What Is Public Health and Public Health Nursing?
Marie Truglio-Londrigan
Sandra B. Lewenson
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Recognizing limits to what the health service professions can now do, in relation to common health problems faced everyday, by no means negates the fact that as conditions essential for health are more fully known and are provided and used by individuals and communities, more and more individuals will be enabled to experience greater health (Peplau, 1952, p. 15).
LEARNING OBJECTIVES
At the completion of this chapter, the reader will be able to
Define the meaning of public health and public health nursing.
Describe what is meant by the terms “care of the public” and “population-based care.”
Describe the vision, mission, overarching goals, topics, and objectives of Healthy People 2020.
Examine the 10 essential public health services in relation to the core functions of public health practice.
Examine the role of the public health nurse within the larger context of public health.
KEY TERMS
Assurance
Core functions of public health
Essentials of public health
Health promotion
Healthy People 2020
Maintaining health
Preventing disease
Public health
Public health nursing
Risk reduction
It never fails. Sit around a table and discuss the health of the public or population-based care and one frequently receives blank stares. What is public health? What does it mean when one speaks about the health of the “public” or “population-based care”? What is the role of the public health nurse within this larger framework? And who pays for public health? These questions need to be answered for those in practice, and this chapter provides answers to these questions, thus enhancing practitioners’ working knowledge of the scientific discipline known as public health. Creating a professional nursing workforce that demonstrates a vigorous practice of integrating culturally congruent nursing actions based on evidence and recognizing the funding streams lay the groundwork for a strong public health infrastructure that will ultimately enhance and sustain the public’s health.
Public Health Defined
To fully understand the concept of public health, it is important to review the definitions put forth over time by those in practice. This exercise will assist the reader in knowing and understanding the important characteristics and features of this discipline.
“Public health work is as old as history,” wrote J. Howard Beard in 1922. Beard’s article, published in The Scientific Monthly, charts the early progress of public health starting with the early Egyptians, who filtered mud from the Nile River to create a safer water source for citizens. Throughout history the health of the public has been a concern for local and national governments and all members of society. The public health movement in the United States originated in Boston, Massachusetts, in the mid 1800s when Lemuel Shattuck’s noted reports on the healthcare needs of the community became the “blueprint for American health organization” (Beard, 1922; Scheele, 1949, p. 293). A noted public health leader in the early 20th century, C. E. Winslow (1920), defined public health as follows:
{T}he science and the art of preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts for the sanitation of the environment, the control of community infections, the education of the individual in principles of personal hygiene, the organization of medical and nursing service for the early diagnosis and preventive treatment of disease, and the development of the social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health. (p. 30)
The definition of public health has changed over time to accommodate the needs of American society.
In 1988, the Institute of Medicine (IOM) defined public health as “what we, as a society, do collectively to assure the conditions in which people can be healthy” (IOM, 1988, p. 1). Society collectively works together to provide services generally to a population to prevent disease and to maintain health (Buttery, 1992). The Association of Schools of Public Health’s website defines public health as “the science and art of protecting and improving the health of communities through education, promotion of healthy life styles, and research for disease and injury prevention” (n.d., para. 1). In 2003, the IOM published The Future of the Public’s Health in the 21st Century. This report was comprehensive in nature and spoke to partnerships; intersectoral collaboration; the strengthening of the public health infrastructure, including the building of our nation’s public health workforce; and an enhanced understanding of what we mean when we speak of community and population, along with an awareness of the shifting of our demographics
(the aging of our population and the shift from acute to chronic care). Another IOM report, titled For the Public’s Health: The Role of Measurement in Action and Accountability (2010), looks at the critical importance of measurements in summarizing the impact that the health system has on the population, thus emphasizing the importance of outcomes. Although brief, this information serves as a template to remind us of the progressive steps we have taken over the decades.
(the aging of our population and the shift from acute to chronic care). Another IOM report, titled For the Public’s Health: The Role of Measurement in Action and Accountability (2010), looks at the critical importance of measurements in summarizing the impact that the health system has on the population, thus emphasizing the importance of outcomes. Although brief, this information serves as a template to remind us of the progressive steps we have taken over the decades.
Populations
When one considers the preceding definitions of public health, one comes to understand that the discussion of health moves beyond the health of the individual, family, and community to the health of the population. For example, Hurricane Katrina hit the U.S. Gulf Coast, with particular destruction in Louisiana, on August 29, 2005. In the weeks that followed, healthcare professionals cared for individuals and their family members who were evacuees without shelter and who had suffered from physical and emotional distress. Brodie, Weltzien, Altman, Blendon, and Benson (2006) surveyed the experiences of the Hurricane Katrina evacuees. Their results provide valuable information for public health professionals, “highlighting challenges of effectively evacuating cities’ most at-risk residents during a disaster and providing for longterm health needs of vulnerable populations in the aftermath” (p. 1407). The outcomes of this research also provided important guidelines for public health officials as they planned for future evacuations when disasters hit and discussed how to ensure the protection of the public during this evacuation. Table 1-1 gives additional examples of how a specific public health intervention, such as education, may vary depending on whether the focus is on individuals, families, populations, or communities.
The concept of caring for populations can be difficult to understand and perhaps serves as a barrier to the way nurses or other healthcare workers are educated and approach care. The noted 20th-century nursing leader Virginia Henderson, when questioned on how one could nurse an aggregate, said, “I think it impossible to nurse an aggregate effectively until you have effectively nursed individuals and acquired considerable judgment as to what helps clients or patients prevent disease, cope with it, or die with dignity when death is inevitable” (Abrams, 2007, p. 384). This question has been raised many times in hopes of understanding what a population means and what it means to care for a population. Definitions of “populations” illustrate characteristics and features specific to public health. Williams and Stanhope (2008) define a population or aggregate as “a collection of individuals who have one or more personal or environmental characteristics in common” (p. 11). The Association of Community Health Nursing Educators, as demonstrated in Levin et al. (2007), uses the same definition as Williams and Stanhope. The American Nurses Association (2007) builds on the definition of population as “those living in a specific geographic area (e.g., a neighborhood, community, city, or county) or those in a particular group (e.g., racial, ethnic, age, disease) who experience a disproportionate burden of poor health care outcomes” (p. 5).
Henderson’s concern about nursing populations versus nursing individuals may stem from her concern about the division in health care that separates the care of populations from the care of individuals. Henderson asked, “Should we have one category of health workers treating disease and another preventing it? Or should we all be trying primarily to prevent disease, and, even while treating it, to be helping the victim to prevent a recurrence?” (Abrams, 2007, p. 384). Changing definitions of public health nursing explore the dichotomy between care of the individual and the aggregate.
Table 1-1 EXAMPLES OF THE “EDUCATIONAL” INTERVENTIONS FOR INDIVIDUALS, FAMILIES, POPULATIONS, AND COMMUNITIES | ||||||||||||||||||||
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Preventing Disease and Maintaining Health
Other important characteristics of public health are preventing disease and maintaining health. Care is the main focus of public health nurses and practitioners, with an emphasis on health promotion and risk reduction. To understand these concepts fully, public health nurses can turn to the historic work of Leavell and Clark (1965), who note, “The ultimate objectives of all medical, dental, and public health practice, whether carried out in the office, the clinic, the laboratory, or the community-at-large, are the promotion of health, the prevention of disease, and the prolongation of life” (p. 14).
According to Leavell and Clark’s (1965) seminal work, there are three levels of prevention. The first level, primary prevention, includes interventions designed to promote health via health promotion strategies and to specifically protect the individual from disease “by providing immunizations and reducing exposure to occupational hazards, carcinogens, and other environmental health risks” (Greiner & Edelman, 2006, p. 17). These interventions take place before the presence of disease and disability, in the period known as the prepathogenesis period. The second level of prevention, which occurs in the period of pathogenesis, takes place once disease is present. Interventions include screening activities and early treatment to prevent the consequences of advanced disease, such as disabilities. Finally, the third level of prevention includes rehabilitation intervention strategies; “This is more than stopping a disease process; it is also the prevention of complete disability. … Its positive objective is to return the affected individual to a useful place in society and make maximum use of his remaining capacities” (Leavell & Clark, 1965, p. 26). Figure 1-1 offers a pictorial view of the natural history of any disease.
Today, public health nursing activities in primary, secondary, and tertiary prevention have evolved and take into consideration the idea that health is not linear; in fact, if a person requires tertiary rehabilitative services, health promotion strategies are still important. The question Henderson raised earlier speaks to this nonlinear approach and encourages public health nurses to think about providing care for disease while simultaneously promoting health.
Multiple Disciplines
The definitions of public health thus far given demonstrate the collective nature of public health and the need for multiple disciplines to work together in ensuring the health of the public. Figure 1-2 is a visual depiction of this.
The IOM speaks to this collective endeavor as a process that must involve multiple individuals and multiple organizations: “The concept of a public health system describes a complex network of individuals and organizations that have the potential to play critical roles in creating the conditions for health. They can act for health individually, but when they work together toward a health goal, they act as a system—a public health system” (2003, p. 28). The IOM further describes participants as “actors” in the public health system. Actors include the governmental public health infrastructure, such as local and state departments of health; the healthcare delivery system; academia; and communities; in turn, communities may include schools, religious organizations, and other notfor-profit organizations, just to name a few. In addition, businesses and corporations are considered important actors because they too play a role in influencing population health with regard to the working conditions and healthcare benefits they provide. Finally, the IOM identifies the media as important actors in the public healthcare system. Consider the impact that the media can have with their ability to reach populations through the various media streams. Ultimately, public health system actors, with their integrative and participatory roles, serve as a reminder of the historic Declaration of Alma-Ata International Conference (1978) that recognized primary health care as a major strategy for achieving health for all. At this historic international conference, participants expressed a need for all governments and other international organizations to engage in actions that would ensure the implementation of primary health care around the world. The Declaration of Alma-Ata International Conference (1978) described and explained primary health care as follows:
 Figure 1-1 Levels of prevention. |
 Figure 1-2 The intersectorial public health system. |
{R}equires and promotes maximum community and individual selfreliance and participation in the planning, organization, operation and control of primary health care, making fullest use of local, national and other available resources; and to this end develops through appropriate education the ability of communities to participate. (para. 12)
Ensure the Public’s Health
Working together as actors is important, but the ability to ensure the health of the public is critical. How does one ensure the health of the public? The involvement and role of the government are important in this regard. The IOM (2003) speaks to this very issue:
In the United States, the government’s responsibility for the health of its citizens stems, in part, from the nature of democracy itself. Health officials are either directly elected or appointed by democratically-elected officials. To the extent, therefore, that citizens place a high priority on health, these elected officials are held accountable to ensure that the government is able to monitor the population’s health and intervene when necessary through laws, policies, regulations, and expenditure of the resources necessary for the health and safety of the public. (p. 101)
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