population health

three core functions of public health

-assessment -policy development -assurance

Chapter 16: Promoting Healthy Communities Student Case Studies Robert T. is a community-oriented nurse and a member of the Jonesville Healthy City Committee. Also on the committee are the mayor, a hospital administrator, several ministers, an epidemiologist, and several other community leaders. Through an initial community assessment, the Jonesville Healthy City Committee identified several areas of need. These areas include lack of health care access for the homeless and uninsured, lack of knowledge about health-promotion behaviors, and substance abuse among teenagers. The committee shares its assessment results with the community at a town meeting. Through the group discussion that follows, the committee decides to focus first on addressing the need for improved health care access for the homeless and uninsured. Many members of the community state that they would like to see a homeless shelter built that would provide lodging and free health care services. Nurse Robert suggests that a nurse-managed clinic would provide a possible way to improve health care access for the uninsured. The committee continues to discuss possible solutions to the health care access problem and ways to obtain funding for the projects previously discussed. 1. Using the community health-promotion model as a guide, prioritize the following steps in community health promotion. Which step has the Jonesville Healthy City Committee reached? A. Assess the community. B. Build partnerships for health. C. Plan for community-wide health. D. Monitor and evaluate health progress. 2. Which approach is the Jonesville Committee taking: top-down or bottom-up? Explain your answer. 3. Several factors could influence the Healthy Communities and Cities process for Jonesville, including political support, leadership development, and community participation. As a community-oriented nurse, what could Nurse Robert do to facilitate leadership development?

1. ANS: Correct order of prioritization: (1) B. Build partnerships for health, (2) A. Assess the community, (3) C. Plan for community-wide health, and (4) D. Monitor and evaluate health progress. The Jonesville Committee is at the C. Plan for community-wide health step. They have identified problems, set priorities, and are now planning actions and securing resources. 2. ANS: The committee is using a bottom-up approach because committee members are planning programs on the basis of what the community wants. For example, the committee decided to prioritize addressing health care access because of what they learned from community members at the town meeting. In a top-down approach, experts and health professionals take the lead in identifying community health problems and implementing programs with little input from the individuals for whom the programs are being planned. 3.ANS: Community-oriented nurses recognize that although leaders are active in every community, they may not understand their potential for promoting health within the community. Nurse Robert can recommend to the committee relevant consultants, speakers, conferences, workshops, and network sessions that are related to improving health care access so that everyone can understand the scope of the problem.

Chapter 01: Public Health Foundations and Population Health Student Case Studies This is Debbie's first year working as a nurse at the local health department in a rural county. Most of her days are spent in the clinic seeing clients who often do not have health insurance. Over the past month, Debbie has noticed that several young Hispanic men who are migrant workers have come to the health department, each diagnosed with tuberculosis. Debbie is concerned about what the outbreak of tuberculosis among the migrant workers could mean for the community. Through a community health profile, Debbie identified the group of migrant farmworkers as being at highest risk for contracting tuberculosis. Debbie brought the tuberculosis outbreak to the attention of the health department's communicable disease control department. The communicable disease control department then contacted the local school system, which requires tuberculosis skin tests for enrollment in school. Debbie also developed an educational program for the migrant workers, their families, and their employers to teach them about tuberculosis and how to prevent its spread. Questions 1. What indicators should Nurse Debbie look at when she develops her community health profile? 2. What is Nurse Debbie's nursing area? A. Community health nursing practice B. Public health nursing practice C. Neither 3. In this case study, how were the core functions of public health applied?

1. ANS: Debbie should look at the indicators of sociodemographic characteristics, health status, health-risk factors, health care resource consumption, functional status, and quality of life. 2.A. Community health nursing practice. Community health nursing practice is the synthesis of nursing theory and public health theory applied to promoting, preserving, and maintaining the health of populations through the delivery of personal health care services to individuals, families, and groups. The focus of community health nursing practice is the health of individuals, families, and groups and the effect of their health status on the health of the community as a whole. Debbie is concerned about what the outbreak of tuberculosis among the migrant workers could mean for the community. The focus of public health nursing practice is the community as a whole and the effect of the community's health status (including health care resources) on the health of individuals, families, and groups. 3.ANS: Assessment, policy development, and assurance are the core functions of public health. Assessment: Debbie diagnosed and investigated health problems and health hazards in the community when she performed the community health assessment and identified the migrant farmworkers as being at highest risk for contracting tuberculosis. Policy Development: Debbie informed, educated, and empowered people about health issues when she developed an educational program for the migrant workers and their families. Assurance: Health department staff enforced laws and regulations that protect health and ensure safety when they contacted the local school system and required tuberculosis skin tests for enrollment in school.

Chapter 13: Epidemiology Student Case Studies Mary M. is the nurse epidemiologist for the Warren County Health Department. A local church contacted Nurse Mary when several church members became sick after the annual church picnic. Of 200 people who attended the picnic, 100 became ill with diarrhea, nausea, or vomiting. Ten people required emergency medical treatment or hospitalization. Incubation periods ranged from 1.5 to 30 hours, with a mean of 6 hours and a median of 3.5 hours. Duration of illness ranged from 1 to 80 hours, with a mean of 30 hours and a median of 15 hours. The annual church picnic was a potluck lunch buffet. The menu included macaroni casserole (brought by the Joneses), turkey with gravy and stuffing (brought by the Smiths), potato salad (brought by the Changs), green bean casserole (brought by the Champs), chili (brought by the Turners), homemade bread (brought by Granny Ivy), chocolate cake (brought by the Bushes), and cookies (brought by the Beckmans). Nurse Mary interviewed the church members who were ill and found that three food items were significantly associated with illness: turkey, gravy, and stuffing. Nurse Mary interviewed the Smiths, who had brought the turkey, gravy, and stuffing to the picnic. A review of food-handling procedures revealed that the turkey had cooled for 4 hours at room temperature after cooking—a time and temperature sufficient for bacterial growth and toxin production. Furthermore, the same utensils were used for the turkey and for other foods before and after cooking. Nurse Mary trained the Smiths in proper food-handling practices, emphasizing hand washing, proper cooling methods, and better equipment and utensil sanitation. Nurse Mary also offered a similar class to the church congregation. 1. Identify the agent, host, and environment in this case study. 2. Is Nurse Mary performing descriptive epidemiology or analytic epidemiology? 3. Which level of prevention is Nurse Mary exemplifying? A. Primary prevention B. Secondary prevention C. Tertiary prevention D. Combination of above E. None of the above

1. ANS: The agent is the bacterium that grew within the turkey. The hosts were the people who ate the turkey, gravy, and/or stuffing. The environment was the poor food-handling conditions; that is, the turkey left at room temperature for too long and the utensils used to handle the turkey, which contaminated the gravy and stuffing. 2. ANS: Nurse Mary is performing analytic epidemiology because she is looking at the how and why of the illness outbreak (looking for which foods caused the illness and what caused bacteria to grow in those foods). Descriptive epidemiology describes the distribution of disease, death, and other health outcomes across the population according to person, place, and time; it provides a picture of how things are or were, that is, the who, where, and when of disease patterns. 3.Nurse Mary teaches the Smiths and the church congregation proper food-handling practices to prevent future outbreaks. Nurse Mary does not provide secondary prevention because she performs no health screening in the above case. Nurse Mary does not provide tertiary prevention because she provides no treatment for those who became ill.

Chapter 18: Building a Culture of Health to Influence Health Equity Within Communities Student Case Studies Alice W. is the school health coordinator for Williams County, a rural county whose main farm crop is tobacco. Nurse Alice is concerned about the risky health behaviors of middle and high school students in Williams County. She decides to use the social ecological model to guide interventions. Survey results reveal that 38% of the students are trying and using tobacco as early as 12 years of age. Furthermore, the survey shows that students were able to get cigarettes by stealing them from parents and siblings who smoked or from unsupervised cigarette machines; they also obtained cigarettes through older students who were able to buy cigarettes from local convenience stores without being asked for ID. Of students who were smoking on a regular basis, 40% believed that smoking was bad for them and had tried to quit but were unsuccessful. Results indicated that variables at each level—intrapersonal, interpersonal, institutional, and policy and community levels—explained the high levels of risky behaviors among middle and high school students. With help from school administrators, school nurses, parent volunteers, and student volunteers, Nurse Alice develops a health-promotion plan to reduce adolescent tobacco use. School nurses in the middle and high schools will provide smoking-cessation classes to help teens who are using tobacco quit smoking. Smoking-cessation classes will also be offered to family members of students in the schools. Additionally, school principals create the new policy that smoking is not allowed by anyone (e.g., students, teachers, parents) on school grounds. 1. What are the community factors that might have attributed to the high rate of risky behaviors among middle school and high school students? 2. What social factors does Nurse Alice need to be aware of when planning a health-promotion program to decrease tobacco use among adolescents? Why is it important to keep these factors in mind? 3. With use of the Integrative Model for Community Health Promotion, what is Nurse Alice's focus of care, and what client system in her health-promotion plan will decrease adolescent smoking? (Hint: There is more than one client system.)

1.ANS: Community factors that might have contributed include unsupervised vending machines, not checking IDs when purchasing cigarettes, and lack of smoking-cessation classes for teens. 2. ANS: Social factors that Nurse Alice must be aware of include peer pressure, public view toward smoking (many people in the community rely on tobacco for income), and availability of cigarettes. Successful interventions are more likely when nurses understand how social and health resources are related to the health behaviors of individuals and communities, and how personal and community resources may affect behavioral choices. Understanding the social factors that influence adolescent smoking in Williams County will give Nurse Alice insight into this issue, making her more likely to choose interventions that will be effective. 3. ANS: Nurse Alice's focus of care is illness/disease prevention because each intervention is aimed at preventing diseases related to tobacco use, by teaching smoking-cessation classes, or not encouraging smoking (smoke-free school zone). The focus of care is not illness care because interventions do not address diseases caused by tobacco use. The focus of care is not health promotion because interventions are tailored toward a specific topic rather than promotion of a broad healthy lifestyle. Nurse Alice uses several client systems for decreasing adolescent smoking: individual (students who smoke are offered smoking-cessation classes), family (family members of students in school are offered smoking-cessation classes), and aggregate (schools become smoke-free zones).

2. A state public health region reported 39 cases of meningitis in children 15 years of age and younger to date this year. Seven of those children died. The total population of the region is 780,000, of whom 84,000 are children 15 years old and younger. What is the age-specific meningitis death rate for children age 15 years and younger for this region to date this year? a. 0.08/1000 b. 0.46/1000 c. 1/1000 d. 8/1000

ANS: A A rate is a measure of the frequency of a health event in a defined population in a specified period of time. In this example, seven child deaths divided by the total number of children age 15 years and younger in the population (which is 84,000) = 0.0000833 × 1000 = 0.0833/1000.

5. A community-oriented nurse has identified obesity as a problem in the middle school. The next step in a population-focused practice is to make information available about the health of the middle school students. Which core public health function does this represent? a. Assessment b. Assurance c. Policy development d. Research

ANS: A Assessment is a core function of public health and refers to systematically collecting data concerning the population, monitoring the population's health status, and making information available on the health of the community. In a community-oriented approach, a nurse would apply both nursing and public health theory. In this case, assessment would be the first step from the perspective of both theories. Because the practice is population focused and community oriented, it would involve the assessment of the community subpopulation of middle school children and the impact of obesity on their overall health status.

7. A nurse planning a smoking cessation clinic for adolescents in the local middle schools and high schools is providing what type of care? a. Community-oriented b. Community-based c. Secondary care d. Tertiary care

ANS: A Community-oriented nurses emphasize health promotion, health maintenance, and disease prevention, as well as self-reliance on the part of clients. Regardless of whether the client is a person, family, or group, the goal is to promote health through education about prevailing health problems, proper nutrition, beneficial forms of exercise, and environmental factors such as the safety of food, water, air, and buildings.

8. A community-oriented nurse conducts home visits to new parents to assess the health status of the infant, the parent-child relationship, the parents' knowledge regarding the care of the infant, and the need for health department and social services referrals. This can best be described as an example of which type of care? a. Clinical community health practice b. Community-based practice c. Population-focused practice d. Public health nursing

ANS: A Community-oriented nurses who provide direct care services to individuals, families, or groups are engaging in a clinically oriented practice even when they apply concepts of population-focused, community-oriented strategies along with their direct care clinical strategies.

5. Nurses working with communities to implement the CHPM are most effective when they do which of the following? a. Begin where the community is and then work to facilitate implementation of all nine steps. b. Serve in the role of expert resource, spearheading the community's work. c. Teach basic community and public health concepts before teaching the Health Communities Model. d. Work with community leaders to begin with step one and progress through step nine of the model.

ANS: A Nurses should begin where the community is. Nurses help facilitate implementation of the model, coaching community leaders so they understand and implement all steps of the model. Nurses are most effective when they serve as facilitators and coaches.

10. After hearing about home radon exposure on the news, a man and his wife contact the public health department to inquire about whether or not they should have their home tested. Which stage of the transtheoretical model (TTM) are the man and his wife at in regards to the process of change? a. Preparation b. Contemplation c. Action d. Pre-contemplation

ANS: A Preparation is the stage where the person intends to do something. Pre-contemplation is when the person does not plan to change; this may be because the person does not know there is a problem or does not want to do anything about it. In the contemplation stage, the person begins thinking about making a change in the future and examines the pros and cons of doing so. Action occurs when the person actually buys a radon testing kit and uses it in his home.

8. In the community-based participatory research (CBPR) approach, the use of lay community members to promote health within the community is an effective intervention because community members: a. are best at determining the health needs and planning interventions for their community. b. create a passive partnership with community leaders and public health nurses. c. provide oversight and funding decisions for the health-promotion activities. d. relieve local service providers of mundane tasks.

ANS: A The CBPR approach to community assessment allows understanding of sociocultural contexts, systems, and meaning through a collaborative research process. In CBPR, partnerships are active and community members are involved in assessing, planning, implementing, and evaluating change. Both professionals and community residents determine health needs and plan interventions. As residents increase their awareness, they are better able to determine what they want for themselves, their families, and their community and they are more likely to take leadership roles in program development, using health professionals as consultants.

7. The local public health nurse (PHN) participates in a town board's community assessment process, which identifies teenage pregnancy as a community concern for action. Based on the Healthy People in Healthy Communities MAP-IT model, a logical next step would be: a. coalition building. b. evaluation of outcomes. c. health-risk assessment. d. wellness appraisal.

ANS: A The MAP-IT technique helps the community plan a path to achieve the change that its members want to see in the community. The Healthy People in Healthy Communities MAP-IT process recommends mobilization of individuals and organizations; assessment of the areas of greatest need, resources, and strengths; the planning of an approach; implementation of the plan; and tracking of progress over time.

1. The Healthy Communities and Cities (HCC) movement can best be described as which of the following? a. International movement of communities and cities focused on mobilizing local resources to improve the health of the community. b. Movement that began in the United States that targets health promotion in community practice. c. Movement that focuses on the effective development and use of public policy as the primary means for improving health. d. Program that uses the principles of primary, secondary, and tertiary prevention to mobilize citizens to improve the health of their communities.

ANS: A The goal of this international movement was to promote health through community engagement and collaboration to activate and diffuse local changes that support good health. The premise was that community members must be involved in identifying the need for health programs and in developing programs to meet those needs.

6. Primary health care seeks to provide affordable social, biomedical, and health services that are relevant and acceptable in terms of the individual's health, needs, and concerns. Which principle does is this model of primary health care incorporate? a. Appropriate technology b. Community participation c. Equity d. Multisectoral participation

ANS: A The principles of primary health care and the Ottawa Charter for Health Promotion were influential in the development of the HCC movement. The principles of primary health care include equity, health promotion, community participation, multisectoral cooperation, appropriate technology, and international cooperation. Appropriate technology refers to the provision of affordable social, biomedical, and health services that are relevant and acceptable in terms of the individual's health, needs, and concerns.

6. The state public health agency has received multiple complaints regarding the availability of elder transportation services to a specific county senior center. The state agency assigns a public health nurse to work with the community to evaluate its program for elder transportation services to publicly sponsored eldercare programs. Which public health core function does the nurse apply in this situation? a. Assurance b. Policy development c. Primary prevention d. Public transportation

ANS: A The public health core function of assurance focuses on the responsibility of public health agencies to be sure that activities are appropriately carried out to meet public health goals and plans. This involves making sure that essential community-oriented health services are available and accessible, especially to vulnerable populations who would otherwise not receive necessary services. Assurance also includes assisting communities to implement and evaluate plans and practices.

9. At the request of a local housing authority, a PHN conducted a survey at a public housing facility to determine the need for a nurse-managed clinic. When residents and community leaders were asked what services were most needed from the clinic, they listed well-child screening, parenting education, and medication management. The PHN, the local health department, and the community members collaborated in all phases of the project from planning to evaluation to establish a community nursing center at the site. This example best illustrates the application of population-focused community model at which level? a. Aggregate client system level b. Environmental level c. Family client system level d. Individual client system level

ANS: A Within the integrative model of community health promotion, for the needs of this resident population to be met, it was paramount that the nurse understand the perceived problems of both the housing authority and the residents; the services desired by the residents; the resources available at the facility; and the strengths of the aggregate community to participate actively in the assessment, planning, implementation, and evaluation of a community nursing center. Application of a population-focused community model at the aggregate client system level laid the foundation for an active partnership and sustainable and effective intervention.

1. The aspects of the locality development model or bottom-up approach that have been integrated can best be described as which of the following? (Select all that apply.) a. Emphasizing consensus and cooperation b. Building a sense of community c. Using a rational-empirical approach d. Producing fundamental social change e. Rational-empirical problem solving by outside experts

ANS: A, B Different models of community practice exist. The locality development model is a process-oriented model that emphasizes consensus, cooperation, and building of group identity and a sense of community. The social planning (top-down approach) model stresses rational-empirical problem solving, usually by outside professional experts. Social planning does not focus on building community capacity or fostering fundamental social change. The social action model concentrates on increasing the problem-solving ability of the community through concrete actions that attempt to correct the imbalance of power and privilege of an oppressed or disadvantaged group in the community. The Community Health Improvement Model aims at creating partnerships within the community and focuses on community leadership development for health while using a bottom-up approach like the locality development model. This multisectoral cooperation (primary health care principle) by all parties in a community, from local government officials to grassroots community members, creates a stronger foundation for health-promoting public policy development, the highest-priority health-promotion action identified for producing sustainable community health change.

1. Research articles that include epidemiologic determinants and distribution would include which questions? (Select all that apply.) a. Who is affected most by pesticide exposure? b. Where in the city are lead levels highest? c. How does herbicide runoff affect drinking water? d. What season of the year sees the most trauma? e. Why do children get injured on playgrounds?

ANS: A, B, C, D, E "Who," "what," "when," and "where" questions address epidemiologic distribution. "How" and "why" questions address epidemiologic determinants.

3. A state public health region reported 39 cases of meningitis in children 15 years of age and younger to date this year. Seven of those children died. The total population of the region is 780,000, of whom 84,000 are children age 15 years old and younger. Only four cases of meningitis were reported in the public health region during the previous year. No other public health region in the state has an incidence of meningitis that is higher than expected for that region. Based on the information given, the relative frequency of meningitis in the region at this time can best be described as: a. endemic. b. epidemic. c. pandemic. d. sporadic.

ANS: B An epidemic occurs when the rate of disease, injury, or other condition exceeds the usual (endemic) level of that condition.

5. A business executive develops flu-like symptoms 1 day after returning by air from a trans-Atlantic 2-day conference that involved lengthy meetings. The scenario best illustrates the interaction of: a. host and agent. b. host, agent, and environment. c. risk and causality. d. morbidity and disease.

ANS: B Epidemiologists understand that disease results from complex relationships among causal agents, susceptible persons, and environmental factors. These three elements—agent, host, and environment—are called the epidemiologic triangle. Changes in one of the elements of the triangle can influence the occurrence of disease by decreasing or increasing a person's risk of disease.

7. The nurse knows the Ottawa Charter identified the most effective health-promotion action as: a. creating supportive environments. b. developing health-promoting public policy. c. reorienting health services. d. strengthening community action.

ANS: B The Ottawa Charter for Health Promotion (World Health Organization, 1986) lays the foundation for the HCC movement definition of health promotion. In order of priority, the Ottawa Charter identifies developing health-promoting public policy, creating supportive environments, strengthening community action, developing personal skills, and reorienting health services as the key strategic health-promotion action for achieving health for all. Health-promoting public policy supports health in a broad ecological sense that includes environmental, physical, social, and mental well-being. Although efforts to change individual behavior are important, the contributions of policies that affect the broader environment are thought to be more effective in achieving social change. Good examples of such impacts are statewide seat belt laws, helmet laws, and local nonsmoking ordinances.

3. The HCC model process relies on a problem-solving approach to achieve goals. The best example of this approach is which of the following? a. Community activists lobbying their state legislature to mandate increased primary care access b. Community-oriented nurses using the nine-step Community Health Promotion Model (CHPM) to encourage and empower community members to take responsibility for change c. Health care professionals working independently to determine priorities for their community and then educating their community about these health-promotion needs d. Teachers using health-promotion curricula to reduce teenage smoking in their community

ANS: B The goal of the CHPM is to encourage community members to take responsibility for the changes they wish to see happen. The model focuses on community involvement in every step of the process. Health care providers can best act as facilitators, educators, and promoters of the model, not "experts" who dictate solutions to the community.

9. Nurses consider opportunities for population-focused practice that result from the rapid transformation of health care delivery from a medical model to a health promotion/disease prevention model. Which is an example of such opportunity? a. Operator of a nurse practitioner-run urgent care center in a major retail location b. Director of clinical services providing a wide range of services to populations seen by the system c. Clinical director of a home health agency d. School nurse position in the local high school

ANS: B The new focus on populations, coupled with the integration of acute, chronic, and primary care occurring in some health care systems, is likely to create new roles for individuals, including nurses, who will span inpatient and community-based settings and focus on providing a wide range of services to the populations served by the system. Such a role might be director of client care services for the health care system, who has administrative responsibility for a large program area. There will be a demand for individuals who can design programs of preventive and clinical services to be offered to targeted subpopulations and for those who can implement such programs.

7. A nurse is concerned about the accuracy of the purified protein derivative (tuberculin) test in screening individuals with tuberculosis exposure for follow-up chest radiography. The nurse's concern is related to which aspect of the test's validity? a. Reliability b. Sensitivity c. Specificity d. Variability

ANS: B The validity of a screening test is measured by its sensitivity and specificity. Sensitivity quantifies how accurately the test identifies those individuals with the condition or trait of interest. Sensitivity is calculated as the proportion of persons with the disease that the test correctly identifies as having the disease (true positives). High sensitivity is needed when early treatment is important and when the identification of every case is important.

1. Which of the following community health improvement projects uses the health-oriented perspective? a. Health-promotion project aimed at monitoring an adolescent's compliance with an asthma treatment regimen b. Project to improve well-being in residents of an assisted-living facility through yoga and relaxation programs c. Project aimed at teaching clients with diabetes how to maintain glucose control by using a sliding scale for dosing insulin d. Program aimed at improving school performance by teaching high school teachers how to detect drug abuse and screen students for drug use

ANS: B There are two distinct perspectives from which nursing science can be viewed. The disease-oriented perspective views health objectively in humans who are biological entities in which illness occurs and can be controlled through compliance with professional recommendations. The health-oriented perspective views health as a process in complex beings (humans) that interact with the environment and with others. Health behavior within this latter health-oriented perspective involves a holistic view of lifestyle and interaction with the environment and not simply compliance with a prescribed regimen.

9. When the association between maternal alcohol use and low birth weight is being studied, the nurse investigator's failure to consider the variable of smoking could introduce bias into the observed association, because smoking has a correlation with both factors. This effect could best be described as: a. causality. b. confounding. c. information bias. d. selection bias.

ANS: B When looking for the existence of statistical association between some factor and a health outcome, the investigator must consider the three general categories of bias. Bias is a systematic error resulting from study design, study execution, or confounding. Bias resulting from the relationship of the outcome and the study factor with some third factor not accounted for in the study design is called confounding. In practice, one can often identify potentially confounding variables and adjust for them in analysis.

1. Public health nursing specialists are interested in which of the following topic(s)? (Select all that apply.) a. Educational materials for individuals with HIV/AIDS b. Evaluation of an outreach program for at-risk pregnant teenagers c. Community subpopulations with high rates of type 2 diabetes d. New technologies to monitor diabetes e. Prevalence of hypertension among various age, race, and gender groups

ANS: B, C, E Public health specialists often define problems at the population or aggregate level as opposed to the individual level. At the population level, public health specialists are usually concerned with more than one subpopulation and frequently with the health of the entire community.

4. The role and goals of the community health nursing practice can best be described as: a. community-based interventions aimed at promoting, preserving, and maintaining the health of populations residing in institutional facilities such as nursing homes. b. education of nurses and other staff working in community-based and community-oriented settings to improve the overall effectiveness of their programs to meet client needs. c. population-level strategies aimed at promoting, preserving, and maintaining the health of populations through the delivery of personal health care services to individuals, families, and groups in an effort to improve the health of the community as a whole. d. activities targeted at improving the health status of clients served by community-based health service agencies such as hospice and home health agencies.

ANS: C Community health nursing practice is the synthesis of nursing theory and public health theory applied to promoting, preserving, and maintaining the health of populations through the delivery of personal health care services to individuals, families, and groups. The focus of community health nursing practice is the health of individuals, families, and groups and the effect of their health status on the health of the community as a whole (individual to families to groups to community flow). This is different from public health nursing, which is the synthesis of nursing theory and public health theory applied to promoting and preserving the health of populations. The focus of public health nursing practice is the community as a whole and the effect that the community's health status, including health care resources, has on the health of individuals, families, and groups (community to groups to families to individual flow). Both community health and public health nursing are considered to be community-oriented practices involving free-living (noninstitutionalized) clients. Community-based nursing practice is setting specific, and care is provided to clients where they live (home health or hospice nursing, community-based clinic), work (occupational health nursing), and/or attend school (school nursing). The emphasis of community-based nursing practice is acute and chronic care (illness care) and the provision of comprehensive, coordinated, and continuous services, usually within a specialty area.

5. In the disease-oriented perspective, health behavior is based on client: a. access to care. b. adjustment of lifestyle. c. compliance with a prescribed regimen. d. response to treatment.

ANS: C In the disease-oriented perspective, health is objectively defined as the absence of disease, and humans are conceptualized as composed of organ systems and cells. Therefore, health care focuses on identifying what is not working in a given system and repairing it. In this paradigm, health behavior is viewed as how the client complies with the recommendations of the health professional.

6. A child learns at a school safety presentation the importance of wearing a bicycle helmet and requests a helmet for a birthday gift. The parent purchases a helmet like the ones worn by the child's peers. Which of the following statements best describes the relationship of healthy or risky behaviors to lifestyle choices? a. The family is responsible for the health behaviors of children. b. The individual is responsible for health behaviors. c. There is multilevel responsibility for health behaviors. d. The community has a sense of responsibility for health behaviors.

ANS: C In the ecological perspective, individuals ultimately make decisions to engage in healthy or risky behaviors, and lifestyle improvement efforts typically focus on the individual as the target of care. From a public health perspective, however, risky behaviors may have significant implications for the overall health status of the community and contribute to health-related economic losses of the community. Health behaviors have multiple determinants that are both internal and external to the individual, family, community, and society.

9. A nurse expands a community exercise program to include a senior exercise program targeted at strength and balance training in response to the HCC initiative to address the needs of free-living elders in the local community. The nurse is most likely applying the Ottawa Charter for Health Promotion priority health-promotion activity of: a. developing personal skills. b. establishing health-promoting public policy. c. reorienting health services. d. strengthening community.

ANS: C Nurses participating in a CHPM collaborative partnership can redirect community health services toward local priorities and plans based on the HCC committee's desired actions for health. This redirecting of community health services is an example of "reorienting health services," a priority health-promotion action of the Ottawa Charter for Health Promotion.

6. A nurse teaches an asthmatic client to recognize and avoid exposure to asthma triggers and assists the client's family in implementing specific protection strategies in the home, such as removing carpets and avoiding pets. This nurse's activities can best be described as: a. comprehensive assessment. b. primary prevention. c. secondary prevention. d. treatment intervention.

ANS: C Secondary prevention usually encompasses interventions designed to increase the probability that a person with a disease will have that condition diagnosed at a stage when treatment is likely to result in cure. However, nurses often use health education interventions when caring for individuals with a diagnosed health problem with the aim of preventing further complications or exacerbations.

4. Which is an example of tertiary prevention related to HCC? a. Assessing the need for programs to treat alcohol addiction b. Assessing the strengths of local schools' adolescent pregnancy prevention programs c. Initiating an evaluation of a program to address endemic hepatitis A in a community d. Organizing a community forum to explore health-promotion priorities

ANS: C Tertiary prevention includes initiation of community action when problems have occurred, and evaluation of progress and effectiveness of programs and policies.

4. A community-oriented nurse wants to design the most effective intervention to reduce Coronary Heart Disease (CHD) morbidity and mortality in a rural area. The program approach should incorporate which strategies? a. Aggregate primary prevention b. Individual level primary, secondary, and tertiary prevention c. Multilevel intervention with a focus on primary, secondary, and tertiary prevention d. Promotion of optimal health for the individual, family, aggregate, and total community

ANS: C The Framingham, Alameda, and other studies have shown that effective health promotion must incorporate strategies that deal with all levels in the community—individual, family, aggregate, and total community; that is, they must adopt a multilevel approach. These studies also demonstrate that a program to reduce CHD morbidity and mortality needs to incorporate primary, secondary, and tertiary prevention strategies. An integrated model of community-oriented nursing care reflects the four client systems and multiple foci of care approach.

1. A state public health region reported 39 cases of meningitis in children 15 years of age and younger to date this year. Seven of those children died. The total population of the region is 780,000, of whom 84,000 are children age 15 years old and younger. What is the prevalence proportion of meningitis in this region thus far in the current year? a. 4.1/100,000 b. 5/100,000 c. 46/100,000 d. 50/100,000

ANS: C The prevalence proportion is a measure of existing disease in a population at a particular time and is calculated by dividing the number of existing cases by the current targeted population. In this example, 39 cases divided by the total number of children age 15 years and younger in the population (which is 84,000 children) = 0.0004642 × 100,000 = 46.42/100,000.

2. A registered nurse is seeking a position as a public health nurse. In reviewing the job description, the nurse would expect to find a description of a position that focused on which functions? a. Monitoring pregnant teenagers for symptoms of complications of pregnancy b. Offering free hypertension screening and treatment referral at local health fairs to low-income, uninsured, community members c. Partnering with local seasonal farmworkers to design a program aimed at preventing illness and injury, and advocating for this population with local political and community leaders d. Preventing injury among a population of elderly residents in an assisted living facility and treating residents' chronic illnesses

ANS: C The scope of practice of public health nurses is population focused and community oriented, with a primary emphasis on population-level interventions that target strategies for health promotion and disease prevention. In addition, public health nursing is concerned with the health of all members of a population or community, particularly vulnerable populations, and uses political processes as a major intervention strategy. The other options might be specific interventions a public health nurse could implement as part of broader programming.

2. An effective community-oriented diabetes program should include which of the following? a. Access to a certified diabetes educator to teach the client self-management strategies. b. Care that incorporates the American Diabetes Association treatment guidelines. c. Availability of a primary care provider, medication and supplies, and nutritionist. d. Self-management education and family education, access to affordable clinical care, medication, and testing supplies.

ANS: D According to this model, health care and health-related behavior are a function of individual (self-management), interpersonal (family), organizational (clinic care), community (access to medication and supplies), and population factors (accessible medical care in the community).

3. A public health nurse leader is encountering barriers when trying to shift the public health agency's efforts to a population-focused practice. Which of the following is most likely to be the rationale for the lack of support? a. Colleagues' push for nurses to focus on population initiatives. b. Costs associated with staff training and revision of documents. c. Lack of support from the agency's funding sources. d. Opinions that nursing should focus on direct client care and services.

ANS: D Barriers to implementing population-focused care include lack of understanding of the public health nurse role and its relationship to other roles in nursing, such as direct care and services; workplace role socialization that determines what roles are appropriate and inappropriate or accessible and inaccessible for nurses; and lack of comprehensive training at the graduate level in the disciplines basic to public health such as epidemiology, biostatistics, community development, service administration, and policy formation.

2. A nurse has decided to use a bottom-up approach of HCC to meet Healthy People 2020 goals for elders in the community setting. Which would be the most appropriate intervention? a. Design and implement a health-promotion activity that can be scheduled at a senior center. b. Organize a meeting of local politicians, clinicians, and community members to prioritize needs for elderly clients with diabetes. c. Recruit the mayor and city council to designate an annual Elder Health day. d. Include community members in multisectoral meetings to choose, design, and implement a culturally appropriate health-promotion activity for older adults.

ANS: D Healthy People 2020 goals include establishment of educational and community-based programs that focus on disease prevention and health promotion. Goals for community settings and select populations include culturally appropriate community health-promotion and disease-prevention programs. Increasing the proportion of older adults participating in organized health-promotion activities is also a goal. Following the implementation steps of the Community Health Improvement Model: Development of Community Structure for Health Promotion, the nurse working to achieve Healthy People 2020 goals should mobilize local political, health professional, and community members, including members of the target population, to prioritize, design, and implement culturally appropriate health-promotion activities for seniors in the community.

1. In 1988, the Institute of Medicine (IOM) published a report on the future of public health and its mission that defined public health as: a. what public-private partnerships do to treat vulnerable populations. b. what the government does to ensure that vital programs are in place. c. what the U.S. Public Health Service does to prevent disease, promote health, and deliver services. d. what society does collectively to ensure the conditions in which people can be healthy.

ANS: D In 1988, the IOM's report stated that public health is "what we, as a society, do collectively to assure the conditions in which people can be healthy." Consequently, the mission of public health is "to generate organized community effort to address the public's interest in health by applying scientific and technical knowledge to prevent disease and promote health." This clearly places the emphasis on the desire of the population and community to ensure access to services that foster the health status of the overall community through the equitable distribution of resources addressed to community problems that affect health.

4. John Snow played a critical role in the development of modern disease surveillance when he did which of the following? a. Devised a more statistically valid method of analyzing epidemiologic data b. Discovered causal agents for anthrax, tuberculosis, and cholera c. Tracked the incidence of tuberculosis in the tenements of New York City d. Used geographic mapping to demonstrate the connection between water supply and cholera

ANS: D John Snow is considered the father of modern epidemiology because of the methods he used in his groundbreaking work to connect the incidence of cholera with the water supply. Snow showed that households receiving water from one water company, whose intake valve was in an area of the river contaminated by sewage, had a much higher rate of cholera than those receiving water from other companies drawing water from less-contaminated parts of the river.

8. Case fatality from breast cancer has decreased in recent years, although the incidence of breast cancer has increased. Descriptive epidemiology would use the component of time to explain this change in terms of: a. cyclical patterns. b. event-related clusters. c. point epidemic. d. secular trends.

ANS: D Long-term patterns of morbidity or mortality rates (i.e., over years or decades) are called secular trends. Secular trends may reflect changes in social behavior or health practices.

3. The Framingham Heart Study and the Alameda County study are historically important to the development of public health multilevel interventions. Which statement best describes the contribution made by these studies? a. Both focus on urban health risks and interventions to reduce the impact of those risks on the local population. b. Both are longitudinal studies that can help community-oriented nurses design interventions to reduce cardiac morbidity and mortality. c. Both studies show that young men who cease smoking reduce their risk of coronary disease, even if they develop moderate obesity as they become middle-aged. d. Both studies examined personal and environmental factors that influence long-term health outcomes and demonstrate the need for individual and community level interventions.

ANS: D The Framingham Heart Study examined factors that influence the development of coronary heart disease (CHD). This study led to development of health risk appraisals, predictive risk models, and strategies to reduce CHD risk. The Alameda County study followed a large sample for 4 years to investigate the relationship of social and behavioral factors to mortality. Both studies are highly significant in detecting individual and environmental risk factors for disease and in prompting multilevel community-oriented intervention programs.

8. The collaborative partnership best practice of "identifying specific community and system changes to be sought to effect widespread behavior change and community health improvement" would best apply to which concept of the Ottawa Charter for Health Promotion strategic framework? a. Creating supportive environments b. Establishing health-promoting public policy c. Reorienting health services d. Strengthening community action

ANS: D The Ottawa Charter for Health Promotion identified the strengthening of community action as a priority health-promotion action. The strengthening of community action refers to promoting the community's capacity, ability, and opportunity to take appropriate action to protect and improve the health of the community.

epidemiologic triangle

Host - Agent - Environment

community oriented nursing practice

a philosophy of nursing service delivery that involves the generalist or specialist public health and community health nurse. The nurse provides health care through community diagnosis and investigation of major health and environmental problems, health surveillance, and monitoring and evaluation of community and population health status for the purposes of preventing disease and disability and promoting, protecting, and maintaining health to create conditions in which people can be healthy.

community based nursing practice

a setting-specific practice whereby care is provided for clients and families where they live, work, and attend school. The emphasis of community-based nursing practice is acute and chronic care and the provision of comprehensive, coordinated, and continuous services. Nurses who deliver community-based care are generalists or specialists in maternal/infant, pediatric, adult, or psychiatric/mental health nursing.

decision making role of nurse in public health

communication skills -culturally competent -motivating others (by creating a motivating environment) -appraisal and coaching -supervision (decision making and implementation of activities)

community needs assessment

community oriented nursing practice is a philosophy of nursing service delivery that involves generalist or specialist public health and community health nurse. nurse provides healthcare through community diagnosis and investigation of major health and environmental problems, health surveillance, and monitoring and evaluation of community and population health status for the purposes of preventing disease and disabililty and promoting, protecting, and maintaining health to create conditions in which people can be healthy community based nursing practice is a setting specific practice whereby care is provided for clients and families where they live, work, and attend school. the emphasis of community based nursing practice is acute and chronic care and the provision of comprehensive, coordinated, and continuous services. nurses who deliver community based care are generalists or specialists in maternal/infant, pediatric, adult, or psychiatric/mental health nursing

social determinants of health

factors that can lead to resource constraints, poor health, and health risk

public health

focus is greatest good for greatest number 3 core functions: -assessment -policy development -assurance

population health

looking at the health of a group of people; look at outcomes or disparities

compare and contrast primary, secondary, tertiary levels of prevention

primary - dont have disease. trying to prevent disease. secondary - screening in hopes to have early diagnosis (someone can have but not be symptomatic) tertiary - have disease/symptoms. trying to get pt to best possible health with condition they have and not get worse. aim to limit disability and enhance rehab *interdisciplinary

reliability and validity of screening

validity - high probability of correct classification reliability - consistent