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Population Health for Nurses

1.1 Defining Population Health

Population Health for Nurses1.1 Defining Population Health

Learning Outcomes

By the end of this section, you should be able to:

  • 1.1.1 Define population health.
  • 1.1.2 Explain the origin of the population health approach.
  • 1.1.3 Identify the components of population health.
  • 1.1.4 Discuss the global application of population health.

Population health is a comprehensive approach that spans the entire health care continuum, from public health prevention to disease management. Population health aims to support the health of people through diverse activities, including care coordination, health care research, population-level data analysis, and health programming. Activities carried out to improve population health generally support the health status and health outcomes of groups of people rather than one client at a time. Population health interventions take a more holistic approach than those that are generally used in the care of individual clients. Population health considers the impact of public policy and law as well as environmental, social, behavioral, and other factors that might facilitate or hinder health for all people. The requisite knowledge of these disciplines and health areas comes together to address many factors that can influence health.

Consider tobacco use, which, as the leading cause of preventable death in the United States, kills an estimated 1,300 Americans each day. Individual counseling and interventions such as prescription medications and nicotine gum can help individuals quit smoking. While a population health approach to addressing tobacco smoking cessation would support the availability of individual tools, it would also consider the broader factors contributing to smoking rates and smoking uptake across the population. A population health approach to smoking cessation might include the following:

  • Developing community-wide antismoking campaigns
  • Advocating for schools, businesses, restaurants, and other public places to develop smoke-free policies
  • Researching the reasons that community members start or do not quit smoking
  • Analyzing population-level data to identify trends in smoking
  • Passing legislation to increase taxes on tobacco products to discourage their purchase and fund population health programs focused on cessation

Overall, a population health approach that considers the multifaceted facilitators and deterrents of smoking can help reduce smoking rates, thereby improving the health of smokers and the population at large.

Drunk driving is another example of a serious public health problem. The National Highway Traffic Safety Administration estimates that in the United States, one person is killed due to drunk driving every 39 minutes. Drunk driving impacts not only the life of the victim but also the lives of their friends, family, and community, and those of the driver as well. Individual-level interventions that work to improve the health of drivers and of community members to whom a driver may pose a risk include individual counseling, installing breathalyzer car ignition devices, and levying fines or revoking driver’s licenses to hold drivers accountable and prevent future drunk driving occurrences. Population health interventions go beyond those aimed at specific drunk drivers. A population health approach to drunk driving reduction could include the following:

  • Developing and implementing stricter laws and regulations regarding alcohol use and driving
  • Leading campaigns to raise awareness about the dangers and penalties of drunk driving
  • Collaborating with taxi companies and ride-share programs on weekends and holidays to offer free or reduced rides
  • Training servers, bartenders, and liquor store employees on the responsible service and sale of alcohol
  • Identifying high-risk areas for drunk driving accidents to increase signage and safety checks in these areas

In nursing, a population is a group of people that may receive care in various settings at the local, regional, national, and global levels (American Association of Colleges of Nursing [AACN], 2021). Examples of populations include all students at a specific college campus (local), all people who live or work in Northern California (regional), all residents of the United States (national), or all children with asthma across nations (global). The health care continuum encompasses public health, acute care, ambulatory care, and long-term care to collectively address a population’s diverse health needs. The health care continuum and the role of nurses will be discussed further later in the chapter.

Population health involves collaborative efforts among health care professionals, communities, industries, academia, and governmental organizations to improve health outcomes among a population (AACN, 2021). A myriad of efforts in population health can explain or address why some populations are healthier than others and help determine how resources might be allocated to have the greatest impact on improving health across the population. As the smoking cessation and drunk driving examples illustrate, population health approaches focus on implementing education, policy, and programming that provide optimal outcomes for the money, time, and other resources invested. Nurses working in many settings—such as hospitals, schools, homes, communities, industries, and businesses—not only support but also shape population health across the United States (Ariosto et al., 2018). Nurses are critical in advocating for policies, implementing interventions, and ensuring that diversity, equity, inclusion, justice, and ethics are prioritized to achieve population health goals focused on health promotion, disease prevention, risk reduction, and emergency preparedness (AACN, 2021).

There is no definitive history of exactly when population health emerged and evolved into what health care providers, teams, and organizations know it as today (Szreter, 2003). Scholars note several defining moments from the 18th century through the modern day, such as observations of differences in health conditions between the wealthy and the impoverished, among people employed in various industries, and between those with and without access to clean water (Bynum, 1983; LaBerge, 1993; Porter, 1991). These historical moments allowed for recognition of the relationship between a healthy human population and a healthy, functioning society. Although population health concepts and principles have been relevant to professional nursing practice for centuries, in the United States the passage of the Patient Protection and Affordable Care Act (ACA) in 2010 is credited with beginning to shift the focus of health care services from treating diseases in individual people to promoting health among populations (Ariosto et al., 2018). Emphasizing preventive efforts and proactively facilitating health instead of reactively treating diseases as they occur is a central tenet of population health. The shift is essential, as many recognize that a U.S. health care system that spends an estimated 75 to 90 percent of its resources addressing diseases and hospitalizations and invests very little in preventive efforts is a system that is failing (Raghupathi & Raghupathi, 2018; Shrank et al., 2019; Centers for Disease Control and Prevention [CDC], 2023). By shifting the focus from reactive disease treatment to proactive health promotion, population health offers a more positive path forward. Under a population health–focused system, health care professionals are encouraged to work collaboratively to promote early intervention, provide health education, empower clients, and effect social change to reduce the burden of disease for individuals and the health care system at large.

The Quintuple Aim

Population health can impact numerous specific conditions, diseases, and health risks through interventions that cross disciplines and support a great breadth and depth of positive health change. As a field of study and practice, population health works toward specific aims developed by the Institute for Healthcare Improvement (IHI). In 2007, the IHI developed a framework called the Triple Aim to support optimal performance of the health care system (Berwick et al., 2008). In 2014, the IHI updated the framework to the Quadruple Aim to acknowledge that the health of providers and other health care professionals must be supported to achieve population health goals (Bodenheimer & Sinsky, 2014). Today, the four aims consist of:

  1. improving the client experience of care (including quality and satisfaction),
  2. improving the health of populations,
  3. reducing the per capita cost of health care, and
  4. improving the well-being of health care professionals.

Recently, experts have suggested a revision to create the Quintuple Aim, which would include a fifth aim of advancing health equity. In both the fourth and suggested fifth aim expansions, experts have posited that improving population health, client experience, and health cost would be impossible without addressing provider health and burnout or health equity (Bodenheimer & Sinsky, 2014; Nundy et al., 2022). Concepts of the Quintuple Aim can guide evaluations of population health programs and initiatives. For example, telemedicine connects to the goals of improving the health of populations, improving the well-being of health care professionals, and advancing health equity. Its services offer several conveniences to clients and clinicians, such as the flexibility to dial in from home and save on commuting fees. These services also remove barriers to receiving care and increase equity in opportunity for clients to see primary care providers and specialists. This can help reduce inequities and disparities with regard to receiving screenings, diagnoses, and treatments for health conditions, which in turn can help improve population health. Telehealth is a growing initiative across health care globally; please see Care Transition and Coordination Across the Community for more information on telehealth. Recently, one research team determined that pediatric telehealth has advanced pediatric care in general so that it has become a better-performing, more equitable system (Cahan et al., 2020). Whether a population, community, or health system elects to use the version with three, four, or five aims, this framework encourages consideration of the interplay among the different aims and innovative approaches to improving health and health outcomes for the population.

Components of Population Health

Population health takes a comprehensive approach that accounts for the complex dynamics among differences in health status, community resources, personal characteristics, familial circumstances, and other factors that can trigger or aggravate health conditions. By recognizing the complex interplay of these numerous and wide-ranging factors, population health takes a holistic view to promote the well-being of all.

Regardless of the situation or specific factors, a guiding theme of population health is the importance and value of taking proactive rather than reactive approaches to improving health. An analogy to summarize population health involves an overflowing sink. Imagine a kitchen faucet is left running unattended, creating a giant puddle on the floor. Better get a mop! Without population health, much of health care focuses on “mopping the floor” instead of “turning off the faucet” (Kaminski, 2021). In other words, health care as a system largely deals with floods—that is, helping clients who are already sick—instead of turning off the water, or addressing the situations and circumstances that make clients sick in the first place. Health care providers, nurses, policymakers, and the health care system at large should focus on the causes of health problems to prevent them before they occur, instead of focusing primarily on treating diseases as they happen. Of course, clients, families, and communities need access to treatment for their health conditions—but what if there was a way to prevent the conditions from happening in the first place?

Four key health concepts have been essential in advancing population health: outcomes, disparities, determinants, and risk factors.

Outcomes are all possible results. Health outcomes are indicators or data points that reflect the degree to which health interventions, care, policies, and behaviors are effective in supporting the health status of populations. Examples of health outcomes include mortality rates, life expectancy, disability rates, birth rates, health care costs, and health-related quality of life measures. Outcomes may come from exposure to interventions that aim to prevent or treat a condition, or they may result from exposure to health risks or situations detrimental to health. For example, creating a policy that allows people under a certain income level to have free health insurance may produce a range of outcomes, including insuring a greater percentage of the population and increasing the number of people who attend wellness exams—and, consequently, increasing the number of people who smoke who may be offered smoking cessation resources. On the other hand, removing or relaxing policies that prohibit smoking in public places may produce quite a different range of outcomes, including making it more difficult for people to quit smoking, exposing more people to secondhand smoke, and increasing rates of children who start smoking.

Disparities are inequalities or differences. A related concept is health inequities, which are avoidable inequalities related to health that stem from a form of injustice (Kawachi et al., 2002; McCartney et al., 2019). For example, children attending the Lincoln School may have higher rates of asthma than children attending the Washington School. The children are all the same age and have the same racial and ethnic distribution, but the parents of children at the Washington School have a higher average income and donated money so that each classroom could have an air conditioner. There is a disparity in access to clean air, as well as in rates of asthma, between children at these two schools. Health Disparities covers this topic in greater detail.

Determinants are the innumerable factors that influence health and generally include nonmedical events, characteristics, or other entities that change a health condition or the level of a health problem (Kindig, 2007; Office of Disease Prevention and Health Promotion, 2022). Within population health, determinants of interest include medical care, public health interventions, income, education, employment, social support, culture, clean air and water, outdoor space, genetics, and behavior (Kindig, 2007). Determinants can interact with each other to bolster health or worsen a problem (Figure 1.2). For example, when a client is unable to finish high school, they may not qualify for a full-time job that pays a living wage and offers access to a health insurance plan. Such a situation would undoubtedly impact the client’s ability to seek care when needed and to engage in health promotion efforts.

Social determinants of health are additional factors that influence the health of populations, families, and individuals. Social determinants of health are conditions and social factors that affect outcomes and risk related to health, functioning, and quality of life. Conditions or factors in hospitals, clinics, workplaces, homes, towns and cities, schools, and beyond influence health outcomes for the population. Economic stability, education access and quality, health care access and quality, neighborhood and built environment, and social and community context are five domains that shape the social determinants of health (Office of Disease Prevention and Health Promotion, 2022). Please see Social Determinants Affecting Health Outcomes for a comprehensive discussion of social determinants of health.

Risk factors are aspects of personal behaviors, lifestyle choices, exposures, or attributes that generally increase the likelihood of acquiring or the severity of a health condition. Risk factors are similar to determinants but tend to be more specific. Consider respiratory disease determinants and risk factors. Air quality and environmental pollution are determinants of respiratory disease, while smoking is a risk factor for respiratory disease. Some determinants may be risk factors; however, other determinants may reduce health risk.

A forest is almost completely obscured from view by smoke.
Figure 1.2 This photo was taken during the 2018 Klondike Fire in Oregon. In addition to threatening human lives and homes, wildfires severely impact air quality, release harmful pollutants, and devastate wildlife and ecosystems. (credit: “Forest road 2512 and smoke-filled air, Klondike Fire” by U.S. Forest Service-Pacific Northwest Region/Flickr, Public Domain)

Healthy People 2030

Tobacco Use

Healthy People 2030 developed 25 measurable objectives, one developmental objective, and one research objective to address tobacco use. Since creating these objectives, three targets have been met or exceeded: reducing cigarette smoking in adolescents, reducing the use of smokeless tobacco products among adolescents, and reducing the lung cancer death rate.

Social Determinants of Health

Social determinants affect how environments where people live, work, and play impact health and well-being for all. This video explains different social determinants of health in depth.

Watch the video, and then respond to the following questions.

  1. What is the greatest risk to economic stability in the community around your nursing school?
  2. How does your nursing school support educational access and quality?
  3. Do clients in the community by your nursing school have adequate access to health care?
  4. Can you identify three risks and three supports in the neighborhood and built environment around your nursing school?
  5. In your nursing school, what experiences do you participate in that contribute to the growth of the social community and context?

Additionally, population health focuses on upstream, midstream, and downstream approaches to improve health outcomes (Figure 1.3) (Salmond & Allread, 2019).

  • Upstream interventions involve enacting policies that change regulations, increase access, or provide economic incentives to impact health across a population. Examples include policy changes regarding the fast food or tobacco industry, provision of universal health care, and compensation for hospitals with lower inpatient admission rates (Porter et al., 2022).
  • Midstream approaches are those that happen within specific organizations. For example, a workplace may provide healthy lunches to employees each day (Porter et al., 2022).
  • Downstream interventions focus on the behavior of individual people to modify the risk of disease, prevent illness, or manage chronic conditions (Brownson et al., 2010; Fornili, 2022). For example, a nurse might counsel a client with hypertension about consuming a low-salt diet.
An illustration of a stream near a town shows the effects of upstream, midstream, and downstream interventions. Upstream interventions include policies that change regulations, increase access, or provide economic incentives to impact health across a population. Midstream interventions include approaches that happen within specific organizations to improve health impacts. Downstream interventions focus on the behavior of individual people to modify the risk of disease, prevent illness, or manage chronic conditions.
Figure 1.3 Population health involves the complex interactions of upstream, midstream, and downstream interventions. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

These key components interact in complex and evolving ways as population health and the health status of the population change over time. By employing upstream interventions, such as policy changes and universal health care, population health addresses the societal factors that impact the health of the population on a broad scale and ultimately the health of individual clients. Midstream approaches can contribute to fostering healthier environments in diverse settings. Downstream interventions, such as those that focus on individual behavior to support health, are also important in a population health model, as members of the population will never be fully free of health conditions requiring treatment. Together, upstream, midstream, and downstream approaches offer a framework for population health programming and interventions that can create positive health outcomes.

Case Reflection

Components of Population Health

Read the scenario, and then respond to the questions that follow.

Forty-year-old Christopher Lee has hypertension. Although he has not attended a health checkup in a few years, he feels that his blood pressure might be lower since he lost his job. Being unemployed has been stressful, but as a Korean American, he experienced anti-Asian sentiment and discrimination from his coworkers during the COVID-19 pandemic. The Lees’ 5-year-old daughter, Sunshine, just started kindergarten and has an EpiPen for a life-threatening nut allergy. She attended an after-school arts and crafts program twice a week but stopped going when Christopher lost his job. The Lees’ 2-year-old son, Woody, is generally healthy and attends the day care where Alexandra works. Christopher’s parents live in South Korea and will visit the United States in a few months to help when the Lees’ new baby is born.

  1. Based on what you now know about the Lee family, what are some possible health challenges they may face?
  2. What are some possible upstream factors influencing their actual or potential health challenges? Are there any midstream and downstream factors that might support or harm their health?

Global Population Health

The need to address the factors and components of population health is a global one, and given the interconnected nature of the health status of people around the world, nurses should prioritize and actively contribute to enhancing global population health in addition to advancing local and national population health programs, goals, and outcomes. Many people around the world face significant challenges to promoting their health, receiving treatments, and reducing health risks. Health outcomes, disparities, determinants, risk factors, and upstream, midstream, and downstream influences are all relevant and crucial to improving global population health. The health status of people as far away as a different continent on other side of the equator can impact the health of clients locally, and nurses have a responsibility to support efforts that advance population health worldwide (Hong & Lee, 2021; Wilson et al., 2016). Nurses have a duty to extend their care, genuine concern, empathy, and compassion to those in need beyond their immediate surroundings. To that end, a global advisory panel on the future of nursing proposed a definition of global nursing:

  • Global nursing is the use of evidence-based nursing processes to promote sustainable planetary health and equity for all people. Global nursing considers social determinants of health, [and] includes individual and population-level care, research, education, leadership, advocacy, and policy initiatives. Global nurses engage in ethical practice and demonstrate respect for human dignity, human rights, and cultural diversity. Global nurses engage in a spirit of deliberation and reflection in interdependent partnership with communities and other health care providers. (Wilson et al., 2016, p. 1537)

When nurses engage in global nursing, they can proactively contribute to bettering population health and reducing the global burden of disease, health conditions, disability, and disparities. By embodying a commitment to global nursing, nurses can positively impact and improve the lives of others and uphold the principles of the discipline. Almost any health issue, concern, condition, or topic can be a global population health problem needing solutions.

Climate Health

People living in the western United States may recall having “smoke days” off from school due to poor air quality from wildfire smoke, while those from the East Coast and Midwest may recall a few days in June 2023 when the skies were tinted orange and air quality was exceptionally poor due to wildfire smoke movement from Canada. That same summer, wildfires burning out of control across Greece caused the evacuation of 19,000 people (Smith & Chrisafis, 2023). Exposure to wildfire smoke and poor air quality impacts the health of humans and animals alike. It exacerbates respiratory conditions, may cause congenital anomalies, and can even contribute to lower academic performance for students (Amjad et al., 2021; Gan et al., 2020; Wen & Burke, 2022). Wildfires are one example of an extreme weather or climate event that causes significant harm to mental health and well-being and contributes to morbidity and mortality around the globe (Ebi et al., 2021).

In addition to causing wildfires, extreme weather—in the form of high temperatures, torrential rains, and prolonged drought—puts the health of the population at risk around the world. The levels of extreme heat that were experienced across Asia, Europe, and the United States during the summer of 2023 are enough to worsen existing respiratory conditions and cause heat stroke, a life-threatening emergency (CDC, n.d.). Heavy rains and flooding can contribute to the development of climate-sensitive infections like malaria, dengue, diarrheal diseases, and emerging infections, as disease-causing pathogens are able to thrive in the unusually wet conditions (Choisy et al., 2022). Global climate scientists are particularly concerned about the effects of climate change in Asia, where temperatures have been rising two times faster than in other parts of the world (Dabla-Norris et al., 2021). Climate health is truly a global health concern.

Supporting climate health is a key priority area in population health nursing; see Environmental Health. Participating in global nursing allows nurses to address the impact of extreme weather events on the health of the global population. Nurses can provide care that mitigates the health effects of climate events, promote policies that support global climate health, and collaborate to ensure equitable access to a healthy local and global climate.

Vaccines

In the United States, COVID-19 vaccines were available to health care workers and older adults living in long-term care facilities in late 2020 and to the general public in spring 2021. The global population of health care workers, clients, and families did not have the same timely access to vaccines. High-income countries had purchased 54 percent of the world’s available vaccine doses by March 2021, but 81 percent of the global adult population lives in low- and middle-income countries (Stephenson, 2021). Disparities in vaccine access were detrimental to immediate and long-term global population health outcomes and contributed to avoidable deaths. Nurses addressing global population health can advocate for equitable worldwide vaccine distribution, provide education on the importance of vaccination to those who require vaccines and those who determine where vaccine clinics may be located, and provide timely access to vaccine administration (Figure 1.4).

A seated client holds up their sleeve so that a healthcare worker can administer a vaccination. Two other healthcare workers sit at a table behind them. All four people in the photo wear face masks to cover their nose and mouth.
Figure 1.4 A health care worker vaccinates a client in a vaccine clinic in Colombia. The sign in the background reads Vacuna es segura, which means “The vaccine is safe.” Beyond the challenges of quickly developing a vaccine, making enough for the global population, and handling logistics such as transportation and storage, a major barrier to global health in 2021—and to ending the COVID-19 pandemic—was informing the public that the vaccine was safe and effective. (credit: “Colombia COVID-19 Vaccine at Mobile Site” by USAID/Colombia/Flickr, Public Domain)

Transportation

Access to health care can mean many things. Is there a provider or specialist in the client’s area who can adequately address the client’s health needs, and is that provider or specialist accepting new clients? Is a health care professional available who speaks the client’s native language to facilitate clarity during a health visit? Can the client physically get to a location providing health care services? Researchers recently determined that 8.9 percent of the global population is not able to access a health care provider within one hour by vehicle (Weiss et al., 2020). The time it takes a client or family to reach a health care facility can impact whether the client receives preventive health care, emergency services, and management of chronic conditions. For example, accessibility to emergency care services has a great impact on the health of people who are having a stroke, as certain medical interventions must be implemented during specific time frames from the onset of stroke symptoms (Lee et al., 2021). To support population health outcomes related to care access, nurses should contribute to developing innovative solutions for improving transportation options to ensure that people can reach facilities for care needs across the continuum. Global population health is also supported when nurses bring health care to homes and communities with low access.

Why Should You Care about Global Health?

In this video, Dr. Deboki Chakravarti, a science educator with the American Public Health Association, discusses global health. She addresses the major challenge in global health—helping people live the healthiest possible lives, regardless of where they live—and shares how some examples of global health problems, such as global disease eradication, food distribution, health access, and COVID-19 vaccine refrigeration, were solved via collaborative solutions.

Watch the video, and then respond to the questions that follow.

  1. Can you name one way in which global nursing approaches may have supported the global health topics Dr. Chakravarti shares in the video?
  2. What other global population health challenges are you aware of? What can nurses near to and far from the immediate health challenges do to address these problems?
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