Many dimensions describe the nature of community. These include an aggregate of people, a location in space and time, and a social system (Box 6-1). Show
Location in Space and TimeRegardless of shared features, geographic or physical location may define communities of people. Traditionally, community is an entity delineated by geopolitical boundaries; this view best exemplifies the dimension of location. These boundaries demarcate the periphery of cities, counties, states, and nations. Voting precincts, school districts, water districts, and fire and police protection precincts set less visible boundary lines. Census tracts subdivide larger communities. The U.S. Census Bureau uses them for data collection and population assessment. Census tracts facilitate the organization of resident information in specific community geographic locales. In densely populated urban areas, the size of tracts tends to be small; therefore, data for one or more census tracts frequently describe neighborhood residents. Although residents may not be aware of their census tract’s boundaries, census tract data help define and describe neighborhood communities. Research Highlights Development of a Dynamic Model to Guide Health Disparities Research Rew et al. (2009) reported on a 6-year project in which public health nurses were involved with 19 studies to analyze health disparities among low-income, rural, Mexican-American, and American Indian populations. Through a series of projects, the team identified a number of predisposing risk factors and barriers to access and utilization of services that contribute to disparities in health outcomes in the targeted populations. The risk factors they observed included gender, race/ethnicity, low income level, and geographic location. Identified barriers included language, transportation problems, lack of awareness of health problems, a distrust of the health system, cultural beliefs, lack of insurance, and lack of culturally sensitive providers. The researchers noted several areas or needs for health promotion for the targeted populations. These were related to diabetes, mental health problems, and “life-span issues” (e.g., high rates of adolescent pregnancies, poor diet/nutrition, choice of occupation, end-of-life care). As a result, the researchers suggested a set of health promotion interventions including working to enhance interest in engaging in regular exercise, health promotion during pregnancy, and life-span efforts to prevent injury, focusing on prevention of accidents among infants/small children, elders, and those with occupational risks. From Rew L, Hoke MM, Horner SD, et al: Development of a dynamic model to guide health disparities research, Nurs Outlook 57(3):132-142, 2009. A geographic community can encompass less formalized areas that lack official geopolitical boundaries. A geographic landmark may define neighborhoods (e.g., the East Lake section of town or the North Shore area). A particular building style or a common development era also may identify community neighborhoods. Similarly, a dormitory, a communal home, or a summer camp may be a community because each facility shares a close geographic proximity. Geographic location, including the urban or rural nature of a community, strongly influences the nature of the health problems a community health nurse might find there. Public health is increasingly recognizing that the interaction of humans with the natural environment and with constructed environments, consisting of buildings and spaces for example, is critical to healthy behavior and quality of life. The spatial location of health problems in a geographic area can be mapped with the use of Geographic Information System software, assisting the nurse to identify vulnerable populations and for public health departments to develop programs specific to geographic communities. Location and the dimension of time define communities. The community’s character and health problems evolve over time. Although some communities are very stable, most tend to change with the members’ health status and demographics and the larger community’s development or decline. For example, the presence of an emerging young workforce may attract new industry, which can alter a neighborhood’s health and environment. A community’s history illustrates its ability to change and how well it addresses health problems over time. Community health nurses apply the nursing process to address needs of individuals, families, vulnerable populations, and entire communities. See Figure 16.7[1] for an illustration of the nursing process in community health nursing. Figure 16.7 Nursing Process in Community Health NursingAssessmentThe community health nurse typically begins a community health needs assessment by determining what data is already available.[2]As previously discussed in the “Community Health Concepts” section, national, state, county, and local health needs assessments are widely available. refers to analyzing previously collected data to determine community needs. Community health nurses may also engage in primary data collection to better understand the community needs and/or study who may be affected by actions taken as a result of the assessment.[3] includes tools such as public forums, focus groups, interviews, windshield surveys, surveys, and participant observation. Public Forumsare gatherings where large groups of citizens discuss important issues at well-publicized locations and times. Forums give people of diverse backgrounds a chance to express their views and enhance understanding of the community’s specific needs and resources. Forums should be planned in a convenient location with accessibility to public transportation and child care. They should also be scheduled at convenient times for working families to gain participation from a wide range of populations. Focus Groupsare a systematic method of data collection through small-group discussions led by a facilitator. Participants in focus groups are selected to represent a larger group of people. Groups of 6-10 people with similar backgrounds or interests are interviewed in an informal or formal setting. Focus groups should be scheduled at several dates and times to ensure a broad participation from members of the community. Here are advantages of focus groups:
Interviewsare structured conversations with individuals who have experience, knowledge, or understanding about a particular topic or issue. are conducted with people in key positions in the community and have specific areas of knowledge and experience. These interviews can be useful for exploring specific community problems and/or assessing a community’s readiness to address those problems.[4] Advantages of interviews include the following[5]:
Interviews can have these disadvantages:
Windshield SurveysA is a type of direct observation of community needs while driving and literally looking through the windshield. It can be used to observe characteristics of a community that impact health needs such as housing, pollution, parks and recreation areas, transportation, health and social services agencies, industries, grocery stores, schools, and religious institutions. View the following YouTube video of a windshield survey[6]: Windshield Survey Nursing. Surveysuse standardized questions that are relatively easy to analyze. They are beneficial for collecting information across a large geographic area, obtaining input from as many people as possible, and exploring sensitive topics.[7] Surveys can be conducted face to face, via the telephone, mailed, or shared on a website. Responses are typically anonymous but demographic information is often collected to focus on the needs of specific populations. Disadvantages of surveys can include the following[8]:
Participant ObservationParticipant observation refers to nurses informally collecting data as a member of the community in which they live and work. This is considered a subjective observation because it is from the nurse’s perspective. Informal observations are made, or discussions are elicited among peers and neighbors within the community. Sociocultural ConsiderationsWhen analyzing community health needs, it is essential to do so through a sociocultural lens. Just as an individual’s health can be influenced by a wide variety of causes, community health problems are affected by various factors in the community. For example, a high rate of cancer in one community could be related to environmental factors such as pollution from local industry, but in another community, it may be related to the overall aging of the population. Both communities have a high rate of cancer, but the public health response would be very different. Another example related to mental health is related to various situational factors affecting depression. A high rate of depression in one community may be related to socioeconomic factors such as low-paying jobs, lack of support systems, and poor access to basic needs like grocery stores, whereas in another community it may be related to lack of community resources during frequent weather disasters. The public health response would be different for these two communities. Nurses must also recognize and value cultural differences such as health beliefs, practices, and linguistic needs of diverse populations. They must take steps to identify subpopulations who are vulnerable to health disparities and further investigate the causes and potential interventions for these disparities. For example, mental health disparities pose a significant threat to vulnerable populations in our society, such as high rates of suicide among LGBTQ+ youth, reduced access to prevention services among people living in rural areas, and elevated rates of substance misuse among Native Americans. These disparities threaten the health and wellness of these populations.[9] Key points to consider when assessing a community using a sociocultural lens include the following:
DiagnosisSimilar to how nurses individualize nursing diagnoses for clients based on priority nursing problems identified during a head-to-toe assessment, community health nurses use community health needs assessment data to develop community health diagnoses. These diagnoses are broad, apply to larger groups of individuals, and address the priority health needs of the community. Resources such as Healthy People 2030 can be used to determine current public health priorities. A is a summary statement resulting from analysis of the data collected from a community health needs assessment.[10]A clear statement of the problem, as well as causes of the problem, should be included. A detailed community diagnosis helps guide community health initiatives that include nursing interventions. A community diagnosis can address health deficits or services that support health in the community. A community diagnosis may also address a need for increased wellness in the community. Community diagnoses should include these four parts:
Here are some examples of community health diagnoses based on community health needs assessments:
Outcome IdentificationOutcomes refer to the changes in communities that nursing interventions and prevention strategies are intended to produce. Outcomes include broad overall goals for the community, as well as specific outcomes referred to as “SMART” outcomes that are specific, measurable, achievable, realistic, and with a timeline established. Broad goals for communities can be tied to national objectives established by Healthy People 2030, as previously discussed in the “Community Health Concepts” section. Healthy People objectives are classified by these five categories[11]:
SMART outcomes can be created based on the objectives listed under each category. For example, if an overall community goal is related to “Drug and Alcohol Use” under the “Health Behaviors” category, a SMART outcome could be based on the Healthy People objective, “Increase the proportion of people with a substance use disorder who got treatment in the past year.”[12] Based on this Healthy People objective, an example of a SMART outcome could be the following:
Planning InterventionsNursing interventions for the community can be planned based on the related Healthy People category and objective. For example, based on the sample SMART outcome previously discussed, a planned nursing intervention could be the following:
Community health nursing interventions typically focus on prevention of illness with health promotion interventions. After performing a community health needs assessment, identifying priority problems, and establishing health goals and SMART outcomes, the nurse integrates knowledge of health disorders (e.g., diabetes, cancer, obesity, or mental health disorders) and current health risks in a community to plan prevention interventions. There are two common public health frameworks used to plan prevention interventions. A traditional preventive framework is based on primary, secondary, or tertiary prevention interventions. A second framework, often referred to as the Continuum of Care Prevention Model, was established by the Institute of Medicine (IOM) and includes universal, selected, and indicated prevention interventions. Both frameworks are further discussed in the following sections.[13] Primordial, Primary, Secondary, Tertiary, and Quaternary InterventionsPreventive health interventions may include primordial, primary, secondary, tertiary, and quaternary prevention interventions. These strategies attempt to prevent the onset of disease, reduce complications of disease that develops, and promote quality of life.[14] Primordial Preventionconsists of risk factor reduction strategies focused on social and environmental conditions that affect vulnerable populations. In other words, primordial prevention interventions target underlying social determinants of health that can cause disease. These measures are typically promoted through laws and national policy. An example of a primordial prevention strategy is improving access to urban neighborhood playgrounds to promote physical activity in children and reduce their risk for developing obesity, diabetes, and cardiovascular disease.[15] See Figure 16.8[16] for an image of a neighborhood playground. Figure 16.8 Primordial Prevention: Neighborhood PlaygroundsPrimary Preventionconsists of interventions aimed at susceptible populations or individuals to prevent disease from occurring. An example of primary prevention is immunizations.[17] Nursing primary prevention interventions also include public education and promotion of healthy behaviors.[18] See Figure 16.9[19] for an image of an immunization clinic sponsored by a student nurses’ association. Figure 16.9 Primary Prevention: An Immunization ClinicSecondary Preventionemphasizes early detection of disease and targets healthy-appearing individuals with subclinical forms of disease. Subclinical disease refers to pathologic changes with no observable signs or symptoms. Secondary prevention includes screenings such as annual mammograms, routine colonoscopies, Papanicolaou (Pap) smears, as well as screening for depression and substance use disorders.[20] Nurses provide education to community members about the importance of these screenings. See Figure 16.10[21] for an image of a mammogram. Figure 16.10 Secondary Prevention: MammogramsTertiary Preventionis implemented for symptomatic clients to reduce the severity of the disease and potential long-term complications. While secondary prevention seeks to prevent the onset of illness, tertiary prevention aims to reduce the effects of the disease after it is diagnosed in an individual.[22] For example, rehabilitation therapy after an individual experiences a cerebrovascular accident (i.e., stroke) is an example of tertiary prevention. See Figure 16.11[23] for an image of a client receiving rehabilitation after experiencing a stroke. The goals of tertiary prevention interventions are to reduce disability, promote curative therapy for a disease or injury, and prevent death. Nurses may be involved in providing ongoing home health services in clients’ homes as a component of interprofessional tertiary prevention efforts. Health education to prevent the worsening or recurrence of disease is also provided by nurses. Figure 16.11 Tertiary Prevention: Post-Stroke Rehabilitation. Used under Fair Use.Quaternary Preventionrefers to actions taken to protect individuals from medical interventions that are likely to cause more harm than good and to suggest interventions that are ethically acceptable. Targeted populations are those at risk of overmedicalization.[24]An example of quaternary prevention is encouraging clients with terminal illness who are approaching end of life to seek focus on comfort and quality of life and consider hospice care rather than undergo invasive procedures that will likely have no impact on recovery from disease. See additional examples of primordial, primary, secondary, tertiary, and quaternary prevention strategies in Table 16.3a. Table 16.3a Examples of Prevention Interventions[25],[26]
In the United States, several governing bodies make prevention recommendations. For example, the United States Preventive Services Task Force (USPSTF) makes recommendations for primary and secondary prevention strategies, and the Women’s Preventive Services Initiative (WPSI) makes recommendations specifically for females. The Advisory Committee on Immunizations Practices (ACIP) makes recommendations for vaccinations, and various specialty organizations such as the American College of Obstetrics and Gynecology (ACOG) and the American Cancer Society (ACS) make preventative care recommendations. Preventive services have been proven to be an essential aspect of health care but are consistently underutilized in the United States.[27] Nurses can help advocate for the adoption of evidence-based prevention strategies in their communities and places of employment. Continuum of Care Prevention ModelA second framework for prevention interventions, referred to as the “Continuum of Care Prevention Model,” was originally proposed by the Institute of Medicine (IOM) in 1994 and has been adopted by the Substance Abuse and Mental Health Services Administration (SAMHSA).[28] See Figure 16.12[29] for an illustration of the Continuum of Care Prevention Model. Figure 16.12 Continuum of Care Prevention Model. Used under Fair Use.The Continuum of Care Prevention Model can be used to illustrate a continuum of mental health services for community members that includes prevention, treatment, and maintenance care:
See additional examples of prevention strategies using the Continuum of Care Prevention Model in Table 16.3b. Table 16.3b Examples of Continuum of Care Prevention Strategies
Read A Guide to SAMHSA’s Strategic Prevention Framework PDF for more about planning prevention strategies for substance misuse and related mental health problems. Culturally Competent InterventionsTo overcome systemic barriers that can contribute to health disparities, nurses must recognize and value cultural differences of diverse populations and develop prevention programs and interventions in ways that ensure members of these populations benefit from their efforts.[39] SAMHSA identified the following cultural competence principles for planning prevention interventions[40]:
Review additional concepts related to culturally responsive care in the “Diverse Patients” chapter of Open RN Nursing Fundamentals. Evidence-Based PracticeIt is essential to incorporate evidence-based practice when planning community health interventions. SAMHSA provides an evidence-based practice resource center for preventive practices related to mental health and substance abuse. See these resources, as well as examples of evidence-based programs and practices in the following box. Examples of Evidence Based Prevention Practices related to Mental Health and Substance Misuse[41]
ImplementationCommunity health nurses collaborate with individuals, community organizations, health facilities, and local governments for successful implementation of community health initiatives. Depending on the established community health needs, goals, outcomes, and target group, the implementation of nursing interventions can be categorized as clinical, behavioral, or environmental prevention:
EvaluationWhen evaluating the effectiveness of community health initiatives, nurses refer to the established goals and SMART outcomes to determine if they were met by the timeline indicated. In general, the following questions are asked during the evaluation stage:
What principles were used in the creation of the Healthy Cities Movement?The principles on which the “Healthy Cities” Movement is based are inspired by equity, health promotion*, community participation, intersectoral actions, and sustainability (World Health Organization, Regional Office for Europe, 1992).
What occurred when the healthy communities and cities concept was brought to the United States?When the Healthy Communities and Cities concept was brought to the United States: smaller communities and localities were targeted instead of large cities. The Healthy Communities and Cities initiative supports the idea that: healthy cities and communities must be both environmentally and socially sustainable.
What best describes a health oriented perspective viewpoint?The health-oriented perspective includes the view that humans are complex and interconnected with others and the environment. Health behavior within this perspective involves a holistic view of lifestyle and interaction with the environment and not simply compliance with a prescribed regimen.
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