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Population Health for Nurses

29.4 Public Health Nursing and Public Health Departments

Population Health for Nurses29.4 Public Health Nursing and Public Health Departments

Learning Outcomes

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

  • 29.4.1 Examine the structure and organization of local and state public health agencies in the United States.
  • 29.4.2 Identify how state and local public health departments are financed.
  • 29.4.3 Differentiate between the functions of state and local health departments.
  • 29.4.4 Delineate how public health differs from other practice areas across the continuum of care.

Public health nursing promotes and protects a population’s health by synthesizing knowledge from nursing, social, and public health sciences and applying it for social betterment (ANA, n.d.; ANA, 2022). Social betterment was a term first used in 1912 by Lillian Wald, often considered the first public health nurse in the United States, to describe the role of public health nurses (PHNs) in addressing the upstream determinants of health—the places where people live, work, learn, play, and worship (ANA, 2022). Public health nursing in the United States is grounded in ensuring the circumstances and environment in which health equity and well-being for populations can be attained by minimizing health disparities for all (ANA, 2022). This nursing specialty is a population-based practice with a focus across multiple levels—individuals, families or small groups, communities, and systems within the overall context of the community as a whole (ANA, 2022).

Baptism of Fire – Henry Street Settlement

This video highlights Lillian Wald’s work with vulnerable populations in New York City in the late 1890s and early 1900s. Wald and her colleagues provide a great example of how public health nursing positively impacts the lives of individuals, families, and communities and how advocacy can alter federal policies and laws.

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

  1. Why were the efforts of the reformers called the “settlement movement”?
  2. How does Lillian fulfill the role of the public health nurse?
  3. What surprised you most about Lillian’s work in public health?

PHNs use all levels of prevention with an emphasis on primary prevention and a focus on improving health outcomes by addressing the SDOH, particularly the physical and the environmental determinants of health. Health equity, social justice, and environmental justice are highlighted as pillars of public health nursing (ANA, 2022). Refer to Foundations of Public/Community Health for more details on the role of public health nursing. The United States has a complicated public health system composed of individuals, government workers, and organizations in both the public and private sectors collaborating in various ways at the local, state, and national levels (Public Health Law Center [PHLC], 2015). This section explains different types of public health governance structures, explores public health funding, and compares the roles of the state and local health departments.

Public Health Governance Structures

The government public health sector comprises federal, state, the District of Columbia, and local and tribal public health agencies. There are almost 3,000 local governments and over 500 federally recognized tribal agencies. States have leeway in defining their public health role, resulting in national variability (PHLC, 2015). Just as states have the leeway to define their role in public health, there is no uniform public health governance structure. Although the governance structures of state health departments (SHDs) vary from state to state, the relationships between SHDs and local health departments (LHDs) also vary widely. The following are four general types of governance health structures between SHDs and LHDs (CDC, 2022g; Leider et al., 2018; PHLC, 2015):

  • Centralized
    • LHDs are units of the state government and led by state employees.
    • SHDs manage LHDs as divisions of the SHD.
  • Decentralized
    • LHDs are led by local governments and the employees of local governments.
    • Local governments make most of the financial decisions in this model and keep more power and accountability for delivering public health services.
  • Mixed
    • Some LHDs are led by the state government and some by the local government.
    • In this model, generally LHDs keep more power and accountability for delivering public health services.
  • Shared
    • LHDs may be led by state employees or by employees of local governments.
    • If led by state employees, the local government can make financial decisions and issue public health orders. If led by local government employees, then the state has the authority.
    • In this model, generally LHDs keep more power and accountability for delivering public health services.

The Association of State and Territorial Health Officials (ASTHO) interactive dashboard gives detailed information on each state’s and each region’s public health agency structure. ASTHO first reported data in 2007 and updates data every 2 to 3 years, defining the scope of state and territorial public health services, identifying the variations in practice among states and territorial agencies, and representing the work overseen by the various health agencies nationwide. On an individual state level, the ASTHO website outlines the governance structure, workforce, and finance structure, affording the public an understanding of how their state public health departments function (ASTHO, 2023).

State Health Departments

The CDC is the federal government organization charged with population health protection and improvement activities (Leider et al., 2018). Other federal agencies with public health functions include the U.S. Department of Health and Human Services (HHS), the Health Resources and Services Administration (HRSA), the Food and Drug Administration (FDA), the Substance Abuse and Mental Health Services Administration (SAMHSA), and the National Institutes of Health (NIH) (Leider et al., 2018). Although the CDC has set a federal public health agenda, much of the oversight of public health is left to individual states. The structure of state-level public health varies. State health agencies are tasked with implementing federal regulations or policies, such as Medicaid, Medicare, and the Children’s Health Insurance Programs (Leider et al., 2018).

Within the United States, about 55 percent of SHDs are independent, whereas the other 45 percent are organized as one unit of a larger health-related agency that includes mental health services, long-term care services, public assistance, and traditional public health functions (PHLC, 2015). Each state’s health department is usually the primary public health authority and supports delivering public health services. A council or board of health often oversees and directs SHDs. These boards often advise elected officials on PH matters, develop state PH policies, and develop legislative PH agendas. State legislatures approve state PH agency budgets, establish PH laws and regulations, determine fees for health services, and establish taxes to support public health. State PH agencies are often influenced by the elected officials in the state (PHLC, 2015).

Public health system funding is difficult to generalize as the structure of the public health system is determined by how state and local health departments are empowered within a state with much variation across the nation (Leider et al., 2018). SHDs receive both federal and state funds. Alternate funders are foundations and for-profit institutions (Leider et al., 2018). The federal government is the largest funder of state public health. Federal agencies will provide funds for particular diseases or programs, which can decrease the public health program’s ability to respond to local needs and priorities (Leider et al., 2018). Public health systems for territories and tribal nations are funded externally by the federal government. They tend not to have a distinct public health operation as they integrate population-oriented services with direct health care services (Leider et al., 2018).

Local Health Departments

Local health departments obtain authority from the state. Their roles and scope of authority are contingent on state policy and the governing relationship between the state and LHD. As noted previously, the role and governing structure of LHDs vary widely. Some LHDs provide direct clinical care, whereas others focus solely on population-based services (Leider et al., 2018). Some LHDs in large cities have functional abilities similar to those of SHDs, although small LHDs often provide a limited set of public health services. LHDs can be designed as locally governed, a branch of the state health department, a state-created region, or a department serving multiple counties. The commonality is that LHDs have governmental power and are responsible for public health at the local level (PHLC, 2015). They are also responsible for following state laws and regulations (Leider et al., 2018).

The National Association of County and City Health Officials (NACCHO) estimates there are 2,800 LHDs in the United States of varying size and complexity (Leider et al., 2018). Spending estimates for LHDs are complicated and not readily available as they are self-reported by the nation’s LHDs and capture only basic information such as revenues and expenditures. LHDs are often supported by cities, counties, and local governments, partially financed through local property taxes or via a devoted public health revenue stream from the local government (Leider et al., 2018). Local government support of public health agencies averages about 3 percent of total local taxes (Leider et al., 2018). Some state legislatures fund LHDs through grants and contracts managed by the SHD. The federal government will also support some large local governments with grants, but most often federal dollars go to SHDs first to then be further disbursed to LHDs (Leider et al., 2018).

Trends in Public Health Funding

Public health is chronically underfunded with fragmented infrastructure (Johns & Rosenthal, 2022; Leider et al., 2018). Historically, public health is deeply siloed with funding dedicated to specific diseases or focal areas and allocated across many entities in the public health system. State and local health departments fund and conduct public health activities. The federal government provides additional funding through its various branches, with the CDC being the primary funder, yet the CDC’s funding decreased by more than 8 percent between 2010 and 2021 (Johns & Rosenthal, 2022). Federal contributions have remained stagnant, resulting in state and local funding sources compensating for the lack of increased funding. This has created an inequitable system, as each locality has different funding sources (Johns & Rosenthal, 2022). Due to these funding differences, there are also significant differences in local public health services nationwide.

Public health spending increases of as little as $10 per capita have been linked to decreased mortality rates of as much as 7 percent and an overall greater percentage of the population reporting being in good or excellent health (Johns & Rosenthal, 2022). Similarly, decreases in low birth weight, rates of STIs, and foodborne illnesses have been directly linked to spending on public health initiatives (Johns & Rosenthal, 2022). Investments in public health can offload some of the burden on the U.S. health care system. In 2019, less than 3 percent of the overall $3.8 trillion spent on health care in the United States went toward public health (Johns & Rosenthal, 2022). This mirrors the finding that, over the past two decades, between 2 and 3 percent of health spending went directly to public health. Health care costs are increasing, with most of the spending going toward treating preventable conditions, yet population health in the United States continues to decline. For every $1 spent on public health interventions focused on diabetes and cardiovascular health, $5 in health spending is saved (Johns & Rosenthal, 2022).

Functions of Public Health Agencies

States have autonomy in public health efforts promoting population health. In centralized governance structures, LHDs are a subsidiary of the SHD and follow the direction of the SHD in their efforts to protect and promote the health of residents. In decentralized governance structures, LHDs have autonomy in public health efforts to promote the safety and well-being of constituents. Since both SHDs and LHDs are tasked with promoting and protecting the health of residents in their districts, they may have overlapping roles.

Role of State Health Departments

State health departments have a variety of responsibilities within public health that include the governance functions of policy development, resource stewardship, legal compliance, partner engagement, continuous improvement, and oversight (PHLC, 2015).

  • Policy development
    • Contribute to developing policies to protect, promote, and improve public health.
    • Ensure the agency is consistent with laws, rules, and regulations.
  • Resource stewardship
    • Ensure the availability of necessary resources to implement the essential public health services. These resources may include finances, workforce, legal support, and technology.
  • Legal compliance
    • Exert legal authority as needed in the roles, responsibilities, and functioning of the governing body, health officers, and staff.
  • Partner engagement
    • Develop and fortify community partnerships through engagement and education.
    • Ensure teamwork and partnership among all relevant partners in promoting the community’s health.
  • Continuous improvement
    • Evaluate and monitor progress regularly.
    • Set measurable outcomes used to monitor the health status of the community.
    • Assess the health agency’s ability to meet its responsibilities.
  • Oversight
    • Accept responsibility for public health performance in the community.
    • Provide supervision and guidance as needed to support the agency in meeting established outcomes.

State health departments provide population-based public health services focusing on prevention—primary, secondary, and tertiary. SHDs promote health and well-being by ensuring access to health care services, focusing on prevention and health equity, and by ensuring water and food safety, ensuring children have access to all childhood vaccines, and overseeing the health care-related professions and services (Commonwealth of Massachusetts, 2023a). The box below presents the typical duties of state health departments.

Common State Health Department Duties

  • Epidemiological disease surveillance and data collection
  • State laboratory services
  • Preparedness and response to public health emergencies
  • Population-based health promotion and prevention strategies
    • Vaccine order management and inventory distribution
    • Tobacco cessation support
    • HIV and AIDS education on prevention, screening, and management
    • STI education, counseling, screening, treatment, and partner notification
    • Nutrition education
    • Physical activity education
  • Direct health care services
  • Regulation of health care providers and other licensed professionals
  • Environmental health
  • Technical assistance and training

(See PHLC, 2015.)

Role of Local Health Departments

LHDs coordinate public health activities in their jurisdiction and follow the SHDs rules and regulations. The responsibilities are diverse and will vary depending on state law (Commonwealth of Massachusetts, 2023b; PHLC, 2015). They may include:

  • Monitoring the health status of the community
  • Understanding health issues facing the community
  • Protecting the community from health problems and hazards
  • Educating the community on a variety of health topics to assist them in making healthy choices
  • Engaging the community in identifying and addressing health problems
  • Developing public health policies and plans
  • Enforcing public health laws and regulations
  • Assisting community members in accessing health services
  • Maintaining a competent public health workforce
  • Evaluating and improving programs and interventions
  • Enforcing state sanitary, environmental, housing, and health codes

LHDs are involved in many activities designed to keep communities safe and healthy. There are more than 3,000 LHDs across the nation, and these city, county, and tribal departments work to ensure the safety of food, water, and air, among many other activities (NACCHO, 2017). Examples of activities include immunizations, food safety, infectious disease control, long-term disease service, injury and violence prevention, tobacco control, emergency preparedness, maternal and child health, and environmental health (NACCHO, 2017).

Role of the Public Health Nurse

PHNs serve many roles across the public health spectrum and constitute the largest portion of the professional public health workforce (Association of Public Health Nurses [APHA], 2022). PHNs can meet the needs of a variety of clients, especially more vulnerable populations, due to a strong clinical nursing background and knowledge from both the public health and social sciences (APHA, 2022). Current PHN practice is moving toward public health work across disciplines to address the SDOH and improve community health by advancing a culture of health (ANA, 2022b). The Robert Wood Johnson Foundation created the Culture of Health in 2013 to improve all individuals’ health and well-being. It aligns with the public health nurse’s role in advancing health equity and strengthening the integration of health services and health systems by fostering cross-sector collaboration (ANA, 2022b).

Public health nursing is a specialty with roots in the sciences of nursing and public health. It focuses on population health at the community and systems levels, emphasizing health promotion, disease prevention, and risk reduction. Note that the work setting is not the defining characteristic of public health nursing; instead, it is the focus on population health and partnering with populations in communities as the foundation of public health nursing practice (ANA, 2022b). Examples of the PH nursing role may include:

  • Conducting health screenings such as blood pressure, weight, and depression
  • Leading group coaching sessions to assist individuals in setting SMART (specific, measurable, attainable, realistic, and timebound) personal health goals
  • Overseeing mass vaccination clinics
  • Designing outreach activities (such as addressing vaccine hesitancy) to vulnerable communities
  • Partnering with disaster relief agencies to assist individuals in accessing clean water and safe food
  • Managing directly observed therapy for active tuberculosis cases
  • Advocating for the needs of complex medical care clients within the community
  • Visiting community members in their homes to provide direct clinical care services

Public health nursing can be practiced in any location with a population of people:

  • Health departments
  • Schools
  • Community health centers
  • Visiting nursing
  • Health clinics
  • Correctional facilities
  • Occupational work sites
  • Mobile vans
  • Tribal government agencies
  • Churches or other faith-based programs
  • Rural health care
  • Refugee and immigrant clinics
  • Primary care clinics
  • Ambulatory outpatient facilities
  • Voluntary organizations
  • Homeless shelters

The primary role of the PHN is to promote, protect, and improve the health and welfare of the public. PHNs develop, deliver, and evaluate services and programs that focus on the health of populations while collaborating with many entities and serving as a safety net for vulnerable populations (ANA, 2022b).

Public Health Nursing: A Career with Meaning

This short video highlights the role of the public health nurse.

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

  1. One nurse in the video says that public health nurses look at health in a holistic way. What does this mean?
  2. When making home visits, public health nurses enter a client’s “space.” What are some possible challenges with caring for clients in their homes? What are some benefits?

Public health departments help build and maintain healthy communities, states, and the nation. Every 10 years, the Department of Health and Human Services’ Healthy People goals and targets establish the nation’s health improvement priorities. By supporting policy, advocacy, and education, nursing has a great impact on public health especially in the areas of immunizations, infection prevention, environmental health, and the response to the opioid crisis (ANA, n.d.). PHNs have the knowledge, skills, and leadership abilities to promote a culture of health by improving the health of individuals, families, and communities and heeding the call of The National Academy of Medicine’s report, The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity (ANA, 2022).

The Spirit of Healing: Faith Community Nursing

Faith-based nursing, also known as parish nursing or faith community nursing, focuses on the client’s spiritual care to prevent or minimize illness and promote holistic health care (Galan, 2023). The purpose of this specialty is to nurture the human spirit with health education and spiritual support while connecting the client to resources within the congregation or faith community.

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

  1. What is the relationship between the role of faith-based or faith community nursing and community health?
  2. What roles did you see these faith-based nurses taking in the care of their clients?
  3. How did the relationships that the parish nurse cultivated with her clients empower the clients to take action to promote their own health and well-being?
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