At the same clinic, taking an individual’s blood pressure
reading may function as a method for monitoring the
health status of an older person who has already been
diagnosed with hypertension.

Through early detection, nurses can implement
interventions that will alter the natural history of the
disease. For example, on admission to long-term care
facilities, elderly patients are routinely screened for skin
integrity. If there is any evidence of skin breakdown,
nursing interventions are immediately put in place to
halt the progression of a stage 1 pressure ulcer (bed sore)
to a stage 2. In stage 1, the skin is reddened, but there is
no break in the skin. Without intervention, the patient
is at greatly increased risk for skin breakdown and rapid
development of a stage 2 to a stage 3 pressure ulcer.

There are many circumstances when early detection
and initiation of treatment prior to the development
of clinical disease can improve outcomes. Public health
efforts to prevent premature death due to cancer include
media campaigns for mammography screening, colono-
scopies, and prostate screening. Screening is also con-
ducted for behavioral health issues such as at-risk alcohol
use (see Chapter 11). Screening for syphilis and early
treatment can prevent serious disability, reduce the in-
cidence of syphilis infection in newborns, and prevent
premature death. Nurses participate in these efforts
by conducting screenings and by educating patients to
encourage their participation in screening.

Health education is done with a secondary prevention
focus. For example, a nurse participating in a blood pres-
sure screening health fair will include secondary preven-
tion health education for adults with a blood pressure
reading greater than or equal to 130/80. Adults with a
blood pressure reading between 130/80 and 139/89 are
considered to have stage 1 hypertension, and those with
a blood pressure reading greater than 140/90 have stage

C H A P T E R 2 n Optimizing Population Health 31

7711_Ch02_023-054 23/08/19 10:21 AM Page 31

2 hypertension. It is recommended that the diagnosis of
hypertension be based on the average of ≥2 readings ob-
tained on ≥2 occasions.26 Thus, it is important to refer
persons with blood pressures greater than 130/80 to a
primary care physician for follow-up. Early intervention
through lifestyle changes and medical intervention can
reduce the development of life-threatening conditions
such as stroke or myocardial infarction.

Tertiary Prevention: The primary focus of nursing
interventions in most acute care settings is tertiary pre-
vention. Once an individual has been diagnosed with
clinical disease, prevention aims at reducing disability,
promoting the possibility of cure when possible, and pre-
venting death. Efforts are made to interrupt the natural
progression of the disease or to reduce the impact of the
injury through multiple strategies including medical, en-
vironmental, and psychosocial.

Health education is a key tertiary prevention activity
for the nurse. For those with chronic diseases, a disease
self-management approach is often used. This approach
puts the individual in charge of managing his or her
disease with the goal of reducing disability and prevent-
ing premature death. The nurse serves as the teacher/
facilitator by helping the individual to identify the key
strategies needed to manage disease, such as regular foot
care and blood sugar monitoring in patients with
diabetes. The use of chronic disease self-management is
effective in reducing health-care utilization in general
populations, improving perceived self-efficacy, and
improving perception of health status for various non-
communicable chronic diseases.27,28,29

Universal, Selected, and Indicated Prevention
Models
The traditional public health framework consisting of
levels of prevention was introduced in the 1950s and

still has utility today, especially for diseases in which the
natural history and causal pathways for development of
the disease are well understood. It is also useful when
the early clinical and subclinical signs of the disease
are known and the disease is actually preventable. On the
flip side, the framework has limitations because of the
underlying linear approach to diseases with a clear etiol-
ogy. The framework is difficult to adapt to diseases or
disorders (see Chapters 10 and 11) with complex risk
factors; a curvilinear progression; and broad health
outcomes that encompass not only physical outcomes
but also psychological, social, and economic outcomes.
It also limits the majority of the prevention efforts to in-
terventions conducted by health-care providers and is
not as readily applicable to the broader interdisciplinary
field of public health.

An alternate approach using a continuum-of-health
framework was proposed by the IOM in the 1990s and
has been adopted by the Substance Abuse and Mental
Health Services Administration (SAMHSA).25 This model
divides the continuum of care into three parts: preven-
tion, treatment, and maintenance (Fig. 2-4). Under pre-
vention there are three categories: universal, selected, and
indicated. This model was first adopted by the behavioral
health field because there is less distinction in mental
disorders and substance use disorders between the tradi-
tional levels of prevention that were developed based
on the natural history of disease—primary (stage of sus-
ceptibility), secondary (subclinical stage), and tertiary
(clinical stage).24

A universal prevention intervention is one that is
applicable to the whole population and is not based on
individual risk. The intervention is aimed at the general
population. The purpose is to deter the onset of a health
issue within the population. Public health media cam-
paigns use a universal approach by targeting everyone

32 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Compliance
With Long-term

Treatment
(Goal: Reduction
in Relapse and

Recurrence)

Standard
Treatment
for Known
Disorders

Case
Identification

Indicated

Selective

Universal

Aftercare
(Including

Rehabilitation)

Maintenance

Treatment

P
re

ve
nt

io

n

Figure 2-4 Continuum-of-Care
Prevention Model. (From the Substance
Abuse and Mental Health Services Admin-
istration. [2004]. Clinical preventive
services in substance abuse and mental
health update: From science to services
[DHHS Publication No. (SMA) 04-3906].)

7711_Ch02_023-054 23/08/19 10:21 AM Page 32

in the population with such things as a billboard anti-
smoking campaign or TV ads aimed at preventing
drunk driving. All individuals in the population are
provided with the information and/or skills necessary
to prevent disease regardless of risk. Often the interven-
tion is passive, as in media campaigns, in that nearly all
of the population is exposed to the intervention. The
intervention often does not include participation on an
individual level. However, universal vaccination pro-
grams are not passive and require active participation
by individuals. This is an appropriate approach when
the entire population is at risk and would benefit from
prevention programs.

Selective prevention interventions are aimed at a
subset of the population that has an increased level of
risk for developing disease. This can be based on demo-
graphic variables such as age, gender, or race, or it can be
based on other risk factors such as genetic, environmen-
tal, or socioeconomic risk factors. Examples of selective
prevention interventions include: efforts to screen
women for breast cancer who have a known family
history of breast cancer, or providing community edu-
cation programs to prevent lead poisoning in older
urban neighborhoods. This level of prevention targets
everyone in the subgroup regardless of risk. For exam-
ple, everyone in a neighborhood with older buildings is
included in the selective lead poisoning intervention
whether or not they have already removed the lead
from their own residence. Once again, a selective inter-
vention can be passive or have an active component on
the individual level.

Indicated prevention interventions are provided to
populations with a high probability of developing
disease. Like secondary prevention, the purpose of indi-
cated interventions is to intervene with individuals with
early signs of disease or subclinical disease to prevent the
development of a more severe disease. The difference is
that the individuals included in the intervention have
already been identified as being at greater risk for the
disease whereas in secondary prevention the effort is to
identify those with the disease among an apparently
healthy population. The indicated prevention approach is
used in the substance abuse field to develop programs for
individuals with early warning signs of increased potential
for developing a substance use disorder, such as falling
grades or at-risk alcohol use. Only those individuals with
specific risk factors for developing the disease but who do
not yet meet the diagnostic criteria for the disease are
included in the intervention. The purpose is to reduce
behavioral risk factors that contribute to the develop-
ment of disease and to delay onset of disease or severity

of disease. The level of intervention provided is more
intensive and often multilevel. It always requires individ-
ual participation. An example of an indicated prevention
program is that of a weight-loss program for adolescents
who are obese and are showing signs of hyperglycemia
but who have not been diagnosed with type 2 diabetes.
Such an intervention would probably include case man-
agement, health education, nutritional counseling, and
an individualized exercise plan. If the program is effec-
tive, participants may not only delay the onset of type 2
diabetes but may also reverse the hyperglycemia and not
develop the disease.

Delivery of Public Health Prevention Strategies
The delivery of prevention services includes the use of
three basic strategies—clinical, behavioral, and environ-
mental. Clinical prevention strategies are those that
use a one-to-one delivery method between the health-
care provider and the patient, and usually occur in tra-
ditional health-care settings. These can include health
protection activities such as vaccinations, as well as
screening, and early detection of disease. Behavioral
prevention, often focused on health promotion strate-
gies, is aimed at changing individual behavior such
as exercise promotion, smoking cessation, or responsi-
ble drinking. Environmental prevention focuses on
health protection by improving the safety of the envi-
ronment such as fluoridating water, banning smoking
in public places, enacting laws against drunk driving,
enforcing clean air acts, and building green spaces for
recreation.21

In an effort to standardize clinical prevention strate-
gies through the application of evidence-based preven-
tion practices, the Agency for Healthcare Research and
Quality (AHRQ) created the U.S. Preventive Services
Task Force.30 This task force is made up of a panel of
experts in primary care and prevention. These experts
systematically review the evidence found in published
research related to the effectiveness of prevention strate-
gies and then develop recommendations for clinical
interventions. These recommendations are helpful in the
development of a clinical prevention program.

The earlier example of type 2 diabetes illustrates how
to apply both frameworks to a serious national health
issue. Globally, many health issues contribute to prema-
ture death. The CDC provides yearly updates on the
top 10 causes of death in the United States (Box 2-2).31,32

This is based on the classification of the death or injury
using accepted codes entered in the death registry for
each death. This information is sent to the U.S. Depart-
ment of Health and Human Services, which then sends

C H A P T E R 2 n Optimizing Population Health 33

7711_Ch02_023-054 23/08/19 10:21 AM Page 33

the information to the CDC. The cause of death listed on
the death certificates at the local level is the basis for the
aggregate statistics related to mortality rates at the state
and national levels. Though this provides important in-
formation, the underlying risk factors provide the infor-
mation needed to build health promotion, protection,
and risk-reduction interventions.

Not only is cause of death classified by disease or
injury, it is also further classified by risk factor, that
is, the underlying cause of death. Four health at-risk
behaviors—lack of exercise or physical activity, poor
nutrition, tobacco use, and drinking too much alcohol—
are underlying causes for illness and premature death.33

In other words, it is important not only to track the
causes of actual deaths but also to track the occurrence
of preventable risk factors to help predict whether efforts
to prevent these deaths are working. This information
helps to guide major prevention efforts aimed at reduc-
ing both morbidity and mortality in populations.

Each death can also be classified in quantitative terms
using attributable risk and prevented fraction. Attribut-
able risk is the measure of the proportion of the cases or
injuries that would be eliminated if a risk factor was not
present. Epidemiologists begin by determining the the-
oretical limit of the impact of prevention aimed at re-
moving the risk factor. That is, if the risk factor did not
exist, how many cases would be eliminated? For example,
if no one smoked, how many cases of lung cancer would
be eliminated, or if no one drove while intoxicated, how
many motor vehicle crashes (MVCs) would not occur?
It is calculated using the population attributable risk
(PAR), which is based on the strength of the risk factor
and the prevalence of the risk factor in the population.
To determine the strength of the risk factor, epidemiol-
ogists calculate what is referred to as the relative risk (RR)
(Chapter 3). If these pieces of the equation are known,

that is, the RR and the prevalence, then the PAR can be
calculated.21

Those who wish to implement a prevention program
can use the PAR to calculate the cost benefit and cost effec-
tiveness of the prevention program. However, the PAR is
population based and operates on the assumption that the
risk factor is removed from the entire population being
targeted. The prevented fraction provides the information
on what can be accomplished based on the intervention
actually being delivered at the community level. The
prevented fraction is defined as a measure of what can
actually be achieved in a community setting. It includes
the proportion of the population at risk that actually
participates and the number of cases prevented. This
approach takes into account the number of participants in
a program who will actually succeed in eliminating the risk
factor. For example, how many obese children participat-
ing in an after-school activity program will actually reduce
their weight to a normal body mass index?

Prior to implementing an intervention aimed at
prevention, it is important to understand the underly-
ing risk factors. The top four risk factors for preventable
death in the United States—tobacco use, improper
diet, physical inactivity, and alcohol use—relate to
behaviors.33 At first glance, it appears that a behavioral
intervention is the best approach. However, other in-
terventions are also helpful, including environmental
and policy-based interventions. For example, alcohol-
related MVCs can occur with just one episode of heavy
episodic drinking. The teenage driver who has con-
sumed alcohol for the first time at high levels and then
drives home may become involved in an MVC that
results in the death of people who are not consuming
alcohol. The teen did not have an alcohol use disorder
but instead had engaged in at-risk alcohol use. The nat-
ural history of disease does not fit this health-related
issue, yet prevention of alcohol-related MVCs is an
important issue. The questions become:

• What types of interventions will work to prevent dis-
ease or injuries?

• Is it primary, secondary, or tertiary prevention?
• Can it occur using a clinical, behavioral, or environ-

mental approach?
• In designing this approach, should it be addressed

as a universal, selected, or indicated preventive
intervention?

In answering these questions, it is important to have
a better understanding of some potential public health
nursing interventions and a framework that guides
public health nursing practice.

34 U N I T I n Basis for Public Health Nursing Knowledge and Skills

• Heart disease: 635,260
• Cancer: 598,038
• Accidents (unintentional injuries): 161,374
• Chronic lower respiratory diseases: 154,596
• Stroke (cerebrovascular diseases): 142,142
• Alzheimer’s disease: 116,103
• Diabetes: 80,058
• Influenza and pneumonia: 51,537
• Nephritis, nephrotic syndrome, and nephrosis: 50,046
• Intentional self-harm (suicide): 44,965

BOX 2–2 n Number of Deaths for Top 10 Leading
Causes of Death, 2017

Source: (31)

7711_Ch02_023-054 23/08/19 10:21 AM Page 34

A Public Health Nursing Framework
Conceptual frameworks and models guide the practice
of public health nurses (PHNs). One of the models im-
plemented by the Minnesota State Department of Health
in 2001 is the Intervention Wheel, which illustrates how
PHNs can improve the health of the individuals, families,
communities, and systems34,35 (Fig. 2-5). The model
evolved from the practice of PHNs in Minnesota and

consists of several components. The first component is
the population basis of all interventions. This component
illustrates that the focus of all interventions is population
health. The second component consists of the three levels
of care: individual/family, community, and systems. Care
can be provided at all three levels of working with indi-
viduals, the community as a whole, or with systems. In-
dividual level practice focuses on knowledge, attitudes,
practices, beliefs, and behaviors of individuals. A PHN’s

C H A P T E R 2 n Optimizing Population Health 35

Public Health Interventions
Applications for Public Health Nursing Practice

March 2001

Minnesota Department of Health
Division of Community Health Services
Public Health Nursing Section

Figure 2-5 Components of
the Intervention Wheel. (From
Minnesota Department of Health,
Division of Community Health
Services, Public Health Section.
[2001]. Public health interventions:
Applications for public health
nursing practice.)

7711_Ch02_023-054 23/08/19 10:21 AM Page 35

home visit to a new mother is an example of individual-
level practice. During the visit, the PHN provides antic-
ipatory guidance about the value of breastfeeding.

Community-level practice is focused on changing
norms, attitudes, practices, awareness, and behaviors. An
example of community-level practice is the development
of a faith-based program focused on smoking cessation.
Systems-level practice is concerned with policies, laws,
organization, and power structures within communities.
For example, a coalition of several senior housing sites
could be formed to address pest control and improve-
ment of overall environmental conditions, or a group of
parents could come together to build a safe playground
for the children.

The third component consists of 17 public health
interventions (Box 2-3). Three of these interventions—
health education, screening, and case management—are
discussed in this chapter as they relate to levels of pre-
vention, and the other interventions are discussed in
other chapters.

A Primary Prevention Approach:
Health Education
The purpose of health education is to positively change be-
havior by increasing knowledge about health and disease.
Health education is an important nursing intervention,

36 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Advocacy pleads someone’s cause or act on someone’s
behalf, with a focus on developing the community,
system, individual, or family’s capacity to plead their
own cause or act on their own behalf.

Case finding locates individuals and families with identified
risk factors and connects them with resources.

Case management optimizes self-care capabilities of indi-
viduals and families and the capacity of systems and
communities to coordinate and provide services.

Coalition building promotes and develops alliances among
organizations or constituencies for a common purpose.
It builds linkages, solves problems, and/or enhances
local leadership to address health concerns.

Collaboration commits two or more people or organiza-
tions to achieve a common goal through enhancing the
capacity of one or more of the members to promote
and protect health. (Henneman, Lee, & Cohen. [1995].
Collaboration: A concept analysis. Journal of Advanced
Nursing, 21, 103-109.)

Community organizing helps community groups to iden-
tify common problems or goals, mobilize resources, and
develop and implement strategies for reaching the goals
they collectively have set. (Minkler, M. [Ed.]. [1997].
Community organizing and community building for health
[p 30]. New Brunswick, NJ: Rutgers University Press.)
Delegated functions are direct care tasks that a regis-
tered professional nurse carries out under the authority
of a health-care practitioner as allowed by law. Dele-
gated functions also include any direct care tasks that a
professional registered nurse entrusts to other appro-
priate personnel to perform.

Consultation seeks information and generates optional
solutions to perceived problems or issues through in-
teractive problem-solving with a community, system,
family, or an individual. The community, system, family,

or individual selects and acts on the option best meet-
ing the circumstances.

Counseling establishes an interpersonal relationship with
the community, a system, the family, or an individual
intended to increase or enhance their capacity for self-
care and coping. Counseling engages the community, a
system, family, or an individual at an emotional level.

Disease and other health event investigation systemati-
cally gathers and analyzes data regarding threats to
the health of populations, ascertains the source of
the threat, identifies cases and others at risk, and
determines control measures.

Health teaching communicates facts, ideas, and skills that
change knowledge, attitudes, values, beliefs, behaviors,
and practices of individuals, families, systems, and/or
communities. (Adapted from American Nurses Associa-
tion [2010]. Nursing’s social policy statement: The essence
of the profession. [2010]. Silver Springs, MD; American
Nurses Publishing.)

Outreach locates populations-of-interest or populations-
at-risk and provides information about the nature of the
concern, what can be done about it, and how services
can be obtained.

Policy development places health issues on decision mak-
ers’ agendas, acquires a plan of resolution, and deter-
mines needed resources. Policy development results in
laws, rules and regulations, ordinances, and policies.

Policy enforcement compels others to comply with the
laws, rules, regulations, ordinances, and policies created
in conjunction with policy development. (Minnesota
Department of Health, Division of Community Health
Services, Public Health Section. [2001]. Public health in-
terventions: Applications for public health nursing practice.
Retrieved from http://www.health.state.mn.us/
divs/opi/cd/phn/docs/0301wheel_manual.pdf.).

BOX 2–3 n Public Health Interventions

7711_Ch02_023-054 23/08/19 10:21 AM Page 36

and it is important in changing behavior at all levels of
prevention. The Joint Committee on Health Education
and Promotion Terminology defined health education
as learning aimed at acquiring information and skills
related to making health decisions.36 The WHO defines
health education as “… any combination of learning
experiences designed to help individuals and communi-
ties improve their health, by increasing their knowledge
or influencing their attitudes…”37 Health education in-
volves not just teaching but also encouraging and giving
confidence to people to take the necessary action to im-
prove health, which includes making changes in social,
economic, and environmental determinants of health.

Theories of Education
Because health education involves teaching, understand-
ing how people learn is essential to effective teaching.
There are a number of learning theories that help us
understand how learning occurs from both a physiolog-
ical and social basis. The main theories come under four
categories: behaviorism, cognitivism, constructivism,
and humanism.

Behaviorism is the theory of classical conditioning. In
this framework, the behavior change is what is impor-
tant, and it is achieved with an environmental stimulus
that results in a response. The focus is only on the
observed behavior change and not on the mental activity.
Learning is based on reward and punishment by condi-
tioning (e.g., when a monkey learns to push a button for
a reward of food).38

The cognitive framework focuses more strongly on
inner mental activity. It is more rational than it is on re-
flexively responding to an external stimulus. There is be-
havior change as a result of knowledge that has changed
thought patterns. It frequently occurs as a result of varied
sensory inputs with repetition. The social learning theory

of Bandura is rooted in both the behavior and cognitive
frameworks, emphasizing that understanding, in addition
to behavior and environment, are all interrelated. He
stresses imitation of a behavior and reinforcement in
learning.39 An example of Bandura’s theory of social
learning is television commercials. An action is portrayed,
eating a certain food or using a certain cleaning product,
and the audience, seeing it as desirable, is encouraged to
model or imitate that behavior.

Constructivism is a learning theory that reflects on
our own experiences.40 We actively construct our own
world as we increase our experience and knowledge. It
is a process that builds knowledge within our own
unique framework. A good example is problem-solving
learning. To learn, students are actively involved in in-
tegrating new knowledge in their own frameworks with
guidance from the teacher. For example, children can
learn about what happens to their heart rate with exercise
by experimenting with different types of exercise and
counting pulse rates. They experience the concept of a
heart rate rather than merely having it verbally explained
to them.

Humanism learning uses feelings and relationships,
encouraging the development of personal actions to
fulfill one’s potential and achieve self-actualization.38

It is self-directed learning, examining personal motiva-
tion and goals. This is also a theory of adult learning.40

As an example, an individual diagnosed with elevated
cholesterol purchases books, seeks out articles, talks with
knowledgeable people, and in general informs him- or
herself about the problem and actions to take to solve the
problem then self-initiates these activities to improve
health.

All learning theories influence how we teach. The
identified teaching methods based on these theories
are varied but include the need to be developmentally

C H A P T E R 2 n Optimizing Population Health 37

Source: (34)

Referral and follow-up assist individuals, families, groups,
organizations, and/or communities to identify and
access necessary resources to prevent or resolve
problems or concerns.

Screening identifies individuals with unrecognized health
risk factors or asymptomatic disease conditions in
populations.

Social marketing uses commercial marketing principles and
technologies for programs designed to influence the
knowledge, attitudes, values, beliefs, behaviors, and
practices of the population-of-interest.

Surveillance describes and monitors health events
through ongoing and systematic collection, analysis,
and interpretation of health data for the purpose of
planning, implementing, and evaluating public health
interventions (Centers for Disease Control and
Prevention. [2012]. CDC’s vision for public health
surveillance in the 21st century. Morbidity and Mortality
Weekly Report, S61).

BOX 2–3 n Public Health Interventions—cont’d

7711_Ch02_023-054 23/08/19 10:21 AM Page 37

appropriate with children and with adults with varying
levels of education. Many of the more recent theories
provide a more balanced learning; encourage experien-
tial learning; and solve real problems in real places
by using role playing, visual stimuli, service learning,
interpersonal learning, and the promotion of complex
higher-order thinking.

Adult Learning
Pedagogy (pedagogical learning) is the correct use of
teaching strategies to provide the best learning. Andra-
gogy is similar but is specifically the art and science of
helping adults learn using the correct strategies.40 In
nursing, we are often teaching adults, as it is adults who
generally develop chronic diseases, are in a position to
promote health, and care for children. In the 1950s
Malcolm Knowles, using humanism learning theory,
suggested that adults learn differently from children and
that the role of the instructor is quite different. Adults
bring a great deal of experience to the learning situation,
and this experience influences what education they
receive and how they receive it.41 They are active learners
and need to see applications for the new learning.
Knowles identified six suppositions for adult learning:

1. The adult needs to know why he or she is learning
something.

2. The adult’s own experiences are an important part
of the learning process.

3. Adults need to participate in the planning and eval-
uation of their learning.

4. Adults learn better if the information has immediate
relevance.

5. Adults like problem-centered approaches to learning.
6. Adults respond better to internal rather than to

external motivation.

The role of the teacher in this situation is to direct the
learner.41

To be an effective educator the nurse needs to be flex-
ible. Nurses organize the learning experience by first as-
sessing the individual’s or population’s learning needs.
They then select the best learning format, create the best
possible learning environment, and send a clear message.
The learning should be participatory and include evalu-
ation and feedback.

Health Literacy
One of the first considerations before planning health
education is to consider the health literacy of the indi-
vidual client, the group, or the population. In conjunc-
tion with literacy, culture and language should also be

included. Health literacy is defined as “the degree to
which individuals have the capacity to obtain, process,
and understand basic health information and services
needed to make appropriate health decisions.”42 The
HMD division of the National Academies of Sciences,
Engineering, and Medicine built on this definition and
added key issues related to the individual receiving in-
formation. They stated that health literacy is something
that “emerges when the expectations, preferences, and
skills of individuals seeking health information and serv-
ices meet the expectations, preferences, and skills of those
providing information and services. Health literacy arises
from a convergence of education, health services, and
social and cultural factors.”42

Assessing literacy levels is currently done based on
levels, with levels 4 and 5 representing the top level and
level 1 and below representing the lowest literacy level.
According to the National Center for Education Statis-
tics, 18% of U.S. adults scored at or below level 1.43

They reported an association between age and literacy
with a greater percentage of those between the ages
of 25 and 44 scoring at the top level. For those who
were unemployed, 75% had 12 years of education or
less and approximately a third scored at level 1 or
below.44 There is evidence of a causal relationship
between health literacy and health outcomes. Those in-
dividuals with basic health literacy had a higher level
of health-care utilization and higher expenditures for
prescriptions.45 To address the problem of health liter-
acy the CDC put together five talking points about
health literacy that can be adapted to a specific organ-
ization as a means to advocate for promotion of heath
literacy (Box 2-4).46

Shame and stigma of having low health literacy have
been found to be major barriers to seeking care. The IOM
committee found that health education occurred in most
primary and secondary schools, but there was no univer-
sal sequencing, and only about 10% of teachers were qual-
ified health educators. One of the most telling of the IOM
findings was that health professionals had limited training
in patient/population education and had few opportuni-
ties to develop skills to improve a patient’s health literacy.
The IOM gave multiple suggestions on how to improve
health literacy, and points of intervention (Fig. 2-6). Some
of the most relevant to nursing included:

• Improve K through 12 basic health education.
• Help individuals learn how to assess the credibility of

what they see and read about health.
• Provide clear communication, allow ample time to

give this information, and encourage questions from
the patient.42

38 U N I T I n Basis for Public Health Nursing Knowledge and Skills

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In the past few years, considerable research has been
done that brings better understanding to the magnitude
and consequences of the health literacy problem. One of
the issues is how to assess correctly and rapidly the level
of health literacy in a patient/population. Though there
are tools to screen for health literacy, they were developed
primarily for research purposes and are not currently rec-
ommended for routine use. Instead the recommendation
is to use universal health literacy precautions, which
translates into providing patients with information both
oral and written that is understandable and easily acces-
sible to persons across all education levels.47 The AHRQ
recommends use of universal health literacy precautions
and lays out what needs to be done (Box 2-5). The AHRQ
developed an evidenced-based toolkit for health-care

providers to help implement universal health literacy
precautions within a health-care setting. The goal is to
increase the health literacy of all patients, not just those
that appear to need assistance.48

Develop a Teaching Plan
Writing a teaching plan for individuals or populations
provides a means to lay out what will be taught, using
what methods, as well as a method for evaluating the
effectiveness of the teaching plan (Box 2-6). The teaching
begins with the assessment of the health education need.
What does this individual or population need to learn, or
what would they benefit from learning, to promote
health, prevent disease, or help manage an identified
health problem? Next, the nurse assesses the type of
learner or learners who will receive the education. For
example, what is their level of health literacy? Also, what
is the cultural context for the population? What is their

C H A P T E R 2 n Optimizing Population Health 39

Potential Intervention Points

Health
System

Culture
and

Society

Health
Outcomes
and Costs

Education
System

Health
Literacy

3

1

2

Figure 2-6 Potential points for intervention in the
health literacy framework. (From Nielsen-Bohlman, L.,
Panzer, A., Kindig, D. [2004]. Health literacy: A prescription to
end confusion [IOM Report].)

You are a health literacy ambassador. It is up to you to
make sure your colleagues, staff, leadership, and commu-
nity are aware of the issues. Whether to review for
yourself, present to others, or convince your leadership,
the following resources may help you talk about health
literacy.

Five Talking Points on Health Literacy: These brief
talking points may be helpful if you need to tell someone
quickly what health literacy is and why it is important.
Add in talking points relevant to your organization.

1. Nine out of 10 adults struggle to understand and use
health information when it is unfamiliar, complex, or
jargon-filled.

2. Limited health literacy costs the health-care system
money and results in higher than necessary morbidity
and mortality.

3. Health literacy can be improved if we practice clear
communication strategies and techniques.

4. Clear communication means using familiar concepts,
words, numbers, and images presented in ways that
make sense to the people who need the information.

5. Testing information with the audience before it is
released and asking for feedback are the best ways
to know if we are communicating clearly. We need
to test and ask for feedback every time information is
released to the general public.

BOX 2–4 n The CDC’s Five Talking Points on Health Literacy

Source: (45)

Health literacy universal precautions are the steps that
practices take when they assume that all patients may
have difficulty comprehending health information and
accessing health services. Health literacy universal precau-
tions are aimed at:

• Simplifying communication with and confirming
comprehension for all patients, so that the risk of
miscommunication is minimized.

• Making the office environment and health-care system
easier to navigate.

• Supporting patients’ efforts to improve their health.

BOX 2–5 n Health Literacy Universal Precautions

Source: (47)

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age, gender, and level of vulnerability? All of this infor-
mation will help drive how the information is provided.
Inclusion of the recipients in the planning process can be
an important strategy as can be the use of peer teachers.

Once the assessment has been completed, the next
step is to identify the goal(s) of the health education

program. Again, inclusion of the recipients in the pro-
gram will result in shared goals and greater engagement
of those receiving the program. For example, if from the
nurse’s perspective the goal of a proposed health educa-
tion program is to reduce premature births, including
women in the community who are pregnant or who may
become pregnant in the development of the program
may help shape the articulation of goals. What are the
immediate benefits to them for having a full-term baby?
What other issues are they concerned about related to
pregnancy and birth? This way specific objectives can be
written that truly meet the goals of the community.

To help frame learning objectives, Bloom identified
three learning domains: cognitive, affective, and psy-
chomotor.50 Identifying which learning domain is being
targeted is important when developing the plan. Within
the cognitive domain, Bloom identified six levels of cog-
nitive learning, from simple knowledge recall to more
abstract and higher-level synthesis and evaluation. Each
level, especially the first three, builds on the next. This is
referred to as Bloom’s Taxonomy, and this classification
is useful in looking at levels of learning, outcomes, and
the correct action verbs to be used when writing specific-
level learning objectives (Box 2-7). The first level of
learning is knowledge, which refers to remembering or
recalling specific information that has been taught. Com-
prehension is the second level and requires some demon-
stration of really understanding what was learned.
Application, the third level, requires using the knowledge
in real situations such as problem-solving. The next level
is analysis, wherein the acquired knowledge is broken
down by its organization and things such as making
inferences and looking for motives or causes. The last
two are synthesis and evaluation. In synthesis, the ac-
quired knowledge is used creatively to produce some-
thing new. Evaluation provides a way to judge the end
product. In addition to cognitive learning, Bloom also
identified affective and psychomotor learning. The affec-
tive domain looks at a growth in feelings, values, and at-
titudes. Psychomotor learning is the development of
manual or physical skills, a domain frequently taught by
nurses.

Once the plan is developed, the next step requires
identifying materials and resources needed for effective
teaching. Factors include the length of the lesson, where
it will be taught, what activities will promote the best
learning, and how much time will be needed to prepare
the lesson. It is helpful to write out a description of the
lesson including the key concepts and the learning do-
main of knowledge, attitude, and/or practice. The final
two steps are to write out the detailed procedure for the

40 U N I T I n Basis for Public Health Nursing Knowledge and Skills

1. Identify the health education need in the selected
population (individual/family/community).

2. Assess the learner; include health literacy, culture,
language, age, and learning style.

3. Write a goal for the teaching intervention.
4. Write specific, measurable objectives for the teaching

intervention (consider Bloom’s Taxonomy).
5. Identify materials and resources needed for the

teaching plan; include the appropriate teaching
environment and the length of the lesson.

6. Describe the lesson; include key concepts.
7. Write out the procedure step by step for teaching

the lesson using a variety of teaching methods.
8. Have a plan for the evaluation.

BOX 2–6 n Steps in Developing a Health Education
Teaching Plan

n CULTURAL CONTEXT
National Institutes of Health: Clear
Communication
The NIH Office of Communications and Public Liaison
(OCPL) established a “Clear Communication” initiative
related to health literacy with cultural respect as one of
the two foci of the initiative. Specifically:

• Cultural respect is a strategy that enables organizations
to work effectively in cross-cultural situations. Developing
and implementing a framework of cultural competence
in health systems is an extended process that ultimately
serves to reduce health disparities and improve access to
high-quality health care.

• Cultural respect benefits consumers, stakeholders, and
communities. Because a number of elements can influence
health communication—including behaviors, language,
customs, beliefs, and perspectives—cultural respect is also
critical for achieving accuracy in medical research. NIH
funds and works with researchers nationwide for the
development and dissemination of resources designed to
enhance cultural respect in health-care systems.49

Further resources are available through their Web site.

7711_Ch02_023-054 23/08/19 10:21 AM Page 40

teaching plan, carefully outlining each activity, and, if ap-
propriate, the follow-up for these activities. The final
component is to determine how an evaluation will meas-
ure whether or not the intended learning took place. The
evaluation plan should reflect the learning objectives and
be in place before teaching begins to anticipate how to
measure the outcomes.

Methods of Instruction
There are many ways to learn the same information, and
each of us has a preference for how we like to learn. There
are lists of different teaching methods that include formal
presentations, small-group work, field trips, role playing,
written assignments, and Internet activities, to identify a
few. Usually, experiential learning is most effective for
adults. Lecture format rarely appeals to an adult who
wants guided interactive learning. If people can feel it,
handle it, see it, taste it, smell it, and discuss it, they can
better integrate it into their own life experiences. A group
concerned with nutrition and being overweight may be
told that Ritz crackers, potato chips, corn chips, and
cheeseburgers are high in fat and also high in calories.
The group can be given numbers of calories and grams,
but it is not easily integrated into their life experiences.
However, if the portion size of four Ritz crackers, 10 po-
tato chips, and 1 ounce of corn chips, all having 8 to
9 grams of fat, are demonstrated, it is easier for people to
put it into the context of their own lives.

Using real-life scenarios to teach how to solve health
problems has also been quite effective. Giving new moth-
ers a vignette in which a family is having difficulty getting
adequate sleep at night because their 4-month-old
infant is awake all night allows for group discussion and
problem-solving that can be relevant at the moment. This
is information these women can take home and apply
immediately. Teaching children the importance of exer-
cise by using videos, Internet, and PowerPoint slides
can be entertaining and provide basic knowledge. Help-
ing children form walking groups and joining them for
their walks can help them apply this knowledge and start
to change behavior. Written material can help encourage
discussion, but the material must be appropriate for
literacy, content, culture, and language.

Regardless of the teaching method, it is always impor-
tant to emphasize the benefits of the proposed behavior
change and to personalize the message. A good strategy
is to apply the intended new behavior within the context
of the individual’s lifestyle and needs. Help clients weigh
the cost and benefit of the new health behavior. Key
points should be emphasized during teaching and new
information provided in small increments. Most people
can absorb only one or two new pieces of information in
an encounter. Learners are the best source of information
about what they want to learn and if the teaching method
is meeting their needs. Feedback should be frequently
sought from learners.

C H A P T E R 2 n Optimizing Population Health 41

Knowledge Comprehension Application Analysis Synthesis Evaluation
Define Discuss Interpret Distinguish Plan Judge
Repeat Recognize Apply Calculate Design Appraise
List Explain Use Test Assemble Value
Name Interpret Practice Compare Invent Assess
Tell Outline Demonstrate Question Compose Estimate
Describe Distinguish Solve Analyze Predict Select
Relate Predict Show Examine Construct Choose
Locate Restate Illustrate Compare Imagine Decide
Write Translate Construct Contrast Propose Justify
Find Compare Complete Investigate Devise Debate
State Describe Examine Categorize Formulate Verify
Arrange Classify Classify Identify Create Argue
Duplicate Express Choose Explain Organize Recommend
Memorize Identify Dramatize Separate Arrange Discuss
Order Indicate Employ Advertise Prepare Rate

Locate Practice Appraise Propose Prioritize
Determine

BOX 2–7 n Bloom’s Taxonomy of Learning*

Source: (49)
*Active verbs represent each level.

7711_Ch02_023-054 23/08/19 10:21 AM Page 41

The environment should not be neglected in a teach-
ing plan. The physical environment is important and
should be maximized as much as possible even when
many things in a community setting may be outside of
one’s control. A space should be the right size, have a
comfortable temperature, adequate places to sit, the nec-
essary resources for the planned lesson, and a place
where, as appropriate, the learners can receive and share
confidential information. However, one also needs to
create an environment conducive to learning in which
the learner has space to be an active learner and to learn
from real situations with someone to assist with guidance
and direction to master the material. It should be a place
in which individuals feel free to voice opinions, experi-
ment with new ideas, and identify what they do not
know; a place in which there is enthusiasm for learning
in a nonthreatening environment.

Evaluation
Successful learning changes behavior. Deciding how to
evaluate whether this learning has occurred requires re-
ferring back to the specific objectives for the level of
learning that was to take place and the specific outcomes
expected. If the first stage of teaching was to increase
knowledge, an appropriate method is needed to measure
whether the knowledge did increase. If the objective was
for the mother to explain how the different childhood
immunizations will keep her child healthy and prevent
disease, the mothers should be asked to repeat back the
information they have just received or play a game in
which they have to know the answers to specific factual
questions. If the objective was to help individuals apply
knowledge, the applied learning should be evaluated
in a different way. For application, one can provide a sce-
nario at the end of the teaching session and then note
how students solve the problems utilizing the informa-
tion just taught. A follow-up discussion with the group
may be held after they have had time to apply their new
knowledge. If the objective was for the mother to practice
primary prevention by having her child fully immunized
by 2 years of age, the mother’s behavior may be observed
after the teaching to determine whether the knowledge
has been applied and the child has been fully immunized.

There are several tools that can be used to evaluate
health education. It is always a good idea to ask for verbal
reaction to the teaching at the end of a teaching session.
This is useful in planning for future health education
sessions. To measure an increase in knowledge, a classic
pre- and post-test should be used, or a pre- and post-
interview/observation. Using a formal testing method is
frequently not well liked by adult learners, especially

those who have limited literacy skills. They respond
better to the oral interview, but this is more difficult to
carry out. To assess change, one can observe and inter-
view over a specific time period, especially to note the
sustainability of the change. These tools need to be
thoughtfully developed to provide objective, reliable
data. Likewise, long-term effects of the teaching may be
evaluated using objective predesigned tools (for more
complete discussion of evaluation, see Chapter 5).

Health education forms the basis for many health pre-
vention programs aimed at improving the health of in-
dividuals as well as of families. Nurses learn this skill first
with individuals, then families, and finally with popula-
tions and communities. Health education operates under
the assumption that improving health literacy is central
to improving health. In addition to health education,
other activities regularly performed by nurses, such as
screening, contribute to building the health of commu-
nities. Often these activities require the use of health
education as a strategy to improve full participation in
the prevention activity.

A Secondary Prevention Approach:
Screening and Early Identification
Just as health education is the basis of many primary
prevention programs, screening is central to secondary
prevention. The classic definition of screening is the
presumptive identification of unrecognized disease or
defect by the application of tests, examinations, or other
procedures that can be applied rapidly to sort out those
with a high probability of having the disease from a
large group of apparently well people.51 Screening is not
diagnostic and only indicates who may or may not have
a disease or a risk factor for disease.

Nurses routinely screen for health risks and disease
across health-care settings. This type of intervention
clearly fits within the secondary prevention phase of the
traditional public health prevention model. This allows
for early identification and treatment of disease as well
as the reduction of risk for those who are at greatest
risk for developing disease or sustaining injury. A good
example is blood pressure screening. If those with hyper-
tension are identified prior to development of clinical
symptoms, the institution of behavioral and clinical
interventions such as diet modification and the use of a
diuretic can bring the individual’s blood pressure back
to within the normal range and prevent adverse health
consequences associated with hypertension, such as
stroke. Screening conducted to detect risk factors in

42 U N I T I n Basis for Public Health Nursing Knowledge and Skills

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people without disease includes screening for at-risk
drinking or fall risk. This type of screening is aimed at
distinguishing those with a higher risk for developing
disease or injury from those with low risk. For example,
screening for at-risk drinking not only identifies those
who may have an alcohol use disorder but also identifies
those with a current drinking pattern that puts them at
risk for developing an alcohol use disorder, developing
alcohol-related adverse consequences, or experiencing
alcohol-related injury (see Chapter 11).

When using the traditional public health model,
screening clearly falls into the category of secondary
prevention. The purpose is to identify within a group
of apparently well people those who probably have the
disease. For those with complex risk factors and a less
clear natural history of disease, the traditional model
has less utility. This is true with mental health, sub-
stance use disorders, and injury. In these cases, screen-
ing is done for the purpose of detecting risk for disease
or injury prior to the occurrence of disease as well as
the detection of disease in those who are apparently
well. It can be classified as both primary and secondary
prevention.

Using a continuum of health approach to prevention
provides a broader context for understanding the role of
screening as a prevention intervention. Screening in-
cludes identification of those with risk factors for disease
or injury as well as those with subclinical disease. In the
first case the assumption is that early detection of risk
and delivery of risk reduction interventions will reduce
disease or injury from occurring. In the second case,
the assumption is that early identification and treatment
of those with disease will result in reduction of the mor-
bidity and mortality associated with the disease. This
allows for screening to prevent disease or injury from
occurring in the first place (primary prevention) as well
as to prevent adverse health consequences that can be
avoided with early detection and treatment of disease
(secondary).

Most diseases are associated with a complex set of risk
factors and often do not progress in a linear fashion. In
addition, the broader continuum health model takes into
account not only adverse physical outcomes, but also
psychological, social, and economic outcomes. An exam-
ple of screening that reflects primary prevention is the
approach being used to prevent childhood obesity.
Screening for risk factors such as inactivity and high
caloric intake can help identify children without disease
who would most benefit from an intervention. Thus, the
screening process is conducted in a population without
disease to separate those with a high probability for

developing disease or sustaining an injury from those
with low or no risk factors for the disease or injury.

Diagnosis, Screening, and Monitoring
The difference between diagnosis, screening, and monitor-
ing is often blurred. For example, taking blood pressure
readings at a blood pressure screening event that only
includes people who have not been diagnosed with hyper-
tension is clearly screening, detecting probable disease in a
population of apparently well people. Taking a blood pres-
sure reading for a patient every 4 hours on a medical-surgi-
cal unit in the hospital is done to monitor the patient’s vital
signs and detect possible changes in the patient’s status,
and it is not a screening activity. Taking blood pressure
readings at a booth at a health fair where many of the par-
ticipants come to the booth and state that they have
hypertension and need to know how they are doing is a
combination of screening and monitoring, because many
of the participants have already been diagnosed. The nurse
practitioner or physician takes a blood pressure reading
during a physical work-up to assist in establishing a differ-
ential diagnosis for hypertension. The same activity is done
to screen, monitor, or assist in obtaining a diagnosis.

For each of these activities, there are set parameters
for the measure. In the case of monitoring the patient,
the nurse compares the most recent blood pressure read-
ing with the patient’s baseline reading and the readings
over the admission to determine whether there has been
a change in the patient’s status. The blood pressure read-
ing is part of a larger nursing assessment and, if the read-
ing reflects a change in the patient’s status, the nurse may
change the plan of care for either a positive or negative
change. When using the blood pressure reading from a
diagnostic standpoint, there are specific guidelines for
the clinician, and the blood pressure levels are based
on the average of two or more readings. These readings
are taken during the course of two or more visits.26 Using
the guidelines, the clinician can make a diagnosis of
stage 1 or stage 2 hypertension, or classify the patients as
prehypertensive. The guidelines have been revised based
on growing evidence related to both hypertension and
the development of a new category of risk, prehyperten-
sion, and are evidence based.26

The guidelines state that the process for diagnosing
hypertension occurs after an initial screening. So how
does the screening differ from the diagnostic stage be-
cause the same measurement is taken—a blood pressure
reading using standard equipment? In this case, the main
difference is that the screening is based on one reading
rather than two or more blood pressure readings over a
number of visits, and the purpose of taking the blood

C H A P T E R 2 n Optimizing Population Health 43

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pressure reading is to identify those who may be hyper-
tensive and are in need of further assessment and possi-
ble treatment. The clinician conducting the screening
will refer the individual whose blood pressure meets the
cutoff for probable hypertension to a clinician who is
qualified to conduct the needed assessment and is able
to make a differential diagnosis.

Sensitivity and Specificity
For all of these activities—screening, monitoring, and
diagnosis—the clinician must have a clear understanding
of the reliability and validity of the measure chosen to
screen for risk and/or probability of disease. Understand-
ing the reliability and validity of a screening tool provides
the clinician conducting the screening with the guide-
lines for deciding what is a positive screen and what is a
negative screen, that is, who most probably has the dis-
ease and who most probably does not. Or in the case of
screening for risk, it provides the guidelines for deciding
what is considered high risk and what is considered
low risk. In the case of blood pressure screening, the
screening is done for the most part using the same basic
instrument used to diagnose disease and monitor phys-
ical status, but for other health issues, the screening tool
is different from the diagnostic tool. Determining the
validity of the instrument for screening uses different
criteria than for diagnosis or for monitoring status.

In screening, the reliability and validity of the instru-
ment is crucial. Reliability is defined as the ability of the
instrument to give consistent results on repeated trials.
Validity is defined as the degree to which the instrument
measures what it is supposed to measure. For screening
instruments, the two aspects of validity that are the main
concerns are the sensitivity and the specificity of the in-
strument. Sensitivity is defined as the ability of the
screening test to give a positive finding when the person
truly has the disease, or true positive. Specificity is de-
fined as the ability of the screening test to give a negative
finding when the person truly does not have the disease,
or true negative.

44 U N I T I n Basis for Public Health Nursing Knowledge and Skills

l APPLYING PUBLIC HEALTH SCIENCE
The Case of the Silent Killer
Public Health Science Topics Covered:

• Screening
• Population assessment
• Health planning

Choosing a screening instrument requires under-
standing the importance of both sensitivity and

specificity. For example, in a hypothetical case a
team of nurses at a large urban hospital noticed that
there had been an increase in admissions of African
American men with a diagnosis of cardiovascular dis-
ease secondary to hypertension. They wanted to put
a large-scale blood pressure screening program in
place for the African American men in their city to
improve early detection of hypertension and poten-
tially reduce the need for hospitalization. Prior to
implementing the program, they wanted to make sure
that the method they used to screen for hypertension
was valid. This was important for two reasons. First,
they did not want to have too many false negatives. In
other words, they wanted to identify as many men as
possible with hypertension because there was such a
high morbidity and mortality rate for untreated hy-
pertension in the male African American population.
Second, they did not want too many false positives,
because this population had limited resources to pay
for care. Unnecessary visits to the physician could
result in reduced participation in the program, espe-
cially because an accurate diagnosis requires more
than one visit to a health-care provider. Too many
false positives could result in unnecessary utilization
of health-care resources.

Prior to initiating a full-scale screening program,
the nurses conducted a pilot with 250 African Ameri-
can men who had not been diagnosed with hyperten-
sion, who were not taking antihypertensive (blood
pressure–lowering) drugs, and who were not acutely
ill. To do the screening, they used a standard blood
pressure cuff and stethoscope and measured the
blood pressure in millimeters of mercury (mm Hg).
The nurses debated over the cutoff point. The 2017
guidelines for a diagnosis of stage one hypertension
is a blood pressure reading greater than or equal to
130 systolic (mm Hg) or greater than or equal to
80 diastolic was not yet released.26 Thus, they chose
the then-current diagnostic criteria of a blood pressure
reading greater than or equal to 140 systolic (mm Hg)
or greater than or equal to 90 diastolic. To evaluate the
sensitivity and specificity of the screening, all the partici-
pants were asked to complete three follow-up visits
with a primary care physician to establish whether or
not the participants had hypertension. Because this was
a pilot study, the nurses obtained written consent from
the participants and followed the Internal Review Board
process required by their institution.

Once they had obtained approval, the nurses con-
ducted the pilot study with 250 participants. First, the

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C H A P T E R 2 n Optimizing Population Health 45

A = True positives (screened positive and had the disease)

Screening for stage 1 or 2 hypertension with 250 persons

B = False positives (screened positive and did not have the disease)

C = False negatives (screened negative and had the disease)

D = True negatives (screened negative and did not have the disease)

Screening
Results Yes No Total

40

A

Yes 15 55

Disease (+ = BP �140/90)

B

C D

15No 180 195

55Total 195 250

Figure 2-7 Sensitivity and specificity matrix.

nurses screened the participants for possible hyperten-
sion by obtaining a blood pressure reading. They then
obtained follow-up data on all 250 in relation to
whether or not they were diagnosed with stage one or
stage two hypertension based on the current classifica-
tion of hypertension for adults age 18 years and older.
A diagnosis of hypertension is based on the average
of two readings greater than or equal to 130 systolic
(mm Hg) or greater than or equal to 80 diastolic.26 The
nurses then calculated basic frequencies on their data
and found that 55 of the participants screened positive
for hypertension and, on follow-up, 55 were diagnosed
with hypertension. On the surface, it looked as though
their screening instrument was 100% sensitive as they
correctly identified all who had the disease, but that
was not the case.

To determine the sensitivity and specificity of the
method they used to screen for hypertension, the
nurses constructed a two-by-two matrix using screen-
ing and diagnostic data (Fig. 2-7). They determined the
number of participants that belonged in each box of
the matrix. Each box of the matrix corresponds to four
different categories of participants: (1) those who were
true positives, that is, they screened positive and the
physician diagnosed them with hypertension, box A;

(2) those who were false negatives, that is, they
screened negative but the physician diagnosed them
with hypertension, box C; (3) those who were false
positives, that is, they screened positive and the physi-
cian did not diagnose them with hypertension, box B;
and (4) those who were true negatives, that is, they
screened negative and the physician did not diagnose
them with hypertension, box D.

Using these numbers, the nurses examined the sen-
sitivity of their instrument. They took the total of all
the persons who had positive screens and were subse-
quently diagnosed with either stage one or stage two
hypertension and divided it by the total number of peo-
ple diagnosed with the hypertension and multiplied this
by 100. Another way to express this formula is to use
the letters in the lower right-hand corner of two of the
boxes in the matrix, boxes A and C. The total number
of true positives, or A, is 40, and the total number
with disease (true positives plus false negatives)
equals 55, or A + C. Thus, the formula for sensitivity
is (A/(A + C)) × 100. In this example, the sensitivity is:
(40/55) × 100, or 72.7%

They then determined the specificity of their instru-
ment. To do this, they repeated what they had done
with sensitivity, but now they were concerned with
the relationship between those who were true nega-
tives and the total number who screened negative.
Again, the letters in the lower right-hand corner of
the boxes are used to construct the formula, but this
time the boxes of interest are boxes B and D. The
total number of participants who are true negatives,
or D, is 180, and the total number without disease
equals 195, or D + B. The formula for specificity is
(D/(B + D)) × 100. In this example, the specificity is:
(180/(15 + 180)) × 100 = 92.3%

In this example, the specificity of the screening
test was higher at 92.3% than the sensitivity that is
72.7%. More than 25% of the participants who had hy-
pertension would have been missed if the participants
relied on screening alone, but less than 10% of those
without disease were incorrectly identified as possibly
having hypertension when they actually did not have
the disease (see Fig. 2-5). The nurses had met one of
their requirements for the program (high specificity)
but not the other requirement of high sensitivity.
How could they address these issues?

First, they could look at the reliability of the instru-
ment they were using to obtain the blood pressure
reading. Because the method of measurement for
screening and diagnosis in this case is the same, the

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46 U N I T I n Basis for Public Health Nursing Knowledge and Skills

120/80

True negatives

False positive
and negative
screening

True positives

100/70 130/85 140/90 160/10 180/11 200/12

Figure 2-8 Distribution of blood pressure readings in
those with and without hypertension.

reliability could be a concern. There are two possible
issues: variation in the method and observer variation.
Observer variation has been known to happen when
taking blood pressures using the standard method
owing to observer variation in hearing acuity and expe-
rience in taking blood pressures. The nurses actually
addressed this issue prior to conducting the pilot
study. They did both inter-rater and intra-rater reliabil-
ity, testing at baseline for the nurses who would con-
duct the screening. For the inter-rater reliability, they
had different nurses take the blood pressure on the
same individual to determine the variation between
each rater’s blood pressure reading. For intra-rater
reliability, they compared one nurse or rater’s measure
of repeated blood pressures on the same person.
They initially found low inter- and intra-rater reliability
between the nurses. They then conducted a blood
pressure training workshop for all the nurses who
participated in the screening. Following training, the
reliability of the measure was high.

Because the nurses felt confident that they had
been using a reliable instrument, they considered ad-
justing their cutoff point. As they were working on the
project the 2017 Guideline for the Prevention, Detection,
Evaluation, and Management of High Blood Pressure in
Adults was released. They decided to reexamine the
sensitivity and reliability of their screening using the
new criteria for stage one hypertension of a blood
pressure reading greater than or equal to 130 systolic
(mm Hg) or greater than or equal to 80 diastolic.
Adjusting the cutoff point to a lower value could im-
prove the sensitivity of the screening process, but
would it result in reducing the specificity as they first
feared? Making this decision was done not only based
on the new guidelines, but also by comparing the con-
sequences of a false negative with the consequences
of a false positive. In this case, a false positive would
result in extra visits to the physician, whereas a false
negative would result in untreated disease. Missing
more than a quarter of the population being screened
was a serious problem. Hypertension is known as the
silent killer, that is, the disease has few if any clinical
symptoms until damage has occurred. A person with
the disease often does not know he or she has it until
damage has already occurred.

The nurses plotted the blood pressure readings on
a chart to help determine the cutoff point for 100%
sensitivity and 100% specificity to help decide whether
a lower cutoff point would increase sensitivity while
still maintaining adequate specificity. Plotting out the

normal distribution of the blood pressure values in
those with hypertension and those without hyperten-
sion helped to illustrate what would happen if they
changed the cutoff value (Fig. 2-8). If they changed
the value to 130/80, they would have 100% sensitivity,
but their specificity would drop to nearly 50%. If they
shifted the cutoff point to 145/95, they would achieve
100% specificity but decrease their sensitivity to less
than 70%. Choosing a cutoff value is always a compro-
mise. In this case, the nurses decided to use the diag-
nostic criteria for stage one hypertension as their
cutoff point. This increased their sensitivity to over
80% whereas the specificity decreased only a small
amount to a little less than 90%.

Armed with the information on the reliability and
validity of their screening method, the nurses were
ready to present a proposal to their hospital for
conducting the hypertension screening program as
a citywide outreach program for the hospital. They
approached the director of the community outreach
department with their information, sure that they
would be able to proceed. The director asked them
questions to which they could not respond, so they
went back to obtain more information.

The first question the director posed was, “What
is the expected yield of the screening program?” The
nurses were not sure what this meant. They found
that the yield is defined as the number of previously
undiagnosed cases of disease that result in treatment
following screening. They already had a crucial piece
of information, the sensitivity of the screening program
they proposed. The higher the sensitivity is, the greater
the potential yield will be. The next issue related to

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C H A P T E R 2 n Optimizing Population Health 47

yield is the prevalence of undetected disease. This
depends on the duration of the disease, the duration
of the subclinical phase of the disease, and the level
of available care. The natural history of disease (see
Fig. 2-2) was a helpful guide for the nurses. They went
back to their original literature review related to hy-
pertension and once again found clear evidence that
the duration of the subclinical phase (stage 1) can be
long, and early treatment can have significant effects on
reducing morbidity and mortality. They also reviewed
the statistics on access to care for the low-income
African American population with high levels of
poverty in their city. Owing to changes in the cutoff
for Medicaid eligibility in their state, access to care
was limited and African American males in the immedi-
ate area were less likely to have regular physical
checkups. The nurses also charted out the current
national estimates on the prevalence of undiagnosed
hypertension in African American males. They found
that more than 40% of African Americans have
hypertension, and hypertension was often not diag-
nosed in this population until individuals became
symptomatic.52,53

The nurses concluded that, because of the high
sensitivity of their screening method and the high
prevalence in the target population, the potential yield
was high. However, they had not reviewed the avail-
ability of medical care. Because they needed to deter-
mine whether treatment was available for those who
screened positive, they did a review of all the primary
care clinics in the area. They also reviewed their pilot
data on the resources used by the participants to iden-
tify which primary care clinics were most frequently
used. They then contacted these clinics to determine
whether the clinics would be able to handle a large
influx of potentially new clients following the screening.
The nurses were able to establish that the existing
primary care system was sufficient and that the major-
ity of clinics and primary care offices were willing to
put in writing their support for the project.

The second question the director asked had to do
with multiphasic screening, defined as administering
multiple tests to detect multiple conditions during the
same screening program. The nurses had not consid-
ered this idea, but felt it had merit and reviewed the
current information on health and African American
males. They found that colorectal cancer (CRC) and
high cholesterol were two other serious health prob-
lems for African American males. However, conducting
CRC screening would require a different approach

owing to the complexity of the screening procedure.
Although combining blood pressure screening with
screening for high cholesterol was promising, it was
more invasive and would require purchasing more
supplies, possibly using more personnel. The nurses
also did not have pilot data to provide information on
the sensitivity and specificity of screening with a sample
from the target population, so they would have to rely
on national data.

The director had also asked about the cost benefit
of the program. Because they were asking the hospital
to fund this program, the director wanted to know
the possible benefits of the program related to cost,
simplicity of administration, safety, and acceptability
of the population. The nurses mapped out the actual
budget of the proposed program. Because no new
equipment was needed, the majority of the cost was in
staff time. To reduce costs, the nurses collected a pool
of nurse volunteers willing to participate in the pro-
gram. The taking of blood pressures is safe and nonin-
vasive, and takes little time to complete. This helps
reduce cost because the time needed to conduct the
screening per individual is short.

When reviewing the acceptability of the program,
they were careful not to make the assumption that, be-
cause blood pressure clinics are common, the popula-
tion they wished to engage would come to theirs.
They had asked the participants in their pilot study for
feedback on the best site for conducting the screening
and they also enlisted the help of members of the
community in identifying the right sites and means of
advertising the program. They also reviewed the litera-
ture for evidence of other successful screening pro-
grams with African American males. Though some of
the participants had mentioned schools or churches as
good sites, the site that was mentioned most and also
supported in the literature was the local barbershop.

The nurses shared their data with the director
and reported that the blood pressure screening
program they proposed had a potentially high yield
and the cost would be low given the availability of vol-
unteers. They suggested that the screening program be
conducted in the local barbershops but recommended
that further work be done to develop a partnership
with the owners of these shops prior to implementing
the program. They then discussed the possibility of de-
veloping a multiphasic screening program by combining
blood pressure screening with other screenings such
as cholesterol but cautioned that this would require
additional funding and time investment.

7711_Ch02_023-054 23/08/19 10:21 AM Page 47

Criteria for Screening Programs and Ethical
Dilemmas
Screening is performed on a regular basis across popu-
lations and settings, and is often taken for granted as a
worthwhile endeavor. Prior to implementing a screening
program, it is important to determine whether the
screening program meets certain criteria. There are
serious ethical considerations that must be addressed.
For the majority of screening, the core assumption is that
the screening program will reduce disease-associated
morbidity and mortality due to early identification and
engagement in treatment. The other major assumption
is that all those who screen positive for probable disease
have access to appropriate assessment and treatment
services. These assumptions form the basis of the criteria
used to determine whether a screening program should
be implemented.

Criteria for Screening Programs
The first criterion is to be certain that the screening test
has high specificity and sensitivity. This is complex as
demonstrated in the previous case study. There is always
a trade-off between specificity and sensitivity. When
planning a screening program, it helps to review the im-
pact of missing true cases versus falsely identifying a per-
son with the disease as having the disease. For example,
if the disease being screened has a high mortality rate, it
may be more important to identify as many individuals
with the disease as possible; that is, it should have a high
sensitivity. That way there is a good chance of detecting
disease, even if the specificity is low and the percentage
without disease that ends up going through diagnostic
testing is high. However, those who screen positive and
do not have disease may unnecessarily experience a high
level of stress while waiting to find out whether they
do indeed have the disease. On the opposite end, if the
mortality for the disease is lower and the cost and incon-
venience of diagnostic testing is high, high specificity
may be more important than high sensitivity. The best-
case scenario is to have a test with both high specificity
and high sensitivity. There is always a trade-off.

The next important criterion is that the test needs to
be simple to administer, inexpensive, safe, rapid, and ac-
ceptable to patients. Screening that can be done quickly
with minimal time and effort has a higher likelihood
of success. It also needs to be safe. Some screening tests
are invasive and may carry some risk. For example, a
colonoscopy requires some anesthesia with its associ-
ated risk. A paper-and-pencil questionnaire is noninva-
sive and carries minimal risk. Also, a simple one-page

48 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Figure 2-9 Blood pressure screening. (From Centers for
Disease Control and Prevention, James Gathany, 2005.)

The director then challenged them to describe how
they would evaluate the success of the program. In
response they shared with him the hospital discharge
data that had initially sparked their interest in doing
the screening. They felt that this would provide suffi-
cient baseline data to help evaluate the outcome of
the screening program. The director asked them to
clarify what their programmatic outcome would be.
They were not sure, so the director asked them to
come back when they had a clear idea of how they
would evaluate the success of the program (for more
on evaluation, see Chapter 5). After reviewing basic
models for program evaluation, they decided on a
short time span for their evaluation and chose simple
measures to evaluate the impact of the program. They
chose to measure the number of people who attended
the program, the number of positive screens, and the
number of positive screens who accepted information
related to referral for treatment. They went back to
the director and stated that, owing to the limited re-
sources for the targeted population, there were three
clinics that were most often used by residents in the
targeted community. The nurses felt it would be practi-
cal to track individuals postscreening. To do this, they
proposed to first keep a record of how many men
attended the screening. They then would contact each
of the clinics and ask them to track the number of men
who said they had been referred by the screening
program. Based on all the information provided, the
director finally approved their request, and the nurses
were able to institute the screening program (Fig. 2-9).

7711_Ch02_023-054 23/08/19 10:21 AM Page 48

paper-and-pencil screening tool is rapidly administered,
whereas a colonoscopy requires a minimum of 24 hours
including preparation for the test, the administration of
the test, and recovery from the test. Acceptability of the
screening test is often dependent on cost, time, safety,
and ease of administration, which are reasons that it is
harder to get individuals to have the recommended
colonoscopy screening than it is other screening tests.

Even paper-and-pencil tests should be reviewed for
simplicity. Many screening tests take too long to admin-
ister, decreasing the chance that a person will complete
a test. Consider the difference between screening for pos-
sible depression using a 10-item questionnaire that can
be inserted into a regular health assessment versus a
32-item questionnaire. A 10-item test is simpler. It is also
easier to learn and perform, and can be delivered by non-
medical personnel. A good example of a measurement
tool for depression with high sensitivity, specificity, and
reliability is the 10-item Center for Epidemiologic Stud-
ies Short Depression Scale (CES-D 10).54,55 The original
screening tool was 20 items long and took longer to learn
and administer. The shorter form is easier to administer
and more acceptable to patients.

The next criterion is that the disease be sufficiently se-
rious to warrant screening. The purpose is to prevent the
adverse consequences associated with the disease. In the
case of colonoscopy, the screening test does not meet the
rapid, simple, inexpensive, and acceptable criteria. How-
ever, the severity of the disease outweighs the inconven-
ience and cost of the screening test. CRC is the third
leading cause of cancer-related deaths in the United
States.54 Screening and early detection of CRC increase the
chance of a cure in a disease with a high mortality rate
when treated in its late stages. Screening often leads to the
identification of precancerous lesions (i.e., adenomas),
which can be removed, thus preventing CRC.56

The next criterion addresses the issue of whether the
treatment for disease is easier and more effective when
the disease is detected early. This is not the case for all
diseases and is the reason that there is ongoing scientific
inquiry into the utility of screening tests. If screening is
done, will it reduce the disease-associated morbidity and
mortality through initiation of early treatment and to
what extent? If there was a screening test for Parkinson’s
disease, what type of early treatment exists? Because
there is no known cure and treatment is confined to
reducing symptoms, early detection does not serve to
reduce the disability associated with the disease. Con-
versely, mammography has the potential of identifying
breast cancer in the early stages, thus increasing the
potential survival rate.

This then raises the issue of the acceptability of the
available diagnostic services and treatment. If screening is
done, will those who screen positive seek further assess-
ment? Will those with a positive diagnosis engage in treat-
ment? This issue was raised over the use of a reliable
instrument to screen for at-risk drug use. There is no evi-
dence that screening resulted in subsequent assessment
and treatment. Those who screened positive were not
likely to follow up with the next steps related to the screen-
ing. Based on this, the National Quality Forum’s (NQF)
publication on evidence-based treatment for substance use
disorders does not recommend that health-care providers
screen for at-risk drug use as a standard practice in general
populations.54 When screening will not result in the
needed follow-up, the screening program will not result
in reduced disease-related morbidity and mortality.

Another criterion for implementing a screening pro-
gram is to determine whether the prevalence of a disease
is high in the population to be screened. Despite the
NQF’s recommendation that screening for at-risk drug
abuse not be conducted in the general population, it is
applicable in a population in which the prevalence of
at-risk drug use is high, such as an inner-city program for
adolescent males with failing grades. The prevalence is
higher, and the program staff can be trained to provide
health education along with the screening, thus improving
the acceptability of subsequent referral and possible treat-
ment by the boys in the program who screen positive.

This criterion is also helpful when deciding whom to
target when putting together a screening program. The
IOM continuum health prevention model referenced
earlier30 provides a framework for deciding whom to in-
clude in the screening program. A universal approach
would include everyone in the population regardless of
age, gender, or other characteristic. A screening program
that uses a selected approach would focus on those at
higher risk. Making these decisions is based on preva-
lence and risk for disease. For example, breast cancer
screening through mammography is not done using a
universal approach. Instead, age, gender, and risk factors
are used to determine who should get a mammogram
and how often.

The final and ethically the most important criterion is
that resources are available for referral for diagnostic
evaluation and possible treatment. In our example of
putting together a screening program for hypertension
in African American men, the team first ascertained
whether there were available resources to handle those
with a positive screen. The main issues to address are
economic access, physical access, and capacity to treat.
Economic access refers to the ability to pay for care. Will

C H A P T E R 2 n Optimizing Population Health 49

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all those who attend the screening program be able to re-
ceive follow-up diagnostic services and possible treat-
ment? If the answer is yes, will they have physical access
to the clinics providing the care? For example, what type
of transportation is available to get to the clinics provid-
ing services, and will everyone who attends the screening
have adequate transportation in terms of time, utility,
and cost? Finally, if a large-scale screening program
is done, does the existing health-care system have the
capacity to provide diagnostic and treatment services for
the anticipated increase in individuals needing these
services? This last criterion is rarely addressed and can
result in serious consequences.

Ethical Considerations
The criteria discussed raise serious ethical questions
related to screening. It is unethical to conduct screening
if treatment is not available. Screening programs are
often done without thinking through the consequences.
A serious ethical question is, what will be done with the
positive screens? Availability of treatment is not just
related to the existence of health-care resources that pro-
vide the treatment but also to the ability of those partic-
ipating in the screening to access those resources. What
if nurses conducted blood pressure screening with a
homeless population in a neighborhood where the near-
est hospital was three bus rides away; the nearby clinics
required a minimal co-pay of $50.00; there were no
pharmacies in the area that provided medications to
those without the ability to pay; the soup kitchens in the
area served donated food that was high in salt, fat, and
sugar; and there were limited public toilets? What would
they do with the homeless persons who had a positive
screen? Even if they managed to see a physician who
then prescribed a salt-free diet and a powerful diuretic,
how would they be able to fill the prescription and fol-
low the diet? If they were able to fill the prescription,
how would they handle the frequent need to urinate
without getting arrested for urinating in public? The pri-
mary question is, did the screening program result in re-
duced morbidity and mortality in this population? Was
it ethical to conduct the screening without ensuring first
that a system was in place to provide the needed health-
care services?

Another example involves the American Cancer
Society’s eagerness to provide free breast exams and
mammography to low-income Hispanic and African
American women in a midwestern city. The organization
engaged several partners to provide the service (at a time
before most states provided free screening to low-income

women). The director of one of those clinics agreed to
see a specific number per week for free (one criterion was
no health insurance). However, the director insisted that
the clinic would do this only if the American Cancer
Society had a plan in place for diagnosing and treating
any woman who screened positive for the cancer. The
ethical and moral question that the planners then ad-
dressed was what to do if they told a participant in the
screening program that she had cancer and then had no
way for her to receive treatment. The planners were able
to contract with three physicians and two hospitals that
agreed to provide care. The screening program began and
the first woman screened was positive for breast cancer,
requiring major surgery. She had no insurance and no
resources to pay for the surgery. To be eligible for Med-
icaid, she would have had to give up her home, a resource
for which she had spent a lifetime saving. Because of the
preplanning, this woman and the four other women
participating in the program who were diagnosed with
cancer all received the needed surgery. Without the gen-
erosity of the physicians and hospitals, they would not
have been able to have the surgery, and the planners
of the screening program would have been left with a
serious ethical dilemma.

Another ethical issue has been raised by the possible
use of genetic screening as a means of identifying those
who are genetically at risk for developing disease. For ex-
ample, with our increased knowledge related to geneti-
cally linked disease, genetic screening can help determine
whether a well person without disease is at risk for de-
veloping disease. A woman’s risk of developing breast
and/or ovarian cancer is greatly increased if she inherits
a deleterious (harmful) BRCA1 or BRCA2 mutation.
Men with these mutations also have an increased risk of
breast cancer. Both men and women who have harmful
BRCA1 or BRCA2 mutations may be at increased risk of
other cancers. Should genetic screening be done and, if
so, what interventions should occur related to positive
results? There are no easy answers. Consider the woman
who screens positive for a BRCA1 or BRCA2 mutation.
Should she consider removing her healthy breasts prior
to the development of disease?

Tertiary Prevention and
Noncommunicable Disease
Secondary prevention attempts to reduce morbidity and
mortality through early detection and treatment. Tertiary
prevention is another powerful prevention approach that

50 U N I T I n Basis for Public Health Nursing Knowledge and Skills

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can also reduce the burden of disease. During the past
100 years, as the life span of populations has increased,
the prevalence of NCD (Chapter 9), also referred to as
chronic diseases, increased, creating a growing burden
of noncommunicable chronic disease in the United
States and across the world.57 According to the WHO, in
contrast to CDs, NCDs are defined as disease that are not
passed from person to person, they have a long duration
and usually a slow progression. There are four main
categories of NCDs: cardiovascular diseases, cancers,
chronic respiratory diseases, and diabetes.55 Almost half
of the population in the United States has been diagnosed
with at least one noncommunicable chronic disease, and
four in every five health-care dollars are spent on the care
of NCD. Although the U.S. health system is built on an
acute care model, the vast majority of the care provided
is for the management of noncommunicable chronic
diseases.56

Once it has been identified, how do NCDs fit into
the prevention frameworks previously presented? Using
the traditional public health model, tertiary prevention
is the logical choice. The goal of tertiary prevention in-
terventions is to prevent premature mortality and ad-
verse health consequences related to an NCD. For some
diseases, such as hypertension, tertiary prevention efforts
can result in the person returning to a normal state; that
is, a combination of behavioral changes and pharmaceu-
tical interventions can result in the patient’s blood pres-
sure returning to normal limits. In other diseases, the
prevention strategies are aimed at slowing the progres-
sion of the disease and reducing the likelihood of adverse
consequences related to the disease. With pharmaceuti-
cal interventions, patients with Parkinson’s disease can
improve their gait and reduce the tremors. This reduces
their risk of falls and other injuries while improving their
ability to perform ADLs, but they are not returned to a
normal state.

Tertiary prevention appears at first glance to be indi-
vidual based rather than population based. However, the
burden of NCDs affects the whole population, and move-
ment toward more population-level interventions is gain-
ing momentum. In 2009, the WHO released a report
calling for “urgent action to halt and turn back the growing
threat of chronic diseases.”56 In that report, the WHO
stressed that population interventions can be done related
to reducing the burden of already diagnosed chronic dis-
eases. In the 2014 WHO report on NCDs, the Director
General released a statement that: “WHO Member States
have agreed on a time-bound set of nine voluntary global
targets to be attained by 2025. There are targets to reduce

harmful use of alcohol, increase physical activity, reduce
salt/sodium intake, reduce tobacco use and hypertension,
halt the rise in diabetes and of obesity, and to improve cov-
erage of treatment for prevention of heart attacks and
strokes. There is also a target to improve availability and
affordability of technologies and essential medicines to
manage NCDs. Countries need to make progress on all
these targets to attain the overarching target of a 25%
reduction of premature mortality from the four major
NCDs by 2025.”57

Tertiary care also occurs with CDs during both the
acute and recovery stages of infection. For many CDs,
tertiary care focuses on provision of acute care, that is,
treatment of the disease to prevent further morbidity
and mortality, such is the case of treatment for influenza
or measles. For some CDs such as HIV, there is no cure
and the infection requires long term care to prevent
and/or treat AIDS. Other CDs require long-term care to
bring about a disease-free state such as tuberculosis. Due
to the long-term duration of AIDS and other CDs, the
preferred term NCD helps to distinguish between dis-
eases based on the ability of a disease to be transmitted
from one human to another. In addition, with CDs part
of tertiary prevention becomes primary prevention, that
is, the prevention of transmission to other persons (see
Chapter 8).

n Summary Points
• Health promotion and protection are major

emphases of national and global health
organizations.

• The socioecological model of health promotion
uses an upstream approach that includes the social,
environmental, and economic contexts of healthy
populations.

• The health of a population is greater than the
sum of the health of each individual in the
population.

• Health prevention frameworks provide
guidance for the development of prevention
interventions.

• Health education and health literacy are keys
to improving the health of populations.

• Screening for possible disease has the potential
to reduce disease-related morbidity and mortality
but has serious ethical issues that must be
addressed.

• Tertiary prevention can help to reduce the burden
of chronic diseases.

C H A P T E R 2 n Optimizing Population Health 51

7711_Ch02_023-054 23/08/19 10:21 AM Page 51

7. Bauer, G., Davies, J.K., Pelikan, J., Noack, H., Broesskamp,
U., & Hill, C. (2003). Advancing a theoretical model for
public health and health promotion indicator development:
Proposal from the EUHPID consortium. European Journal of
Public Health, 13(3s), 107-113.

8. Institute of Medicine. (2003). The future of the public’s
health in the twenty-first century. Washington, DC: National
Academies Press.

9. Golden, S.D., McLeroy, K.R., Green, L.W., Earp, J.A.L.,
& Lieberman, L.D. (2015). Upending the social
ecological model to guide health promotion efforts toward
policy and environmental change. Health Education &
Behavior, 42(1 suppl), 8S-14S. https://doi.org/10.1177/
1090198115575098.

10. World Health Organization. (2018). Health promotion.
Retrieved from http://www.who.int/topics/health_
promotion/en/.

11. O’Donnell, M.P. (2008). Evolving definition of health
promotion: What do you think? American Journal of Health
Promotion, 23(2), iv. doi: 10.4278/ajhp.23.1.iv.

12. Li, A.M. (2017). Ecological determinants of health: food
and environment on human health. Environment Science
and Pollution Research International, 24, 9002-9015.
doi: 10.1007/s11356-015-5707-9.

13. World Health Organization. (2018). Social determinants
of health. Retrieved from http://www.who.int/social_
determinants/sdh_definition/en/.

14. Braveman, P., Egerter, S., & Williams, D.R. (2011). The social
determinants of health: coming of age. Annual Review of
Public Health, 32, 381-398.

15. Martins, D.C., & Burbank, P.M. (2011). Critical interaction-
ism: an upstream-downstream approach to health care
reform. Advances In Nursing Science, 34(4), 315-329.
doi:10.1097/ANS.0b013e3182356c19.

16. U.S. Department of Agriculture. (2018). National school
lunch program. Retrieved from https://www.fns.usda.gov/
nslp/national-school-lunch-program-nslp.

17. U.S. Department of Agriculture. (2018). Interim final rule:
child nutrition program flexibilities for milk, whole grains,
and sodium requirements. Retrieved from https://
www.fns.usda.gov/school-meals/fr-113017.

18. Morgan I.S., & Marsh, G.W. (1998). Historic and future
health promotion contexts for nursing. Journal of Nursing
Scholarship, 30(4), 379-383.

19. Pender, N., Murdaugh, C.L., & Poarsons, M.A. (2014).
Health promotion in nursing practice (7th ed.). Upper Saddle
River, NJ: Prentice Hall.

20. Dicker, R., Coronado, F., Koo, D., & Parish, G. (2012).
Principles of epidemiology in public health practice (3rd ed.).
Atlanta, GA, Centers for Disease Control and Prevention.

21. Centers for Disease Control and Prevention. (1992). A
framework for assessing the effectiveness of disease and
injury prevention. Morbidity and Mortality Weekly Report,
41(RR-3).

22. Centers for Disease Control and Prevention. (2009).
Novel H1N1 flu facts and figures. Retrieved from http://
www.cdc.gov/h1n1flu/surveillanceqa.htm.

23. Centers for Disease Control and Prevention. (2018). People
at high risk of developing flu complications. Retrieved from
https://www.cdc.gov/flu/about/disease/high_risk.htm.

52 U N I T I n Basis for Public Health Nursing Knowledge and Skills

t CASE STUDY
The Centers for Disease
Control and Prevention Asks
the Question: “Should I Get
Screened for Prostate Cancer?”

The CDC follows the U.S. Preventive Services Task
Force recommendations that the prostate specific anti-
gen (PSA)-based screening should not be done for men
who do not have symptoms.58 Other organizations
have made different recommendations. Based on your
review, answer the following questions:

1. What is the sensitivity and specificity of PSA tests?
2. The CDC states that one of the reasons is “… the

PSA test may have false positive or false negative
results. This can mean that men without cancer
may have abnormal results and get tests that are
not necessary.” What is the biggest issue?

3. How well does a PSA differentiate between
non-aggressive and aggressive prostate cancer?

4. Review the information on PSA screening and the
criteria and ethical guidelines for conducting a
screening program on pages 48-50. Of the list of
criteria and ethical issues listed in this chapter,
which ones are a concern related to PSA
screening?

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28. Enworom, C.D., & Tabi, M. (2015). Evaluation of kidney
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29. Salvatore, A. L., SangNam, A., Luohua, J., Lorig, K.,
Ory, M. G., Ahn, S., & Jiang, L. (2015). National study of
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trieved from https://www.uspreventiveservicestaskforce.org/
Page/Name/about-the-uspstf.

31. Centers for Disease Control and Prevention. (2017).
Faststats: leading causes of death. Retrieved from https://
www.cdc.gov/nchs/fastats/leading-causes-of-death.htm.

32. National Center for Health Statistics. (2017). Health,
United States, 2016: With chartbook on long-term trends
in health. Hyattsville, MD: National Center for Health
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33. Institute of Medicine and National Research Council.
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34. Keller, L.O., Strohschien, S., Lia-Hoagberg, B., & Schaffer, M.
(2004). Population-based public health interventions:
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35. Minnesota Department of Health, Division of Community
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interventions: Applications for public health nursing practice.
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36. Joint Committee on Health Education and Promotion
Terminology. (2014). Report of the 2011 Joint Committee
on Health Education and Promotion Terminology.
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37. World Health Organization. (2018). Health education.
Retrieved from http://www.who.int/topics/health_
education/en/.

38. Shunk, D.H. (2012). Learning theories: An educational per-
spective (6th ed.). Boston: Pearson.

39. Bandura, A. (1977). Social learning theory. New York:
General Learning Press.

40. Hughes, N., & Schwab, I. (2010). Teaching adult health
literacy: principles and practice. Berkshire, England:
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41. Knowles, M.S. (1990). The adult learner: A neglected species
(4th ed.). Houston, TX: Gulf.

42. The Institute of Medicine, Committee on Health Literacy,
Board on Neuroscience and Behavioral Health. (2004).
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DC: The National Academies Press.

43. U.S .Department of Education, National Center for
Education Statistics. (2016). Skills of U.S. unemployed,
young, and older adults in sharper focus: results from the
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cies (PIAAC) 2012/2014. Retrieved from https://nces.ed.gov/
pubs2016/2016039rev.pdf.

44. Rasu, R.S., Bawa, W.A., Suminski, R., Snella, K., & Warady,
B. (2015). Health literacy impact on national healthcare
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ijhpm.2015.151.

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46. Hersh, L., Salzman, B., & Snyderman, D. (2015). Health
literacy in primary care practice. American Family Physician,
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47. Agency for Health Care Research and Quality. (2015). AHRQ
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and-African-Americans_UCM_301832_Article.jsp#.
Wxly1fZFw2w.

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adults: Evaluation of a short form of the CES-D (Center for
Epidemiologic Studies Depression Scale). American Journal
of Preventive Medicine, 10, 77-84.

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tal cancer statistics. Retrieved from https://www.cdc.gov/
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disease prevention and health promotion: National Center for

Chronic Disease Prevention and Health Promotion. Retrieved
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58. World Health Organization. (2014). Global status report
on noncommunicable diseases 2014. Geneva: Author.

54 U N I T I n Basis for Public Health Nursing Knowledge and Skills

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55

KEY TERMS

Active surveillance
Agent
Analytical epidemiology
Attack rate
Biostatistics
Causality

Demography
Descriptive epidemiology
Environment
Epidemiology
Host
Incidence

Infectivity
Life expectancy
Morbidity
Mortality
Passive surveillance
Percent change

Prevalence
Prospective
Rate
Retrospective
Secondary attack rate
Web of causation

n Introduction
In 2017, a National Public Radio headline reported “U.S.
has the worst rate of maternal deaths in the developed
world,” based on a recent study of global levels of maternal
mortality.1 Information from the Centers for Disease Con-
trol and Prevention (CDC) also confirms that pregnancy-
related deaths, defined as the death of a woman during or
within 1 year of the end of pregnancy, have been increas-
ing in the United States since 1987 when this information
was collected.2 A headline like this inspires many ques-
tions: Why is the mortality rate increasing? What factors
are influencing this disparity between the U.S. and other
developed countries? Is a particular population affected
more by high rates of maternal mortality? How was this
information collected? Is this an accurate headline based
on the information?

As nurses, if we were to investigate these data
further we would discover that there are great disparities
in the pregnancy-related mortality within the U.S.
According to the CDC, for example, black women have a
much higher rate of pregnancy-related deaths compared

with white women (12.7 deaths per 100,000 live births for
white women vs. 43.5 deaths per 100,000 live births for
black women).2 However, for a public health nurse, this
suggests the need for further inquiry into what factors
might be driving this difference: poverty, urban/rural
differences, racial stigma, or differing access to care. See
Chapter 17 for more details specific to maternal child
health, and maternal mortality and public health.

Collecting, analyzing, and synthesizing data to under-
stand public health questions such as disparities in mater-
nal mortality is the heart of epidemiology. Epidemiology,
the combination of three Greek words: epi, translated
as “upon”; demos, translated as “people”; and logy, or
“the study of something”, is broadly defined as the study
of factors that influence health and disease in populations.3
Epidemiology is a natural fit for the nursing profession
because nursing, unlike many of the health-related pro-
fessions, extends well beyond one-on-one patient-clinician
interactions to engaging groups of people where they live,
work, and play. Public health nursing has traditionally
blended health promotion, disease prevention, health
education, and population-based initiatives in an effort to

Chapter 3

Epidemiology and Nursing Practice
Erin Rachel Whitehouse and William A. Mase

LEARNING OUTCOMES

After reading the chapter, the student will be able to:
1. Describe aspects of person, place, and time as they

relate to epidemiological investigation.
2. Explain the epidemiological triangle.
3. Apply the epidemiological constants to an investigation.
4. Identify sources of epidemiological data.
5. Apply basic biostatistical methods to analyze

epidemiological data.

6. Differentiate cohort and case-control study design and
select appropriate measures of effect.

7. Explain surveillance and the difference between active
and passive surveillance.

7711_Ch03_055-076 21/08/19 11:06 AM Page 55

maximize the health and wellness of individuals through
population-level strategies. As 21st-century health profes-
sionals, nurses are now more than ever required to
demonstrate both competency and proficiency in the prin-
ciples of epidemiology.

Today the curriculum in accredited colleges of nurs-
ing is shifting toward the inclusion of epidemiology as
core content. The historical development of epidemiol-
ogy is replete with references to the same women who
carved out the nursing profession. Public health nursing
and population-based health and wellness are evident in
the pioneering efforts of Florence Nightingale, Lillian
Wald, Clara Barton, Mary Breckinridge, and Dorothea
Dix. Each of these legendary women initiated public
health efforts from a population health perspective
toward the reduction of disease and promotion of health
within populations.

What Is Epidemiology?
Epidemiology has been defined many ways. Tradition-
ally, it is the study of the distribution of disease and
injury in human populations. More recently, broader

56 U N I T I n Basis for Public Health Nursing Knowledge and Skills

n CELLULAR TO GLOBAL
Epidemiology and biostatistics are critical fields to
understand health outcomes from a cellular to global
level. Mycobacterium tuberculosis (TB), the leading
cause of communicable disease deaths globally, is an
example of a disease that affects health on a cellular,
individual, community, and global level.4 Diabetes, smok-
ing, and HIV infection are leading risk factors both for
the development of TB and for poorer treatment
outcomes through mechanisms such as increased
inflammation, decreased immunity, and structural lung
damage. TB is also related to community factors such
as poverty because risk factors like overcrowded
housing increase the risk of exposure and subsequent
development of TB. Drug-resistant TB, which is resist-
ant to the first-line TB antibiotics, is an increasing
challenge in part due to insufficient health systems
that do not have the appropriate resources to treat it.
Finally, preventing and treating TB is a global challenge
given the movement of populations due to migration,
war, famine, natural disasters, and even tourism.
Epidemiological principles are one tool to understand
how risk factors on cellular, local, national, and global
levels impact population health outcomes like mortality
from TB.

definitions of the term move beyond the study of disease
and include the examination of factors that affect the
health and illness of populations, thus providing the basis
for interventions aimed at improving the health and
well-being of populations. The focus of epidemiology is
on populations rather than on individuals. Epidemiology
takes an analytical investigative approach to this study of
health and disease, and is built on three central elements:

• Person: Which groups of individuals are affected?
• Place: Where does the health issue occur, i.e., what

geographically defined region?
• Time: Over what specified period of time does the

health issue occur?

These three elements of person, place, and time are
the bricks of epidemiology. The mortar cementing these
bricks is made up of the methods of quantitative com-
parison used by epidemiologists when studying patterns
of disease and health. The tools used by epidemiologists
are best described as comparative, numeric, and analyt-
ical. To effectively quantify illness and disease, accurate
data are required. Epidemiological data sources vary
widely. Some of the more frequently used data sources
include hospitals, community-based clinical practices,
health departments, workplaces, schools, and health
insurance reimbursement claims. The capacity for an
epidemiologist to effectively analyze and present data is
inextricably linked to the network of health-care–related
workers throughout an array of health and human
service–related industries. Nurses are pivotal to the ac-
curate assessment and timely reporting of health-related
data upon which epidemiology is grounded.

Historical Beginnings
John Snow is celebrated as the founder of modern epi-
demiology just as Florence Nightingale is recognized
as the founder of modern nursing (see Chapter 1). John
Snow’s watershed work, Snow on Cholera, introduced
methods of epidemiological investigation and methods
upon which contemporary epidemiological methods are
founded.5 His use of the epidemiological strategy, now
defined as disease mapping, to study the incidence of
cholera deaths reported in London, England, laid the
foundation for investigation of disease in populations.
The Lambeth Company provided residents of London
with drinking water collected from the Thames River.6
Snow’s enumeration and subsequent investigation of
cholera deaths reported for residents living near the
Lambert Company’s Broad Street water pump is her-
alded as the defining event upon which all future
epidemiological methods are based. Snow developed a

7711_Ch03_055-076 21/08/19 11:06 AM Page 56

timely measures for disease investigation using contem-
porary 21st-century methods. The three elements of per-
son, place, and time are as central to an epidemiological
investigation now as they were in the time of Snow, and
they form the building blocks for modern-day epidemi-
ological investigations.

Since the time of Snow’s work, epidemiology has gone
through various phases. The first phase is referred to as
the sanitary phase. It was based on the miasma theory
that illness was related to poisoning by foul emanations
from soil, air, and water. During this phase, public health
efforts focused on improving sanitation. This approach
to illness prevailed until the discovery of microscopic
organisms that were linked to disease, which led to the
germ theory and the communicable disease phase of epi-
demiology. This phase led to the examination of single
causes for a disease and worked well in a world where com-
municable diseases were the number one killers. With the
emergence of antibiotics and the reduction of communicable
disease, the life expectancy of populations increased,

frequency distribution of the number of human deaths
by placing a hash mark on a city street map. Upon visual
inspection of the map it became clear to Snow that there
were residential patterns of deaths. He demonstrated that
greater numbers of cholera deaths were clustered within
the vicinity of a specific public water source, the Broad
Street water pump. The number of cholera deaths near
the Broad Street pump far exceeded the deaths in other
areas of London (Fig. 3-1).

Snow’s work illustrated the three central elements re-
lated to his investigation: person, place, and time. The
person variable can be defined as the number of human
cholera deaths. Place is visually demonstrated by the
street mapping method Snow used to count human
deaths by street of residence. Finally, the time variable in
Snow’s study was the 5-year period between 1849 and
1854 when the Lambeth Company drew community
water from the contaminated source, the Thames River.
In the 150 years since Snow’s community disease map-
ping, epidemiologists have developed more effective and

C H A P T E R 3 n Epidemiology and Nursing Practice 57

Figure 3-1 Snow map.
(Published by C.F. Cheffins,
Lith, Southhampton Buildings,
London, England, 1854, in Snow, J.
[1885]. On the mode of commu-
nication of cholera (2nd Ed.).
John Churchill, New Burlington
Street, London, England. http://
www.ph.ucla.edu/epi/snow/
snowmap1_1854_lge.htm)

7711_Ch03_055-076 21/08/19 11:06 AM Page 57

especially those in developed countries. This resulted in
the emergence of noncommunicable diseases and a new
phase in epidemiology, the risk factor phase. This phase
of study is still a mainstay of epidemiological investiga-
tions. It relies on the linking of exposures to the occur-
rence of injury or disease and helps us identify risk
factors that, when reduced, may result in a subsequent
reduction in morbidity and mortality. The most recent
phase in epidemiology is the ecological model as pro-
posed by Susser and Susser in the 1990s.7,8 This helps
move the science of epidemiology to a broader perspec-
tive and, as explained in Chapter 1, reflects not only
the biological and behavioral influences on health but
also a deeper understanding of the role of the physical
environment and the underlying conditions in the social
environment that create poor health.

Risk Factors
Risk factors are a foundational concept in epidemiology.
The World Health Organization (WHO) defines a risk
factor as “any attribute, characteristic, or exposure of an
individual that increases the likelihood of developing a
disease or injury.”9 Although there are several ways to
classify risk factors, we will explore three major categories
of risk factors: behavioral, environmental, and genetic.

Behavioral Risk Factors
The CDC began the now nationwide Behavioral Risk
Factor Surveillance System (BRFSS) in 1984.10 They in-
tended to study the way that human behavior influences
health and wellness, and identify behaviors that might
influence health conditions, such as the impact of under-
age drinking on the risk of unprotected sex. This human
health behavioral survey is the largest telephone survey
assessment in the world. The BRFSS provides timely
health behavior data for policy makers in all 50 states as
well as the District of Columbia, Puerto Rico, U.S. Virgin
Islands, and Guam. These data are effective in providing
health-related trend analysis and serve to guide and direct
local, state, and national pro-health initiatives. Figure 3-2
presents national-level trended data on tobacco use.11 It is
exciting to see that the Healthy People 2020 goal for ado-
lescent smoking has been reached! The BRFSS can be used
to present population-level trend data related to many
behavioral risk factors. For community-based health
educators, these data are an effective resource to assist in
planning community health interventions.

Environmental Risk Factors
Is it possible that the community in which one lives
and/or works puts one at an increased or decreased risk

for developing a given illness or disease? Yes, it does. The
Agency for Toxic Substances and Disease Registry
(ATSDR) Web site provides useful information on ad-
verse health effects linked to health-related environmental
risk from exposure ranging from arsenic to zinc and
everything in between (see Web Resources on DavisPlus).
Often, increased environmental risk for residents of com-
munities is related to specific industries located in and
around the community. By mapping industries related to
hazardous waste, it is possible to identify populations at
greater risk for disease at the local and state levels. The
federal government has set aside funds referred to as the
Superfund to clean up uncontrolled hazardous waste sites
across the country through the Environmental Protection
Agency (EPA). The states with the greatest number of
Superfund clean-up sites include New Jersey, Pennsylvania,
and New York, with more than 100 Superfund sites per
state. The EPA Web site at http://www.epa.gov/superfund/
provides information on identifying possible industry-
related environmental hazards.

Public health professionals working in environmental
health often focus on three critical areas in assuring the
health of the public: safe air quality conditions, safe water
supplies, and safe soils throughout the nation’s agricul-
tural industry. The majority of the human health risks

58 U N I T I n Basis for Public Health Nursing Knowledge and Skills

40

35

30

25

20

15

10

5

0

19
97

19
99

20
01

20
03

20
05

20
07

20
09

20
11

20
13

20
15

20
17

Adults (%)**

Percentage of high school students who smoked cigarettes on at least 1
day during the 30 days before the survey (i.e., current cigarette use).
(Youth Risk Behavior Survey 1997-2017)

Percentage of adults who were current past 30-day cigarette smokers
(National Health Interview Survey 1997-2017)

*

**

P
er

ce
nt

ag
e

(%
)

Students (%)*

Figure 3-2 Trends in Current Cigarette Smoking by
High School Students* and Adults** United States 1997
to 2017. (Source: 11a, 11b.)

7711_Ch03_055-076 21/08/19 11:06 AM Page 58

are associated with what we breathe and ingest. It is
important to keep in mind that the environmental risks
affecting humans are indeed vast, including automobile
safety, seatbelt use, and safe conditions throughout pub-
lic recreational facilities. Public health professionals use
a combination of education, engineering, and enforce-
ment to achieve our mandated goals and objectives.
There are more details about the role of public health
science and environmental health in Chapter 6.

Genetic Risk Factors (Genomics)
The field of genetic epidemiology otherwise known as
genomics seeks to understand and explain heritability
of factors that have an impact on the development of
illness and disease. The past 2 decades have witnessed the
expansion of research into genetic markers for disease.
We will likely see a transformation in the evaluation,
assessment, and tools surrounding genetically relevant
strategies at the population level because of emerging
individual-level genetic knowledge.

Application of genomics to population health poses
some practical and ethical dilemmas. First, at the pop-
ulation level, the purpose is to develop interventions
relevant to the population that will result in a general
improvement of health at the population level. Genetic
testing is done at the individual level and usually results
in individual decision making related to potential risk
for development of disease. For diseases such as cystic
fibrosis that are related to one gene, genetic testing can
help with early identification and treatment for those
born with the disease and may assist parents make
childbearing decisions prior to conception. However,
most diseases occur due to multiple factors and are
linked to more than one gene as well as numerous other
risk factors. Evidence on the benefit of genetic screen-
ing for most diseases is limited. In addition, genetic
testing can be costly.

A good example of the controversy over the benefits
of genetic testing is the issue of BRCA1 and BRCA2. These
human genes are referred to as tumor suppressors. Based
on recent research, it is apparent that mutation of these
genes is associated with hereditary breast and ovarian
cancers.12 The company that developed the screening test
for BRCA1 and BRACA2 initiated an advertising campaign
encouraging women to have the genetic screen. Though
the National Cancer Institute lists possible options for
managing cancer risk for those with a positive screen, it
acknowledges that the evidence concerning the effective-
ness of these strategies is limited. Testing can cost up to
$3,000 for those who do not know their family history.
The high cost raises the ethical question of taking a

universal approach to screening all women for this
genetic risk factor, especially as less than 10% of all breast
cancers are genetically related and the direct benefit of the
testing in reducing cancer rates is not known. Genomics
is a growing field with the potential benefit of better
understanding the role individual genetic makeup plays
in an individual’s health. However, as the BRCA1 and
BRCA2 screening example illustrates, the applicability of
genomics to population-level interventions from a prac-
tical and ethical standpoint has still not been determined.

Epidemiological Frameworks
There are several frameworks guiding the field of epi-
demiology such as the epidemiological triangle, the web
of causation, and the ecological model. The latter two
frameworks evolved from the epidemiological triangle
framework. Public health professionals continue to use
these and other frameworks to assist in a better under-
standing of health phenomena.

The Epidemiological Triangle
The classic model used in epidemiology to explain the
occurrence of disease is referred to as the epidemiological
triangle. There are three main components to the trian-
gle: agent, host, and environment (Fig. 3-3). In commu-
nicable diseases, the model helps the epidemiologist map
out the relationship between the agent or the organism
responsible for the disease and the host (person) as well
as the environmental factors that enhance or impede
transmission of the agent to the host.

Although this model is ideally suited for explaining
the transmission of an infectious agent to a human host,

C H A P T E R 3 n Epidemiology and Nursing Practice 59

Figure 3-3 Epidemiological triangle.

Environment

Agent Host

7711_Ch03_055-076 21/08/19 11:06 AM Page 59

it is now applied to noncommunicable diseases, such as
lung cancer, with a specific exposure, such as cigarette
smoke, representing the agent or causative factor. The
agent can be viewed as the causative factor contributing
to noninfectious health problems or conditions. The
agent may be biological (organism), chemical (liquids,
gases), nutritive (dietary components or lack of dietary
components), physical (mechanical force, atmospheric
such as an earthquake), or psychological (stress). The
host is the susceptible human or animal, whereas the
environment is all of the external factors that can influ-
ence the host’s vulnerability to the risk factors related to
the disease.

The value of this model lies in the fact that it helps in
the development of interventions. For example, in the
case of the H1N1 outbreak, epidemiologists first worked
at isolating the agent. Based on the type of agent, a
flu virus, it was clear that the environment needed for
transmission was both the breathing in of air droplets
that contained the virus and coming in contact with the
virus via a fomite, that is, an inanimate object such as a
water faucet. Based on this information, three prevention
interventions were instituted. The initial approach
focused on the environment. To reduce exposure of
people to the virus in the environment, all those with
signs and symptoms of H1N1 were asked to stay home
and to cough into their arms rather than their hands.
Uninfected individuals were also instructed to use hand
sanitizers. The second approach was aimed at protect-
ing the host (person) through the development and
distribution of the H1N1 vaccine. The use of a vaccine
reduced the susceptibility of hosts to the agent, which,
in turn, reduced further introduction of the virus into
the environment. In this example, no interventions were
aimed at the agent because no viable options were avail-
able to directly eradicate the agent.

The Epidemiological Constants of Person,
Place, and Time
In addition to the epidemiological triangle, there are three
constants that are the foundation for any epidemiological
investigation: person, place, and time (Fig. 3-4). The
person aspect typically includes demographic variables
including age, gender, and ethnicity. Place considerations
include such variables as city resident, office building user,
or downhill skier. Finally, the third constant, time, is a
critical dimension of consideration. Conditions in one lo-
cation with the same subset of individuals can change
substantially as a product of the passage of time. It is
important to keep in mind that this model is the founda-
tion upon which our understanding of illness and disease

are built and can help guide investigations into a health
issue in a population.

Who, What, When, Where, Why, How, and How
Long: To further understand the use of the epidemio-
logical triangle and the constants of person, place, and
time, seven questions have been used to conduct an
epidemiological investigation. These questions have most
often been used to examine the epidemiology of commu-
nicable diseases. The who question relates to the person,
the place question to where, the when and how long ques-
tions to time, the what to the causative agent, and the
why and how to the mechanism for acquiring disease,
such as the mode of transmission in communicable dis-
eases. These seven questions provide an effective model
by which illness can be analyzed at the population level in
order to develop interventions that will improve health
and/or prevent disease. This approach is an example of nat-
uralistic experimentation, a study that occurs in the natural
world and not in a controlled laboratory environment.

60 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Person

Place Time

Figure 3-4 Epidemiological constants.

n CULTURAL CONTEXT
Epidemiology is rooted in asking questions, collecting
and analyzing data, and making informed decisions to
influence policy or practice. Understanding the cultural
context of a given population is critical in all steps of the
process. Differences across ethnicity, geography, race,
nationality, or religion can potentially affect risk factors
or perceptions of health and risk. Are you asking the

7711_Ch03_055-076 21/08/19 11:06 AM Page 60

Causality
Although the seven questions help the investigator learn
about the occurrence of disease, that knowledge only
begins to provide a broader understanding of the mul-
tiple factors that could be related to the occurrence of
the disease. Epidemiologists investigate possible causes
of disease to better understand how to prevent and treat
disease. The term cause is traditionally used to indicate
that a stimulus or action results in an effect or outcome.
For example, if you turn on a light switch, the observed
effect is that the light bulb lights up. When it comes to
epidemiology, causality refers to determining whether
a cause-and-effect relationship exists between a risk
factor and a health effect. In health, causes can include
a number of things related to person, place, and time.
Using the light switch example again, it may be first
assumed that the singular cause for lighting the bulb is
the physical act of flipping the switch. In actuality, there
are other factors involved, including the presence of
a source of electrical energy, a working electrical con-
nection between the switch and the light, and a light
bulb that is not burned out.

As presented throughout this chapter, epidemiologi-
cal studies typically report measures of associations based
on population-based correlations; that is, an increase
or decrease in the amount of the risk factor and the fre-
quency of the risk factor are parallel to the increase or
decrease of the incidence of the health issue. It is always
important to keep in mind that correlation, the fact that
two variables are correlated with one another, does not
necessarily mean that one factor causes the other. For ex-
ample, heavy smokers often have a yellow stain on the

fingers that hold the cigarette. Although the presence of
yellow stains on the fingers may be correlated with lung
cancer, the yellow stain is not the cause of lung cancer.

To examine the possibility of causality, the first step
is to determine whether there is a statistical relationship
between the risk factor and the health issue. In other
words, can the association between the two be attributed
to chance alone—does the association between the
two occur at a frequency higher than what could be
attributed to chance? After determining that the relation-
ship does not occur by chance alone, the next step is to
determine whether the relationship is causal. In some
cases, the relationship between two variables is statisti-
cally significant, but the relationship is noncausal.
For example, in a group of schoolchildren, height may
be statistically correlated with grade level; that is, the
higher the grade level, the taller the children, but grade
level is not the causal factor for the increase in height.

A causal relationship is present when there is a direct
or indirect relationship between the two factors. If it
is a direct relationship, then the factor causes the disease.
For example, the mumps virus directly causes mumps.
A nondirect relationship exists when the factor con-
tributes to the development of the disease through its ef-
fect on other variables. Being overweight does not
directly cause disease, but it adversely affects the body,
thus increasing the risk of cardiovascular disease and
diabetes, for example.

Results from studies conducted in the field can be
limited because sources of error might be present. These
errors most likely relate to assumptions of causality. For
example, error can occur when deciding who was actu-
ally exposed to a potential risk factor and who was not.
There can be errors in how some important variable was
measured and errors relating to who received a vaccine
and who did not.

C H A P T E R 3 n Epidemiology and Nursing Practice 61

right questions to understand risk factors that might be
particular to the population? Are you using the correct
terminology so that the population of people under-
stands the question in the way that it is being asked?
One of the best ways to ensure that a survey or out-
break investigation is conducted in a way that respects
the cultural context is to involve people from the
population in creating and executing the research or
investigation. This can provide critical information for
access to key informants, asking appropriate and rele-
vant questions, and understanding the data within the
perspective of the population. Thus, although epidemio-
logic principles are broad and apply locally to globally,
it is important to always frame epidemiology questions
and investigations within the appropriate cultural
context.

l APPLYING PUBLIC HEALTH SCIENCE
Public Health Science Topics Covered:
• Applied Epidemiology
• Health Promotion

Smoking and tobacco use are considered by the
WHO to be among the biggest public health threats
because they kill up to half of the people who use to-
bacco.13 Smoking increases the risk for noncommunica-
ble diseases like cardiovascular disease or lung cancer
and also increases the risk for communicable diseases
like tuberculosis as described in the cellular to global
section of this chapter. However, smoking’s influence is

7711_Ch03_055-076 21/08/19 11:06 AM Page 61

62 U N I T I n Basis for Public Health Nursing Knowledge and Skills

not limited to people who use tobacco; it also affects
children, families, and communities through second-hand
smoke exposure. In addition, 80% of the 1.1 billion
smokers globally live in low- and middle-income coun-
tries where the burden of disease for tobacco-related
conditions and premature death is high.13

To think about how to understand the impact of
smoking within a specific population, an epidemiologist
can explore who is smoking within their community
and who might be exposed to smoke (person), where
the sources of smoke or tobacco exposure are within
a community (place), and how the population of smok-
ers has changed (time). This information is then used
to develop community-specific health improvement
initiatives that target those populations at greatest risk
for harm from smoking or tobacco use. The first
step in the investigation of any illness is to begin with
inquiry. Ask questions across the seven areas of who,
what, when, where, why, how, and how long.

Jane Paterson is a public health nurse employed by
the City Health Department of River City, a hypothetical
midwestern city with a population of 75,000 and a mix
of urban and suburban residents. One of the primary
objectives of Jane’s job is to develop community-based
health promotion and disease prevention initiatives tar-
geting smoking with a focus on youth. According to the
most recent U.S. Census data available, there are
3,000 urban and 7,000 suburban River City residents
aged birth to 18 years. Of the 3,000 urban residents in
this age group, 1,500 have used some form of tobacco
product. Of the 7,000 nonurban residents in this
age group, 1,000 have used some form of tobacco
product.

To understand the smoking data among youth in
River City, Jane considers the tools in her epidemio-
logic toolbox. She needs to ask questions to under-
stand who smokes, why they smoke, what risk factors
influence their decision to smoke, how youth are
obtaining cigarettes, how much they cost, and what
factors might influence their decision to quit. She also
needs to look at the data to explore what common
risk factors for smoking, such as poverty or parents
who are smokers, might be influencing the youth of
River City. She needs to understand who already
smokes and who is at risk for future smoking to de-
velop an evidence-based intervention that targets these
specific populations. The data from the U.S. Census
informed Jane that there was a higher percentage of
youth who smoked from the urban areas of River City,
but do these percentage differences suggest an actual

difference in the risk of smoking between urban and
nonurban youth? See Box 3-5 later in the chapter to
look at the calculation of odds ratio to explore the
difference in smokers from urban and nonurban
areas and an explanation of odds ratios further in
this chapter.

In addition, Jane needs to understand the risk fac-
tors within River City and what community factors
might influence youth smoking. Jane explored legisla-
tion regarding smoking and found that River City has a
low tax on cigarettes compared with other cities and
counties in the area. She also noted that the public
schools were not smoke-free zones and, although
restaurants were supposed to be smoke-free, there
was minimal enforcement of these regulations espe-
cially in places where older adolescents tended to
congregate. Thus, on a community level, risk factors
for smoking influenced the relatively low cost of
tobacco products and the limited bans on public
smoking.

Finally, Jane wanted to explore trends over time
to understand how smoking had changed over the
past 10 years in the community. Jane had previous
data from community assessments that documented
smoking in River City, and she found that there was
an overall decrease in the percentage of adults who
smoked, but that the smoking rates for youth remained
largely unchanged. Jane realized that, to develop a
more thorough understanding of youth smoking, she
needed a bit more data about smoking. So, she used
the CDC Web site and the Youth Risk Behavioral
Survey to understand the specific risk factors related
to youth smoking.14 She was also able to access infor-
mation from her state to compare the smoking rates
in River City to state levels.

Once Jane had looked at the data on smoking, she
reported to her supervisor at the Health Department
that she felt that a multiprong intervention was needed
to prevent smoking, to provide smoking cessation
incentive for youths that smoked, and to advocate
for policy-level interventions such as proposing an
increased tax on tobacco products and extending the
smoke-free zones in the community. She was able to
advocate for her programming because she had data
that demonstrated that River City had higher smoking
rates compared with other cities in her region and
fewer community-based interventions, such as smoke-
free schools and high tobacco taxes. Jane also pro-
posed conducting a survey of high school students
in the schools within River City, selecting some

7711_Ch03_055-076 21/08/19 11:06 AM Page 62

Web of Causation
One difficulty for Jane is determining which risk factors
for youth smoking are priority concerns for River
City. Multiple factors are correlated with smoking
among youth including environmental risk factors both
internal and external, parental smoking habits, gender,
race, poverty, and educational status of the youth
and their parents. Untangling the risk factors to deter-
mine what type of intervention should be developed is
a challenge. To help understand the multiple factors
that contribute to the development of disease, epidemi-
ologists use a framework called the web of causation.
This framework or model can be used to illustrate the
complexity of how illness, injury, and disease are deter-
mined by multiple causes and are at the same time af-
fected by a complex interaction of biological and
sociobehavioral determinants of health (Fig. 3-5).15,16,17

It helps health-care providers develop more compre-
hensive strategies to reduce disease- and injury-related
morbidity and mortality through primary and second-
ary prevention measures.

The term web is used because the model acknowledges
the complexity related to occurrence of disease.15 Simply
stated, the spider is the reason the fly is caught in the web.
What are the factors that converged, resulting in the
ill-fated fly being caught in the web? The fly selected
the path that led him to the web, he was ill equipped to
extract himself from the web once entangled, the spider
selected that specific location to construct his web, etc.
The list of predetermining factors is endless. The fact is,
for both the fly caught in the spider’s web as well as for
humans, there is frequently no one single cause for an
undesirable outcome but a convergence of circum-
stances, actions, inactions, and behaviors.

Ecological Model
The ecological model has been used in recent years to
design health promotion efforts and understand health
behavior. The terms health promotion and health behav-
ior have been used during the past 25 years to help
understand the interventions that can be done to help
maintain and improve health (health promotion), and the
behaviors that contribute either positively or negatively
to overall health (health behaviors). The ecological model
provides a formal theoretical foundation on which public
health nursing has established a professional identity and
knowledge base.

Ecological studies use groups, not individuals, as the
unit of analysis.18 Conclusions from ecological studies
should be considered with caution. The classic notion
of the stork bringing the baby to new parents is a con-
temporary manifestation of what one might suggest
could have been an ecological study, demonstrating
the ecological fallacy discussed later in this chapter.
Anchored in the pagan belief that storks brought babies
to expecting mothers, the arrival of storks in northern
Germany coincided with the storks’ spring and the
increase in the number of human births. The increased
birth rates in spring might have something to do with
the 9-month elapsed time between summer and normal
human gestation. Analyses of health-related behaviors
at the group level are carried out by epidemiologists,
providing the evidence by which practice-based health-
care providers can begin the development of interven-
tions using the ecological model approach. An effective
ecological model defines, understands, changes behav-
ior, and ultimately promotes population-level health
and wellness.

C H A P T E R 3 n Epidemiology and Nursing Practice 63

urban and some nonurban schools, to better understand
why students start smoking and what might motivate
them to quit to develop an effective school-based
intervention to reduce youth smoking. Jane used her
epidemiology skills to understand the existing data and
how that might inform smoking reduction efforts but
also to help her understand gaps in the data so that she
could plan the next steps for developing an effective,
tailored public health intervention.

Endocarditis

Bacteria
(External

Environment)

Bacteria
Reservoir
(Human)

Hereditary
(Genetics)

Bacteremia
(Human)

Antibiotic
Prophylaxis

Cardiac
Abnormalities

Oral/Dental

Figure 3-5 Web of causation and endocarditis.

7711_Ch03_055-076 21/08/19 11:06 AM Page 63

Tools of Epidemiology: Demography
and Biostatistics
The science of epidemiology requires the use of particu-
lar tools to help epidemiologists study health and
wellness as well as determine which interventions will
help improve the health of populations. Among these
tools are demography and biostatistics. Understanding
how to apply demography and biostatistics helps nurses
in all settings to provide better care and promote the
health of the populations they serve.

Demography
Demography is the population-level study of person-
related variables or factors. The field of demography
has been around since the early 20th century. Warren
Thompson, an early pioneer, developed the demographic
transition model used today to explain the shift from
high birth and death rates to low birth and death rates
within populations.19 Warren Thompson is to the field
of demography as Florence Nightingale is to nursing and
John Snow is to epidemiology. Establishing methods for
tracking populations over time adds to the methods of
tracking disease established by John Snow. Public health
and health-related disciplines use demography and asso-
ciated methods to better understand population-level
patterns related to health phenomena.

Typically, person-related variables are compared over
two or more time periods to establish trends within
the population of interest. Comparing demographic
data from time 1 to time 2 is fundamental to the promo-
tion and establishment of relevant prohealth environ-
ments, policies, and behaviors across time. For example,
comparing the percentage of the population below the
poverty level in a particular community from 2010 to
2020 can help identify changes in the population that
may affect access to health care. Another example is to
put together a visual depiction of demographic data
using the demographic transition model (Fig. 3-6). This
model refers to population change over time, especially
in relation to birth and death rates.

One measure of the health of populations used to
compare populations from a global perspective is life ex-
pectancy. Life expectancy is the average number of years
a person born in a given country would live if mortality
rates at each age were to remain constant in the future.20

Based on 2015 estimates worldwide, there is a wide
range among countries in relation to the average life ex-
pectancy at birth (50.1 years in Sierra Leone to 83.7 years
in Japan).20 One of the reasons for lower life expectancy

in low- and middle-income countries is that they expe-
rience more difficulty with control and eradication
of communicable diseases and the illnesses associated
with maternal, child, and women’s health. Also, many of
these countries lack the health benefits of more stable
economies with advanced industrial and technological
developments. The study of trends across time results in
interventions including policy reform, re-engineering,
educational initiatives, and enforcement of standards
and laws to assure the health of the public. Public health
is a dynamic interdisciplinary field associated with other
fields such as political science, sociology, criminology,
and psychology. Ultimately, the sociobehavioral determi-
nants of health contributing to the health of individuals
are affected substantially by subsystems such as political,
social, and environmental factors.21

Obtaining Population Data
A challenge for public health professionals is obtaining
current and accurate population data. There are various
sources of data from the local to the international level.
Data are obtained initially through various routes
including surveys, mandatory health data reports, inde-
pendent research, and hospital data, to name a few.
Some of the data are available on the Internet, whereas
other data are protected and special permission is
needed to obtain them.

Census Data: Census data are extremely useful
sources of demographic data. These public domain data
are available on the official U.S. Census Bureau Web site
(see Web Resources on DavisPlus) as well as in multiple
formats upon special request. It is advised that public
health researchers, health promotion planners, and other

64 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Figure 3-6 Demographic transition.

1 2

Time

Total Population

Birth Rate

Death Rate

3 54

B
ir

th
s/

D
ea

th
s

pe
r

1,
00

0

7711_Ch03_055-076 21/08/19 11:06 AM Page 64

professionals charged with developing and implement-
ing health promotion and disease prevention initiatives
access and review local, regional, and state-level
data provided in the U.S. Census. Accessing U.S. Census
data related to a population located in a specific geo-
graphical area is a very effective starting point when
seeking to quantify a health-related phenomenon.
Demographic variables include gender, race, housing,
economic level, age, and other relevant data. However,
census data reflect populations within a specific geo-
graphical area. The census data are available from
the national level down to the neighborhood or census
block level and are useful if the population of interest is
defined based on a geographical community. The data
can be viewed based on ZIP code, town, county, or state.
Accessing the Web site provides a mechanism for
exploring a town or county to determine what the pop-
ulation is, how many housing units are rented or owned,
and how many people living in the town or county have
an income below the poverty level.

Community Data: More typically, public health pro-
fessionals are asked to address community-level health
issues. Community data are valuable resources with both
strengths and limitations. Before addressing sources of
community data, it would be useful to review the discus-
sion of community in Chapter 1. Which of the following
is representative of a community—residents in Portland,
Oregon, diabetics in the tri-state area, women above age
65 years, or gay men in Houston, Texas? An answer of
“all of the above” would be correct. Community data are
not limited to simply a geographical location but can
take on additional characteristics such as disease status
(diabetes), sexual orientation (gay, lesbian, bisexual), and
demographics (race, ethnicity, and age). Examples of
typical opportunities for public health nurses and other
health-related professionals to use community data
include hospital-based initiatives, health plan initiatives,
nonprofit agency initiatives, special interest groups, and
local/state/federal initiatives.

One example of community data relating to the health
of residents in cities, states, and territories is the Behav-
ioral Risk Factor Surveillance Study (BRFSS) found at the
CDC Behavioral Risk Factor Surveillance System Fre-
quently Asked Questions section of its Web site. Disease-
specific data and health-planning and education resource
materials can be found at the American Diabetes Asso-
ciation Web site as well as at local area health-care agen-
cies (see Web Resources on DavisPlus). As previously
mentioned, if the community is a geographical commu-
nity, the U.S. Census data can be used to focus on demo-
graphic information such as the number of women older

than age 65 years. More challenging might be tapping
community-level data on variables such as sexual orien-
tation. Challenges in estimating these variables (e.g.,
number of gay men living in Houston, Texas) are diffi-
cult to overcome as there is a lack of accurate and reliable
data sources. Data relating to these more complex vari-
ables can be, and often are, generated through original
data collection at the community level.

The Nurses’ Health Study, now more than 30 years
old, is of special interest to nursing professionals.
Information on this study can be found on a Harvard
University Web site (see Web Resources on DavisPlus).
This study provides community-level data that have been
generalized to women’s health in the general population.
By seeking to better understand community-level data,
such as women’s health, a more complete understanding
of the factors influencing health and appropriate proac-
tive measures toward the improvement of women’s
health can be successfully achieved. Community data can
relate to person, place, and time variables and a myriad
of interactions between these three broad categories.
Responsible investigators should always take a critical
look at the sources of data and remain cognizant that
errors likely exist within any data to be used in the
development of community health programming. Poten-
tial sources of error should not halt efforts to promote the
health of the public but should be carefully considered
and reported openly.

Biostatistics
Biostatistics reflects the analysis of data related to
human organisms and is used in public health science
and other biological sciences. It examines variations
among biological organisms (people, mice, cells). Thus,
it is a core part of public health science.

Mean, Median, and Mode
Demographers use descriptive statistics as well as ad-
vanced inferential statistical methods to describe the size,
structure, and distribution patterns of populations and
subpopulations within geographically defined regions.
These measures include the computation of the mean,
median, mode, quartiles, and interquartile ranges. De-
mographers also compute the percent change in popu-
lations over time as well as estimate population counts
for the future. These come under the umbrella of descrip-
tive data analysis.

Most epidemiologists regard descriptive data analysis
as the initial step in analysis of demographic data. How-
ever, the analysis of data at the descriptive or inferential
level of analysis is only as good as the accuracy of the data

C H A P T E R 3 n Epidemiology and Nursing Practice 65

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being used. Though the accuracy of data and the methods
by which data are gathered go beyond the scope of this
text, public health scientists should ensure that they de-
velop thoughtful and evidenced-based original data col-
lection protocols and review published science carefully
to evaluate whether data were collected in an accurate
and meaningful way.

Determining the mean, the median, and the mode
uses basic math skills. All three are measures of central
tendency. The mean is what is commonly considered the
average, as it is the mathematical average of a set of num-
bers. The mean is calculated by summing the total of all
values and dividing by the total number of values in the
set. The median is the middle value in a set of values. For
example, if you have 20 individual patient blood pres-
sures, the 10th occurrence in an ordered set from lowest
to highest is the median. The mode is the value that oc-
curs more times within a data set than any other occur-
rence. To help you understand these basic concepts,
complete the question in Box 3-1.

Percent Change
It is useful to have a time 1 and a time 2 measurement to
determine a percent change related to a demographic
variable or health statistic. The time 1 measure is often
referred to as the baseline and can be used to establish
the proportion or percentage of illness or disease within
the population. This is often used to evaluate changes in
a population over time and is calculated by taking the
new number (B) and subtracting the original number
(A) then dividing the resulting number by the original
number A (Box 3-2). This information is quite valuable
when completing community assessments (see Chapter 4),
because it explains shifts in population that may have an
impact on the health of the community or the type of
interventions needed. For example, if there has been a
positive 20% change in the population who are over the
age of 85, then the community may have increased health
needs related to aging, but if the opposite has occurred,
a 20% decrease in those over the age of 85 and a 20% in-
crease in those aged 1 to 5 years, there may be less need
for interventions aimed at the very old and more inter-
ventions needed to support infant health.

Rates
To help in understanding the distribution of disease in a
population, epidemiologists calculate rates. In under-
standing the magnitude of a health-related phenomenon,
epidemiologists need both a numerator and a denomi-
nator. What does this statement mean? Imagine that a
health educator in Columbus, Ohio reports that there

66 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Methods Review
Mean, Median, Mode, Quartiles, and Interquartile Range
Twenty students have been admitted to the dual degree
MSN/MPH degree program. You have been asked by the
Dean of the College to report the average age of these
students.

Data Set [Not real persons]:
Name Gender Age in Years
1. Angela Jones F 23
2. Bill Baker M 32
3. Connie Clark F 22
4. Dennis Daniels M 24
5. Emily Edwards F 56
6. Frank Fitzgerald M 23
7. Georgia Grant F 24
8. Herald Hall M 22
9. Ingrid Israel F 22

10. James Jennings M 24
11. Kelly Karr F 22
12. Lawrence Lee M 35
13. Melissa Martin F 22
14. Nelson Newman M 21
15. Olivia Owen F 22
16. Paul Pierce M 31
17. Quinn Queen F 27
18. Robert Reynolds M 23
19. Sarah Salzman F 22
20. Timothy Tucker M 22
Q1: The mean, median, and mode are all measures of

central tendency—averages. You should report all
three.
A: Mean = 25.96
A: Median = 23
A: Mode = 22

BOX 3–1 n Calculating Population Mean, Median,
and Mode

Formula
(Time B–Time A)/Time A × 100 = percent change

Population 2010 2020 Percent
City A Time A Time B change
Hispanic 1,512 1,955 29.3%
85 years of age 215 92 –57.2%

or older

BOX 3–2 n Calculating Percent Change [Not from
an actual data set]

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are 12,500 smokers in his city and a health educator in
Columbus, Indiana reports that there are 11,800 smok-
ers in his city. Based on these two estimates, it is fair to
say that smoking is a greater problem in Columbus,
Ohio, than it is in Columbus, Indiana, correct? It is clear
that there are 700 more smokers in the Ohio city than
there are in the Indiana city. However, the denominator
is missing in this equation. By going to the U.S. Census
Bureau and learning what the city population estimate
was, we can effectively establish a denominator. It is
always advisable to use the same source if possible so that
comparable population estimates and associated collec-
tion methods are assured in establishing estimates. If the
estimated population for Columbus, Ohio is 730,657 and
for Columbus, Indiana, it is 39,059, then it is possible to
calculate the percentage. Now the facts are that 1.7% of
the population in Columbus, Ohio, smokes compared
with 30.2% in Columbus, Indiana!

Using these data from the two towns, we just calcu-
lated the rate of smoking in each population. To further
illustrate how a rate is determined, consider being the
health commissioner of Petersburg, Oregon, with a
population 5,000. Of the total population, 1,250 people
report that they are current cigarette smokers. The health
department receives a weekly report on the number of
influenza cases reported in the city in the month of
January (Table 3-1). One should assume that these data
are accurate and that no reporting error exists.

Given the data in Table 3-1 and the information on
how many people live in the city, we can construct pop-
ulation rates of influenza cases across the two classifica-
tions of smoker and nonsmoker. First, using the data in
the table, calculate the rate of influenza in smokers
during week 1. To do this, divide 50 by 1,250, which
illustrates a rate of 4%, or 4 in every 100 smokers came
down with the flu in week 1. In comparison, less than
1% of nonsmokers came down with the flu in week 1

(1 in 100). If one considers the total population percent-
ages by week, there was a spike in cases during the third
week of January. However, by breaking the data out by
smoking status, it is clear that there are variations in the
monthly pattern across the two groups. Therefore, a rate
represents the proportion of a disease or other health-
related event, such as mortality, within a population at a
certain point in time. It is the basic measure of disease
used by epidemiologists and other health professionals
to describe the risk of disease in a certain population over
a certain period of time.

How to Calculate: Calculating rates is a relatively
simple mathematical procedure, if one can secure an
accurate estimate of disease or illness in the population
to use as the numerator and an accurate total population
estimate to serve as the denominator (Box 3-3). Again,
using the data in Table 3-1, focus on the first cell
corresponding to week 1: smokers with influenza. The
numerator is 50 (week 1 influenza cases) and the denom-
inator is 1,250 (smokers residing in Petersburg, Oregon).
The number 100 represents a constant, in this case per
100 smokers. The constant could be 1,000 or 10,000 de-
pending on the frequency of the disease in the popula-
tion. This approach allows for the presentation of rates
based on various constants. One may express a rate in
terms of 1,000 or 10,000 rather than 100 if the number
of cases is small. For example, infant mortality rate is
expressed as the number of infant deaths for infants less
than age 1 year per 1,000 live births.

Types of Rates: Mortality and morbidity are two
commonly used rates in epidemiology as well as within
the health-care professions. Mortality refers to the num-
ber of deaths within a given population. To calculate
the mortality rate, take the number of deaths within a
specified time-period and divide it by the total number
of individuals within the same population during the
same time period. A commonly used mortality rate is the

C H A P T E R 3 n Epidemiology and Nursing Practice 67

TABLE 3–1 n Fabricated Data—Influenza in Anytown, USA

Week Influenza Smoker Influenza Nonsmoker Total Influenza

Number of New Cases Number of New Cases Number of New Cases

1 50 (4.0%) 20 (0.5%) 70 (1.4%)

2 40 (3.2%) 25 (6.8%) 65 (1.3%)

3 80 (6.4%) 50 (1.35%) 130 (2.6%)

4 700 (56.0%) 100 (2.7%) 800 (16.0%)

1,250 (Smokers) 3,700 (Nonsmokers) 5,000 (Total Population)

7711_Ch03_055-076 21/08/19 11:06 AM Page 67

infant mortality rate, as this measure is considered an
effective metric by which to gauge the health-care “sys-
tems” of a nation. To calculate the infant mortality rate,
take the number of infant deaths among those ages birth
to 365 days and divide by the total number of live births
during the same 365-day period. To establish a rate,
include a multiplier that represents the previously men-
tioned constant (e.g., × 1,000). Morbidity refers to the
number or proportion of individuals experiencing a
similar disability, illness, or disease. Examples of condi-
tions and diseases reported using morbidity are the num-
ber of infants within a county with pertussis (“whooping”
cough), the number of new mothers delivering at
St. Ann’s in 2020 experiencing postpartum depression,
the number of returning service men and women expe-
riencing post-traumatic stress disorder (PTSD), and
the number of adults in the United States living with
diabetes. Note that the challenge in reporting these con-
ditions as rates is in accurately establishing the denomi-
nator or the total number of individuals at risk for the
condition in question.

Attack rates are calculated by placing the number of
ill or diseased people in the numerator and dividing by
the total number of ill plus well people (in the susceptible
population) in the population of interest, then multiplying
by a given multiplier (e.g., 100,000). The secondary attack
rate can be calculated by taking the number of new cases
of a disease or illness among the contacts of the initial
(primary) cases, dividing by the number of people in the
population at risk, then multiplying by a given multiplier
(e.g., 100,000).

Prevalence, Incidence: Prevalence and incidence
rates are used by epidemiologists to demonstrate the
burden of disease or illness within the population of
interest. However, these practitioners must carefully
consider when and how to report these rates, as they can

be misleading. What is the difference between preva-
lence and incidence? Incidence can be best understood
as the number of new cases of a disease or illness at a
specific time or period of time. Prevalence is the total
number of accumulated cases of a disease or illness both
new and pre-existing at a given time.

Imagine that you are a public health official and that
you have been serving the people of New York City
for the past 25 years. In 1994, the total number of newly
diagnosed cases of HIV was 2,500 and the total number
of existing or prevalent cases in 1994 was 5,000. In 2014,
20 years later, the number of newly diagnosed cases of
HIV is 1,000 and the total number of existing or preva-
lent cases is 50,000. The change in annualized new HIV
cases went from 2,500 to 1,000 and the prevalence went
from 5,000 to 50,000 over the 15-year period. This
20-year change shows a decrease in new cases, whereas
the prevalence rate comparing the difference across
the 20-year period is a 10-fold increase. Given these data,
would it be fair for a reporter from the New York Times
to feature a headline of “HIV in New York City Drasti-
cally Increases 10-fold Since the Mid-1990s!” or “HIV in
NYC Decreases After 20 Years of Prevention Educa-
tion”? Both headlines are accurate, yet neither is a fair
nor accurate account of the state of HIV in the city.

A prevalence rate is basically the number of existing
cases (numerator) divided by the total number of persons
in the population (denominator). The rate calculated
using the information in Table 3-1 can be understood as
a point prevalence or the number of ill people divided by
the total number of people in the population “group” at
a specific point in time. An associated measure, referred
to as the period prevalence, is calculated as the number
of ill people divided by the estimate of the average num-
ber in the population during a specified time period. An
application of period prevalence might be the number of
people living with a chronic disease within a given pop-
ulation during a specified time, such as a year. Asthma is
a chronic disease that might be effectively presented
using a period prevalence.

In addition to prevalence, there are other rates
reported by epidemiologists that are important to under-
stand and use appropriately (Table 3-2). They are inci-
dence rate, attack rate, and secondary attack rate. An
incidence rate can be calculated by placing the number of
new cases diagnosed in a given period of time divided by
the total number at risk in the population over that same
time period and multiplying by a given multiplier (e.g.,
100,000). For example, the incidence of H1N1 in a school
during a specified period of time would be the number of
new cases of H1N1 divided by the denominator, those

68 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Using the data in Table 3-1, focus on the first cell corre-
sponding to week 1—smokers with influenza.

The rate of influenza was calculated using the follow-
ing formula:

(Number of cases [numerator] ÷ population
[denominator]) × a constant = rate per 100; 1,000;

10,000; or 100,000.

For this case:

(50 ÷ 1,250) × 100 = 4.0%

BOX 3–3 n Calculating Rates

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children in the school who had not had H1N1 in the
past. Those children who had had H1N1 would be re-
moved from the denominator to indicate those children
at risk.

A good way to examine the difference between the in-
cidence and prevalence rate is the prevalence pot (Fig. 3-7),
defined in Chapter 2. The prevalence pot represents all
the current cases of a disease in a population. Entering
into the pot are the new cases reflected by the incidence
rate. Exit from the prevalence pot occurs by one of three
events: death, cure, or disability. For some diseases such
as HIV/AIDS the only way a case leaves the prevalence
pot is through death. For other diseases such as polio, all
three options occur. The size of the prevalence pot de-
pends both on the incidence rate and on the duration of
the disease. Over time the prevalence pot for HIV/AIDS
in the United States has grown not because of dramatic
increases in the incidence of HIV/AIDS but because of
the pharmaceutical interventions that have extended
life expectancy. For other serious health threats such as
the 2017-2018 H3N3 virus, the prevalence pot grew
rapidly with the increase in incidence but dropped
rapidly once incidence rates dropped because of the
short duration of the disease.

The incidence and prevalence rates are affected by fac-
tors such as the number of people being screened for the
disease and the number of people surviving with a posi-
tive HIV status. During the early 1980s and into the
1990s, few people survived a positive diagnosis for more
than a few years. Thus, the absence of effective medical
treatment options would have resulted in higher death
rates and subsequently lower prevalence rates. As screen-
ing tests became more widely available and stigmatizing
labels began to be reduced, more people became willing
to be screened for HIV. What is missing from the pres-
entation is the number of people tested who were not
positive for HIV. The lesson to be learned is that data

reporting does not necessarily result in effective interpre-
tation. Careful, cautious, and intentional epidemiological
data reporting is a critical task of the public health infor-
mation officer.

Comparing Dependent and Independent Rates:
Data in Table 3-1 provide a useful illustration of inde-
pendent and dependent rates. The weekly influenza rates
independent of smoking status for the month of January
are 15.0, 12.5, 26.0, and 16.0 per 100 persons, respectively.
Simply stated, these weekly rates are independent of the
smoking status of the individuals within the population.
The converse is true for dependent rates where the rates
of influenza by smoking status by week range from
approximately 40% to 32%, spiking to 64%, and finally
dropping to 56%. The week 3 spike pattern is also
reflected in the nonsmoking population. However, the
proportion of nonsmokers with influenza is consistently
25% to 50% lower than that estimated for smokers. There-
fore, a public health official might accurately state that

C H A P T E R 3 n Epidemiology and Nursing Practice 69

Figure 3-7 Prevalence pot.

Death

Leaving the pot

New Cases
People newly

diagnosed

The
Prevalence Pot:

Total Current
Cases

All people with
the disease

Entering the pot

Disability

Cure

TABLE 3–2 n Differentiating Rates

Measure

Point prevalence

Incidence rate

Attack rate

Secondary attack rate

Multiplier

e.g., 100,000

e.g., 100,000

e.g., 1,000

e.g., 1,000

Numerator

Number ill

Number of new cases over
specified time

Number of new cases during
an epidemic period

Number of new cases among
contacts of known cases

Denominator

Population at risk at specific
point in time

Total number at risk during
time period

Total number in population
at start of epidemic period

Total number of population
at risk

7711_Ch03_055-076 21/08/19 11:06 AM Page 69

influenza rates (independent of smoking) for Petersburg,
Oregon, for January ranged between 12.5% and 26%. In
addition, dependent rates adjusted for smoking status for
the city and time-period demonstrated a substantially
greater proportion of influenza among smokers.

The terms independent rates and dependent rates
are also used to describe rates that are independent or
not independent of each other. For example, if you
were concerned with the infant mortality rate in city Y
compared with the infant mortality rate in city X, the
two rates would be independent of each other. By con-
trast, if you wanted to compare the rates between city
Y in state X and the rate in state X, the rates are
dependent; that is, all of the cases in city Y are included
in the count of cases in state X because the city is in
state X.

Descriptive and Analytical Epidemiology
Now that we have examined the basic demographics of
the population of interest, what else can be done to learn
about the specific health issue? There are three broad
categories of epidemiological studies that help to answer
questions about the health of populations: descriptive,
analytical, and experimental studies. The majority of
epidemiological investigations, particularly community-
based public health investigations, are defined as either
descriptive or analytical. In descriptive or observational
case control and cohort studies, the investigator has
no control over the exposure or nonexposure status of
subjects. By contrast, experimental epidemiology con-
sists of the research methodology whereby the investiga-
tor has direct control over the subject’s assignment to
exposure status. Clinical trials fall into the latter classifi-
cation. Experimental studies tend to fall under the
authority of clinical research scientists and are housed in
academic research centers, federal agencies, or private
research and development agencies, such as pharmaceu-
tical companies.

Descriptive Epidemiology
Descriptive epidemiology refers to the analysis of
population and health data that are already available. It
includes the calculation of rates (e.g., mortality) and an
examination of how they vary according to demographic
variables (e.g., gender, race, socioeconomic status).22

Similar to demography, descriptive epidemiology pro-
vides an understanding of the general features of
the population of interest. In contrast to demography,
the epidemiologist shifts from a broad population demo-
graphic representation to one that illustrates aspects

of health, wellness, and/or disease considerations within
the population.

Analytical Epidemiology
Analytical epidemiology involves examining health-
related data to determine the association between risk
factors and the occurrence of a health phenomenon. In
descriptive epidemiology, the epidemiologist can use the
findings to formulate a hypothesis about possible causes
for the health phenomenon. In analytical epidemiology,
the purpose is to test the hypothesis. There are three
basic types of studies that use analytical epidemiology
methods: the case-control study, the cohort study, and
the clinical trial. The study may use a cross-sectional
design that reports health-related information for a spe-
cific point in time. Or the study may use a prospective,
retrospective, or longitudinal design related to data
collected in more than one time period.

Cross-Sectional Studies
Cross-sectional studies or surveys examine risk factors
and disease using data collected at the same point in
time. It is easy to remember that a cross-sectional study
provides an estimate of the disease status or frequency
at one point in time; thus, it is truly a cross section of
the disease or illness within the population of interest
at a given moment in time. It is also called a prevalence
study. For example, numerous health surveys are
conducted by the National Center for Health Statistics
as a means of determining the prevalence of disease at
a given point in time. They are relatively easy to admin-
ister, and the data can be collected in a rather short pe-
riod of time. However, because they are cross-sectional,
they do not provide a temporal, or time-related, se-
quence of events. For example, if nurse Jane in River
City wanted to determine specific risk factors for smok-
ing among adolescents, she might conduct a survey of
the students through the school system to ask about
specific smoking habits and risk factors. Jane might
also ask whether any of the students’ parents smoked.
However, because Jane collected data at one point in
time, she cannot with confidence assert that parental
smoking preceded smoking initiation by the student.
However, the data can provide valuable information on
which risk factors might be related to smoking among
the youth in River City.

The cross-sectional design methods are not limited to
the study of disease or even illness factors. For example,
this research design methodology can be used to evaluate
satisfaction with health-care–related services within a
community.

70 U N I T I n Basis for Public Health Nursing Knowledge and Skills

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Case-Control Studies and Odds Ratio
The case-control study design allows the epidemiologist
to compare the ratio of disease in those exposed to a risk
factor with those who were not exposed to the same risk
factor. Using the case-control method, the epidemiolo-
gist has a specified number of people with a disease or
illness. These individuals who are defined as diseased
or ill are the “cases.” The epidemiologist then must seek
to establish a representative group of people without the
disease or illness as the controls. Then both the cases and
controls are measured related to a specific exposure or
multiple exposures.

A standard two-by-two table is used to divide
individual-level or person-specific data into disease
status (yes/no) and exposure status (yes/no). The odds
ratio (OR) is defined as the odds of having a disease or
condition among the exposed in comparison with the
odds of those who were not exposed. The calculation of
the OR is a relatively simple mathematical procedure.
The OR is mathematically expressed as [OR = AD/BC]
(Box 3-4). The epidemiologist then determines whether
the OR for those with the disease who have experienced
exposure is significantly greater than the controls by
calculating confidence intervals and p-values for each OR
point estimate. This calculation goes beyond the intro-
ductory nature of this text. Intermediate and advanced
epidemiology textbooks can and should be consulted to
gain depth of understanding of these calculations.

Take, for example, individuals with oral cancer of the
gums. The researcher hypothesizes that people who use
or have a history of using smokeless tobacco (chewing
tobacco) are at greater risk of developing oral cancer. The
researcher now needs a group of individuals to serve as
the controls. To construct the two-by-two table and
establish the risk of oral cancer from chewing tobacco,
she needs a group of individuals who have not been ex-
posed to chewing tobacco. The cases are the individuals
with oral cancer who are asked to report on exposure
variable and use of chewing tobacco. The challenge is to
find a fair representative group that fits into the control
or “no disease” category. Often studies of this nature are
conducted using controls at the same health-care facility

with a different disease or illness. In this scenario, skin
cancer patients will be used as controls. The biological
plausibility of developing skin cancer as a result of
using chewing tobacco is unlikely but could indeed be a
confounder. A confounder is a studied variable that can cause
the disease that is also associated with the exposure of
interest. Confounders can make it difficult to establish a
clear causal link unless adjustments are made for their
effects. Confounders are potential limitations in all epidemi-
ological studies; methods of controlling for confounders are
addressed in advanced epidemiological textbooks.

Case-control studies have limitations. There can be
effects from multiple determinants of health, the com-
plexity of additive, and/or interactive exposures on
health. There are also potential problems related to the
representativeness of the cases and the controls, that is,
how well they reflect the target population. Another issue
is accurately determining exposure. Case-control studies
are done retrospectively; that is, disease has already
occurred in the cases. For both cases and controls, deter-
mining whether individuals have been exposed requires
obtaining a history from the individuals rather than
through direct observation of the exposure. See Box 3-5
for a case-control study of the smoking among youth in
River City.

Cohort Studies and Relative Risk
Cohort studies are studies that follow a specific popula-
tion, subset of the population, or group of people over a
specified period of time. Cohort studies can be effective
in generating a wealth of data relating to the population

C H A P T E R 3 n Epidemiology and Nursing Practice 71

Disease Disease
Status (Yes) Status (No)

Exposure status (Yes) A B
Exposure status (No) C D

BOX 3–4 n Calculating Odds Ratio

Set up a two-by-two table for children aged birth to
18 years with residency (urban/nonurban) on one axis
and smoking status (yes/no) on the other axis.

Answer:
Smoker Smoker
(Yes) (No) Totals

Urban 1,500 1,500 3,000
Non-urban 1,000 6,000 7,000
Totals 2,500 7,500 10,000

Calculate the appropriate measure of association.
HINT: Either relative risk or odds ratio.

Answer: Odds ratio — AD ÷ BC = 1,500 × 6,000 ÷
1,500 × 1,000 — [OR = 6.0] Interpretation: River City
youth between the ages of birth to 18 years living in
the urban district have six times the risk of smoking as
compared with nonurban youth.

BOX 3–5 n Case-Control Study for River City

7711_Ch03_055-076 21/08/19 11:06 AM Page 71

of interest. The epidemiologist has substantial control
over the data collection process; therefore, cohort studies
have strong validity. This validity comes with high costs
that include actual direct costs in personnel as well as
costs in time from data collection to the generation of
findings and conclusions. Two types of cohort studies are
found in application:

• Prospective
• Retrospective (also called historical)

Two Web links are provided in the following section.
The first directs you to the Fels Longitudinal Study
established in 1929, the longest-running continuous
human life span and development study in the world.
This longitudinal study is housed at the Wright State
University Boonshoft School of Medicine in Dayton,
Ohio, and can be accessed at https://medicine.wright.
edu/epidemiology-and-biostatistics/fels-longitudinal-
study-collection. The second is to the Framingham study,
a commonly referenced cardiovascular health study
established in 1948. Both studies are longitudinal and
provide useful data to researchers on human populations
over time. Information on the Framingham study can be
accessed at http://www.framinghamheartstudy.org.23

The relative risk is the measure of association used for
cohort studies. Relative risk is determined by comparing
the incidence rate in the exposed group with the inci-
dence rate in the non-exposed group. This measure is
calculated by dividing the number of people in the
yes/yes (cell A) divided by the row total (cells A+B)
divided by the number of people in the yes/no (cell C)
divided by that row total (cells C+D) (Box 3-6).

For example, if we were interested in exploring the
risks of using oral birth control pills and stroke (these are
fabricated data), we could follow 500 women from age
18 to 25 during a specific time period. We would divide
these women into two groups: those taking an oral birth
control pill (250) and those using alternative birth con-
trol or none (250). We find that after following these
500 women during the 32-year study, among those who
were taking the pill, 100 suffered a stroke and 150 had no
stroke, whereas among those not taking the pill, 24 had

a stroke and 225 had no stroke. How would the relative
risk be calculated?

Confounder WARNING
Of the 100 women taking oral contraception, 90 were
cigarette smokers. What additional information is needed
to establish a confounder effect based on tobacco use? As
explained earlier, a confounder is another variable that
may actually account in whole or in part for the relation-
ship between the observed variable (taking the pill) and
the outcome (stroke).

Most cohort studies use a prospective longitudinal
approach that requires following a group over a long
period of time, which can be 30 years or more. An exam-
ple is the Nurses’ Health Study that began in 1976.
The purpose of the study was to examine the long-term
effects of oral contraceptives.24 The researchers have
added to this important study with the Nurses’ Health
Study II in 1989 and the Nurses’ Health Study III in 2008.
Data are collected from participants every 2 years with a
sustained 90% response rate. Clearly, this type of design
is limited in application because waiting more than
30 years to establish conclusive results can be problem-
atic. In addition, the notion of confounders, or factors
affecting the outcome other than the factor of interest, is
a limitation. Despite these challenges, data from large co-
hort studies have contributed greatly to our understand-
ing of risk factors related to disease. The Framingham
heart study is still ongoing today, spanning three gener-
ations.23 Prior to the study, the common belief was that
cardiovascular disease was part of the aging process. The
information obtained in the study changed the approach
to the prevention and treatment of cardiovascular disease
and continues to contribute to our understanding of
cardiovascular disease today.

There are times when a cohort study is done retro-
spectively. Imagine a situation in which 500 women
today are asked to report on their past 32 years of history.
Specifically, data are collected on all 500 women relating
to oral contraception usage and stroke. Note: In this ret-
rospective study design, you can add a variable such as
cigarette smoking. This design methodology provides the
researcher with the opportunity to report findings in the
present relating to the variables of interest. Recall is often
a problem with any study design that seeks to collect data
from the subjects based on their recall regardless of the
recall period. Often an individual can’t remember what
he or she ate for breakfast a week ago, or what his or her
last fasting blood sugar was. Imagine how much error
might be present in collecting health behavior data from
the general population. Sources of error in this design

72 U N I T I n Basis for Public Health Nursing Knowledge and Skills

HINT: (A ÷ [A + B]) ÷ (C ÷ [C + D])

Stroke No Stroke Total
Oral pill 100 150 250
No oral pill 25 225 250

BOX 3–6 n Calculating Relative Risk

7711_Ch03_055-076 21/08/19 11:06 AM Page 72

also include subject attrition or discontinued participa-
tion, a concern known as right censoring, which is beyond
the scope of this introductory text; confounding; and
other issues related to following a large cohort over a
long period of time.

Clinical Trials and Causality
Clinical trials represent a special type of epidemiological
investigation and the related research methods are a spe-
cial subset. Clinical trials vary widely in their method, but
generally have a control and an experimental group, and
require random assignment to one of these groups. The
control group is not exposed to a treatment, medication,
or therapy, whereas the experimental group is exposed
to the treatment or intervention of interest. The two
groups are then compared to evaluate whether there are
statistically significant differences in outcomes between
the two groups. Clinical trials are more likely to result
in findings that lend themselves to causal statements
of relationships. Cohort and case-control studies can
demonstrate an association between two variables, but a
clinical trial gets much closer to establishing causality.
That said, causality is always a challenging goal to attain
and causal assumptions within clinical research trials
should be carefully considered.

Outbreak Investigations
Outbreak investigation is fundamental to field epidemi-
ology and pivotal to the role of epidemiologists, public
health nurses, and public health workers. As previously
confirmed, epidemiology is truly an applied science. Epi-
demiologists use quantitative data analysis methods at
the population level to better understand health-related
circumstances within communities. The unit of analysis
is groups of people, not the individual. It is critical to
remain cognizant of the risk of committing an ecological
fallacy. The fallacy refers to the erroneous assumption
that one can draw conclusions for individuals based on
group findings, which occurs when the researcher draws
conclusions at the individual level based solely on the
observations made at the group level. An example of an
ecological fallacy can be illustrated based on a study of
obesity in women in two cities. Consider that the women
in City A had a higher body mass index (BMI) on average
than the women in City B. It would be a fallacy to con-
clude, just based on these averages, that a randomly
selected woman from City A would have a higher BMI
than a randomly selected woman from City B. Because
the BMI reported in the study reflected an average
and not a median, there is no information about the

distribution of BMI values in the two cities, and a ran-
domly selected individual woman from City A may
have a lower BMI than a randomly selected woman from
City B.

Although much of the work of public health nurses
and public health workers is focused on implementing
initiatives that prevent disease or illness, the outbreak in-
vestigation is in response to elevated levels of a disease
or illness within the defined population. The outbreak
investigation is one of the more commonly recognized
applications of epidemiology by the general public.
Examples of commonly recognized outbreak investiga-
tions include foodborne illness investigations resulting
from salmonella; gastroenteritis illness investigations at
community daycare centers resulting from Shigella; com-
munities with elevated numbers of pediatric asthma
emergency room visits and subsequent hospitalization;
health-care providers with unusually high numbers of
patients with uncontrolled type 2 diabetes; employees
with elevated levels of asbestosis; communities with un-
expectedly high numbers of infants with elevated blood
lead level; and, on a global level, the Ebola outbreaks in
Africa. Outbreak investigations are an important appli-
cation of epidemiology because of the truly applied na-
ture of the inquiry. The investigation is not simply an
academic exercise but an opportunity to initiate disease
or illness investigation, analyze data collected within the
community or workplace, interpret data, implement
health promotion and risk reduction interventions, and
evaluate short- and long-term health and the effects of
wellness on the population. Precipitating factors relating
to person, place, and time are essential as is an awareness
of disease or illness etiology. Outbreak investigations
can occur in relation to communicable diseases, chronic
disease, and exposure to toxic agents.

Investigation strategies are dependent on the type of
agent resulting in illness, the communicability of the
illness, the virulence of the agent, and the infectivity of the
agent. The infectivity of the agent is defined as the propor-
tion of persons exposed to an infectious agent who become
infected by it and the specific route of infection. As pre-
sented earlier in this chapter, three key aspects of tracking
disease within a population and developing strategies to
reduce the spread and severity of outbreaks are contingent
on person, place, and time considerations. The importance
of effective surveillance of disease and illness is vital in es-
tablishing expected levels of illness within the population.
The CDC maintains publicly reportable data on a number
of diseases (see Web Resources on DavisPlus).

Illnesses such as influenza and pertussis have seasonal
variations and can be substantially reduced through

C H A P T E R 3 n Epidemiology and Nursing Practice 73

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preventive vaccination. The number of reported in-
fluenza cases typically spikes annually from December
through March. Public health community-wide vaccina-
tion campaigns are initiated in the autumn each year in
an attempt to prevent disease through targeted immu-
nization at the population level. A vaccine for the pre-
vention of pertussis was developed in the 1940s, and
aggressive public health childhood immunization initia-
tives resulted in a low number of reported cases nation-
ally in the mid-1970s. Unfortunately, the number of
pertussis cases has increased during the past 30 years
with an increasing proportion of cases among the adult
and older segments of the U.S. population.25

Communicable Disease Outbreaks
Communicable diseases can be the result of a point source
or a common source followed by secondary spread within
the population. Typically, person-to-person spread is
observed as with the case with the Ebola virus. However,
communicable diseases such as the West Nile virus are
spread through vectors, specifically insect to human. The
21st century has witnessed a substantial reduction of
diseases as a result of improved environmental condi-
tions and sanitation systems. Person-to-person spread
of communicable disease continues to present substan-
tial challenges to professions charged with promoting
health and reducing the burden of disease at the popu-
lation level. Unlike systems, which can be re-engineered
to eliminate risks of exposure, strategies addressing
person-to-person transmission of disease can be daunting.
Global public health and disease prevention initiatives
such as hand hygiene education and safe sex practices
are initiatives seeking to address person-to-person spread
of communicable diseases. See Chapter 8 for further in-
formation on how to investigate a communicable disease
outbreak.

Noncommunicable Disease Outbreaks
In the latter decades of the 20th century, chronic dis-
eases have replaced communicable diseases as the most
significant disease classification in high-income coun-
tries. Simply stated, as a result of aggressive interven-
tions during the past 100 years, the mortality rate from
communicable diseases has dramatically declined, con-
tributing to higher life expectancy. With this increased
life expectancy, more people are surviving long enough
to develop noncommunicable diseases that occur later
in life such as cardiovascular disease. Often referred to
as lifestyle diseases, illnesses related to poor diet, a lack
of exercise, and tobacco and alcohol use have become
epidemic. Some typically diagnosed noncommunicable

diseases include heart disease, type 2 diabetes, cancer,
and chronic obstructive pulmonary disorder (COPD).
Initiatives including tobacco cessation programs, bal-
anced nutrition education, and exercise/fitness programs
have been and continue to be developed to combat the
negative impact of noncommunicable diseases.

Although not necessarily demonstrative of traditional
outbreak investigation, noncommunicable diseases can
be studied with epidemiological methods comparing
risk factors such as tobacco use and BMI, and the pres-
ence or absence of disease states. Unlike communicable
diseases in which there exists a direct cause-and-effect
relationship between the exposure and the onset of dis-
ease, noncommunicable diseases are usually connected
to multiple risk factors, and it can be harder to demon-
strate a direct cause and effect. This presents challenges
in both demonstrating direct causes of disease and
changing destructive behaviors within the population
that compromise health.

Exposure to Toxins
Similar to noncommunicable diseases, exposure to toxins
has emerged as a substantial risk to human health and
wellness. As with noncommunicable diseases, a direct
cause-and-effect relationship is difficult to prove. In fact,
toxic substances often have thresholds below which
exposures do not present human health risks but above
which can prove to have adverse and at times fatal con-
sequences. The movement during the past 40 years has
been to advance the study of risk exposure to potentially
toxic substances. Organizations including the National
Institute for Occupational Safety and Health (NIOSH),
CDC, EPA, and ATSDR have made substantial gains
in research and policy to reduce toxic risks adversely
affecting the health of the public.

Surveillance
James Maxwell, a physician in the 1800s, once said
“We owe all the great advances in knowledge to those
who endeavor to find out how much there is of any-
thing.”26 This could be a summary of epidemiology but
also specifically of surveillance, which focuses on deter-
mining and monitoring “how much there is” of diseases,
health conditions, environmental disasters, or other risk
factors. The CDC defines public surveillance as “the on-
going, systematic collection, analysis, and interpretation
of health-related data essential to planning, implemen-
tation, and evaluation of public health practice.”27 Sur-
veillance principles are used when universities provide
information on interpersonal violence on campus, the CDC
reports on communicable disease outbreaks or changes

74 U N I T I n Basis for Public Health Nursing Knowledge and Skills

7711_Ch03_055-076 21/08/19 11:06 AM Page 74

to the rates of tobacco use, or the WHO provides
national and global level estimates on the prevalence of
tuberculosis infection. All these reports are based on col-
lecting and interpreting data to make practice or policy
recommendations.

There are two main types of surveillance: passive and
active. Passive surveillance is when data are collected
based on individuals or institutions that report on health
information either voluntarily or by mandate. The onus
for collecting and reporting of the data to public health
or governmental agencies is on health-care providers or
public health professions in the field. For example, day-
care centers are often required to report an increase in
the number of cases of communicable disease like hand
foot and mouth (caused by an enterovirus) to the local
or state health departments so that the health depart-
ments can report and monitor communicable diseases.
One of the challenges in passive surveillance is ensuring
that those reporting the data have adequate resources to
collect accurate data. If the data is inaccurate or only
some agencies are reporting the data then there is a risk
that the data will be biased or will not reflect the actual
conditions of the population. Surveillance in low- and
middle-income countries can be particularly challenging
where local and national governments may not have ad-
equate resources to accurately collect morbidity and
mortality data. The consequence of poor surveillance
data is that it can be difficult to accurately prioritize
health-care resources on a national and global level be-
cause the true levels of disease are poorly understood.

One example using the results of surveillance to
understand the impact of disease is the global burden of
disease. As will be discussed in more detail in Chapter 9,
the burden of disease is defined by the WHO as the dif-
ference between a population’s actual health status and
the “ideal” health status if everyone were to live to their
fullest potential and life span. It is measured in the years
of life lost to both premature mortality and disability.28,29

These data include information about the impact of a
health problem on a population using indicators such as
monetary cost, mortality, and morbidity, and refers to
this as the burden of disease. To help measure the burden
of disease, statisticians calculate the disability-adjusted
life years (DALY) that considers not only mortality
but also the morbidity and the disability associated with
a disease or risk factor. Such reports are compiled by
organizations like the WHO based on global surveillance
reports and other local and national data sources. These
data help researchers evaluate the impact of interven-
tions and identify areas for action (see Chapter 9 for
additional information and how to calculate DALY).

A second type of surveillance is active surveillance,
which involves the deployment of public health profes-
sionals including nurses to identify cases of a disease or
health condition under surveillance. This could involve
reviewing medical records, interviewing health-care
providers or hospital administrators, and surveying those
exposed to the condition. Active surveillance is typically
used in an outbreak where there is a sudden change in
the number of cases of a particular disease or condition.
The Ebola responses in Sierra Leone and Liberia provide
examples of active surveillance where multiple organiza-
tions including the CDC and WHO were involved
in finding cases, tracking the spread of disease, and
deploying staff to prevent further transmission.

C H A P T E R 3 n Epidemiology and Nursing Practice 75

t CASE STUDY
Investigating Motor Vehicle
Crashes using Epidemiology

Learning Outcomes
• Apply epidemiology methods to a public health

concern.
• Explore sources of epidemiologic data on a national,

state, and local level.

You are a public health nurse at your state’s health
department tasked with identifying one of the leading
causes of mortality and morbidity, and working with a
local university to design a study to further explore
risk factors related to the identified cause. After com-
paring state-level surveillance data to national data,
you realize that motor vehicle crashes (MVCs) are
a leading cause of death and injury in your state.

Discussion Points
• Using the seven questions for epidemiologic investi-

gations, list what type of information you would like
to gather about MVCs.

• Identify where you might find additional information
regarding MVCs on a local, state, or national level.

• If you were to design an epidemiologic study to
gather more data on MVCs in your state, what type
of study could you design? What are the pros and
cons to your study design?

n Summary Points
• Epidemiology provides the scientific basis for under-

standing the occurrence of health and disease.
• An epidemiological investigation revolves around

person, place, and time.

7711_Ch03_055-076 21/08/19 11:06 AM Page 75

• An understanding of risk factors for disease
from an individual and ecological perspective
is essential for the development of effective
interventions.

• The two-by-two table is a principle pertaining to
epidemiological investigation and analysis.

• Epidemiological investigations include descriptive
and analytical epidemiology.

• Surveillance, both passive and active, helps to
identify and respond to public health concerns
such as outbreaks of communicable diseases.

REFERENCES

1. Martin, N., & Montagne, R. (2017, May 12). U.S. has the
worst rate of maternal deaths in the developed world.
NPR. Retrieved from https://www.npr.org/2017/05/12/
528098789/u-s-has-the-worst-rate-of-maternal-deaths-
in-the-developed-world.

2. Centers for Disease Control and Prevention. (2017). Preg-
nancy mortality surveillance system. Retrieved from https://
www.cdc.gov/reproductivehealth/maternalinfanthealth/
pmss.html.

3. Friis, R.H., & Sellers, T.A. (2014). Epidemiology for public
health practice (5th ed.). Boston, MA: Jones & Bartlett.

4. World Health Organization. (2017). Global tuberculosis
report 2017. Retrieved from http://www.who.int/tb/
publications/global_report/en/.

5. Snow, J. (1965). Snow on cholera. Cambridge, MA: Harvard
University Press.

6. Lilienfeld, A.M., & Lilienfeld, D.E. (1980). Foundations of
epidemiology (2nd ed.). New York, NY: Oxford University
Press.

7. Susser, M., & Susser, E. (1996a). Choosing a future for
epidemiology: I. Eras and paradigms. American Journal
of Public Health, 86(5), 668-673.

8. Susser, M., & Susser, E. (1996b). Choosing a future for
epidemiology: II. From black boxes to Chinese boxes and
eco-epidemiology. American Journal of Public Health,
86(5), 674-677.

9. WHO. (n.d.). Risk factors. Retrieved from http://www.
who.int/topics/risk_factors/en/.

10. CDC. (2018). Behavioral risk factor surveillance system.
Retrieved from https://www.cdc.gov/brfss/index.html.

11a. CDC. (2017). Youth risk behavior survey 1997-2017. Data
retrieved from https://www.cdc.gov/healthyyouth/data/
yrbs/.

11b. CDC. (2017). National health interview survey 1997-2017.
Data retrieved from https://www.cdc.gov/nchs/nhis/
index.htm.

12. National Cancer Institute. (2018). BRCA mutations: cancer
risk and genetic testing. Retrieved from http://www.cancer.
gov/about-cancer/causes-prevention/genetics/brca-fact-sheet.

13. WHO. (2018). Tobacco. Retrieved from http://www.
who.int/mediacentre/factsheets/fs339/en/.

14. CDC. (2018). Youth and tobacco use. Retrieved from
https://www.cdc.gov/tobacco/data_statistics/fact_sheets/
youth_data/tobacco_use/index.htm.

15. Krieger, N. (1994). Epidemiology and the web of causation:
Has anyone seen the spider? Social Science Medicine, 39(7),
887-903.

16. Diez Roux, A.V. (2007). Integrating social and biological
factors in health research: A systems review. Annals of
Epidemiology, 17(7), 569-574.

17. Shapiro, S. (2008). Causation, bias and confounding: A
hitchhiker’s guide to the epidemiological galaxy, part 2.
Principles of causality in epidemiological research: Con-
founding, effect modification, and strength of association.
Journal of Family Planning and Reproductive Health Care,
34(3), 185-190.

18. Reifsnider, E., Gallagher, M., & Forgione, B. (2005). Using
ecological models in research on health disparities. Journal
of Professional Nursing, 21(4), 216-222.

19. Lee, P.R., & Estes. C.L. (2003). The nation’s health (7th ed.).
Burlington, MA: Jones & Bartlett.

20. WHO. (2016). Life expectancy increased by 5 years since
2000, but health inequalities persist. Retrieved from
http://www.who.int/mediacentre/news/releases/2016/
health-inequalities-persist/en/.

21. Szklo, M., & Nieto, F.J. (2012). Epidemiology: Beyond the
basics (3rd ed.). Boston, MA: Jones & Bartlett.

22. Babbie, E. (2016). The practice of social research (14th ed.).
New York, NY: Wadsworth.

23. National Heart, Lung and Blood Institute & Boston University.
(2018). Framingham heart study. Retrieved from http://
www.framinghamheartstudy.org/.

24. The Nurses’ Health Study. (n.d.). Retrieved from http://
www.nurseshealthstudy.org/

25. CDC. (2018). Pertussis (whooping cough). Retrieved from
https://www.cdc.gov/pertussis/surv-reporting.html.

26. Gordis, L. (2014). Epidemiology (5th ed.). Philadelphia, PA:
Elsevier Saunders.

27. Thacker, S.B., & Birkhead, G.S. (2008). Surveillance. In:
M.B. Gregg (Ed.), Field epidemiology. Oxford, England:
Oxford University Press.

28. Murray, C., & Lopez, A. (1996). The global burden of disease:
A comprehensive assessment of mortality and disability from
diseases, injuries, and risk factors in 1990 and projected to
2020. Cambridge, MA: Harvard University Press.

29. Murray, C., & Lopez, A. (2013). Measuring the global
burden of disease. The New England Journal of Medicine,
369, 448-457.

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77

KEY TERMS

Aggregate data
Assets
Census block
Census tract
Community
Community-based

participatory research
(CBPR)

Community Health
Assessment

Community Health
Assessment and
Group Evaluation
(CHANGE)

Comprehensive
community assessment

Deidentified data
Focus group
Geographic information

system (GIS)

Health impact assessment
Inventory of resources
Kinship/Economics/

Education/Political/
Religious/Associations
(KEEPRA)

Key informant
Mobilizing for Actions

Through Planning and
Partnerships (MAPP)

PhotoVoice
Population
Population pyramid
Primary data
Qualitative data
Quantitative data
Rapid needs assessment
Secondary data
Windshield survey

n Introduction
Assessment, the first step in the nursing process, is fo-
cused on determining the health status and needs of an
individual. In public health practice, a community
health assessment is a strategic plan that describes the
health of a community by collecting, analyzing, and
using data to educate and mobilize communities; de-
velop priorities; obtain resources; and plan actions to im-
prove health.1,2 Assessment is one of the three core public
health functions established by the Institute of Medicine
(IOM)3 in 1988 (see Chapter 1) and is critical to the work
of public health, especially as it relates to the other core
functions, policy development and assurance.3

Nurses conduct community assessments as the first step
in the development of health programs and interventions
aimed at optimizing the health of a community or popula-
tion. For example, Dulemba, Glazer, and Gregg (2017)
conducted a community assessment prior to developing an
action plan for persons with chronic obstructive pul-
monary disease (COPD) who were residing in east-central
Indiana and west-central Ohio.4 Other health-care profes-
sionals and community partners have come together and
used the principles of community health assessment to bet-
ter understand the health needs of vulnerable groups. For
example, a team in Chicago utilized a community partici-
patory method to do an assessment in a Mexican immi-
grant community.5 A thorough assessment prior to putting

Chapter 4

Introduction to Community Assessment
Christine Savage and Joan Kub

LEARNING OUTCOMES

After reading the chapter, the student will be able to:
1. Define community health assessment within the context

of population health.
2. Describe six approaches to conducting an assessment

(comprehensive community assessment, population
focused, setting specific, problem focused, health impact,
rapid needs assessments).

3. Describe two assessment frameworks (MAPP,
CHANGE).

4. Use secondary data to identify health characteristics of a
community.

5. Describe qualitative and quantitative methods to collect
primary data for conducting an assessment.

6. Describe the use of multiple techniques and tools
(geographic information system [GIS], PhotoVoice) to
conduct community assessments.

7. Discuss the usefulness of community assessments.
8. Use the frameworks in conducting a hypothetical

assessment of a community.
9. Analyze primary and secondary data to identify strengths

and needs of a community.

7711_Ch04_077-106 22/08/19 11:35 AM Page 77

in place community/population health interventions not
only provides needed information on risk factors within
the community, but also increases the understanding of the
complex interactions between multiple aspects of a com-
munity that impact health such as culture, environment,
infrastructure, and resources. It also provides a method of
assessing the resources of the community as well as the per-
spectives of those who live in the community. Conducting
assessments in partnership with the community is an es-
sential component and provides buy-in from the beginning
as evidenced by the assessments referenced earlier when
conducted in both an urban and a rural community.

Just as an individual nursing assessment requires
special skills, a community assessment also requires a
unique set of skills to systematically examine the health
status, needs, perceptions, and assets or resources of a
community. Some of the skills or competencies needed
to conduct such an assessment include selecting health
indicators, using appropriate methods for collecting data,
evaluating data, identifying gaps, and interpreting and
using data. Basic community health assessments skills for
frontline public health professionals, also referred to as
Tier 1 professionals, are set out by the Council on Link-
ages Between Academia and Public Health Practice
(Box 4-1).6 Note, of the eight competency domains for
public health professionals, assessment/analytical com-
petency is the first domain. As with the nursing process,
assessment is the first step in the process for achieving
optimal health in populations and communities.

Definitions of Community
and Community Health
Defining the concepts of community and community
health is critical in thinking about a community
assessment.

A community, as defined in Chapter 1, is a group of
individuals living within the same geographical area,
such as a town or a neighborhood, or a group of individ-
uals who share some other common denominator, such
as ethnicity or religious orientation. In contrast to aggre-
gates and population, individuals within the community
recognize their membership in the community based on
social interaction and establishment of ties to other
members in the community, and often participate in col-
lective decision making.

There is a great deal of media interest in the health of
communities. Media outlets often use various indices
such as mental wellness, lifestyle behaviors, fitness,
health status, and nutrition to identify the healthiest
cities in our country. Public health agencies also focus

78 U N I T I n Basis for Public Health Nursing Knowledge and Skills

on defining the health of a community. At the national
level there are programs with goals to improve the
health of communities such as the Centers for Disease
Control and Prevention’s past program Partnerships to
Improve Community Health (PICH).7

Three important characteristics help define the health
of a community: health status, structure, and competence.
Selected biostatistics provide vital information about lead-
ing health issues in a community. Statistics commonly
used when doing a community assessment related to
health and disease are covered in Chapter 3. These statis-
tics include indicators such as mortality rates and morbid-
ity rates (the incidence and prevalence of disease).
Mortality is often depicted by crude rates or age-adjusted
rates. Next there is the structure of a community, which
includes the demographics of the community as well as
the services and resources available in the community. The
demographic data include such indicators as age, gender,
socioeconomic indicators, racial/ethnic distributions, and
educational levels. The community health services and re-
sources include information about the resources available

Analytic/Assessment Skills—Tier 1
1. Describes factors affecting the health of a community
2. Identifies quantitative and qualitative data and

information
3. Applies ethical principles in accessing, collecting,

analyzing, using, maintaining, and disseminating data
and information

4. Uses information technology in accessing, collecting,
analyzing, using, maintaining, and disseminating data
and information

5. Selects valid and reliable data
6. Selects comparable data
7. Identifies gaps in data
8. Collects valid and reliable quantitative and

qualitative data
9. Describes public health applications of quantitative

and qualitative data
10. Uses quantitative and qualitative data
11. Describes assets and resources that can be used for

improving the health of a community
12. Contributes to assessments of community health

status and factors influencing health in a community
13. Explains how community health assessments use

information about health status, factors influencing
health, and assets and resources

14. Describes how evidence is used in decision making

BOX 4–1 n Core Assessment Competencies
for Public Health Professionals

Source: (6)

7711_Ch04_077-106 22/08/19 11:35 AM Page 78

Comprehensive Assessment
Since the 1988 IOM report, The Future of Public Health,
improving health in populations or communities has
been linked to performing comprehensive assessments.3
There is a mandate for public health agencies to regu-
larly and systematically collect, assemble, analyze, and
make available information on the health of the com-
munity, including statistics on health status, community
health needs, and epidemiological studies of health
problems.12 In addition, the Affordable Care Act re-
quires that nonprofit hospitals conduct community
health assessments.13 Data regarding demographic and
health characteristics of the entire population are col-
lected in these assessments. A comprehensive commu-
nity assessment is the collection of data about the
populations living within the community, an assessment
of the assets within a community such as the local health
department capacity, and identification of problems and
issues in the community (unmet needs, health disparity)
and opportunities for action.14

Since 1992, the CDC has guided communities in con-
ducting assessments, making health decisions, and de-
veloping policy. There are a number of tools available
for conducting community assessments such as the
Community Health Assessment and Group Evalua-
tion (CHANGE) tool that includes a process for con-
ducting a comprehensive assessment of a community.
Other tools are available such as Mobilizing for Actions
Through Planning and Partnerships (MAPP) as well
as some that are specific to a one aspect of community
health such as PACE-EH (Chapter 6), which targets
environmental health (Table 4-1).14

Population-Focused Assessment
A population, as defined in Chapter 1, is a larger group
whose members may or may not interact with one an-
other but who share at least one characteristic such as
age, gender, ethnicity, residence, or a shared health
issue such as HIV/AIDS or breast cancer. The common
denominator or shared characteristic may or may not
be a shared geography or other link recognized by the
individuals within that population. For example, per-
sons with type 2 diabetes admitted to a hospital form
a population but do not share a specific culture or place
of residence and may not recognize themselves as part
of this population. In many situations, the terms aggre-
gate and population are used interchangeably. An as-
sessment can be focused on a specific population for
purposes of planning and developing intervention pro-
grams. A population-focused assessment, for example,
might focus on pregnant women or immigrants living

in the community as well as service use patterns, treatment
data, and provider/client ratios.

Finally, the health of a community may be conceptu-
alized as effective community functioning, a concept de-
veloped by Cottrell in the 1970s and expanded by
Goeppinger and Baglioni in the 1980s.8,9 Conditions and
select measures of community competence include com-
mitment to the community, conflict containment, accom-
modation (working together), participant interaction,
decision making, management of the relationships with
society, participation (use of local services), awareness of
self and other, and effective communication. These com-
munities value connections between people in the com-
munity as well as those outside of the community. A
competent community is able to identify its needs,
achieve some goals and priorities, agree on ways to im-
plement those goals, and collaborate effectively.10,11 The
establishment of a Neighborhood Watch program to ad-
dress growing crime in a community is an example of ef-
fective functioning in which the community comes
together, works to come up with a solution to a problem,
and promotes a higher level of functioning by pulling to-
gether to address an issue.

Types of Community Health Assessments
The purpose of assessments is to gather information and
identify areas for improving the health of communities
and populations. Assessment is the first step in the
process of health planning and provides essential data
needed to decide where best to allocate community re-
sources. Assessments also provide baseline data. For ex-
ample, if the community is concerned about the health
of infants and mothers, a community assessment can
provide the data needed to determine what the actual sta-
tus of maternal and infant health (MIH) is for the com-
munity; whether problems exist for the community as a
whole; or whether there is a disparity in MIH based on
socioeconomic status, ethnicity, or geographical location
in the community. Baseline data on premature births, in-
fant mortality, and vaccination rates help health planners
determine whether the intervention had an impact dur-
ing the evaluation phase of health planning (Chapter 5).
The key is to understand what type of assessment is best.
There are several types of community health assessments:

• Comprehensive assessment
• Population-focused assessment
• Setting-specific assessment
• Problem- or health-issue-based assessment
• Health impact assessments
• Rapid needs assessment

C H A P T E R 4 n Introduction to Community Assessment 79

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within a community. One community assessment was
conducted to examine the health needs of Hispanic
immigrants, especially in relation to the issue of
adolescent pregnancy. The findings provided the in-
formation needed for the development of new inter-
ventions that would engage adolescents and other
stakeholders.15

A population-focused assessment can also focus on a
certain age range or a population with a specific health
characteristic that may put the group at risk (e.g., chil-
dren or, specifically, children with disabilities). In health
departments, nurses are often involved with writing
grants to serve the needs of mothers and children (see
Chapter 17). Identifying health indicators of interest is a
beginning step in the process of conducting this type of

assessment. For example, the World Health Organiza-
tion (WHO) identified 11 maternal-child health indica-
tors (Box 4-2).16 These indicators provide insight into the
health of this population and a mechanism for tracking
accomplishment in improving these indicators over time.

Setting-Specific Assessment
Assessments can also be focused on a specific setting.
Assessments of this nature may focus on identifying
strengths and weaknesses of an organization or policies
and programs within an organization. Similar to other
assessments, a setting-specific assessment requires a
clear understanding of the purpose of the assessment to
proceed in an organized manner. An occupational
health assessment conducted within a company will

80 U N I T I n Basis for Public Health Nursing Knowledge and Skills

TABLE 4–1 n Community Assessments Tools

Author, Date
Model Released or Updated Brief Description

Association for Community Health
Improvement, Community
Health Assessment toolkit

(http://www.assesstoolkit.org/)

Catholic Health Association
(http://www.chausa.org/

communitybenefit)

Mobilizing for Action through
Planning and Partnerships (MAPP)

(http://www.naccho.org/programs/
public-health-infrastructure/mapp)

State Health Improvement Planning
(SHIP) Guidance and Resources

(http://www.astho.org/WorkArea/
DownloadAsset.aspx?id=6597)

Community Health Assessment
and Group Evaluation (CHANGE)

(https://www.cdc.gov/healthy
communitiesprogram/tools/
change/pdf/changeactionguide.pdf)

Protocol for Assessing Community
Excellence in Environmental
Health (PACE-EH)

(http://www.naccho.org/topics/
environmental/PACE-EH)

American Hospital
Association,
updated 2011

Catholic Hospital
Association,
updated 2012

National Association
of County and
City Health
Officials and
CDC, 2001

Association of State
and Territorial
Health Officials
and CDC, 2011

CDC, updated 2010

National Association
of County and
City Health
Officials and CDC,
2000

• Toolkit for planning, leading, and using community
health needs assessments

• Provides six-step assessment framework and practical
guidance

• Access to the full toolkit requires paid membership

• For hospital staff who conduct or oversee community
health needs assessments and plan community benefit
programs

• Focus on collaboration, building on existing resources,
and using public health data

• Framework for community health improvement
planning at the local level

• Strong emphasis on community engagement and
collaboration for system-level planning after identifying
assets and needs

• Framework for state health improvement planning
• Emphasis on community engagement and

collaboration for system-level planning after identifying
assets and needs

• Tool for all communities interested in creating social
and built environments that support healthy living

• Focus on gathering and organizing data on community
assets to prioritize needs for policy changes

• Users complete an action plan

• Tasks to investigate the relationships among what they
value, how their local environment impacts their
health, and next steps

• For local health agencies to create a community-based
environmental health assessment

Source: (14)

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most likely consist of a description of the company, the
working population, the health programs, and stressors
present at the worksite. The same principles apply in as-
sessing a school setting. The PHN must identify indica-
tors relevant to the setting. Health indicators relevant to
an industrial setting might include work-related injury
or days absent. At a school setting the assessment would
most likely begin with a description of the school, the
history, policies, support services, the actual school
building from an environmental perspective, the popu-
lation (teachers, staff, and students), and the existing
programs with an emphasis on health. There are many
additional tools that can be used to assess components
of school health. The School Health Index,17 a tool avail-
able through the CDC, addresses physical activity,
healthy eating, tobacco use prevention, unintentional
injury, violence prevention, and asthma rates within a
school system (see Chapter 18).

This type of health assessment treats the setting as the
community and considers the population located in the
setting. Thus, a setting assessment includes components
of a comprehensive assessment and a population assess-
ment. Taking the example of a health assessment con-
ducted at an industrial worksite by an occupational
health nurse (see Chapter 20), it would be helpful to col-
lect and analyze data relevant to the environment, the re-
sources available to promote health, and health statistics

specific to the population. According to the CDC, a
workplace assessment involves obtaining information re-
lated to the health of employees within the workplace set-
ting, including protective and risk factors to identify
opportunities to improve the health of the workers.18

Problem- or Health-Issue-Based Assessment
Assessments can also focus on a specific problem or
health issue. In many cases, assessments and tool kits for
specific health issues can be found on the Internet. For
example, obesity is a growing problem in the United
States, and communities are identifying the need to pro-
mote an understanding of the policies, practices, and en-
vironmental factors that contribute to the nutrition and
physical activity choices within a community. An assess-
ment can help a community identify physical activity and
nutrition policies, practices, and environmental condi-
tions within the local community at large, such as work-
sites, school systems, and the health-care delivery system.
Assessments can help identify specific issues related to
the health issue and can also be population and/or setting
specific. They can also help reach vulnerable populations
and identify health needs such as an assessment of the
transgender population conducted in Wisconsin. The
community assessment helped identify that health-care
providers play a key role in facilitating access to care for
this population.19 Often assessments related to a specific
health issue include analysis of data to help determine
who is at risk for the disease, such as the use of a case
control study (see Chapter 3).

Health Impact Assessment
There are two other types of assessments: health impact
assessment (HIA) and rapid needs assessment. The
WHO notes that there are several definitions of a HIA.
The main definition it has adopted is based on a 1999
European Centre for Health Policy definition of an HIA.
According to the WHO, an HIA “… is a means of assess-
ing the health impacts of policies, plans, and projects in
diverse economic sectors using quantitative, qualitative,
and participatory techniques.”20 A growing awareness of
the multiple determinants of health, with a focus on the
environment, has resulted in an increased focus and uti-
lization of HIAs throughout the world. HIA methods are
used to evaluate the impact of policies and projects on
health, and a successful HIA is one in which its findings
are considered by decision makers to inform the devel-
opment and implementation of policies, programs, or
projects. HIAs are often associated with assessments of
the environment or assessments focused on the social in-
fluences of large projects. Zoning laws, for example, may

C H A P T E R 4 n Introduction to Community Assessment 81

1. Maternal mortality ratio
2. Under-5 child mortality, with the proportion of

newborn deaths
3. Children under 5 who are stunted
4. Proportion of demand for family planning satisfied

(met need for contraception)
5. Antenatal care coverage (at least four times during

pregnancy)
6. Antiretroviral prophylaxis among HIV-positive

pregnant women to prevent HIV transmission and
antiretroviral therapy for (pregnant) women who
are treatment-eligible

7. Skilled attendant at birth
8. Postnatal care for mothers and babies within 2 days

of birth
9. Exclusive breastfeeding for 6 months (0–5 months)

10. Three doses of combined diphtheria-tetanus-
pertussis immunization coverage (12–23 months)

11. Antibiotic treatment for suspected pneumonia

BOX 4–2 n The WHO 11 Indicators of Maternal,
Newborn, and Child Health

Source: (16)

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increase the availability of walking paths that in turn may
help to reduce the prevalence of obesity in a community.
Examples of these types of assessments include an HIA
of urban transport systems21 or the value of assessing im-
pact of policies on health inequities.22 An HIA provides
advice to a community on how to optimize the health of
the community, is conducted prior to implementing a
community-level intervention, and includes specific
steps (Box 4-3).20,23

Rapid Needs Assessment
Another type of assessment is a rapid needs assessment,
a tool that helps establish the extent and possible evolu-
tion of an emergency by measuring the present and
potential public health impact of an emergency, deter-
mining existing response capacity, and identifying any
additional immediate needs.24,25 This type of assessment
was first used in international settings during the 1960s
to assess for immunization coverage, morbidity from
diarrheal and respiratory diseases, and service coverage.
In the 1970s, it was used in the smallpox eradication pro-
gram in West Africa and was then adapted by the WHO
for the Expanded Program of Immunization to assess
immunization coverage in the 1980s. At the national
level, the CDC, the Federal Emergency Management
Agency, and the U.S. Public Health Service (USPHS)
have all adopted a rapid needs assessment format when
responding to a disaster. A rapid needs assessment is an
effective use of limited resources and in general involves
a straightforward collection of data. It is undertaken
immediately after a disaster or event usually during the
first week. The goal is to understand immediate needs,
determine possible courses of action, and identify
resource requirements.25

Concepts of Relevance to Community
Assessments
There are important concepts relevant to conducting a
community assessment discussion: needs, assets, and the
use of community-based participatory research. These
reflect the importance of working with a community
while maximizing the strengths of the community rather
than focusing on deficits within the community. In the
past, community assessments were done by outsiders
and, for the most part, highlighted where the health gaps
were without acknowledging assets within the commu-
nity or including the community as a partner.

Needs Assessments Versus Asset Mapping
Initially, community assessments were based on the
premise that the purpose of a community health assess-
ment was to identify needs. In 1995, Witkin and
Altschuld defined a needs assessment as “a systematic
set of procedures undertaken for the purpose of setting
priorities and making decisions about program or or-
ganizational improvement and allocation of resources.
The priorities are based on identified needs.”26 A need
was considered a discrepancy or a gap between what is
and what should be.26

In contrast with this view of community health assess-
ments, Kretzmann and McKnight published a landmark
book that made the argument that an assessment should
focus on the positive assets of a community rather than
on its deficits. Assets are useful qualities, persons, or
things. They combined this concept of assets with the
concept of mapping, that is, exploring, planning, and lo-
cating, and proposed that community assessments
should include asset mapping. Some of their ideas grew
out of the plan to rebuild troubled urban communities
based on capacity building.27 According to Kretzmann
and McKnight, a needs approach characterizes commu-
nities as a list of problems, makes resources available to
service providers instead of residents, contributes to a
cycle of dependence, and focuses on maintenance and
survival strategies instead of development plans. By con-
trast, an asset mapping approach focuses on effectiveness
instead of deficiencies, builds on interdependencies of
people, identifies how people can give of their talents,
and seeks to empower people.27

The assets approach, based on Kretzmann and McK-
night’s work, is based on constructing a map of assets
and capacities. Three aspects of a community can be in-
cluded in an asset map: (1) people, (2) places, and (3) sys-
tems.27 People include individuals and families living
within the community; places include the resources

82 U N I T I n Basis for Public Health Nursing Knowledge and Skills

• Screening (identifying plans, projects, or policies for
which an HIA would be useful)

• Scoping (identifying which health effects to consider)
• Assessing risks and benefits (identifying which people

may be affected and how they may be affected)
• Developing recommendations (suggesting changes

to proposals to promote positive health effects or to
minimize adverse health effects)

• Reporting (presenting the results to decision makers)
• Monitoring and evaluating (determining the effect of

the HIA on the decision)

BOX 4–3 n Major Steps in Conducting a Health
Impact Assessment (HIA)

Source: (20)

7711_Ch04_077-106 22/08/19 11:35 AM Page 82

within the community such as schools, businesses, recre-
ational facilities, and health-care resources. Systems in-
clude both formal systems such as government and
churches as well as informal systems within the commu-
nity such as neighborhood organizations. These systems
are not always discrete and separate but, rather, influence
each other.28 Although these approaches of needs and
assets appear diametrically opposed, the reality is that
comprehensive community assessments consist of the
identification of both weaknesses and strengths. Identi-
fying the strengths as well as the problems is critical in
the analysis of data.

Community-Based Participatory Research
The second concept of particular relevance to assessment
is community engagement in the process of the assess-
ment. There are various terms used to describe this
approach including community engagement, citizen
engagement, public engagement, translational science,
knowledge translation, campus-community partner-
ships, and integrated knowledge translation.34 In this
book, we use the term community-based participatory
research (CBPR). The definitions related to this ap-
proach all include engagement of members of the com-
munity as full partners in the process of assessment. The
idea is to use a collaborative approach that combines the
knowledge and interest of the community members with
the expertise of the professionals. The end goal is to
achieve change that will work toward improving the
health of the community.29-31

CBPR emphasizes the essential principles of capacity
building, shared vision, ownership, trust, active partici-
pation, and mutual benefit.29 A benefit of this approach
is that it is a colearning process wherein the researchers
and community members contribute equally and achieve
a balance of research and action. In addition, it is a way
of providing culturally competent care. For the PHN
working with the community, it is important to be aware
of the principles of CBPR. One of the first steps in the
community assessment is to engage partners in the
process and to develop a common vision.30

The engagement of communities in the community
assessment process using CBPR methods has become an
accepted method for not only engaging the community
in the process but also engaging the end users in the ac-
tion that will be taken to improve health.31 When using
CBPR methods, it is important to evaluate the possible
ethical issues that can arise. These include issues of
power, fairness, appropriate selection of representatives,
obtaining consent, upsetting community equilibrium,
and issues of dissemination of sensitive data.29,32

Assessment Models/Frameworks
Models or frameworks provide the structure and guid-
ance for conducting an assessment. PHNs can choose a
model based on what best fits the type of assessment that
is being conducted. Examples of models that can help
guide a comprehensive community health assessment
are the Community Health Assessment and Group Eval-
uation (CHANGE) tool and the Mobilizing for Actions
Through Planning and Partnerships (MAPP) strategic
model.

Community Health Assessment and Group
Evaluation
The CDC based the CHANGE tool on the socioecolog-
ical model (see Chapter 2) to help communities build
an action plan based on identified assets and areas for
improvement. The stated purpose of the CHANGE
tool is “to enable local stakeholders and community
team members to survey and identify community
strengths and areas for improvement regarding current
policy, systems, and environmental change strate-
gies.”33 The process provides a community with the
foundation for conducting a program evaluation. The
idea is to start with the end in mind and include eval-
uation in the beginning of the assessment process.33

This tool includes a set of Microsoft Office Excel
spreadsheets that communities can use to manage the
data they collect. The tool provides a guide to doing a
community assessment and helps with prioritizing
areas for improvement.

CHANGE uses an eight-step process for conducting
the assessment (Table 4-2) and was updated in 2018.
The first three steps focus on gathering and educating
the team. Steps 4 through 6 involve gathering, in-
putting, and reviewing data from the assessment. The
last two steps are the development of an action plan
starting with an analysis of the consolidated data.
CHANGE is a tool to help a community complete an
assessment that not only provides a diagnosis but also
ends with the presentation of an action plan. The idea
is to create a living document that the community can
use to prioritize the health needs of the community and
provide a means for structuring community activities
around a common goal.33

Mobilizing for Actions Through Planning
and Partnerships
The National Association of County and City Health
Officials in cooperation with the Public Health Practice
Program Office, CDC, developed a planning tool for

C H A P T E R 4 n Introduction to Community Assessment 83

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improving community health. The tool was developed
with input from a variety of organizations, groups, and
individuals who made up the local public health system
between 1997 and 2000 (Fig. 4-1). The vision for imple-
menting MAPP is for “communities [to achieve] im-
proved health and quality of life (QoL) by mobilizing
partnerships and taking strategic action.”34

The MAPP assessment model was based on earlier
models used by public health departments (PHDs)
such as the Assessment Protocol for Excellence in Pub-
lic Health (APEXPH), which was released in 1991.35

Building on the concepts included in the APEXPH
model, MAPP strengthened the community involve-
ment component of assessment and aligned the
model with the 10 essential public health services (see
Chapter 1).34 The MAPP tool includes the full scope of
health planning including assessing, diagnosing, devel-
oping an intervention, implementing the intervention,
and evaluating the effectiveness of the intervention. By
contrast, CHANGE focuses on assessment and diagno-
sis with evaluation built in as the goal (see Table 4-2).
Communities and PHDs have used MAPP across the
country because it includes an action phase, providing
a comprehensive approach to improving the health of
a community.

The focus of the first five phases of MAPP is the process
involved in working with the community on strategic
planning and conducting four separate assessments. The
MAPP handbook34 contains access to the tools, resources,
and technical assistance needed to conduct the assessment,

including a toolbox to provide an explanation and the
many examples of assessments that have been conducted.
The MAPP process has six phases: (1) organizing for suc-
cess and partnership development, (2) visioning, (3) per-
forming the four assessments, (4) identifying strategic
issues, (5) formulating goals and strategies, and (6) moving
into the action cycle.

Phase 1: Organizing for Success
and Partnership Development
This phase is focused on identifying who should be in-
volved in the process and developing the partners who
will participate in the process. The recommended part-
ners include the core support team and a steering com-
mittee. The core team does the majority of the work
including recruiting participants. The steering commit-
tee provides guidance and oversight to the core support
team and should broadly represent the community. It is
important to obtain broad community involvement
during this phase that includes inviting persons to serve
on the steering committee and informing the commu-
nity of opportunities for involvement that will occur
throughout the planning process.34

Phase 2: Visioning
This phase is done at the beginning of the assessment
process and is focused on mobilizing and engaging the
broader community. An advisory committee guides
the effort by conducting visioning sessions, resulting
in a vision and values statement. The following are

84 U N I T I n Basis for Public Health Nursing Knowledge and Skills

TABLE 4–2 n Best Practice Approach to Public Health Assessment: Comparison of MAPP With CHANGE

Mapp Change

Phase 1: Partnership

Phase 2: Visioning

Phase 3: Assess residents, public
health system, community
health, and forces of change

Phase 4: Identify strategic issues

Phase 5: Formulate goals and
strategies

Phase 6: Action cycle

Action Step 1: Assemble the Community Team.
Action Step 2: Develop team strategy.

Action Step 3: Review all five CHANGE sectors.

Action Step 4: Gather data.
Action Step 5: Review data gathered.
Action Step 6: Enter data.

Action Step 7: Review consolidated data.
Action Step 7a: Create a CHANGE Summary Statement.
Action Step 7b: Complete the Sector Data Grid.
Action Step7c: Fill Out the CHANGE Strategy Worksheets.
Action Step 7d: Complete the Community Health Improvement Planning Template.

Action Step 8: Build an action plan.

Source: (33)

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some sample questions that can guide brainstorming
during this phase:

• What does a healthy community mean to you?
• What are the important characteristics of a

healthy community for all who live, work, and
play here?

• How do you envision the local public health system
in the next 5 or 10 years?

Phase 3: Performing the Four Assessments
Four assessments form the core of the MAPP process.
The assessment phase results in a comprehensive picture
of a community by using both quantitative and qualita-
tive methods and consists of the following:

Community Themes and Strengths Assessment:
This provides important information about how the res-
idents feel about issues facing the community. It also
provides qualitative information about residents’ percep-
tions of their health and QoL concerns. Some questions
to guide this assessment include:

• What is important to your community?
• How is QoL perceived in your community?
• What assets do you have that can be used to improve

community health?

Local Public Health System Assessment (LPHSA):
This focuses on the organizations and entities that con-
tribute to the public’s health. It is concerned with how
well the public health system collaborates with other
public health services. The LPHSA answers the following
questions:

• What are the components, activities, competencies,
and capacities of your local public health system?

• How are the essential services being provided in your
community?

Community Health Status Assessment: The com-
munity health status assessment is largely focused on
quantitative data about many health indicators. These in-
clude the traditional morbidity and mortality indicators,
QoL indicators, and behavioral risk factors resulting in
a broad view of health.

Forces of Change Assessment: This is an analysis of
the external forces, positive and negative, that have an im-
pact on the promotion and protection of the public’s
health. It is concerned with legislation, technology, and
other impending changes that can influence how the pub-
lic health system can work. It answers questions such as:

• What is occurring or might occur that affects the health
of our community or the local public health system?

C H A P T E R 4 n Introduction to Community Assessment 85

Figure 4-1 Mobilizing for
Action Through Planning and
Partnerships (MAPP). (Source:
National Association of County
and Community Health Officials.
[2013]. Retrieved from http://
www.naccho.org/topics/
infrastructure/MAPP/index.cfm.)

7711_Ch04_077-106 22/08/19 11:35 AM Page 85

• What specific threats or opportunities are generated
by these occurrences?

Phase 4: Identifying Strategic Issues
During this phase, the assessment data are used to deter-
mine the strategic issues the community must address to
reach its vision. Some questions to help the community
in determining the important strategic issues include the
following:

• How large a public health issue is the item?
• Can we do it?
• Is it reasonable, feasible, and financially cost

effective?
• What happens if we do nothing about it?

Phase 5: Formulating Goals and Strategies
Goals and strategies are formulated for each of the strate-
gic issues. A community health improvement plan is
often created during this phase. Both the steering com-
mittee and the core team work together to “… identify
broad strategies for addressing issues and achieving goals
related to the community’s vision.”34

Phase 6: Moving Into the Action Cycle
This is the phase in which the actual planning, imple-
menting, and evaluating of the strategic plan takes place.
Phases 5 and 6 are described in more detail in Chapter 5,
which is focused on health planning.34

A Comprehensive Community Health
Assessment
MAPP and CHANGE are examples of frameworks that
provide blueprints for conducting a community health
assessment. Regardless of the framework, the first step is
engagement of partners in the process. As described in
the CHANGE tool, this first action step involves assem-
bling a diverse and representative community team. The
team then establishes the purpose of the assessment. This
begins with a clarification of how the community is being
defined. Is the community being defined in relation to a
clear geopolitical community such as a city or a county,
or is the community a neighborhood that may not have
clear geopolitical boundaries? For example, a group of
researchers was conducting a focused assessment of ma-
ternal and infant care in subsidized housing in Winton
Hills, Ohio, a neighborhood located within the Cincin-
nati, Ohio, metropolitan area. It had no political stand-
ing (it was designated as a town or city but did not
have governmental systems in place). Instead, it was a

neighborhood that roughly matched a designated ZIP
code, so for the purposes of the assessment the commu-
nity was defined based on a specific ZIP code.36

Once the community has been defined, it is important
to identify indicators and the sources of data for those
indicators. This step often involves a discussion of the
history of the community and the proposed project.
Through these efforts, the team can identify sources of
data that are already in existence. In some cases, previous
surveys have been conducted that can provide good base-
line data to help understand trends and changes in the
community. Other data can be obtained from national-
level surveys; the U.S. Census Bureau; and sources of
local data, such as reports on crime, motor vehicle acci-
dent, and fire.

Next, the team can develop a timeline to help guide
the assessment. A timeline helps the team decide at
what point each step in the assessment will take place,
the estimated time for completing each of the steps,
and who will be responsible for each step. If the team
is using the CHANGE model, the members will try
to understand the total picture and will include as-
sessment of five sectors of the community: (1) the
community-at-large sector, (2) the community insti-
tution/organization sector, (3) the health-care sector,
(4) the school sector, and (5) the worksite sector. Once
this is complete, the team will then begin to gather
data for each sector and evaluate the quality of the
data. Different methods can be used to collect data, in-
cluding obtaining secondary data available from other
sources and collecting primary data. Primary data
includes any data collected directly by the assessment
team, in contrast to secondary data, which is the
examination of data already collected for another
purpose such as census data. Under step 4 in the
CHANGE model, the different primary data collection
methods listed that can be used include doing a wind-
shield survey, PhotoVoice, doing a walkability audit,
conducting focus groups, and administering a survey
to individuals.

Windshield Survey
A windshield survey is an example of primary data
collection that can help the team get an initial under-
standing of the community and is sometimes viewed
as part of a preassessment phase. The windshield sur-
vey is what it sounds like—a drive-through or walk-
through the community to observe the community.
The idea is to observe the community to help in
understanding it prior to conducting a more formal
assessment.

86 U N I T I n Basis for Public Health Nursing Knowledge and Skills

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A windshield survey is the first step in taking the pulse
of the community. The questions a windshield survey can
begin to answer include:

• Are there obvious health-related problems?
• What is the perspective of the media in relation to

the community?
• What does the community look like?

Just by driving around, key issues related to the envi-
ronmental health of the community can be observed,
such as the number of for-sale signs, the amount of green
space, the number of bars, the number of churches, the
number of open (or closed) businesses, and the general
upkeep of the community. Clean streets, well-kept parks,
busy grocery stores, and religious places of worship with
multiple services offered are signs of a healthy commu-
nity. By contrast, trash in the streets, vacant lots, multiple
bars, vacant places of worship, boarded-up businesses,
and a lack of grocery stores are all visual indicators of a
community that may have some serious health challenges.

A windshield survey can also provide information on
the demographics of a community. Observations made

while driving through (or walking around) can provide
a beginning understanding of the age groups in the com-
munity simply by observing how many children, older
adults, or young people are on the street. This can be
time-dependent. For example, in the early morning,
young parents and children may be observed as the chil-
dren walk to the school. Later in the morning, older
adults may be observed.

The use of a windshield survey template provides guid-
ance when conducting a windshield survey. A template in-
cludes a list of specific aspects of the community to be
aware of during the drive/walk through and provides a
place to make observations (Table 4-3). It is important to
record the observations while conducting the survey
rather than filling them in later. Be sure to add observa-
tions that stand out even if they are not included in the
template. The template should serve as a guide but may
not cover all of the information that emerges. For example,
in one windshield survey the team was struck by the use
of black metal fencing around a neighborhood composed
solely of subsidized housing. Later, when conducting
interviews with key informants they discovered that the

C H A P T E R 4 n Introduction to Community Assessment 87

TABLE 4–3 n A Sample Template for Conducting a Windshield Survey

Area Suggested Prompts for Observation Findings Follow Up Needed

Prior to
conducting
the survey

Green space

Community
Organizations

Health Care

Transportation

Food, beverages
and tobacco

• Establish geopolitical boundaries that define the community
• Access census data for overall information based on census

track or ZIP code
• Obtain other secondary data as determined by the survey team

• Parks
• Playgrounds
• Trees and other plantings

• Churches
• Senior citizen centers
• Others?

• Pharmacies
• Clinics/physician’s offices
• Hospitals
• Dentists

• Bus and trolley lines
• Trains
• Cars

• Big chain grocery stores
• Corner markets
• Farmers’ markets
• Liquor stores
• Bars
• Vaping and hookah lounges

Continued

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residents felt the fencing further confirmed their percep-
tion of being separated from the larger urban community.

One approach to observing the formal institutions
within a community is to examine the interrelationship be-
tween different aspects of a community, often referred to
as KEEPRA (Kinship/Economics/Education/Political/
Religious/Associations) . It provides a list of categories to
consider while collecting observational related data:

• Kinship—What observations can you make about
family and family life?

• Economics—Does the community appear to have
a stable economy or are there signs of economic
decline or economic growth?

• Education—What observations can you make related
to schools and other educational institutions such as
libraries and museums?

• Political—Is there evidence of political activity in
the community such as signs supporting someone’s
candidacy for elected office?

• Religious—Are there any mosques, churches, or
synagogues in the community?

• Associations—What evidence do you see of neighbor-
hood associations? Business associations? What other
resources are present such as recreation centers?

Using the CHANGE list of sectors is another possible
approach to conducting an observational review of the
formal institutions in a community:

• Community-at-Large Sector includes community-
wide efforts that have an impact on the social and
built environments such as improving food access,
walkability or bikeability, tobacco use and exposure,
or personal safety.

• Community Institution/Organization Sector
includes entities within the community that
provide a broad range of human services
and access to facilities such as childcare
settings, faith-based organizations, senior
centers, boys and girls clubs, YMCAs, and
colleges or universities.

• Health-Care Sector includes places where
people go to receive preventive care or treatment,
or emergency health-care services such as
hospitals, private doctors’ offices, and community
clinics.

• School Sector includes all primary and secondary
learning institutions (e.g., elementary, middle,
and high schools, whether private, public, or
parochial).

88 U N I T I n Basis for Public Health Nursing Knowledge and Skills

TABLE 4–3 n A Sample Template for Conducting a Windshield Survey—cont’d

Area Suggested Prompts for Observation Findings Follow Up Needed

Entertainment

Housing

Business

Education

People

Environment

Other
observations

• Theaters (movie and live)
• Concert halls

• Types of housing (single family, apartments, subsidized housing
• Appearance of houses and lawns
• Abandoned houses/apartment buildings

• Store fronts
• Types of businesses (dollar stores, pawn shops, check cashing

vs. upper end stores)
• Empty store fronts

• Schools (public/private)
• Colleges/universities
• School bus routes

• Gender, ethnicity, and age distribution by time of day
• Appearance
• Interactions

• Air quality
• Cleanliness of community

• Add other observations that do not fit into the previous
categories

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C H A P T E R 4 n Introduction to Community Assessment 89

• Worksite Sector includes places of employment such
as private offices, restaurants, retail establishments,
and government offices.33

Secondary Community Health Data Collection
Once the windshield survey is complete it is often helpful
to review secondary data prior to collecting more pri-
mary data. Examples of secondary data sources include
census data, crime report data, national health survey
data, and health statistics from the state or local depart-
ment of health. What is usually available is aggregate
data, data that do not include individual level data, such
as infant mortality rate. Many of the sources of aggregate
level community data are accessible via the Internet. Ob-
taining other sources of secondary data, especially data
at the individual level, usually requires seeking permis-
sion and is usually provided as deidentified data, that is,
data that does not include individual identifiers.

An essential component of a community health as-
sessment is the review of sociodemographic data. From
a geographical perspective, the team can access census
data relevant to their community from the U.S. Census
Bureau. These data provide the team with information
on the number of people in their community; the num-
ber of households; and information related to age, gen-
der, marital status, occupation, income, education, and
race/ethnicity. The U.S. Census Bureau collects census
data in the United States every 10 years. The data are re-
ported at the aggregate level based on geopolitical per-
spective. Aggregate data are obtainable at the national,
state, county, metropolitan area, city, town, census track,
or census block. According to the U.S. Census Bureau, a
census tract is a relatively permanent statistical subdivi-
sion of a county that averages between 2,500 and 8,000
inhabitants that is designed to be homogeneous with re-
spect to population characteristics and economic status.
A census block is an area bounded on all sides by visible
features. Examples of boundaries provided by the U.S.
Census Bureau include visible boundaries such as roads,
streams, and railroad tracks, and by invisible boundaries
such as the geographical limits of a city or county. Typi-
cally, it is a smaller geographical area, but in some rural
areas a census block may be large.37 The data provide a
snapshot of the population every 10 years. In between
those years, changes may occur, and local data may be
needed to supplement census data especially toward the
end of a decade.

Another source of secondary health data at the aggre-
gate level about a community is the PHD. Examples of
public health information related to morbidity and mor-
tality, and potentially available at the PHD include the

crude mortality rate, the infant mortality rate, motor ve-
hicle crash rate, and the incidence and prevalence rates
of communicable and noncommunicable diseases. To
get a better understanding of the rates, it helps to obtain
age-specific mortality rates for leading causes of death
and age-adjusted, race-, or sex-specific mortality rates.
An example of Web-based sources of health-related ag-
gregate data at the county level is the Web site main-
tained by the University of Wisconsin Population Health
Institute and sponsored by the Robert Wood Johnson
Foundation. It provides information on health indicators
at the county level with comparative statistics at the state
and national levels.38 Another source of data is vital sta-
tistics. These statistics provide information about births,
deaths, adoptions, divorces, and marriages. These data
are available through state public health departments.

Information on the health of a community can also be
obtained from surveys that are conducted routinely at
the national level and often at the regional level. The Na-
tional Center for Health Statistics (NCHS), a division of
the CDC, provides data about the prevalence of health
conditions in the United States. The NCHS manages sur-
veillance systems including the National Health Inter-
view Survey (NHIS) and the National Health and
Nutrition Examination Survey (NHANES). The NHIS
surveys approximately 35,000 households annually. The
survey focuses on a core component of health questions
including health status and limitations, injuries, health-
care access and use, health insurance, and income and
assets. In addition, a supplement is used each year to re-
spond to new public health data needs as they arise.39 The
NHANES is an annual survey that began in the 1960s
and combines an interview with medical, dental, and lab
tests, and physiological measures.40 The Behavioral Risk
Factor Surveillance System (BRFSS), administered by the
CDC, is a telephone survey of 350,000 adults in 50 states,
the District of Columbia, Puerto Rico, the U.S. Virgin Is-
lands, and Guam. It has been conducted on an annual
basis since 1984 and collects information on health risk
behaviors, preventive health practices, and health-care
access primarily related to chronic disease and injury.42

The CDC also publishes the Morbidity and Mortality
Weekly Report, which reports communicable diseases and
health concerns by state with each publication providing
current state- and city-level incidence data on reportable
diseases. Other examples of aggregate health data include
the annual report to Congress and other reports to Con-
gress on health-related issues such as alcohol and drug
use (see Chapter 11). Other sources of health data in-
clude cancer registries and the National Institute of Oc-
cupational Safety and Health (NIOSH). The National

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Cancer Center of the National Institutes of Health main-
tains 11 population-based cancer registries. They provide
data on the number of individuals diagnosed with cancer
during the year. NIOSH monitors exposures to environ-
mental factors in work settings.

Secondary data are also available that are not specific
to individuals, that is, data related to the environment.
The Environmental Protection Agency (EPA) collects
data on environmental pollutants and the Department
of Transportation collects data on the number of vehi-
cles using the roads. Another example is information
obtained and maintained by the U.S. Department of
Agriculture (USDA), which includes information on
farmers markets, the Food Access Research Atlas, and
the Food Desert Locator, an online map highlighting
thousands of areas where, the USDA says, low-income
families have little or no access to healthy fresh food.42

Secondary sources of local data also exist but may not
be readily available in aggregate form on the Internet.
These include information on the organizations within
the community such as hospitals, schools, and police
department information. Gathering the data from var-
ious local organizations (minutes, reports) may be help-
ful in relation to the different sectors included in the
CHANGE model such as information about the
schools. Although these records may be helpful to some
extent, there are limitations. Records of any nature
often have limitations because they may not be com-
plete, may not be in a usable format, or the keepers of
the data may not be willing to provide the information
to the community assessment team. The list of available
secondary data is long and interesting, and should be
reviewed as the first step to avoid the more expensive
process of having the team collect the data.

Primary Community Health Data Collection
When the review of the available secondary data is com-
plete, the next step is to determine gaps in the data and
decide what further data needs to be collected by the
team. The CHANGE model provides a list of possible
methods and suggests that multiple methods should be
used (two or more).33 These data are then combined with
the secondary data to determine needs and assets.

Inventory of Resources
The agencies and organizations present in a community
often have a significant effect on health. The CHANGE
handbook has sample organizational questionnaires that
can be used for each of the five sectors to help collect data
on different organizations such as health-care organiza-
tions and schools.33 The use of these questionnaires can

help the team gather essential information about the re-
sources within the community.

Quantitative Data: Surveys
When gaps in data are identified, one method for obtain-
ing the missing data is to conduct a survey to collect
community level quantitative data. Quantitative data are
data that can be assigned numerical values such as the
number of new cases of tuberculosis or the assigning of
a number to a categorical variable such as ethnic group.

A first step in conducting a community health survey
is to outline the purpose of the survey. The team decides
on the information needed then decides on the target
population and the method for obtaining a representa-
tive sample of the population and the survey delivery
method. For example, a hypothetical community assess-
ment team in county X found that the members did not
have enough information on the health-related quality
of life (HRQoL) of older adults living in their commu-
nity. The county had just completed a telephone health
survey, and this population was underrepresented. After
careful consideration they decided that their target pop-
ulation was in fact those older than age 65 who were not
currently residing in a health-care facility. The use of an
e-mailed survey seemed to pose even more problems re-
lated to response rate than did a telephone survey. So
they decided that a face-to-face approach was best to de-
liver the survey. The team members decided they needed
to reach those living in different areas of the county as
well, so they put together a sampling process that would
help them include older adults living in different areas of
the county. This example demonstrates that conducting
a survey can be complex and may include issues related
to time, which requires careful planning. The advantages
of surveys include their cost-effectiveness and ability to
make inferences about a population based on the repre-
sentativeness of the sample. A survey allows for the col-
lection of a large amount of information from a large
number of individuals.

Defining the Sample: There are several approaches
to defining the sample. Defining the community or target
population is once again the critical step. If the focus of
the assessment is on adolescents within a specific school,
the sampling will be based on the adolescents in that
school; however, if the purpose of the assessment is to
say something about adolescents in the city, a different
sampling approach is needed.

Sampling Approaches: Once the target population is
defined, there are several types of sampling approaches.
A simple random sample involves a list of the eligible in-
dividuals and then selection is made based on a random

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selection, possibly based on using a list of random num-
bers. Convenience sampling is a common approach that
takes into consideration the availability of participants.
Some different types of convenience sampling include
quota sampling, which involves a fixed number of sub-
jects; interval sampling, which is the selection of subjects
in a sequence (i.e., every eighth person); or snowball sam-
pling, which starts with a small group of participants and
then uses those participants to identify other participants.
One other type of sampling used with large numbers is
systematic sampling, in which a list of the possible par-
ticipants is presented, and the number needed for the
sample is divided into the total population. For example,
from that point, n, every nth person is chosen.

Methods for Conducting a Survey: There are also
several methods for conducting a survey. A survey can
be mailed, done by telephone, given in certain settings as
a written document or by computer, or conducted
through a face-to-face interview. The format for the sur-
vey is determined based on consideration of cost, re-
sources, and preference. In some cases, the choice of the
format may be determined by the study participants, as
noted in the previous example of the survey conducted
with the older adults in the county.

Deciding Items to Be Included in a Survey: Choos-
ing and developing the items to be included in a survey
is another decision to be made in planning the actual as-
sessment. Most health surveys use a quantitative ap-
proach; that is, the questions are closed-ended and can
be entered into a database using statistical software to
help with analysis. Some surveys also include open-
ended questions that allow respondents to provide infor-
mation not asked in the survey questions.

Evidence-Based Tools for Community Assess-
ment: There are several health status evidenced-based
instruments available for conducting a community
health assessment. One example is the CDC HRQoL
questionnaire, either the 14-item or 4-item set of
Healthy Days core questions (CDC HRQoL– 4).43 The
questionnaire is based on the broad concept of QoL as
it relates to health. Assessment of QoL includes subjec-
tive evaluations of both positive and negative aspects
of life. Health is only one aspect of QoL. Other aspects
include employment, education, culture, values, and
spirituality. The advantage of using the CDC HRQoL
questionnaire is that it allows for comparison of the
community sample with national benchmarks. The
HRQoL has been in the State-based Behavioral Risk Fac-
tor Surveillance System (BRFSS) since 1993.

Other reliable and valid tools are available to include
in an assessment. The challenge is to find a tool that

matches the information needs based on gaps in knowl-
edge related to the health of the community you are
assessing and the utilization of the right format for
obtaining the data. Most community health assessment
surveys include multiple instruments to assess the health
of the community. Along with the 4-item HRQoL ques-
tionnaire, the team may decide to include a number of
other tools within the survey such as a tool that measures
satisfaction with available of health care. The key is to use
valid and reliable tools whenever possible.

Qualitative Data
Although quantitative data can provide a wealth of in-
formation, other approaches to data collection provide
an opportunity to gather more in-depth information
about the health of a community. One approach to
achieving this is to gather qualitative data, that is, data
that cannot be assigned a value and that represent the
viewpoint of the person providing the information.
These data are not generalizable to a large population but
can provide insight into the how, why, what, and where
of the phenomenon being studied, in this case, the health
status of a community.

Focus Groups: The most commonly used method for
collecting data when conducting a community assess-
ment is the focus group(s). A focus group is an interview
with a group of people with similar experiences or back-
grounds who meet to discuss a topic of interest. It is usu-
ally a one-time event that is semistructured and informal,
and there is a facilitator and possibly a cofacilitator who
guide the discussion.44 A focus group typically includes
six to eight participants. The facilitator(s) use an inter-
view guide that has unstructured open-ended questions
for purposes of discovering opinions, problems, and
solutions to issues. The interview generally lasts for 1 to
2 hours. Once the focus group has been conducted, an
analysis of either the transcribed tape recording or notes
from the group session consists of examining the data for
patterns that emerge, common themes, new questions
that arise, and conclusions that can be reached.44

Key Informants: Another approach to gathering more
in-depth data is to conduct individual interviews with key
informants. A key informant is often represented as a gate-
keeper, one who comes closest to representing the com-
munity. Although interviews can be time consuming,
interviews with one or more key informants can provide a
wealth of information about the opinions, assumptions,
and perceptions of others about the health of a community.
The interview can be conducted face-to-face or over the
telephone, and the tool to conduct the interview can be
structured, semistructured, or unstructured. A structured

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interview is more formal, with specific identical questions
being asked of each person interviewed. A semistructured
interview is less structured, with a list of questions that
guide the interview but with time for a more relaxed con-
versation. An unstructured interview is conducted by ask-
ing questions that seem appropriate for the person being
interviewed.

The next consideration is who to interview. This really
depends on the purpose of the assessment and the inter-
view. If a PHN wants to learn more about the resources
for adolescents in a community, the nurse will want to
interview personnel in health clinics and recreation cen-
ters, school nurses, parents, and adolescents about their
perceptions of resources and needs in the community. If
there is a need to learn about the needs of the older adults
living in the community, the sites for identifying key in-
formants may now shift to health clinics, senior citizen
centers, nursing homes, long-term care sites, seniors
themselves, and organizations representing them. If it is
a comprehensive assessment, it is important to make sure
that everyone is represented. It is important to include
business representatives, government employees, and
members of voluntary organizations. Another issue to
examine is the makeup of the community based on eth-
nicity to make sure that each group’s members have had
a chance to voice their opinions. For example, during a
community assessment conducted in Lancaster County,
Pennsylvania, the team realized they would have a zero-
response rate on the telephone health survey for residents
in the county who belonged to the Amish community
because they do not use telephones. To address this issue,
the team conducted focus groups with both the women
and the men in the Amish community.45

Determining the type of interview to conduct with a
key informant, face-to-face or by telephone, requires
some thought about the advantages and disadvantages
of both formats. Some of the advantages of face-to-face
interviews are flexibility, ability to probe for specific an-
swers, ability to observe nonverbal behavior, control of
the physical environment, and use of more complex
questions. The telephone interview needs to be shorter
but allows for the ability to interview people who do not
have the time to meet face-to-face. It is important to
summarize the interview immediately, especially if it is
not being recorded. An analysis of the interview data is
similar to the analysis of focus group data. The commu-
nity health assessment team reads the notes or tran-
scripts from the interviews and identifies common
themes between key informants as well as specific issues
for the group they represent. To help verify the infor-
mation provided by a key informant, it is helpful to use

triangulation, a technique that allows the interviewer to
verify the information with another source.

PhotoVoice: PhotoVoice is another qualitative
methodology used to enhance community assessments. It
is based on the theoretical literature on education for crit-
ical consciousness, feminist theory, and community-based
approaches to document photography.46,47 PhotoVoice in-
volves having community members photograph their
everyday lives within the context of their community, par-
ticipate in group discussions about their photographs, and
have an active voice in mobilizing action within the com-
munity. When using this technique in a community assess-
ment, residents can be provided with disposable cameras
and asked to take pictures that reflect family, maternal, and
child health assets and concerns in the community. From
these photographs, the participants’ concerns will be high-
lighted, and concerns such as developing safe places for
recreation and making improvements in the community
environment can emerge.

Additional Tools and Strategies
Community Mapping: Community mapping is an-

other step during the assessment phase that can be used
in the initial windshield survey, during the inventory
data collection, during interviews, and in more advanced
analyses of both assets and problems in a community.
The advantages of mapping assets are that the strengths
of the community are outlined and can be used then in
developing an action plan. Mapping allows the commu-
nity assessment team to visualize the community and to
study concentrations of disease, to identify at-risk pop-
ulations, to better understand program implementation,
to examine risk factors, or to study interactions that affect
health. It is a process of collecting data through direct
observation and using secondary data sources to describe
the physical characteristics of a neighborhood or com-
munity, the location of institutions and resources, and
the social and demographic characteristics of a commu-
nity. It has the potential to provide data that can help
identify place-based social determinants of health that
could then lead to interventions at the individual and the
community level to initiate precise risk reduction and
mitigation.48 In the study by Aronson and colleagues,
primary data were collected by walking through the com-
munity with residents noting categories of interest.
Secondary data collected included housing inspection
data, liquor license data, crime reports, and birth certifi-
cates. The purpose of this assessment was to study the
community context and how it might contribute to
infant mortality, with an evaluation of Baltimore
City Healthy Start, a federally funded infant mortality

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prevention project. The Healthy Start Program was an
initiative whose purpose was to reduce infant mortality
by providing comprehensive services to women and their
children and partners, and at the same time to contribute
toward a neighborhood transformation. The researchers
mapped vacant houses, liquor stores, and crime data. The
data showed that participation in the prevention pro-
gram was higher in lower risk census blocks. Changes
were made to obtain better penetration of the program
based on these findings.49

Geographic Information System (GIS): A geo-
graphic information system (GIS) is a tool that is increas-
ingly used in public health. GIS is a computer-based
program that can be used to collect, store, retrieve, and
manipulate geographical or location-based information.50

GIS databases consist of both spatial and nonspatial data.
Nonspatial data include demographic or socioeconomic
data that can be identified by geographical boundaries,
whereas spatial data are assigned by exact geographical lo-
cation by geocoding or address matching. It is used glob-
ally to help identify populations at risk such as maternal
and infant populations in Iran and in the U.S.51,52 In the
study conducted in Iran related to maternal health, they
were able to identify priority geographical areas.51 In New
Jersey, researchers used GIS to link neighborhood charac-
teristics with maternal infant outcomes.52 The GIS maps
generated demonstrated the associations between adverse
birth outcomes, poverty, and crime.52

Analysis of the Data
Once the data have been collected, it is important to an-
alyze them. The CHANGE model includes three action
steps related to this phase of the assessment: (1) review
the data, (2) enter the data, and then (3) review the con-
solidated data. Reviewing the data refers to having the
team brainstorm, debate, and reach consensus on the
meaning of the data. Entering the data is the process of
transcribing the data into a software program such as
Excel to help with the analysis and interpretation of the
data. Data are then rated by all researchers. Reviewing
the data includes four steps: (1) create a CHANGE sum-
mary statement, (2) complete a sector data grid, (3) fill
out the CHANGE strategy worksheets, and (4) complete
the Community Health Improvement Planning tem-
plate. Doing so provides the foundation for the final step
in CHANGE, building the community action plan.33

Making sense of the collected data is done via a variety
of ways. One of the most important points to consider is
what changes over time or noticeable trends. Sociodemo-
graphic comparisons include changes from one census
data collection period to another. The time-period for

comparing disease trends varies by the prevalence of dis-
ease. A communicable disease outbreak may be monitored
on a weekly or monthly basis, whereas trends in heart dis-
ease might require a trend analysis during a 5-year period.
Trends can help identify improvements or declines in
health indicators in the community over time, such as the
infant mortality rate, or they can be used to determine
whether there have been changes in the demographics of
the population over time. For example, is the population
aging or have there been changes in home ownership?

The health indicators and the demographics of the
community can be compared with other populations such
as similar local jurisdictions, the state, and ultimately na-
tional data. The data can also be compared within the
community. Do disparities exist on key health indicators
such as prevalence of disease or access to needed re-
sources? These analyses allow the team to interpret the
statistics to identify the important health issues for the
community. It is a complex process that involves combin-
ing the information obtained from all sources and coming
to conclusions. The CHANGE handbook provides an ex-
cellent guide for a team to use to complete the analysis. It
often requires having a member of the team who not only
is familiar with software but who also has a background
in statistical analysis so that the team can compute rates
and complete a meaningful presentation of the data.

Postassessment Phase: Creating,
Disseminating, and Developing an Action Plan
In the final action step outlined in the CHANGE model,
the community assessment team builds a community ac-
tion plan.33 This requires the development of a project
period with annual objectives and should reflect the data
that were collected. The result of a community health as-
sessment should include a brief narrative describing the
adequacy of services currently provided in relation to the
overall needs of the community. It should highlight the
areas of need in the community that are not met and list
any additional resources that could be developed to meet
any unmet needs in the community.

Evaluating the Assessment Process
Evaluating assessments is as important as conducting as-
sessments to better understand their impact. It involves
including stakeholders in reviewing the findings and
having an opportunity for feedback. To use the data to
help identify priorities, teams may seek validation from
stakeholders or they may engage in a more collaborative
process to help come to a final decision on priorities.53

This is done at the end of the assessment phase and be-
fore the beginning of the planning phase (Chapter 5).

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94 U N I T I n Basis for Public Health Nursing Knowledge and Skills

l APPLYING PUBLIC HEALTH SCIENCE
The Case of the Sick Little Town
Public Health Science Topics Covered:

• Assessment
• Epidemiology and biostatistics

The director of nurses (DON) at a regional Visiting
Nurse Association (VNA) that covered a large regional
area including four rural towns noticed that there was
an increase in patients being referred for home visiting
services from Small Town, a small rural community
within their service area. They provided follow-up care
for persons following a hospitalization and well-baby vis-
its for mothers and infants deemed to be at risk such as
premature infants and teenage mothers. The VNA was
part of a large medical center that had just launched its
“We are community!” campaign. The DON approached
the vice-president responsible for community outreach
services, pointed out the increase to him, and suggested
that a community assessment might help to identify
what was behind the increased admissions. The vice-
president stated that this matched the medical center’s
“We are community!” campaign and asked the DON
whether her team would be willing to form a task force
to conduct an assessment of the community to uncover
the reason for the increase in admissions, better under-
stand the health issues and strengths within the commu-
nity, and at the same time build a better bridge to the
community. He authorized a certain part of the DON’s
workload to include leading the assessment project and
authorized her to designate two of her visiting nurses as
members of her initial outreach team.

The next day the DON met with the two of her
home health nurses, Sonja and Viki, who covered Small
Town. She also invited Donna, the PHN who worked
for the county health department, to meet with them
and join their assessment team. As they began, Sonja
remembered from her public health nursing course
that it was important to start with a model to guide the
assessment. She also remembered doing a windshield
survey for her community health project in school.
“I drive around Small Town frequently to see my
patients, and I never thought about really looking at
the town from a community assessment point of view.”
Viki agreed and suggested that not only should they
do a windshield survey, but they should also invite
members of the community to join them.

Donna told them the county PHD was in the planning
stages of a county assessment, so the concerns of the
visiting nurses were in line with efforts just beginning at

the PHD where they were using the CHANGE model33

to guide the process. She conveyed the health concerns
of the visiting nurses to the head of the county PHD
who then agreed to support the VNA’s work assessing
Small Town as a part of their overall comprehensive as-
sessment for the county thus setting up a collaborative
effort between the VNA, the regional Medical Center
and the county PHD.

For their next step, Sonja, Viki and Donna made a
list of those who should be a part of the CHANGE
committee and planned how to get broad community
involvement. They used the CHANGE guidelines to
help develop their process. Sonja and Viki, who had
been working in the community and knew some key
stakeholders in the community, and the PHN asked the
county PHD epidemiologist to assist with the data
collection and analysis.

The core team then began building a CHANGE
committee that could help broaden community
involvement. When completed, the preliminary
CHANGE committee consisted of four residents of the
community; the school nurse; the director of the
community recreation center; a member of the police
force; the CEO of the regional medical center; Donna,
the PHN from the county PHD; the two visiting
nurses, Sonja and Vicki, and their DON; the PHD epi-
demiologist; and the publisher of the town newspaper.

The CHANGE committee and the core team next
began to work on developing the team strategy process
included in the CHANGE model. One of the visiting
nurses was worried that the project was no longer
under the control of the medical center. Donna ex-
plained that having the assessment come from the com-
munity rather than the medical center would truly
support the medical center’s “We are community!”
campaign. Further, she explained that the CHANGE
model would conclude with a community action plan.
She explained that having a clear picture of the health of
Small Town USA required buy-in from multiple con-
stituents within the community.

The core team expanded to reflect the diversity of
the community. The team talked with the town historian
to find former community initiatives and built communi-
cation strategies for keeping the community informed by
writing an article for the weekly newspaper, seeking
input and suggestions. After running the article, the edi-
tor reported getting many e-mails about the campaign
with suggestions for information that the team should
include. The committee worked to bring this input
together and came up with a final vision statement:
“Small Town, the place to be for healthy living.”

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C H A P T E R 4 n Introduction to Community Assessment 95

The next logical step was to map out the borders of
Small Town, located in the state of Massachusetts along
a small river, using local maps. The town included a total
of 75 square miles and was a 35-minute drive from the
medical center. Four towns bordered Small Town, three
of which had a smaller population than Small Town. The
town with the slightly higher population was to the east
of the town and could be reached by a main road that
went through Small Town. It took 20 to 25 minutes to
drive from the center of Small Town to the center of
each of the other four towns. Most of the population
lived in the center of town. The outskirts of town were
wooded and included a small state park.

Collect Secondary Data: Sociodemographic Data

Descendants from the Mayflower and their contempo-
raries initially settled the town. That gave the team a
starting point for the original culture—English and Puri-
tan. These early settlers had moved west to farm. Man-
ufacturing grew over time with the river providing a
source of power for mills. The founding families built
mills and brought more settlers to the area to work in
the mills. Merchants then came to sell goods to the
workers. The town developed an informal class system
of workers, owners, and merchants. Although the first
wave of workers was Irish, eventually most of the
workforce came from French Canada. The team found
that many of the residents of the town had last names
that were French. By World War I, the Irish section of
town was small and was considered the lowest rung of
the social classes. The church with the largest congrega-
tion was the Catholic Church, because this was a town
of few owners and many workers, almost all of whom
were Catholic. Thus, Small Town had a firm class struc-
ture as well as three major ethnic groups—English,
French Canadian, and Irish—for most of its history.

In the 1970s, when the town was the recipient of
state funds to build subsidized housing for families on
welfare, there was an influx of families into the town who
were at or below the poverty level, all of whom were
white and most of whom were single mothers. They be-
came the new lowest rung on the class ladder. By 2015, a
few Hispanic families from Puerto Rico were moving into
the town. Despite this modest influx, the majority (89%)
of the population still identified themselves as white.

Knowing the history, the team’s next step was to
complete a demographic assessment of the town
beginning with specific demographic indicators that
were available from the U.S. Census Bureau includ-
ing gender, age, race, home ownership, and income.
They constructed a population pyramid related

to the age of the population from estimates using
the 2016 American Community Survey data and the
2010 census data located on the U.S. Census Bureau
Web site American Fact Finder for 2010, and com-
pared it with the population of the United States
(Fig. 4-2).54

Male Female

-6
Percent

-4 -2 0

Ye
ar

s

100+
95–99
90–94
85–89
80–84
75–79
70–74
65–69
60–64
55–59
50–54
45–49
40–44
35–39
30–34
25–29
20–24
15–19
10–14

5–9
0–4

2 4 6

Male Female

-6
Percent

-4 -2 0

Ye
ar

s

100+
95–99
90–94
85–89
80–84
75–79
70–74
65–69
60–64
55–59
50–54
45–49
40–44
35–39
30–34
25–29
20–24
15–19
10–14

5–9
0–4

2 4 6

Figure 4-2 Population pyramids: Small Town (top) and
the United States (bottom). (Source: A, Data from Centers for
Disease Control and Prevention [2010]. Community Health
Assessment and Group Evaluation [CHANGE] action guide:
Building a foundation of knowledge to prioritize community
needs. Atlanta, GA: U.S. Department of Health and Human
Services; B, Data from U.S. Census Bureau, Population Division.)

A

B

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96 U N I T I n Basis for Public Health Nursing Knowledge and Skills

10

20

30

40

50

60

70

80

90

100
105

0
0

United States Virgin Islands: 2050

5 5

10

20

30

40

50

60

70

80

90

100
105

0
0

United States Virgin Islands: 2100

5 5
(Thousands)

10

20

30

40

50

60

70

80

90

100
105

0
0

United States Virgin Islands: 1950

5

FemalesMales

10

20

30

40

50

60

70

80

90

100
105

0
0

United States Virgin Islands: 2010

5 5

A population pyramid can tell you a lot about a
population. If the pyramid has a broad base and a small
top, it is an example of an expansive pyramid in which
there is most likely a rapid rate of population growth.
A population pyramid with indentations that even out
from top to bottom indicates slow growth. A stationary
pyramid has a narrow base, with equal numbers over
the rest of the age groups and tapering off in the oldest
age groups. A declining pyramid is one that has a high
proportion of people in the higher age groups. In 2010,
the population pyramid for North America met the
definition of a slow growth pyramid. The projected
2050 pyramid for North America is a classic example of
a stationary pyramid. By contrast, the population pyra-
mid for Somalia in 2010 demonstrated a clear example
of an expansive pyramid, indicative of rapid population

growth. However, it also indicated that the longevity of
the population was lower than in North America. By
2050 the population pyramid for Somalia is projected to
match the 2010 pyramid for North America, indicating
that population growth is projected to slow (Fig. 4-3).55

The team examined their population pyramid
and compared it to the U.S. Data (Fig. 4-2), and made
some conclusions about the population in Small Town.
What would they be? How does Small Town compare
with the United States? Note the larger base and the
wide top. This indicates that the population seems to
be made up of young families and older adults with a
smaller number of in the 45-year to 59-year range.
These data provided the team with a starting point for
understanding the possible reason for the increase in
requests for home health services.

Figure 4-3 United States
populations pyramids
compared with population
pyramids of Somalia. A,
United States; B, Somalia.
(Data from Worldlifeexpectancy
available at http://www.
worldlifeexpectancy.com/
world-population-pyramid.)A

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C H A P T E R 4 n Introduction to Community Assessment 97

10

20

30

40

50

60

70

80

90

100
105

0
0

Somalia: 2050

4 2 2 4

10

20

30

40

50

60

70

80

90

100
105

0
0

Somalia: 2100

4 2 2 4
(Millions)

10

20

30

40

50

60

70

80

90

100
105

0
0

Somalia: 1950

4 2

Males Females

2 4

10

20

30

40

50

60

70

80

90

100
105

0
0

Somalia: 2010

4 2 2 4

Figure 4-3—cont’d B

The epidemiologist from the county PHD recom-
mended that they track the population based on age
and race, and determine the percent change from
2010 to 2016 using census track data. Percent change
(see Chapter 3) represents the change in a variable
from one point in time to another. They were sur-
prised at the simplicity of the math required to
calculate the percent change. The epidemiologist
explained that they should subtract the old value
from the new value. They then would divide this by
the old value. Then when they multiplied the result
by 100, they had the percent change. He showed
them how to set it up in an Excel file so that they
could enter all the population numbers they were
interested in, set up the formula, and then have
a table ready for distribution to the committee
(Box 4-4, Table 4-4). Percent change can tell a lot

New value minus the old value divided by the old value
times 100 equals the percent change.
Example:
If the town’s population in 2000 was 2,000, and in 2010
it grew to 2,520, the percent change is 26%:

2,520 – 2,000 = 520

520/2,000 = 0.26 × 100 = 26%

BOX 4–4 n Percent Change

about a population. In the case of Small Town, the
percent change in the Hispanic population showed a
shift in the town. In 2010, almost 97% of the popula-
tion was white. In 2016, 89% of the population
was white. This information can also help estimate

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98 U N I T I n Basis for Public Health Nursing Knowledge and Skills

TABLE 4–4 n Percent Change for Demographic
Characteristics in Small Town USA,
2010–2016

2010 2016 % Change

Total

Male

Female

White

Black

American Indian

Asian

Other

Two or More
Races

Hispanic

Vacant Housing
Units

Population 25 Years
or Older

High School
Graduates

Bachelor’s Degree
or Higher

Mean Travel Time
to Work

Median Household
Income

Families Below
Poverty Level

9,611

4,766

4,845

9,223

77

29

60

98

124

195

213

6,056

4,974

848

29.5

$43,750.00

171

10,164

5,039

5,125

9,018

122

33

45

101

152

693

189

6,591

6%

6%

6%

–2%

58%

14%

–25%

3%

23%

255%

–11%

9%

changes in the population in the future. If the current
trend continues with a 2% decline in the white popu-
lation and a 255% increase in the Hispanic population
during the next 6 years, what would the population
look like in 2021?

Using Census Bureau data, the team looked at
gender, age, race, home ownership, poverty level,
crime, and fire safety. As discussed earlier in the
section Secondary Community Health Data Collec-
tion, secondary data are collected for a different
purpose from the current study or assessment. In
this case, the federal government collected census

data. These data are collected every 10 years, the
decennial census, to compile information about the
people living in the United States. In addition, the
census bureau conducts the American Community
survey to provide 5-year estimates. These data
provide the federal government with the information
needed for the apportionment of seats in the U.S.
House of Representatives. The U.S. Census Bureau
also conducts many other surveys and is a rich
source of secondary population data. The Census
Bureau provides these data in aggregate format
and by law cannot release data in a way that could
identify individuals.56

To access the census data, the team went to
the American FactFinder section of the U.S. Census
Bureau’s Web site and were able to print out a
sheet that included the estimates for 201654 including
general, social, economic, and housing characteristics.
Under economic characteristics, they found that,
in Small Town, 67% of the population older than
age 16 were in the workforce, and the median
household income was $42,625. The fact sheet
also listed comparative percentages for the United
States so that they could compare Small Town
with the nation. Small Town statistics were compara-
ble to the national statistics on all the economic
indicators except poverty. In Small Town, 18.5% of
the families lived below the poverty level compared
with 15% of the U.S. population. They were also
able to print out fact sheets for the county, the
state, and the surrounding towns, thus comparing
Small Town with its neighbors. The economic
indicators between the closest neighboring town
and Small Town differed in relation to income, with
Small Town having a lower median household income
($38,564 compared with $46,589), although the
poverty level statistics were approximately the same.
Again, compared with the state, the town had a
lower median income ($38,564 compared with
$75,297).

The team then reviewed the other demographic
categories. A few facts were noted as possibly being
important. First, the median value of the houses in
Small Town USA was lower than in the rest of the
state ($173,600 versus $358,000) and the percentage
of the population older than age 25 with a bachelor’s
degree or higher was lower than in the rest of the
state (14% versus 41%). Based on the review of the
demographics, a picture was beginning to emerge
of the town. What would your impressions be?

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C H A P T E R 4 n Introduction to Community Assessment 99

What further data would you need if you were
on this team?

Health Status Assessment Using
Secondary Data

At this point, Sonja wondered about the actual health
of the town. She reminded the team that this project
was started because of the increased requests for
visiting nursing services and suggested that the team
look at the Massachusetts Department of Health
Community Health Profile that included a health status
indicator report for Small Town. This report provided
information on health indicators and reduced the need
for the team to find these data themselves. This report
used secondary sources of data collected by PHDs,
referred to as vital records including information
on death certificates, reportable diseases, hospital
discharges, and infant mortality.

The health status indicators chosen by the
Massachusetts Department of Health included
perinatal and child health indicators, communicable
diseases, injury, chronic disease, substance use
and hospital discharge data. The core group brought
the published information to the larger community
group for discussion. One of the members of the
community group noted that at the top of the report
was a section on small numbers and wanted to know
what that meant. The epidemiologist explained that
the numbers of cases for each indicator are placed in
a cell in a table. Sometimes the numbers in these
cells for smaller towns contain small numbers. The
general rule of thumb, he explained, is that if there
are fewer than five observations (or cases) then
the rates are usually not reported. If they are
reported, then rates based on small numbers should
be interpreted very cautiously, because there are
not enough cases to create a base from which to
draw conclusions.

The perinatal and child health indicators included
births, infant deaths, and other perinatal and postnatal
data from 2016. They found a small numbers problem
right away with only one infant death in 2016. How-
ever, Small Town had a higher low-birth-weight rate
than the state (9.4 per 100 live births versus 7.4 per
100 live births). They also found that the rate of births
to teenage mothers was higher than the rate for the
state (12.5% versus 9.4%). There were no differences
in prenatal care in the first trimester or the percentage
of mothers receiving publicly funded prenatal care
compared with the rate for the state.

On most of the other indicators, Small Town had
lower or similar rates to the state. The rates that
were higher than the state rates were those for
cardiovascular deaths (397 per 100,000 deaths versus
214 per 100,000 deaths) and for hospital discharges
related to bacterial pneumonia (495.3 per 100,000 deaths
versus 329.6 per 100,000 deaths). The team also noted
that some of the rates were age-adjusted, and they
wanted to know more about the process. The county
epidemiologist explained that crude rates may not be
as good an indicator because populations may differ
on a characteristic, in this case age, which accounts
for some of the difference between the rates in two
populations. For example, if death rates for cardiovas-
cular disease in a city in Florida with a high proportion
of retirees in the community were compared with
the rates in a town that has a younger population,
the crude death rate would most likely be higher in
the Florida community. Adjusting the rate based on age
allows for comparing rates in such a way that controls
for the age variance between the two populations. The
age-adjusted rate is the total expected number of
deaths divided by the total standard population times
100,000, which is why the rate is expressed as per
100,000 deaths.
Comparing Rates
The team concluded that there was a difference
between Small Town and the state in relation to low
birth weight, teen births, bacterial pneumonia, and
cardiovascular disease–related deaths. A member of
the team living in the community wanted to know
whether these differences should cause concern.
The epidemiologist agreed to compare the town’s rates
with the rates of the state and the four towns adjacent
to Small Town to help determine whether the differences
were significant, that is, not attributable to chance. He
also explained that he would use a different approach
to compare the rates between Small Town and
Massachusetts than he would when comparing the
town with the rates of the other four towns. When
comparing the rates between the town and the state,
the rates are dependent, that is, the cases in the town
are included in the total number of cases for the state.
But when comparing the different towns with one
another they are independent rates, because the cases
in one town are not included in the number of cases
in the other town. When he was done, he reported
that all the rates were significantly higher than the
state rates. However, only three rates—bacterial pneu-
monia, teen births, and cardiovascular disease–related

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100 U N I T I n Basis for Public Health Nursing Knowledge and Skills

TABLE 4–5 n BRFSS Adult Data for Small Town

Prevalence in Prevalence in
Health Behavior Small Town USA Massachusetts

Current smoking
(2010-2016)

Binge drinking
(2010-2016)

Overweight

Leisure-time
activity

19%

18%

67%

68%

18%

17%

54%

74%

deaths—were significantly higher than the rates in the
adjoining towns.

The team was also interested in gathering secondary
data regarding behavioral risk factors. One of the mem-
bers reminded the group that the Behavioral Risk Fac-
tor Surveillance System (BRFSS) was available for the
community. Since 1984, the BRFSS has been tracking
health conditions and risk behaviors.41 The assessment
committee was interested in lifestyle factors affecting
premature mortality. The lifestyle risk factors that they
were particularly interested in were tobacco use, alco-
hol use, exercise, and nutritional patterns. Some of
these findings can be seen in Table 4-5. Based on these
data, they concluded that nutrition and obesity were
important risk factors that might help explain the
higher cardiovascular mortality rate.

Health Status Assessment Using Primary Data

At this point, one of the members of the community
who regularly attended the meetings stated that this
information was good, but it was all just numbers and
rates, and did not really capture how the individuals in
the town viewed their own health. Others agreed, and
they asked whether there was a way to collect data from
people living in the town about how healthy they thought
they were. They concluded that they could conduct a
survey. In addition, the committee members realized they
needed to complete an inventory of resources first
to have a better idea of the resources within the commu-
nity. They divided the community up and identified
common resources in which they were interested. They
wanted more information about schools, recreation
centers and activities, neighborhood associations,
churches, health-related clinics, hospitals, and agencies.
They used the CHANGE handbook to help guide their
data collection related to these organizations.33

Health Status Surveys

When this was complete, it was time to begin the
survey. Donna explained that a survey could be
constructed to collect health-related information from
individuals by using a paper-and-pencil method. Unlike
the secondary data they had been reviewing, a survey
relies on self-report in which individuals respond to
the survey designed for a speci