SOCIETAL INFLUENCES ON COMMUNITY- ORIENTED, POPULATION-FOCUSED
DISPLAY 14.5 DETERMINING WORTH OF HEALTH INFORMATION ON
THE INTERNET
What are the credentials and affiliation of the author?
Is it easy to determine who is the publisher or sponsor of the Web site?
Evaluate how the publisher or sponsor might gain economically through your use of the information.
Is the date of publication of the Web site included? Is the information current?
Are both sides of an issue described? Does the author discuss pros and cons of information presented?
What references are included to substantiate the information in the article?
The Internet is a superb vehicle for rapidly tracing the international spread of infectious diseases. For example, the World Health Organization has an Internet site for countries to report epidemiologic and laboratory data on influenza. The Centers for Disease Control and Prevention (CDC) offers current data on communicable diseases through the online publication Morbidity and Mortality Weekly Report. In addition, many local health departments and health agencies have their own Web sites that can provide information and resources specific to the needs of the local communities. In addition, health care providers are integrating electronic medical records into their practices. Between 2007 and 2013, the number of medical practices that implemented electronic health records increased by 175.6% (USDHHS, 2016c). This can improve health care efficiency and care delivery, increase health care quality and safety and support clinical and consumer decision making (USDHHS, 2016b). See Chapter 8 for more on communicable diseases.
New forms of technology continue to be introduced. Today, forms of communication can range from cell phones and text messages to instant messaging and social networking.
This new technology provides innovative ways to enhance health communication and social marketing. Nurses can utilize social media such as Web blogs, Facebook, and Twitter to disseminate health messages to specific target populations (CDC, 2015). Health messages distributed through a variety of modalities including mass media such as television and radio, small media such as brochures, social media such as computer networking, and interpersonal communication such as face-to-face interactions increase the exposure of the message to a wider swath of the population (CDC, 2015).
As technology advances, nurses must keep up to date on new ways information can be
shared. In addition, the lines between professional recommendations and peer advice can become blurred, leading to the risk of decisions being made on information that is not based on empirical evidence (USDHHS, 2016b).
Genetics, Genomics, and Genetic Engineering
Genetics, the science of heredity and genomics, the study of the entire genome, are terms that have gained increased attention from nurses over the past decade. An outgrowth of this knowledge is genetic engineering, which can be defined as “the group of applied techniques of genetics and biotechnology used to cut up and join together genetic material and especially DNA from one or more species of organism and to introduce the result into an organism in order to change one or more of its characteristics” (Merriam-Webster, n.d., para. 2). The development of the field was made possible by the discovery of certain enzymes that can “cut” DNA from two or more different sources into pieces that can be recombined in a test tube. Gene manipulation also required the development of methods for inserting these recombinant DNA molecules into cells by the use of so-called vectors such as viruses (Fig. 14–7).
FIGURE 14–7 DNA discoveries have changed health care.
The topic of genomics is a new area that included Healthy People 2020. This topic was added because genomics is associated with nine of the 10 leading causes of death. Genetic testing might help to reduce the risk for certain types of cancer (USDHHS, 2016a).
Healthy People 2020 objectives currently include two recommendations related to genomics. The first genomics recommendations are for women at increased risk for breast, ovarian, tubal, or peritoneal cancer to receive genetic counseling and obtain information about BRCA-12 testing options. The second recommendation is for people who are newly diagnosed with colorectal cancer to receive counseling and information about genetic testing (USDHHS, 2016a).
Genomics is another rapidly changing field. There is a lull of research regarding genetic tests and family health history tools and the risk versus benefits of using genomics in health care decision making. This is an area that needs further exploration. Issues of future exploration include assuring privacy and confidentiality of information acquired through genomics, including this information in electronic health records, implementation of testing, and exploration of how practitioners can use this information for patient education and recommendations (USDHHS, 2016a).
The Human Genome Project has opened dramatic possibilities for health and well- being, as well as created ethical challenges in the near future. The potential scientific capacity to alter methods of human reproduction raises concerns about creating unintended consequences for the human race. Another source of concern is that science is “playing God.” For some people, the possibility of being able to select the gender, intelligence, or eye color of a child raises concerns about interfering with nature and creates conflict with religious or ethical views. In addition, genetic screening could be used to deny rights and opportunities to people. For example, someone who is found to carry a gene that increases the risk for heart disease might be denied health insurance coverage. Another source of concern has been the distrust many people have of government, large commercial enterprises, and the scientific community. Some people believe that they are not being told the truth about scientific or other issues.
In dealing with these concerns, it is the public health nurse’s responsibility to be aware of the latest scientific information when educating communities, so that the decisions made best fit the community’s value system. Advocating for the highest scientific rigor in genetic engineering research is another important role of public health nurses. Public health nurses need to advocate for research that not only maps DNA but also identifies interventions that can change the outcome for people at risk for genetic disorders. Nurses need to balance what is good for the community as a whole against potential costs to people at risk, advocating for policies and regulations that ensure such a balance. The Essentials of Baccalaureate Education for Professional Nursing Practice (American Association of Colleges of Nursing, 2008) emphasized the impact of advances in genetics and genomics.
Specifically, Essential VII: Clinical Prevention and Population Health stresses that the graduate be prepared to (1) “Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities, and populations”
and (2) “Conduct a health history, including environmental exposure and a family history that recognizes genetic risks, to identify current and future health problems” (p. 24).
Global Economy
The global economy has grown exponentially over the past half century. It expanded six times more than the world’s population. Per capita income tripled while the population doubled in size (Executive Summary, 2015). The rapid rate of growth is attributed to two factors, a growing labor force and increased productivity. The labor force grew due to reductions in high fertility rates, infant mortality rates, and expanded life expectancy. This resulted in a bulge of people of working age from 58% in 1964 to 68% in 2014 (Executive Summary, 2015). Productivity varied between countries with productivity in developed countries five times higher than those of developing countries. Employment rates are beginning to peak and downturns are appearing. Germany, Russia, Italy, and Japan have already begun to experience this downturn, it is expected to hit China and Korea within the next decade, and other countries will follow over the next half century (Executive Summary, 2015). Steps have been identified by economists to boost the world’s economy, they include enabling catch-up through transparency and competition, especially in emerging markets; using incentivizing innovation to push the frontier; mobilizing labor, particularly among women and young people; and allowing cross-border economic flow for goods and trade services (Executive Summary, 2015). Figure 14–8 depicts a European Central Bank.
FIGURE 14–8 European Central Bank in Frankfurt, Germany.
The United Nations adopted the Millennium Development Goals (MDGs) in an effort to counter the impact of global poverty and hunger. Interventions would focus on universal primary education, improved maternal and child health, address gender inequalities, promote environmental stability, and reduced rates of HIV/AIDS and other communicable diseases. Progress on these goals varied, and areas such as the sub-Saharan African and South Asian regions did not experience much progress at all (Sridhar et al., 2013). In 2015, the 2030 Agenda for Sustainable Development was developed as an extension of the MDGs (WHO, 2015). This initiative focuses on economic, social, and environmental issues with 17 Sustainable Development Goals (SDGs). Financing for global health and shifts in governance have potential to impact these goals. Rising economies are developing in Brazil, China, and India. These countries have the potential to assume more influence in global governance. Countries that have traditionally held dominance, such as the United States and European countries, may not hold the same influence. These shifts in influence can
impact global health decisions. Health issues have dropped off the agenda of international meetings such as G8 and G20. Historically, the G8 meetings resulted in global strategies on tuberculosis and HIV/AIDS. These topics are no longer part of the conversations.
Universal goals may be needed to address the interests of emerging economies (Sridhar et al., 2013). Shifts have occurred in funding at the World Health Organization and World Bank. Funding through these organizations has flattened and is earmarked for special project. New funding organizations have emerged, such as the Global Fund and the GAVI Alliance. The Global Fund is becoming the largest donors at $3.2 billion in 2010. The Bill and Melinda Gates Foundation and other private sector and nongovernmental organizations have voting rights on this board. They narrow down on a few health topics such as immunizations, bed netting, or access to antiretroviral medication. They also measure their success based on outcomes on specific topics rather than a wide range of countries around the globe. Their funding is more discretionary and based on donations rather than through government funds. Unfortunately, donations have been dropping (Sridhar et al., 2013). Philanthropic organizations are becoming more of a force in global health issues. It is important that these various organizations align goals and work together rather than having competing projects (Sridhar et al., 2013). For more on global health, see Chapter 16.
The increase in noncommunicable diseases impacts social and economic opportunity and result in greater inequality (Sridhar et al., 2013). More than 80% of noncommunicable diseases are occurring in middle- to low-income countries. For example, the increased consumption of high-sugar beverages in low-income nations results in increased chronic illnesses and more years lost to disability while rates of heart disease is dropping in the United States. Other factors impacting chronic illness are climate change and increased numbers of people living in urban settings (Sridhar et al., 2013).
Universal health coverage (UHC) is another economic issue that impacts the global economy. In 2012, the United Nation General Assembly voted to adopt a resolution on UHC that would encourage governments to move forward with promoting this initiative for affordable access to quality health care. The risk is that various countries may interpret differing meanings to the term UHC (Sridhar et al., 2013). The World Health Organization is moving toward promoting UHC globally rather than a state level; however, this is very difficult to achieve as every situation is different, requiring individual solutions (Sridhar et al., 2013). See Chapter 16 for more on global health issues.
Migration
Migration is the act of moving from one region or country to another, temporarily, seasonally, or permanently. Throughout history, people have migrated from place to place to seek improved opportunities or to escape intolerable conditions in their home countries.
In the late 20th century and the early years of the 21st century, a dramatic increase occurred in the number of refugees who migrated from their homes to escape invasion, oppression, or persecution (WHO, 2012). For example, recent displacement of Syrian refugees who are escaping civil unrest and violence has impacted neighboring countries.
The crisis in Syria began in 2011, and as of October of 2014, more than 3.2 million refugees had entered Lebanon, Turkey, and Jordan (Doocy, Lyles, Delbiso, & Robinson, 2015). These refugees are poor and vulnerable. The receiving countries have limited resources to assist them. As new refugees enter, their needs differ from those who have been already in the country for 1 to 4 years. The type of violence that they escaped can also impact their specific needs (Doocy et al., 2015). This type of ongoing mass exodus puts extraordinary strain on resources and requires ongoing assessment of needs (Doocy et al., 2015). See Chapter 16.
We also saw an increased reliance on migrant farmworkers, people who move from one region to another seasonally, following the crops. The health care needs of migrants and migrant refugees are enormous. Environmental factors are a primary reason for compromised health and include inadequate waste disposal, crowded and unsanitary living conditions, lack of access to healthful foods, and air pollution from an increased concentration of vehicles used for moving refugees. Compounding these problems are language and cultural barriers, as well as distrust and fear that may interfere with meeting the needs of these vulnerable populations. The potential detriments to health associated with migration require that public health nurses ensure that surveillance systems able to detect emerging health problems are in place; programs to prevent health problems and treat existing conditions also need to be developed (Ruiz-Casares et al., 2013). See Chapter 29 for more on migrant health issues.
Terrorism and Bioterrorism
Terrorism is one way in which a small number of people who perceive that they have been unfairly treated can exert influence on a larger group or nation. Groups wishing to harm other countries need sophisticated skills and coordination for most conventional weapons.
Terrorists may also use unconventional weapons when highly motivated, such as flying planes into buildings, strapping bombs to their bodies, or even allowing bombs to be implanted in their bodies.
Some methods of bioterrorism may be even cheaper and easier to use. Bioterrorism is the use of living organisms, such as bacteria, viruses, or other organic materials, to harm or intimidate others, in order to achieve political ends. Some of the possible biologic agents used include Bacillus anthracis, smallpox virus, Brucella, and botulinum toxin (see Chapters 8 and 17). The federal government has adopted an increasingly proactive approach to reduce the risk of both natural-occurring and deliberate outbreaks of disease. This approach requires a melding of biodefense needs with an increased emphasis on biosecurity, balancing both public health and national security interests (Koblentz, 2012).
Because of escalating concerns about bioterrorism, public health workers increasingly recognize the need for skills in dealing with a bioterrorist attack. They need to engage in emergency preparedness activities and be prepared to initiate response activities in the event of an actual bioterrorism attack (CDC, 2011). Preparedness includes the following:
Establish relationships with mutual aid partners.
Conduct hazard vulnerability and risk assessment.
Identify resources.
Acquire resources.
Develop objectives and a plan.
Put plans into place to mass casualties.
Develop plan for communicating with members of the community.
Train personnel.
Conduct training exercises and engage in after-action reviews.
Response includes the following:
Assess the situation.
Activate key personnel.
Develop objectives and action plan.
Participate in the Emergency Operations Center (EOC).
Coordinate with the safety officer to identify hazards.
Communicate with key partners.
Deploy resources.
Respond to health-related requests.
Communicate with the public.
Involve legal counsel.
Document all activities.
Engagement in ongoing public health response duties incorporates:
Surveillance
Meeting the needs of the community Addressing needs of special populations Engaging in the recovery phase
Perhaps more importantly, public health nurses need to be involved in primary prevention of bioterrorism through advocating for the elimination of biologic weapons and addressing the root causes of terrorism, such as poverty, hunger, poor housing, limited educational opportunities, lack of clean water, and inadequate or no health care. See Chapter 17.
Climate Change
Climate change can be considered societal changes because they may be influenced by economics. Since the Industrial Revolution, increased amounts of carbon dioxide, methane, and nitrous oxide created by manufacturing industries, automobile emissions, and consumer products have been introduced into the earth’s atmosphere. These increases have contributed to climate changes that are expected to affect sea level; the production of food, fiber, and medicines; and the spread of infectious diseases. Conversely, significant increases in fuel efficiency and efforts to reduce pollution could avoid millions of deaths around the world. Population-focused nurses need to educate the public about the potential dangers of continuing to contaminate the environment and to advocate for changes in public policy that reduce air and water contaminants. In 2008, the American Nurses Association’s House of Delegates passed a Global Climate Change initiative that encourages nurses to “advocate for change on both individual and policy levels; to support local public policies that endorse sustainable energy sources and reduce greenhouse gas emissions; and … to support initiatives to decrease the contribution to global warming by the healthcare industry”
(ANA, 2012). This built on elements of the 2007 Public Health Nursing: Scope and Standards of Practice most notably in terms of ethics in practice, challenging nurses to contribute to “resolving social and environmental issues and barriers to healthy living conditions” (p. 34). Chapter 9 explores health-related environmental issues in more detail.
S U M M A R Y
Public health nursing is a community-oriented, population-focused nursing specialty that is based on interpersonal relationships. The unit of care is the community or population rather than the individual, and the goal is to promote healthy communities.
Theories and models of community/public health nursing practice aid the nurse in understanding the rationale behind community-oriented care. Florence Nightingale’s environmental theory emphasizes the importance of improving environmental conditions to promote health. Orem’s self-care model provides a framework, within which the public health nurse can promote a community’s collective independence and self-care ability.
Neuman’s Health Care Systems Model describes the nurse’s role as one of assisting clients to remain stable within their environment, whereas Rogers’ model of the science of unitary man focuses on client–environment interaction and holistic health. King’s Theory of Goal Attainment reminds nurses to work in partnership with clients to achieve the best health outcomes. Parse’s Human Becoming Theory posits quality of life from each person’s own perspective as the goal of nursing practice. Pender’s model focuses on the promotion of health behaviors in people; the goal of nursing is to enhance the likelihood that people will engage in health-promoting behaviors by assessing and influencing perceptual and modifying factors. Roy’s adaptation model describes the nurse’s goal as one that promotes healthful coping mechanisms and adaptive responses to stressors. Salmon’s construct for public health nursing prescribes education, engineering, and enforcement with individuals, families, communities, and nations. Finally, the models used in public health nursing practice, the Minnesota Intervention “Wheel,” the Los Angeles County–Public Health Nursing Practice Model, and the Omaha System Model of the Problem-Solving Process provide a mechanism for public health nurses to assess, plan, intervene, and evaluate the care they provide in their communities.
The eight principles of public health nursing applied to community/public health nursing practice provide a framework within which the nurse works to promote and protect the health of populations. They emphasize the primacy of prevention, the need for outreach, and the importance of working in collaboration for the greatest good of the greatest number of people.
Nurses must anticipate and adapt to societal changes in order to fulfill their mission of promoting the health of all people. Contemporary societal influences on public health nursing include communication technology, genetic engineering, the global economy, migration, terrorism, and climate changes.