DIMENSIONS OF THE COMMUNITY AS
These characteristics are discussed in more detail later in this chapter under the discussion on “Planning to Meet the Health Needs of the Community.” See Chapter 1 for more information on healthy communities.
Addressing community health by examining the process, in addition to the structure and status dimensions, provides a broader view into the complexities of community health and community actions for change. It is key not only to examine health outcomes but also to consider how the interactions between processes and structure impact health outcomes (Public Health Accreditation Board, 2013).
Another perspective identifies the community as having three features: a location, a population, and a social system. Figure 15–1 presents a visual interpretation of this perspective. Each of these features has several components that need to be addressed and represents further information that must be collected and analyzed when assessing the health of a community. These are detailed in Tables 15–1 to 15–3.
FIGURE 15–1 Three features of a community. The community has (1) a physical location, represented here by the square boundary; (2) a population, shown here by the central circle; and (3) a social system, divided here into subsystems.
Table 15–1 Community Profile Inventory: Location Perspective
Table 15–2 Community Profile Inventory: Population Perspective
Table 15–3 Community Profile Inventory: Social System Perspective
Location
Every physical community carries out its daily existence in a specific geographic location.
The health of a community is affected by location, because placement of health services, geographic features, climate, plants, animals, and the human-made environment are intrinsic to geographic location. The location of a community places it in an environment that offers resources and also poses threats (Nykiforuk et al., 2012; Thomas, DiClemente,
& Snell, 2013). The healthy community is one that makes wise use of its resources and is prepared to meet threats and dangers. In assessing the health of any community, it is necessary to collect information not only about variables specific to location but also about relationships between the community and its location. Do groups cooperate to identify threats? Do health agencies cooperate to prepare for an emergency such as a flood, tornado, or earthquake? Does the community make certain that its members are given available information about resources and dangers? Table 15–1 describes the location perspective of the Community Profile Inventory, including the six location variables: community boundaries, location of health services, geographic features, climate, flora and fauna, and the human-made environment.
Community Boundaries
To talk about the community in any sense, one must first describe its boundaries (Schildkraut, 2014). Measurements of wellness and illness within a community depend on defining the outer geographic limits of the unit under consideration and also the more informal boundaries that are present (Swarts, 2011). Nurses need to be clear, for example, that a target community of the elderly includes a description of age and location (e.g., all persons age 65 and older in a given city or county). Some communities are distinctly separate, such as an isolated rural town, whereas others are closely situated to one another, such as the suburbs of a large metropolis. Therefore, it is important for the nurse to know the nature of each location and clearly define its boundaries.
Location of Health Services
If the members of a town must travel 200 miles to the nearest clinic or dental office, the health of the community will be affected. When assessing a community, the community health nurse needs to identify the major health centers and know where they are located (Barnett, 2012). For example, an alcoholism treatment center for indigent alcoholics was located 30 miles outside one city. This location presented transportation problems and profoundly affected the length of time they remained at the center and the willingness of clients to voluntarily seek treatment there. If a well-baby clinic is located on the edge of a high-crime district, parents may be deterred from using it. It is often helpful to plot the major health institutions, both inside and outside the community, on a map that shows their proximity and relationship to the community as a whole.
Geographic Features
Communities have been constructed in every conceivable physical environment, and environment certainly can affect the health of a community (see Chapter 9). A healthy community is one that takes into consideration the geography of its location, identifies possible problems and likely resources, and responds in an adaptive fashion (Kindig &
Isham, 2014). For example, Anchorage, Alaska, and San Francisco, California, are both located on a geologic fault line and are subject to major earthquakes. In such places, the health of the community is determined, in part, by its preparedness for an earthquake and its ability to cope and respond quickly when such a crisis occurs.
Soil and water pollution pose a serious threat to food safety, and both represent an important threat to human health. Concerns of this kind have become increasingly problematic in China, where a combination of pollution and an increasing food safety risk has affected a large part of the population. Clean water shortages in the country have forced residents to use wastewater irrigation to fulfill the water requirements for agricultural production. Water shortages, coupled with the overapplication of pesticides and chemical pollutants, have caused serious agricultural land and food pollution leading to increased health risks for those living in affected areas (Lu et al., 2015; Starks et al., 2011).
Climate
Winter weather patterns are expected to become more variable as average global temperatures continually increase. Research findings indicate that there is a relationship between temperature variability and health outcomes, including cardiovascular, respiratory, cerebrovascular events, and all-cause morbidity and mortality. Epidemiologic studies indicate that the populations most vulnerable to variations in cold winter weather are the elderly, rural, and, generally, populations living in moderate winter climates (Conlon, Rajkovich, White-Newsome, Larsen, & O’Neill, 2011).
The intense summer heat of a location such as Phoenix, Arizona, can create many health problems (e.g., heatstroke, heat exhaustion). Skin cancer incidence is associated with unprotected sun exposure, which increases the risk for people who live in warm, sunny regions (Townsend et al., 2011). Asthma and other lung diseases are exacerbated in the Central San Joaquin Valley of California because mountains surround this area and create an air inversion, trapping vehicle and agricultural by-products in what can be described as a
“large bowl,” causing smog during many months of the year. Asthmatic children in densely populated areas of Baltimore, Maryland, have been found to experience exacerbations of asthma symptoms in both the summer and winter months (Teach et al., 2015). Climate can also affect infectious disease rates (McMichael, 2015). A healthy community encourages physical activity among its members, but the climate affects this activity.
Although long, cold winters can restrict activity, one community, St. Paul, Minnesota, holds an annual Winter Carnival. Sporting events, parades, ice sailing, dog sledding, a treasure hunt, and hot air balloon races bring thousands of Minnesotans outdoors at a time
when they might otherwise be confined by the weather.
Flora and Fauna
Plant and animal populations in a community are often determined by location. The way a community responds to these populations, whether wild or domesticated, can affect the health of the community. More than 26 million American children and adults live with asthma. Evidence of a connection between asthma attacks and community environments has been demonstrated both in the United States and abroad (Iqbal, Oraka, Chew, &
Flanders, 2014). Inner-city children have been shown to demonstrate higher rates of asthma, and research has shown strong allergic reactions, especially to rat and cat allergens (Rao et al., 2015).
Public health officials note chronic environmental factors as a possible cause for increased asthma cases: pollution from high-traffic areas, secondhand smoke in homes, and poor living conditions characterized by dust mites, mold, industrial air pollution, mouse and cockroach droppings, and animal dander. However, research completed at Johns Hopkins University in 2015 counters that claim. Researchers examined records for 23,065 children living in 5,853 census tracts and found asthma prevalence of 12.9% for inner-city children and 10.6% for those living outside of inner cities. When they statistically adjusted for age, gender, region, and race/ethnicity, no statistical difference was found. They noted that poverty increased the risk of asthma for children (Keet et al., 2015).
For 2015, the city named “asthma capital” of the United States was Memphis, Tennessee (Asthma and Allergy Foundation of America, 2015). Many of the asthma capitals that year were in the South, largely because of the lack of smoke-free legislation in many tobacco-producing states, along with poor air quality and high pollen counts. To further make the case for a connection between environment and asthma, in Atlanta, the 1996 Olympics brought an unexpected benefit: a 42% reduction in asthma-related emergency room visits. With the Olympic congestion downtown, Atlanta restricted traffic and thus improved air quality. The same outcomes were experienced with the Beijing Olympics. Internationally, Singapore also noticed a reduction in emergency room visits for asthma after it restricted automobile traffic in its central business district (Li et al., 2011).
Poison oak, ivy, and sumac can be found across the United States, and these plants produce an allergic contact dermatitis in many people who come in contact with it (Petersen, 2011). In the Sierra foothill communities of central California, black widow and tarantula spiders, scorpions, and rattlesnakes are resident populations that pose potential health threats. The poison from a single snakebite may cause serious injury or death (Gras, Plantefève, Baud, & Chippaux, 2012). In the south–central Midwest, the bite of the brown recluse spider injects a toxin that can lead to necrotic skin ulcers as well as systemic symptoms (Quan, 2012). In the Northeast and Mid-Atlantic states, increased deer populations—and consequently deer ticks—bring with them an increased incidence of Lyme disease (Tran & Waller, 2013).
Public health nurses need to know about the major sources of danger from plants and animals affecting the community under study. Are there community agencies that provide educational information about these dangers? Does the populace understand their significance? Are emergency services, such as a poison control center, available to community members?
The Built Environment
Every community is located in the midst of an environment created and transformed by human ingenuity. People build houses and factories, dump wastes into streams or vacant lots, fill the air with gases, and build dams to control streams. All of these human alterations of the environment have important implications for community health (Trowbridge & Schmid, 2013). A Public Health Nursing (PHN) might improve the health of a community by working with community members, legislators, and stakeholders to improve the design of the built environment to promote health and well-being. Such initiatives have become an emerging priority within public health, particularly as the ongoing epidemics of childhood and adult obesity persist (Trowbridge et al., 2013).
Evidence-based environmental design guidelines and evaluation tools are available to promote physical activity and healthy eating.
The promotion of walking has become a common and effective intervention for increasing physical activity, both as recreational exercise and as a daily activity to prevent and control obesity (Trowbridge & Schmid, 2013). Other modifications of the built environment that have been found effective in promoting healthy behaviors include the designation of exercise areas and building safe walking and biking paths (Simiyu, Njororai,
& Jivetti, 2015).
Population Characteristics
When one considers the community as the client, examining the health status of the total population in a given community is a critical component. The population consists not of a specialized aggregate but of all the diverse people who live within the boundaries of the community. The health of any community is greatly influenced by the attributes of its population. Various features of the population suggest health needs and provide a basis for health planning (Nguyen, Knight, Roughead, Brooks, & Mant, 2015; Schoenbaum, Schoen, Nicholson, & Cantor, 2011). A healthy community has leaders who are aware of the population’s characteristics, know its various needs, and respond to those needs.
Community health nurses can better understand any community by knowing about its population variables: size, density, composition or demography, rate of growth or decline, cultural characteristics, social class structure, and mobility. Table 15–2 presents the population perspective section of the Community Profile Inventory.
Size
Dover, Delaware (with about 35,000 people), and the city of Los Angeles, California (with around 4 million people), have radically different health problems. If a single case of Salmonella poisoning occurred in Dover, health officials would probably quickly learn of it.
It would be relatively easy to trace the course, check the few restaurants in town, and interview people about sanitation practices. However, many cases might occur in Los Angeles without the health department’s knowledge. Moreover, once the cases were discovered, tracing the source of contamination might involve a long and complicated search. This is only one small way in which population size can affect the health of a community. The size of a community also influences the presence of inadequate housing, the heterogeneity of the population, and almost every conceivable aspect of health needs and services (Nauenberg, Laporte, & Shen, 2011). Knowing a community’s size provides community health nurses with important information for planning. See Chapter 29 for issues related to rural and urban population health.
Density
In some communities, thousands of people are crowded into high-rise apartment buildings.
In others, such as farm communities, people live great distances from one another.
Population density, or the number of people residing within a square mile area, is used to describe how many people live within a community. Using our example of Dover, Delaware, at 1,566 people per square mile, and the greater Los Angeles area with 23,557 people per square mile, it is readily apparent which one is more densely populated. The full impact of living in high-density communities is being researched, and some research has already shown that crowding affects individual and community health. Motor vehicle exhaust from highways has been shown to be associated with higher risk of asthma and reduced lung function in children, as well as higher pulmonary and cardiac mortality in
adults (Cesaroni et al., 2013). When compared with rural populations, urban populations in some countries have a higher incidence of allergic diseases and respiratory symptoms, thought to be associated with higher air pollution levels (Shpakou, Brożek, Stryzhak, Neviartovich, & Zejda, 2012).
A low-density community, however, may have problems. When people are spread out, provision of health care services can become difficult. There may not be enough resources in the form of taxes to support public health services. Rural communities often suffer from inadequate distribution of health care personnel, including private physicians and community health nurses. A national study of rural–urban health disparities found a higher prevalence of poverty, premature death, and all-cause mortality in rural areas than in more densely populated metropolitan areas (Singh & Siahpush, 2014). Artnak, McGraw, and Stanley (2011) noted “quality health care services in rural communities for the chronically ill and dying remain problematic” (p. 140). One large study found that populations using critical access rural hospitals had higher mortality rates for acute myocardial infarction (MI), congestive heart failure, and pneumonia when compared with patients at nonrural hospitals (Joynt, Harris, Orav, & Jha, 2011). Other rural health risks include greater rates of injuries from traffic accidents (Burrows, Auger, Gamache, & Hamel, 2013) and illnesses related to agricultural pesticide exposure. Recent studies have also found an association between increasing pesticide exposure and attention-deficit hyperactivity disorder (ADHD) that may be stronger for hyperactive–impulsive symptoms compared to inattention and in boys compared to girls. Given the growing use of pesticides, these results may be of considerable public health importance (Wagner-Schuman et al., 2015).
A healthy community takes into consideration the density of its population. It organizes to meet the differing needs created by its density levels (e.g., it recognizes differences in density between the inner city and the suburbs and allocates services accordingly). See Chapter 29 for more on health risks specific to rural and urban areas.
Composition/Demographics
Communities differ in the types of people who live within their boundaries. A retirement community in Florida whose members are mostly older than age 65 has one set of interests and concerns, whereas a city with a large number of women in their childbearing years will have another set of concerns. A healthy community is one that takes full account of the needs of its constituents and provides for their differences. Age, sex, educational level, occupation, and many other demographic variables affect health concerns (Zheng, Tumin,
& Qian, 2013). In communities with a high proportion of low-income families, considerations must be made to accommodate the needs of the poor (Lee et al., 2011).
Occupation can also affect health. For example, in a town where 75% of the workers are employed in a textile mill, the community lives with the threat of brown lung disease, which is caused by cotton dust. In areas where tobacco is the main source of income and a large proportion of the population is engaged in its production, green tobacco sickness—or acute nicotine poisoning—is a concern because workers can absorb nicotine through the
skin, and precautions must be taken to prevent this from happening (Fassa et al., 2014).
Understanding a community’s composition is an important early step in determining its level of health.
Rate of Growth or Decline
Community populations change over time. Some grow rapidly. The growth of Las Vegas, Nevada, as a popular place to live has placed extreme demands on the environment, along with the provision of health care and other services. Other populations may experience a decline because of economic change, for example, those areas of the United States where steel and auto manufacturing have declined. Any significant fluctuation in population size can affect the health of the community, much like the size of a hospital is often correlated with rates of drug-resistant infections (Kouyos, Wiesch, & Bonhoeffer, 2011). As people leave to find new employment or better living conditions, consumption of goods and services drops. Community morale may suffer, and community leadership may decline.
Even a stable community can have problems (e.g., members may resist needed change because they notice little fluctuation in their population; commercial and residential properties may be abandoned or left vacant).
Cultural Characteristics
A community may be composed of a single cultural group, such as Ojibway Indians on their reservation in Wisconsin, or it may be made up of many cultures or subcultures. For instance, if a city has a large Hispanic population, along with a group of Native Americans living in the inner city and a cluster of Vietnamese refugees, the cultural differences among these members will influence the health of the community. These differences can create conflicting or competing demands for resources and services or create intergroup hostility.
A healthy community is aware of such cultural differences and acts to promote understanding among cultural subgroups (Spector, 2013). See Chapter 5 for more about transcultural nursing in the community.
Social Class and Educational Level
Social class refers to the ranking of groups within society by income, education, occupation, social class, or a combination of these factors. There is no absolute agreement on income levels or other criteria to designate social class categories (upper, middle, lower), other than the government formula used to compute poverty level (USDHHS, 2015).
Although class distinctions are not clearly defined, class rankings based on occupation, education, and wealth (income plus assets) seem to correlate with many different health outcomes and are used frequently in research (Mondal & Shitan, 2014). Occupational level, in particular, has historically and consistently proven to be a reliable measure, with surprisingly similar rankings among all societies for which data exist (Adcock & Brown, 1957). This classic research has shown that people with higher occupational levels generally have higher incomes and education, exert greater political influence, and are more highly