Nurses have always been tenacious in their responsive- ness to the rapidly changing health and societal landscape, and are well situated to address contemporary family
health issues. This is an era of unprecedented change in health care. Some of these fast-paced trends include rapid technological advances, escalating health care costs, man- aged care, demands for increased accountability for public agencies, and terrorism threats. Modern nurses maintain a readiness to address new and resurfacing health-related issues, illnesses, or disaster management responsibilities.
Nurses frequently serve as catalysts to help coordinate societal, community, and individual efforts to help achieve health and wellness goals.
It is useful to have a framework when thinking criti- cally about the complex topics encountered in family health. The Intervention Wheel, formerly known as Minnesota’s “public health intervention model,” is par- ticularly well suited for examining health issues with an action-oriented, holistic lens. The lens used to view the intervention model is population-based, meaning that epidemiology of the population’s health status as a whole is assessed (Keller, Strohschein, Schaffer, &
Lia-Hoagberg, 2004b) (Fig. 2-1).
The model is an inclusive framework and was devel- oped, refi ned, and extensively critiqued by more than 200 nurses throughout the country (Keller et al., 2004a).
It encompasses three levels at which interventions can be initiated, from the micro-level of the individual to the moving toward evidence-based practice Reducing Health Disparity
Shoultz, J., Fongwa, M., Tanner, B., Noone, J., & Phillion, N. (2005). Reducing health disparities by improving quality of care: Lessons learned from culturally diverse women. Journal of Nursing Care Quality, 21(1), 86–92.
The purpose of this study was to view culturally diverse women’s perspectives on health care services as a framework for improv- ing the quality of health care using Fongwa’s Quality of Care Model. The study design was based on an analysis of existing data from 15 focus groups that consisted of participants from 5 different cultural subgroups. Findings from three previous studies completed by the researchers were applied to Fongwa’s Model. The model was selected for its usefulness in identifying ways to improve the health care system and enhance quality of care from the perspective of diverse cultures. The original studies were conducted to gain women’s perspectives on alcohol and drug use, smoking cessation, and domestic violence. Themes that emerged from these studies were refl ective of the women’s perceptions of the care they received. The fi ndings led the researchers to reframe their focus for the improvement of health care by exploring three common aspects: patient/client/consumer, provider, and setting.
From the patient/client/consumer perspective, women iden- tifi ed that they wanted to include their partners in health promotion activities. They also requested that education on domestic violence be integrated into a variety of community activities. The participants believed that this approach would allow them to access the information without fear that the perpetrator of violence would be suspicious of their activities.
The women further stated that they preferred a female provider of their own ethnicity or one who understood their values and
beliefs. They felt it would be easier to discuss diffi cult topics with such a provider.
The study participants reported that their providers fre- quently appeared rushed and overly busy, which was perceived as a barrier to receiving quality care. They believed that in order to develop a trusting professional relationship, it was important for the provider to take time and listen, remain nonjudgmental, and ensure confi dentiality. They felt that any care given should be modifi ed to fi t the specifi c needs of the individual.
The women preferred that the clinical environment include brochures and fl yers written in appropriate languages. In their view, these actions would help to create an environment responsive to the participants’ needs, and supportive of their making changes to improve health.
The researchers concluded that encouraging women’s input, listening to their needs and modifying the system based on their suggestions would encourage the women to recognize their power in improving their own health and the health care system in general.
1. Based on the study do you believe that suffi cient evidence exists to generalize these fi ndings to all culturally diverse populations?
2. How is this information useful to clinical nursing practice?
See Suggested Responses for Moving Toward Evidence-Based Practice on the Electronic Study Guide or DavisPlus.
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chapter 2 Contemporary Issues in Women’s, Families’, and Children’s Health Care 27
macro-level environment. Interventions are targeted toward individuals/families, communities, and larger insti- tutional and societal systems. Thus, broad determinants of health such as environment, employment, insurance, class, race, social support, access to health services, genetic endowment, and personal histories can be integrated, making health care interventions more comprehensive and effective.
In short, the public health intervention model is population-based, defi nes levels of practice, and has a com- prehensive prevention focus. There are 17 categories of intervention tactics outlined in the model: social market- ing, advocacy, policy development, surveillance, disease investigation, outreach, screening, case fi nding, referral, case management, delegated functions, health teaching, counseling, consultation, collaboration, coalition building, and community organizing (Keller et al., 2004b).
HOW THE INTERVENTION WHEEL WORKS The issue of childhood obesity provides a good example for demonstrating how the Minnesota public health inter- vention model can be used to confront a contemporary health problem. Approaches that are currently being used to address the problem of childhood obesity range from those at the micro-level to the macro-level spheres of practice.
Childhood obesity has traditionally been framed as an issue of personal or parental responsibility. Viewing child- hood obesity as merely a personal responsibility excuses society’s responsibility and limits shared solutions. Nurses need to broaden their scope to examine health processes more globally. For example, nurses need to ensure that social, political, and structural conditions are addressed so that it is possible for people to achieve health.
There are many interesting and promising strategies for addressing childhood obesity. Some urban areas are pro- actively collaborating to redesign their communities. One
intervention is to build community sidewalks, establish- ing a more inviting environment for children to bicycle or walk to school. Communities have formed coalitions that advocate for neighborhood safety, so that walking, biking, and running can be safe. Some have looked at the strategic geographical proximity of fast food restaurants to schools, and have brought those observations to public conscious- ness. Fast food restaurants are clustered three to four times more often within walking distances of schools (Austin et al., 2005). This deliberate geographical place- ment exposes America’s children to poor quality food that is frequently inadequate for health promotion.
Other strategies are targeted at schools, such as altering choices in school vending machines and cafeterias to include healthy alternatives to junk food. Some schools have already done so on their own. Others are advocating interventions at the state and federal levels, such as bring- ing back physical education courses in schools where they have been eliminated.
Currently, only 8% of U.S. public schools require daily physical education. Some schools collaborate with com- munity health programs and screen for body mass index (BMI) and refer overweight children for early intervention and follow-up. Several schools have implemented the Planet Health program, developed by The Harvard School of Public Health. The Planet Health curriculum is inter- twined with existing lessons already being taught in mid- dle schools, such as science, math, and English. Students who participated in the pilot Planet Health interdisciplin- ary studies increased their fruit and vegetable intake, decreased their television viewing time, and lowered their BMI(Gortmaker et al., 1999).
Television presents another avenue for targeting obe- sity in children. Television is used more as an electronic babysitter than ever before. According to a 2006 Kaiser Foundation study, children younger than 6 years of age average 2 hours of media viewing per day(Kunkel et al., 2004). It is “used by parents to help manage busy sched- ules, keep the peace, and facilitate family routines such as eating, relaxing, and falling asleep”(Rideout & Hamel, 2006). Television viewing contributes to childhood obe- sity because it fosters physical inactivity as well as exposes children to a bombardment of junk food adver- tising (Fig. 2-2).
The American Psychological Association has a task force that researches television advertising that is specifi - cally aimed at children. The task force has learned that children younger than the age of 8 do not yet have the experience and knowledge to critically evaluate advertis- ing messages, and they tend to accept advertising as fac- tual. American children view an average of 40,000 televi- sion ads per year (Kunkel, 2001). Many messages are aimed at marketing unhealthy foods to children, and are aired strategically at times when children are most likely to watch. One study demonstrated an average of 11 food commercials per hour during children’s Saturday morning cartoons (Kunkel, 2001). Therefore, an average child is exposed to approximately one food commercial every fi ve minutes. Advertising strategies for snacks, sugared cere- als, soft drinks, and fast food contribute to the epidemic of childhood obesity, and the task force is urging policy- makers to better protect young children from this expo- sure (Kunkel et al., 2004).
Marketing
Enforcement Investigation
Follow-up Advocacy
Social
Development & Surveillance
Health Event
Outreac h
Screen ing
Refel &rra
Policy Disease
Commun
ity
Co alition
Collab oration
Consultation Counselling Health
Delegated Case Organiz
ing
Bu ilding
Teaching Functions
Managem ent Population-Based
Population-Based
Industrial-Focused
Community-Focused
Systems-Focused Population-Based
Case F inding
Figure 2-1 The Public Health Intervention Model.
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28 unit one Foundations in Maternal, Family, and Child Care
There are initiatives at the federal level to address the childhood obesity problem as well. For example, the U.S.
Food and Drug Administration (FDA) recommends strengthening food labeling in grocery stores as well as in restaurants. In some cases, consultation with restaurants is resulting in healthier portion sizes and the offering of lower fat options. The Centers for Disease Control (CDC) is using a multicultural social marketing technique to spread the word nationally about exercise benefi ts to children.
The public health intervention model gives an inte- grated view because it includes both the local and the more global system realms. The use of this model guides health professionals toward enhancing the capacity of all segments of society to move toward health and wellness.
For nurses, it is becoming increasingly clear that the tra- ditional approach to “caring” must be broadened beyond the individual patient, and instead become oriented toward the public’s health in order to effect real change in health outcomes. Intervention programs must be multitiered and oriented toward the broader social context because this is where most patients are located.
Now Can You— Discuss the public health intervention model?
1. Describe the three levels of intervention in the public health intervention model?
2. Apply the intervention model to the health problem of childhood obesity?
3. Discuss why the public health intervention model provides an integrated view of health and wellness?
Healthy People 2010: A Blueprint for Action
Healthy People 2010 is the guide that defi nes health pri- orities for the United States. It is the nation’s compass that points to specifi c focus areas that will guide progress toward the ultimate goal of optimal health for all Ameri- cans. The Healthy People 2010 blueprint for action is coordinated by the Offi ce of Disease Prevention and Health Promotion in the U.S. Department of Health and
Human Services. Prominent health scientists, both inside and outside of government, use population-based studies to create this blueprint for national health goals which are renegotiated every decade. Healthy People 2010 can be accessed at www.healthypeople.gov.
Healthy People 2010 includes two overarching health outcome goals that overlie all others:
• To increase the quality and years of healthy life
• To eliminate health disparities within America’s population
The Healthy People 2010 document contains a compre- hensive set of 467 measurable disease prevention and health promotion objectives for the nation to achieve over the fi rst decade of this century. There are 28 focus areas. Leading health indicators include several preven- tion factors such as physical activity, control of over- weight and obesity, abstention from tobacco use and substance abuse, and responsible sexual behavior. Other leading indicators include mental health, prevention of injury and violence, environmental quality, immuniza- tion, and access to health care.
Ideally, the best method to address health priorities is through the early prevention of health problems. There are three levels of prevention. The most desirable level is pri- mary prevention, which encompasses health promotion as well as activities specifi cally meant to prevent disease from occurring. Secondary prevention refers to early identifi ca- tion and prompt treatment of a health problem before it has an opportunity to spread or become more serious. Finally, tertiary prevention is intended to restore health to the highest functioning state possible. These three levels of prevention may be applied to a child’s day care setting. Pri- mary prevention would involve teaching children and workers proper hand hygiene to prevent illness. Secondary prevention would encompass screening and isolating chil- dren who develop signs and symptoms of infection to pre- vent its spread. Tertiary prevention would involve strate- gies such as keeping the child at home, administering fl uids, encouraging rest, and administering antibiotics if indicated, until the child is once again restored to health.
This focus on prevention has the potential to make an enor- mous difference in family health status.
Current health indicators demonstrate that Americans today are healthier than they have ever been, with a steady upward trend to an average life expectancy of 77.3 years.
Dreaded diseases that struck terror in families 100 years ago such as plague, polio, tetanus, and whooping cough (pertussis) are under control even though new health problems continually threaten to surface. Although heart disease remains the leading cause of death in the United States, rates have plummeted in recent years, most likely due to the present emphasis on healthy lifestyles and the availability of cholesterol-lowering medications.
However, there is no room for complacency regarding the present state of the nation’s health. Despite some positive trends, the United States lags behind other industrialized countries. The World Health Organization ranks the United States as 37th in health system status, even though health spending per capita in the United States exceeds that of all other countries. Remarkably, health spending consumes one-seventh of the United States’ gross national budget.
Figure 2-2 Typical American child fi xed on the television set while snacking on popcorn.
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chapter 2 Contemporary Issues in Women’s, Families’, and Children’s Health Care 29
Despite large health care expenditures, health care and other resources are unevenly distributed in the United States. Persistent health disparities remain disturbing. An African American baby, for example, is more than twice as likely to be low birth weight and two and one-half times more likely to die during the fi rst year of life than a Euro- pean American baby. Sudden infant death syndrome (SIDS) is more than three times higher in American Indian and Alaska native babies than in European American babies.
Additional information about health disparities can be accessed at the Centers for Disease Control’s Web site, http://www.cdc.gov/.
Now Can You— Relate the value of having national Healthy People 2010 goals to align health care improvement efforts?
1. Discuss the two overarching goals of Healthy People 2010?
2. Defi ne the three levels of prevention and give an example of each?
3. Describe prevention measures that have made a difference in reducing heart disease, the leading cause of death in the United States?