• In 2006, the U.S. rate of infant deaths per 1000 live births was 6.7. At least 29 other developed countries had lower infant mortality rates; the lowest was Hong Kong with 1.8 (Table 22, p 184).
• Between 2003 and 2005, the U.S. neonatal mortality rate per 1000 live births for all races was 4.6; across races and ethnicities the rates varied. For infants born to white women the rate was 3.7; for Black and African-American women, 9.2; for Hispanic or Latina women, 3.9; for American Indian or Alaskan Native, 4.3; for Asian or Pacific Islanders, 3.3 (Table 21, pp 182-183).
• In 2005 life expectancy at birth for men in the United States was 74.9 years; Hong Kong had greatest life expectancy with 77.8 years. For U.S. women, the life expectancy at birth in 2005 was 79.9; Japan ranked first with 85.5 (Table 23, p 187).
What are the factors driving these differences? Factors that influence health status across the life cycle are known as the determinants of health. They include: income, education, employment, social support, biology and genetics, physical environment, housing, transportation, and personal health practices.
Resolving health inequities and addressing the determinants of health are key distinguishing characteristics of public health nursing. In a recent interpretive qualitative study of PHNs’ practice in Nova Scotia, researchers found that PHNs routinely implemented “ecosocial surveillance functions” that focused on monitoring changes in social determinants of health. The researchers observed that PHNs “…monitored both bottom-up changes in individual, family, and community determinants of health, and top-down vertical changes or policy directives in the larger system” (Meagher-Stewart et al, 2009, p 557).
Assessing the health status of the populations that comprise the community requires ongoing collection and analysis of relevant quantitative and qualitative data. Community assessment includes a comprehensive assessment of the determinants of health. Data analysis identifies deviations from expected or acceptable rates of disease, injury, death, or disability as well as risk and protective factors. Community assessment generally results in a lengthy list of community problems and issues. However, communities rarely possess sufficient resources to address the entire list. This gap between needs and resources necessitates a systematic priority-setting process. Although data analysis provides direction for priority setting, the community’s beliefs, attitudes, and opinions as well as the community’s readiness for change must be assessed (Keller et al, 2002). PHNs, with their extensive knowledge about the communities in which they work, provide important information and insights during the priority-setting process.
A hallmark of public health nursing practice is a focus on health promotion and disease prevention, emphasizing primary prevention whenever possible. Although not every event is preventable, every event has a preventable component.
Community-level practice changes community norms, community attitudes, community awareness, community practices, and community behaviors. It is directed toward entire populations within the community or occasionally toward populations at risk or populations of interest. An example of community-level practice is a social marketing campaign to promote a community norm that serving alcohol to under-aged youth at high school graduation parties is unacceptable. This is a community-level primary prevention strategy.
Systems-level practice changes organizations, policies, laws, and power structures within communities. The focus is on the systems that impact health, not directly on individuals and communities. Conducting compliance checks to ensure that bars and liquor stores do not serve minors or sell to individuals who supply alcohol to minors is an example of a systems-level secondary prevention strategy practice.
Individual-level practice changes knowledge, attitudes, beliefs, practices, and behaviors of individuals. This practice level is directed at individuals, alone or as part of a family, class, or group. Even though families, classes, and groups are comprised of more than one individual, the focus is still on individual change. Teaching effective refusal skills to groups of adolescents is an example of individual secondary prevention strategy level of practice.
The interventions are grouped with related interventions; these wedges are color coordinated to make them more recognizable (Figure 9-3, A). For instance, the five interventions in the red wedge are frequently implemented in conjunction with one another. Surveillance is often paired with disease and health event investigation, even though either can be implemented independently. Screening frequently follows either surveillance or disease and health event investigation and is often preceded by outreach activities in order to maximize the number of those at risk who actually get screened. Most often, screening leads to case finding, but this intervention can also be carried out independently. The green wedge consists of referral and follow-up, case management, and delegated functions—three interventions that, in practice, are often implemented together (Figure 9-3, B). Similarly, health teaching, counseling, and consultation—the blue wedge—are more similar than they are different; health teaching and counseling are especially often paired (Figure 9-3, C). The interventions in the orange wedge—collaboration, coalition building, and community organizing—although distinct, are grouped together because they are all types of collective action and are most often carried out at systems or community levels of practice (Figure 9-3, D). Similarly, advocacy, social marketing, and policy development and enforcement—the yellow wedge—are often interrelated when implemented (Figure 9-3, E). In fact, advocacy is often viewed as a precursor to policy development; social marketing is seen by some as a method of carrying out advocacy.
The interventions on the right side of the Wheel (i.e., the red, green, and blue wedges) are most commonly used by PHNs who focus their work more on individuals, families, classes, and groups and to a lesser extent on work with systems and communities. The orange and yellow wedges, on the other hand, are more commonly used by PHNs who focus their work on effecting systems and communities. However, a PHN may use any or all of the interventions.
At the community level, PHNs work with health educators on public awareness campaigns. They perform outreach at schools, senior centers, county fairs, community festivals, and neighborhood laundromats.