The purpose of this activity is to engage in a volunteer experience with a safety net project or community
program. The historical roots of the nursing profession originate from the work of Florence Nightingale in
giving service to those populations with increased risk or susceptibility to poor health outcomes. This
experiential learning activity will provide you with an opportunity to demonstrate the ability to provide a
service to the community while learning about and responding to a priority need of a specific sub population
of your community. You will come to understand the expanded role of nurses as advocates beyond the
Shows Evidence of Commitment to
Social Justice, the Greater Good,
and the Public Health Principles
n Patricia M. Schoon
with Noreen Kleinfehn-Wald and Colleen B. Clark
Erica is a new public health nurse (PHN) in a large urban county where 40% of the children live in pov-
erty. During Erica’s home visit to a young family, the mother states that the 2- and 3-year-old children
have become “slow to get things and were tripping and falling more than usual.” A year ago, the family
had moved from a newer apartment building into a 70-year-old building when the husband lost his job.
Erica notices paint chips on the floor and is concerned that they are from lead-based paint. She advises
the mother to have her children’s blood lead levels checked. The mother says she does not have health
insurance and cannot afford a trip to the doctor. Erica tells the mother the paint should be replaced,
but the mother is concerned that the landlord will not listen to her. Erica consults with her public health
nursing supervisor about what else can be done.
COMPETENCY #11 Shows Evidence of Commitment to Social Justice, the Greater Good, and the
Public Health Principles
A. Applies principles of social justice to promote and maintain the health and well-being of populations
B. Understands the impact of the social determinants of health on vulnerable and at-risk populations
C. Advocates for the disadvantaged and underserved
D. Participates in collaborative social actions to reduce health disparities and inequities
Source: Henry Street Consortium, 2017
Advocacy: Actions to ensure that individuals or populations have basic human rights and justice: “Advocacy
pleads someone’s cause or acts on someone’s behalf, with a focus on developing the community, system,
individual, or family’s capacity to plead their own cause or act on their own behalf” (Minnesota Department of
Health [MDH], 2001, p. 263).
Charity: Giving of oneself (volunteering) or of one’s resources to those in need.
Civic Engagement: Working with community members to improve the civic life of the community through
social and political actions based on an understanding of the community, its diversity, assets, and problems
Ethnicity: A collective group of individuals with presumed common ancestry sharing cultural symbol and prac-
tices. Individual identification of ethnicity may be voluntary and self-defined (Ford & Harawa, 2010; Lee, 2009).
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252 PART II n Entry-Level Population-Based Public Health Nursing Competencies
Health Disparities: Preventable, population-specific differences in health and disease (incidence and preva-
lence), health outcomes, or access to care that place some populations at greater risk than others and that are
primarily the result of the social determinants of health.
Health Equity: “When every person has the opportunity to realize their health potential—the highest level of
health possible for that person—without limits imposed by structural inequities. Health equity means achieving
the conditions in which all people have the opportunity to attain their highest possible level of health” (MDH,
2014, p. 11).
Human Rights: Individual and family rights to live an independent, fulfilling, healthy life and earn a living wage
for food, clothing, housing, and a safe environment; self-determination and autonomy. Human rights are rights
inherent to all human beings. They are universal and inalienable, interdependent and indivisible, equal and non-
discriminatory, entailing both rights and obligations (Office of the High Commissioner for Human Rights, n.d.).
Institutionalized Racism: Historical and systematic discrimination that results in normalization and acceptance
of differences in how minority populations of race and ethnicity are perceived and treated that results in edu-
cational, social, economic, and health inequities (Blodern, O’Brien, Cheryan, & Vick, 2016; Feagin & Bennefield,
2014; Gordon-Burns & Walker, 2015).
Market Justice: Personal resources and choices provide the basis for use and distribution of healthcare services
based on concepts of individualism, self-interest, and individual effort; no collective obligation of society or
government exists to provide for healthcare (Budetti, 2008).
Race: A social construct rather than a biological construct that is consistent with historical racial and ethnic
population histories as opposed to specific genetic differences; different from ethnicity although frequently
combined in healthcare practice; may be considered part of ancestral background (Frank, 2008; Jaja, Gibson,
& Quaries, 2013; Lee, 2009).
Racialization: A process in which racial, ethnic, and cultural descriptions of groups of people in combination
with statistical data combines to create distinct and different categories of people who are identified as having
common risk factors and behaviors. This process leads to stereotyping groups of people with the tendency to
see people as part of a specific group rather than as individuals (Cloos, 2015; Smedley & Smedley, 2005). This
phenomenon is part of institutionalized racism.
Social Determinants of Health: The social determinants of health are the circumstances in which people are
born, grow up, live, work, and age, as well as the systems put in place to deal with illness. These circumstances
are in turn shaped by a wider set of forces: economics, social policies, and politics (World Health Organization
Social Justice (syn., distributive justice): The concept that individuals have the right to receive resources based
on their needs and that a collective social obligation exists to provide for basic human needs, including health
services (Budetti, 2008).
COMPETENCY #11 (continued)
Taking Action for What Is Right—
Applying Principles of Social Justice
Professional nurses have a social contract with their clients
and the public to ensure that the healthcare needs of indi-
viduals, families, populations, and communities are met
in a caring, nonjudgmental, just, and equitable manner.
Nurses as professionals and as private citizens are guided
by the rule of law that protects basic human rights and by
ethical principles that undergird basic human rights and
social justice, a core principle of public health. Nurses in
public health are confronted with ethical issues or moral
challenges surrounding human rights and social justice
on a daily basis. Moral challenges are situations in which
a nurse’s ethical beliefs are challenged and require critical
thinking to arrive at a solution that protects the rights of
individuals, families, and communities. The integration of
caring (a core component of nursing) and social justice (a
core component of public health), in conjunction with the
moral challenge resulting when PHNs witness their clients
experiencing health disparities and social injustice, propel
PHNs to become involved in social and political advocacy
(Falk-Rafael & Betker, 2012).
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253CHAPTER 13 n Competency #11
Article 25 also speaks to many of the social determinants
of health that have both societal and individual origins (see
Respect for human rights is a basic tenet of ethical nurs-
ing practice (American Nurses Association [ANA], 2015,
2016; Fowler, 2015). The International Council of Nurses
(ICN, 2011) views healthcare as a basic right for all individ-
uals; they state that nurses are obligated to provide fair and
equal treatment and have a responsibility to safeguard client
rights at all times and are held accountable for both their
actions and their inactions. The ANA Code of Ethics identi-
fies the obligations of nurses to support both human rights
and principles of social justice for all:
A fundamental principle that underlies all nursing
practice is respect for the inherent dignity, worth,
unique attributes, and human rights of all individu-
als. The need for and right to health care is universal,
transcending all individual differences. Nurses con-
sider the needs and respect the values of each person
in every professional relationship and setting; they
provide leadership in the development and implemen-
tation of changes in public and health policies that
support this duty (ANA, 2015, p. 1).
In addition, the ANA code stipulates that nurses are
obligated as individuals and as a profession to act at the
community and systems levels of practice to reduce health
n Provision 8: “The nurse collaborates with other
health professionals and the public to protect human
rights, promote health diplomacy, and reduce health
disparities” (p. 31).
n Provision 9: “The profession of nursing, collectively
through its professional organizations, must articulate
nursing values, maintain the integrity of the profession,
and integrate principles of social justice into nursing
and health policy” (p. 35).
As students, you will be challenged and at times conflicted
by the decisions you face that require choosing between two
important and good things. For example, do you decide to
respect individual autonomy and confidentiality, or do you
find it necessary to enforce a public health law? This chapter
provides guiding principles for social justice, information
about population health disparities that confront PHNs,
and a framework for public health advocacy interventions
to help prepare you for the difficult situations you may
encounter as a student and as a professional nurse.
Guiding Principles for Taking Actions
for What Is Right
Matwick and Woodgate (2016) report that social justice is
considered a core value of nursing present since the late 19th
century and evident in the actions of public health nursing
leaders such as Nightingale and Wald. It is central to the
practice of public health nursing. The two key attributes
of social justice in nursing practice are equitable distribu-
tion of resources and helping relationships that occur when
those with social advantage and power help those with less
social advantage and power. Matwick and Woodgate believe
that in order to practice social justice, nurses need to rec-
ognize and acknowledge social oppression and inequities,
which then lead nurses to take caring actions toward social
reform. They propose the following definition of social jus-
tice (p. 182):
Social justice in nursing is a state of health equity
characterized by both the equitable distribution of
services affecting health and helping relationships.
Principles of social justice and human rights provide a
framework for the ethical principles of public health prac-
tice. The principles of social justice that are key to the health
and well-being of populations include:
n Collective social responsibility for community members
n Responsibility of government to ensure the basic human
rights and healthcare needs of its citizens
n Equitable allocation of healthcare resources based
n Protection of the rights of individuals and families to
live safe, healthy, and fulfilling lives
The United Nations published The Universal Declara-
tion of Human Rights detailing 30 articles defining human
rights (UN, 1948). The Preamble states, “Whereas inherent
recognition of the inherent dignity and of the equal and
inalienable rights of all members of the human family is the
foundation of freedom, justice, and peace in the world…
a common understanding of these rights and freedoms is
of the greatest importance.” Articles 1 and 25 provide an
international standard for health as a basic human right.
TABLE 13.1 Selected Human Rights From the
UN’s Universal Declaration of Human Rights
Article 1. All human beings are born free and equal in dignity
and rights. They are endowed with reason and conscience and
should act towards one another in a spirit of brotherhood.
Article 25. (1) Everyone has the right to a standard of living
adequate for the health and well-being of himself and of his
family, including food, clothing, housing, and medical care
and necessary social services, and the right to security in the
event of unemployment, sickness, disability, widowhood, old
age or other lack of livelihood in circumstances beyond his
control. (2) Motherhood and childhood are entitled to special
care and assistance. All children, whether born in or out of
wedlock, shall enjoy the same social protection.
Source: United Nations, 1948
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254 PART II n Entry-Level Population-Based Public Health Nursing Competencies
For example, at the individual/family level of practice,
a PHN would arrange to have an interpreter present when
providing health education and counseling to an immigrant
family who cannot speak English. At the community level,
PHNs could create a social marketing campaign to help
the community understand and respond to the challenges
English language learners have in understanding English
language signage posted throughout the community. At
the systems level, PHNs could work with interprofessional
teams to improve access to healthcare services for immi-
grants and English language learners. Figure 13.1 depicts the
three levels of practice.
Nurses have a social contract with the public. The Ameri-
can Nurses Association Guide to Nursing Social Policy State-
ment (Fowler, 2015) outlines the social contract that nurses
have with the public. The contract involves 16 elements of
reciprocal expectations between nursing and the public
(p. 19). The ninth expectation, Promotion of the Health of the
Public, stipulates that nurses have a social responsibility to
address health disparities at all levels of society:
Promotion of the Health of the Public: It is expected
that nurses will address the problems faced by indi-
vidual patients including issues of health disparities
and that nursing will be involved with and lead in
health-related issues important to society. In some
instances, nursing will be in the vanguard of emerging
health-related issues. Nursing will participate in the
promulgation of healthcare policy at regional, state,
national, and global levels. Protection of the public
through advocacy also includes whistleblowing (p. 21).
The World Health Organization (WHO) considers the
human right to healthcare from a very holistic perspective
The right to the highest attainable standard of health
requires a set of social criteria that is conducive to the health
of all people, including the availability of health services,
safe working conditions, adequate housing, and nutritious
foods (WHO, 2015, para. 1). Achieving the right to health is
closely related to that of other human rights, including the
right to food, housing, work, education, non discrimination,
access to information, and participation. The right to health
includes both freedoms and entitlements.
n Freedoms include the right to control one’s health and
body (e.g., sexual and reproductive rights) and to be free
from interference (e.g., free from torture and from non-
consensual medical treatment and experimentation).
n Entitlements include the right to a system of health
protection that gives everyone an equal opportunity to
enjoy the highest attainable level of health.
WHO also identifies principles and standards of human
rights that provide guidance to address the causes of human
rights inequities. These principles and standards are out-
lined in Table 13.2 (2015, para 7).
These human rights, especially those emphasizing access
to living conditions that encourage health, guide much of the
work that PHNs do. Sometimes advocating for the human
rights of individuals and concurrently advocating for social
justice for vulnerable individuals, families, or populations
results in ethical conflicts. Nurses have ethical responsibil-
ities to protect the rights of individuals and to protect the
health and welfare of the community. Consequently, some
actions, such as mandated reporting of specific communi-
cable disease incidents, require nurses to identify an ethical
rationale for whether they choose to protect the individual
or the community when protecting both simultaneously
is not possible. Public health professionals have a code of
ethics (Public Health Leadership Society, 2002) that directs
them to act to protect vulnerable and at-risk populations
and to work to eliminate health disparities. (See Table 13.3
for principles and examples of PHN actions.)
FIGURE 13.1 How a PHN Can Practice at All Three Levels
Arrange to have an interpreter
present when providing health
education and counseling to an
immigrant family who cannot
Create a social
to help the
throughout the community
Work with interprofessional
teams to improve access to health
care services for immigrants and
English language learners
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255CHAPTER 13 n Competency #11
PHNs have both a moral and a legal obligation based on
human rights to secure and provide public health services to
those who need them. However, because resources are finite,
PHNs are faced with the difficult situation of setting priori-
ties to determine which at-risk populations and who among
these populations will receive services. PHNs employed
by governmental agencies work with community partners
to identify need, available resources, and service gaps. A
human rights approach presented by Gruskin and Daniels
(2008, p. 1573) provides a framework for these decisions:
n Direct concern with equity in the utilization of
n Examination of the factors that may constrain or sup-
port planned interventions, including the legal, policy,
economic, social, and cultural context.
n Participation and negotiation between all stakeholders,
even as primary responsibility rests with government
officials to facilitate these processes and to determine
which interventions may have the biggest impact on
n Government responsibility and accountability for the
manner in which decisions are made, resources are allo-
cated, and programs are implemented and evaluated,
including the impact on these decisions on health and
TABLE 13.2 Human Rights–Based Approaches
Nondiscrimination: The principle of nondiscrimination
seeks “…to guarantee that human rights are exercised
without discrimination of any kind based on race, colour,
sex, language, religion, political or other opinion, national or
social origin, property, birth or other status such as disability,
age, marital and family status, sexual orientation and gender
identity, health status, place of residence, economic and social
Availability: A sufficient quantity of functioning public
health and healthcare facilities, goods and services, as well
Accessibility: Health facilities, goods, and services should
be accessible to everyone. Accessibility has four overlapping
dimensions: nondiscrimination; physical accessibility; eco-
nomic accessibility (affordability); information accessibility.
Acceptability: All health facilities, goods, and services must
be respectful of medical ethics and culturally appropriate as
well as sensitive to gender and life-cycle requirements.
Quality: Health facilities, goods, and services must be
scientifically and medically appropriate and of good quality.
Accountability: States and other duty-bearers are answerable
for the observance of human rights.
Universality: Human rights are universal and inalienable.
All people everywhere in the world are entitled to them.
Source: WHO, 2015
TABLE 13.3 Ethical Principles That Guide Public Health Professionals in Confronting Health Disparities
Principles PHN Practice Examples
Public health should address principally the fun-
damental causes of disease and requirements for
health, aiming to prevent adverse health outcomes.
n Focusing on primary prevention with individuals, families, and
n Assessing the social determinants of health as part of the community
n Sharing the data on the social determinants of health that adversely
affect the health of community members
Public health should advocate and work for the
empowerment of disenfranchised community mem-
bers, aiming to ensure that the basic resources and
conditions necessary for health are accessible for all.
n Targeting services to vulnerable and at-risk populations experiencing the
greatest levels of health disparities
n Advocating through the political process for funding and services for
vulnerable and at-risk populations
n Using an assets-based approach to collaborate with community members
to empower them to manage their own healthcare needs
Public health programs and policies should be
implemented in a manner that most enhances the
physical and social environments.
n Providing services to the uninsured and underinsured in homes and in
community and mobile clinics
n Creating and providing culturally sensitive services
n Collaborating with community organizations that provide safety-net
Source: Public Health Leadership Society, 2002
256 PART II n Entry-Level Population-Based Public Health Nursing Competencies
EVIDENCE EXAMPLE 13.1
Social Justice and Human Rights Issues Identified by Practicing PHNs
A focus-group process was used to identify social justice and
human rights issues that cause staff PHNs to confront ethi-
cal dilemmas on a daily basis. Sixteen nurses working in a
suburban-rural county public health agency used storytelling
to draw out examples of the social justice issues and human
rights principles that were being violated which resulted in neg-
ative health outcomes. All four examples identified resulted in
reduced health outcomes for individuals and families.
Right to self-determination (human right)—Clients are in
need of services but do not qualify for existing programs. For
example, an elderly person may need personal care attendant
services but does not qualify for medical assistance, so the
client remains at risk for placement in a long-term care facility.
Right to a standard of living adequate for the health and
well-being of individuals and families (human right)—The
working poor often work in entry-level jobs and earn salaries
that make them ineligible for public services, even though their
income is not enough to adequately support their families.
Autonomy (human right) versus greater good (social
justice)—A client with a communicable disease chooses to
break home isolation and exposes many people by going out
in public. Parents choose not to vaccinate their child, who then
becomes ill with pertussis and exposes an entire classroom of
children, including one child who is immune-compromised.
Inequitable distribution of power, money, and resources
(social justice)—Legal immigrants arriving in the state have
received no health examination in their home country and are
not provided with a health screening upon arrival in the United
States. Other foreigners seeking admission to the country as
refugees have a health examination and have a health screen-
ing upon arrival in their county of residence.
Source: Kleinfehn-Wald, 2010
Market Justice Versus Social Justice
Globally, healthcare systems vary but are generally based on
principles of market justice, social justice, or a combination
of the two. The U.S. healthcare system, like the rest of the
U.S. economy, is based on free enterprise and the principles
of market justice. An alternative healthcare system, based
on social justice, is embodied in the nonprofit and govern-
mental healthcare systems. See Chapter 7 for a discussion
of the U.S. healthcare system. Advocates of social justice
believe that the government has a role to play in the provi-
sion of and assurance of basic health services to its citizens.
Advocates of market justice believe that individuals and the
private sectors are better prepared to meet the healthcare
needs of private citizens. Social justice requires that the gov-
ernment be responsible and accountable for the health and
well-being of its citizens. Market justice requires that indi-
viduals be responsible for their own health and well- being.
Table 13.4 compares the concepts of market and social jus-
tice relative to healthcare.
The United States has a dominant and enduring cul-
tural value of individualism—a belief that individuals are
able to create their own destiny and that individual rights
are more important than society’s rights (Ludwick & Silva,
2000). This cultural belief presents a significant barrier to
the development of a social justice model of healthcare. It
is important for nurses in the United States to understand
the cultural values of our society to determine how health
equity might be achieved.
Social Determinants of Health
Social determinants of health are the conditions and cir-
cumstances that vulnerable populations experience over
their life span in their homes, neighborhoods, work places,
schools, and the larger community. The social determinants
of health include access to healthcare and the systems put
in place to deal with their ongoing health status and illness.
These circumstances are in turn shaped by a wider set of
economic, social, and political forces at the local, national,
and global levels (WHO, n.d.). These social determinants
of health have a significant impact on the health status of
populations—often a negative one. Research has shown that
interventions that address social determinants of health
well in advance of identified health problems or concur-
rently with medical care improve health and reduce health
disparities (Williams, Costa, Oduniami, & Mohammed,
2008). The social determinants of health (social and eco-
nomic factors and physical environment) account for 40%
of the health determinants that influence health outcomes,
as illustrated in Figure 13.2.
Examples of social determinants of health identified by
Healthy People 2020 are outlined in Table 13.5. Both the cat-
egories of social determinants and physical determinants in
the table are considered social determinants of health.
Healthy People 2020 has identified objectives for the
social determinants of health in the following categories:
economic stability, education, neighborhood and built
environment, and social and community context (Healthy-
257CHAPTER 13 n Competency #11
TABLE 13.4 Market Justice Versus Social Justice in the United States
Market Justice Social Justice
People are entitled only to those valued ends, such as status,
income, and happiness, that they acquire by individual efforts,
actions, or abilities. The focus and beliefs include:
n Individual rights and responsibility
n Death and disability as individual responsibilities and
n Minimal collective action
n Freedom to act with minimal obligations for the
n Respect for the rights of individuals
n Individuals and the local private and public sector having
responsibility and control over health and healthcare
n Local short-term goals that are treatment-oriented
n Government infringement on individual rights, its
inefficiency, and mistrust of it
n Support for the medical model of healthcare
People in society receive benefits by belonging to a community,
and the burdens and benefits of society should be fairly and
equitably distributed. The focus and beliefs include:
n Individual rights as members of the community
n Death and disability as collective responsibilities and
n Collective action for the common good
n General obligation to protect individuals against disease
n Quality of life; stewardship of future
n Private business’s obligation to the community as a whole
n Global, long-term goals that are prevention-oriented
n Government obligation and responsibility to protect citizens
and trust that it will do the right thing
n Support of a universal or single-payer model of healthcare
Sources: Based on work by Keller, 2010, & Beauchamp, 2013
It is important to note that the list of the social deter-
minants of health does not include culture or ethnicity.
Nor is the category of race considered a health determinant
that results in poorer health outcomes. In order to organize
public health data in a way that identifies populations with
poorer health outcomes and health disparities, governmen-
tal agencies report health outcomes by specific categories
of people (grouping people by a set of defined biological,
cultural, and ethnic characteristics). The purpose of this
categorization is to identify and target specific population
groups for specific interventions to reduce health disparities
(Cloos, 2015; Smedley & Smedley, 2005). This categorization
is referred to as racialization in that these categories lead
to stereotyping individuals by racial, ethnic, and cultural
categories. PHNs must be careful that, when developing
interventions for specific population groups (immigrants,
Native Americans, etc.), they are able to set aside data-
driven stereo types and develop services that meet the needs
of unique individuals.
FIGURE 13.2 Determinants of Health
Source: MDH, 2014, p. 12
258 PART II n Entry-Level Population-Based Public Health Nursing Competencies
TABLE 13.5 Healthy People 2020 Social Determinants of Health
of Health Examples
Social n Availability of resources to meet daily needs (e.g., safe housing and local food markets)
n Access to educational, economic, and job opportunities
n Access to healthcare services
n Quality of education and job training
n Availability of community-based resources in support of community living and opportunities for
recreational and leisure-time activities
n Transportation options
n Public safety
n Social support
n Social norms and attitudes (e.g., discrimination, racism, and distrust of government)
n Exposure to crime, violence, and social disorder (e.g., presence of trash and lack of cooperation in a
n Socioeconomic conditions (e.g., concentrated poverty and the stressful conditions that accompany it)
n Residential segregation
n Access to mass media and emerging technologies (e.g., cellphones, the Internet, and social media)
Physical n Natural environment, such as green space (e.g., trees and grass) or weather (e.g., climate change)
n Built environment, such as buildings, sidewalks, bike lanes, and roads
n Worksites, schools, and recreational settings
n Housing and community design
n Exposure to toxic substances and other physical hazards
n Physical barriers, especially for people with disabilities
n Aesthetic elements (e.g., good lighting, trees, and benches)
Source: HealthyPeople.gov, n.d.
Impact of Social Determinants of Health
In the United States, the social determinants of health of
social status (e.g., education, income, place of residence, his-
torical discrimination based on perceptions of race and eth-
nicity) and the ability to control one’s life and health have a
significant impact on health outcomes of both individuals
A comparison of life expectancy among different social
groups in the United States illustrates both health dispar-
ities and health inequities. For example, the gap in life
expectancy between the rich and the poor and those with
more education versus those with less education is widening
(Isaacs & Choudhury, 2015). Although gaps in life expec-
tancy might be partially explained by lifestyle decisions and
biological factors, societal factors also play a role. Those who
are poor or live in poor neighborhoods have less access to
healthy food, parks and public spaces, jobs, and education
(California Newsreel, 2008, p. 2). Children from low-income
families are about seven times as likely to be in poor or fair
health compared to children in the highest-income families
(p. 1). In a study of 40,000 children, obesity rates for all U.S.
children ages 10 to 17 increased 10% from 2003 to 2007, while
the rate increased 23% for low-income children (Singh,
Siahpush, & Kogan, 2010). Social determinants of health
have a significant impact on early childhood development
that persists into adulthood. Poverty, language differences,
and vocabulary skills all have an effect on high school gradu-
ation rates, which have an impact on adult earning potential
and health status across the life span (Robinson et al., 2017).
Infant mortality rates are considered a gold standard
of health worldwide. The U.S. infant mortality rate, esti-
mated at 5.80/1,000 live births for 2017, ranks 170th glob-
ally ( Central Intelligence Agency [CIA], 2017). Education,
income, and access to prenatal care are all causative factors.
A review of African-American infant deaths in Milwaukee
259CHAPTER 13 n Competency #11
from 2008 to 2010 demonstrated that many of the mothers
received late or no prenatal care (Salm Ward, Mazul, Ngui,
Bridgewater, & Harley, 2013). Infant mortality rates in the
U.S. continue to decrease, but significant gaps among racial
groups are noted in Figure 13.3 (Matthews & Driscoll, 2017).
Life expectancy trends, although improving, also demon-
strate health disparities, with Black males consistently
having the lowest life expectancy over a 14-year period from
1999 to 2013 (see Figure 13.4).
Although Figure 13.4 only includes the racial categories
of Black and White, there are data of years of potential lives
lost before age 75 (death of individuals before their expected
life span) that demonstrate disparities across multiple racial
categories from 1990 to 2015 (see Table 13.6).
FIGURE 13.3 Infant Mortality in the United States, 2005–2014
Source: Matthews & Driscoll, 2017
FIGURE 13.4 U.S. Life Expectancy by Race and Sex, 1999–2013
Source: Kochanek, Arias, & Anderson, 2015
260 PART II n Entry-Level Population-Based Public Health Nursing Competencies
housing, employment, social power, and opportunity) and
spatial (e.g., geographic locations within neighborhoods,
cities, counties, states, and areas of the country and concen-
tration of poverty and race in specific neighborhoods) social
determinants are the major causes of health disparities.
Institutionalized racism is a significant social determi-
nant of health that provides multiple and complex pathways
to poor health (Ramaswamy & Kelly, 2015). PHNs need to
be educated about the social determinants of health embed-
ded in society in order to advocate effectively to reduce the
effects of institutionalized racism and work to change the
systems that perpetuate it. An explanation of the multiple
and often hidden causes of institutionalized racism that
result in health disparities for African Americans is illus-
trated in Figure 13.5.
Progress is being made in reducing the health disparities
between identified racial groups in the United States, but
gaps do remain. The gap in life expectancy between African
Americans and Whites is decreasing; however, the remain-
ing gap is most pronounced between Black and White
males. The reduction of the gap for Black males was related
to decreased death rates for cancer, HIV, and unintentional
injuries. For Black females, the reduced gap was due to
decreased death rates for heart disease, HIV, and cancer.
The burden of excess deaths of the five leading causes of
death (heart disease, stroke, chronic respiratory disease,
cancer, and unintentional injury) is greater for those who
It is important to note that health disparities represented
by racial comparison mask the actual causes of the health
disparities. Race is primarily a social construct rather than
a genetic marker. So, although health data comparisons
by racial categories historically and socially defined in the
United States demonstrate correlation, these data do not
demonstrate causation. Structural (e.g., income, education,
TABLE 13.6 U.S. Years of Potential Life Lost
Before Age 75 by Sex, Race, and Hispanic
Origin, 1990 & 2015 (Age adjusted per 100,100
under age 75)
Category by Race 1990 2015
All 9,085.5 6,757.7
American Indian or
Asian or Pacific Islander 4,705.2 3,049.7
Black (non-Hispanic) 16,583.0 9,702.3
Hispanic or Latina 7,963.3 4,750.4
White 8,159.5 6,514.8
Source: National Vital Statistics System (NCHS), 2016
FIGURE 13.5 Impact of Institutionalized Racism on Health Outcomes of African Americans
Source: Doede, 2015, p. 152
POOR SOCIAL POLICIES:
Labor market, housing,
Lack of pension,
paid leave, or
UNABLE TO AFFORD
Fresh food, prescriptions,
safe housing, exercise
LITTLE OR NO ACCESS TO
POOR PUBLIC POLICIES:
STRUCTURAL DETERMINANTS INTERMEDIATE DETERMINANTS
261CHAPTER 13 n Competency #11
collaboration, and implement programs to promote health
equity at the state and local level (see the upcoming Fig-
ure 13.6). The idea is to move from a fragmented planning
approach to an integrated approach that deals with all of the
factors that can improve population health status: imple-
menting policies that can improve health across all health,
political, economic, and social sectors; developing an under-
standing of what health is and valuing it; and empowering
communities to have the capacity to improve the health of
their citizens (ASTHO, 2016).
Nurses represent the largest segment of healthcare pro-
fessionals with more than 3.6 million nationwide. The Gal-
lup annual honesty and ethics survey has recognized the
nursing profession as the most trusted profession for the last
16 consecutive years (Brenan, 2017). With this acknowledge-
ment comes privilege: advantages, power and authority, and
a mandate to promote health equity and social justice by tak-
ing actions to reduce health disparities (Reutter & Kushner,
2010). Health disparities are preventable, population-specific
differences in health and disease (incidence and prevalence),
health outcomes, or access to care that place some popu-
lations at greater risk than others and that are primarily
the result of the social determinants of health. PHNs know
from experience that the populations they serve experience
different levels of health status and have differing abilities
to achieve their health potential. These disparities in health
status are often the result of social determinants of health
that negatively affect individual and family health outcomes
and are not within the control of individuals and families to
change. PHNs work to eliminate the social determinants of
health that lead to health inequalities or health inequities:
n Health inequalities are differences in health disparities
based on social conditions that reflect the level of depri-
vation of one group versus another group.
n Health inequities are systematic disparities in health
and in the major social determinants of health between
diverse populations with different social positions that
persist over time (e.g., race; class; and advantages or
disadvantages such as wealth, power, and prestige).
The Commission on the Social Determinants of Health,
established by the WHO in 2005, recommends that the
focus be on creating the conditions in which health and
well-being can flourish (Baum, Gollust, Goold, & Jacobson,
2007). The Commission made three recommendations for
action: (1) improving daily living conditions in which peo-
ple are born, grow, live, work, and age; (2) tackling the ineq-
uitable distribution of power, money, and resources; and
(3) measuring and understanding the problems of health
inequities and assessing the impact of action (Baum et al.,
2007). In 2015, the UN General Assembly adopted resolu-
tion 70/1. Transforming Our World: The 2030 Agenda for
Sustainable Development (2015). This resolution addresses
the social determinants of health at a global level and sets
out an action plan for people, the planet, prosperity, peace,
and partnership. This action plan identifies 17 Sustainable
Development Goals (SDG) (see Chapter 1).
live in rural areas than in urban areas (Garcia et al., 2017).
The excess death rate for unintentional injury was 50%
higher in rural versus urban populations.
Health Equity and Health Disparities
A major goal of public health is to achieve health equity;
health equity exists when all people have the right and abil-
ity to reach their health potential regardless of their social
positions or social circumstances (Brennen Ramirez, Baker,
& Metzler, 2008). Reutter and Kushner (2010, p. 272) outline
the requirements of health equity as follows:
n Resources should be allocated equitably and fairly.
n Human rights perspective includes the right to health
and its prerequisites, the right to participate fully in
society, and the right to nondiscrimination.
n Access to healthcare and the social determinants of
health (social, economic, material, cultural, and political
structures) should be equitable.
n Health equity is shaped by politics and achieved
through the political process.
n Achieving health equity requires an intersectional
approach (beyond the healthcare sector).
Many initiatives across the United States focus on devel-
oping solutions to health inequities at the local and state lev-
els. The National Academy of Science in partnership with
the Robert Wood Johnson Foundation (2017) published a
report detailing how communities working collaboratively
with diverse partners could identify and implement solu-
tions to achieve health equity. The initiatives described in
this report are based on several beliefs (National Academies
of Sciences, Engineering, and Medicine, 2017):
n Health equity is crucial for the well-being and vibrancy
n Health is a product of multiple social, economic,
environmental, and structural factors.
n Health inequities are mainly a result of poverty,
structural racism, and discrimination.
n Communities have the ability or agency to promote
n Supportive public and private policies and programs
at all levels facilitate community action.
n Collaboration and engagement of new and diverse
(multi-sector) partners is essential to promoting
Their report provides a roadmap for community-based
Another initiative, A Triple Aim of Health Equity, was
established by the Association of State and Territorial
Health Officials (ASTHO) to empower state and territorial
health agencies to develop policies, develop cross-sector
262 PART II n Entry-Level Population-Based Public Health Nursing Competencies
EVIDENCE EXAMPLE 13.2
Food insecurity refers to the USDA’s measure of lack of access,
at times, to enough food for an active, healthy life for all
household members and limited or uncertain availability of
nutritionally adequate foods. Food-insecure households are
not necessarily food insecure all the time. Food insecurity
may reflect a household’s need to make trade-offs between
important basic needs, such as housing or medical bills, and
purchasing nutritionally adequate foods. The lack of access at
times to enough food to provide for a healthy, active life for
all family members is a significant health determinant risk in
the United States. In 2015, 42,238,000 people were identified
as food insecure. Of these people, 26% were above the 185%
of poverty level ($45,510 annual income for a family of four),
which made them ineligible for almost all governmental nutri-
tion assistance programs. In some states, the Supplemental
Nutrition Assistance Program (SNAP) has raised the eligibility
to 200% of poverty (Feeding America, 2017).
SNAP uses the Thrifty Food Plan (TFP) to calculate the cost
to provide a nutritious diet that meets minimum daily dietary
requirements as a means to determine the amount of SNAP
family cash food benefits. A systematic review of market bas-
ket surveys (MBS) using actual grocery store food prices was
conducted by Horning and Fulkerson (2014). They found that
SNAP cash allotments based on TFP calculations may not be
sufficient to meet a nutritious family diet based on the actual
cost of groceries. The ability of low-income families to change
their behaviors to eat a healthier diet may be cost prohibitive.
Nurses need to advocate for increases in food assistance and
the affordability of healthy foods.
Native Diabetes Wellness Program
GOAL 10 Poverty and food insecurity have been identified as risk factors for obesity and diabetes in
Native Americans. The Native Diabetes Wellness Program (NDWP) was established in 2004 to reduce
health inequities in tribal communities. Principles of practice included cultural humility and communi-
ty-led participation. The Eagle Books series for young children, highlighting the wisdom of traditional
ways of health, and a K–12 curriculum, Health Is Life in Balance, were instituted in 2006. The interactive
Diabetes Education in Tribal Schools curriculum included engagement, exploration, explanation, elab-
oration, and evaluation. The Traditional Foods Project for American Indian and Alaska Native Com-
munities was instituted by the CDC in 2008. The project included sustainable, ecological approaches
to traditional foods and physical activity, increased access to local foods, and revived and shared stories of healthy traditional
practices. Community members were engaged to track the progress of the project. In 2012 and 2013, Traditional Foods Project
partners and NDWP staff were invited to present to the CDC Tribal Advisory Committee, which recommended continuing the
Traditional Foods Project for a year beyond the 5-year cycle. Partners applied for a sixth year of funding for 2014 by demonstrat-
ing their evaluation results and plans to sustain their native food systems. Factors identified as important for the success of the
program included: the significance of land; interest in Native American food pathways and food sheds; respect for traditional
knowledge; consistency with traditional values; the role of elders as teachers of traditional knowledge fostered intergenerational
relationships; traditional foods facilitate dialogue about health; emphasis on planning; the importance of community-driven plan-
ning; and sustained efforts beyond the project’s end (CDC, 2016).
Advocacy: PHN Advocacy
for Population Health
Advocacy is considered a fundamental basis of nursing
(Curtin, 1979; Gadow, 1999; MacDonald, 2006), while social
justice is considered the fundamental basis of public health.
The ANA (2013) directs PHNs to advocate for the protection
of the health, safety, and rights of populations (Standard
16). In public health nursing, a primary focus of advocacy
is health equity.
PHNs most often work with vulnerable individuals and
families—those who are oppressed, marginalized, disen-
franchised, or underserved and therefore at greater risk for
disease, disability, and premature death. Although it is pos-
sible to improve the health status of individuals and families
one by one, it is more effective, when possible, for PHNs to
take actions to improve the health status of vulnerable pop-
ulations as a whole.
263CHAPTER 13 n Competency #11
The Journey to PHN Advocacy
Caring leads to advocacy, and PHNs care passionately about
those experiencing health disparities. PHNs enter into the
practice of “critical caring” when they recognize health dis-
parities in individuals and families and work to change the
context of people’s lives to improve their health (Falk-Rafael,
2005a). It is not always easy to advocate for clients, either at
the individual or the population level of public health prac-
tice. Social justice dilemmas are part of the everyday lives of
nurses. What is different for PHNs is that they often have to
confront and resolve these dilemmas when they are out in
the community by themselves. In an acute care setting, eth-
ics committees can usually help resolve ethical issues related
to autonomy, rights to self-determination, rights to refuse
treatment, and rights to a safe and comfortable death. In the
home and community setting, PHNs are often practicing
alone, although they consult with other health team mem-
bers when faced with challenging situations. Sometimes
ethical decisions related to social justice and human rights
need to be made during a home visit, such as reporting
unsafe “garbage” homes to the county sanitarian, contact-
ing animal control about a client’s pet that has just bitten a
young child, or requesting court-ordered Directly Observed
Therapy (DOT) for a client with active TB who is not adher-
ing to the medication regime. Sometimes PHNs carry out
advocacy interventions by themselves, and sometimes they
are part of a group advocating for change.
The pervasive barriers to advocacy are economic, polit-
ical, and public opinion obstacles. Shankardass, Lofters,
Kirst, and Quinonez (2012) believe that political will is
shaped by public awareness and opinion. The ability of
PHNs to create awareness of health inequities in their com-
munities at the local or national level is key to influencing
the health equity agenda of both the public and the politi-
cians. Advocacy messaging generally needs to be tailored to
the specific human rights or social justice theme and tai-
lored to the targeted audience. The key messaging themes
that should be considered when developing an advocacy
message include: health as a value and social justice; human
rights and governmental policies; environmental sustain-
ability; economic cost of health inequities; and self-interest,
in that inequities may lead to economic and social instability
and may risk the health of others. Effective messaging strat-
egies include: cooperative approaches; social mobilization
and building a broader base of support; empowering dis-
advantaged groups; forming coalitions and networks with
business, scientists, and policymakers; engaging the media;
involvement in the political process; and taking advantage
of windows of opportunity (Shankardass et al., 2012).
Advocacy for health equity is defined as “a deliberate
attempt to influence decision makers and other stake-
holders to support or implement policies that contribute
to improving health equity using evidence” (Farrer, Mari-
netti, Cavaco, & Costongs, 2015, p. 394). The types of data
analysis that are useful include: program evaluation data,
particularly an analysis of cross-sector initiatives that show
the impact on health disparities; cost-benefit analysis to
assure policymakers that resources are not being wasted;
analysis of the differential impact of specific policies to
determine expected and unexpected outcomes; and presen-
tation of narratives and stories.
It is important to consider how data is collected and when
and where it is presented. Effective data is recent, timely,
and local (Farrer et al., 2015). The data collection and eval-
uation process should include participation of community
members. Disadvantaged and vulnerable populations have
less voice and less power in shaping public policy. Finding
ways to include community members who do not normally
have a voice is important. Strategies to include community
members are discussed in Chapter 8.
Advocacy and Empowerment
To foster self-determination, facilitate empowerment, and
promote self-advocacy, nurses need to create an atmosphere
that supports and respects the rights of the populations they
advocate for (Mallik, 1997). Nurses also need to feel and
be empowered to take action (Cawley & McNamara, 2011).
Table 13.7 outlines an empowerment framework for nurses.
Critical caring is a theory that is linked in the social activ-
ism of Nightingale and grounded in Watson’s human car-
ing theory and creative health promotion processes, and
in feminist theory. Critical caring provides a framework
for PHNs to engage in empowered caring (Falk-Rafael &
Betker, 2012). Falk-Rafael and Betker interviewed expert
Canadian PHNs using a multimodal research design. Their
research identified three overarching themes from partic-
ipants’ reports: 1) the moral imperative and difficulty in
articulating an ethical framework for practice, 2) pursuing
social justice by advocating for health equity, and 3) expe-
riencing barriers to their moral agency (i.e., being unable to
do what their moral sense impelled them to do) and moral
distress. The premise that “critical caring is a caring ethic
through which social justice may be expressed” was sup-
ported by Falk- Rafael and Betker’s research (p. 110). Caring
is also a relational ethic based on the experiential aspects
of PHN practice. The critical caring theory supports the
importance of creating and maintaining supportive physi-
cal, social, economic, and political environments for clients
and nurses having a critical role in creating these environ-
ments (p. 110).
264 PART II n Entry-Level Population-Based Public Health Nursing Competencies
TABLE 13.7 A Framework for Becoming Empowered and for Empowering Others
Definition Components Empowerment Strategies
Personal power is the power
you acquire and exercise
through your informal and
formal roles in your family
n Personal roles: family and friends
n Community roles: neighborhood,
volunteer, elected official
n Cultural and ethnic ties
n Organizational membership:
religious, political, other
n Become involved as a citizen with an issue you are
n Get to know your neighbors and community.
n Identify yourself to family, friends, neighbors, com-
munity members, and stakeholders as a professional
who is committed to improving the health of the
n Participate in community or organizational meetings.
Share your knowledge about healthcare.
n Form linkages and networks between different groups
and organizations that share common beliefs and
n Know your elected and appointed officials.
Professional power is the
power you acquire and exer-
cise through your formal role
as a professional nurse.
n Legitimacy through licensure
n Social contract with public
n Professional expertise and
n Membership in professional
n Professional networks
n Find a professional and career mentor.
n Join a professional nursing organization.
n Attend conferences and meetings.
n Embrace the concept of lifelong learning through
continuing education, certification, and formal
n Strive to provide evidence-based care.
n Develop strategies for monitoring quality and safety
n Role-model professional nursing practice.
n Become a mentor for novice nurses.
Organizational power is
the power you acquire and
exercise through your formal
and informal roles in your
workplace and the healthcare
n Position and job description
n Organizational communication
n Coordination of care
n Dispersed power of nursing
throughout your organization
n Become involved in the work of the organization
beyond patient care.
n Become a member of a practice committee.
n Collaborate with people in other disciplines,
management, and administration.
n Join an interdisciplinary group whose goal is
improvement in patient care or population health.
n Work with a consumer group to improve healthcare
in your community.
n Be politically active at the local level. Be GLOCAL:
Think global, act local. At some point, you may wish
to become involved at the state and national levels.
Source: Schoon, Miller, Maloney, & Tazbir, 2012, p. 188
265CHAPTER 13 n Competency #11
about abuse, and then the nurses can effectively intervene
and advocate for safety (Hughes, 2010; Vanderburg, Wright,
Boston, & Zimmerman, 2010). Home visiting by itself has
been identified as a nursing intervention that reduces health
disparities (Abbott & Elliott, 2016). See Chapter 10 for more
information on caring relationships.
PHNs are aware that they can take actions to advocate for
specific health needs of families that are related to both indi-
vidual health determinants and social health determinants.
They know that individuals and families can only change
health determinants that are related to their own biological,
behavioral, and life circumstances. They generally cannot
change the health determinants that are societal in nature,
or the social determinants of health. See Chapter 1 for a
discussion of health determinants, protective factors, and
risk factors. Table 13.8 illustrates the diverse individual and
social determinants of health confronting a young family at
risk for elevated blood lead levels at the individual/family,
community, and systems levels.
Advocacy at the Individual/Family
Level of Public Health
Nurses advocate for individuals and families by safeguard-
ing their autonomy, acting on their behalf, and champi-
oning social justice in the provision of healthcare (Bu &
Jezewski, 2006). Advocacy is aimed at building the capacity
of individuals or families to manage their own healthcare
needs. PHNs recognize the inequalities that exist within
social determinants of health and challenge the status quo
to change the social environment.
When PHNs advocate for individuals and families, they
often do so within trusting relationships (MacDonald,
2006). For example, over time, nurses working with abused
children or women often become aware of the abusive situa-
tions when they are providing trustworthy care for common
physical health conditions. Trusting relationships make it
possible for the clients to disclose very personal information
TABLE 13.8 Erica’s Clients: Health Determinant Analysis—Risk for Elevated Blood Lead
Levels in Children
Protective Factors Risk Factors
n Mother exhibits health-seeking behaviors and
accepts assistance from the PHN and public
n Children are healthy except for increased
n Apartment owner is concerned about the
tenants’ health and willing to apply for funding
for lead abatement.
n Exposure to lead-based paint in home
n Children’s developmental stages and ages
n Children’s liver and kidneys unable to excrete
n Family’s inability to afford safe housing
n Lack of medical insurance
Social determinants of
n Community volunteer resources for
n Faith-based resources
n Community health priorities of child health
and environmental health
n Older, substandard housing with lead-based
n Lack of safe, affordable housing
n High poverty level due to poor economy
n Downsizing of local businesses
Social determinants of
n Taxpayer funding of public health services
n Public health nursing services available
n Environmental health services available
n Medicaid and CHIP funds for healthcare
available for low-income, uninsured families
n Local clinic willing to admit Medical
n Public health clinic able to arrange for blood
lead level testing.
n Lead-abatement funding available
n Lack of affordable private or public health
n Limited access to affordable healthcare
n Fewer medical clinics accepting Medical
266 PART II n Entry-Level Population-Based Public Health Nursing Competencies
owner to a state program that provides financial assistance
for lead abatement. The apartment owner is relieved to
know that he can get financial assistance for lead abate-
ment to provide a safer environment for his tenants.
Erica reflects on the positive health outcome for the two
children with increased lead levels and the lead abatement
of the apartment building that is scheduled for next month.
She remembers that she had been in a hurry on the home
visit and was impatient when the mother started talking
about her children rather than responding to the questions
Erica was asking. Luckily, Erica managed to focus on the
mother’s concerns rather than her own. She knows that
if she had not taken the time to listen carefully, she might
have missed the mother’s comments about the children’s
symptoms and might not have noticed the paint chips. Erica
renews her commitment to listen to clients telling her what
their priorities and needs are. She decides she will be more
observant when assessing the homes and neighborhoods of
children in her caseload. Erica knows that collecting data
and reporting her findings are the first steps in advocating
Advocacy at the Community and
Systems Levels of Public Health
To reduce health disparities, PHNs need to be engaged in
interventions at both community and systems levels of prac-
tice. PHNs spend most of their time working with individ-
uals and families to modify their health determinants (i.e.,
reduce their risk factors and strengthen their protective
factors) and empower them to manage their own healthcare
needs. PHNs are interested in reducing health disparities
among populations as well. To do this, PHNs must under-
stand the multiple causes or health determinants that influ-
ence populations’ health statuses. Individuals and families
within populations that experience health disparities suffer
consequences even if their personal behaviors and biolog-
ical/genetic factors encourage health. Thus, PHNs must
advocate for change in the societal causes of population
health disparities by working at the community and systems
levels of practice. Working with individuals and families to
help them change their own behaviors and risk factors can-
not by itself eliminate health disparities at the population
level. In a perfect world, health resources would be infinite,
and everyone would have access to all the healthcare they
need. Unfortunately, this is not the case, and much of the
time people cannot even agree on the type of healthcare that
is needed. It is important for PHNs to work with other com-
munity members to create a sustainable community part-
nership to work to achieve health equity. Table 13.9 provides
Erica receives a phone call from the mother of the children
with suspected high lead levels. She has been able to enroll
her children in a state-run healthcare plan and is looking
for a medical clinic on a bus line. The clinic she finds is
no longer taking patients on government assistance. Erica
knows that not many medical clinics are in the mother’s
neighborhood and cannot think of one on a bus line. She
checks the county’s database on medical clinics and the
metropolitan transportation agency website to investigate
bus service routes. She contacts the American Red Cross
and faith-based and charitable organizations in the neigh-
borhood for transportation assistance. These searches take
an entire afternoon, but Erica is successful in finding a
clinic that accepts people on government assistance and a
local church that has a volunteer transportation program.
Erica tells the mother that she will make a home visit to
draw blood from the children to screen them for high lead
Erica asks her supervisor how to code these hours on
her time sheet, as she is not providing direct nursing care.
Her supervisor tells Erica that she is carrying out the nurs-
ing interventions of Advocacy and Case Management by
finding resources that can help her client become more
Erica returns to the family and draws blood from the
children. Environmental Health staff has visited the fam-
ily’s apartment to determine whether the paint and paint
chips are lead-based. Two weeks later, Erica, her PHN
supervisor, and the Environmental Health staff meet to
review their findings. Both children have increased blood
lead levels, and a significant amount of lead-based paint
has been found throughout the apartment. Erica arranges
for the mother and children to be seen in the county pub-
lic health clinic. Chelation therapy is recommended for the
children, but the county does not provide that service. Lead
abatement is recommended for the apartment building,
but the owner says that he cannot afford it.
Erica knows that the human rights of the families in the
apartment complex are at risk because of their exposure
to lead-based paint and inability to change their living sit-
uation because of poverty and lack of affordable and safe
housing. She knows that the human rights of the children
cannot be met if they do not receive the medical care they
need. Realizing that the individual rights of the apart-
ment owner are in conflict with the social justice rights of
the apartment residents, Erica tries to find just solutions.
Erica refers the family to a social worker to apply for the
state Medicaid/Medical Assistance program and Children’s
Health Insurance Program (CHIP) services. She thinks
funding is available for medical treatment for the children
through these programs. Erica also refers the apartment
267CHAPTER 13 n Competency #11
Determining Public Health Priorities
PHNs need to identify the social justice and human rights
issues they encounter in their practice to determine what
actions they need to take and what their agencies’ priori-
ties should be. Dealing with the issue of health disparities
often appears overwhelming. Tools to identify the dispari-
ties in specific populations and their causes help PHNs and
their partners develop targeted interventions. One exam-
ple is a Health Equity Assessment Tool (HEAT) developed
in New Zealand (Signal, Martin, Cram, & Robson, 2008)
that provides a planning and intervention process to iden-
tify and reduce health disparities in the Maori population.
Table 13.10 provides a list of 10 questions that guides the pro-
cess from assessment through intervention.
TABLE 13.9 Public Health Nursing Interventions
at the Community and Systems Levels of Practice
That Include and Support Advocacy
Advocacy: Florence Nightingale demonstrated advocacy
throughout her nursing career. As superintendent of a
London hospital for impoverished women, she successfully
had the hospital policy changed from admitting only those
who belonged to the Church of England to admitting
women of all faiths. Her nursing leadership of 38 nurses in
Ottoman, Turkey, during the Crimean War was directed
primarily at improving the plight of the wounded (Selanders
& Crane 2012).
Community Organizing: A community action model was
used in California to increase the community’s capacity to
address the social health determinants of tobacco-related
health disparities and to develop local policies to eliminate or
weaken smoking-related social health determinants (Lavery
et al., 2005).
Collaboration: PHNs in Alberta, Canada, were concerned
about the incidence of postpartum depression. They initiated
a demonstration project in which they collaborated with a
group of obstetricians and a group of midwives to have preg-
nant women referred to PHNs for psychosocial screening,
health education, referral, and follow-up. Of the 150 women
assessed, 37% had a history of postpartum depression, and
33% had a family history of depression. They accessed 93
services. Of the 75 women who participated in the program
evaluation, 68% reported that the PHN intervention was
helpful. The outcomes were so positive that the collaborative
program was continued (Strass & Billay, 2008).
Policy Development and Policy Enforcement: Barriers that
limit access to healthcare in the uninsured elderly popu-
lation were explored in a journal article in a special health
policy feature. Key barriers were lack of transportation, lack
of insurance, complexity of the healthcare system, poverty,
lack of family support, culture, communication, and race
and ethnicity. Recommendations included improvements to
health insurance coverage, use of the case management model
of care, outreach services, improvements to transportation,
and cultural competency and communication. Many of these
recommendations were directed toward needed changes in
federal healthcare policy (Horton & Johnson, 2010).
examples of how advocacy at the community and systems
level can lead to improved population health status.
Lathrop (2013) believes that nurses can take a leadership
role in advocating for health equity at the local, national,
and global levels of society. The areas targeted for advocacy
are: structural change at the national and global levels; liv-
ing and working conditions at the national and local levels;
community interventions such as health fairs at the local
levels; and individual and family interventions.
EVIDENCE EXAMPLE 13.3
National Association of School Nurses—
Speaking Up for Children
The National Association of School Nurses (NASN) advo-
cates for child health and the resources needed to promote
health and safety among school children. School nurses
are aware of the significant number of children coming to
school with preventable physical and mental health condi-
tions. School nurses work hard to obtain the needed health
and social services for these children, but they know that
they cannot solve the problem of inadequate resources
by working one nurse to one child at a time. NASN has a
history of lobbying for school health resources to meet
children’s needs. To more effectively lobby at the national
level, NASN moved its headquarters to Washington, DC,
in 2005. The NASN Annual Conference in 2005 brought
hundreds of school nurses to Washington, DC; prepared
them for lobbying efforts; and provided opportunities for
the nurses to meet with their elected representatives to talk
about child and school health issues, explain the role of the
school nurse, and discuss the positive impact school nurses
have on child health. The NASN 2007 policy agenda, Capi-
tal Investment for Children, was an effort to secure a place
at the national policymaking table for school nurses so that
they could advocate for children with unmet health needs.
NASN continues its efforts to work with national, state,
and local officials to achieve its goal of achieving a ratio
of school nurses to students in each school that can ade-
quately meet their health needs (Denehy, 2007).
268 PART II n Entry-Level Population-Based Public Health Nursing Competencies
Reducing Health Disparities—
Downstream Versus Upstream Approach
Evidence has shown that the medical model alone, based on
market justice, will not eliminate health disparities. Social
determinants of health have been identified as a major cause
of health disparities; however, the medical model deals pri-
marily with individual causes of morbidity and mortality,
such as genetics, healthcare access and quality, and indi-
vidual health knowledge and behaviors. When the focus of
healthcare is on the individual experiencing disease (sec-
ondary and tertiary prevention), this is called the down-
stream approach. Interventions aimed at reducing these
causes, although important, will not by themselves allevi-
ate health disparities. Individuals and families do not have
equal access to private healthcare systems, governmental
supports, or societal resources.
When the focus of healthcare is on modifying the social
determinants of health to prevent disease and disability
(primary prevention), this is called the upstream approach.
Beauchamp (2013) argues that collective societal and govern-
mental action based on social justice is necessary to protect
the health of the public and that the burdens and benefits of
TABLE 13.10 The Ten HEAT Planning Process
Questions to Reduce Health Disparities
1. Which inequalities exist in relation to the health issue
2. Who is most advantaged and how?
3. How did the inequities occur? What are the mechanisms
by which the inequalities were created, maintained, or
4. Where/how will you intervene to tackle the issue?
5. How will you improve Maori health outcomes and reduce
health inequalities experienced by the Maori?
6. How could this intervention affect health inequalities?
7. Who will benefit most?
8. What might the unintended consequences be?
9. What will you do to make sure the intervention does
10. How will you know whether inequalities have been
Source: Signal et al., 2008
FIGURE 13.6 A Framework for Health Equity
Source: Alameda County Public Health Department, 2008, p. 4
269CHAPTER 13 n Competency #11
these efforts should be shared equally except in situations
where health disparities exist. However, there is no consen-
sus within U.S. society for this position. Iton (2008) advo-
cates a dual upstream-downstream approach (Figure 13.6).
The dual approach involves taking an upstream approach to
prevent disease and improve the health of populations while
maintaining the downstream approach that treats individu-
als’ diseases and disabilities. Figure 13.6 illustrates the dual
The collective social action that is needed to integrate
the upstream and downstream approaches and to create
inter-sectoral partnerships among governmental and pri-
vate institutions is a journey that the United States has
just begun. However, until there is an integrated system of
healthcare that addresses all of the determinants of health,
there will be little of the social change required to achieve
health equity. A community partnership model that could
be implemented at the local, national, and global levels to
achieve health equity is presented in Figure 13.7.
Read the following story and reflect upon upstream versus
Two people were walking by a river. Suddenly, they observed
babies floating down the river. They ran to the river to pull out as
many babies as they could possibly reach. One of the rescuers
yelled, “I’m going upstream to find out how these babies are
getting into the river.” This rescuer climbed the pathway up the
side of the river, found where the babies were being thrown into
the river, and immediately prevented more babies from being
thrown into the water. This is upstream thinking and action in
contrast to downstream action. Falk-Rafael (2005b) explains
how downstream approaches that are aimed at meeting the
needs of individuals and families must be paired with upstream
approaches that aim to change power in societal relationships
and structures to give voice to those with poor health and social
Think of a health disparity you would like to see decreased in
a specific population. How would you use upstream thinking to
achieve your goal? Do you think a dual approach of combining
upstream and downstream strategies might work? What would
FIGURE 13.7 Community Partnership Model to Achieve Health Equity
Source: Modified from Phases of a Social Determinants of Health Initiative, Brennen Ramirez et al., 2008, p. 33
Focus on Social
270 PART II n Entry-Level Population-Based Public Health Nursing Competencies
outcomes of societal inequities and health disparities. Civic
engagement involves more than charity: It is a means to
achieve social justice through upstream actions—changing
the social structure that creates health disparities. It involves
social and political advocacy. Like others, you might tend to
prefer to carry out acts of charity and avoid political engage-
ment (Gehrke, 2008; Iton, 2008). However, it is important
that you participate in civic engagement at some point in
your nursing education and career. Civic engagement may
occur at the local, national, and international levels.
Participating in the Political Process
Professional nurses are expected to advocate for popula-
tions experiencing health disparities by using the political
process. The role of a political advocate is embedded in
the social contract that the profession of nursing has with
Civic Engagement as Social
As advocates for social justice, PHNs by necessity must be
involved in the civic life of their communities to have an
impact on the social determinants of health. Nurses have
both professional and citizenship obligations to the com-
munities in which they work and live as part of the collec-
tive responsibility for social action to improve population
health. Civic engagement involves working to improve the
civic life of communities in partnership with community
members. Nursing students who participate in civic engage-
ment develop knowledge, skills, values, and motivations to
make a difference (Gehrke, 2008, p. 53–54). Many nursing
students are comfortable volunteering in their communities
as a form of charity. These actions are commendable, but
volunteering is not considered civic engagement. Charity is
downstream action—an adaptive response to ameliorate the
TABLE 13.11 Political Process Activities
Stages of the Political Process Examples of Civic Engagement
Candidate selection, endorsement, and support in the primary
and general elections.
Work for a candidate by making phone calls, knocking on
doors, assembling mailings, putting up yard signs, donating
money, and attending rallies and other campaign activities for
candidates who support your political health agenda. Participate
in candidate screening through your local nurses’ association.
Writing, introducing, passing the bill, and enabling legisla-
tion for funding. Both houses of Congress (one or two at state
level) must pass the bill, and the bill must then be signed by the
Contact your legislators about bills you want legislators to sup-
port; write letters and emails or go to the Hill for a face-to-face
meeting and attend hearings on the bill. Testify at conference
hearings, write letters to the editor of the local newspaper, post
blog entries, and call in to radio programs.
The omnibus reconciliation bill at the end of each legislative
session provides funding. A government department is given
“budget authority,” or the right to implement the legislation and
allocate the funding.
Lobby for a bill’s funding. Find out which state agency has
budget authority to enact and fund the legislation. Provide
testimony on the best way to fund programs, and discuss who is
going to benefit.
The department with budget authority holds hearings to deter-
mine the rules and regulations that need to accompany the bill.
Attend hearings about the rules and regulations that are going
to enable the bill to be implemented and monitored for cost,
quality, and access. Ask to be put on an email list to receive
notice of meetings and actions taken.
Legislation that is enacted is usually evaluated at the end of the
2-year budget cycle of the legislature. Every program funded and
implemented has to be evaluated and a report sent to the legis-
lative auditor’s office. The evaluation of the success of a project
is a significant factor in determining whether the program is
continued or renewed.
Testify and present reports about the effectiveness and impact
of programs. Download a copy of the report and meet with a
legislator’s staff person or the “budget authority” agency to dis-
cuss the evaluation and make recommendations for continuing
or modifying the program.
271CHAPTER 13 n Competency #11
TABLE 13.12 Strategies for Working With Legislators
n Get to know legislators well—their districts and constituencies, voting records, personal schedules, opinions, expertise,
and interests. Be sure to have a good understanding of the legislator and his/her concerns, priorities, and perspectives.
n Acquaint yourself with the staff members for the legislators, committees, and resource officials with whom you will
be working. These people are essential sources of information and have significant influence in some instances in the
development of policy.
n Identify fellow advocates and partners in the public health community to better understand the process, monitor
legislation, and assess strengths and weaknesses. Finding common ground on an issue sometimes brings together strange
bedfellows but makes for a stronger coalition.
n Identify the groups and other legislators with whom you may need to negotiate for changes in legislation. Do not dismiss
anyone because of previous disagreements or because you lack a history of working together. Yesterday’s opponent may be
n Foster and strengthen relationships with allies and work with legislators who are flexible and tend to keep an open mind.
Don’t allow anyone to consider you a bitter enemy because you disagree.
n Be honest, straightforward, and realistic when working with legislators and their staff. Don’t make promises you cannot
keep. Never lie or mislead a legislator about the importance of an issue, the opposition’s position or strength, or other
n Be polite, remember names, and thank those who help you—both in the legislature and in the public health advocacy
n Learn the legislative process and understand it well. Keep on top of the issues and be aware of controversial and
n Be brief, clear, accurate, persuasive, timely, persistent, grateful, and polite when presenting your position and
communicating what you need/want from the legislator or staff member.
n Be sure to follow up with legislators and their staff. If you offer your assistance or promise to provide additional
information, do so in a timely and professional manner. Be a reliable resource for them today and in the future.
Source: APHA, 2018
society (Des Jardin, 2001). Nurses who have personal and
professional senses of empowerment are able to work within
their communities to improve population health through
the political process (Carnegie & Kiger, 2009). PHNs are
uniquely suited to participate in the political process, as
they are confronted daily with the social determinants of
health that often negatively affect their clients’ health.
PHNs often participate in the Policy Development and
Enforcement process, which requires an understanding of
how the political process works and the critical points in
moving forward. Taking the time to understand the policy-
making process is essential if you want to advocate for
vulnerable populations with your elected officials (e.g., leg-
islators, mayor, city council, county commissioners, school
board). After you understand how laws, regulations, and
ordinances are made, you can be more confident about par-
ticipating in the process. Your knowledge of healthcare and
the health needs of your community makes you an expert
in the eyes of elected officials. Developing a trusting rela-
tionship with your legislators can help you influence health
policy development (Deschaine & Schaffer, 2003).
Nurses need to be involved in the political process from
the electoral process to the legislative audit process. How-
ever, most citizens, nurses included, have no experience
actively participating in the political process. So, it is time
to start! Table 13.11 can guide you through the stages of
the political process and provide examples of how you can
The American Public Health Association (APHA, 2018)
has identified ten key points of advocacy that might be
helpful to you as you think about approaching your leg-
islators (see Table 13.12). Which of these strategies would
you feel comfortable using? Think about your authentic
272 PART II n Entry-Level Population-Based Public Health Nursing Competencies
Erica is going to attend a Nurses Day on the Hill event at
the state capitol. She wants to talk with her senator and rep-
resentative about the need for funding programs to rehab
older homes to remove lead paint. She asks the mother of
the children with lead paint poisoning if it would be okay to
share her family’s story. She knows that real-life stories are
more effective than statistical data. Erica attends Nurses
Day on the Hill and talks with her senator and represen-
tative. She provides them with a one-page handout on the
dangers of lead-based paint to young children. She is sur-
prised at how receptive they are to her and that they treated
her as an expert! More than 1,000 nurses are at the event.
Erica is surprised that so many nurses took the time to
attend. She feels proud to be part of such a large group that
advocates for the health needs of the community. She real-
izes that nursing requires more than just working a shift.
Erica knows that if she is going to make a difference as a
public health nurse, she needs to advocate for her clients at
both the systems and the community levels of practice.
Erica has been with the county public health agency
for a year. She is committed to social justice and wants to
improve her ability to advocate for vulnerable individuals
and families. She wants to be able to support agency ini-
tiatives to improve population health in her community.
TABLE 13.13 Erica’s List of Agency Initiatives
Opportunities Taken Opportunities Missed
Brief conversation with a county health board member. Told a
client story about a teenage mom who benefitted from the exis-
tence of a Healthy Families Collaborative. (Coalition Building)
In the past legislative session during a debate on a ruling regard-
ing preservatives in vaccines, I could have written a personal
letter to my legislator. (Policy Development)
Articulated several “talking points” from the state department
of health policy on vaccines and autism at the early childhood
meeting for parents to encourage other parents to have their
children vaccinated. (Community Organizing)
Did not attend a meeting organized by city hall regarding hiking
and biking trails in my community. I could have been a voice for
obesity prevention in my community. (Community Organizing)
Led a focus group with Cambodian immigrants on cultural
competency in services for the elderly in their community.
Provided a summary report to the Cambodian community and
service providers. (Collaboration)
Missed an opportunity for PHN team case study discussion to
identify unmet health needs among their caseloads. I could have
learned how my caseload was similar to or different from other
PHNs’ caseloads and how this influences our decision-making
and priority-setting processes. (Collaboration)
Represented the agency on a task force organized by the state
health department to develop guidelines on blood lead and
healthy housing. (Policy Development)
Missed a meeting with a senior coalition to lobby county com-
missioners to extend green light walking time to allow seniors to
walk across streets safely. I could have learned more about this
health risk for the elderly. (Coalition Building)
Met with the OB nurse manager, the Newborn Nursery nurse
manager, and the Infection Control nurse at the local hospital to
discuss Tdap vaccination of staff as a means to prevent pertussis
in newborn infants. (Collaboration)
Did not return a survey regarding vending machine policies in
the school district. I could have helped with the data-collection
process. (Policy Development)
Erica has noticed that agency nurses in management
positions frequently carry out community-organizing,
coalition-building, and policy-development interventions.
Sometimes she supported these agency initiatives. Erica
makes a list of the opportunities she participated in and the
opportunities she missed.
Table 13.13 lists the opportunities that Erica put together.
Ethical Application for Social Justice
and Nursing Advocacy
PHNs often make ethical decisions related to social justice
and human rights. Most of the time these decisions are
related to the health status of individuals and families, but
sometimes they are clearly related to the health status and
health disparities of diverse populations. You need to be able
to identify and describe the ethical principles based on social
justice and human rights that guide you. It is also import-
ant to understand how your ethical beliefs and the ethical
beliefs of others affect your capacity to act when confronted
with health disparities. You need to have a strong sense of
your own ethical beliefs. All PHNs bring personal biases to
273CHAPTER 13 n Competency #11
ethical decision-making, and they have differing abilities
and skills to take action. Consider your level of moral cour-
age, the ability to confront moral challenges based on stead-
fast commitment to fundamental ethical principles despite
potential risks (Edmonson, 2010; Gallagher, 2011; Lachman,
2010; Murray, 2010). Think about the ethical environment
that surrounds you, the social environment consistent with
principles of human rights and social justice that is support-
ive of individual or collective actions of moral courage. Do
you have the personal and professional resources you need
as a student and future nurse to be the advocate you want
Reflect on the experiences you and your peers have participated
in or observed as part of your community clinical. Were any of
these ethical principles demonstrated in PHN practice?
Consider the following case study: A PHN making a home visit
to a recently paroled inmate of the local jail notes on the referral
that the man is PPD positive on repeat testing and needs to start
antiviral medications for TB. The man has the medication with
him but is not taking it. The PHN considers her options:
n Should she encourage him to resume treatment for latent
n Should she notify his physician or his parole agent of his
n What is the ethical problem, and how would you resolve it?
n Review the ethical principles listed in Table 13.14, and use
them to resolve the ethical dilemma.
TABLE 13.14 Ethical Principles and Actions in Advocacy
Ethical Perspectives Examples
Rule ethics (principles) n Public health resources and services are allocated based on need, so they might be distributed
n Identify individuals, families, populations, and communities who are vulnerable and
experiencing health disparities.
n Provide public health nursing services to those who are most vulnerable, at greatest health risk,
and experiencing health disparities and health inequities, focusing on equal access to goods.
Virtue ethics (character) n Make ethical decisions based on social justice and human rights.
n Focus on fair procedures rather than outcomes.
n Provide support for individuals, families, populations, and communities who advocate for
n Be caring and compassionate.
n Select advocacy goals and actions that are culturally congruent with the racial and ethnic
diversity of individuals, families, and populations within the community.
n Advocate for the health and well-being of individuals, families, populations, and communities.
n Include and partner with clients in priority setting, goal setting, and advocacy actions.
n Empower clients to manage their own healthcare needs.
n Increase capacity of individuals, families, populations, and communities to manage their
n Take actions to address social injustice at all levels of public health nursing practice.
n Focus on ensuring equal access to resources.
n Focus on traditions and practices in a community.
Sources: Table based on work by Racher, 2007, and Volbrecht, 2002
274 PART II n Entry-Level Population-Based Public Health Nursing Competencies
4. PHNs advocate for health equity and justice for indi-
viduals, families, populations, and communities at all
three levels of practice—individual/family, community,
5. PHNs bear professional accountability to advocate for
vulnerable individuals, families, populations, and com-
munities experiencing health disparities.
6. It is important for students and PHNs to become
involved in civic engagement and the political process
to help create social and structural change for health
1. Social justice and human rights serve as the foundation
for public health nursing advocacy.
2. Public health priorities and actions are directed at vul-
nerable populations experiencing health disparities and
3. To reduce health disparities at the local, national, and
global levels, it is necessary to eradicate the social
determinants of health that create negative health
It is difficult to think about the bigger picture on a daily
basis when providing nursing care to vulnerable individu-
als and families. The annual review period is a good time
to compare your professional goals with actual practice to
determine the congruence between goals and practice and
to identify future opportunities for professional growth and
Think about your experiences in your public health nurs-
ing clinical and the advocacy competencies you developed
n Which vulnerable populations have you worked with
as a student nurse?
n How did you know whether an individual, family,
or population was experiencing a health disparity?
n Which health disparities did you identify in your
n How did you explore the causes of health disparities
in your community?
n Which unmet health needs did you identify in your
n Which clients did you advocate for as part of your
public health clinical?
n Which advocacy actions did you observe or participate
in during your public health nursing clinical?
n What worked and what did not? What would you do
n If you were going to develop an intervention at the com-
munity or systems level of practice for an unmet health
need, what would it be? How would you start?
Refer to the Cornerstones of Public Health in Chap-
ter 1. Which of these cornerstones support the social justice
approach of achieving health equity through community
partnerships? Does this cornerstone also support social jus-
tice as a foundation of public health nursing?
Erica is preparing for her annual review with her super-
visor. She decides that one of her goals for the following
year will be to develop her advocacy skills at the commu-
nity and systems levels of practice. She believes that her
values and perspectives are consistent with social justice
and the mission and goals of the county public health
agency. She believes that she has been effective in advo-
cating for individuals and families, such as the family
whose children had increased blood lead levels. She now
understands that she has to intervene at all three levels
of practice to create change sufficient to improve popu-
lation health. Erica is ready to work on her ACTIONS!
275CHAPTER 13 n Competency #11
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APPLICATION OF EVIDENCE
Think about how Erica developed and demonstrated public
health nursing advocacy competencies as she worked with
the two young children with increased blood lead levels and
their mother, analyzed her own practice, and set the goal of
developing additional advocacy competencies. Discuss the
following questions with your classmates:
1. Which values and perspectives motivated Erica to act
in a socially just manner?
2. Which aspects of the situation required Erica to take
actions for this family?
3. Which ethical conflict between social justice and indi-
vidual human rights did Erica have to resolve? How did
she resolve it?
4. Why was it important for Erica to include others and
work as part of a team?
5. Which health determinants required Erica to take
actions at the systems level of practice?
6. Which advocacy actions did Erica take to help the
family and owner of the building?
7. What were the health outcomes of her actions and the
8. Which future civic engagement or community engage-
ment actions might Erica participate in to protect
children from environmental hazards?
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Works Within the Responsibility
and Authority of the Governmental
Public Health System
n Marjorie A. Schaffer
with Bonnie Brueshoff and Raney Linck
Dan was recently employed as a public health nurse (PHN) by a county health department. After two
months on the job, he is asked to assist other PHNs in responding to a recent outbreak of measles. All con-
firmed cases to date are in the Somali population. Unfortunately, the Somali communities have been tar-
geted with misinformation about vaccine risks and have subsequently struggled with low rates of MMR
Dan has never worked for the government. Through the orientation process, he begins to wonder
whether he will ever understand how the different levels of government work together. He refers to his ori-
entation materials for Population-Based Public Health Nursing Competency #5, which focuses on work-
ing with governmental systems. He comments to his supervisor, Carol, “This competency has so many
parts. How will I ever understand what all these terms mean for the work I am doing?”
COMPETENCY #5 Works Within the Responsibility and Authority of the Governmental Public Health System
A. Describes the relationship among the federal, state, and local levels of public health system
B. Identifies the individual’s and organization’s responsibilities within the context of the Essential Public
Health Services and Core Functions
C. Understands practice implications for laws, regulations, and rules relevant to public health
D. Adheres to legal mandates such as data privacy and mandated reporting
E. Differentiates the public health model from the medical model
F. Understands the independent public health nursing role as described in the Scope and Standards of
Public Health Nursing
G. Describes the role of government in the delivery of community health services
H. Identifies components of the healthcare system:
1) Funding streams such as Medicare, Medicaid, Prepaid Medical Assistance Plan (PMAP), categorical
2) Programs utilized by state and local health departments, such as Women, Infants, and Children (WIC)
program, home visiting, and school health
3) Community resources
Source: Henry Street Consortium, 2017
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AN: 1917387 ; Patricia M. Schoon, Carolyn M. Porta, Marjorie A. Schaffer.; Population-Based Public Health Clinical Manual, Third Edition: The Henry Street Model
148 PART II n Entry-Level Population-Based Public Health Nursing Competencies
Funding Stream: Source of revenue for public health programs and services.
Local Public Health Department: An “administrative or service unit of local or state government concerned
with health, and carrying some responsibility for the health of a jurisdiction smaller than the state” (National
Association of County and City Health Officials [NACCHO], 2016, p. 12).
Medical Model: Focuses on the individual; concerned with restoring health for individuals who seek care.
Public Health Infrastructure: The underlying framework for the public health system, which includes: 1) a quali-
fied workforce, 2) up-to-date data and information systems, and 3) capable agencies for assessing and respond-
ing to public health needs (Healthy People 2020, 2017b).
Public Health Model: Focuses on the health of populations; concerned with promoting, protecting, and
maintaining the health of every citizen.
Statutory Authority: A set of rules or a statute that gives an agency authority to determine rules to carry out
assigned duties (Minnesota Department of Health [MDH], 2016).
DAN’S NOTEBOOK (continued)
Taking Responsibility for
Improving Population Health
PHNs work in all levels of government; in urban, suburban,
and rural settings; and in a variety of community agencies
and organizations. Federal, state, and local governments all
provide essential resources for contributing to the public’s
health. This chapter discusses how levels of government
work together to promote public health and how PHNs
deliver population-based public health services in these set-
tings, agencies, and organizations.
How Are the Federal, State, and Local
Levels of Public Health Connected?
At the federal level, the U.S. Department of Health and
Human Services (DHHS) oversees many other agencies that
focus on the health and well-being of U.S. citizens. One of
these agencies is the Centers for Disease Control and Preven-
tion (CDC). The CDC keeps track of disease outbreaks and
health statistics and protects the health and quality of life
for U.S. populations. The CDC website is a good source for
statistics and other information you need for public health
interventions. For example, a PHN could use the CDC web-
site to find updated statistics on state and national obesity
trends and evidence-based strategies for obesity prevention.
Other agencies that come under the DHHS umbrella
oversee Medicare and Medicaid Services; research and
healthcare quality; substance abuse and mental health ser-
vices; and the safety of food, cosmetics, medications, bio-
logical products, and medical devices. For example, a PHN
could access information on food-safety alerts, such as the
contamination of ground beef (salmonella, typhimurium)
and salad bars (norovirus).
State health departments often work with both federal
and local levels of government. State health departments
regulate facilities and organizations that influence health
and health services. Examples of healthcare facilities reg-
ulated by the state include hospitals, clinics, and nursing
homes. State functions include financing and administering
programs (Stanhope & Lancaster, 2016) and offering tech-
nical assistance to local health departments for program
development and services. The organization and functions
of state healthcare departments can differ greatly among the
states. Regardless of the organizational structure, a strong
partnership between state and local health departments is
essential to promote and protect the health of populations.
Local public health departments (LHDs) include both
city and county health departments. They get directives
from the state and federal levels and report to their local
elected board members. Local agencies display consider-
able variability in the populations they serve and how they
accomplish their work. Table 7.1 identifies characteristics of
LHDs found in the 2016 National Profile of Local Health
Departments report (NACCHO, 2016).
LHDs often take actions to comply with state health
department regulations and federal guidelines. In Dakota
County in Minnesota, when a PHN received a report on a
suspected case of measles, the PHN (local level) documented
information from the Minnesota Department of Health
(state level) and followed up on the measles contacts. The
PHN reached all contacts and recommended contacts be in
quarantine for the incubation period for showing symptoms
of measles. In addition, relevant surveillance activities were
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149CHAPTER 7 n Competency #5
conducted by the PHN per MDH (state) and CDC (federal)
On the Healthy People 2020 website, go to
“Topics and Objectives,” and under “P” click
“Preparedness.” Government agencies,
nongovernmental organizations, the private sector, communi-
ties, and individuals work together to “strengthen and sustain
communities’ abilities to prevent, protect against, mitigate the
effects of, respond to, and recover from incidents with negative
health effects” (Healthy People 2020, 2017a, para. 1). What are
some ways that PHNs can use the information in this section to
contribute to accomplishing this goal? Think about actions that
will address the needs of individuals, families, and communities
during a major health incident. Which levels of government will
be involved in PHN responses? See Table 7.2 in this chapter.
How Do the Essential Public Health Services
and Core Functions Guide the Public Health
Department and Your Work as a Public
In the United States, PHNs and other public health profes-
sionals who work for governmental public health agencies
have a scope of practice based on core public health functions
and the essential services of public health (Institute of Med-
icine [IOM], 1988).
TABLE 7.1 Characteristics of Local Health Departments
LHD Characteristic Data
Populations served n Fewer than 50,000 persons: 61% of LHDs
n 500,000 or more: 6% of LHDs
Per capita expenditures n 2008: $63 per person
n 2016: $48 per person
Examples of partners n Emergency responders (98% of LHDs)
n K–12 schools (98% of LHDs)
n Hospitals (95% of LHDs)
n Media (95% of LHDs)
Registered nurses n 94% of LHDs employ registered nurses
n Median number of nurses ranged from 1 in LHDs serving populations under 10,000 to 542
for LHDs serving populations greater than 1 million
n Registered nurses comprise 18% of the LHD workforce (not all are PHNs)
n Overall percentage of nurses decreased by 28% between 2008 and 2016, related to health
department budget cuts for programs and staffing
Other public health staff
n 91% of LHDs employ office and administrative support staff
n Larger LHDs also often employ epidemiologists, statisticians, information systems specialists,
public information professionals, health educators, and public health physicians
Source: NACCHO, 2016
EVIDENCE EXAMPLE 7.1
Three Levels of Government Working Together in
LHDs work with the state and federal levels of govern-
ment to provide emergency preparedness services. At
the local level, 45% of LHDs reported they responded to
an all-hazards event in the past year and 90% participated
in an emergency preparedness exercise (NACCHO, 2016).
PHNs have specific skills for preparing for and respond-
ing to disasters. In addition to acting as first responders in
disaster events, PHNs use a population approach to col-
laborate on policy development, disaster response plans,
and disaster drills and training (Jakeway, LaRosa, Cary, &
Schoenfisch (2008). PHNs contribute to the following four
disaster phases (Jakeway et al., 2008, p. 355):
n Mitigation: Prevent a disaster or emergency; minimize
vulnerability to effects of an event
n Preparedness: Ensure capacity to effectively respond
to disasters and emergencies
n Response: Provide support to people and communities
affected by disasters and emergencies
n Recovery: Restore systems to functional level
See Table 7.2 for an example of how the three levels of gov-
ernment work together in emergency preparedness.
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150 PART II n Entry-Level Population-Based Public Health Nursing Competencies
TABLE 7.2 Emergency Preparedness Example
Local State Federal
Planning LHDs write all-hazards plans to
direct local emergency responses,
including staffing of Open Points
of Dispensing (PODs), communi-
cations with the public and other
partners, and Department Opera-
tions Center (DOC) on setup and
LHDs conduct exercises to test
plans in order to practice skills and
identify areas for improvement.
The state health department
consults with LHD on plans and
writes grant requests regard-
ing required plan elements and
required exercises that need to be
completed in order to receive grant
The Centers for Disease Control
and Prevention (CDC) is the
funding source for both state and
local health departments. The CDC
creates and conducts a biannual
assessment, the Operational
Readiness Review, to measure the
overall status of both state and local
preparedness around the 15 Public
Health Preparedness Capabilities.
LHDs complete a Hazard and
Vulnerability Assessment with
Emergency Management to evalu-
ate greatest risks in the jurisdiction
(geographical area). Based on those
risks, the LHD can do community
outreach and provide trainings to
mitigate some of the adverse effects
of different emergencies.
The state health department
regularly communicates and meets
with LHD staff to provide training
and consultation and interpret
CDC guidance. The state employs
regional consultants to individ-
ually work with the LHDs and
coordinate risk and prevention
activities across the region.
The CDC stockpiles medications
and supplies based on assessed
public health risks such as a future
influenza pandemic, bioterrorism,
or emerging infectious agents.
These are called Strategic National
Stockpiles (SNS). The CDC also
funds development of vaccines and
other prophylactic pharmaceuticals
to prepare for future needs.
Response The LHD sets up a Department
Operations Center from which
the Incident Command will run
the response to a Public Health
Emergency. This response could
be staffing a hotline, communicat-
ing with the public, setting up a
shelter, or dispensing prophylactic
medication or vaccine through a
Point of Dispensing (POD).
The state public health agency
provides situational updates,
subject matter experts, and emer-
gency messaging to the public.
The state can request emergency
medications, vaccines, equipment,
and supplies from the Strategic
National Stockpile and push that
out to the LHD to dispense to the
The CDC interacts with interna-
tional partners to coordinate inter-
national public health emergency
responses, such as the 2015 Ebola
outbreak. The CDC also can help
deploy staff to state and local part-
ners for assistance. This is called
the Epidemic Intelligence Service
(EIS). They have medical response
teams available to assist state and
local partners when local resources
PHN Role PHNs working in LHDs hold lead-
ership roles in incident command
and can provide subject matter
expertise regarding the health
implications of an emergency. At
a Point of Dispensing, nurses staff
the roles of screening (assessing
for contraindications, allergies, or
drug interactions), dispensing, and
PHNs working at the state help
provide subject matter expertise
around infectious pathogens, mass
dispensing guidelines, and public
health interventions. The majority
of emergency preparedness work
at the state level falls under the
population-based section of the
Public Health Intervention Wheel.
Many emergency preparedness
interventions are consistent with
the PHN role.
PHNs at the CDC are involved in
many preparedness roles, including
serving as experts in vaccine guide-
line development. PHNs are part of
the disease response teams at the
national level that are deployed to
local responses as needed. Nurses
serve in leadership roles in emer-
gency preparedness and planning
Contributed by Christine Lees, MPH, BSN, PHN, Dakota County Public Health and Amalia Roberts DNP, RN, PHN, Dakota County Public Health
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151CHAPTER 7 n Competency #5
Figure 7.1 demonstrates the relationship between the core
functions and the essential services that government agen-
cies and their staff must carry out (Source: CDC, 2014).
The three core functions are:
n Assessment: Community assessment of population
health needs by monitoring and investigating levels of
population health and illness
n Policy Development: Development of health policies,
goals, plans, and interventions to meet priority commu-
nity health needs
n Assurance: Measurement of outcomes of health poli-
cies, goals, plans, and interventions and the competency
and adequacy of public health professionals to deter-
mine whether a community’s priority health needs have
been met in an efficient, effective, and timely manner
The Ten Essential Services of Public Health (CDC, 2014)
in Figure 7.1 need to be carried out by PHNs and other public
health professionals to maintain the health of a community
and its diverse populations. Table 7.3 outlines these essential
services and provides examples of each.
TABLE 7.3 Ten Essential Services of Public Health, With Examples
Essential Service Example
1. Monitor Health n Carry out community assessment to determine levels of health and illness in community and
2. Diagnose and Investigate n Check lead levels of preschool children, infants, and toddlers at risk for lead poisoning.
n Offer diabetes screening in the Native American community.
3. Inform, Educate, and
n Teach first-time parents how to care for their new baby.
n Provide car seat education to new parents.
4. Mobilize Community
n Develop a network of community services for elderly people within the community.
5. Develop Policies n Work with county board members to develop a policy for playground safety in local
6. Enforce Laws n Report suspected child abuse or neglect.
n Monitor compliance with immunization laws for school children.
7. Link to/Provide Care n PHNs and emergency department staff develop a referral and follow-up system for homebound
elderly who visit the emergency department and then return home.
8. Assure Competent
n Update public health nursing staff on the influenza virus.
n Teach rural PHNs how to do well-water testing.
n Precept nursing students.
9. Evaluate n Carry out evaluation studies to determine the effectiveness of public health nursing programs,
such as home visiting to new families.
n Evaluate programs that LHDs contract with for service provision.
10. System Management and
n Determine needs for public health services and service gaps in the community.
n Provide data to justify claims that tax dollars improve the public’s health and demonstrate a
return on investment.
Source: CDC, 2014
FIGURE 7.1 Essential Public Health Services and Core Functions
Source: CDC, 2014
152 PART II n Entry-Level Population-Based Public Health Nursing Competencies
The following section shows how PHNs accomplish the
work that is outlined in the essential services and core func-
tions and contribute to the well-being of populations. In a
survey of 57 PHNs working in local and state governments
and representing 28 states, they identified the amount of
time spent providing each of the essential services. The per-
centage of time spent on each essential service ranged from
7% to 14% (Keller & Litt, 2008). See Figure 7.2.
Dan remembers seeing the Public Health Core Functions in
his orientation manual—assessment, policy development,
and assurance. He says to Carol, “Let’s see if I understand
how this works.”
“For the measles outbreak, I can see assessment hap-
pening when we are identifying how many children in the
targeted age group live in our county. For policy develop-
ment, we are following the directives given by the CDC and
the state department of health for vaccine administration.
I can see how we are working with and through others to
ensure that as many children as possible have access to the
vaccine. Assurance occurs when we make sure the vaccine
is accessible to the population groups that need to be vacci-
nated and that the vaccine has been administered to them.”
Carol affirms Dan’s analysis of how the core functions
were represented in the response efforts to the measles out-
break. Dan then says, “I am not sure about all those essen-
tial services. Do PHNs conduct all ten in response to the
Carol answers, “Let’s analyze how each of the essential
services occurs when our health department responds to the
measles outbreak. Let’s develop a handout to put into the
orientation manual to help everyone understand how we
are providing the essential services.”
See Table 7.4 for the handout that Dan and Carol developed.
Application of Ten Essential Services to
Measles Outbreak Response
A measles outbreak occurred in Minnesota in late March
of 2017. This was the worst measles outbreak in Minnesota
since 1990. A total of 79 cases were reported, which primar-
ily affected the Minnesota Somali community. All local
health departments in Minnesota had a role in prevent-
ing the spread of this infectious disease, involving activi-
ties such as active awareness and risk communication with
How Do Public Health Nurses
Use Statutory Authority?
Statutory authority refers to the statutes (laws) and rules
through which the government gives authority to agencies
to carry out specific duties. In the public health arena, PHNs
are responsible for adhering to public health laws that have
been enacted to protect and promote the health of commu-
nities. Public health laws may be federal, state, or local, but
many are implemented at the local level.
Public health law is often established in response to crit-
ical public health problems that affect populations. Mello
and colleagues (2013) identified three criteria for determin-
ing opportunities for establishing public health law: 1) the
EVIDENCE EXAMPLE 7.2
National Public Health Accreditation
In 2011, a national voluntary accreditation program for
local, state, territorial, and tribal leaders was established to
ensure accomplishment of the Core Functions and the Ten
Essential Services. The Public Health Accreditation Board
(PHAB) oversees the accreditation process. Participation
in the accreditation process helps health departments to
identify their strengths and weaknesses; establish quality
improvement strategies; communicate their accountability
to community members, stakeholders, and policymakers;
and be competitive in funding opportunities (CDC, 2017b).
FIGURE 7.2 Percentage of PHNs’ Time Dedicated to Essential
Services (n = 57)
153CHAPTER 7 n Competency #5
TABLE 7.4 Ten Essential Services: Measles Outbreak Response by Local Public Health
Essential Service Application Example
1. Monitor health Monitored data on those at risk due to being unvaccinated, and monitored clinic and hospital data
of reported cases provided by Minnesota Department of Health
2. Diagnose and Investigate Communicated with summer camps and daycares on symptoms to watch for and resources
3. Inform, Educate,
Worked with local media outlets and sent a Health Advisory to medical providers on the outbreak,
including what to watch for and report
4. Mobilize Community
Worked with Somali community leaders and organizations to reach the at-risk population
5. Develop Policies Adopted policies from CDC and state department of health on vaccine recommendations
6. Enforce Laws Activated response by utilizing the Health Department Emergency Response Plan
7. Link to/Provide Care Coordinated with the Department of Human Services regarding childcare licensing regulations
and potential changes needed due to outbreak
8. Ensure Competent
Provided training for staff to assist with contact investigation and follow-up to ensure competence
for roles and responsibilities
9. Evaluate Once outbreak was over, a “hot wash” was conducted to document the response work and lessons
10. System Management
CDC vaccine information posted on website, which included basic information and vaccination
law targets a significant public health problem, 2) factors
contributing to the public health problem are understood
well enough to change behavior through law, and 3) a feasi-
ble intervention can be implemented.
Public health law is potentially an effective tool for
improving population health outcomes. However, compet-
ing interests and values about laws may affect individual
choice. This adds complexity to enacting laws that address
threats to individual and population health. It is important
to provide objective and timely evidence to support legal
policy that contributes to improving population health.
Major trends in public health law and practice include the
following focus areas (Hodge et al., 2013):
n The Affordable Care Act
n Emergency legal preparedness
n Health information privacy and data sharing
n Tobacco control
n Drug overdose protection
n Food policy
n Vaccination requirements and exemptions
n Sports injury law and policy
n Public health accreditation
n Maternal and child health
Public health laws influence funding for public health
programs. For example, emergency preparedness programs
received major funding following bioterrorism events and
threats. Funding increases the number of public health prac-
titioners employed in emergency preparedness programs.
Public health laws also protect the health of the public.
PHNs need to understand public health law and how it pro-
tects individual, family, and community safety. Laws con-
cerned with public health include public health nuisance;
quarantine; mandated reporting of communicable disease;
mandated reporting of suspected abuse and neglect of chil-
dren, the disabled, and the elderly; and commitment. See
examples of local public health laws in Table 7.5.
For PHNs who practice in school settings, a federal
law titled the Family Educational Rights and Privacy Act
(FERPA) protects the privacy of student educational records
(U.S. Department of Education, 2015; U.S. DHHS and the
U.S. DoE, 2008). When the school contracts for school nurs-
ing services from a community agency, the school nurse is
tional records (Association of State and Territorial Health
Officers [ASTHO], 2015).
The Network for Public Health Law (https://www.
networkforphl.org/) compiles information and resources
about public health law at all levels of government. It iden-
tifies primary legal issues and offers technical assistance for
a variety of topics.
154 PART II n Entry-Level Population-Based Public Health Nursing Competencies
TABLE 7.5 Public Health Law Examples
Type of Law Key Features Example
Civil commitment Protects mentally ill individuals from danger to
themselves or others; addresses process of obtain-
ing a court order to obtain treatment for mental
illness when individuals are unable or unwilling
to seek treatment voluntarily and need protection
from harming themselves or others due to illness.
Civil commitment laws vary across states.
PHNs collaborate with family members, other
health professionals, community agencies, and
the government in the civil commitment process
by providing information about the process and
referring to resources.
Data privacy The federal government administers the Health
Insurance Portability and Accountability Act
(HIPAA) of 1996. PHNs are accountable for ensur-
ing the data-privacy aspect of HIPAA. In some
states, laws specify that information important for
ensuring public health can be disclosed.
Minnesota’s Data Sharing Law allows the sharing
of immunization data with schools and childcare
providers without parental permission. Healthcare
providers can share information about commu-
nicable diseases with the state health department
without patients’ permission. Otherwise, the
sharing of individual and family healthcare infor-
mation requires that clients sign a release of infor-
mation form authorizing sharing of information.
Mandated reporting of
suspected child abuse
Professionals in relevant disciplines who have
a reason to believe a child is being neglected or
abused are obligated to report the information to
the local welfare agency. Many states also offer
civil immunity for people who make reports, and
penalties if suspected child abuse is not reported
PHNs are mandated reporters for suspected child
abuse and neglect.
Mandated reporting of
Mandates reporting of communicable diseases so
that occurrence of the disease can be monitored.
During the H1N1 epidemic in 2009, surveillance
of incidence of H1N1 cases helped determine the
number of flu clinics to be offered and whether
schools needed to close.
Include conditions that threaten the health of the
public and require response or action from the
local health department. Examples are: garbage
accumulation, sewage, noise, junked cars, aban-
doned swimming pools, rodent infestation, and
faulty electrical wiring or plumbing.
Top three complaints were mold, garbage
houses, and accumulation of rubbish or junk
Quarantine Provides for isolating individuals or groups to pre-
vent the spread of communicable disease; restricts
activities or travel of an otherwise healthy person
with possible exposure to a communicable disease
to prevent disease transmission.
Can be used to reduce the effects of bioterrorism
or pandemic events, such as the spread of avian
influenza or Ebola.
School-entry laws Mandate evidence of vaccination for specific com-
municable diseases or a legal exemption signed by
School-entry laws, in place since the 1960s, have led
to increased vaccination rates and decreased rates
of childhood communicable diseases (Horlich,
Shaw, Gorji, & Fishbein, 2008). Some parents
might object to compulsory vaccinations for their
children because of medical reasons or religious/
Sources: Minnesota Department of Health, 2003, 2005, 2015, 2016, 2017a, 2017b; Minnesota Department of Health State Community Health Services
Advisory Committee, 1992; National Alliance on Mental Illness, 2016; Office of the Reviser of Statutes, 2016
155CHAPTER 7 n Competency #5
TABLE 7.6 Differences Between the Public Health and Medical Models
Public Health Model Medical Model
Mission is to promote, protect, and maintain the health of
Mission is to restore health to those who seek care (i.e., treatment
Focus is on the primary health needs of communities and
Focus is on the primary health needs of individuals.
Health seen as a birthright of every citizen. Healthcare seen as a service to be sought.
Goal is client/family and population self-sufficiency. Goal is providing quality service to meet immediate medical
Focus is on prevention. Focus is on treatment.
Seeks to protect the public’s health before problems arise. Seeks to meet the needs of patients who present for care of an
Reaches out to identify individuals, families, and populations
with service needs (case-finding).
Addresses the needs of patients who present for care.
Focus is on populations, the community, and the family. Focus is on the individual.
Provides services that others cannot or will not provide. Generally provides services that are reimbursable.
Seeks social change to improve the health status of
Seeks change to improve health status of an individual.
Provides services primarily in community settings. Provides services primarily in healthcare facilities.
Provides health-promotion services in the home and might
provide services to meet medical needs or refer those individ-
uals with medical needs to a home care agency.
Provides home care services for medical needs related to disease
Comparison of the Public Health and Medical Models
As you think about how government organizations guide
and deliver public health services, and the responsibilities of
the government and PHNs for improving the health status of
individuals and populations, consider how PHNs use a public
health model in contrast to a medical model. One difference is
that the public health model focuses on populations, whereas
the medical model focuses on individuals. Another differ-
ence is the public health focus on prevention of disease as
opposed to the medical model focus on treatment of disease.
In the public health model, healthcare is viewed as a right,
whereas in the medical model, healthcare is a service. PHNs
can use the public health model to help frame their practice
as prevention-oriented and population-based. See Table 7.6.
Consider how the public health model differs from the tradi-
tional medical model when planning interventions to improve
health status among populations to ensure that interventions
are consistent with the mission of public health.
Some services are provided in both public health and med-
ical settings, but their approaches to healthcare differ. For
example, childhood screening is provided in public health
programs to improve the well-being of the population of chil-
dren in the community. From the perspective of the medical
model, an individual child is screened on routine visits in a
clinic to evaluate that child’s health status.
In 2008, the Minnesota state legislature signed into law the
Statewide Health Improvement Program, changed to State-
wide Health Improvement Partnership in 2017 (SHIP). SHIP
is designed to reduce risk factors for chronic disease; reduc-
ing these risk factors ultimately decreases healthcare costs.
Partnership strategies engage communities in implementing
evidence-based interventions to reduce obesity and tobacco
use. SHIP awards community-level grants to support public
health solutions in Minnesota counties. Since SHIP strategies
have been implemented, the adult obesity rate in Minnesota
has decreased in comparison to obesity rates in surround-
ing states from 27.6% in 2014 to 26.1% in 2015 (Minnesota
Department of Health, 2017d). Many partners work together
to improve health, including schools, businesses, apartment
owners and managers, farmers, hospital, clinics, faith commu-
nities, and local government.
156 PART II n Entry-Level Population-Based Public Health Nursing Competencies
How Do the Scope and Standards of
Public Health Nursing Guide the Public
Health Nurse in Independent Practice?
The great majority of interventions implemented by PHNs
represent independent nursing practice and are consistent
with interventions delineated by the Public Health Inter-
vention Wheel. Public Health Nursing: Scope and Standards
of Practice, published in 2013 by the American Nurses Asso-
ciation, is also important for guiding the professional role
expectations and actions of PHNs (see Chapter 1). The docu-
ment has two sections—standards of practice and standards
of professional performance. The standards of practice
detail how the nursing process is applied in public health
nursing. Table 7.7 analyzes how each of these role expecta-
tions occurred in the response to the measles outbreak.
How Is the Government Involved in the
Delivery of Community Health Services?
Often, governmental organizations collaborate with private
and nonprofit organizations to deliver community health
services. Governmental organizations may provide funding,
oversight, consultation, and other resources to support the
public health work of private and nonprofit organizations.
How do the core functions of assessment, policy develop-
ment, and assurance take place in the following evidence
After the flurry of responses to the measles outbreak had
subsided, Dan reflects on how his work differs from that of
his previous position as a nurse for a pediatric clinic. Dan
comments to his supervisor, Carol, “I never realized how
the government is responsible for public health. I now think
about people who need the MMR vaccine not as individu-
als, but as populations. We prioritized which populations
were at risk. We also made sure that the vaccine was avail-
able to everyone, regardless of whether they could pay for
the vaccine. In the clinic, we followed a medical model that
approached clients as individuals.”
Carol adds, “Yes, the public health model is oriented to
finding people who need health services rather than always
waiting for people to identify their needs. In addition, pub-
lic health is oriented toward changing health and social
systems to create environments that encourage improve-
ment in health status. By reaching out to those populations
most in need of the vaccination, we have actually created
an environment that will help keep people healthy in the
communities served by our agency.”
EVIDENCE EXAMPLE 7.3
Childhood Obesity Prevention
A program in School District 197 in Dakota County, Minnesota,
is consistent with the public health model approach. SHIP fund-
ing was awarded to the school district to encourage students
to eat a variety of fruits and vegetables. The program is based
on the following premises: 1) obesity contributes to diseases
that affect a population (heart disease, diabetes, and other
chronic diseases); 2) disease and health problems result from
individual vulnerability and environmental factors, and 3 of 5
Minnesotans are overweight or obese due to insufficient phys-
ical activity and unhealthy eating (Minnesota Department of
Health, 2017d); and 3) interventions should be targeted toward
changing environmental factors. Interventions include:
n During lunch each week, students have an opportunity to
taste a less common fruit or vegetable.
n After tasting, students fill out a survey on their interest in
having the new food on the lunch menu.
n Foods with favorable ratings among the students are
included in school lunch menus, when feasible.
n Parents are encouraged to send lunches or snacks that
include vegetables and fruits instead of less healthy alter-
natives such as chips and candy.
n In addition, sugary drinks were banned from school
vending machines, which was a policy developed by the
state Department of Education in collaboration with the
Department of Agriculture.
School nurses and parents reported children were willing to try
new foods. Stacie O’Leary, the health service coordinator for
the school district, observed the project goal led to making an
environmental change in the school district.
157CHAPTER 7 n Competency #5
TABLE 7.7 Standards of Professional Performance—Application to Measles Outbreak in Minnesota
Ethics Recognized that the outbreak is about unvaccinated children versus specific communities or ethnic
Education Provided education materials to childcare centers and summer camps on signs and symptoms of
measles and where to refer to for any concerns
Accessed information from the CDC for vaccine safety and adverse reactions
Quality of Practice Adhered to CDC vaccination recommendations, including the exceptions to be made for providing
earlier vaccinations per CDC
Communication Held meetings in communities with populations at risk to dispel the misinformation about vaccine
risks, including the Somali community where key Somali leaders were involved
Leadership Activated Incident Command Structure to coordinate the response and work with local
Collaboration Worked with MDH and other LHDs to provide outreach and surveillance to the population at risk
Completed After Action/Improvement Plan that follows guidelines from the Homeland Security
Exercise and Evaluation Program
Resource Utilization Worked with the Minnesota Vaccines for Children Program that provides free or low-cost vaccines
for eligible children through age 18
Environmental Health Promoted practices that reduced exposure to those most at risk within the community
Advocacy Provided outreach throughout the county to promote and encourage measles vaccination and
communicate clinic schedules
EVIDENCE EXAMPLE 7.4
Government Collaboration With Communities
n The Minnesota Health Department adopted a statewide
Breastfeeding-Friendly Health Department (BFHD) pro-
gram to support initiating and maintaining breastfeeding
for 12 months and beyond. One of the ten steps for being
a BFHD is collaborating with community partners. For
example, the BFHD initiative recommends collaborating
with community partners to ensure access to breastfeed-
ing classes, educating the community on breastfeeding
support, encouraging local public places to provide a
breastfeeding-friendly environment, and providing work-
place lactation support training to local businesses. The
initiative aims to establish breastfeeding as a community
norm (MDH, 2017e).
n The Orange County Health Department California created
a coalition called Waste Not Orange County. The coalition
advocates for food security screening in primary health-
care settings and food donation sites. They educate the
community about food donations, identify individuals and
families experiencing food insecurity, and connect them to
sources of food. They partner with Food Finders, which is a
nonprofit organization that picks up excess food from hos-
pitals, restaurants, and supermarkets and distributes it to
food shelves. The coalition implemented a health inspec-
tion protocol, using volunteers to educate businesses
about food donations and market the coalition’s activities
to the business community. To incentivize food dona-
tions, the coalition awarded window seals to participating
businesses and featured a photo of the business on their
coalition website (Garcia-Silva, Handler, & Wolfe, 2017).
158 PART II n Entry-Level Population-Based Public Health Nursing Competencies
What Should the Public Health Nurse
Know About the Healthcare System?
The United States healthcare system is financed by a com-
bination of public and private entities that provide services
to insured, underinsured, and uninsured populations.
Private healthcare organizations may be for-profit or non-
profit. Many government programs provide services using a
combination of federal, state, and local funds. Local health
departments often provide services to low-income residents.
PHNs can assist community residents with referrals to clin-
ics that are free or have sliding fee scales and connect them
with insurance navigators for accessing healthcare coverage.
Table 7.8 identifies major programs and funding sources
in the U.S. Healthcare System.
The ACA included provisions for health promotion ini-
tiatives to contribute to better health outcomes and reduce
costs. As part of the ACA, the National Prevention Strategy:
America’s Plan for Better Health and Wellness (National
Prevention Council, 2011) has four major strategies:
1. Building healthy and safe community environments
2. Expanding quality preventive services in clinical and
3. Empowering people to make healthy choices
4. Eliminating health disparities
The seven priority areas are: (1) tobacco-free living, (2)
preventing drug abuse and excessive alcohol use, (3) healthy
eating, (4), active living, (5) injury and violence-free living,
(6) reproductive and sexual health, and (7) mental health
and emotional well-being. The National Prevention Strategy
identifies evidence-based recommendations for reducing
the incidence of preventable death and major illness.
Several other federal agencies are responsible for oversee-
ing health research, dissemination of health information, and
Mobile Outreach Nurse-Led Clinic USA
GOAL 9 Nurses are firsthand witnesses to client needs and healthcare system challenges, which posi-
tions them to create innovative solutions. Elisabeth Knight, a nurse practitioner, brings health services
to rural and low-income areas of southern Arizona, where many lack access to healthcare and insur-
ance. Along with a medical assistant and a driver, Elisabeth provides health clinics in a truck equipped
with exam rooms and a lab. Services include preventative care, basic wellness advice, management of
chronic conditions, and prenatal and birth care to expectant mothers. The Arizona legislature provided
funding for the mobile clinic. The College of Medicine at the University of Arizona, Tucson, oversees the
program. The mobile clinic serves 2,400 people yearly; everyone is accepted, regardless of their income
and ability to pay. Elisabeth observed, “Part of what we’re able to do is teach people to manage their chronic conditions by provid-
ing the tools, information and knowledge they need to take care of themselves, which helps us keep them out of the emergency
room” (International Council of Nurses, 2017).
health regulations to protect public health and safety. These
include (Mossialos, Djordjevic, Osborn, & Sarnak, 2017):
n Centers for Disease Control and Prevention:
Conducts research and programs to protect public
health and safety
n National Institutes of Health: Oversees biomedical
and health-related research
n Health Resources and Services Administration:
Supports strategies to improve healthcare access
n Agency for Healthcare Research and Quality:
Conducts evidence-based research
n Food and Drug Administration: Regulates food,
tobacco products, pharmaceutical drugs, medical
devices, and vaccines
Because of the high cost of healthcare, service delivery
is changing. New ways of structuring healthcare aim to
improve health outcomes and reduce costs. Recent initia-
tives include (Mossialos et al., 2017):
n Healthcare or Medical Home: A patient-centered
model that emphasizes care coordination and continuity
n Accountable Care Organization (ACO): Provider
networks that take on contractual responsibility for
providing quality care for a defined population.
n Bundled payments: Organizations providing care are
reimbursed with a single payment for all services deliv-
ered by multiple providers for a single episode of care,
such as surgical or chronic illness care.
In addition, the U.S. healthcare system has implemented
special Information Technology infrastructures to maintain
public health in four areas. See Table 7.9. A program called
Electronic Health Record (EHR) Meaningful Use is creating
a secure electronic reporting infrastructure for real-time
159CHAPTER 7 n Competency #5
TABLE 7.8 Major U.S. Healthcare System Programs and Funding
Centers for Medicare and Medicaid
Established by Congress in 1965 fol-
lowed by many incremental legislative
Federal agency administers Medicare, a federal program for adults 65 and older and
some people with disabilities.
Works in partnership with state governments to administer Medicaid.
The Affordable Care Act (ACA)
Established by Congress in 2010
“…established ‘shared responsibility’ between the government, employers, and individ-
uals for ensuring that all Americans have access to affordable and good-quality health
insurance. However, health coverage remains fragmented, with numerous private and
public sources, as well as wide gaps in insured rates across the U.S. population” (p. 173).
The ACA gives states the option of expanding Medicaid through subsidies from the
Regulated at state level.
“In 2014, state and federally administered health insurance marketplaces were estab-
lished to provide additional access to private insurance coverage, with income-based
premium subsidies for low- and middle-income people” (p. 173).
Medicare beneficiaries have the option of purchasing private supplemental insurance to
cover additional health services and cost-sharing.
Source: Mossialos et al., 2017
TABLE 7.9 Public Health IT Structures
Public Health Reporting System Description
Syndromic Surveillance (SS) SS examples include monitoring for injury trends, such as bicycle accident–related inju-
ries; tracking the burden of disaster-related conditions in hospitals following a natural
disaster, such as a tornado; and tracking the severity of asthma and upper respiratory
tract infections during allergy season.
79% of local health departments (LHDs) have implemented in 2016, with 3% in process.
Creates a centralized repository of all immunization data with two-way electronic record
exchanges that include sending and receiving immunization histories for individuals
and related demographic information, as well as observations about an immunization
event, such as reactions or eligibility for a funding program.
85% of local health departments (LHDs) have implemented in 2016, with 3% in process.
Electronic Laboratory Reporting (ELR) State and local laws require the reporting of particular lab results to public health agen-
cies regarding communicable diseases such as anthrax, botulism, smallpox, and more.
Through reporting, these agencies can act quickly to control the spread of the disease
(e.g., vaccinating or treating close contacts of a patient, identifying contaminated foods,
or uncovering industrial practices that cause toxic exposures).
49% of local health departments (LHD) have implemented in 2016, with 8% in process.
Cancer Registry Population-based cancer surveillance is essential for coordination of care, activities, and
resource allocation to decrease the mortality and morbidity of this disease, which is the
second-leading cause of death in the United States.
Cancer registries exist in all 50 states, Washington D.C., Puerto Rico, and the U.S.
Sources: CDC, 2013, 2017a; Georgia Department of Health, 2017; International Society for Disease Surveillance, 2012; NACCHO, 2016; Savage, 2011
160 PART II n Entry-Level Population-Based Public Health Nursing Competencies
analysis. The goal is that whenever a provider charts health-
care data in a hospital or clinic EHR, the data is automati-
cally submitted to public health agencies. This provides an
early warning system for bioterrorism, communicable dis-
ease outbreaks, as well as insights in how to prepare for and
provide better care during extreme weather events and mass
gatherings like major sporting events (Yoon, Ising, & Gunn,
The Institute for Healthcare Improvement (IHI) devel-
oped the Triple Aim Initiative as a framework for improv-
ing health system performance. The three dimensions that
healthcare policymakers need to pursue are: 1) improving
the patient experience, 2) improving the health of popula-
tions, and 3) reducing the per capita cost of healthcare (IHI,
2017). See Figure 7.3.
EVIDENCE EXAMPLE 7.5
Since implementation of the ACA, access to healthcare
has increased in the United States. The groups with the
greatest gains in access include young adult, Hispanic,
black, and low-income populations, which demonstrates
some progress in reducing health disparities. In addition,
cost control measures have reduced some expenses.
Incentives to reduce avoidable hospital readmissions
for Medicare patients have decreased the 30-day read-
mission rate nationally. Since Medicare payments to
the lowest-performing hospitals were reduced in 2012,
hospital-acquired conditions decreased by 17% over a
3-year period. Although healthcare spending following
ACA implementation has slowed, data through July 2016
showed that national healthcare spending had increased
4.9% in the previous year (Mossialos et al., 2017).
EVIDENCE EXAMPLE 7.6
Impact of ACA on PHN Daily Work
Edmonds, Campbell, and Guilder (2016) surveyed 1,143
PHNs across the United States on their knowledge, percep-
tions, and practices under the ACA. Forty-five percent of
PHNs reported their work changed due to the ACA. PHN
activities related to ACA provisions included: integration
of primary care and public health, provision of clinical
preventive services, care coordination, client navigation,
establishing private-public partnerships, implementation
of population health strategies and population health data
assessment and analysis, community health assessment,
involvement with medical homes and Accountable Care
Organizations, and maternal and child health home visiting
EVIDENCE EXAMPLE 7.7
Comparison of U.S. Healthcare System With Other
The United States has worse health outcomes and higher
care costs in comparison with ten other high-income coun-
tries ( Australia, Canada, France, Germany, Netherlands,
New Zealand, Norway, Sweden, Switzerland, and the
United Kingdom). The U.S.:
n Ranks last in overall healthcare system performance
n Ranks last in access, equity, and healthcare outcomes
n Ranks next to last in administrative efficiency
n Ranks fifth in care process (prevention, safe care,
coordination, patient engagement)
n Has worse population health outcomes in infant
mortality and life expectancy at age 60
Out of the 11 countries in the study, the U.S. was the only
country that did not have universal access to healthcare.
Access to primary care in the U.S. is poor, which means
there is “inadequate prevention and management of
chronic diseases, delayed diagnoses, incomplete adher-
ence to treatments, wasteful overuse of drugs and technol-
ogies, and coordination and safety problems” (Schneider,
Sarnak, Squires, Shah, & Doty, 2017).
IHI emphasizes that all three dimensions need to be
IHI believes that to do this work effectively, it’s
important to harness a range of community determi-
nants of health, empower individuals and families,
substantially broaden the role and impact of primary
care and other community based services, and assure
a seamless journey through the whole system of care
throughout a person’s life (IHI, 2017, para. 5).
FIGURE 7.3 Triple Aim Initiative
Health of a
161CHAPTER 7 n Competency #5
through presenting data about public health needs and col-
laborating with other public health professionals and orga-
nizations to make a case for funds needed to implement
effective public health programs.
Programs of Local Public Health Departments
In larger health departments, you might become more
specialized with skills and knowledge for a specific public
health program, such as follow-up for clients with tuber-
culosis or family-planning clinics. In rural health depart-
ments, your skill set and knowledge may have to be broader,
because you might work in a variety of programs and set-
tings. Although variation exists among programs that
LHDs provide, some public health services are provided
more frequently, such as immunizations and surveillance
and epidemiology for communicable/infectious diseases. In
addition, population-focused home visiting programs can
be offered that target specific vulnerable or high-risk popu-
lations, such as parenting adolescents.
LHDs have numerous responsibilities and activities;
percentages of the occurrence of specific activities in local
health departments are the following (NACCHO, 2016):
n Communicable disease surveillance (93%)
n Adult immunization provision (90%)
n Child immunization provision (88%)
n Environmental health (85%)
n Tuberculosis screening (84%)
n Tuberculosis treatment (79%)
n Food service establishment inspection (78%)
n Food-safety education (77%)
n Schools/daycare centers (74%)
n Population-based nutrition services (74%)
n Maternal and child health (69%)
n Women, Infants, and Children (WIC) (66%)
n Home visits (60%)
n Family planning (53%)
The NACCHO 2016 report showed that emergency pre-
paredness has become an important responsibility of public
health, with 81% of health departments providing emer-
gency preparedness training to staff. Data from this report
noted that LHDs provided screening for a number of dis-
eases and conditions in addition to tuberculosis, includ-
ing high blood pressure, blood lead, diabetes, cancer, and
cardiovascular conditions. Additional health services that
may be provided by LHDs are prenatal care, well child clin-
ics, oral health, home healthcare, primary care, and mental
health and substance abuse services.
Increasingly, LHDs are employing informatics special-
ists, given the growth in the use of information technology
(IT). Information technology use by LHDs has increased in
all categories since the 2008 NACCHO report, particularly
Some health policy experts recommend adding a fourth
aim (Quadruple Aim), which addresses the goal of improv-
ing the work environments for healthcare providers, clini-
cians, and staff (Bodenheimer & Sinksy, 2014).
The ACA does address Triple Aim dimensions to some
degree. However, given the U.S. political climate, the future
of the ACA is uncertain. Differing values and beliefs about
the right to healthcare and partisan politics have contrib-
uted to the inability of the 2017 Congress to move forward
with a clear healthcare agenda.
Understanding Funding Streams in
Local Public Health Departments
In your PHN role, you might be called on to contribute to
planning and writing grant applications for funds for spe-
cific public health programs. Funding for local public health
comes from a mix of local, state, and federal funds, fees,
and reimbursements. Because there are multiple sources
of funding for public health, budgets are complex and vary
each fiscal year. Sources of funding include local taxes,
Medicaid, Medicare, client fees, Local Public Health Act
state funds, federal Temporary Assistance for Needy Fami-
lies (TANF), and private insurance (Riley, Gearin, Parrotta,
Briggs, & Gyllstrom, 2013).
Public health programs and funding sources vary across
states. For example, in Minnesota, for clients receiving Med-
icaid (low-income adults, children, pregnant women, and
individuals with disabilities), state law authorizes the Pre-
paid Medical Assistance Program (PMAP). This program
provides managed care, which includes regular preventive
services and illness care, and may include dental care, free
car seats, disease management programs for members with
chronic conditions, and smoking cessation programs.
Categorical grants are a potential source of funding for
local public health programs. Categorical grants, awarded
by federal and state governments, are competitive, may have
specific eligibility criteria, and are often project-oriented.
An example is the Maternal and Child Health Block Grant
Program (Title V), the nation’s oldest federal-state partner-
ship, which aims to improve the health and well-being of
women and children. Funds are distributed to states (who
distribute to local health departments) based on a formula
and require a match; every 4 dollars of federal Title V money
received must be matched by at least 3 dollars of state or
Funding sources often respond to current crises, such as
bioterrorism and opioid overdosing. Public health funding
is dependent on a flourishing economy; a downturn in the
economy means that public health resources might be more
limited. Research studies show that there is strong relation-
ship between local public health spending and performance
of public health departments (MDH, 2012). PHNs have an
important role to play in advocating for population health
162 PART II n Entry-Level Population-Based Public Health Nursing Competencies
that assist in working on and achieving public health goals.
Nonprofit organizations provide services that contribute to
the well-being of persons, communities, or society and do
not aim to make a profit. They might be funded by grants or
donations and sometimes receive funds from governmental
Dan notes that nurses from the Medical Reserve Corps are
volunteering to help staff some of the immunization clinics.
He asks one of the nurses, Grace, how she became involved
in the Medical Reserve Corps. Grace comments, “I have a
regular job at the hospital in my community, but when I
heard about the Medical Reserve Corps, I decided I wanted
to help my community if a disaster occurred. I am a volun-
teer. I found out about this organization when some of my
friends went to New Orleans to help with health needs after
Dan later speaks with his supervisor, Carol, about the
Medical Reserve Corps.* Carol says, “Since Hurricane
Katrina, many healthcare workers in our state have signed
up to be in the program, and now it includes more than
7,000 volunteers. This program strengthens the public
health response, which we call public health infrastructure,
when a disaster occurs. Local coordinators oversee the pro-
gram and provide training and support so that volunteers
are ready to respond to the disaster. Our health commis-
sioner can mobilize volunteers when they are needed.”
Dan responds, “The Medical Reserve Corps is a great
community resource. I am going to tell my friends from
my last job at the hospital about this wonderful volunteer
PHNs might encounter an ethical problem regarding
immunizations for children if parents are concerned that
immunizations can cause their children harm (for example,
the worry about the measles vaccination causing autism).
An important role for PHNs is to know about evidence on
the effects of immunizations to communicate to parents.
(See Table 7.10 for the application of ethical perspectives to
for the use of electronic records. The NACCHO 2016
report identified the following uses of IT in local health
n Have electronic immunization registries (85%)
n Electronic disease reporting systems (79%)
n LHD website 78%
n Use Facebook (65%)
n Have electronic health records (EHRs) or plan to
implement EHRs (37%)
n Use Twitter (25%)
PHNs are expected to have knowledge about the many
resources that are available to individuals, families, and
communities and the referral process needed to receive ser-
vices from those resources. LHDs cannot carry out their
mission without community partnerships and resources.
PHNs build cooperative partnerships with community
agencies, organizations, other professionals, and commu-
nity groups to respond to community health concerns. (See
Chapter 8.) Many nonprofit organizations are vital partners
EVIDENCE EXAMPLE 7.8
n The Minnesota Visiting Nurse Agency (MVNA) is a
nonprofit organization that provides family-centered
and community-based public health nursing services to
clients from diverse racial, ethnic, and socioeconomic
backgrounds. PHNs coordinate care with healthcare
providers and local community agencies. In their family
health program, PHNs support family self-sufficiency
and use of community resources, such as WIC, Min-
nesota Family Investment Program (MFIP), schools,
Early Childhood Family Education, Follow Along, Child
and Teen Checkups, Help Us Grow, and Way to Grow
n In a qualitative study that explored public health inter-
ventions used in school nursing practice, the school
nurses (SNs) in the study referred students and fami-
lies to many community resources, including vision and
hearing assessment and care, insurance, free or low-
cost medical care, teen pregnancy, clothing, shelter,
dental, mental health, and child protection. SNs who
practiced in rural schools described barriers to finding
needed community resources due to fewer resources,
lack of transportation, parents’ work schedules, and a
lack of healthcare organizations willing to provide care
for children receiving Medicaid (Anderson et al., 2017).
163CHAPTER 7 n Competency #5
TABLE 7.10 Ethical Action in Providing Immunizations to Children
Ethical Perspective Application
Rule ethics (principles) n Promote justice by providing access to immunizations for families with children, which is
consistent with school-entry laws.
n Prevent harm to the children by promoting immunization for this population.
n Use evidence about the effectiveness of immunizations and debunk misinformation to provide
education about benefits.
Virtue ethics (character) n Respect individual parental rights to refuse immunization for their children per the law, which
allows parental exemption based on religious or other values.
Feminist ethics ( reducing
n Be aware of using authority in a manner that oppresses parents.
n Encourage parents’ voices and perspectives in making decisions about what to do.
n The U.S. healthcare system has poorer healthcare out-
comes in comparison to other high-income countries.
n The Triple Aim Framework—which focuses on improv-
ing the patient care experience, improving population
health, and reducing healthcare costs—is an innovative
approach for guiding strategies to improve health sys-
n Funding for public health comes from public and pri-
vate sources and determines the programs and services
that local public health departments can provide.
n Local public health departments work with non-
profit organizations to improve the health status of
n All levels of government (local, state, and federal) have
responsibility for promoting public health and often
n Three core functions of public health and ten essen-
tial services determine the goals of public health
n PHNs who are employed by governmental agencies are
responsible for upholding specific laws that protect the
n The public health model focuses on populations and
prevention, in contrast to the medical model, which
focuses on individuals and provides healthcare services
in response to illness and injury.
Governmental organizations develop and enforce laws and
regulations to prevent disease and promote the health of pop-
ulations. They also provide the resources needed to improve
public health. These resources include staff members with
expert knowledge and funds to support public health pro-
grams and services. As a PHN working for a governmental
organization, it is both a responsibility and an honor to con-
tribute to improved population health through one’s expert
knowledge and skills. Consider how PHNs use their expert
knowledge and skills in governmental responses to natural
disasters and severe weather.
Locate your state health department web page on emer-
gency preparedness for natural disasters. Select a natural
disaster that may potentially impact the health of the popu-
lation. Consider how PHNs are involved in helping commu-
nities respond to a natural disaster.
n What are the responsibilities of the local, state, and fed-
eral levels of government in responding to the disaster?
n How could community resources be involved in
responding to the consequences of the disaster (disease
prevention and health promotion)?
n How would PHN actions in response to the disaster
be consistent with the Cornerstones of Public Health
Nursing? (See Chapter 1.)
164 PART II n Entry-Level Population-Based Public Health Nursing Competencies
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APPLICATION OF EVIDENCE
1. Which essential services would be most relevant in
responding to the natural disaster of flooding in a
2. Give a practice example that illustrates each of the
three core functions for responding to a flood in a
3. Refer to Table 7.7, which identifies the ANA Standards
of Professional Performance for Public Health Nursing.
How do the following standards apply to the example of
a flooding disaster: education, collaboration, resource
utilization, leadership, and advocacy?
4. Which public health laws and legal issues do PHNs
need to keep in mind when responding to a flood
165CHAPTER 7 n Competency #5
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