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2019v1.0
 Tenth Edition

Health
Promotion
THROUGHOUT THE LIFE SPAN
Carole Lium Edelman, MSN, GCNS-BC, CMC
Private Practice
Professional Geriatric Care Management
Westchester County, New York

Elizabeth Connelly Kudzma, DNSc, MPH, WHNP-BC, CNL

Professor Emeritus
School of Nursing
Curry College
Milton, Massachusetts
Elsevier
3251 Riverport Lane
St. Louis, Missouri 63043
HEALTH PROMOTION THROUGHOUT THE LIFE SPAN,
TENTH EDITION ISBN: 978-0-323-76140-6

Copyright © 2022 by Elsevier, Inc. All rights reserved.

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To our wonderful families, friends, students, and colleagues —
that they promote health in themselves and others.
CONTRIBUTORS

Erin Bompiani, PT, DPT, PCS June Andrews Horowitz, PhD, RN, PMHCNS-BC, FAAN
Assistant Professor Associate Dean for Graduate Programs & Research & Professor
Physical Therapy and Athletic Training College of Nursing
College of Health Professions University of Massachusetts Dartmouth
Pacific University Dartmouth, Massachusetts;
Hillsboro, Oregon Professor Emeritus
William F Connell School of Nursing
Michael Bridges, DPT Boston College
Associate Professor Chestnut Hill, Massachusetts
School of Physical Therapy and Athletic Training
Pacific University Susan Rowen James, PhD, RN
Hillsboro, Oregon Professor Emeritus
School of Nursing
Kevin K. Chui, PT, DPT, PhD, GCS, OCS, CEEAA, FAAOMPT Curry College
Chair and Professor Milton, Massachusetts
Waldron College of Health and Human Services
Radford University Marni B. Kellogg, PhD, RN, CPN, CNE
Roanoke, Virginia Assistant Professor
Community Nursing
Donna M. Dello Iacono, NP, PhD, CNL University of Massachusetts Dartmouth
Senior Lecturer North Dartmouth, Massachusetts
Nursing
Curry College Debora Elizabeth Kirsch, RN, MS, CNS, CNE
Milton, Massachusetts; Clinical Assistant Professor Retired
Nurse Practitioner College of Nursing
Nursing/Anesthesia SUNY Upstate Medical University
Brigham and Women’s Hospital Syracuse, New York
Boston, Massachusetts
Carolyn Cable Kleman, PhD, MHA, RN
Miriam Ford, PhD, FNP-BC Assistant Professor
Chief Nurse Administrator School of Nursing
Nursing University of North Carolina Wilmington
Mercy College Wilmington, North Carolina
Dobbs Ferry, New York
Louise LaFramboise, PhD, RN
Cassandra Marie Godzik, PhD, RN, PMHNP-BC, CNE Associate Professor and Interim Assistant Dean
Assistant Professor College of Nursing
Graduate School of Nursing University of Nebraska Medical Center
Regis College Omaha, Nebraska
Weston, Massachusetts
Kimberly L. Malin, BA, MS, DHSc
Susan A. Heady, PhD, RN
Assistant Professor
Professor
School of Physical Therapy and Athletic Training
Nursing Department
Pacific University
Webster University
Hillsboro, Oregon
St. Louis, Missouri
Amber S. McIlwain, MS
Jeremy E. Hillard, DPT
Assistant Professor
Associate Professor, Director of Clinical Education
School of Healthcare Administration and Leadership
School of Physical Therapy and Athletic Training
College of Health Professions
College of Health Professions
Pacific University
Pacific University
Hillsboro, Oregon
Hillsboro, Oregon

iv
 CONTRIBUTORS v

Staci Nix McIntosh, MS, RD Yvonne M. Smith, PhD, APRN-CNS

Assistant Professor (Lecturer) Assistant Professor
Director of Teaching and Learning College of Nursing
Department of Nutrition and Integrative Physiology Kent State University
University of Utah Kent, Ohio
Salt Lake City, Utah
Jody A. Spiess, PhD, RN, GCPH
Susan Moscou, FNP, MPH, PhD Assistant Professor
Associate Professor Webster University
Nursing Program St. Louis, Missouri
Mercy College
Dobbs Ferry, New York Lynnette Leeseberg Stamler, PhD, DLitt, RN, FAAN
Professor and Associate Dean for Academic Programs
Susan Natale, PhD, RN, NEA-BC College of Nursing
Associate Professor University of Nebraska Medical Center
School of Nursing Omaha, Nebraska
Curry College
Milton, Massachusetts Frank Tudini, PT, DSc, OCS, FAAOMPT
Associate Professor
Karen Goyette Pounds, PhD, PMHCNS, BC Department of Physical Therapy
Clinical Associate Professor College of Health, Education and Professional Studies
College of Nursing and Health Sciences The University of Tennessee at Chattanooga
University of Massachusetts Dartmouth Chattanooga, Tennessee
New Bedford, Massachusetts;
Psychiatric Clinical Nurse Specialist Diane Marie Welsh, DNP, APRN, CNE
Department of Psychiatry Dean
Boston Medical Center Young School of Nursing
Boston, Massachusetts Associate Professor of Nursing
Regis College
Emily Quinn, PhD, CCC-SLP Weston, Massachusetts
Assistant Professor of Pediatrics
School of Medicine Stacy Wong, PT, DPT, PCS
Oregon Health & Science University Associate Director of Clinical Education and Assistant Professor
Portland, Oregon School of Physical Therapy and Athletic Training
College of Health Professions
Anne Rath Rentfro, PhD, MSN, BSN Pacific University
Professor (retired) Portland, Oregon
College of Nursing
The University of Texas Sheng-Che Yen, PhD
Brownsville, Texas Associate Clinical Professor
Department of Physical Therapy, Movement and
Susan Scott Ricci, APRN, MSN, MEd, CNE Rehabilitation Sciences
Nursing Faculty Northeastern University
College of Nursing Boston, Massachusetts
University of Central Florida
Orlando, Florida

Leslie Kennard Scott, PhD, APRN, PPCNP-BC, CDE, MLDE

Associate Professor
College of Nursing
University of Kentucky
Lexington, Kentucky
CE
R OVNITERWI B
EUR ST O R S

Jessica Barkimer, PhD, RN, CNE Arlene McGuane, RN, MSN-Ed

Assistant Professor Assistant Professor of Practice
School of Nursing Nursing
MSOE University Russell Sage College
Milwaukee, Wisconsin Troy, New York

Brenda A. Battle, RN, BSN, MBA Susan Natale, PhD, RN, NEA-BC
Vice President, Urban Health Initiative and Chief Diversity, Associate Professor
Inclusion and Equity Officer School of Nursing
Office of Community Affairs and Diversity, Inclusion Curry College
and Equity Milton, Massachusetts
University of Chicago Medicine
Chicago, Illinois Maria Pratt, PhD, MScN, BScN, BA, RN
Assistant Professor
Karin L. Ciance, RN, BSN, MSN, DNP School of Nursing
Assistant Professor of Nursing McMaster University
Nursing Hamilton, Ontario, Canada
Anna Maria College
Paxton, Massachusetts Carol Rossman, DNP, FNP-BC, PPCNP-BC
Professor
Janice A. Edelstein, EdD, MSN, RN, PHCNS-BC, ANEF School of Nursing
Associate Professor Andrews University
Nursing Berrien Springs, Michigan
Marian University of Fond du lac
Fond du Lac, Wisconsin Felisa Smith, RN, BSN, MSA, MSN/Ed, CNE
Accelerated BSN Program Coordinator
Lisa Jaurigue, PhD, RN, CNE Nursing and Allied Health
Clinical Assistant Professor Norfolk State University
Edson College of Nursing and Health Innovation Norfolk, Virginia
Arizona State University
Phoenix, Arizona

Wendy Manetti, PhD, FNP

Assistant Professor
Nursing
University of Scranton
Scranton, Pennsylvania

vi

PURPOSE OF THE BOOK
The case for promoting and protecting health, and preventing
disease and injury, was established by accomplishments in the
20th and 21st century. Americans and global populations want
better care; public concerns about physical fitness, good nutri-
tion, and avoidance of health hazards such as environmental
pollution have been adopted in the lifestyles of global citizens.
Encouraging positive health changes has been a major effort of
individuals; the local, state, and federal governments; health
professionals; and society in general. In the United States, public
and private attempts to improve the health status of individuals
and groups traditionally have focused on reducing communica-
ble diseases and health hazards. These include the delivery and
best practices to improve access to and reduce costs of health
services and to improve the overall quality of life for all people.
Americans increasingly recognized that the health of each per-
son is influenced by the health environments of all individuals
worldwide.
Throughout the history of the United States, the public health
community has assessed the health of Americans. In 1789, the
Reverend Edward Wigglesworth developed the first American
mortality tables through his study in New England. Population
statistics gathered in England and America, including those of
Florence Nightingale, proved that scientific data could change
health outcomes. The Report of a General Plan for the Promotion
of Public and Personal Health was completed by Lemuel Shat-
tuck in 1880. Healthy People, The Surgeon General’s Report on
Health Promotion and Disease Prevention, was first published in
1979, and was followed by Healthy People 2000, 2010, and 2020.
The history of Healthy People is described comprehensively in
Chapter 1.
Professionals who undertake health-promotion strategies
need to understand the basics of health protection and disease
and injury prevention. Health protection is directed at popu-
lation groups of all ages and involves adherence to standards,
outcomes, infectious disease control, and governmental regu-
lation and enforcement. These activities emphasize reducing
exposure to various sources of hazards, including those related
to air, water, foods, drugs, motor vehicles, and other physical
agents. Health care providers present individuals, families, and
communities with disease- and injury-prevention services,
which include immunizations, screenings, health education,
and counseling. To implement prevention strategies effectively,
it is essential to develop activities targeted to and tailored for all
age groups in various settings including schools, industries, the
home, the health care delivery system, the larger community,
and the world.
Healthy People 2020 reflected earlier assessments of major
risks to health, changing public health priorities, and emerging
issues related to national and global health preparedness and
prevention. The following vision statement was established: A
society in which all people live long healthy lives.
P R E FA C E
The mission within this vision was improving health through
strengthening policy. Healthy People 2020 goals moved forward to:
• Identify nationwide health improvement priorities.
• Increase public awareness and understanding of the determi-
nants of health, disease, and disability and the opportunities
for progress.
• Provide measurable objectives and goals that can be used at
the national, state, and local levels.
• Engage multiple sectors to take action that are driven by the
best available evidence and knowledge.
• Identify critical research and data collection needs.
These overarching goals for Healthy People 2020 continued
the tradition of earlier Healthy People initiatives of advocating
for improvements in the health of every person in our country.
They addressed the environmental factors and placed particular
emphasis on the determinants of health:
• Eliminate preventable disease, disability, injury, and prema-
ture death.
• Achieve health equity, eliminate disparities, and improve the
health of all groups.
• Create social and physical environments that promote good
health for all.
• Promote healthy development and healthy behaviors across
every stage of life.
As this edition was undergoing revision and in the midst of the
COVID-19 pandemic, new goals and objectives were proposed
and formed for the next decade in Healthy People 2030. Healthy
People 2030 reduced the number of objectives to avoid overlap
and emphasize public health priorities. The vision statement for
Healthy People 2030 is “a society in which all people can achieve
their full potential for health and well-being across the life span.”
• The major goals of Healthy People 2030 are:
• 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 the 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.
Healthy People 2030 objectives are matched with data from
earlier objectives of Healthy People so that objective data and
investigations may be compared across decades. Healthy People
2030 objectives are also arranged for easier search into major
topic areas:
• Health conditions
• Health behaviors
vii
viii PREFACE
• Populations
• Settings and systems
• Social Determinants of Health
The databases within Healthy People continue to indicate
targets and assessments of health status and risk for evalua-
tions and future planning, not only for health policymakers
and health care providers but also for individuals, families, and
communities at the local, regional, national, and global levels.
APPROACH AND ORGANIZATION
This edition presents health data with related theories and skills
that are needed to understand and practice when providing care.
This book focuses on primary prevention intervention; its three
main components are (1) health promotion, (2) specific health
protection, and (3) prevention of specific diseases. Primor-
dial prevention is an earlier piece of primary prevention, which
addresses policy interventions to decrease risky lifestyle behav-
iors. Health promotion is the intervention designed to improve
health, such as providing adequate nutrition, a healthy environ-
ment, and ongoing health education. Specific protection and pre-
vention strategies, such as massive immunizations (for example,
COVID-19–related), periodic examinations, and safety features in
the workplace, are the interventions used to protect against illness.
In addition to primary prevention, this book discusses
secondary prevention interventions, focusing specifically on
screening and education. Such programs include blood pres-
sure, cholesterol, and diabetes screening and referral (the
acute components of secondary prevention are generally not
addressed in this book).
This text is presented in five parts, each forming the basis for
the next.
Unit 1, Foundations for Health Promotion, describes the
foundational concepts of promoting and protecting health and
preventing diseases and injuries, including diagnostic, thera-
peutic, and ethical decision-making.
Unit 2, Assessment for Health Promotion, focuses on individ-
uals, families, and communities and the factors affecting their
health. The functional health pattern assessments developed
by Gordon serve as the organizing framework for assessing the
health of individuals, families, and communities.
Unit 3, Interventions for Health Promotion, discusses theo-
ries, methodologies, and case studies of nursing interventions,
including screening, health-education counseling, stress man-
agement, and crisis intervention.
Unit 4, Application of Health Promotion, also uses Gor-
don’s functional health patterns, emphasizing developmental,
cultural, ethnic, and environmental variables in assessing the
developing person. The intent is to address the health concerns
of all Americans regardless of gender, race, age, or sexual orien-
tation. Although most human development theories discussed
may be based on the research of male subjects, newer theories
based on female subjects are included. The hope is to describe
human development that more accurately reflects the complex-
ity of human experiences throughout the life span.
Unit 5, Emerging Global Health Issues, presents a single chap-
ter that discusses changing population groups and their health
needs as well as related implications for research and practice in
the 21st century. Throughout the text, research abstracts have
been added to highlight the science of nursing practice and to
demonstrate to the reader the relationship among evidence,
practice, and outcomes.
Throughout these units, the evolving health care profes-
sions and the changing health care systems, including future
challenges and initiatives for health promotion, are described.
Emphasis is placed on the current concerns of reducing health
care costs while increasing life expectancy and improving the
quality of life for all Americans. This promotes the reader’s
immediate interest in thoughts about the content of the chapters.
Key Features
• A full-color design, including color photos and enhanced
graphics, is implemented throughout for better accessibility
of content and visual enhancement.
• Each chapter starts with a list of objectives to help focus the
reader and emphasize the content the reader should acquire
through reading the book.
• Key Terms including quality and safety terms are listed at the
front to acquaint readers with the important terminology of
the chapter.
• Each chapter’s narrative begins with a Think About It sec-
tion, the presentation of a clinical issue or scenario that
relates to the topic of the chapter, followed by critical think-
ing questions. This promotes the reader’s immediate interest
in and thought about the chapter.
• Evidence-Based Practice boxes provide brief synopses on
current health-promotion research studies that demonstrate
the links between research, theory, and practice.
• Health and Social Determinants/Health Equity boxes offer
cultural perspectives on various aspects of health promotion.
• Quality and Safety boxes provide information regarding
specific scenarios to improve health.
• Genomics boxes explore current genetic issues, controver-
sies, and dilemmas with respect to health promotion, provid-
ing an opportunity for critical analysis of care issues.
• Best Practice/Innovative Practice boxes highlight inventive
and resourceful projects, programs, and research studies that
draw upon new ways of implementing health promotion.
• Healthy People 2030 boxes present a list of selected objec-
tives that are relevant to each chapter’s topic.
• The Case Study highlights a realistic clinical situation rel-
evant to the chapter topic.
• Study Questions are located on the book’s website to offer
additional review and self-study practice.
New Features
1. An increased focus on social determinants, health equity, in-
clusion, and vulnerable populations
2. Recommendations provided in updated sources and evi-
dence throughout the text
3. An increased focus on genomics reflects increasing scientific
evidence supporting the health benefits of using genetic in-
formation and family health history to guide public health
interventions

4. Next-Generation NCLEX® (NGN) Examination–Style Case
Studies for Health Promotion added to Evolve help guide in-
structors on the new question formats on the NCLEX®
5. The latest information on updates in The Patient Protection
and Affordable Care Act
6. Expanded discussion of QSEN competencies related to health
promotion
7. Updated photos and graphics bring a fresh look and feel to
the text
Evolve Resources
The expanded website for this book provides materials for both
students and faculty and is accessible at http://evolve.elsevier
.com/Edelman/.
For Students
Study Questions: Multiple choice NCLEX® examination format
PREFACE ix
For Instructors
• Next-Generation NCLEX® (NGN) Examination–Style Case
Studies for Health Promotion
• TEACH for Nurses including Nursing Curriculum Stan-
dards, Teaching Activities, and Case Studies
• Image Collection with all images from the book
• Lecture Slides in PowerPoint
• Test Bank: 700 questions in NCLEX® examination format
The current trend to emphasize the developing health of peo-
ple mandates that health care professionals understand the many
issues that surround individuals, families, national and world com-
munities in social, work, and family settings, including biological,
inherited, cognitive, psychological, environmental, and sociocul-
tural factors that can put their health at risk. Most important is that
they develop interventions to promote health by understanding
the diverse roles these factors play in the person’s beliefs and health
practices, particularly in the areas of disease and injury prevention,
protection, and health promotion. Achieving such effectiveness
requires collaboration with other health care providers and the
integration of practice and policy while developing interventions
and considering the ethical issues within individual, family, and
both national and world communities’ responsibilities for health.
Carole Lium Edelman
Elizabeth Connelly Kudzma
ACKNOWLED GMENTS

We had the good fortune of receiving much assistance and support from many friends, relatives,
and associates. Our colleagues read chapters, gave valuable advice and constructive suggestions,
helped clarify concepts, and provided case examples.
We also acknowledge the contributions of all the authors. In developing this text, they gave the
project their total commitment and support. Their professional competence aided greatly in the
development of the final draft of the manuscript. Elizabeth Kudzma and I worked and learned
from each other during the planning and development of this book; throughout the entire pro-
cess, close contact prevailed.
Many thanks to the Elsevier editorial and production team: Elizabeth McCormick, Rachel
McMullen, and Heather Bays-Petrovic. We appreciate and thank them for their ongoing help and
support. It was a true pleasure working with them.
I am fortunate to have faith in the Lord, who gives me courage and strength to face life’s dif-
ficulties in a positive manner. In particular, over the past year, for my ability to successfully avoid
getting COVID-19 and continue to successfully work on this 10th edition. My children, John and
Megan Gillespie, Tom and Heather Gillespie, and Deirdre O’Brien, and my grandchildren, Ryan,
Caroline, Meredith, and Colleen, continue to bring joy to me as a mother and grandmother. Their
patience and love continue. Fredric Edelman provides much encouragement and support. Both
my brother and sister-in-law, John and Marilyn Lium, are inspirational to me and a remind me
that every day in life is precious.
Carole Lium Edelman

The insights and clinical experiences of Curry College traditional, accelerated, and master’s stu-
dents have provided commentary and a source of rich experience on which to draw. My faculty
colleagues also have assisted me in identifying important innovations in digital processes, testing,
education, and practice. These chapter manuscripts were assembled during the COVID-19 pan-
demic; I thank all the contributors who set aside time to write and update chapters while manag-
ing remote teaching and the concerns of their students about the spread of the virus. I also thank
the world-wide teachers and educators who use the book and who request separate editions and
language translations. My sister, Mary Draper, my brother Mark Connelly, and my daughter Kath-
erine, keep me grounded and informed of political and economic changes. And, thanks go most
of all to my husband, Daniel, who has provided support, wise discussion, and insight throughout
the phases of this endeavor.
Elizabeth Connelly Kudzma

x
 CONTENTS

UNIT 1 Foundations for Health Promotion Arab Americans, 31

Health Care Issues of Arab Americans, 32
1 Health Defined: Health Promotion, Protection, and Selected Health-Related Cultural Aspects, 33
Prevention, 1 Asian Americans, 33
Carolyn Cable Kleman, Yvonne M. Smith Health Care Issues of Asian Americans, 34
Exploring Concepts of Health, 2 Selected Health-Related Cultural Aspects, 35
Models of Health, 3 Native Hawaiians and Other Pacific Islanders, 36
Wellness-Illness Continuum, 5 Native Hawaiians/Pacific Islander Health Issues, 37
Strategies to Address Health Disparities Among
High-Level Wellness, 5
Native Hawaiians/Pacific Islanders, 38
Health Ecology, 5
Latino/Hispanic Americans, 39
Functioning, 5
Health Issues of Latino/Hispanic Americans, 39
Health, 6
Selected Health-Related Cultural Aspects, 40
Illness, Disease, and Health, 6
Black/African Americans, 40
Planning for Health, 6
Health Issues of Black/African Americans, 40
Healthy People 2020/2030, 7
Selected Health-Related Cultural Aspects, 41
Goals, 7
American Indians/Alaska Natives, 42
Healthy People 2030, 9
Health Care Issues of American Indians/Alaska
Levels of Prevention, 10
Natives, 42
Primordial Prevention, 10
Selected Health-Related Cultural Aspects, 43
Primary Prevention, 10
Lesbian, Gay, Bisexual, and Transgender People, 43
Secondary Prevention, 13
LGBT Health Issues, 44
Tertiary Prevention, 14
Strategies to Reduce Health Disparities in LGBT
Quaternary Prevention, 14
Populations, 45
Levels of Prevention Strategies, 14
Homelessness: A Continuing Saga, 45
The Intersectionality of Public Health, Population
The Nation’s Response to the Health Challenge, 48
Health, and Health Promotion, 14
Nursing’s Response to Vulnerable Populations and
The Nurse’s Role, 14
Health, 50
Nursing Roles in Health Promotion and Protection, 15
3 Health Policy and the Delivery System, 59
Improving Prospects for Health, 16
Debora Elizabeth Kirsch
Population Effects, 16
The Health of the Nation, 62
Shifting Problems, 17
Healthy People 2030, 63
Moving Toward Solutions, 17
Health Indicators of a Nation, 64
Tying It All Together Using the Nursing Process, 18
Historical Role of Women in Health Promotion, 68
Problem Identification, 18
A Safer System, 68
Planning Interventions, 19
Global Health, 69
What Was the Actual Cause of Frank’s Problem?, 20
Historical Perspectives, 69
Evaluation of the Situation, 20
History of Health Care, 70
2 Vulnerable Populations and Health, 25
Early Influences, 70
Kimberly L. Malin, Amber S. Mcllwain, Frank Tudini, Sheng-Che Yen,
Industrial Influences, 70
Kevin K. Chui
Socioeconomic Influences, 70
Social Determinants of Health and Health Equity, 25
Public Health Influences, 70
Vulnerable Populations in the United States, 27
Scientific Influences, 71
Ethnicity, Ethnic Group, Minority Group, Race, and
Political and Economic Influences, 72
Racism, 28
Split Between Preventive and Curative Measures, 72
Culture, Values, and Value Orientation, 28
Organization of the Delivery System, 72
Cultural and Linguistic Competency, 28
Private Sector, 72
Immigrants/Refugees, 30
Move to Managed Care, 73
Health Issues of Immigrants/Refugees, 30
Public Sector, 77
Strategies to Reduce Health Disparities in
Financing Health Care, 83
Immigrant/Refugee Population, 30
Costs, 83
Folk Healing and Nursing Care Systems, 31
Sources, 84

xi
xii CONTENTS
Employer Health Benefits, 84
Mechanisms, 86
Managed Care Issues, 87
Health Insurance, 88
Pharmaceutical Costs, 90
The Uninsured: Who Are They?, 91
Health Care Systems of Other Countries, 92
Canadian Health Care System, 92
4 The Therapeutic Relationship, 96
June Andrews Horowitz, Karen Goyette Pounds
Values Clarification, 97
Definition, 97
Values and Therapeutic Use of Self, 98
The Communication Process, 99
Function and Process, 101
Types of Communication, 102
Effectiveness of Communication, 103
Interprofessional Communication and
Teamwork, 105
Factors in Effective Communication, 105
Health Literacy, 107
The Helping or Therapeutic Relationship, 107
Characteristics of the Therapeutic Relationship, 108
Ethics in Communicating and Relating, 109
Therapeutic Techniques, 109
Barriers to Effective Communication, 112
Setting, 114
Stages, 114
5 Ethical Issues Related to Health Promotion, 121
Yvonne M. Smith, Carolyn Cable Kleman
Health Promotion as a Moral Endeavor, 122
Health Care Ethics, 123
Origins of Applied Ethics in Moral Philosophy, 123
Types of Normative Ethical Theories, 123
Limitations of Moral Theory, 124
Feminist Ethics and Caring, 127
Professional Responsibility, 128
Accountability to Individuals and Society, 128
Codes of Ethics, 128
Advocacy, 129
Problem-Solving: Issues, Dilemmas, Moral Distress,
and Moral Injury, 129
Preventive Ethics, 130
Ethical Principles in Health Promotion, 131
Autonomy as Civil Liberty, 132
Autonomy as Self-Determination, 132
Exceptions to Autonomous Decision-Making, 134
Confidentiality, 135
Veracity, 136
Nonmaleficence, 137
Beneficence, 138
Justice, 139
Strategies for Ethical Decision-Making, 139
Locating the Source and Levels of Ethical
Problems, 139
Values Clarification and Reflection, 140
Use a Decision-Making Framework, 140
Ethics of Health Promotion: Cases, 141
Case 1: Addressing Health Care System Problems—
Elissa Needs Help, 141
Case 2: She’s My Client!—Lilly and “Jake”
(a.k.a. Paul), 142
Case 3: Don’t Touch My Things! Ms. Smyth and
Autonomy, 142
UNIT 2 Assessment for Health Promotion
6 Health Promotion and the Individual, 145
Anne Rath Rentfro
Gordon’s Functional Health Patterns: Assessment of
the Individual, 148
Functional Health Pattern Framework, 148
The Patterns, 151
Health Perception–Health Management Pattern, 152
Nutritional-Metabolic Pattern, 152
Elimination Pattern, 154
Activity-Exercise Pattern, 155
Sleep-Rest Pattern, 157
Cognitive-Perceptual Pattern, 157
Self-Perception–Self-Concept Pattern, 159
Roles-Relationships Pattern, 160
Sexuality-Reproductive Pattern, 160
Coping–Stress Tolerance Pattern, 161
Values-Beliefs Pattern, 162
Individual Health Promotion Through the Nursing
Process, 163
Collection and Analysis of Data, 163
Planning Care, 165
Implementation, 165
Evaluation, 165
7 Health Promotion and the Family, 170
Anne Rath Rentfro
The Nursing Process and the Family, 172
The Nurse’s Role, 173
Family Theories and Frameworks, 173
The Family from a Developmental Perspective, 173
The Family from a Structural-Functional
Perspective, 175
The Family from a Risk-Factor Perspective, 175
Gordon’s Functional Health Patterns: Assessment of
the Family, 178
Health Perception–Health Management Pattern, 178
Nutritional-Metabolic Pattern, 179
Activity-Exercise Pattern, 179
Sleep-Rest Pattern, 180
Cognitive-Perceptual Pattern, 180
Self-Perception–Self-Concept Pattern, 180
Roles-Relationships Pattern, 181
Sexuality-Reproductive Pattern, 186
Coping–Stress Tolerance Pattern, 187
Values-Beliefs Pattern, 187
Environmental Factors, 188
Nursing Analysis, 189
Analyzing Data, 189

Planning With the Family, 194
Goals, 195
Implementation With the Family, 195
Evaluation With the Family, 197
8 Health Promotion and the Community, 202
Anne Rath Rentfro
The Nurse’s Role, 206
Influencing Health Policy, 206
The Nursing Process and the Community, 208
Methods of Data Collection, 209
Sources of Community Information, 211
Community from a Systems Perspective, 211
Structure, 211
Function, 212
Interaction, 213
Community from a Developmental Perspective, 213
Community from a Risk-Factor Perspective, 213
Gordon’s Functional Health Patterns: Assessment of
the Community, 214
Health Perception–Health Management Pattern, 214
Nutritional-Metabolic Pattern, 214
Elimination Pattern, 215
Activity-Exercise Pattern, 215
Sleep-Rest Pattern, 215
Cognitive-Perceptual Pattern, 216
Self-Perception–Self-Concept Pattern, 216
Roles-Relationships Pattern, 216
Sexuality-Reproductive Pattern, 216
Coping–Stress Tolerance Pattern, 216
Values-Beliefs Pattern, 217
Analysis With the Community, 217
Organization of Data, 217
Guidelines for Data Analysis, 217
Community Analysis, 219
Planning With the Community, 220
Purposes, 220
Planned Change, 221
Implementation With the Community, 221
Evaluation With the Community, 222
UNIT 3 Interventions for Health Promotion
9 Screening and Health Promotion, 226
Elizabeth Connelly Kudzma
Advantages and Disadvantages of Screening, 228
Advantages, 228
Disadvantages, 229
Selection of a Screened Disease, 229
Significance of the Disease for Screening, 229
Detection, 231
Should Screening for the Disease Be Done?, 234
Ethical Considerations, 235
Borderline Cases and Cutoff Points, 235
Economic Costs and Ethics, 235
Selection of Screenable Populations, 236
Person-Dependent Factors, 236
CONTENTS xiii
Environment-Dependent Factors, 238
National Guidance and Health Care Reform, 238
The Nurse’s Role, 241
Racial and Ethnic Approaches to Community Health, 241
10 Health Education, 245
Susan A. Heady, Jody A. Spiess
Nursing and Health Education, 246
Definition, 247
Goals, 247
Learning Assumptions, 250
Family Health Teaching, 250
Health Behavior Change, 250
Ethics, 251
Genomics and Health Education, 252
Diversity and Health Teaching, 252
Community and Group Health Education, 253
Teaching Plan, 254
Determining Expected Learning Outcomes, 254
Selecting Content, 255
Designing Learning Strategies, 256
Evaluating the Teaching-Learning Process, 257
Referring Individuals to Other Resources, 257
Teaching and Organizing Skills, 258
11 Nutrition Counseling for Health Promotion, 261
Staci Nix McIntosh
Nutrition in the United States, 262
Classic Vitamin-Deficiency Diseases, 262
Nutrition-Related Health Status, 262
Dietary Inadequacy, 263
Dietary Excesses, 263
Food and Nutrition Recommendations, 264
Healthy People Initiative: Nutrition Objectives, 264
Dietary Guidelines for Americans, 265
MyPlate Guidelines, 266
Dietary Reference Intakes, 266
Dietary Supplements and Herbal Medicines, 268
Micronutrient Toxicity, 269
Circumstances When Nutrient Supplementation Is
Indicated, 271
Food Safety, 271
Food-Borne Illness, 271
Common Food-Borne Pathogens, 272
Food Safety Practices, 272
Food, Nutrition, and Poverty, 273
Poverty and Income Distribution, 273
Food Assistance for Low-Income Individuals, 273
Nutrition Screening, 276
Nutrition-Related Chronic Disease, 277
Cardiovascular Disease, 277
Nutrition Intervention for Atherosclerosis, 277
Epidemiology, 279
Nutrition Intervention for Hypertension, 280
Dietary Approaches to Stop Hypertension, 280
Cancer, 280
Osteoporosis, 282
Calcium, 282
Vitamin D, 283
xiv CONTENTS

Obesity, 283 Assertive Communication, 345

Diabetes Mellitus, 284 Empathy, 346
Human Immunodeficiency Virus and Acquired Healthy Pleasures, 347
Immunodeficiency Syndrome, 287 Spiritual Practice, 347
12 Physical Activity, 293 Clarifying Values and Beliefs, 347
Frank Tudini, Kevin K. Chui, Michael Bridges, Jeremy E. Hilliard, Setting Realistic Goals, 348
Sheng-Che Yen Humor, 349
Defining Physical Activity in Health, 293 Engaging in Pleasurable Activities, 349
Healthy People 2020 and 2030 Objectives, 294 Effective Coping, 349
Physical Activity Objectives: Making Progress, 294 14 Complementary, Integrative, and Alternative
Aging, 296 Strategies, 354
Effects of Exercise on the Aging Process, 297 Donna M. Dello Iacono
Cardiac Risk Factors, 298 Background, 355
High-Density Lipoprotein and Serum Some Known Facts, 355
Triglyceride Levels, 298 What Is the Difference Between Holism and
Hypertension, 298 Allopathy?, 355
Hyperinsulinemia and Glucose Intolerance, 300 Person-Centered Care, 356
Obesity, 301 Health and Wellness, 357
Osteoporosis, 302 Health Policy, 357
Arthritis, 303 Interventions, 360
Low Back Pain, 306 Whole Medical Systems, 360
Immune Function, 307 Biologically Based Practices/Natural Products, 361
Mental Health, 308 Manipulative and Body-Based Practices, 361
Exercise Prescription, 309 Mind-Body Medicine, 362
Aerobic Exercise, 310 Energy Therapies, 363
Warm-Up and Cool-Down Periods, 311 Nursing Presence, 365
Flexibility, 312 Safety and Effectiveness, 366
Resistance Training, 312
Exercise the Spirit: Relaxation Response, 312
Monitoring the Inner and the Outer Environment, 313 UNIT 4 Application of Health Promotion
Hydration, 314
Special Considerations, 314 15 Overview of Growth and Development Framework, 370
Coronary Heart Disease, 314 Elizabeth Connelly Kudzma
Diabetes, 315 Overview of Growth and Development, 371
Building a Rhythm of Physical Activity, 316 Growth, 371
Adherence and Compliance, 316 Concept of Development, 379
Creating a Climate That Supports Exercise, 318 Theories of Life Span Development, 380
13 Stress Management, 330 Psychosocial Development: Erikson’s Theory, 381
June Andrews Horowitz, Marni B. Kellogg Cognitive Development, 381
Sources of Stress, 331 Cognitive Development: Piaget’s Theory, 381
Physical, Psychological, Sociobehavioral, and Cognitive Development: Vygotsky’s Theory, 382
Spiritual/Homeodynamic Consequences of Moral Development: Kohlberg’s Theory, 383
Stress, 333 Moral Development: Gilligan’s Theory, 383
Physiological Effects of Stress, 333 Behavioral Biological Development, 384
Psychological Effects of Stress, 334 16 The Childbearing Period, 387
Sociobehavioral Effects of Stress, 335 Susan Scott Ricci
Spiritual Effects of Stress, 335 Biology and Genetics, 388
Health Benefits of Managing Stress, 335 Duration of Pregnancy, 388
Assessment of Stress, 336 Fertilization, 388
Stress-Management Interventions, 337 Implantation, 388
Developing Self-Awareness, 338 Fetal Growth and Development, 388
Nutrition: Healthy Diet, 342 Placental Development and Function, 389
Physical Activity, 342 Maternal Changes, 389
Cognitive-Behavioral Restructuring, 343 Changes During Transition From Fetus to
Affirmations, 345 Newborn, 397
Social Support, 345 Nursing Interventions, 397

Apgar Score, 397
Sex, 398
Race and Culture, 398
Genetics, 399
Gordon’s Functional Health Patterns, 399
Health Perception–Health Management Pattern, 399
Nutritional-Metabolic Pattern, 400
Elimination Pattern, 403
Activity-Exercise Pattern, 403
Sleep-Rest Pattern, 404
Cognitive-Perceptual Pattern, 405
Self-Perception–Self-Concept Pattern, 407
Roles-Relationships Pattern, 407
Sexuality-Reproductive Pattern, 409
Coping–Stress Tolerance Pattern, 410
Values-Beliefs Pattern, 410
Environmental Processes, 411
Physical Agents, 411
Biologic Agents, 411
Chemical Agents, 416
Mechanical Forces, 419
Radiation, 420
Determinants of Health, 420
Social Factors and Environment, 420
Levels of Policy Making and Health, 421
Health Services/Delivery System, 423
Nursing Application, 423
17 Infant, 429
Susan Scott Ricci
Biology and Genetics, 430
Developmental Tasks, 430
Concepts of Infant Development, 433
Sex, 435
Race, 435
Genetics, 436
Gordon’s Functional Health Patterns, 437
Health Perception–Health Management Pattern, 437
Nutritional-Metabolic Pattern, 437
Elimination Pattern, 442
Activity-Exercise Pattern, 443
Sleep-Rest Pattern, 444
Cognitive-Perceptual Pattern, 446
Self-Perception–Self-Concept Pattern, 448
Roles–Relationships Pattern, 448
Sexuality–Reproductive Pattern, 450
Coping–Stress Tolerance Pattern, 450
Values–Beliefs Pattern, 451
Environmental Processes, 452
Physical Agents, 452
Biological Agents, 454
Chemical Agents, 456
Motor Vehicles, 459
Radiation, 460
Determinants of Health, 460
Social Factors and Environment, 460
Levels of Policy Making and Health, 464
CONTENTS xv
Health Services/Delivery System, 465
Nursing Application, 465
18 Toddler, 471
Diane Marie Welsh, Cassandra Marie Godzik
Biology and Genetics, 472
Gordon’s Functional Health Patterns, 474
Health Perception–Health Management
Pattern, 474
Nutritional-Metabolic Pattern, 474
Elimination Pattern, 476
Activity-Exercise Pattern, 477
Sleep-Rest Pattern, 477
Cognitive-Perceptual Pattern, 478
Self-Perception–Self-Concept Pattern, 481
Nursing Interventions for Self-Perception/Self-
Concept Pattern, 481
Roles-Relationship Pattern, 482
Sexuality-Reproductive Pattern, 483
Coping–Effective/Ineffective Stress
Tolerance Pattern, 483
Values-Beliefs Pattern, 484
Environmental Processes, 484
Physical Agents, 484
Biological Agents, 486
Chemical Agents, 486
Levels of Policy Making and Health, 488
Health Services/Delivery System, 488
Nursing Application, 489
19 Preschool Child, 492
Erin Bompiani, Stacy Wong, Emily Quinn, Kevin K. Chui
Biology and Genetics, 494
Gender, 496
Race, 496
Genetics, 496
Gordon’s Functional Health Patterns, 496
Health Perception–Health Management
Pattern, 496
Nutritional-Metabolic Pattern, 497
Elimination Pattern, 498
Activity-Exercise Pattern, 499
Sleep-Rest Pattern, 500
Cognitive-Perceptual Pattern, 502
Self-Perception–Self-Concept Pattern, 508
Roles-Relationships Pattern, 509
Sexuality-Reproductive Pattern, 510
Coping–Stress Tolerance Pattern, 510
Values-Beliefs Pattern, 512
Environmental Processes, 512
Physical Agents, 512
Biological Agents, 515
Chemical Agents, 516
Determinants of Health, 519
Social Factors and Environment, 519
Levels of Policy Making and Health, 520
Health Services/Delivery System, 521
Nursing Application, 521
xvi CONTENTS
20 School-Age Child, 528
Leslie Kennard Scott
Biology and Genetics, 529
Elevated Blood Pressure, 529
Physical Growth, 530
Gordon’s Functional Health Patterns, 531
Health Perception–Health Management
Pattern, 531
Nutritional-Metabolic Pattern, 533
Elimination Pattern, 535
Activity-Exercise Pattern, 536
Sleep-Rest Pattern, 536
Cognitive-Perceptual Pattern, 537
Self-Perception–Self-Concept Pattern, 541
Roles-Relationships Pattern, 542
Sexuality-Reproductive Pattern, 544
Coping–Stress Tolerance Pattern, 544
Values-Beliefs Pattern, 546
Environmental Processes, 546
Physical Agents, 546
Accidents, 546
Biological Agents, 549
Chemical Agents, 550
Cancer, 551
Determinants of Health, 552
Social Factors and Environment, 552
Levels of Policy Making and Health, 554
Health Services/Delivery System, 555
Nursing Application, 556
21 Adolescent, 562
Susan Rowen James
Biology and Genetics, 563
Sex and Puberty, 563
Gordon’s Functional Health Patterns, 566
Health Perception–Health Management
Pattern, 566
Nutritional-Metabolic Pattern, 568
Elimination Pattern, 569
Activity-Exercise Pattern, 569
Sleep-Rest Pattern, 570
Cognitive-Perceptual Pattern, 570
Self-Perception–Self-Concept Pattern, 571
Roles-Relationships Pattern, 572
Sexuality-Reproductive Pattern, 573
Coping–Stress Tolerance Pattern, 575
Values-Beliefs Pattern, 577
Environmental Processes, 577
Physical Agents, 577
Biological Agents, 579
Chemical Agents, 581
Determinants of Health, 582
Social Factors and Environment, 582
Levels of Policy Making and Health, 583
Health Services/Delivery System, 583
Nursing Application, 584
22 Young Adult, 588
Susan Natale
Biology and Genomics, 589
Gordon’s Functional Health Patterns, 590
Health Perception–Health Management
Pattern, 590
Nutritional-Metabolic Pattern, 595
Elimination Pattern, 596
Activity-Exercise Pattern, 597
Sleep-Rest Pattern, 598
Cognitive-Perceptual Pattern, 598
Self-Perception–Self-Concept Pattern, 599
Roles-Relationships Pattern, 600
Sexuality-Reproductive Pattern, 602
Coping–Stress Tolerance Pattern, 606
Values-Beliefs Pattern, 607
Environmental Processes, 608
Physical Agents, 608
Biological Agents, 609
Chemical Agents, 609
Determinants of Health, 611
Social Factors and Environment, 611
Levels of Policy Making and Health, 611
Health Services/Delivery System, 611
Nursing Application, 612
23 Middle-Age Adult, 619
Susan Moscou, Miriam Ford
Biology and Genetics, 620
Life Expectancy and Mortality Rates, 621
Gender and Relationship Status, 623
Social Determinants of Health, 623
Genetics, 623
Gordon’s Functional Health Patterns, 623
Health Perception–Health Management
Pattern, 623
Habits, 623
Health Indicators, 624
Nutritional-Metabolic Pattern, 624
Oral Health, 626
Elimination Pattern, 627
Activity-Exercise Pattern, 627
Sleep-Rest Pattern, 628
Cognitive-Perceptual Pattern, 628
Skill Acquisition, 628
Perceptual Changes, 629
Self-Perception–Self-Concept Pattern, 630
Roles-Relationships Pattern, 631
Caring for Aging Parents, 633
Divorce and Separation, 634
Death, 634
Sexuality-Reproductive Pattern, 634
Coping–Stress Tolerance Pattern, 636
Stress and Heart Disease, 636
Values-Beliefs Pattern, 637
Environmental Processes, 637

Physical Agents, 637
Biological Agents, 638
Chemical Agents, 638
Tobacco, 638
Determinants of Health, 638
Social Factors and Environment, 638
Nursing Application, 640
24 Older Adult, 647
Miriam Ford, Susan Moscou
Poverty, 648
Healthy People 2020 and Healthy People 2030, 649
Biology and Genetics, 650
Theories of Aging, 651
Gordon’s Functional Health Patterns, 652
Health Perception–Health Management
Pattern, 652
Nutritional-Metabolic Pattern, 653
Elimination Pattern, 655
Activity-Exercise Pattern, 656
Sleep-Rest Pattern, 657
Cognitive-Perceptual Pattern, 658
Self-Perception–Self-Concept Pattern, 661
Roles-Relationships Pattern, 662
Sexuality-Reproductive Pattern, 663
Coping–Stress Tolerance Pattern, 664
Values-Beliefs Pattern, 665
CONTENTS xvii
Environmental Processes, 665
Physical Agents, 665
Biologic Agents, 668
Chemical Agents, 669
Social Determinants of Health, 670
Social Factors and Environment, 670
Levels of Policy Making and Health, 674
Health Services/Delivery Systems, 675
Nursing Application, 675
UNIT 5 Emerging Global Health Issues
25 Health Promotion for the 21st Century: Throughout the Life
Span and Throughout the World, 680
Lynnette Leeseberg Stamler, Louise LaFramboise
Introduction, 681
Air Pollution and Climate Change, 683
Noncommunicable Diseases, 685
Communicable Diseases, 686
COVID-19 Pandemic, 686
Fragile and Vulnerable Settings, 688
Antimicrobial Resistance, 689
Vaccine Hesitancy, 690
Weak Primary Care and Poor Access, 691
UNIT 1 Foundations for Health Promotion

1
Health Defined: Health Promotion,
Protection, and Prevention
Carolyn Cable Kleman, Yvonne M. Smith

http://evolve.elsevier.com/Edelman/

OBJECTIVES
After completing this chapter, the reader will be able to:
• Analyze concepts and models of health as used historically
and as used in this textbook.
• Evaluate the consistency of Healthy People 2020/2030 goals
with various concepts of health.
• Analyze the progress made in this nation from the original
Healthy People document to the foci in Healthy People
2020.
• Differentiate between health, illness, disease, disability, and
premature death.
• Compare the four levels of prevention (primordial,
primary, secondary, and tertiary) with the levels of service
provision available across the life span.
• Critique the role of research and evidence as well as the nurse's
role in health education and research for the promotion and
protection of health for individuals and populations.

KEY TERMS
Adaptive model of health Eudaimonistic model of health Person-centered care
Applied research Evidence-based practice Qualitative studies
Asset planning Functional health Quality of life
Clinical model of health Health Quantitative studies
Community-based care Health disparities Role performance model of health
Cultural competence Health in all Policies Social determinants of health
Disease Health promotion Social ecological model of health
Ecological model of health Health-related quality of life (HRQoL) Specific protection
Empathy High-level wellness Well-being
Epidemiology Illness Wellness
Ethnocentrism Interprofessional practice Wellness-illness continuum
Eudaimonistic Levels of prevention

THINK ABOUT IT
Use of Complementary and Alternative Therapies
One of the biggest challenges to health care providers is the blending of Western
medicine and health practices with the health practices from other cultures and
ethnic groups. The federal government formed the National Center for Comple-
mentary and Alternative Medicine (NCCAM; http://nccam.nih.gov) to conduct
and support basic and applied research and training and to disseminate informa-
tion on complementary and alternative medicine to practitioners and the public.
As demographics of the United States shift, more people use a combination of
therapies in self-care and for the treatment of specific illnesses.
• What questions should you ask to obtain information from people about their
use of nontraditional therapies?
• What information should you know about the benefits or limitations of using
complementary therapies, such as acupuncture, spiritual healing, herbal rem-
edies, or chiropractic?
• What resources should you trust for information on the efficacy and use of
herbal remedies relative to prescription medications?
• Which ideas of health would be most compatible with the use of alternative
therapies?
• How can alternative therapies be integrated into the newer Healthy People
2030 objectives?

1
2 UNIT 1 Foundations for Health Promotion
Health is a core concept in society. This concept is modified
with qualifiers such as excellent, good, fair, or poor, on the basis
of a variety of factors. These factors may include age, sex, race
or ethnic heritage, comparison group, current health or physical
condition, past conditions, social or economic situation, geo-
graphical location, or the demands of various roles in society.
In addition, there is growing evidence that larger societal and
environmental concerns determine health outcomes. This chap-
ter will discuss health as a concept and related concepts such
as wellness, illness, disease, disability, and functioning. These
concepts are frequently embedded in theories, such as theories
of health behavior or health planning (Gehlert & Ward, 2019).
Some motivating factors behind the move to disease preven-
tion and health promotion in society will be examined with
an introduction to Healthy People, the federal government’s
health objectives for the nation. The implementation of these
concepts as nursing actions will also be addressed from ideal
and pragmatic standpoints. Research and evidence supporting
these concepts, and recommendations for further research, will
be presented.
Nurses understand the pivotal role they play in promot-
ing health and preventing disease, the important role of
research in the knowledge of what is “healthy,” and the cen-
tral role of epidemiology (the study of health and disease in
society) and public health theories in the everyday practice
of nursing.
EXPLORING CONCEPTS OF HEALTH
Definitions of health in the nursing literature can be classi-
fied broadly within two major paradigms. The first paradigm
is the wellness-illness continuum, a dichotomized portrayal
of health and illness ranging from high-level wellness at the
positive end to depletion of health at the negative end. High-
level wellness is further conceptualized as a sense of well-
being, life satisfaction, and quality of life. Movement toward
the negative end of the continuum includes adaptation to dis-
ease and disability through various levels of functional ability
(Newman, 2003; Travis & Ryan, 2004; de Hond, Bakx, & Ver-
steegh, 2019). The wellness-illness conceptualization was the
focus of early research and is consistent with some of the cat-
egories Smith (1983) identified in her philosophical analysis of
health. Research based on this paradigm conforms primarily
to scientific methods that seek to control contextual effects,
provide the basis for causal explanations, and predict future
outcomes (Hardin & Kaplow, 2017).
The second paradigm characterizes health as a perspec-
tive developmental phenomenon of unitary patterning of the
person-environment. The developmental perspective of health
has been present in the nursing literature since 1970, but it was
not identified clearly with health until the late 1970s and early
1980s. It has been conceptualized as expanding conscious-
ness, pattern or meaning recognition, personal transformation,
and, tentatively, self-actualization. This shift toward a develop-
mental perspective has had clear implications for the way in
which health is conceptualized (Newman, 2003; Endo, 2017).
Although not endorsing the developmental perspective to the
extent of Rogers (1970) and Reed (1983); Murdaugh and col-
leagues (2019) and Allen and Warner (2002) state that health
is an outcome of ongoing patterns of person and environment
interactions throughout the life span. Research within this
paradigm seeks to address the dynamic whole of the health
experience through behavioral and social mechanisms over
time. Health can be better understood if each person is seen
as a part of a complex, interconnected biologic and social
system. Research based on this paradigm conforms primar-
ily to constructivist scientific methods that seek to describe
and understand health experiences in more depth (Orchard &
Mahler, 2018).
The social ecological model of health (Bronfenbrenner,
1977; Shelton, 2019) is a comprehensive developmental
approach and is useful for promoting health at individual,
family, community, and societal levels (Fig. 1.1). This model
emphasizes the social determinants of health—those factors
in society that have an influence on health and the options
available to people to improve or maintain their health, and
how they impact people at all environmental levels from indi-
vidual to the policy level. In this way, the ecological model of
health is more compatible with Smith’s descriptions of health
as adaptation and eudemonia (self-actualization). The social
determinants of health also form the basis for Healthy People
2020 and the newer 2030 Healthy People objectives (US Depart-
ment of Health and Human Services, Office of Disease Preven-
tion and Health Promotion, 2020). Each of these ideas will be
examined in more detail throughout this chapter.
People involved in health promotion must consider the
meaning of health for themselves and for others. Recogniz-
ing differences in the meaning of health can clarify outcomes
and expectations in health promotion and enhance the qual-
ity of health care (Svalastog, Donev, Kristoffersen, & Gafovic,
2017). Because health is used to describe a number of entities,
including a philosophy of care (health promotion and health
maintenance), a system (health care delivery system), practices
(evidence-based health practices), behaviors (personal health
behaviors), costs (health care costs), and insurance (uninsured
health care), the reason that confusion continues regarding the
use of the term “health” becomes clear. People’s use of the term
“health” and its incorporation into these various entities have
also changed over time.
Americans born before 1940 experienced the greatest
changes in how health is defined. Because infectious diseases
claimed the lives of many children and young adults at that
time, health was viewed as the absence of disease. The physi-
cian in independent practice was the primary provider of health
care services, with services provided in the private office. The
federal government was only beginning to establish its role in
working with states to address public health and welfare issues
(Barr et al., 2003).
As the national economy expanded during and after World
War II in the 1940s and 1950s, the idea of role performance
became a focus in industrial research and entered the health
care lexicon. Health became linked to a person’s ability to fulfill
a role in society. Increasingly, the physician was asked to com-
plete physical examination forms for school, work, military, and
 CHAPTER 1 Health Defined: Health Promotion, Protection, and Prevention
FIG. 1.1 Social Ecological Model. (Adapted from Bronfenbrenner, U. [1977]. Toward an experi-
mental ecology of human development. America Psychologist, 32[7], 513–531.)
insurance purposes, while physician practice became linked
more directly to hospital-based services. The federal govern-
ment expanded its role through funding for hospital expansion
and establishment of the new Department of Health, Education,
and Welfare, currently the Department of Health and Human
Services (Barr et al., 2003). It was recognized that a person
might recover from a disease yet be unable to fulfill family or
work roles because of residual changes from the illness episode.
Concepts of disability and rehabilitation entered the health care
arena. The work or school environment was viewed as a possible
contributor to health, illness, disability, and death.
From the 1960s to the present, there have been incredible
changes in the health care delivery system while federal and
state governments attempted to control spending and health
care costs escalated (Barr et al., 2003; Badash et al., 2017).
Primary care providers, including nurse practitioners and other
advanced practice nurses, now attempt to involve individuals
and their families in the delivery of person-centered care, and
teaching individuals about individual responsibilities and life-
style choices has become an important part of their job. Health
care became an interdisciplinary endeavor even while managed
care companies limited the health-promotion options available
under insurance plans. During this time the idea of adaptation
had an important influence on the way Americans view health.
Increasingly, health became linked to individuals’ reactions to
the environment rather than being viewed as a fixed state. Adap-
tation fit well with the self-help movement during the 1970s and
with the progressive growth in knowledge from research of dis-
ease prevention and health promotion at the individual level.
Emphasis is being placed on the quality of a person’s life
as a component of health (USDHHS, Public Health Service,
2020; USDHHS, Office of Disease Prevention and Health Pro-
motion, 2020). Research on self-rated health and self-rated
function (Bombak, 2013; Gyasi & Phillips, 2018) indicates
that there are multiple factors contributing to a person’s per-
ception of his or her health, sometimes referred to as func-
tional health (Gordon, 2020) or health-related quality of
life (HRQoL) (Andresen et al., 2003; Karimi & Brazier, 2016;
3
USDHHS, Office of Disease Prevention and Health Promo-
tion, 2020). Multiple tools are available for measuring quality
of life, including a general measure established by the World
Health Organization (WHO, 2004) (World Health Organiza-
tion Quality of Life, WHOQOL-BREF) and the Revised McGill
Quality of Life Questionnaire (Cohen et al., 2017) for use at the
end of life (Box 1.1: Quality and Safety Scenario). There is also
an acknowledgment of the importance of resiliency as a factor
that contributes to health. Resilience is one’s ability to deal with
stressful or traumatic life events. The Resilience Scale has been
used to quantitatively measure resilience in many populations
(The original Resilience Scale, 2020).
Models of Health
Throughout history, society has entertained a variety of con-
ceptual models of health. Smith (1983) describes four distinct
models in her classic work.
Clinical Model
In the clinical model, health is defined by the absence of signs
and symptoms of disease and illness is defined by the presence
of signs and symptoms of disease. People who use this model
may not seek preventive health services or they may wait until
they are very ill to seek care. The clinical model is the conven-
tional model of the discipline of medicine.
Role Performance Model
The role performance model of health defines health in terms
of individuals’ ability to perform social roles. Role performance
includes work, family, and social roles, with performance based
on societal expectations. Illness would be the failure to perform
roles at the level of others in society. This model is the basis for
occupational health evaluations, school physical examinations,
and physician-excused absences. The idea of the “sick role,”
which excuses people from performing their social functions,
is a vital component of the role performance model. It is argued
that the sick role is still relevant in health care nowadays (Davis
et al., 2011; Burnham, 2012).
4 UNIT 1 Foundations for Health Promotion
BOX 1.1 QUALITY AND SAFETY SCENARIO
Fall Prevention in the Home
Falls in the home are a common yet preventable source of both fatal and nonfatal
injuries. In 1 year, 2016, falls resulted in more than 29,000 deaths and 3.2 million
emergency department visits. In the year 2030 the number of estimated falls
will be 49 million, with 12 million fall injuries. The Stopping Elderly Accidents,
Deaths & Injuries Program by the Centers for Disease and Prevention is a pro-
gram that addresses coordination of fall prevention activities in primary care and
implementation of fall prevention programs (www.cdc.gov/homeandrecreation-
alsafety/falls/index.html).
There are specific factors that contribute to fall risk, including changes to the
person attributable to age, medication use, and environmental hazards. Nurses
are in key roles to work with older adults to assess fall risks and help them to
gain control over this aspect of their health. The National Center for Injury Pre-
vention and Control at the Centers for Disease Control and Prevention provides
guidelines for fall prevention in older adults at https://www.cdc.gov/homean-
drecreationalsafety/falls/index.html.
Risk factors attributable to the aging process include visual, hearing, and
functional limitations. Although pets have proven to be a benefit for older adults
by providing companionship and comfort, they can also scamper underfoot or
the older adult may trip over the pet because the pet is not seen or heard. Loss
of night vision and depth perception can also contribute to falls when lighting
is poor or when a person is moving from room to room. Older adults should be
encouraged to always wear prescribed vision and hearing aids when moving
about the house or apartment. Loss of upper and lower body strength can also
contribute to fall risk. Lower body strength is needed to lift the legs and feet high
enough to navigate stairs and changes in texture of flooring. Upper body strength
allows the use of supports when a person is moving about. Watch the person
maneuver about the living space, and note the use of furniture, walls, and other
objects for support.
Medications can contribute to disequilibrium. A careful review of currently
used medications, both prescribed and over-the-counter medications, can help
identify medications that could possibly contribute to fall risks. Environmental
risks include clutter, too much furniture for the room, placement of items in typi-
cal walkways, lighting problems, needed repairs to flooring and walls, and the
From Johnston, Y. A., Bergen, G., Bauer, M., Parker, E. M., Wentworth, L., McFadden, M., et al. (2019). Implementation of the stopping elderly accidents, deaths, and in-
juries initiative in primary care: An outcome evaluation. The Gerontologist, 59(6), 1182–1191. Centers for Disease Control and Prevention, Home and Recreational Safety,
Older Adult Falls. Retrieved from https://www.cdc.gov/homeandrecreationalsafety/falls/index.html.
Adaptive Model
In the adaptive model of health, people’s ability to adjust posi-
tively to social, mental, and physiologic change is the measure
of their health. Illness occurs when the person fails to adapt
or becomes maladaptive to these changes. As the concept of
adaptation has entered other aspects of American culture, this
model of health has become more accepted. For example, par-
ticipating in goal-directed activities can be useful in adapting
to a decreased level of functioning in older adults (Carpentieri,
Elliott, Bret, & Deary, 2017).
Eudaimonistic Model
In the eudaimonistic model, exuberant well-being indicates
optimal health. This model emphasizes the interactions between
physical, social, psychological, and spiritual aspects of life and
the environment that contribute to goal attainment and create
meaning. Illness is reflected by a denervation or languishing, a
lack of involvement with life. Although these ideas may appear
to be new when compared with the clinical model of health,
need for supports such as grab bars and railings. Again, watching the person
navigate through the home is helpful in recognizing potential trip hazards and
areas where additional supports are needed. Adequate hydration is another
consideration, especially if the person is taking medications that contribute to
dehydration without regular fluid replacement or if the temperature of the home
and environment is too high.
Health outcomes for the person can be significant. Falls can cause minor
injury and embarrassment, but they can also cause life-threatening injuries such
as fractures and head injuries. If a fall has occurred, it is helpful to do a root
cause analysis to determine those factors that contributed to the fall. Ask per-
mission before attempting to make any alteration to the home, because items
and their placement may have sentimental importance to the person. Address
medication changes with the person, pharmacist, and/or primary care provider.
Some medication habits may be hard for the person to change.
The nursing implications of fall risk are many and varied. Assessment skills
must be practiced in a variety of settings so that the nurse is vigilant for potential
hazards and individual factors that might precipitate a fall. Older adults should
be routinely observed performing their daily routines to identify visual, hearing,
and functional decline. In addition, if a person reports a fall, that report should
trigger a more extensive evaluation of that individual because falls may be indic-
ative of future fall risk.
Falls are a frequent but preventable occurrence, especially for older adults.
Falls also contribute millions of dollars each year to the cost of health care as a
result of personal injury and disability. That is why fall prevention is a key feature
of quality and safety education for nurses.
Questions
• Can you identify at least four items in your own environment that may contrib-
ute to your fall risk?
• How would you structure an interview with an older adult to determine the
presence of fall risks in that person’s home?
• What evidence and arguments would you use to encourage an older adult to
modify the home environment to decrease the risk of a fall?
aspects of the eudaimonistic model predate the clinical model
of health. This model is also more congruent with integrative
modes of therapy (National Institutes of Health, National Cen-
ter for Complementary and Alternative Medicine, 2019), which
are used increasingly by people of all ages in the United States
and the rest of the world. In this eudaimonistic model, people
dying of cancer may still consider themselves healthy if they are
finding meaning in life.
These ideas of health provide a basis for how people view health
and disease and how they view the roles of nurses, physicians, and
other health care providers. For example, in the clinical model
of health, a person may expect to see a health care provider only
when there are obvious signs of illness. Personal responsibility for
health may not be a motivating factor for this individual because
the provider is responsible for dealing with the health problem
and returning the person to health. Therefore attempts to teach
health-promoting activities may not be effective with this person.
On the other hand, those who adopt a eudaimonistic model of
health may find that practitioners working under a clinical model
 CHAPTER 1 Health Defined: Health Promotion, Protection, and Prevention
do not address their more comprehensive health needs. They
may instead seek out a practitioner of alternative medicine or the
counsel of a priest, rabbi, or minister to complement the services
of the more traditional health provider.
Wellness-Illness Continuum
The wellness-illness continuum, as stated earlier, is a dichoto-
mous depiction of the relationship between the concepts of
health and illness. In this paradigm, wellness is a positive state
in which incremental increases in health can be made beyond
the midpoint (Fig. 1.2). These increases involve improved physi-
cal and mental health states. The opposite end of the continuum
is illness, with the possibility of incremental decreases in health
beyond the midpoint. This depiction of the relationship of well-
ness and illness fits well with the conceptual and clinical model
of health (McMahon & Fleury, 2012). This paradigm is useful
when thinking about the transitions between wellness and ill-
ness (Polacsek, Boardman, & McCann, 2019).
High-Level Wellness
From a dichotomous representation of health and illness as
opposites, Dunn (1961) developed a health-illness continuum
that assessed a person not only in terms of his or her relative
health compared with that of others but also in terms of the
FIG. 1.2 Wellness-illness continuum with high-level wellness
added. Moving from the center to the right demonstrates
movement toward illness. Moving from the center to the left
demonstrates movement toward health. Moving above the line
demonstrates movement toward increasing wellness. Moving
below the line demonstrates movement toward decreasing
wellness. (Modified from US Department of Health and Human
Services, Public Health Service [1982]; McMahon, S., & Fleury,
J. [2012]. Wellness in older adults: A concept analysis. Nursing
Forum, 47[1], 39–51. Becker, C. M., Glascoff, M. A., Felts, W.
M., & Kent, C. [2015]. Adapting and using quality management
methods to improve health promotion. Explore, 11[3], 222–228.)
5
favorability of the person’s environment for health and wellness
(see Fig. 1.2). Adding this second dimension to the health-ill-
ness continuum created a matrix in which a favorable environ-
ment allows high-level wellness to occur and an unfavorable
environment allows low-level wellness to exist. Social and phys-
ical environmental factors can positively or negatively influence
wellness.
With this addition, it became possible to combine the clini-
cal model of health with models based on social and environ-
mental parameters. The concept demonstrates that a person
can have a terminal disease and be emotionally prepared for
death, while acting as a support for other people and achieving
high-level wellness. High-level wellness involves progression
toward a higher level of functioning, an open-ended and ever-
expanding future with its challenge of fuller potential and the
integration of the whole being (Ardell, 2007). This definition
of high-level wellness contains ideas similar to those in the
eudaimonistic model of health. In addition, high-level well-
ness emphasizes the interrelationship between the environ-
ment and the ability to achieve health on both a personal and
a societal level.
Health Ecology
An evolving view of health recognizes the interconnection
between people and their physical and social environments.
Newman (2003) expressed this interconnection within a devel-
opmental framework, and the work of Gordon (2020) applies
this interconnection to functional health patterns as presented
in subsequent chapters. Health from an ecological perspective is
multidimensional, extending from the individual into the sur-
rounding community, and including the context within which
the person functions. It incorporates a systems approach within
which the actions of one portion of the system affect the func-
tioning of the system as a whole (Institute of Medicine, 2003,
2010). This view of health expands on high-level wellness by
recognizing that there are social and environmental factors that
can enhance or limit health and healthy behaviors. For example,
most people can benefit from physical activity such as walk-
ing, and people are more likely to walk in areas where there
are sidewalks or walking paths and where they feel safe. Nurses
can encourage people to walk but may also need to advocate
safe areas for people to walk and work with others to plan for
people-friendly community development.
Functioning
One of the defining characteristics of life is the ability to func-
tion. Functional health can be characterized as being present
or absent, having high-level or low-level wellness, and being
influenced by neighborhood and society. Functioning is inte-
gral to health. There are physical, mental, and social levels of
function, and these are reflected in terms of performance and
social expectations. Function can also be viewed from an eco-
logical perspective, as in the example of walking used previ-
ously. Loss of function may be a sign or symptom of a disease.
For example, sudden loss of the ability to move an arm or leg
may indicate a stroke. The inability to leave the house may
indicate overwhelming fear. In both cases the loss of function
6 UNIT 1 Foundations for Health Promotion
is a sign of disease, a state of ill health. Loss of function is a
good indicator that the person may need nursing interven-
tion. Research in older adults indicates that decline in physical
function is a sentinel event and may indicate the future loss of
physical function and death (Boltz et al., 2012; Greiner et al.,
1999; Gyasi & Phillips, 2018).
HEALTH
Health, as defined in this text, is a state of physical, mental, spiri-
tual, and social functioning that realizes a person’s potential and
is experienced within a developmental context. Although health
is, in part, an individual’s responsibility, health also requires col-
lective action to ensure a society and an environment in which
people can act responsibly to support health. The culture and
beliefs of people can also influence health action. This definition
is consistent with the WHO definition of health as the state of
complete physical, mental, and social well-being and not merely
the absence of disease and infirmity (WHO, 2020a) but moves
beyond this definition to encompass spiritual, developmen-
tal, and environmental aspects over time. The physical aspect
includes one’s genetic makeup, which when combined with the
other aspects influences one’s longevity. This broader definition
is applicable across the life span, as well as in situations where
illness may be a chronic state. For example, in this broader
definition of health, a person with diabetes may be considered
healthy if he or she is able to adapt to his or her illness and live a
meaningful, spiritually satisfying life. Health is considered to be
part of the metaparadigm for nursing (Fawcett & Garity, 2009),
which includes the four components of person, health, environ-
ment, and nursing. As can be seen in the discussion thus far,
health can be viewed in a variety of ways.
ILLNESS, DISEASE, AND HEALTH
It is easy to think of health or wellness as the lack of disease
and to consider “illness” and “disease” as interchangeable terms.
However, “health” and “disease” are not simply antonyms and
“disease” and “illness” are not synonyms. Disease literally means
“without ease.” Disease may be defined as the failure of a per-
son’s adaptive mechanisms to counteract stimuli and stresses
adequately, resulting in functional or structural disturbances.
This definition is an ecological concept of disease, which uses
multiple factors to determine the cause of disease rather than
describing a single cause. This multifactorial approach increases
the chances of discovering multiple points of intervention to
improve health.
Illness is composed of the subjective experience of the
individual and the physical manifestation of disease (Holling-
sworth & Didelot, 2005). Both are social constructs in which
people are in an imbalanced, unsustainable relationship with
their environment and are failing in their ability to survive
and create a higher quality of life. Illness can be described as
a response characterized by a mismatch between a person’s
needs and the resources available to meet those needs. In addi-
tion, illness signals to individuals and populations that the
present balance is not working. Within this definition, illness
has psychological, spiritual, and social components. A per-
son can have a disease without feeling ill (e.g., asymptomatic
hypertension). A person can also feel ill without having a diag-
nosable disease (e.g., as a result of stress). Our understanding
of disease and illness within society, overlaid with our under-
standing of the natural history of each disease, creates a basis
for promoting health.
PLANNING FOR HEALTH
Public health has always had the prevention of disease in society
as its focus. However, during the past 30 years, the promotion
of health and individual responsibility moved to the forefront
within public health, becoming a driving force in health care
reform.
A key milestone in promoting health was the advent of
Healthy People (US Department of Health, Education, and Wel-
fare, Public Health Service, 1979), the first Surgeon General’s
report on health promotion and disease prevention issued in
the later years of President Carter’s administration.
The document identified three causes of the major health
issues in the United States as allowing careless habits, environ-
mental pollution, and harmful social conditions (e.g., hunger,
poverty, and ignorance) to persist that destroy health, especially
for infants and children.
Healthy People was a call to action and an attempt to set
health goals for the United States for the next 10 years. Each
decade overarching goals are identified for Healthy People
(Table 1.1). Unfortunately, a change in political leadership, a
lack of political and social willpower, and the spiraling costs
of hospital-based health care intervened. The need to report
progress toward these national objectives led a larger, renewed
effort in the form of The 1990 Health Objectives for the Nation:
A Midcourse Review (USDHHS, Public Health Service, 1986).
This midcourse review noted that, although many goals were
achievable, the unachieved goals were hindered by current
health status, limited progress on risk reduction, difficulties in
data collection, and a lack of public awareness.
Healthy People 2000 (USDHHS, Public Health Service,
1990) and Healthy People 2000 Midcourse Review and 1995
Revisions (USDHHS, Public Health Service, 1996) were land-
mark documents in that a consortium of people representing
national organizations worked with US Public Health Service
officials to create a more global approach to health. In addition,
a management-by-objectives approach was used to address each
problem area. These two documents became the blueprints for
each state as funding for federal programs became linked to
meeting these national health objectives. While the objectives
became more widely implemented, methods for collecting data
became formalized, and the data flowed back into the system to
form the revisions set in 1995. The core of these health objec-
tives remained: that is, prevention of illness and disease was the
foundation for health.
Healthy People 2010 (USDHHS, Public Health Service, 2000)
introduced two overarching goals (see Table 1.1).
 CHAPTER 1 Health Defined: Health Promotion, Protection, and Prevention 7

TABLE 1.1 Current and Historical Overarching Goals of Healthy People

1990
1 To continue to improve infant
health and to reduce infant
mortality.
2 To improve child, adolescent,
and young adult health and
reduce deaths among these
groups.
3 To improve the health of
adults and reduce deaths
among this group.
4 To improve the health and
quality of life for older
adults, and to reduce the
average annual number of
days of restricted activity
attributable to acute and
chronic conditions.
5 Engage leadership, key
GOALS OF HEALTHY PEOPLE
2000
Increase the span of
healthy life.
Reduce health disparities.
Create access to preventive
services for all.
2010 2020
Increase quality and years Attain high quality, longer
of healthy life. lives free of preventable
disease, disability, injury,
and premature death.
Eliminate health Achieve health equity,
disparities. eliminate disparities, and
improve the health of all
groups.
Create social and physi-
cal environments that
promote good health
for all.
Promote quality of life,
healthy development, and
healthy behaviors across
all life stages.
2030
Attain healthy, thriving
lives and well-being, free
of preventable 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.
constituents, and the
public across multiple
sectors to take action
and design policies that
improve the health and
well-being of all.

These goals addressed the issues of longevity and quality
of life. Both longevity and quality of life address the concern
that people are living longer but frequently with numerous
chronic health problems that interfere with the quality of their
lives. However, quality of life is also an issue for people who are
unable to achieve a long life. Combining these two ideas placed
an emphasis on both longevity and quality of life as areas that
need improvement.
Eliminating health disparities addressed the continuing
problems of access to care; differences in treatment based on
race, gender, and ability to pay; and related issues such as urban
versus rural health, insurance coverage, Medicare and Medicaid
reimbursement for care, and satisfaction with service delivery.
HEALTHY PEOPLE 2020/2030
Goals
For Healthy People 2020, there are four overarching goals (see
Table 1.1). These four goals established the territory in which
health promotion and disease prevention efforts occur. Research
in a variety of areas has clearly indicated that health disparities
are directly and indirectly linked to longevity and quality-of-
life issues (Clay et al., 2018; Xu et al., 2018). For example, the
American Cancer Society reports that Black men die of prostate
cancer more frequently than any other racial or ethnic group,
with their death rate almost 2.4 times higher than that of White
men (American Cancer Society, 2016) (Box 1.2: Health and
Social Determinants/Health Equity).
The Healthy People 2020 topic areas include adolescent
health; blood disorders and blood safety; dementias, includ-
ing Alzheimer disease; early and middle childhood; genomics;
global health; health care–associated infections; HRQoL and
well-being; lesbian, gay, bisexual, and transgender health; older
adults; preparedness; sleep health; and social determinants of
health. These topic areas are an expansion on previous areas and
incorporate recent evidence more directly in each area.
The detailed objectives can be found at https://www.healthy-
people.gov/2020/topics-objectives. These topic areas span age
categories from conception to death and incorporate preven-
tion, access, treatment, and follow-up at the individual, family,
provider, work site, and community levels. The 42 topical areas
8 UNIT 1 Foundations for Health Promotion
BOX 1.2 HEALTH AND SOCIAL
DETERMINANTS/HEALTH EQUITY
Influence of Personal Cultural Values on Health Care
Delivery
Culture influences every aspect of human life, including beliefs, values, and
customs regarding lifestyle and health care. As health care providers, nurses
need to be aware of their own beliefs, values, and customs and how these
ideas translate into behavior. It is easy to assume that an individual’s own per-
spective is correct and shared by others. This is especially true when one is
working with other health care providers who share the same culture. This con-
cept is referred to as ethnocentrism and can lead to a devaluing of the beliefs,
values, and customs of others. It can be associated with racism, leading to so-
cial inequities, discrimination, and prejudice. Although it is impossible for any
person to ignore the cultural influences on their lives, nurses and other health
care providers have a special obligation to be aware of their own social and
cultural biases. Our focus as nurses must be on the cultural influences in the
daily lives of individuals through the development of cultural competence
and cultural humility. The ability to view other people’s situations from their
perspective is known as empathy. Diversity awareness will continue to chal-
lenge providers to lifelong learning about the people for whom they provide
care as the racial and ethnic mix in society changes.
lead to specific objectives for each topical area. One example is
used here for illustration.
Objective PA-2.1. Increase the proportion of adults who engage
in aerobic physical activity of at least moderate intensity for at
least 150 minutes/week, or 75 minutes/week of vigorous intensity,
or an equivalent combination. This objective directly addresses
each of the overarching goals, either directly or indirectly. Phys-
ical activity can contribute to the maintenance or improvement
in mobility, which improves the quality of life and prevents dis-
ability. It is something in which most people can participate. It
enhances positive mental health through stress reduction and
physical fitness, which contribute to the development of healthy
behaviors. However, it takes social action and awareness to
address the need for social and physical environments that sup-
port physical activity across the life span.
Access to health care to obtain a complete physical examina-
tion before starting to exercise and the quality of the work or
neighborhood environment available for exercise can contrib-
ute to success or failure of this objective. This objective is related
to other objectives such as nutrition, obesity, and stroke preven-
tion (Box 1.3: Best Practice/Innovative Practice).
In addition, current knowledge of physical activity and spe-
cific populations was considered when the Healthy People 2020
objectives were being created. Women, low-income popula-
tions, Black and Hispanic people, people with disabilities, and
those older than 75 years exercise less than do White men with
moderate-to-high incomes (USDHHS, National Institutes of
Health, National Heart, Lung, and Blood Institute, 2020). These
health disparities can influence the number of people in these
groups who develop high cholesterol levels or high blood pres-
sure, which further increases their risk of heart disease and
stroke. Although this objective addresses adults, other objectives
address the need for beginning exercise activities at an early
BOX 1.3 BEST PRACTICE/INNOVATIVE
PRACTICE
Process for Assessing, Evaluating, and Treating
Overweight and Obesity in Adults
Overweight and obesity are major concerns in public health because they
contribute to other health problems such as high cholesterol level, high blood
pressure, diabetes mellitus, heart disease, functional limitations, and disabil-
ity. As part of the National Heart, Lung, and Blood Institute’s (2020) obesity
education initiative, titled Aim for a Healthy Weight, nurses have an important
role to play in health education related to obesity prevention and control. More
complete information and guidelines can be obtained from https://www.nhlbi
.nih.gov/health-topics/overweight-and-obesity.
Make the Most of the Individual’s Visit and Set an Effective Tone for
Communication: Nurses ask individuals about their weight history, weight-
related health risks, and desire to lose weight. The approaches used need to
be respectful of a person’s lifestyle, habits, and cultural influences. Discus-
sions need to be nonjudgmental and goal directed.
Assess the Individual’s Motivation/Readiness to Lose Weight:
Nurses explain body mass index and why it is the preferred method of deter-
mining overweight and obesity in adults. Individuals need to understand the
methods of data collection and measurement of height and weight, as well as
waist circumference, risk factors, and comorbidities. Nurses develop skill in
determining readiness and motivation to lose weight in their patients.
Build a Partnership With an Individual: Nurses work with individuals
to determine what each person is willing to do to achieve a lower weight.
This approach includes knowing the best practices in weight management
and weight loss. Fad diets, dietary supplements, and weight loss pills may
be inappropriate for most people, and formal weight loss programs may be
too expensive for low- and moderate-income families. Use recommended diets
that restrict caloric intake, set activity goals with your patients, encourage the
person to keep a weekly food and activity diary, and provide information on
diet and activity. Be sure to record individual goals and the treatment plan,
including a health-education plan. Nurses are knowledgeable about current
treatment options and their success. Holistic approaches are needed because
food behaviors are influenced by many factors. Listen to individuals’ stories
about food and its role in their lives. Therapies should fit the individual’s goals
and lead to lifestyle change.
age and encouraging young adults to be actively engaged in
exercise. How might this objective be adjusted to the needs of
an older adult population? The target for this objective is that
47.9% of adults engage in aerobic physical activity of at least
moderate intensity for at least 150 minutes per week, or vigor-
ous intensity for 75 minutes per week, or an equivalent com-
bination. This target represents a 10% increase over the 2008
baseline. This approach emphasizes personal responsibility but
now includes society’s role in addressing the social and physical
environments within which those choices are made (USDHHS,
National Institutes of Health, National Heart, Lung, and Blood
Institute, 2020; https://www.nhlbi.nih.gov/health-topics/heart
-healthy-living).
The latest Healthy People 2020 progress update on the goals
of increasing access to health care services, addressing social
determinants of health, and increasing the health-related qual-
ity of health for people indicates small improvements.
The two leading health indicators for access to health care
services of persons with medical insurance (<65 years old)
 CHAPTER 1 Health Defined: Health Promotion, Protection, and Prevention
and persons with a usual primary care provider showed little
or no detectable change (USDHHS, 2014). The latest figure for
the improvement in the rate of persons with medical insur-
ance was 89% (2018), the baseline rate was 83% (2008), and
the goal is 100%. In 2016, 76.4% of people had a usual primary
care provider, the baseline rate was 76.3% (2007), and the goal
is 83.9%. Social determinants of health are represented by the
leading health indicator of students who graduate with a regular
diploma 4 years after starting 9th grade. There has been an over-
all increase from 79% (2010–11) to 85% (2016–17), although
there are dramatic differences in graduation rates according to
race and ethnicity (National Center for Education Statistics:
www.nces.ed.gov). Improving the HRQoL and well-being of
adults is considered by measurement of the proportion of adults
who self-report good or better physical and mental health. In
2010, men reported good or better physical health at a rate of
82.5%, with women trailing at a rate of 75.4%, and 81.1% of men
report good or better mental health compared with 77.3% of
women. Education is related to good or better health. The more
educated one is, the higher the level of reported good or better
health (USDHHS, 2014).
Health care providers need to be responsible for offering
health promotion, providing preventive health services, and
monitoring behaviors. Unfortunately, many of the financial
incentives for providers are to perform tasks and procedures
rather than to counsel and help individuals choose between
various behaviors. The Patient Protection and Affordable Care
Act (US Congress, 2010) now requires primary care providers
to provide free wellness services to older adults and others and
to provide person-centered care. Providers need to take the time
to discuss behaviors that may improve the quality of life and
extend the number of years of life. For example, the addictive
nature of tobacco products, including e-cigarettes, and its effect
on the development and course of a variety of chronic health
conditions are now well recognized. Providers should be asking
every person if they use tobacco products and should be provid-
ing them with ways to quit smoking, including economic and
social incentives.
Providers also need to look for partnership in the commu-
nity through which they can better serve the needs of individu-
als. Healthy People 2020 emphasizes that person-centered care
is essential to health promotion. One approach to person-cen-
tered care to build partnerships is the use of community nursing
centers as partnering organization. The Health Promotion Cen-
ter operated by Fairfield University School of Nursing in Fair-
field, Connecticut, was one example. The nurses and nursing
students who provided health education, screening, and referral
services at the Health Promotion Center worked with existing
community organizations to better meet the health care needs
of underserved people. The Health Promotion Center worked
with senior housing and senior centers to provide compre-
hensive cardiovascular screenings and medication review. As
an extension of this work, funding was secured for a program
called Step Up to Health, a project to increase physical activity
in this population through interactive planning and consumer
ownership of the activities. The project was part of the National
Blueprint Project supported by the Robert Wood Johnson Foun-
9
dation (http://www.agingblueprint.org). The project engaged
older adults in walking programs, line dancing, gardening, and
low-impact exercise programs, including programs from the
National Arthritis Foundation (http://www.arthritis.org/).
Another approach to partnerships is to have providers serve
as active participants on community boards and advisory com-
mittees, which allows providers to become aware of the service
needs in the community and the resources available to meet
those needs.
Work sites and communities need to become partners in
providing opportunities for people to lead healthy lives through
flexible work schedules, work site wellness programs, accessibil-
ity of safe parks, and availability of exercise facilities. Convert-
ing empty lots into community gardens provides beautification
of the area, an opportunity for exercise in caring for the garden,
and a source of fresh vegetables. The availability of bike paths
encourages physical activity.
Churches, temples, and mosques can be vital partners in
meeting Healthy People objectives. Faith communities can break
economic, social, racial, and gender barriers, making them an
excellent source for sharing information on health promotion
and disease prevention. Parish nurses and Faith Community
Nurses are becoming increasingly prevalent, and they incor-
porate Healthy People objectives into their activities (Westberg
Institute, 2020).
Public health officials at all levels are necessary partners in
meeting Healthy People objectives. As part of the core public
health functions of assessment, policy development, and assur-
ance, the US Public Health Service and all state, county, and
local health departments need to collect data, make informa-
tion available to the public, create policies that support Healthy
People objectives, and ensure that needed services are available
from a competent workforce.
Healthy People can form the basis for planning, service deliv-
ery, evaluation, and research in every aspect of the health care
system. The nurse needs to be familiar with this document and
its intent. Nurses should compare their practices with the objec-
tives of Healthy People. In addition, the nurse needs to be aware
of the research and practice changes that occur as a result of the
work toward these objectives.
HEALTHY PEOPLE 2030
The current process of updating Healthy People 2020 to Healthy
People 2030 is underway. With each iteration of Healthy People,
the goals and topic areas of the previous decade are evaluated
and topic areas are changed, added, or removed based on the
current vision and mission of Healthy People. Objectives spe-
cific to those topic areas are developed by experts from mul-
tiple lead federal agencies, the Secretary’s Advisory Committee
on National Health Promotion and Disease Prevention Objec-
tives for 2030, and the public. There are three levels of objec-
tives proposed for Health People 2030. Core objectives are
based on established data found in registries, national surveys,
US Census, etc. Developmental objectives are around high pri-
ority areas that may not have any associated data but do have
evidence-based interventions. Research objectives can address
10 UNIT 1 Foundations for Health Promotion
BOX 1.4 HEALTHY PEOPLE 2030
Proposed Planning Activities
• Set national goals and measurable objectives to guide evidence-based poli-
cies, programs, and other actions to improve health and well-being.
• Provide data that are accurate, timely, and accessible and can drive tar-
geted 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 improve 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 pro-
motion, disease prevention, and treatment.
From US Department of Health and Human Services, Public Health
Service. (2020). Healthy People 2030. https://www.healthypeople
.gov/2020/About-Healthy-People/Development-Healthy-People-2030
/Framework.
areas that do not have evidence-based interventions. These
three levels of objectives are currently being identified and will
reflect the five overarching 2030 goals in Table 1.1. The three
levels of objectives are a new addition to Healthy People, as well
as the overarching goal of engaging leadership, key constituents,
and the public to design polices that will advance Healthy Peo-
ple 2030 objectives. Because public health is complex, Healthy
­People 2030 is also placing an emphasis on complex systems sci-
ence and modeling to help transform the fields of health promo-
tion and disease prevention (Secretary’s Advisory Committee
for Healthy People 2030, 2019) (Box 1.4: Healthy People 2030
Proposed Planning Activities).
LEVELS OF PREVENTION
Prevention, in a narrow sense, means averting the development
of disease. In a broad sense, prevention consists of all measures
that limit disease progression. Leavell and Clark (1965) defined
three levels of prevention: primary, secondary, and tertiary
(Fig. 1.3). Although the levels of prevention are related to the
natural history of disease, they can be used to prevent disease and
provide nurses with starting points for making effective, positive
changes in the health status of the persons for whom they provide
care. Primordial prevention, the earliest form of prevention, has
been added as a type of prevention that reflects policy-level inter-
vention aimed at affecting health before at-risk lifestyle behaviors
are chosen or become habit. Within the four levels of prevention,
there are five steps. These steps include health promotion and
specific protection (primordial and primary prevention); early
diagnosis, prompt treatment, and disability limitation (second-
ary prevention); and restoration and rehabilitation (tertiary pre-
vention). A fifth level of prevention has recently been introduced
and is being discussed as the quaternary level of prevention; this
level considers the potential for overmedicalization (Martins,
Godycki-Cwirko, Heleno, & Brodersen, 2018).
Some confusion exists in the interpretation of these concepts;
therefore a consistent understanding of primordial, primary,
secondary, tertiary, and quaternary prevention is essential. The
levels of prevention operate on a continuum but may overlap in
practice. The nurse must clearly understand the goals of each
level to intervene effectively in keeping people healthy.
Primordial Prevention
“Primordial” refers to the time frame before a risk factor devel-
ops and before disease occurs. Primordial prevention can begin
as early as childhood or even prenatally and is closely linked to
the determinants of health and the environment in which one
lives (Salama, n.d.). Determinants of health include income,
education, literacy, employment, working conditions, social
and physical environment, health practices, genetic makeup,
health services, gender, and culture (Association of Faculties of
Medicine of Canada, n.d.). Primordial interventions are aimed
at determinants of health. For example, if the social environ-
ment one grows up in discourages exercise or encourages eating
high-fat food, that environment could be targeted for primor-
dial prevention. Healthy eating and activity school-based pro-
grams, reduction of sodium in the food supply, and creation of
safe places to ride bikes and walk are examples of primordial
prevention. Most health-promoting primordial prevention
occurs at the national, state, and community levels.
The Healthy People proposed goals for 2030 that include 7
core, 7 developmental, and 10 research objectives related to
improving the public health system, where many primordial
health prevention programs are housed (USDHHS, Office of
Disease Prevention and Health Promotion, 2020).
Primary Prevention
Primary prevention precedes disease or dysfunction. However,
primary prevention is therapeutic in that it includes health as ben-
eficial to well-being, it uses therapeutic treatments, and, as a pro-
cess or behavior toward enhancing health, it involves symptom
identification when stress reduction techniques are being taught.
Primary prevention intervention includes health promotion, such
as health education about risk factors for heart disease, and specific
protection, such as immunization against hepatitis B. Its purpose
is to decrease the vulnerability of the individual or population to
disease or dysfunction. Interventions at this level encourage indi-
viduals and groups to become more aware of the means of improv-
ing health and the actions they can take at the primary preventive
health level and the optimal health level. People are also taught to
use appropriate primary preventive measures. However, primary
prevention can also include advocating policies that promote the
health of the community and electing public officials who will
enact legislation that protects the health of the public.
Health Protection
Primordial and primary prevention activities focus on the
reduction of threats and negative influences on health. Both
types of prevention can occur at an individual level and at the
community, state, national, and even global levels. Ensuring safe
and adequate food, water, and medical therapies for all people
and protecting them against workplace and environmental haz-
 CHAPTER 1 Health Defined: Health Promotion, Protection, and Prevention 11

FIG. 1.3 The three levels of prevention developed by Leavell and Clark with primordial prevention
added. (Modified from Leavell, H., & Clark, A. E. [1965]. Preventive medicine for doctors in the
community. New York: McGraw Hill; Ali, A., & Katz, D. L. [2015] Disease prevention and health
promotion: How integrative medicine fits. American Journal of Preventive Medicine, 49[5], S230–
S240; D’Ascenzi, F., Sciaccaluga, C., Cameli, M., Cecere, A., Ciccone, M. M., Di Francesco, S.,
Ganau A., et al. [2019]. When should cardiovascular prevention begin? The importance of ante-
natal, perinatal and primordial prevention. European Journal of Preventive Cardiology, December
16, 2019, 1–12. doi:10.1177/2047487319893832.)

ards are regional and global objectives. Ruger and colleagues
(2015) suggest the formation of a global health fund that would
unite efforts to ensure adequate protection of all the world’s
people concerning AIDS, tuberculosis, and malaria in recogni-
tion of the global responsibility for social protection.
Health Promotion
The definitions of health promotion differ. O’Donnell (1987) has
defined health promotion as “the science and art of helping peo-
ple change their lifestyle to move toward a state of optimal health.”
Kreuter and Devore (1980) proposed a more complex definition
in an article commissioned by the US Public Health Service. They
stated that health promotion is “the process of advocating health
to enhance the probability that personal (individual, family, and
community), private (professional and business), and public (fed-
eral, state, and local government) support of positive health prac-
tices will become a societal norm.” Healthy People has adopted
the definition of health promotion as “any planned combination
of educational, political, regulatory, and organizational supports
for actions and conditions of living conducive to the health of
individuals, groups, or communities” (Secretary’s Advisory Com-
mittee for Healthy People 2030, 2019).
12 UNIT 1 Foundations for Health Promotion
The Theoretical Basis of Health Promotion. The theoretical
underpinnings for health promotion have evolved since the
early 1980s. Most of these theories are behaviorally based, de-
rived from the social sciences, and extensively researched. These
theories include the theory of reasoned action by Ajzen and
Fishbein (1980), theories of behavior by Bandura (1976, 1999,
2004), the health belief model by Rosenstock (Champion &
Skinner, 2008), Pender’s health-promotion model (Murdaugh,
Parsons, & Pender, 2019), and stages of change theories by
Prochaska (Prochaska et al., 2015). Internet searches on each
of these theories will provide numerous websites where more
detailed information is available.
The Social Nature of Health Promotion. Health promotion
goes beyond providing information. It is also proactive deci-
sion-making at all levels of society as reflected in the Healthy
People 2020 objectives. Health promotion holds the best prom-
ise for lower-cost methods of limiting the constant increase in
health care costs and for empowering people to be responsible
for the aspects of their lives that can enhance well-being. Based
on the need for health-promotion activities within the health
care system, efforts must be made to identify the multiple deter-
minants of health, determine relevant health-promotion strate-
gies, and delineate issues relevant to social justice and access
to care. Individuals, families, and communities must be active
participants in this process so that the actions taken are socially
relevant, economically feasible, and supportive of changes at the
individual level.
The Active and Passive Nature of Health Promotion. Health-
promotion efforts, unlike those efforts directed at specific
protection from certain diseases, focus on maintaining or im-
proving the general health of individuals, families, and com-
munities. These activities are conducted at the public level (e.g.,
government programs promoting adequate housing or reducing
pollutants in the air), at the community level (e.g., Habitat for
Humanity or community health centers), and at the personal
level (e.g., voting to offer low-income housing or to elect public
officials who recognize the need for public oversight). Nursing
interventions are actions directed toward developing people’s
resources to maintain or enhance their well-being—a form of
assets-based planning.
Strategies of health promotion that involve the individual
may be either passive or active. Passive strategies involve the
individual as an inactive participant or recipient. Examples of
passive strategies include public health efforts to maintain clean
water and sanitary sewage systems to decrease infectious dis-
eases and improve health, and efforts to introduce vitamin D
in all milk to ensure that children will not be at high risk of
rickets when living in areas where sunlight is scarce. These pas-
sive strategies must be used to promote the health of the public
when individual participation might be low but the benefit to
society is high.
Active strategies depend on the individual becoming per-
sonally involved in adopting a proposed program of health pro-
motion. Two examples of lifestyle change are performing daily
exercise as part of a physical fitness plan and adopting a stress-
management program as part of daily living. A combination of
TABLE 1.2 Transtheoretical Model Stages
of Change
Precontemplative Not considering change
Contemplative Aware of but not considering change soon
Preparation Planning to act soon
Action Has begun to make behavioral change (recent)
Maintenance Continued commitment to behavior (long term)
Relapse Reverted to old behavior
active and passive strategies is best for making an individual or
society healthier. This text is concerned almost entirely with
active strategies and the nurse’s role in these strategies. Some
passive strategies are presented, but they are presented with the
implicit belief that each individual must take responsibility for
improving health. It is undeniable that passive strategies also
have a valuable role, but they must be used within a context of
encouraging and teaching individuals to assume more respon-
sibility for their health.
An Application of Theory to the Practice of Health Promo-
tion. The Transtheoretical Model (TTM) is an excellent ex-
ample and can be applied to this case study. TTM incorporates
stages of change (readiness to take action), decisional balance
(benefits to and detractors from changing a behavior), self-
efficacy (personal confidence in making a change), and pro-
cesses of change (cognitive, affective, and behavioral activities
facilitating change). The bases of TTM are the stages of change;
these are six stages that people spiral through on a path toward
making and sustaining a behavioral change to promote health.
See Table 1.2.
Each stage offers opportunities for the nurse to provide
information and support behavioral change. Encouraging peo-
ple and suggesting changes to their environment that support
behavioral change can increase individuals’ self-efficacy and
their chances of maintaining a change. This model also recog-
nizes that people need multiple opportunities to make behav-
ioral change before achieving success and that relapse should be
expected (Prochaska et al., 2015).
Although health promotion would seem to be a practical and
effective mode of health care, the major portion of health care
delivery is geared toward responding to acute and chronic dis-
ease. Preventing or delaying the onset of chronic disease and
adding new dimensions to the quality of life are not as easy
because they take time to implement and evaluate and require
personal action. These actions are more closely associated with
everyday living and the lifestyles adopted by individuals, fami-
lies, communities, and nations. Habits such as eating, resting,
exercising, and handling anxieties appear to be transmitted
from parent to child and from social group to social group as
part of a cultural, not a genetic, heritage. These activities may
be taught in subtle ways, but they influence behavior and have
as much of an influence on health as does genetic inheritance.
Although the public may not appreciate the causal relationships
between behavior and health, they should be apparent to health
professionals. Arguably, the concept of risk is the most basic of
 CHAPTER 1 Health Defined: Health Promotion, Protection, and Prevention
all health concepts, because health promotion and disease pro-
tection are based on this concept.
Health-promotion strategies have the potential of enhanc-
ing the quality of life from birth to death. For example, good
nutrition is adjusted to various developmental phases in life to
account for rapid growth and development in infancy and early
childhood, physiologic changes associated with adolescence,
extra demands during pregnancy, and the many changes occur-
ring in older adults. Good nutrition is known to enhance the
immune system, enabling individuals to fight infections that
could lead to disabling illnesses. Other individual activities are
adapted to the person’s needs for optimal personality develop-
ment at all ages. As seen in Unit 4, much can be done on a per-
sonal or group basis, through counseling and properly directed
parent education, to provide the environmental requirements
for the proper personality development of children. Commu-
nity participation is also an important factor in promoting indi-
vidual, family, and group health (see Chapters 6–8).
Personal health promotion is usually provided through health
education (see Chapter 10). An important function of nurses,
physicians, and allied health professionals, health education is
principally concerned with eliciting useful changes in human
behavior on the basis of current research. The goal is to inculcate
a sense of responsibility in individuals for their own health and
a shared sense of responsibility for avoiding injury to the health
of others. For example, encouraging child-rearing practices that
foster normal growth and development (personal, social, and
physical) addresses both the individual parent and the needs of
society. Health education nurtures health-promoting habits, val-
ues, and attitudes that must be learned through practice. These
must be reinforced through systematic instruction in hygiene,
bodily function, physical fitness, and use of leisure time. Another
goal is to understand the appropriate use of health services. For
example, a semiannual visit to a dentist may teach a child better
oral health habits and to visit the dentist regularly, although this is
not the primary purpose of the visit. Parents, teachers, and care-
givers play a vital role in health education. In addition to teaching
individuals, nurses need to develop skills in group teaching and
in providing education within community organizations.
Available research clearly shows an increase in longevity, a
decrease in mortality and morbidity, and an improvement in
the quality of life for individuals who have been involved in
health-promotion activities such as physical activity and avoid-
ance of smoking (Snedden et al., 2019). It must be emphasized
that health promotion requires lifestyle change. Once a lifestyle
change has been adopted, vigilance is needed to ensure that the
lifestyle change is maintained and modified to fit developmental
and environmental changes.
Empirical data linking risk factors, health-promotion activi-
ties, and outcomes are sufficient to drive the development of
the Healthy People 2020 objectives and to be incorporated into
quality improvement measures in managed care. One of the
challenges posed in Healthy People 2020 is the development of
measurable outcome objectives that are based on more realistic
economic models. Early reports on Healthy People 2030 have
decreased the number of objectives into order to focus on the
most important outcomes for investigation.
13
Health promotion is an important concept for nursing
because it embodies many other concepts that nursing is con-
cerned with nowadays. As stated earlier, much of the nursing
role is involved with health teaching. Standard 5B of Nursing:
Scope and Standards of Practice (American Nurses Association
[ANA], 2015b) includes a full section on the practice imple-
mentation of health teaching and health promotion. Nurses
are expected to demonstrate professional role competence
throughout their careers. Health education is clearly an impor-
tant nursing role.
Specific Protection
This aspect of primary prevention focuses on protecting people
from injury and disease, for example, by providing immuniza-
tions and reducing exposure to occupational hazards, carcino-
gens, and other environmental health risks. These hazards and
risks include not only protection of adults from work-related
injuries (e.g., back injuries in nurses, dismemberment in
machinists, exposure to chemicals used in boat repair or expo-
sure to inhaled sawdust by carpenters) but also protection of
infants and children from potential carcinogens (e.g., exposure
of children to diesel emissions, damage to a fetus caused by
radiation).
Primary prevention interventions are considered health pro-
tection when they emphasize shielding or defending the body
(or the public) from specific causes of injury or disease. Imple-
menting nursing interventions that prevent a specific health
problem may seem easier than promoting well-being among
individuals, groups, or communities because the variables are
delineated more clearly in prevention than in promotion and
the potential influences are less diverse.
Examples. Two examples may help demonstrate these dif-
ferences. Immunization against influenza is recommended by
the Centers for Disease Control and Prevention (CDC) and
has become a regular health preservation activity for peo-
ple at risk each fall https://www.cdc.gov/flu/prevent/flushot
.htm). Nurses can participate in this specific protection role
by giving the influenza injections in clinics and offices. An-
other example is the creation of nut-free schools to protect
hypersensitive children from life-threatening allergic reac-
tions to peanuts and nut products. Such initiatives have large-
ly been the result of grassroots parent organizations working
with formal community organizations to adopt policies that
protect the health of these children. Nurses may be involved
in the parent organizations or the school or public health
boards that review the proposed policies. In addition, nurses
must be able to address the need to protect specific portions
of the population at risk.
Secondary Prevention
Although primary prevention measures have decreased the haz-
ards of chronic diseases such as cardiovascular disease, condi-
tions that preclude a healthy quality of life are still prevalent.
Secondary prevention ranges from providing screening activi-
ties and treating early stages of disease to limiting disability by
averting or delaying the consequences of advanced disease.
14 UNIT 1 Foundations for Health Promotion
Screening is secondary prevention because the principal goal
is to identify individuals in an early, detectable stage of the dis-
ease process. However, screening provides an excellent oppor-
tunity to offer health teaching as a primary preventive measure.
Screening activities now play an important role in the control of
diseases such as heart disease, stroke, and colorectal cancer. In
addition, screening activities provide early diagnosis and treat-
ment of nutritional, behavioral, and other related problems.
Nurses play an important role in screening activities because
they provide clinical expertise and educationally sound health
information during the screening process.
Delayed recognition of disease results in the need to limit
future disability in late secondary prevention. Limiting dis-
ability is a vital role for nursing because preventive measures
are primarily therapeutic and are aimed at arresting the disease
and preventing further complications. The paradox here is that
health education and disease prevention activities seem similar
to those used in primary prevention but are applied to a per-
son or population with an existing disease. Modifications to the
teaching plan must be made on the basis of the individual’s cur-
rent health status and ability to modify behavior.
Tertiary Prevention
Tertiary prevention occurs when a defect or disability is perma-
nent and irreversible. The process involves minimizing the effects
of disease and disability by surveillance and maintenance activi-
ties aimed at preventing complications and deterioration. Ter-
tiary prevention focuses on rehabilitation to help people attain
and retain an optimal level of functioning regardless of their
disabling condition. The objective is to return the affected indi-
vidual to a useful place in society, maximize remaining capacities,
or both. The responsibility of the nurse is to ensure that persons
with disabilities receive services that enable them to live and work
according to the resources that are still available to them. When
a person has a stroke, rehabilitating this individual to the high-
est level of functioning and teaching lifestyle changes to prevent
future strokes are examples of tertiary prevention.
Quaternary Prevention
Quaternary prevention is a concept developed by Jamoulle and
colleagues (2013) that describes the potential for the overmedi-
calization of care recipients. The prevention of doing harm, by
overdiagnosing or overtreating and the commercialization of
disease, is the objective of this level of prevention. This process
of prevention requires providers to make ethical and socially
responsible diagnostic and treatment suggestions and include
the care recipient in shared decision-making (Pandve, 2014;
Martin, 2018).
Levels of Prevention Strategies
According to the National Academy of Medicine, there are
three program levels of prevention interventions. Universal pro-
grams are directed toward an entire population and are aimed
at preventing or delaying the behavior of concern. Selective
prevention strategies target specific groups that are at risk for
the behavior. Indicated programs are designed to prevent risk
behaviors (or symptoms) becoming the actual behavior (or dis-
ease). These interventions or programs are focused at the pri-
mordial, primary, and secondary levels of prevention. At the
level of tertiary prevention, programs focus on intervention and
maintenance (Hawkins et al., 2015).
The Intersectionality of Public Health, Population
Health, and Health Promotion
Public health is population-based focusing on the determinants
of health for defined populations. It is also grounded in social
justice, focused on health promotion and disease prevention,
and driven by the science of epidemiology, and it organizes com-
munity services (Keller et al., 2016). Population health is the out-
comes (i.e., length of life, HRQoL, function) of a population that
are influenced by patterns of health determinants, policies, and
interventions (Kindig & Stoddart, 2003). Population is a group
defined by a geographic area, or employees, ethnic groups, pris-
oners, or disabled people. It is not defined as a clinical care recipi-
ent group like individuals with heart failure. A clinical population
focus may be an example of population health management or
population medicine (Kindig, 2015). Because determinants of
health are what drive health outcomes, they are considered in
population health and public health. Determinants include medi-
cal care, public health interventions, aspects of the social and
physical environment, genetics, and individual behavior (Kindig
& Stoddart, 2003). Health promotion efforts empower people to
have control over their own health. These efforts involve advo-
cating for and/or supplying supports for actions and conditions
that can lead to positive health practices. The WHO describes
five key areas for work related to health promotion: good gov-
ernance, health literacy, healthy cities, health-promoting schools,
and social mobilization. Health in All Policies is a collaborative
attempt to consider social determinants that influence the health
of communities when creating and enacting any policy (Rudolph
et al., 2013). Gathering and using health information that sup-
ports healthy decisions requires health literacy. Urban planning
that promotes health requires strong leadership and commitment.
School health programs to promote health and prevent disease
are important for children and the community. Socially mobiliz-
ing groups and communities to create sustainable resources and
services that will enhance health is also an important factor of
health promotion. All three of these concepts of health, public
health, population health, and health promotion, are interwoven
together to meet the needs of groups of people at various ecologic
levels.
THE NURSE’S ROLE
Evolving demands are placed on the nurse and the nursing
profession as a result of changes in society. Emphasis is shift-
ing from acute, hospital-based care to preventive, community-
based care, which is provided in nontraditional health care
settings in the community. This demand for community-based
services, with the home as a major community setting for care,
is closely related to the changing demographics of the United
States. While the home and community become the existing
sites for care, nurses must assume more blended roles, with a
knowledge base that prepares them to practice across settings
 CHAPTER 1 Health Defined: Health Promotion, Protection, and Prevention
using evidence-based practice. Within these roles, nurses
assume a more active involvement in the prevention of disease
and the promotion of health. Nurses can be more independent
in their practice and place a greater emphasis on promoting and
maximizing health, and more than ever nurses are accountable
morally, ethically, and legally for their professional behavior.
Nursing Roles in Health Promotion and Protection
Although nurses often work with people on a one-to-one basis,
they seldom work in isolation. Within the current health care
system, nurses collaborate with other nurses, physicians, social
workers, nutritionists, psychologists, therapists, individuals,
and community groups. In this interprofessional practice,
nurses play a variety of roles.
Advocate
As advocates, nurses help individuals obtain what they are enti-
tled to receive through the health care system, try to make the
system more responsive to individual and community needs,
and help people develop the skills to advocate for themselves. In
the role of an advocate, the nurse strives to ensure that all per-
sons receive high-quality, appropriate, safe, and cost-effective
care. The nurse may spend a great deal of time identifying and
coordinating resources for complex cases.
Care Manager
The nurse acts as a care manager to assist the individual in
navigating the complexities of health care and health decision-
making. Primary roles of the care manager include preventing
duplication of services, maintaining quality and safety, provid-
ing education and advocacy, facilitating self-management, and
reducing costs (Luther, Barra, & Martial, 2019). Information
gathered from reliable data sources enables the care manager
to help individuals avoid care that is unproven, ineffective, or
unsafe. Reliable sources of information on best practices, evi-
dence-based practices, and standard protocols are available from
websites sponsored by the federal government (e.g., https://www.
nih.gov; https://www.cdc.gov), specialty organizations (e.g.,
http://www.arthritis.org; http://www.nursingworld.org; http://
www.aginglifecare.org), and private foundations (e.g., http://
www.rwjf.org; http://www.johnahartford.org). Successful care
management depends on a collaborative relationship among the
care manager, other nurses and physicians, the individual and
his or her family, the insurance provider, and other care provid-
ers who work with the person. A key aspect of this collaborative
relationship is educating and engaging the individual and family
members (Witwer & Wallenstein, 2019). Without engagement,
individuals assume a passive role in their health care. The wishes
of the individual and the family need to be clear to the care man-
ager as part of person-centered care provision. Facilitating com-
munication among parties and engaging the individual in the
process are two of the care manager’s most important functions.
Consultant
Nurses may provide knowledge about health promotion and
disease prevention to individuals and groups as a consultant.
Some nurses have specialized areas of expertise or advanced
15
practice, such as in gerontology, women’s health, or community/
public health, and they are equipped to provide information as
consultants in these areas of specialization (ANA, 2015b). A
gerontologic nurse specialist might be on a community plan-
ning board offering advice about what types of health-promo-
tion activities should be considered in planning a new senior
housing development. All nurses need to develop consultation
skills that can be integrated into practice and allow the individ-
ual nurse to take advantage of opportunities to provide support
on an individual level or for future development at the organi-
zational level (Drury, 2016).
Deliverer of Services
The core role of the nurse is the delivery of direct services such
as health education, influenza vaccinations, and counseling in
health promotion. Visible, direct delivery of nursing care is the
foundation for the public image of nursing. The public demands
that nurses be knowledgeable and competent in their delivery of
services. This role is clearly expressed in Nursing’s Social Policy
Statement (ANA, 2010) and in the Code of Ethics for Nurses with
Interpretive Statements (ANA, 2015a).
Educator
Health practices in the United States are derived from the theory
that health components such as good nutrition, industrial and
highway safety, immunization, and specific drug therapy should
be within the grasp of the total population. Even with its rich
resources, society falls far short of attaining the goal of maximal
health for all. The problem is not a lack of knowledge, but rather
the lack of application; therefore it is incumbent on nurses to be
excellent health educators. To teach effectively, the nurse must
know essential facts about how people learn and the teaching-
learning process. Health literacy is an important component of
successful teaching and learning. (see Chapter 10).
In addition to their storehouse of scientific knowledge,
nurses who are committed to their teaching role know that
individuals are unique in their response to efforts to change
their behavior. Teaching may range from a chance remark by
the nurse, based on assessment coupled with perception of
desirable individual behavior, to structurally planned teaching
according to individual needs. Selection of the methods most
likely to succeed involves the establishment of teacher-learner
goals. Health promotion and protection rely heavily on the
individual’s ability to use appropriate knowledge. Health edu-
cation is one of the primary prevention techniques available to
avoid the major causes of disability and death nowadays and is
a critical role for nurses.
Healer
The role of healer requires the nurse to help individuals inte-
grate and balance the various parts of their lives (Quinn, 2016).
The concept of patient centeredness requires nurses to learn
from the individual or family what is required for healing. The
nurse understands that healing resides in the ability to glimpse
or intuit the “interior” of an individual, to sense and identify
what is important to that other person, and to incorporate the
specific insight into a care plan that helps that person to develop
16 UNIT 1 Foundations for Health Promotion
his or her own capacity to heal. It requires a mindful blending
of science and subjectivity (Benner et al., 2010; Siegel, 2007).
Nurses have a special ability to help people heal. The art of nurs-
ing is the extraordinary ability to manage a broad array of infor-
mation to create something meaningful, sensible, and whole
(see Chapter 14).
Researcher
In the current health care environment, nurses are constantly
striving to understand and interpret research findings that will
enhance the quality and value of individual care. To provide
optimal health care, nurses need to use evidence-based findings
as their foundation for clinical decision-making. When nurses
or other clinicians use research findings and the best evidence
possible to make decisions, the outcome is termed evidence-
based practice. Evidence-based practice is defined as the con-
scientious, explicit, and judicious use of current best evidence
in making decisions about the care of individuals. The practice
of evidence-based nursing means integrating individual clinical
expertise with the best available external clinical evidence from
systematic research (ANA, 2015b).
The National Institute of Nursing Research (NINR) serves
as the focal point in developing research themes for the future
of the profession. NINR supports research to establish a scien-
tific base for the care of individuals throughout the life span,
from the management of individuals during illness and recov-
ery to the reduction of the risks of disease and disability. The
four “investment” themes NINR has identified are promoting
personalized health strategies using symptom science, promot-
ing health and preventing disease, improving the quality of life
for individuals with chronic disease through self-management,
and end-of-life and palliative care through compassion (NINR,
2016). Notice how the Healthy People 2020 objectives match
many of these themes.
Evidence-based practice involves searching for the best
evidence with which to answer clinical research questions.
Research evidence can be gathered from quantitative studies
that describe situations, correlate different variables related to
care, or test causal relationships between variables related to
care. Such studies become incorporated into screening and
treatment standards such as those from the US Preventive Ser-
vices Task Force (2014). Research evidence can also be gath-
ered from qualitative studies that describe phenomena or
define the historical nature, cultural relevance, or philosophi-
cal basis of aspects of nursing care. Applied research is done
to directly affect clinical practice (Burns & Grove, 2017). Sack-
ett and colleagues (1996) stressed the use of the best evidence
available to answer clinical questions and explore the next best
evidence when appropriate. The next best evidence may include
the individual clinical judgment that nurses acquire through
clinical experience and clinical practice and other qualitative
approaches to research.
Nurses need to recognize that research is important as
a basis for their practice and that they need to participate in
the research process. For example, both home health nurses
and nurses in long-term care facilities are required to collect
extensive data on the cognitive and physical functioning of
BOX 1.5 EVIDENCE-BASED PRACTICE
Evidence-Based Programming for Older Adults
The National Council on Aging (NCOA) encourages the use of evidence-based
programs to enhance health and prevent injuries and disability in older adults.
Evidence-based programs are composed of interventions that have been rig-
orously studied and found to be helpful. These programs are translated into
practice using content that has been tested. Three example programs are: Self-
Management Resource Center Programs for chronic disease self-management
education, A Matter of Balance for falls prevention, and Healthy IDEAS for
depression management. All three of these resources have met the evidence-
based quality criteria of the NCOA. Those standards involve demonstrated
program effectiveness through experimental or quasi-experimental research,
published results, translated in at least one community site, and have dis-
semination products that are available to the public. Once a program has been
selected, it must be followed consistently to ensure that the tested interven-
tions are properly being applied.
From National Council on Aging (n.d.). About evidence-based programs.
Retrieved from https://www.ncoa.org/center-for-healthy-aging/basics-of
-evidence-based-programs/about-evidence-based-programs/.
individuals through the Outcome and Assessment Information
Set (OASIS) and Minimum Data Set (MDS) assessment tools.
These data are used as part of the quality improvement process
to indicate areas for improvement in care, thereby contribut-
ing to nursing protocols. Nurses in hospital settings are asked to
participate in research as part of the Magnet Hospital designa-
tion process.
The book chapters contain specific health-promotion
research studies. Time should be taken to review these studies
and explore the relationship between behavior and disease, to
identify which population groups are at risk, and to discover
what types of health-promotion programs work and why they
work. Through knowledge of research, nurses can strengthen
their confidence in making daily decisions about quality care
(Box 1.5: Evidence-Based Practice).
IMPROVING PROSPECTS FOR HEALTH
Population Effects
Cultural and socioeconomic changes within the population
unequivocally influence lay concepts of health and health pro-
motion. Currently there are areas of the United States where the
Hispanic population is larger than any other population group.
By the 2050, it is predicted that the majority of people in the
United States will not be of White European descent (US Cen-
sus Bureau, 2015). Taken together as a portent for future health-
promotion strategies, these predictions about the population
indicate that current knowledge of and approaches to health
promotion may not meet the needs of the future US population
(see Chapter 2).
In addition to changes in the ethnic and racial distribution
within the population, the projected changes in age distribu-
tion will affect health-promotion practice. Considerable growth
is expected in the proportion of the population that is aged 25
years or older. For example, the post–World War II baby boom
will increase the number of people in the 65 years and older
age group between 2010 and 2030 (US Census Bureau, 2014).
 CHAPTER 1 Health Defined: Health Promotion, Protection, and Prevention
Although there was a drop in births after 1960, this decrease
has been offset by an increase in immigration, both legal and
illegal. More-restrictive immigration rules related to homeland
security have limited legal immigration since 2002 (US Depart-
ment of Homeland Security, 2016). Analysis of these population
trends and projections helps health professionals determine
changing needs. In addition, analysis of the social and economic
environment is necessary for the development of social policy
concerning health.
SHIFTING PROBLEMS
The provision of personal health services must be influenced
by current information regarding environmental health. Envi-
ronmental pollution is a complex and increasingly hazardous
problem. Diseases related to industry and technology, includ-
ing asthma and trauma, have become important threats to
health.
The physical and psychological stresses of a rapidly changing
and fast-paced society present daily problems, such as psycho-
social and spiritual poor health habits. Posttraumatic stress dis-
order is becoming a more common diagnosis and suicide is on
the rise (American Foundation for Suicide Prevention, 2020).
Terrorism is also affecting the mental health of our families
(National Academies of Sciences, Engineering, and Medicine,
2017; Comer, Furr, & Gurwitch, 2019). Obesity, partly attrib-
uted to a lack of exercise and increasing food portion size, is a
growing health issue. The ingestion of potentially toxic, non-
nutritious, high-fat foods is another contributing factor (see
Chapter 11). The abuse of tobacco products, drugs, and alcohol
also negatively affects health.
The emphasis on treating disease through the application
of complex technology not only is costly but also contrib-
utes minimally to the improvement of health. An orientation
toward illness clearly focuses on the effects rather than the
causes of disease. During epidemics and pandemics, which
are rare but still occur, basic prevention activities are needed.
Washing hands and physical distancing will help prevent the
spread of these rare and lethal infectious diseases. A medi-
cal model will not suffice in these cases, and following public
health standards are essential. Testing, contact tracing, symp-
tom monitoring, isolation, and treatment are all important
activities that need to occur to curtail the spread of these rare
infectious diseases.
A substantial change in wellness patterns is occurring. Infec-
tious and acute diseases were the major causes of death in the
early part of the 20th century, whereas chronic conditions,
heart disease, cerebrovascular accident (stroke), and cancer are
currently the major causes. An emphasis on the diagnosis and
treatment of disease, which were highly successful in the past,
is not the answer for today’s needs, which are closely related to
and affected by the individual’s biochemical functioning, genet-
ics, environment, and personal choices (Box 1.6: Genomics).
The Patient Protection and Affordable Care Act (US Congress,
2010) was enacted to begin the process of paying for health pro-
motion by providing insurance coverage for more people and by
covering preventive health services.
17
BOX 1.6 GENOMICS
Genetic research is primarily concerned with discovering, detecting, and treat-
ing illnesses related to specific abnormal genetic sequences (Khoury, 2011;
World Health Organization, 2020b). Genomics, as a research focus, involves
the study of all human genes, which are collectively called the human genome.
The study and practice of genomics are concerned with how genes express
themselves and how they interact with each other and the environment to
encourage or discourage disease (Allen et al., 2014). Genomic interests range
from an individual level to a population-based level similar to health-promoting
activities. Genomics at an individual level is concerned with an individual’s
risks related to that person’s genomic profile and environmental stimuli. At the
population level, genomics is concerned with large-scale patterns of genomic
risk and how that plays out in the public arena. Therefore population-based
public health genomics is involved with policy development, prioritizing useful
genomic information, and ensuring that genomic information is discovered and
used ethically and responsibly (Khoury, 2011).
Lifestyle, environment, and genetics and the interaction among the three are
determining factors of disease. Currently the focus of much intervention is on
the lifestyle and environmental contributors to disease. Because we are just
beginning to look at the genomic components of disease and how they inter-
act with lifestyle and environment, the current scientific discussion revolves
around the ethical implications of private and public genomic interventions.
Current debate surrounding population genomics focuses on the public’s “right
not to know” (Edge & Coop, 2020). Genomic information can be used to formu-
late public health information and initiatives. There are potential social justice
ramifications in sharing large-scale genomic information, which may accentu-
ate discrimination and worsen stigma. If the information is too complex or dif-
ficult to comprehend, it may demotivate people from making needed positive
changes. For example, if there is a health behavior that is linked to a particular
genomic profile, knowing that could help those who do not have the genomic
profile become motivated to change their behavior, whereas people with the
genetic profile might become demotivated to change their behavior. Because
it is a combination of factors that cause disease, just because a person has
the genetic profile does not mean it is an absolute that the person will get the
disease, so sharing this information incautiously may be a disservice to public
health as opposed to a service. Careful consideration of the risks and benefits
of sharing public genomic-related information is essential.
From Allen, C., Senecal, K., & Avard, D. (2014). Defining the scope of
public engagement: Examining the “right not to know” in public health
genomics. Public Health Genomics, 42(1), 11–18; Khoury, M. J. (2011). Pub-
lic health genomics: The end of the beginning. Genetics in Medicine, 13(3),
206–209. Edge, M., & Coop, G. (2020). Attacks on genetic privcacy
via uploads to genealogical databases. eLife, 9: e51810. https://doi
.org/10.7554/eLife.51810.
MOVING TOWARD SOLUTIONS
Solutions are neither simple nor easy, but they can be focused
in two major directions: individual involvement and govern-
ment involvement. The first direction concentrates on actions
of the individual, especially actions related to lifestyle choices
across the life span. The learning and the inherent changes that
are involved require the adoption of a new set of skills by people
who will need the assistance of nurses to make those changes.
Approximately 40% of the US population has difficulty securing
the basic necessities of housing, food, utilities, and health care.
These difficulties are most prevalent among adults with lower
incomes but not limited to this group. They are experienced
by families with working members and by those above the
18 UNIT 1 Foundations for Health Promotion
poverty line (Karpman, Zuckerman, & Gonzalez, 2018). Levy
(2016) found that there is a definite link between health status
and hardship. The sicker an older American is, the more likely
he or she is to suffer hardships of food insecurity, medication
reduction, and difficulty paying bills. (Levy, 2016). Motivational
factors play a large role in influencing attitudinal change. As dis-
cussed in Chapter 10, programs for health promotion and health
education are only part of the answer. Financial incentives for
prevention may be another motivating factor, and health advo-
cacy by professionals in the health field is critical. In addition,
private and public action at all levels is needed to reduce social
and environmental health hazards. Toxic agents in the environ-
ment such as particles from diesel emissions and social condi-
tions such as school overcrowding can present health hazards
that may not be detected for years; therefore it is necessary for
individuals and the government to play a role.
Legislation and financing that relate to primary prevention
are discussed in Chapter 3. Government activity, in the form
of legislation, is currently increasing in this area. For example,
increasing the activity time in schools, mandating seat belt use,
and implementing taxes on gasoline use are specific areas for
CASE STUDY
Health Assessment: Frank Thompson and Family
Frank Thompson’s large brick home is located off a rural country road. A few
yards away stands the small house where Frank was born at the start of the
Korean War. Frank was raised knowing the odds that he faced as a poor tenant
farmer. He helped his father, Ben, with their small tobacco and corn crops. They
were unaware that the hazardous chemicals in the pesticides they used would
later affect Ben’s life. As his father often reminded him, Frank had to do better
than others in school so he would not be doomed to the tenant farmer’s life.
However, Frank’s school attendance was erratic because it was interrupted by
the frequent demand of tending field crops. Thin and often tired, Frank had recur-
rent infections. Rural health care services were insufficient or not accessible.
The school nurse helped the Thompson family obtain the necessary medication
for Frank’s initial infection, but the family was never able to afford the penicillin
that was necessary to prevent recurrent infections.
Inspired by the early work of Martin Luther King, Jr., Frank was intent on
helping at home and building something better for his future. Frank managed to
more than compensate for his lost time at school. He passed his college entrance
examinations and was awarded one of the new equal opportunity grants, which
offered him a choice of attending any of the Ivy League schools in the North-
east. Instead, he chose the prestigious public Southern University and eventually
earned a master of business administration degree. He married Sada, his long-
time girlfriend, and the two planned their future.
With a good job in a large local sales firm, Frank built his house and started
a family. He moved from being a salesman to being a division head and often
traveled to regional meetings, sometimes accompanied by Sada and their three
children. Frank’s dream of sharing his success with his family included using part
of his earnings to help his brothers and sisters with their education.
This new way of life meant Frank had little time for relaxation and frequently
had to attend business luncheons and career-promoting social events. Frank kept
late hours and worked long weekends. Food, alcoholic beverages, and cigarettes
helped Frank relax before and after important business and social encounters;
these softened the edges of hard bargaining and were status symbols.
Not surprisingly, Frank gained weight. He had a persistent cough, which was
probably a result of the smoking habit that developed during the early years
governmental intervention. Health ecology and planning are
important areas for government involvement in the future. The
redirection of the existing health care delivery system, putting
more emphasis on primary prevention, is probably the most dif-
ficult and the most far-reaching goal; however, an emphasis on
a wellness system is necessary to improve the health of the US
population.
TYING IT ALL TOGETHER USING THE
NURSING PROCESS
Problem Identification
How many problems are present in Frank’s situation? The
answer depends on who is asked the question and his or her
position in relation to Frank. Each point of view focuses on
different aspects of Frank’s life. His physician, using a clinical
model of health, might say that Frank has coronary heart dis-
ease with an acute myocardial infarction, hypertension, hyper-
lipidemia, chronic bronchitis, and obesity. But Frank’s problems
also represent a failure to meet several of the Healthy People
of his career. Frank’s primary care provider, whom Frank visited regularly, said
Frank’s blood pressure and serum lipid levels were both higher than normal and
that he had chronic bronchitis. The physician urged Frank to take the actions that
Frank already recognized: reduce smoking, drinking, and intake of saturated fats
and calories; get more exercise; and find ways to relax. However, Frank’s life was
too busy for exercise. He had to work harder because he had been promoted, but
he also had to appear in control and relaxed, which was an essential character-
istic for a prospective vice president. To meet these goals, Frank tended to drink
and smoke more. He also refused to take medication for problems he could not
see. Without the outward signs of disease, Frank believed he was out of shape
but generally healthy. Then Sada noted that his chance for promotion might actu-
ally improve if he lost some weight; therefore Frank registered for a physical
fitness program that he could attend on Sunday mornings and before work during
the week. At his first workout, the classic sharp pain gripped his chest and Frank
had a massive heart attack.
Weeks later, Frank was convalescing at home after being released from the
local hospital’s coronary care facility. He was lucky to survive the heart attack,
and he was also fortunate to have most of the health care services covered by
his medical insurance plan; in addition, 80% of his earnings were protected by
the company’s disability program. (Most people in the United States do not have
this protection.)
However, Frank’s dreams of promotion were shattered. For many months he
could go to the office only two or three times a week at most, simply to deal with
routine matters. He could not travel, for business or otherwise, for a long time.
He was also skeptical about his cardiac rehabilitation program because his heart
attack happened during exercise.
Reflective Questions
• As a nurse, how would you explain to Frank that his heart attack was not
caused by his exercise?
• How might a family approach to diet and exercise work with this family, given
its structure and background?
• Are there things you do to cope with stress that may be making your health
worse?
 CHAPTER 1 Health Defined: Health Promotion, Protection, and Prevention
2020/2030 objectives on a personal level. Reducing illness, dis-
ability, and death related to tobacco use and reducing chronic
disease risk through the consumption of healthful diets and
achievement of healthy body weights are two examples. His
nurse can add that he has paid little attention to his lifestyle,
even after changes were recommended. He continues to overeat,
drink too much, smoke, not exercise, and live a stressful life.
Frank’s employer sees a man who has potential but who is now
too disabled to take on new responsibilities and perhaps unable
to continue performing his previous duties. Frank’s children
might feel that he can no longer take them on trips or play with
them. His wife, Sada, knows that their plans for educating their
children, and for travel and enjoyment, might suffer. The human
resource personnel who manage Frank’s health insurance and
retirement program would say that he has an expensive disease,
and the state health planner would point out that Frank’s prob-
lem is only one of a growing number of disabling illnesses that
result from preventable causes. A reviewer for Healthy People
2020 might see Frank as part of the aggregated data on heart
disease, indicating a continuing increase in the incidence of
heart disease among Black non-Hispanic men.
To Frank, his health problems are multidimensional. His ini-
tial fear of dying, pain, dependence, and frustration decreased
as he began to feel better, but Frank is haunted by his realization
that he might never be able to achieve his dreams for himself
and his family. Although theoretically in his prime, Frank sud-
denly sees himself as far older than his years, both in body and
in social achievement. He believes he has reached his limit and
that he will never again have the freedom to choose his future.
He and his family needed to evaluate their situation and make
alternative plans based on asset planning.
Planning Interventions
Rather than emphasizing the chronic health issues and related
problems, the nurse can begin with asset planning within the
family. Asset planning is a planning approach that, given the
realities of the present, helps to focus the family members and
their providers on the building blocks for their future. It focuses
on the assets or strengths of the individual, the family, and the
community, applying those assets to improve or maintain the
current level of functioning.
Frank’s physician and nurse can begin with the fact that Frank
survived his first myocardial infarction. The coronary damage
resulting from this event becomes the baseline for determin-
ing future change in the lives of Frank and his family. Earlier,
Frank’s physician had taken a broader time perspective when
he advised Frank to reduce his cigarette smoking, which was
contributing to both his bronchitis and his hypertension, and
to change his high-fat diet and sedentary habits, which contrib-
uted to his weight problem and his high blood pressure. These
lifestyle changes now become tools for Frank’s recovery and for
change within his family. His cardiac event also becomes a risk
factor for heart disease in the lives of his children.
Looking at the immediate future, Frank’s employer saw the
effect of the event on Frank’s position within the company.
Frank would have a long recovery that could be successful if he
adhered to his cardiac rehabilitation program. Asset planning
19
at this level means examining how to move Frank back into his
work role without further jeopardizing his health. Frank and
Sada also need to examine if he could continue in this position,
given its potential effect on his health.
Frank and his family used a broader perspective than
the medical personnel or the corporation. They knew that to
achieve the family’s economic and educational goals and still
spend time together they had to make decisions that would ulti-
mately affect Frank’s health. Similar to many Americans, they
had been willing to live with Frank’s job pressures and stress-
ful lifestyle caused by the economy. The family members were
aware of their impoverished roots and had no wish to return to
them. However, they also recognized that the strength of their
family, their ability to work together to achieve goals, and their
faith were assets that could be used for support.
Frank’s social network of friends, relatives, and church mem-
bers became an additional asset. They helped the family through
the difficult initial weeks at home by delivering meals, taking
care of the yard work and laundry, and providing companion-
ship so Sada could shop and have time alone. As Frank recov-
ered, they would provide support for the social and lifestyle
changes that Frank and his family needed to make.
The nurse-led cardiovascular rehabilitation group played
a vital role in Frank’s recovery. As the physician continued to
monitor Frank’s cardiac status, the nurse began the long process
of working with Frank to modify his habits. He had stopped
smoking while in the hospital, but with more free time than
usual, he was craving to smoke again. Using an asset planning
approach and Gordon’s (2020) functional health patterns, the
nurse identified the changes that Frank needed to make to
decrease the risk of a second heart attack. A plan was developed
to help Frank begin to take control of his life through behav-
ior changes. These changes included relaxation techniques, diet
modification, smoking cessation, and mild chair exercises. The
support of the family was enlisted to reinforce the changes Frank
was willing to make, because social support and environmental
changes are shown to enhance personal decision-making. His
employer was contacted and agreed to a plan enabling Frank
to work from home via Internet while the workplace became
smoke free. Frank became an asset to the workplace, serving
as a spokesperson for the benefits of lifestyle change. He was
enlisted to talk with other employees about stress management,
exercise, weight reduction, and smoking cessation based on his
personal experiences.
Health planners and public health officials used the broadest
perspective in asset planning by viewing Frank as an example
of a person whose potential shifted as a result of a preventable,
disabling illness. The planners looked to public and private
community patterns and policies that increase healthful hab-
its and living conditions. Work schedules and work load; stress
and safety in work environments; affirmative action programs
for jobs and wages; availability of public transportation sys-
tems, recreational facilities, and economically accessible hous-
ing; farm price subsidies for food and tobacco crops that affect
buying patterns; excise taxes and regulation of health-damaging
drugs such as alcohol and nicotine were all taken into consid-
eration (Richmond, Virginia: Health in all Policies, n.d.; Grzy-
20 UNIT 1 Foundations for Health Promotion
wacz & Fuqua, 2000). The asset planning approach emphasized
the positive actions that could be made at the personal, employ-
ment, community, and societal levels to minimize the effects of
Frank’s illness and related diseases, thereby addressing all levels
of the ecological model of health.
What Was the Actual Cause of Frank’s Problem?
It is not possible to separate one cause from another because
heart disease is a multifactorial disease. In Frank’s case the
sources of illness were found in the many interrelationships in
his life. Attempting to treat or change each factor as a separate
entity can have only a limited effect on the improvement of over-
all health. Frank’s health problems were numerous. In addition
to a poor diet, weight gain, lack of exercise, and smoking, his
hyperlipidemia, an adaptive biologic response to the pressures
in his life, further debilitated him. It eventually led to clogged
coronary vessels, and his responses became maladaptive. His
hypertension, resulting from his diet and time-constrained life-
style, complicated by the buildup of plaque secondary to hyper-
lipidemia, was also a biologic attempt to adjust to a situation
that contributed to an imbalance between his personal resources
and the demands of his family and the economic world. Frank’s
smoking was a psychosocial means to help him relieve some
of the emotional pressures. It may have served this short-term
purpose but only at a silently rising cost to his health. Cigarette
use by persons who have hypertension or high serum choles-
terol levels multiplies their risk of coronary heart disease (Zhu,
Nelson, Toth, & Muscat, 2019).
Evaluation of the Situation
The health status of an individual or population depends on a
sustainable balance of the complex responses between physi-
ologic, psychological, and social and environmental factors.
Health was initially conceived as a biologic state, with genetic
endowment as the starting point. However, health involves psy-
chological and social aspects and is interpreted within the con-
text of the immediate environment.
The interconnections between biophysical, psychological,
and environmental causes and consequences did not end with
Frank’s heart attack. His heart attack was only the most dra-
matic sign that health-damaging responses outweighed health-
promoting ones. The “tip of the iceberg” analogy is frequently
used to illustrate the importance of identifying individuals with
subclinical symptoms. High blood lipid levels, high blood pres-
sure, obesity, smoking, and persistent worrying were no less
important than the infarction in shaping the status of Frank’s
health. Repairing the damage to Frank’s heart without chang-
ing his lifestyle, habits, and work environment would only buy a
brief amount of time before further damage would occur.
The infarction and resulting disability also permanently
reshaped Frank’s environment. After a few months of working
full-time, Frank realized that he needed to find a less stressful
job. He recognized that his sales administration skills were an
asset and began interviewing in the nonprofit sector. Ultimately,
he landed a job at half his previous salary but with excellent
benefits and a flexible work environment. His reduced income
meant that his children’s educational opportunities were more
limited than they were before his heart attack, but his family
responded by seeking tuition support from community organi-
zations. Frank found that his contacts in both the corporate and
the nonprofit sectors increased his value to his new employer.
Frank’s entire life, internal and external, had changed. He had
learned to adapt to his health problems and had developed a
more eudaimonistic approach to health and life.
Frank’s situation illustrates how causes and effects in life and
health tend to merge into constant, inseparable interconnections
between individuals and their worlds. A person’s health status is a
reflection of a web of relationships that characterize that person’s
life. Health is not an achievement or a prize but a high-quality
interaction between a person’s inner and outer worlds that pro-
vides the capacity to respond to the demands of the biologic, psy-
chological, and environmental systems of these worlds.
Which of the Healthy People 2030 proposed objectives listed
in Box 1.7 apply to the promotion of Frank’s health?
Clearly, the area of heart disease and stroke is most applica-
ble. The Healthy People 2030 website (https://www.healthypeo-
ple.gov/sites/default/files/ObjectivesPublicComment508.pdf)
has a number of objectives that relate directly to the prevention
of heart disease, hypertension, and hyperlipidemia, including
objectives that relate to treatment options and training the pub-
lic to recognize and respond to nutrition and weight (Box 1.7:
Selected Healthy People 2030 Objectives). From the information
about Frank and his experience, determine what his children
should be taught on the basis of the Healthy People 2030 objec-
tives in this focus area.
SUMMARY
The ways individuals define health and health problems are
important because definitions influence attempts to improve
health and care delivery. In the case study, Frank Thompson’s
health was affected by obvious, immediate, and personal factors,
such as his diet and employment pressures. Nevertheless, his
problems had their roots in the social and economic conditions
of his parents; in his own early history of illness, education, and
work; and in his and his family’s hopes and aspirations. His phy-
sician defined Frank’s problem in immediate biomedical terms.
Public health planners, who saw Frank’s problem on a longer-
term population basis, sought policy solutions to the problem
of preventing cardiovascular disease.
The view taken in this text is that a broad and longer-term
perspective of health is the best guide to promoting health more
effectively, even as nurses deal with individual problems on a
daily basis. Health is a sustainable balance between internal and
external forces. Health allows people to move through life free
from the constraints of illness and promotes healing.
Illness represents an imbalance that human choices (inter-
twined social, political, spiritual, professional, and personal
choices) contribute to. In the United States, communities may
still have time to reduce the onslaught of chronic disability and
shift the direction, slow the pace, and humanize the scope of
economic and social life.
Shifting directions in current health care patterns may be
possible only when nurses and other health professionals do
 CHAPTER 1 Health Defined: Health Promotion, Protection, and Prevention
BOX 1.7 SELECTED HEALTHY PEOPLE 2030 OBJECTIVES
Access to Health Services
Core Objectives
• AHS-2030-01 Increase the proportion of persons with medical insurance.
• AHS-2030-02 Increase the proportion of persons with dental insurance.
• AHS-2030-05 Reduce the proportion of persons who are unable to obtain or
delay in obtaining necessary medical care.
• AHS-2030-08 Increase the proportion of adults who receive appropriate evi-
dence-based clinical preventive services.
Research Objectives
• AHS-2030-R01 Increase the capacity of the primary care and behavioral health
workforce to deliver high quality, timely, and accessible patient-centered care
• AHS-2030-R02 Increase the use of telehealth to improve access to health
services
Social Determinants of Health
Core Objectives
• SDOH-2030-01 Increase the proportion of children aged 0–17 years living
with at least one parent employed year round, full time.
US Department of Health and Human Services. [Internet]. Healthy People 2030. Office of Disease Prevention and Health Promotion. Retrieved from https://health.gov
/healthypeople/objectives-and-data/browse-objectives.
what is expected of them as leaders in the care of health: to
work with others through open processes; to provide leadership
in finding the vision and the path; and to inform, educate, and
reeducate themselves, their colleagues, the media, and the gen-
eral public using research findings and evidence-based practice
methods.
The responsibility of nurses as health professionals today is
to see the health problem in new ways and help others to do the
same. Responsibility means developing new roles and examin-
ing the problem through others’ viewpoints, including those of
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 2
Vulnerable Populations and Health
Kimberly L. Malin, Amber S. Mcllwain, Frank Tudini, Sheng-Che Yen, Kevin K. Chui

http://evolve.elsevier.com/Edelman/

OBJECTIVES
After completing this chapter, the reader will be able to: • Native Hawaiians/Pacific Islanders
• Differentiate among ethnicity, ethnic group, race, and • Refugees
minority group. • Describe health concerns and issues of vulnerable populations.
• Describe demographic data relative to vulnerable • Discuss selected cultural factors that may have an impact
populations: on the health and well-being of vulnerable populations.
• American Indians/Alaskan Natives • Contrast the folk healing system with the professional care
• Arab Americans system.
• Asian Americans • Explain strategies for health care professionals to meet the
• Black/African Americans needs of vulnerable populations
• Homeless persons • Identify tools available to help meet the health care needs
• Immigrants of immigrants.
• LGBTQ community members • Describe initiatives to address the health care concerns of
• Latino/Hispanic Americans vulnerable populations.

KEY TERMS
Chi Gender expression Race
Complementary alternative and Gender identity Racism
integrative medicine (CAM) Gender transition Refugees
Cultural and linguistic competence Harm reduction Sexual orientation
Culturally congruent practice Health disparities Social determinants of health
Cultural respect Health equity Taoism
Culture Homelessness Transcultural nursing
Ethnic groups Hot and cold concept of disease Transgender
Ethnicity Immigrants Value orientations
Ethnocentric perspective Intersectionality Values
Female genital alteration (FGA) Jing Vulnerable populations
Female genital mutilation/cutting Minority group Yang
(FGM/C) Nurse care systems Yin
Folk healing system Professional care systems

SOCIAL DETERMINANTS OF HEALTH AND conditions, gender discrimination, racism, globalization,

HEALTH EQUITY
Social factors contribute significantly to health disparities
within the United States and across countries. Factors such
as employment conditions, social exclusion, public health
and urbanization contribute to health disparities and ineq-
uity worldwide. These factors, termed social determinants
of health, contribute to an individual’s capability to attain
good health, which is a function of one’s ability to access and
receive quality health care (US Department of Health and
25
Another random document with
no related content on Scribd:
 "No, there's not much honesty or justice in him. And I dare say you
wondered why he was going."

"I wondered certainly."

"I'll tell you. He's going to be married, and he couldn't dare to be

married here, because he knew that he'd got me to reckon with. So he's
planned it on the quiet, and he'll disappear presently no doubt; and then
somebody else will disappear too. And that's Dinah Waycott."

Mr. Stockman was much agitated.

"Good powers! D'you know what you're saying, John?" he asked.

"Very well indeed. And I'll tell you how it was; but I don't want
Maynard to know his dirty job be found out, and I'll beg you to keep dumb
about it till things are a bit forwarder. I can get forty shillings or a month
out of him, and give him a damned good hiding and disgrace him for his
underhand, blackguard conduct—stealing another man's girl—but I want to
do a bit more than that if it's in my power. And so long as you're not on his
side no more, you'll be the best one to help me. I'd do a lot to break this off
and punish Dinah, same as she punished me; and why not? She deserves it
quite so well as him."

"Begin at the beginning," said Joe. "Tell me what you know. I'm your
side without a doubt in this matter. There's a lot hid here you don't
understand, and, for the credit of human nature, I hope you're wrong. This
may be something that you've given ear to, out of ill feeling against Orphan
Dinah. You must be terrible sure of your ground, for there's very good
reasons why you ought to be mistaken. But if you're right, then you be the
tool of Providence and it's well you came to me."

Johnny, who had learned everything from Jane, told the story with only
one addition contrary to facts. Jane lied in a minor particular and concealed
the incident of looking into Dinah's letter. Instead she declared that she had
hidden herself, and watched, and seen Maynard come for the letter and
leave another on the following evening in late dusk. The conclusion
amounted to the same thing.
 Joe was deeply impressed.

"I always held him a bit sly," he said, "and I've lived to find him
ungrateful and hard-hearted where I'd every right to expect something very
different. He struck me at the very moment when a decent man would have
scorned to do so, with all my own troubles thick upon me. But this is
something a lot deeper than his conduct to me, and even a lot worse."

"I'm glad you think so," answered John. "I'm very glad you see he's a
secret, cowardly sort of one. He kindiddled Dinah away from me no doubt;
and very like it is Providence, as you say; and if you don't think he ought to
marry her, then I hope you'll help me to prevent it."

Johnny felt exalted. He had not expected much from his visit to his
kinsman; he had even feared that Joe might already know the facts and
attach no importance to them; but it seemed that Mr. Stockman was quite of
John's opinion. Indeed he declared so.

"I certainly think they ought not to marry," he answered. "And I think a
great deal more than that. Keep your mouth shut close for the present.
There's plenty of time—unless."

"When's the man going?"

"No date be fixed."

"My mother was put out when Dinah went off a bit ago. She got the
idea from Jane that Dinah had gone to be married then. But when they taxed
her, she swore she had not."

"She couldn't tell a lie if she was paid to," declared Mr. Stockman, "and
Maynard certainly weren't in that, because he was here and I saw him every
day about his business. We must rest the blame on the right pair of
shoulders. And it'll break 'em without a doubt. But we'd best to go careful.
Don't you take a step alone. How many know?"

"Only Jane and Jerry and me."

 "Maynard don't suspect?"

"Neither of 'em—they couldn't."

"Then tell your sister and Withycombe to keep dumb as mice for the
minute; and so will I. This is a very serious thing indeed—and a great shock
to me. To think he was that sort!"

John was pleased but mystified. He failed to see why this event should
make so tremendous an impression on Mr. Stockman.

"I'm very glad you think it is so bad," he said. "I was in a bit of doubt if
you'd take my side."

"As to sides," answered Joe, "I'm going to take the side of right, which
is no more than to say I'll do my duty. And that looks pretty clear. I dare say
you are a bit astonished, but understand me. I'm not making your quarrel
mine, and I don't hold at all with your talk about forty shillings or a month
out of Lawrence Maynard. This goes a very great deal deeper than forty
shillings or a month, I may tell you. I'll say no more for the minute; but I
shan't do naught till I've seen you again. Only keep this in mind: Maynard
ain't planning this hookem snivey job and doing it all in secret, because he's
afraid of you, but because he's afraid of me."

Johnny became more and more puzzled. It was clear, however, that he
had won a powerful friend and might now hope to strike a harder stroke
than any with his fist.

"So long as you be going to queer the man's pitch, and punish him, and
get Dinah away from him, I don't care a damn," he said. "If Dinah finds out;
but perhaps he's made her think——"

"Yes; he's made her think a lot, and he's told her a great many dark and
devilish falsehoods—that's very clear indeed," answered Joe.

"And if her eyes be opened, she may come back to sense yet!" cried the
sanguine youth. "Shame will show her the truth perhaps."
 Mr. Stockman did not answer. He was occupied with his own
reflections.

"This shakes me to the vitals," he declared presently. "I thought I knew

pretty well all there was to that man; and I knew less than naught. If
anybody had said he was a wicked scoundrel, I'd have denied and defied it;
but——"

They had descended from the Beacon and were walking on the
Buckland road. Then Joe stopped.

"You go your way now," he said, "and leave me to put this together. You
do naught and I'll do naught for the minute. But there may not be any too
much time. He was going at Michaelmas. 'Tis certain now that's a blind.
He'll take French leave presently and we've got to be before him. Come to
supper o' Wednesday, John. Then us'll see how it looks. That poor woman—
as honest a creature as ever stepped."

"If he's up to any tricks——"

"He is, by God! Now I'll leave you. And be so silent as the grave till you
see me again."

Deeply wondering and greatly rejoicing at his success, John Bamsey

went down the hill, while Mr. Stockman turned and slowly ascended. His
excitement gave way to listlessness presently, for this discovery and the
subsequent sensation could not advance Joe's own problems. He considered
for a moment whether any course existed by which advantage could accrue
to himself out of Maynard's position; but he saw none.

A trap from Ashburton descended, flashing its lights through the leafy
darkness of the road; and when the ray illuminated Mr. Stockman, he heard
a woman's voice bid the driver pull up. It was Mrs. Honeysett who spoke,
and she seized an opportunity to relieve the existing painful conditions. For
she had not seen Joe since she declined him; but here was an excuse and she
took it.
 "You'll be wondering what I'm doing at this time of night," she said,
"but I can't pass you."

Then she alighted and a man alighted with her.

"Just been to Ashburton to meet my brother, Robert," she explained.

"You remember him. He's home for a bit at last."

A huge figure towered in the gloom over Joe and a heavy hand grasped
his own.

"I remember you," said the farmer, "but I forgot you were such a
whacker. Sailed all the Seven Seas, I suppose, since you was last to
Buckland?"

"He's two inches taller than what dear father was," declared Melinda,
relieved to find Mr. Stockman in a humour apparently amiable. "Robert's
going to take a nice rest along with me. In fact he doubts sometimes if he'll
go back to sea at all."

"No, no—I don't doubt that," answered the sailor. "But I be going to
give work a rest."
 "And find a wife, if he can," continued Melinda. "Us must help him,
Joe."

"I always swore as I'd marry a maiden from the Vale," said Robert
Withycombe.

"The puzzle will be to find one, I tell him," laughed Melinda "I know a
likely girl all the same, and so does Mr. Stockman, Bob."

Joe guessed to whom she referred, and it showed him that Melinda
knew nothing of the threatened tragedy.

"I reckon you mean Orphan Dinah," he said. "Well and why not? A very
sensible young woman. The man that gets her will be lucky."

"They'd be a proper pair and I hope Bob will think well of her. But he
must be warned that she's already changed her mind in one quarter."

"That's not against her," replied Joe. "That shows strength of character
and she had every right to do so. I only hope I know another woman who'll
be wise enough to change her mind."

Before this veiled attack, Melinda was silent and Robert spoke.

"My girl, when she comes along, won't have no time to change her
mind. She've got to marry me and be quick about it. Then us must find a
little house to Southampton, or else Plymouth."

Stockman, with certain ideas moving in his head, issued an invitation.

"Perhaps you'll be in luck—who knows? I'd pleasure you for your

sister's sake, because she and me are very good friends, and I hope always
will be. You come to supper o' Wednesday, Robert, and bring Jerry along
with you. I don't ax you, Melinda—not this time. I want to have a tell with
your brothers; mind you make 'em come."

"Come and welcome," promised Robert, while his sister wondered what
might be behind this invitation. They parted; the trap with the sailor and his
kit-bag rolled down the hill and Joe proceeded home. He was gloomy and
his thoughts concerned themselves with Melinda, but not hopefully. All had
changed with her refusal. Even if she did, indeed, find herself in a mood to
accept him on another invitation, it would never be the same to Mr.
Stockman. He did not care for her enough to let any future 'yes' make him
forget the grave rebuff already suffered. Indeed he did not very much want
her now. Like a skeleton between them must ever persist the recollection of
her refusal. He only realised the attractive features of the old arrangement at
the moment when it was about to end, and he still smouldered with intense
heat when he reflected on his daughter's marriage. In the light of this
evening's revelation he was disposed to add another sin to those upon the
head of Lawrence Maynard. It occurred to him that the cowman might have
had a hand in Susan's romance and urged Thomas forward upon his hateful
course. He began to be convinced that Lawrence had inspired Thomas,
possibly for private ends hidden from Joe. He suspected that these men had
made a cat'spaw of him, and since Thomas was certainly not equal to any
such task single-handed, to the subtler Maynard might chief blame be
assigned.

He found himself hating Maynard and taking grim satisfaction in the

thought Lawrence had over-reached himself. Here, at any rate, was an outlet
for Mr. Stockman's pent-up indignation. One man should have justice at his
hands, and if the downfall of Maynard indirectly smote Palk, or even
changed his determination, so much the better. Joe indeed always hoped
that something might happen even at the last moment to upset the marriage
of Susan, and he would have stuck at no reasonable means of doing so. He
had assured himself long ago that, for her own sake, such a step must be
taken if the least opportunity occurred.

CHAPTER XXXIV

AN OFFER
 Now force was ranged against force, and while Dinah and Lawrence
Maynard matured the final details of their exodus, half a dozen men had
become aware of their secret enterprise and were concerned to upset it in
the name of right. Only the manner of doing so offered material for
argument. The situation was reached on the Wednesday night of Joe's
supper party, for when John Bamsey duly arrived to learn the secret, he was
surprised to find Jerry Withycombe and his brother, Robert, also of the
company. Mr. Stockman had so far accepted the inevitable that his friends
might discuss Susan's approaching wedding in his presence, and to-night
Robert Withycombe chaffed Mr. Palk and Susan while he ate. Presently,
indeed, he drank to their united bliss and challenged the rest of the company
to do so. Thomas was gratified and Susan felt much moved to see her father
humbly drink the toast with the rest. Then the diplomatic Joe asked Robert
if he had called at Green Hayes, and what he thought of Jerry's future wife.

Robert praised Jane very heartily.

"She's a bowerly piece," he said, "and clever as they make 'em. What
the devil she finds in this chap I can't guess; but love's blind no doubt. I
shall see 'em hitched up afore I go."

"And yourself, too, by all accounts," said Mr. Palk.

"'Tis odds he won't find nobody good enough," declared Jerry. "He
fancies himself something cruel, because he's sailed pretty near round the
world."

"There's one good enough for any living man at Green Hayes," asserted
Mr. Stockman. "Have you seen Orphan Dinah, Robert?"

"I have, and I ain't wishful to talk on that subject in public—not yet,"
answered the sailor guardedly.

"He's hit—he's hit!" cried Joe. Then he remembered that Johnny was
present and turned with a great show of innocence to Maynard, who took
his supper with the rest.
 "Here's a man that knows Dinah Waycott, and have took a walk or two
with her for that matter. And a very clever man too, and I'm terrible sorry
he's going to leave me. What would you say of Orphan Dinah, Lawrence?"

Maynard was unruffled.

"Lucky the man who gets her," he answered; "she's one in a thousand."

The talk ranged and John grew more and more impatient to know when
vital matters would be reached; but he perceived that Mr. Stockman could
not speak before the company. After supper Maynard disappeared and then,
when his daughter had cleared away, Joe beckoned John and took him
outside.

"I don't trust my family circle in this matter," he said, "and so we'll light
our pipes and go out. 'Tis a moony night and to walk a mile after supper is a
very good rule, thought I don't practise it. Call them two men. They've got
to know so well as you."

In ten minutes Thomas and Susan had Falcon Farm to themselves, while
Joe, with John and the Withycombe brothers, strolled through a still and
moonlit night.

Then he told them that Lawrence was married, and had run away from
his wife.

"That's how we stand, neighbours. Maynard's a secret sort of man in

most of his dealings, but when he came here, he found me not lacking in
friendship, and he told me that much about himself. And I thought the better
of him for it; because it's often the wisest and properest thing that parties
can do, to put a few leagues between self and partner, if marriage be
poisoning 'em both. He weren't to blame for that, so far as I can tell; indeed,
I upheld the man in his action; but now the case is altered, and we may be
pretty sure the fault was his and some innocent creature have already
suffered at his hands. And there's no reason why another should.

"It's all clear enough now. He remembered, no doubt, that he'd told me
his secret, and so he's running this job on the quiet and have doubtless
forged good reasons for Dinah's ear why they should bolt presently, instead
of proclaiming the thing like decent people would. It's because Maynard be
married that he's doing this; and now good chance puts the secret into the
hands of honest men and we must act according. I always leave a rogue to
Providence myself, and never yet found I could do anything better than
what Providence done; but in this case there's a victim, and the victim can
be saved, thank God."

They talked and poured their indignation into the moonlight. Johnny
abounded in drastic suggestions. He desired, above all, to face Maynard
with Dinah, then let her hear the truth and beat the cowman before her. But
one, who as yet knew the least of Dinah, raised a question.

"How if he's told her and she's willing to chance it and don't care?"
asked Robert.

Mr. Stockman protested.

"You little understand the sort she is. She'd die rather than sink to such a
deed. No; he's caught her with a parcel of lies, and he merits a pretty good
punishment no doubt. You might say the loss of her will be punishment
enough; but there's more to it than that I dare say."

"By God, yes!" vowed Johnny.

"If he's catched and headed off in time, the law can't touch him," said
Robert.

"Then 'tis for us to take the law in our own hands," added Johnny, "and
we will."

Joe warned him.

"All in good time," he answered. "It's life or death for Dinah, and
therefore we be called to act; but what we shall do and how we shall both
save her and be evens with this rogue will take some planning. Rough
justice must be done I grant. He must have rope enough to hang himself
with, and he must get the surprise of his life presently; but we must be
clever, else we'll spoil all. I've got ideas, but he's a downy chap and nobody
must do anything to make him smell a rat."

They abounded in suggestions and Johnny pointed a danger.

"While we're talking and planning," he said, "they may give us the slip
any night and be out of reach and vanished off the earth so far as we're
concerned. And I say this: 'tis time we knowed what was in their letters.
They be keeping apart very clever indeed, so as nobody should link up their
names, though my sister always swore they was up to something; but they
write, and Jane has watched Dinah go up for a letter more'n half a dozen
times; and now it's time we know what's doing, else we'll get left."

"To look into a knave's letters to frustrate his tricks be no crime, I

reckon," admitted Robert Withycombe. "What d'you say, Mr. Stockman?"

They all agreed that to read the secret correspondence was permissible,
for Dinah's sake. Indeed Joe held that this had become a duty.

Robert expressed sorrow for her; but he knew the situation with respect
to John Bamsey and did not, therefore, say much. His own emotions to
Dinah, if any had been yet awakened, cooled rapidly. He had no mind to
seek a maiden so much involved.

They parted presently; but John was going to tell Jane the truth that
night, and impose upon her the task of reading letters when she could, to
gather what definite information of Maynard's plans they might contain.

"I hate for Jane to do anything so mean," declared Jerry, "but I see it did
ought to be done."

"It ain't mean, my son; it's for the sake of justice, and to come between
Dinah and living death," explained Joe.

Then the younger men went their way to Buckland, and John, leaving
the brothers there, started for home. He passed Maynard on the way and
guessed that he had left, or brought, a letter. Much he longed to challenge
him, and fully he intended to play an active part in the future proceedings;
but he hid his secret knowledge, and said 'Good night' and passed down the
hill, while the unsuspecting cowman, who had just posted a letter to Dinah,
responded with friendly voice.

But Maynard did not overtake his master, and hearing Tom's slow voice
droning in the kitchen with thin interjections from Soosie-Toosie, he retired
on returning home.

Indeed matters of some moment for Joe awaited him, for the time
brought his thoughts sharply back to himself. Susan hastened to pour out his
evening drink when he came back, and Thomas, who always rose to his feet
when his master entered the kitchen, now asked if he might be permitted to
say a few words.

He spoke and Susan fluttered about in the background, while Joe

listened and sipped from a glass of spirits and water.

"You see things be risen to a crisis," began Tom, "and I feel very much
that the time's ripe for an understanding. It's mournful to keep on like this,
and to-day, by the post, there came a very fine offer of work for me to a
gentleman's farm nigh Exeter. Everything done regardless, and good money
and a cottage. So now's the appointed time to speak, and Susan and me feel
very wishful to pleasure you, and we've come by an idea."

"Go on then. It don't much matter putting your ideas before me, as I'm
not axed to influence them. You'll do as you want to do."

"No," said Thomas; "in reason we want to do your will if it can be done.
You've been very harsh of late, master, and, of course, I can well understand
your feelings about losing Susan. But I never shall see why you was so
cruel rude about it. You may treat people like dirt, if you do it kindly, and
they won't mind; but if you call 'em dirt, then they get a bit restive; and
restive I've got, and so have she. But here it is—an offer in a very friendly
spirit; and we haven't come to it without a lot of thinking and balancing the
bright side against the dark. And, on the whole, for Susan and me it's a
bright thought, and we hope you may think so too."
 "But there's one little thing, father," began Susan, and Mr. Palk stopped
her.

"Leave all to me," he said, "I'll set it out. There's several little things for
that matter, and if the master don't see his way, so be it. First, there's what
we be offering, and next there's the conditions to set against it. And we offer
to stop after we'm married and to go on just as usual. As a son-in-law I
know you've got no use for me; but as a hossman, you've been suited. And
as a hossman I'll willingly bide and do all I know regular and steadfast for
the same money as I'm getting now. And I pray God, if that happened, you'd
come to find me a good son-in-law likewise. And that means your darter
bides at your right hand so long as you want her there. And I'll go farther
than that. I'll say if at any time in the next five years you take a wife and
want us away, we'll go."

"I wish it too, with all my heart, father," declared Susan. "I'd be lost
away from you, and worriting all the time to know whose hands you were
got in. And marrying Thomas won't make no difference, except there'll be
two to think about you instead of one."

Mr. Stockman puffed his pipe and showed by no expression that he

appreciated the proposal.

"I'll give you this credit," he said, "I dare say you mean well."

"No two people ever meant better, father."

"And now for the powder. I expect that, even if I was to see my way,
you've got a barrelful of ugly things you'll demand. And I tell you at once
that it just hangs on a razor-edge whether the idea be good enough as it
stands, without any conditions to it at all. I should have conditions also, and
one of them would be that you undertook to stop and not change your
minds after a year, or bolt off and leave me at your own will."

"Never," answered Susan. "It's understood we don't go unless you wish

it."

"And now your conditions, Palk, if you please."

 "There ain't no powder about 'em, but only right and reason," said
Thomas, "and be it as 'twill, there's only three of 'em. Firstly, that we have a
proper, human wedding, all joyous and cheerful, with you smiling and a
few neighbours to the spread after, and a nice send off; secondly, that we be
allowed ten clear days for a honeymoon round about somewhere; and
thirdly, and lastly, that Susan, when she comes home, be allowed a virgin
girl under her, to help the labour of the house. Just a maid-of-all-work, as
any other married woman would have for her dignity. That's all we ask,
master, and I do hope you may be brought to see there's nothing to it but
will make for your comfort and satisfaction. Susan you know, and you've
often said she was the light of the house, and she wants so to continue; and I
do believe, when you get to know me better and see how I go on and how I
treat Susan, that you'll come to feel a kinder feeling for me also."

"Don't say 'no' without thinking over it and giving us the benefit of your
wisdom, dear father," pleaded Soosie-Toosie, her large eyes fixed upon him.

"I never say 'no' to anything, without thinking it over, Susan. 'Tis all the
other way, and I'm prone to give people the benefit of the doubt too often.
I'll turn this over. You've put the case very clear. We shall see. I'm one for
the long view, as you know. I'll look all round it."

CHAPTER XXXV

FOR RIGHT AND JUSTICE

Joe Stockman decided that he must submit to the propositions of

Thomas and his daughter. He declared that the decision was marked solely
by affection for Susan, and a determination that his son-in-law should have
every opportunity to show his worth under the new conditions. He also let it
be known how this arrangement was his own idea and, indeed, mentioned it
in several quarters as a fact, before he informed the lovers that he was
agreeable. This matter settled, Joe, who was really much gratified and
relieved, modified his gloom, and to the surprise of those most concerned,
proceeded with his part of the contract in a spirit not unamiable. He planned
a substantial entertainment for the wedding-day, permitted Susan to secure a
maid, and decreed that the honeymoon might last a fortnight.

All progressed smoothly; the farmer became affable to everybody,

including Mr. Palk, and made no opposition to the minor details of
housekeeping and general control that the marriage would involve.

"I've drawed the sting of the trouble," he confessed to himself.

And then, two days before the wedding, he received certain secret
information concerning the matter of Lawrence Maynard. He expected it,
for during the same week Maynard had specified a date for leaving.

Then came the vital news from Jane, who dipped into the secret letter-
box from time to time and skimmed the lover's letters to glean facts. These
she had now learned, and they embraced the time of departure and details
concerning it.

Thus Jane and John, with the Withycombe brothers and Mr. Stockman,
heard what was planned, and the younger conspirators now waited for Joe
to determine what actions should be taken. For him zest had already
dwindled out of the adventure. He had secured a new cowman and the
maid-of-all-work was skilled in the dairy; therefore Joe felt satisfied, so far
as his own comfort and welfare were concerned. But there remained Dinah
to be saved, and various courses of action offered themselves, the simplest
being to make all publicly known at once.

Joe, however, decided to take another party into the secret before any
final action, and he was inspired to do so by the visit of Arthur Chaffe, who
arrived at this time, to look into the matter of the dry rot in the stables.

They met and conversed on various subjects, beginning, English

fashion, with the weather; but the weather was not a topic that Arthur ever
permitted to waste his time.
 "An early autumn," said Joe. "The leaves be falling in the topmost trees
a'ready."

"I wish one old leaf would fall," answered the carpenter. "It's among the
saddest things I've known that Ben Bamsey lives on—a poor spectrum and
shadow of his former self. A very harrowing thing for all concerned, and
I've prayed on my knees daily, for a month now, that it may please God to
take him. What a man prays for will show you the measure of his wits, Joe,
and the nature of his character; and for my part I've always made it a habit
to pray for others more than for myself, and found it a very good rule."

"No doubt, no doubt, Arthur. But most people have looked upon Ben as
dead ever since last spring. There's only the outer case of the man left: the
works be gone. And a good thing here and there. He's took from some
shocks and surprises. Run your eye over this job and see what's to be done,
then I'll have a tell with you about something else that calls for a lot of brain
power. Right must be done in a certain quarter; but the question is how best
to do it."

Chaffe proceeded, and when he had settled the matter of the dry rot, he
spoke of the approaching wedding and declared his immense satisfaction
that Soosie-Toosie would stop with her father.

"It's like your good sense, and there's no doubt at all you've done a wise
thing. And Thomas Palk's mind be opening out very well I find. He's a very
good man and, in your hands, though old for a learner, can't fail to enlarge.
In fact I'm very glad about it, and so's everybody. You'd have missed her, of
course, and she'd have felt a lost creature away from you."

"So I believe, and so I acted," answered Joe; "and now list to me,
Arthur, and face a very critical affair. 'Tis understood you don't mention it
again to a living soul for the minute; but I'll ask you to give it your full
attention. I'll tell you now, and after a bit of dinner, which you'll take with
me, please, you can say what you think about it."

Mr. Chaffe protested at stopping for dinner. He was desperately busy

and begged to be allowed to return home; but Joe would not suffer it.
 "No," he said, "a soul be in the balance, Arthur, and I never yet heard
you put your work before the welfare of a soul."

"If a soul's the matter, you must speak and I must hear," answered the
old man; and then he listened to the story, from the moment of Maynard's
arrival at Falcon Farm up to the present and the secret flight, planned to
take place within ten days.

"Maynard goes from me," concluded Joe, "and the next morning he
meets Orphan Dinah at Shepherd's Cross, on Holne Moor. From there they
get down to the in-country, take train for Plymouth, at Brent I expect, and
sail that night, or the next day, to Australia. A very simple and easy plan if
it wasn't interfered with; but of course it ain't going to happen, and the
question is how best to stop it in a righteous and seemly fashion."

Mr. Chaffe was much concerned.

"Who can say he's ever fathomed man or woman?" he asked. "This
throws a light into darkness, Joe, and shows me many things that have
troubled me. Not about Dinah, for she's above board and a good Christian
by nature and upbringing; but about Maynard. He's foxed her into this dark
and dangerous deed, and I'll be bold to say the blame's on his shoulders
only, though nothing ought to have made her agree to run away
unbeknownst from her friends. That shows a lightness; but no doubt the
man have made her love him, and love blinds the best. There's a lot to thank
God for, however. You can see Providence looking far ahead as usual. For if
Maynard hadn't confided the truth to you years ago, we should never have
known, and he'd have brazened it out and committed bigamy in our midst
no doubt."

"He would—the rascal; and I feel his crime did ought to be punished,
whether it succeeds or not. He's tried to do a blackguard act, and it is for us
just men to make him feel his proper reward and chasten the wretch—if
only for his future salvation. But seeing that I've fallen out with him already
in a manner of speaking, when he gave notice, I'm in the position where it
wouldn't become me to smite him, because people would say it was
revenge. And so I put it to you, who stand for nothing but the cause of
religion and justice."
 Mr. Chaffe nodded.

"A very proper line to take. And I might, of course, go in my turn to

higher ones. You see it's a matter for State and Church both, Joe. This man
be out to break the law and ruin an innocent and trusting woman; and he's
also flouting righteousness and planning a great sin. We must rise to the
proper answer; and my feeling would be to take a line on our own, if I can
think of the right one. And if I can't, then we must hand it over to the lawful
authorities."

"No," said Mr. Stockman. "In my view that would be paltry. We've got
to keep the man and woman apart and read him a sharp and bitter lesson.
That's well in our power without going to the police. They couldn't lock him
up if he hadn't done the crime, so it's for us to make justice on the spot and
fall on the man like the trump of doom, just when he thinks he's triumphed.
That's how I see it. And we don't give him no long drawn out punishment,
but just crush him, like you'd crush a long-cripple,* and leave him to his
bad conscience. And as for Dinah, when she finds out the size of her danger
and sees the brink she was standing on, she'll soon forget her troubles, in
thankfulness to God for her great escape."

* "Long-cripple"—viper.

"It calls for a fine touch," declared Arthur. "There's no doubt our duty
stands before us, Joe, and, at a first glance, I'm minded to see with you, that
this feat is within our power and we needn't call for no outside aid. The
thing is to know just how to strike. Your idea of falling on the man like the
crack of doom be good on the whole. But we mustn't overdo it, or forget
we're sinful creatures ourselves. He's got a fearful punishment afore him in
any case, apart from what we may do, because he loses Dinah just at the
very moment when he thinks he's got her safe for evermore. And that's
enough to go on with for him. But the right thought will certainly come to
my mind, since we be acting in the name of religion."

"I'm all for mercy as a rule," answered Stockman; "but not in this case.
Mercy's barred out, because of Maynard's wickedness."
 "There don't seem no very loud call for mercy certainly, when you think
of the far-reaching thing he's led the poor girl into. No; we may stop at
justice I reckon. I'll brood upon it, Joe. I see the line, I believe; but I'll take
it afore my Maker. We want a bit of physical force—we may even have to
handle him, as I see it."

"D'you think so?"

"Yes. For the sake of argument, would John Bamsey and the
Withycombe brothers be strong enough to withstand him?"

Joe believed they might be.

"If they surprised the man, they would. Robert Withycombe's a huge,
strong chap. What be in your mind?"

"Wait till it takes a clearer shape. Put by the thought till after the
wedding. That must be all happiness and joy; and when that's well over and
the happy pair are away, we'll turn to Maynard. We must come to it with
clean hands, Joe, as humble, willing tools of Providence. Us mustn't allow
ourselves no evil hate, or anything like that, but just feel but for the grace of
God us might have been tempted and fallen into the pit ourselves. There's a
bright side, even for him, and I hope in time he'll live to see what we saved
him from."

"We must have a masterpiece of cleverness, and I'll think too," added
Mr. Stockman. "Don't squeak, Arthur; don't tell a living soul about it. We
must just teel a trap for the beggar and catch him alive. And we must spare
Dinah all we can."

"As to Dinah," answered Mr. Chaffe, "if what I see rising up in my mind
be the right course, we may have to give Dinah a pinch also. I quite agree
she must be spared all shame if possible; but I always go the way I'm led by
the still small voice, Joe; and if the ideas creeping in me blaze out and
command to be followed, then very like Dinah may have to be in it—for her
own good. You must remember that Dinah's only a part of human nature,
and we can read her feelings very clear when this bursts upon her."
 "How can we?" asked Joe. "I never can read any woman's feelings very
clear at any time. They never feel about anything same as we do, and their
very eyes ban't built to look at the shape and colour of things as ours be.
They're a different creation in fact, and 'tis folly to pretend they ain't."

"A different creation, no," answered Arthur. "They feel and suffer same
as us, and Dinah Waycott, afore this great downfall, will take the ordinary
course of human nature. Her Christianity will help her to keep a tight hand
on herself; but, being a woman, she'll want to give Lawrence Maynard a bit
of her mind, and he'll deserve it and didn't ought to be spared it."

Mr. Stockman was rather impressed.

"By God, that's true," he said. "And I'm rather glad you thought of it and
not me, Arthur. For if I'd hit on that, people would without doubt have said
'twas the poison of revenge working in me. But coming from you, of course
it can be no more than justice. It's just a thing a bachelor might have hit
upon. The average married man would have felt a twinge of mercy, and
only your high sense of justice would screw you up to such a pitch."

"Nothing be done yet," answered Mr. Chaffe. "And if my thoughts look

too harsh in your eyes presently, I'll willingly tone 'em down where
possible. But often the surgeon as ban't feared to cut deep be the best to
trust. We've got to save the man's soul alive, and seeing the size of the
wound upon it and the danger in which he stands, we should be weak to
botch our work for the sake of sparing him, or ourselves pain. For that's
what mercy to the wicked often comes to, Joe. We forgive and forget for
our own comfort far too often, and let a sinner off his medicine, only
because we don't like to see the ugly face he makes over it."

"In fact, mercy would be weakness and false kindness," admitted Joe.
"And if we want a couple more strong men presently, I know the proper
ones. We must all be ministers of right in this matter, and I'm glad of your
clear head and high opinions. For now I know we shall come through with
credit to ourselves and the respect of the people."

"There again, we must take care our feet don't slip," answered Mr.
Chaffe. "It may hap that this ain't a case for the people. As a lesson and