Because individuals ultimately make decisions to engage in healthy or risky behaviors, lifestyle improvement efforts have focused typically on the individual as the target of care. Following the health belief model (Rosenstock, 1974), individuals generally concentrate on immediate personal rewards or threats when deciding whether to engage in specific behaviors; in this context, they may convince themselves that their immediate personal risks from certain behaviors such as smoking are low, or that the immediate rewards outweigh the risks. However, from a public health perspective, smoking in the United States has resulted in more than 443,000 deaths annually during 2000 to 2004, and the annual health-related economic losses were approximately 5.1 million years of potential life lost and $96.8 billion in productivity losses (CDC, 2008). Therefore, it is clear that health behaviors extend beyond the individual or the intrapersonal and the interpersonal levels, having multiple determinants both internal and external to individuals and communities, as well as determinants within the society.

For example, adolescents’ decisions not to smoke are associated with their individual attributes (e.g., positive self-image), family characteristics (e.g., parent–child connectedness), aggregate characteristics (e.g., peer influence), and community factors (e.g., living in a tobacco-growing region) (Kulbok et al, 2008b). As a result, interventions to initiate or maintain healthy behaviors have greater potential for success when directed systematically toward the multiple targets of the individual, family, group, community, and society—that is, when they use an ecological approach to community health promotion.

Current trends in public health and health promotion emphasize the ecological perspective with interaction between individuals and the environment. The ecological approach also addresses the SDOH (McQueen, 2009) through social networks, organizations, neighborhoods, and communities (Navarro, Voetsch, and Liburd et al, 2007). According to the World Health Organization (WHO), SDOH “are the conditions in which people are born, grow up, live, work and age, including their health. These circumstances are in turn shaped by a wider set of forces: economics, social policies, and politics” (2010, p 1). The WHO is an important contributor to defining and developing strategies to address the SDOH. They outlined ten components of SDOH. (Box 17-1 lists the 10 components.)

There is increasing awareness that to achieve lasting gains in population health, assessments and interventions must be directed to multiple levels of the client system like those outlined in the SDOH. For example, a multilevel analysis of depressive symptoms in a national sample of 18,473 adolescents in the United States (Wight et al, 2005) showed that individual, family, aggregate, and community characteristics accounted for significant differences in adolescent depression. The American Academy of Pediatrics (2005) issued a statement urging pediatricians to increase their partnerships with communities in developing programs to improve child health. Examples of pediatrician-community partnerships (Sanders et al, 2005) include establishing a child health consultant program, working with a community to repair and fund sites to facilitate safe physical activity for children, developing dance programs for overweight and obese adolescent girls, and arranging a program for community leaders to learn about the Medicaid enrollment process. Traditional interventions that target only an individual’s risk or illness are not as effective as interventions and programs developed using an ecological approach that can affect all levels of the client system that contribute to good or ill health (Navarro et al, 2007). More studies are needed to design and test these ecological, multilevel community health interventions.

Farley and Cohen (2005) introduced the curve-shifting principle. This principle complements the ecological model and calls for targeting health interventions at the population level. They built upon representations of the relationship between individual and group behavior (Rose, 1992), with individual behavior being the foundation of the total population distribution. The median of this normal distribution represents prevailing social norms that govern health behavior. Traditional approaches to health behavior interventions for public health problems like obesity focus on the intrapersonal and interpersonal levels for high-risk populations—people at the extremes of the population curve. Although treating high-risk populations may be effective for selected individuals and may move them closer to the center or the prevailing social norm, this approach does little to prevent others from becoming the extremes of the distribution. Therefore, a focus on the total population, not just the high-risk group, with efforts to change the social norm so that everyone is consuming less sugar or participating in more hours of moderate to vigorous physical activity, exemplifies the curve-shifting principle.

Consider another example of the curve-shifting principle involves the built environment. The built environment includes the physical parts of the environment where we live and work (e.g., homes, buildings, streets, open spaces, and infrastructure) (CDC, 2006). Prentice and Jebb (1995) were among the first to report the association between obesity and the built environment by measuring inactivity, car ownership, and television viewing.

Instead of simply teaching children the importance of walking and biking to school, the Safe Routes to Schools initiative improved the environment and the walkability of areas near schools, which correlates with increased local resident walking (Owen et al, 2004). Increased walking among local adult residents is evidence that “…increasing neighborhood walkability may affect people in the larger community, not just schoolchildren” (Watson et al, 2008, p 5). As a result, the population living nearest to walkable areas will walk more, thereby shifting the population social norms about walking and biking, including to school. People’s behavior will change based on targeted interventions to the environment in which they live, a concept advanced by B.F. Skinner, a behavioral psychologist in the 1950s (Skinner, 1978). In following this curve-shifting principle in health promotion and illness prevention, the ecological model works at the population level to shift social norms governing health behavior and ultimately health outcomes.

Laffrey and Kulbok (1999) developed a model for community health promotion to guide nursing and health care. The original intent of the model was threefold. First, the model assists nurses to see the continuity of care at multiple levels. Second, it helps nurses describe their own areas of expertise within the complex health care system. Third, the model provides a basis for collaboration and partnership among nurses, other health care providers, and the population. Each of these collaborators brings expertise to the client system. Important assumptions underlying the model include the need for integration of care in the complex health care system; the inseparable nature of individuals, families, aggregates, and community systems; and the maximization of health potential through health promotion interventions. In addition, the model builds upon complementary health and disease perspectives described previously (Figure 17-1). The health perspective focuses on promoting health as a dynamic and positive quality of life and includes the promotion of physical, mental, emotional, functional, spiritual, and social well-being. The disease perspective includes both the care and prevention of illness (disease and disability) and focuses on reducing risks and threats to health. Although some clinical strategies may be similar in the two perspectives, their ultimate goals differ fundamentally. The difference in these two perspectives is seen in the specific purpose of nursing and health care, as it is applied to health promotion, illness prevention, or illness care.

The integrative model (Laffrey and Kulbok, 1999) includes two major dimensions: client system and focus of care. The client system is multidimensional with nursing and health care targeting the multiple levels of clients. The simplest level of the client system is its most delimited target, the individual. When the individual is the client, the environment includes the family, the broader aggregate, and the community of which the individual is a part. The nurse and health care provider are concerned with how these environments affect the individual as well as his or her health.

Each succeeding level of the client system is more complex, since the client can also be the family, an aggregate, or the community. The aggregate and community make up the environment for the family, and the community is the environment for the aggregate. Examples of different types of assessments and interventions appropriate at each level of client within the system are discussed later in this chapter. It is important to remember that community-oriented care is holistic in nature and is population focused in that it addresses multiple levels of clients and multiple levels of care within the total system. The integrative model of community health promotion is consistent with the ecological approach described earlier, which addresses SDOH through social networks, organizations, neighborhoods, and communities (Navarro et al, 2007).

Focus of care in the integrative model includes health promotion, illness (disease or disability) prevention, and illness care. Each focus is appropriate for some aspects of nursing and health care. It is even more important to remember that the goal of health care is a healthier community, achieved through health promotion interventions. No matter where care begins, it ultimately leads to health promotion of the community. It underscores the need for nurses and health care providers to have a good understanding of care requirements at all of the client levels. The individual, family, aggregate, and community each have characteristics, strengths, and health needs that are unique and that differ from those at the other levels.

The integrative community health promotion model reflects the basic beliefs and values of holistic nursing and health care practice. The model depicts continuity and expansiveness of the client systems and foci of care. Health promotion is the central axis, or core, of the model. At its narrowest focus, individuals receive illness care. According to the model, at the broadest level of care, nurses work with community leaders, other community residents, and health professionals to plan programs to promote optimal health for the community and its people. The goals of nursing and health care actions in the integrative model, at any client level from the individual to the community, are to identify health potential and achieve maximal health. To achieve these goals it is essential to have an active partnership between the nurse, health care providers, and the client system. By facilitating an active partnership with the client system, whether the focus of care is health promotion, illness prevention, or illness care, nurses involve clients in each step of the process of managing care from the assessment of their health needs and resources to implementation and evaluation of outcomes.