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Population Health for Nurses

16.1 The Community as the Client

Population Health for Nurses16.1 The Community as the Client

Learning Outcomes

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

  • 16.1.1 Explain how the community can serve as the focus of care.
  • 16.1.2 Describe a community by location, population, and social systems.
  • 16.1.3 Develop a community profile.

Broadly, a community is defined as a group of people with at least one characteristic in common. The characteristic may be a place, a personal attribute, or a common goal. In each community, there are individuals with health problems and health risks, some of which may be individual, meaning the rest of the community does not face similar circumstances. For example, a person who smokes or lives in a home with smokers faces increased respiratory health risks compared to a person who does not smoke or live with smokers. A person who does not wear sunscreen has an increased risk of skin cancer compared to a person who applies sunscreen daily. However, every community may house a common health condition or shared health risk. For example, a community situated near a factory that disposes of its toxic chemicals in the water supply shares the risks of consuming contaminated drinking water. Similarly, residents of a city that provides automated external defibrillators (AEDs) in high-traffic public places may have a better chance of surviving a cardiac event than those with no accessible AEDs.

In population- or community-based nursing, nurses work to address a community’s collective health instead of individual health needs. Recall the chapter’s opening scenario. Try to list five communities that Elsa belongs to.

Community Attributes

Formal and informal communities exist within and across towns and cities. A community may comprise people who celebrate the same cultural holidays or people who are at risk for the same health condition.

Consider the many communities that may be present in a classroom of nursing students: a community of students, a clinical team, a study group, students with children, and perhaps students studying nursing as a new career. Elsa, from the chapter’s opening scenario, is a member of numerous communities, including residents of the town, people with type 1 diabetes mellitus, high school students who are gender nonconforming, the soccer team, and residents who get around on bikes, among others. Communities of nursing clients may consist of those who inhabit a specific geographic location, share specific characteristics, or access the same social systems. Communities may also form when groups cannot access select health services and social systems.

Individuals do not have to live within mapped boundaries to be part of a geographic community. People who work, worship, or play in an area where they do not live can be interested in that community’s health.

A key activity for geographic communities is civic engagement—involvement in issues of public concern through political and nonpolitical processes that increase community vitality, challenge injustices, and address social problems (Figure 16.2) (American Psychological Association, 2009; Wray-Lake & Abrams, 2020). Other geographically based communities include members of community centers, such as a Council on Aging or a Boys and Girls Club, and populations of school students, home caregivers, and teachers in a geographic community.

A large group of demonstrators stand outside holding hand-lettered signs that say Make Earth Cool Again and The Oceans Are Rising And So Are We.
Figure 16.2 Protest is a form of civic engagement. Protests can inform members of the public of issues, mobilize voters and community members to act for change, and influence the policy process. Here, people are voicing their opinion on the need to address climate change during a climate strike rally in 2019. (credit: “#ClimateStrike Rally” by MN Senate DFL/Flickr, Public Domain)

Healthy People 2030

Civic Participation

Social determinants of health and civic engagement are closely linked. Healthy People 2030 identifies voting, volunteering, participating in group activities and activities such as community gardening, and participating in a recreational sports team as methods of civic participation. Such activities can benefit the health of individuals and populations. Healthy People 2030 aims to increase the proportion of voting-age citizens who vote and increase knowledge of civic activities or interventions that may ameliorate health disparities.

People who share personal characteristics such as race, ethnicity, gender, age, or occupation may create a formal community for mutual support or to advance equitable practices across health care and other fields. Others who share such characteristics may not participate in a formal community but may informally associate with members of the community, remain knowledgeable of the shared successes and challenges the community faces, and advocate for change. Populations of individuals who share health risks may also constitute a community.

Social Media and Other Social Systems

Social media and other social systems provide avenues for the formation and definition of communities. Social and political networks may serve as a basis for uniting as a community for health change. Technology has dramatically enhanced opportunities to join a community, as many people use social networks to participate in civic engagement, learn about health, effect change through sharing stories and knowledge, and organize to advocate for policies and societal changes that advance health. Social media has increased the visibility of community health issues, as community members and advocates can quickly share information with people around the globe.

Advocacy in the context of community health refers to support for a specific health cause or recommendations for community and policy change. Advocacy is a significant health promotion strategy to inform voters and policymakers of pressing community health issues and the consequences of harmful policies or inaction (Jackson et al., 2021). Community members who share their own health experiences encourage the forming of community, as other members who identify with the experiences or want to support health change can join the conversation and become involved. Social media has provided a platform for community members, clinicians, organizations, charities, and others to connect and work together to improve the dimensions of community health in many areas. Health advocates have used social media to call attention to, and impact change for, many issues across the globe, such as alcohol use in the Netherlands, tobacco control in Australia, sexual harassment in Egypt, traffic accidents in Ireland, maternal mortality in the United States, and housing in New Zealand (Albalawi & Sixsmith, 2015; Behm et al., 2022; Bekkers et al., 2011; Chisholm & O’Sullivan, 2017; Hefler et al., 2013; Peuchaud, 2014). Advocating for Population Health covers nurse advocacy in more detail.

Social Media and Community Health Change

Communities have worked to generate health change through social media messaging and campaigns. Over the last few years, many social media movements have raised awareness of select health issues, changed public perception of health problems, and even successfully advocated for policy change in companies and organizations or for greater society through changes to public law. For example, the #MeToo movement that went viral in 2017 contributed to the U.S. Congress passing of the Sexual Assault Survivors’ Bill of Rights.

Using the social media platform of your choice, explore one of the hashtags below, and then respond to the questions that follow.

  • #BlackBreastfeedingWeek
  • #TransHealthMatters
  • #ReclaimingMySize
  • #NativeHealthMatters
  • #NothingAboutUsWithoutUs
  • #MentalHealthAwareness
  • #NotJustSkinDeep
  • #WomensHealthMatters
  • #EveryBodyHasAStory
  • #MedicareForAll
  • #BlackLivesMatter
  • #ThisIsEndometriosis
  • #GirlsCount
  • #HIVNotRetro
  • #FarmworkersFeedUs
  • #TransLivesMatter
  • #HealthEquityNow
  • #QueerAndDisabled
  • #HealthForAll
  • #BreakTheStigma
  • #BlackHealthMatters
  • #SaludLatinx
  1. What is the health message or health change that users of the hashtag hope to make?
  2. What are the characteristics of community members amplifying the health message? Are any voices being amplified that would be silenced without social media?
  3. Since the implementation of the hashtag, has any health change occurred? Think about health change locally, statewide, and nationally.

Community Assessments and Profiles

Assessment is the first and most important step of the nursing process. Nurses cannot address a problem if they do not know it exists, and they cannot support a health behavior or community effort if they do not realize it is occurring. Assessment begins with gathering data. Nurses may take several approaches to gathering data. First, they may conduct a windshield survey. In a windshield survey, nurses explore a community or neighborhood and observe on foot, from a bench or street corner, or through the windows of a vehicle (Centers for Disease Control and Prevention, 2010). Observations made using this type of survey can alert nurses to urgent or potential health risks in the community, as observers may notice the condition of sidewalks and public spaces, community noise levels, street access and activity, and the presence or absence of businesses and places of employment. See Appendix A for an example of a windshield survey template that nurses may use to conduct one of these assessments. Per the University of Kansas Center for Community Health and Development Community Tool Box (2023), during such a survey, nurses should observe:

  • Housing: age and condition of homes in the neighborhood
  • Other buildings: occupancy and accessibility of buildings
  • Public spaces: availability of places to gather and their amenities, upkeep, and utilization
  • Parks: utilization, times of use, activities facilitated
  • Culture and entertainment: presence of museums, libraries, theaters, and sports venues and their accessibility and use by members representative of the full community
  • Streetscape: condition of building facades and storefronts, presence of trees and sidewalks, cleanliness
  • Street use: presence of people during various times of the day
  • Commercial activity: types of businesses, storefront vacancies, stores that provide necessities like groceries
  • Signs: languages, level of information
  • Industry: types of industry, pollution
  • Land use: open space compared to used land; distribution of residential, commercial, and industrial areas
  • Infrastructure: condition of roads, bridges, and sidewalks; differences in condition across the community
  • Public transportation: presence and use of system
  • Traffic: level of traffic, vehicles in traffic
  • Environmental quality: green space presence and distribution, air quality, water sources
  • Race/ethnicity: characteristics of community, separation or cohesion of groups
  • Faith communities: religious institution types and presence
  • Health services: hospital and clinic presence and accessibility
  • Community and public services: presence of mental health centers, food banks, and housing support and their distribution and accessibility by public transit
  • Community safety: police and fire stations
  • Public schools: presence of schools and their level of maintenance or upkeep
  • Higher education: two- and four-year colleges, location, integration with community versus isolation
  • Political activity: political signs (e.g., yard signs during elections), protests, demonstrations
  • Community organizations: service clubs and other groups centered on community issues
  • Media: local outlets, sponsorship/influence
  • Differences among neighborhoods: states of maintenance, presence of community amenities across neighborhoods or sections
  • The “feel” of the community: the observer’s overall impression of the community

Regardless of the method they use to conduct a windshield survey, nurses should conduct the survey in pairs or groups. First, it is unsafe to attempt to drive and note observations at the same time. Additionally, each nurse may have different observations, which can add to the richness of data collected. Nurses may also collect data from open sources in the community, such as publicly available reports, census data, and other public documents (Quinn et al., 2019). For example, department of health reports regarding the rates of communicable illnesses and chronic conditions can help elucidate a community’s health needs, and the posted minutes of a local select board meeting can illuminate health topics on the minds of local community partners and residents. See Assessment, Analysis, and Diagnosis for more information regarding community data sources. Finally, nurses should consult key community partners, policymakers, community leaders, and community members during a community assessment.

Theory in Action

Windshield Surveys

These two videos were created by nursing students as they conducted their own windshield surveys. The first video displays a windshield survey of a community in Ohio with the students’ interpretation of their observations. The second video facilitates a virtual windshield survey of communities in Virginia.

Watch both videos, and then respond to the following questions.

  1. How do you interpret the windshield survey of communities in Virginia?
  2. What other observations would you make of the Virginia communities to prepare a community assessment like the one displayed for the Ohio community?
  3. What conclusions might you draw about health and well-being in the Virginia communities based on the windshield survey?

Including community members in community-based nursing work is essential and should start from the earliest stages of a community initiative. Involving community members’ perspectives and participation supports not only thorough assessments and meaningful change but also ethical practice. Meaningful partnerships with community members show respect for the community, build trust and relationships, minimize risk and burden, build legitimacy, and positively impact health (Adhikari et al., 2020; Haldane et al., 2019).

Community inclusion also helps nurses work against both the narrative and the reality that clinicians often tell people what to do without considering personal, contextual, social, or other factors. Such actions may be perceived as patronizing and marginalizing the community, or treating them as insignificant and making them feel powerless or unimportant. In nursing, decolonization refers to processes that systematically dismantle “western colonial ideologies of superiority, thought, approaches, and privilege” (Fontenot & McMurray, 2020, p. 272). Partnering with members of a community is in alignment with decolonization and can contribute to community interventions that are robust, respectful, culturally responsive, and inclusive (Lin et al., 2020; McCreedy et al., 2018).

The Roots of Health Inequities

Colonialism in Nursing

Colonialism is an ideology with a strong foundation of control and influence. Nursing students may remember learning about colonists in the contexts of history, war, and geography during primary and secondary school. Depending on the country in which a nursing student attended primary and secondary school, colonists and colonialism may have been depicted as a positive story of starting a new life. However, colonists invade, conquer, occupy, dominate, and exploit the lands of other people. Colonialism and racism, the unfair treatment of individuals based on race, share these harmful foundations. Colonialism and racism are both present in nursing; power dynamics, forced dependency, lack of self-determination, and othering shape nursing education, research, and practice as well as health policy. In community health, nurses must ensure meaningful community participation in community assessments and population health program planning in order to confront racism and colonialism in the discipline.

(See Fontenot & McMurray, 2020; Kimani, 2023.)

Gordon’s functional health patterns provide a method of structuring a community assessment and organizing the resulting data (Gordon, 1982). Nurse theorist Marjory Gordon developed the functional health patterns to guide nurses through a thorough assessment of individual clients and families (Gordon, 1982). However, the functional health patterns can also be applied to a community assessment. Ten years after Gordon published her work, nurse scholars Nancy Kriegler and Marilyn Harton used it to develop the community health assessment tool (Kriegler & Harton, 1992). See Table 16.1 for descriptions of the 11 functional health patterns for use in community assessments and the items nurses may assess in each pattern.

Pattern Community Application Assessment Items
Health perception–health management Community provision of health and safety
  • Public safety, police, fire
  • Disaster control plan
  • Safety hazards
  • Reportable diseases
  • Death rate—community, for 10 leading causes of death, infant and maternal
  • Health promotion
  • Care centers—ambulatory, emergency, inpatient, long-term
Nutritional-metabolic Community provision of nutritional needs, including education
  • Public assistance programs
  • Grocery stores, markets, restaurants
Elimination Community handling of waste
  • Water supply
  • Sewage, trash, garbage, hazardous waste disposal
  • Recycling programs
  • Rodent/vermin control
  • Air and noise pollution
Activity-exercise Community provision of transportation and recreational opportunities
  • Work, recreation, and health care transportation
  • Leisure-time activities across age groups
Cognitive-perceptual Community decision-making
  • Government structure and community participation
  • Key community leaders
  • Public and private schools, preschools, adult education, higher education
  • Health education programs
  • Publications, radio, TV, and information networks
Sleep-rest Community experience and expression of rhythms and cycles
  • Types of businesses and industries, hours of operation
Self-perception–self-concept Community view of itself
  • Impact of community history on present-day community
  • Topography, boundaries, area, urban/rural distribution
  • Population demographics
  • Occupations, income level, poverty level, unemployment rate, housing types and costs, owner- versus renter-occupied homes
Role-relationship Community definition of its own role through internal informal and formal relationships and interactions with other communities
  • Relationships within the community and with nearby communities
  • Community-sponsored events, e.g., festivals and parades
Sexuality-reproductive Community provision of resources and education for reproductive health and family structures
  • Family types and sizes
  • Rates of birth, teen pregnancy
  • Prenatal care
  • Reproductive health care facilities, including abortion providers
  • Reproductive education in schools, parenting classes, childbirth classes
Coping–stress tolerance Community provision of support services
  • Federal and state assistance programs and use in the community
  • Community-based assistance programs, e.g., support groups
Value-belief Community addressment of spiritual, cultural, and ethical needs
  • Religious group types, outreach to community, potential impact on community health
  • Social action groups and activities, e.g., programs for unhoused, fundraising for causes, senior citizen programs
Table 16.1 Functional Health Patterns in the Community (See Kriegler & Harton, 1992.)

A functional health pattern assessment can help the nurse to develop a community profile that includes identifying health problems, describing health risks, and determining health promotion activities. Recall the chapter’s opening scenario. What patterns does the description of Elsa’s community address? What questions would the community health nurse have for Elsa and other community members to develop a comprehensive community assessment?

The functional health pattern assessment applies to nursing assessment and practice and can be used during interprofessional community health endeavors. Other tools that may be used include the American Hospital Association’s Community Health Assessment Toolkit, the CDC’s action model, and the CDC’s Community Health Assessment and Group Evaluation (CHANGE) tool. Assessment, Analysis, and Diagnosis provides more information on community health assessment tools, models, and frameworks.

Case Reflection

Conducting a Health Pattern Assessment

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

Think back to the chapter’s opening scenario. As you get to know Elsa, they share more about the community and their friends with you. You learn that their active schedule does not leave much time for rest, and the same is true for their friends, who also balance jobs, sports, and schoolwork. Elsa sometimes has difficulty fitting it all in each week while getting enough sleep. They also talk about having trouble sleeping during the summer, as seasonal residents and vacationers can be noisy. Elsa feels that they have a manageable workload this week; their only major homework is a health class assignment on sexually transmitted infections. They share that the high school students have a health class meeting every other week, where they discuss health topics such as contraception, exercise, substance use, and relationship safety. Elsa appreciates the school community, which is inclusive and fosters a sense of belonging for the most part, although some students say they don’t believe people can have diverse sexual orientation or gender identities, and Elsa wonders if some classmates purposefully misgender them. But the classmates who may be doing this are few, and Elsa’s friend group spans all grades, genders, sports, interests, and other characteristics. Elsa thinks your community assessment is interesting, but they are running late to meet up with their friends at the town square for the annual Green Living Festival, which they describe as a giant yard sale of secondhand clothing and household items. The goal of the festival is for these used goods to be repurposed and stay out of the county landfill.

  1. With all the information you have gathered from Elsa about the community, which functional health patterns can you describe?
  2. What other questions would you like to ask Elsa or their friends about the community so that you could work toward developing a comprehensive community assessment?
  3. In your opinion, which functional health pattern is most essential for the public/community health nurse to work to address first?
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