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Community and
Public Health
Nursing | 3 rd edition

EVIDENCE FOR PRACTICE

Rosanna F. DeMarco, PhD, RN, FAAN

Chair and Professor
Department of Nursing
College of Nursing and Health Sciences
University of Massachusetts Boston
Boston, Massachusetts

Judith Healey-Walsh, PhD, RN

Clinical Associate Professor
Director of the Undergraduate Program
Department of Nursing
College of Nursing and Health Sciences
University of Massachusetts Boston
Boston, Massachusetts

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3rd Edition

Copyright © 2020 Wolters Kluwer.

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Library of Congress Cataloging-in-Publication Data

Names: DeMarco, Rosanna F., author. | Healey-Walsh, Judith, author. | Preceded by (work): Harkness, Gail A.
Community and public health nursing.
Title: Community and public health nursing : evidence for practice / Rosanna F. DeMarco, Judith Healey-Walsh.
Description: 3. | Philadelphia : Wolters Kluwer, [2020] | Preceded by Community and public health nursing / Gail A.
Harkness, Rosanna F. DeMarco. Second edition. [2016]. | Includes bibliographical references
and index.
Identifiers: LCCN 2018058862 | eISBN 9781975144500
Subjects: | MESH: Community Health Nursing | Public Health Nursing | Evidence-Based Nursing | Nursing Theory |
United States
Classification: LCC RT98 | NLM WY 108 | DDC 610.73/43—dc23
LC record available at https://lccn.loc.gov/2018058862

Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices.
However, the author(s), editors, and publisher are not responsible for errors or omissions or for any consequences from
application of the information in this book and make no warranty, expressed or implied, with respect to the currency,
completeness, or accuracy of the contents of the publication. Application of this information in a particular situation
remains the professional responsibility of the practitioner; the clinical treatments described and recommended may not
be considered absolute and universal recommendations.

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text are in accordance with the current recommendations and practice at the time of publication. However, in view of
ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and
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Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for
limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of
each drug or device planned for use in his or her clinical practice.

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Contributors

Stephanie M. Chalupka, EdD, RN, PHCNS-BC, FAAOHN, FNAP

Associate Dean for Nursing
Department of Nursing
Worcester State University
Worcester
Visiting Scientist
Environmental and Occupational Medicine and Epidemiology Program
Department of Environmental Health
Harvard T. H. Chan School of Public Health
Boston, Massachusetts
(Chapter 9, Planning for Community Change)

Susan K. Chase, EdD, RN, FNAP

Professor
College of Nursing
University of Central Florida
Orlando, Florida
(Chapter 23, Faith-Oriented Communities and Health Ministries in Faith
Communities)

Sabreen A. Darwish, RN, BScN, MScN

Second Year PhD Student/Research Assistant
College of Nursing and Health Sciences
University of Massachusetts
Boston, Massachusetts
(Chapter 3, Health Policy, Politics, and Reform)

Karen Dawn, RN, DNP, PHCNS, CDE

Assistant Professor
School of Nursing
George Washington University
Ashburn, Virginia
(Chapter 4, Global Health: A Community Perspective)

Pamela Pershing DiNapoli, PhD, RN, CNL

Associate Professor of Nursing and Graduate Programs
College of Health and Human Services
University of New Hampshire
Durham, New Hampshire
(Chapter 22, School Health)

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

Barbara A. Goldrick, MPH, PhD, RN

Epidemiology Consultant
Chatham, Massachusetts
(Chapter 8, Gathering Evidence for Public Health Practice; Chapter 14, Risk of
Infectious and Communicable Diseases; Chapter 15, Emerging Infectious
Diseases)

Patricia Goyette, DNP-PHNL, RN

Educational Consultant
Everett, Massachusetts
(Chapter 25, Occupational Health Nursing)

Cheryl L. Hersperger, MS, RN, PHNA-BC, PhD Student

Assistant Professor
Department of Nursing
Worcester State University
Worcester, Massachusetts
(Chapter 9, Planning for Community Change)

Anahid Kulwicki, PhD, RN, FAAN

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

Carol Susan Lang, DScN, MScN(Ed.), RN

Associate Director of Global Initiatives
Assistant Professor of Global and Population Health
George Washington University School of Nursing
Washington, DC

Annie Lewis-O’Connor, PhD, NP-BC, MPH, FAAN

Senior Nurse Scientist and Founder and Director of C.A.R.E Clinic
Brigham and Women’s Hospital
Boston, Massachusetts
(Chapter 16, Violence and Abuse)

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

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

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

Christine Pontus, RN, MS, BSN, COHN-S/CCM

Associate Director in Nursing and Occupational Health
Massachusetts Nurses Association (MNA)
Canton, Massachusetts
(Chapter 25, Occupational Health Nursing)

Joyce Pulcini, PhD, RN, PNP-BC, FAAN, FAANP

Professor
Director of Community and Global Initiatives
Chair, Acute and Chronic Care Community
School of Nursing
George Washington University
Washington, DC
(Chapter 4, Global Health: A Community Perspective)

Teresa Eliot Roberts, PhD, RN, ANP

Clinical Assistant Professor
College of Nursing and Health Sciences
University of Massachusetts Boston
Boston, Massachusetts

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

Judith Shindul-Rothschild, PhD, MSN, RN

Associate Professor
Connell School of Nursing
Boston College
Chestnut Hill, Massachusetts
(Chapter 17, Substance Use; Chapter 21, Community Mental Health)

Joy Spellman, MSN, RN

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

Tarah S. Somers, RN, MSN/MPH

Senior Regional Director
Agency for Toxic Substances and Disease Registry, New England Office
US Public Health Service Commissioned Corps
Boston, Massachusetts
(Chapter 19, Environmental Health)

Patricia Tabloski, PhD, GNP-BC, FGSA, FAAN

Associate Professor
Connell School of Nursing
Boston College
Chestnut Hill, Massachusetts
(Chapter 24, Palliative and End-of-Life Care)

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

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Reviewers

Elizabeth Armstrong, DNP, MSN, RN, CNE

Assistant Professor
School of Nursing
University of Bridgeport
Bridgeport, Connecticut

Karen Cooper, MS, RN

Clinical Assistant Professor
Department of Nursing
Towson University
Towson, Maryland

Teresa E. Darnall, PhD, MSN, RN, CNE

Assistant Dean
Assistant Professor
May School of Nursing and Health Sciences
Lees-McRae College
Banner Elk, North Carolina

Florence Viveen Dood, DNP, MSN, BSN, RN

RN-BSN Program Coordinator
Assistant Professor
School of Nursing
Ferris State University
Big Rapids, Michigan

Aimee McDonald, PhD, RN

Assistant Professor
Department of Nursing
William Jewell College
Liberty, Missouri

Rita M. Million, PhD, RN, PHNA-BC, COI

Nursing Faculty
School of Nursing
College of Saint Mary
Omaha, Nebraska

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

Kendra Schmitz, RN, MSN

Assistant Professor
School of Nursing
D’Youville College
Buffalo, New York

Kathleen F. Tate, MSN, MBA, CNE, RN

Assistant Professor
School of Nursing
Northwestern State University
Natchitoches, Louisiana

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 Preface

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

African Proverb

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

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

W
e are experiencing extraordinary changes in healthcare in this new century; changes
that call upon the most creative, analytical, and innovative skills available. While the
world has the resources to reduce healthcare disparities and eliminate the differences
in healthcare and health outcomes that exist between various population groups across the globe,
accomplishing this is a long-term and complicated task. Improvement in the social structure
within which people live, and a redistribution of resources so that all people have access to the
basic necessities of life, require an unprecedented global consciousness and political
commitment.
Ultimately, reducing health disparities and promoting health equity occur within the local
community where people reside. Nurses are by far the largest group of healthcare providers
worldwide and, as such, have the ability and responsibility to be change agents and leaders in
implementing change in their communities. They can be the primary participants in the
development of health policy that specifically addresses the unique needs of their communities.
Through implementation and evaluation of culturally appropriate, community-based programs,
nurses can use their expertise to remedy the conditions that contribute to health disparities.
People need to be assured that their healthcare needs will be assessed and that healthcare is
available and accessible.
In the United States, public health has resurged as a national priority. Through Healthy
People 2020, national goals have been set to promote a healthy population and address the issue
of health disparities. The process of implementing the Healthy People 2020 objectives rests with
regional and local practitioners, with nurses having a direct responsibility in the implementation
process. The nurse practicing in the community has a central role in providing direct care for the
ill as well as promoting and maintaining the health of groups of people, regardless of the
circumstances that exist. Today, there are unparalleled challenges to the nurse’s problem-solving
skills in carrying out this mission.
Whether caring for the individual or the members of a community, it is essential that nurses
incorporate evidence from multiple sources in the analysis and solution of public health issues.
Community and Public Health Nursing: Evidence for Practice focuses on evidence-based
practice, presenting multiple formats designed to develop the abstract critical thinking skills and
complex reasoning abilities necessary for nurses becoming generalists in community and public
health nursing. The unique blend of both the nursing process and the epidemiologic process
provides a framework for gathering evidence about health problems, analyzing the information,
generating diagnoses or hypotheses, planning for resolution, implementing plans of action, and
evaluating the results.

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

CONTENT ORGANIZATION
It is the intention of Community and Public Health Nursing: Evidence for Practice to present the
core content of community and public health nursing in a succinct, logically organized, but
comprehensive manner. The evidence for practice focus not only includes chapters on
epidemiology, biostatistics, and research but also integrates these topics throughout the text.
Concrete examples assist students in interpreting and applying statistical data. Healthy People
goals and measurable objectives serve as an illustration of the use of rates throughout the text.
Additionally, we have added brief learning activities and questions throughout the text to allow
students to apply the Healthy People goals to real-life scenarios. Groups with special needs,
such as refugees and the homeless, have been addressed in several chapters; however, tangential
topics that can be found in adult health and maternal-child health textbooks have been omitted.
A chapter on environmental health concerns has been included, along with a chapter on
community preparedness for emergencies and disasters. Also, a global perspective has been
incorporated into many chapters.
Challenges to critical thinking are presented in multiple places throughout each chapter.
Case studies are integrated into the content of each chapter and contain critical thinking
questions imbedded in the case study content. Also, a series of critical thinking questions can be
found at the end of each chapter. (Please see the description of features below.) Considering the
onus presented by Mark Twain: “Be careful about reading health books. You may die of a
misprint,” every attempt has been made to present correct, meaningful, and current evidence for
practice.
Part One presents the context within which the community or public health nurse practices.
An overview of the major drivers of healthcare change leads to a discussion of evolving trends,
such as the emphasis on patient/client-centered care, the effects of new technology upon the
delivery of care, and the need for people to assume more responsibility for maintaining their
health. Community and public health nursing as it presently exists is analyzed and reviewed
from a historical base, and issues foreseen for both the present and immediate future are
discussed. The nursing competencies necessary for competent community and public health
practice are also presented.
A more in-depth discussion of the complex structure, function, and outcomes of public
health and healthcare systems follows. National and international perspectives regarding
philosophical and political attitudes, social structures, economics, resources, financing
mechanisms, and historical contexts are presented, highlighting healthcare organizations and
issues in several developed countries. The World Health Organization’s commitment to
improving the public’s health in developing countries follows, with an emphasis on refugees and
disaster relief. With the burden of disease growing disproportionately in the world, largely due
to climate, public policy, socioeconomic conditions, age, and an imbalance in distribution of risk
factors, the countries burdened by disease often have the least capacity to institute change. Part
One concludes with examination of the indicators of health, health and human rights, factors that
affect health globally, and a framework for improving world health.
Part Two provides the frameworks and tools necessary to engage in evidence-based practice
focused on the population’s health. Concepts of health literacy, health promotion, disease
prevention, and risk reduction are explored, and a variety of conceptual frameworks are
presented with a focus on both the epidemiologic and ecologic models. Epidemiology is
presented as the science of prevention, and nurses are shown how epidemiologic principles are

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applied in practice, including the use of rates and other statistics as community health indicators.
Specific research designs are also explored, including the application of epidemiologic research
to practice settings.
Part Three is designed to develop the skills necessary to implement nursing practice
effectively in community settings. Since healthcare is in a unique state of transformation,
planning for community change is paramount. The health planning process is described, with
specific attention given to the social and environmental determinants of change. Lewin’s change
theory, force-field analysis, and the effective use of leverage points identified in the force-field
analysis demonstrate the change process in action.
Changes directed at decreasing health disparities must be culturally sensitive, client-
centered, and community-oriented. A chapter on cultural diversity and values fosters the
development of culturally competent practitioners, and the process of cultural health assessment
is highlighted. Frameworks of community assessment are presented and various approaches are
explored. Management of care and the case management process follows. The role and scope of
home care nursing practice and the provision of services is presented along with the challenges
inherent with interdisciplinary roles, advances in telehealth, and other home care services.
Although content on family assessment can be found in other texts, it is an integral
component of community and public health practice. Therefore, theoretical perspectives of
family, and contemporary family configurations and life cycles are explored. Family Systems
Nursing and the Calgary Family Assessment and Intervention Model are provided as guides to
implementing family nursing practice in the community. Evidence-based maternal-child health
home visiting programs and prominent issues related to family caregiving are also highlighted.
Part Four presents the common challenges in community and public health nursing. The
chapter addressing the risk of infectious and communicable diseases explores outbreak
investigation with analysis of data experience provided by the case studies. Public health
surveillance, the risk of common foodborne and waterborne illnesses, and sexually transmitted
diseases are followed by a discussion of factors that influence the emergence/reemergence of
infectious diseases, examples of recent outbreaks, and means of prevention and control.
The challenge presented by violence in the community is presented with an emphasis on
intimate partner violence and the role of the healthcare provider. Because of the cultural
variations in substance use disorder, multifaceted approaches to the problem are discussed with
the recommendation that evidence-based prevention and treatment protocols for substance use
disorder are incorporated by community health nurses in all practice settings. Meeting the
healthcare needs of vulnerable and underserved populations is another challenge. Health
priorities for people who live in rural areas; are gay, lesbian, bisexual, or transgender; are
homeless; or live in correctional institutions are reviewed.
The issues of access to quality care, chronic disease management, interaction with health
personnel, and health promotion in hard-to-reach populations among these populations are also
presented.
The environmental chapter demonstrates how to assess contaminants in the community by
creation of an exposure pathway. The health effects of the exposure pathway can then be
ascertained. Individual assessment of contaminant exposures, interventions, and evaluations are
also explored, ending with a focus on maintaining healthy communities. The final chapter in
Part Four presents the issue of community preparedness. The types of disasters along with
classification of agents are described, disaster management outlined, and the public health
response explained. The role and responsibility of nurses in disasters and characteristics of the
field response complete the content.
Part Five describes five common specialty practices within community and public health
nursing. All have frameworks that define practice and reflect the competencies necessary for
competent practice in a variety of community settings. These include application of the

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

Features Found in Each Chapter

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

OBJECTIVES
Observable changes expected following completion of the chapter

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

CASE STUDIES

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

Evidence for Practice

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

Practice Point

Highlighting of essential facts relevant to practice

Student Reflection

Student stories of their own experience and reflections

KEY CONCEPTS
Summary of important concepts presented in the chapter

CRITICAL THINKING QUESTIONS

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

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

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

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Acknowledgments

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

A Special Thanks in Memoriam to Dr. Gail A. Harkness, DPH, FAAN

The first and second editions of this textbook were led by the efforts of Dr. Gail Harkness. Gail
was a mentor and friend. While she is no longer with us to help support, guide, and enliven this
newest edition, we wanted to take time to honor her memory and produce this edition in her
honor.
Gail was such an intelligent, warm, and wise public health expert who was most passionate
about population health and epidemiology, and particularly infectious diseases past, present, and
evolving. She was a prolific writer and teacher. When I met her, she reached out to me, asking if
I could help her with her vision of a community health and public health textbook for nursing

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students that was affordable and succinct and did not just “rattle on” with facts but situated
public health ideas in the context of evidence, student stories, and current disease prevention and
health promotion innovations. She brought to my mentorship opportunity her global experiences
from the UK (University of Leeds) to Japan (Osaka), as well as her own local work on a town
Board of Health in Massachusetts. Gail loved public health research and the evidence it yielded
to inform policy decisions toward all our health. She was a graduate of the University of
Rochester (undergraduate and graduate programs) in Nursing and received her Doctorate in
Public Health from the University of Illinois, School of Public Health in Epidemiology and
Biometry (the application of statistical analysis to biologic data).
More than being an epidemiologist, she loved the opportunity as an academician to teach
nursing students at all levels to be as passionate about public health as she was. She was a
professor emerita from University of Connecticut. We know her family and friends miss Gail
very much, but her energy and spirit will always be in this textbook.
Rosanna F. DeMarco

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 Contents

PART ONE
The Context of Community and Public Health Nursing

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

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

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

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

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PART TWO
Evidence-Based Practice and Population Health

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

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

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

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

PART THREE
Implementing Nursing Practice in Community Settings

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

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

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

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

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

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

PART FOUR
Challenges in Community and Public Health Nursing

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

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

19
Chapter 16
Violence and Abuse
Overview of Violence
Intimate Partner Violence
Mandatory Reporting of Abuse
Intervention
Human Trafficking
Model of Care for Victims of Intentional Crimes
Forensic Nursing

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

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

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

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

20
PART FIVE
Specialty Practice

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

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

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

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

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

21
Implementing a Program: Example, Smoking Cessation
Epidemiology and Occupational Health
Emergency Preparedness Planning and Disaster Management
Nanotechnology and Occupational Safety and Health

Index

22
 Part 1
The Context of Community
and Public Health Nursing

23
 Chapter 1
Public Health Nursing:
Present, Past, and Future
Judith Healey-Walsh

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

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

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

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

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

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

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KEY TERMS
Aggregate: Population group with common characteristics.
Competencies: Unique capabilities required for the practice of public health nursing.
District nurses: Public health nurses in England who provide visiting nurse services; historically,
they cared for the people in the poorest parish districts.
Electronic health records: Digital computerized versions of patients’ paper medical records.
Epidemiology: Study of the distribution and determinants of states of health and illness in
human populations; used both as a research methodology to study states of health and
illness, and as a body of knowledge that results from the study of a specific state of health or
illness.
Evidence-based nursing: Integration of the best evidence available with clinical expertise and
the values of the client to increase the quality of care.
Evidence-based public health: A public health endeavor wherein there is judicious use of
evidence derived from a variety of science and social science research.
Health disparities: Differences in healthcare and health outcomes experienced by one
population compared with another, frequently associated with race/ethnicity and
socioeconomic status
Health information technology: Comprehensive management of health information and its
secure exchange between consumers, providers, government and quality entities, and
insurers.
Public health: What society does collectively to ensure that conditions exist in which people can
be healthy.
Public health interventions: Actions taken on behalf of individuals, families, communities, and
systems to protect or improve health status.
Public health nursing: Focuses on population health through continuous surveillance and
assessment of the multiple determinants of health with the intent to promote health and
wellness; prevent disease, disability, and premature death; and improve neighborhood quality
of life (American Nurses Association [ANA], 2013).
Telehealth: Use of electronic information and telecommunications technologies to support long-
distance clinical healthcare, patient and professional health-related education, public health,
and health administration.
Social determinants of health: Social conditions in which people live and work.

CASE STUDY

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

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

HEALTHCARE CHANGES IN THE 21ST CENTURY

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A worldwide phenomenon of unprecedented change is occurring in healthcare. There are new
innovations to test, ethical dilemmas to confront, puzzles to solve, and rewards to be gained as
healthcare systems develop, refocus, and become more complex within a multiplicity of settings.
Nurses, the largest segment of healthcare providers in the world, are on the frontline of that
change.
Demographic characteristics indicate that people in high-income countries are living longer
and healthier lives, yet tremendous health and social disparities exist. The social conditions in
which people live, their incomes, their social statuses, their educations, their literacy levels, their
homes and work environments, their support networks, their genders, their cultures, and the
availability of health services are the social determinants of health. These conditions have an
impact on the extent to which a person or community possesses the physical, social, and
personal resources necessary to attain and maintain health. Some population groups, having
fewer resources to offset these effects, are affected disproportionately. The results are health
disparities, or differences in healthcare and health outcomes experienced by one population
compared with another.
For example, the World Health Organization (WHO) estimates that almost half of all
countries surveyed have access to less than half the essential medicines they need for basic
healthcare in the public sector. These essential medicines include vaccines, antibiotics, and
painkillers. Children in low-income countries are 16 times more likely to die before reaching the
age of 5 years, often because of malnourishment, than children in high-income countries. The
double burden of both undernutrition and overweight conditions causes serious health problems
and affects survival (WHO, 2017). Globally, resources exist to remedy these circumstances, but
does the political commitment exist?

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

Role of the Government in Healthcare

A government has three core functions in addressing the health of its citizens: (1) it assesses
healthcare problems; (2) it intervenes by developing relevant healthcare policy that provides
access to services; and (3) it ensures that services are delivered and outcomes achieved. The
United States, the United Kingdom, the European community, and some newly industrialized
countries have embraced these principles. However, governments in other countries struggle to
build any semblance of a health system. Unstable governments struggle with mobilizing the
concern, motivation, or resources to address healthcare issues.
There were unprecedented public health achievements in the United States during the 20th
century. The Centers for Disease Control and Prevention (CDC) has listed the Ten Great Public
Health Achievements as the legislature amends the law based on supportive epidemiologic
analyses and comparisons of health factors over 30 years (Box 1.1). However, healthcare
expenditures are now more than $3.2 trillion per year (CDC, 2016). Infant mortality, longevity,
and other health indicators still fall behind those of many other industrialized nations. The
current U.S. healthcare system faces serious challenges on multiple fronts. Although the United
States is considered the best place for people to obtain accurate diagnoses and high-quality
treatment, until 2014 nearly 45 million Americans lacked health insurance and therefore access
to care. These uninsured Americans were primarily young people, low-income single adults,
small-business owners, self-employed adults, and others who did not have access to employer-
sponsored health insurance.

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

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

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

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

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

Practice Point

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

The United States assesses and monitors people’s health through an intricate system of
surveillance surveys conducted by the HHS, the CDC, and the state and local governments.
Health policy development focuses on cost, access to care, and quality of care. Access is defined
as the ability to get into the healthcare system, and quality care is defined as receiving
appropriate healthcare in time for the services to be effective. Outcomes are ensured by a
continual evaluation system linked in part with the CDC surveys. Despite this elaborate
healthcare system, health disparities related to race, ethnicity, and socioeconomic status still
pervade the healthcare system. Health disparities vary in magnitude by condition and
population, but they are observed in almost all aspects of healthcare, in quality, access,
healthcare utilization, preventive care, management of chronic diseases, clinical conditions, and
settings, and within many subpopulations.
The National Healthcare Quality and Disparities Report (NHQDR) measures trends in the
effectiveness of care, patient safety, timeliness of care, patient centeredness, and efficiency of
care. The report presents, in chart form, the latest available findings on quality of and access to
healthcare (Agency for Healthcare Research and Quality [AHRQ], 2018). For example, Figure
1.1 indicates that quality of healthcare improved overall from 2000 to 2014, although the pace of
improvement varied based on priority area. In addition, as Figure 1.2 demonstrates, that
although some gaps in measures by race/ethnicity are improving, health disparities in quality

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healthcare remain.

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

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

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

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rather than providers, as was common in the past. This transformation is considered the best way
to ensure that patients have access to high-quality care, regardless of their income, where they
live, the color of their skin, or how old or ill they are.
Patient/client-centered care considers cultural traditions, personal preferences, values,
families, and lifestyles. People requiring healthcare, along with their families or significant
others, become an integral part of the healthcare team, and clinical decisions are made
collaboratively with professionals. Clients become active participants in their own care, and
monitoring health becomes the client’s responsibility. Support, advice, and counsel from health
professionals are available, along with the tools that are needed to carry out that responsibility.
The shift toward patient/client-centered care means that a broader range of outcomes needs
to be measured from the patient’s perspective to understand the true benefits and risks of
healthcare interventions.

Practice Point

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

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