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Population Health for Nurses

35.1 Learning from the Past to Guide the Future

Population Health for Nurses35.1 Learning from the Past to Guide the Future

Learning Outcomes

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

  • 35.1.1 Describe lessons learned from the past that continue to inform population health practices and decision-making.
  • 35.1.2 Discuss progress in improving health.
  • 35.1.3 Explain how epidemiological principles will remain essential for the community and public health nurse to safeguard and advance public health.
  • 35.1.4 Recognize how the community and public health nurses can learn from past successes and failures to address emerging health challenges
  • 35.1.5 Identify emerging and persisting population health challenges.

Reflecting on past public health crises is essential to improving preparedness and response strategies and understanding disease processes. These reflections offer invaluable insights that inform decision-making, policy development, and interventions in the face of emerging or recurring health threats. Previous achievements, such as eradicating smallpox and reducing infectious diseases through vaccination programs, demonstrate the success of evidence-based interventions, robust health care systems, and coordinated efforts across the industry. Community and public health nurses have played a significant role in these accomplishments, serving as leaders, researchers, educators, advocates, and collaborative health care partners.

Lessons Learned

Studying past disease outbreaks such as bubonic plague (“Black Death”), the 1918 flu (“Great Influenza”), and HIV can provide insight into managing infectious diseases. Learning from previous public health responses can inform future preparedness, response planning, and interventions. For example, during the COVID-19 pandemic, public health officials coordinated efforts, established infection control guidelines, implemented containment measures, and conducted disease surveillance based on lessons learned from the Great Influenza (Ott et al., 2007).

Lessons from previous hemorrhagic fever outbreaks, such as the Ebola virus, also offered critical insights for effectively managing and responding to the COVID-19 pandemic. Despite their distinct characteristics and diverse pathogens, several vital takeaways from Ebola outbreaks were relevant to the COVID-19 crisis. For example, the Ebola outbreaks demonstrated the need for swift detection and prompt response (Ott et al., 2007).

Past infectious disease outbreaks have also highlighted the significant impact of stigma and discrimination on affected individuals, communities, and public health responses by discouraging individuals from seeking care, reporting symptoms, or adhering to preventive measures. Stigmatizing attitudes and behaviors can lead to fear, secrecy, and concealing information, which hinder disease surveillance, contact tracing, and timely interventions. For example, during the Ebola epidemic in Liberia (2014–2016), many Liberians avoided seeking care or reporting a loved one’s death out of fear that their cultural beliefs and practices, such as washing and touching the deceased’s body, would be scrutinized and violated (Centers for Disease Control and Prevention [CDC], 2019). Health officials deemed such practices high risk as they put individuals in direct contact with the virus during a highly infectious period. This fear and practice impeded surveillance and hindered disease containment efforts. As a result, officials recognized the need to work with communities to adapt burial practices to minimize transmission risks while respecting the freshly deceased. This involved promoting safe burial protocols that minimized direct contact with the deceased (Sencer, 2023). Figure 35.2 depicts a burial team managing the body of an individual who may have died from Ebola infection (Sencer, 2023).

A person wearing full-coverage protective medical clothing kneels in a burial field in which many small wooden crosses stick up from the dirt. Three people in regular clothing stand around this person holding shovels.
Figure 35.2 A burial team in Sierra Leone conducts a safe, respectful burial for an individual who is suspected of having died from Ebola. Improving burial practices during the Ebola outbreak in Africa involved a multifaceted approach that recognized the importance of addressing cultural and community preferences. (credit: “The last burial: Alfred Kelfala from the roving Freetown Ebola burial team carefully lowers the corpse of a small child into its grave” by Simon Davis/DFID/Flickr, CC BY 2.0 DEED)

Building trust and engaging communities is indispensable for successful outbreak responses. Involving communities in disease surveillance, contact tracing, and outbreak control measures has proven effective in prior outbreaks and has been applied in the COVID-19 response.

As Pandemics and Infectious Disease Outbreaks discussed, disease surveillance primarily begins in local, state, and territorial public health departments. The COVID-19 pandemic exposed flaws in establishing effective disease surveillance systems worldwide. Outdated and inaccurate health information, insufficient resources, inadequate public health capacity, and leadership capabilities all hindered global efforts to improve health during the pandemic. Moreover, the pandemic highlighted the limitations of data collection and monitoring beyond the early stages of an outbreak. Therefore, timely and structured public data sharing across countries is paramount. These lessons learned will shape the future of disease surveillance, leading to policies, interventions, and programs that improve population health outcomes and shape the future of public health (Filip et al., 2022).

Theory in Action

Five Hard-Earned Lessons from Pandemics of the Past

The article linked below describes strategies populations have used throughout history to survive a pandemic.

Read the article, and then respond to the following questions.

  1. Define the Miasma Theory of disease spread.
  2. Describe five ways people adapted to life amid disease outbreaks historically.
  3. Do you think that the strategies used in the past are still relevant and effective for today and the future? Why or why not?

Gaining Insight

As noted in What Is Population Health?, population health involves the health outcomes of a group of people in a population, including how those outcomes are distributed. It considers different factors that influence health, such as social determinants, economic conditions, access to health care, and individual behaviors. Population health takes a comprehensive approach, considering societal and environmental factors contributing to health disparities and inequalities beyond the traditional health care system.

As discussed in Foundations of Public/Community Health, public health is vital to improving population health. Public health initiatives and interventions, such as immunization campaigns, health education programs, screening and early detection efforts, and policies to reduce environmental hazards, are population health strategies. By addressing the underlying determinants of health and implementing evidence-based interventions, public health aims to improve the health outcomes of entire populations.

At the community level, community health nurses play a crucial role in implementing public health initiatives. As noted in Public/Community Health in Practice, community health nursing refers to the health status and well-being of a specific community or a group of individuals who share common characteristics, such as geographic location, cultural background, or a particular interest. It emphasizes the health of a localized group within a larger population. Community health considers the unique characteristics, needs, and challenges of the specific community being studied. It involves assessing the community’s health needs, implementing interventions to address them, and evaluating their impact. It often involves collaborations with community members, local organizations, and health care providers to improve health outcomes.

Each function—population health, public health, and community health—aims to enhance the health and well-being of populations through a multifaceted, holistic approach that addresses the interplay of factors impacting health outcomes. Nurses can gain insight from past experiences, both successful and unsuccessful, to employ evidence-based practices and customize strategies to tackle new health challenges at various levels. The past has yielded valuable lessons guiding public and community health practices, particularly in epidemiology and health policy.

Public health nurses like Josh employ a multifaceted, reflective approach. Josh works in a low-income neighborhood where residents face various health challenges, such as high rates of chronic diseases, inadequate housing, limited access to health care facilities, and food insecurity. Josh recognizes that these issues are deeply rooted in systematic inequities and that meaningful change necessitates a comprehensive approach involving population health, public health, and community health. He is aware that each function aims to improve health and well-being by addressing the complex interplay of factors that affect health outcomes. Learning from past experiences, Josh can use evidence-based practices to customize strategies to tackle these challenges at different levels through collaborations with community members, local organizations, and health care providers.


As discussed in Epidemiology for Informing Population/Community Health Decisions, epidemiologists study disease patterns, causes, and risk factors in populations. Past epidemiological studies have produced valuable information regarding disease patterns, health determinants, and risk factors that continue to influence health care decisions. By analyzing biological data, nurses can recognize patterns, comprehend the effects of interventions, and predict potential health outcomes. Epidemiological studies that have made significant contributions include:

  • Framingham Heart Study: Initiated in 1948, this longitudinal study has been instrumental in identifying and understanding cardiovascular disease risk factors for three generations. It has helped establish the link between smoking, high blood pressure, high cholesterol levels, and the development of heart disease. The findings from this study led to the development of preventive measures such as smoking cessation programs, blood pressure control strategies, and cholesterol-lowering interventions (Framingham Heart Study, n.d.).
  • Nurses’ Health Study (NHS3): Initiated in 1976, this long-term cohort study provides valuable insights into various health conditions. It has helped identify risk factors for chronic diseases, including breast cancer, colon cancer, and cardiovascular disease. In addition, the study has contributed to understanding the impact of lifestyle factors, such as diet, physical activity, and hormone use, on disease development and prevention (Nurses’ Health Study, n.d.). Now in its third generation, the Nurses’ Health Study continues to investigate various aspects of women’s health and to identify risk factors for chronic diseases.
  • Global Burden of Disease Study (GBD): The GBD study, initiated in the 1990s, is a comprehensive effort to quantify the global impact of diseases, injuries, and risk factors. It provides data on the prevalence, mortality, and disability associated with various health conditions, helping policymakers and health professionals prioritize interventions and allocate resources effectively. The GBD study has informed strategies for disease prevention, control, and health care planning worldwide (Institute for Health Metrics and Evaluation, 2020).
  • Human Papillomavirus (HPV) Vaccine Trials: Epidemiological studies evaluating the safety and efficacy of HPV vaccines have been pivotal in shaping current vaccination practices. These studies demonstrated the effectiveness of HPV vaccines in preventing cervical cancer and other HPV-related diseases. In addition, the findings from these trials led to the implementation of widespread HPV vaccination programs to reduce the burden of cervical cancer and associated conditions (CDC, 2021).
  • Prospective Urban Rural Epidemiological (PURE) Study: The PURE study is a large-scale global cohort study that examines the impact of lifestyle, environmental, and societal factors on cardiovascular disease and other chronic diseases. It has advanced understanding of the complex interactions between various risk factors and health outcomes, providing evidence for targeted interventions at the individual and population levels. The PURE study has involved 225,000 participants in 27 countries (Population Health Research Institute, 2023).

Theory in Action

Prospective Urban and Rural Epidemiological Study

This short video provides an overview of the PURE study.

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

  1. Identify three focus areas of the PURE study.
  2. What is a modifiable risk factor for health that the PURE study has identified?
  3. What is the expected pattern of cancer worldwide over the next decade?

In public and community health, nurses will continue to rely on epidemiological principles to study patterns within groups or communities, analyze the occurrence of diseases and injuries, and develop strategies to prevent illnesses and improve overall health. Table 35.1 illustrates how community and public health nurses will continue to utilize epidemiological principles in their practice.

Epidemiological Principle Application
Surveillance and data analysis
  • Collect and analyze data to monitor the occurrence and distribution of diseases.
  • Public health nurses collaborate with epidemiologists to contribute to disease surveillance efforts. In addition, they play a vital role in data collection, reporting, and analysis at the community level.
  • Public health nurses often work on disease incidence, prevalence, and other relevant health indicators in local health departments, clinics, or communities. This collaboration helps identify public health trends, track outbreaks, and inform targeted interventions.
Disease investigation and outbreak response
  • When outbreaks or disease clusters occur, epidemiologists investigate the causes, risk factors, and modes of transmission.
  • Community and public health nurses work closely with epidemiologists in outbreak investigations, assisting with contact tracing, case management, and implementing control measures. In addition, they provide direct care to affected individuals, educate the community on prevention strategies, and collaborate with other health care providers to contain and manage the outbreak.
Program planning and evaluation
  • Epidemiological studies provide evidence for designing effective public health interventions and programs.
  • Community and public health nurses contribute their program planning, implementation, and evaluation expertise. They use epidemiological data to identify priority health issues, set program goals and objectives, and develop strategies for intervention.
  • Community and public health nurses also assess the effectiveness and impact of programs, ensuring that they are evidence-based and meet the community’s needs.
Health promotion and disease prevention
  • Epidemiological findings guide public health nursing interventions in health promotion and disease prevention. Epidemiology helps identify risk factors and determinants of disease, allowing public health nurses to develop targeted interventions to address those factors.
  • Community and public health nurses educate individuals and communities on healthy behaviors, administer vaccinations, conduct screenings, and promote lifestyle modifications based on epidemiological evidence.
Research and evidence-based practice
  • Epidemiology generates evidence that informs public health nursing practice and research.
  • Community and public health nurses contribute to epidemiological research by collecting data, participating in studies, and implementing evidence-based interventions. In addition, they translate epidemiological findings into practice, adapting interventions to meet the needs of diverse populations and settings.
Advocacy and policy development
  • Epidemiological data are essential in advocating for public health policies and influencing health-related legislation.
  • Community and public health nurses use epidemiological evidence to advocate for interventions, resource allocation, and policies that promote population health. They collaborate with policymakers and community organizations to shape public health policies and strategies based on epidemiological findings.
Table 35.1 Examples of How Community and Public Health Nurses Utilize Epidemiological Principles

Policy and Legislative Changes

Historical public health policy and legislation changes have improved population health. For example, implementing smoking bans, seat belt laws, and food safety regulations has positively impacted health outcomes. Policy and legislative changes have improved access to health care services and health care coverage. Implementing the Affordable Care Act (ACA) expanded insurance coverage and prohibited insurers from denying coverage based on preexisting conditions. Such policies aim to ensure more individuals have affordable access to essential health care services, reducing barriers to care and improving population health.

Historical advocacy efforts have driven significant progress in improving population health. Examples include campaigns for safe working conditions and access to clean water. By learning from past advocacy successes, community and public health nurses can build on previous achievements, mobilize communities, and drive policy changes to address current and future health challenges. Understanding the impact of policy changes in the past can inform the development and implementation of effective policies in the future, addressing emerging health challenges and promoting health equity.

Looking at historical experiences allows nurses to recognize the influence of social, economic, and ecological factors on population health. Historical data can reveal disparities in health outcomes, the impact of social movements on public health, and the effectiveness of interventions targeting social determinants of health.

Reflecting on past public health practices raises critical ethical concerns. Historical examples of unethical medical research, such as the Tuskegee syphilis study, have influenced the development of ethical guidelines and regulations in public health research and practice. Learning from the past helps ensure that future public health initiatives prioritize ethics, protect human rights, and prioritize the well-being of individuals and communities.

By drawing on the past, public community and public health nurses can learn from successes and failures, apply evidence-based approaches, and adapt strategies to address emerging health challenges. Historical experiences inform the development of effective interventions, policies, and programs, ultimately shaping the future of public health and improving population health outcomes.

Collecting and analyzing historical data is invaluable to public health nurses like Josh. Josh works in a neighborhood characterized by socioeconomic disadvantage, limited access to health care services, and various health disparities. The community faces multiple health challenges, including high rates of chronic diseases, substance use, mental health issues, and limited health literacy.

Josh recognizes the importance of evidence-based practice and the valuable insights that historical data can provide to guide his population’s health initiatives. He collects historical data from various sources, including electronic health records, public health databases, and community surveys. He identifies vital health indicators such as prevalence rates of chronic diseases, immunization coverage, and social determinants of health. Josh carefully analyzes the data, looking for patterns, trends, and disparities across different populations. By disaggregating the data by demographic factors like age, gender, ethnicity, and socioeconomic status, he better understands health needs and disparities within the population. During Josh’s engagement with community members, he identifies a level of mistrust of the public health system. Josh takes additional time to reflect on events from the past that may be influencing community members’ attitudes and levels of fear and avoidance of the public health system.

Sustaining and Expanding Progress

As discussed in Foundations of Public/Community Health, the United States has significantly improved health outcomes and promoted population health. Although progress has been made over the last decade in improving public health and health care outcomes, there are ongoing challenges to address, and future directions must focus on sustaining and expanding these gains.

  • Increased Life Expectancy: Historically, life expectancy in the United States has risen steadily over the decades. Advances in medical treatments, public health interventions, and improvements in health care access have contributed to longer lifespans (Buxbaum et al., 2020). However, since 2015, the United States has seen a decline in life expectancy, primarily driven by the opioid epidemic and the COVID-19 pandemic. Additionally, life expectancy disparities persist across different demographic groups and geographic regions. For example, between 2020 and 2021, life expectancy among Native American and Alaska Native communities was shortened by 2 years, the largest drop of any demographic group (Klobucista, 2022).
  • Decline in Mortality Rates: Mortality rates for significant causes of death, such as heart disease, stroke (Mensah et al., 2017), and certain cancers, have declined in the United States (National Institutes of Health [NIH], 2022a). The decrease in the incidence of certain diseases can be attributed to the progress in medical treatments, enhanced prevention strategies, and improved management of chronic illnesses. However, it is crucial to acknowledge that there are still racial and ethnic inequalities. For instance, from 2014 to 2018, the occurrence rates of bladder cancer decreased among non-Hispanic White, non-Hispanic Black, non-Hispanic Asian/Pacific Islander, and Hispanic men. However, rates increased among non-Hispanic American Indian and Alaska Native (AI/AN) men (NIH, 2022a). Additionally, increasing maternal morbidity and mortality rates disproportionately affect Black/African American and AI/AN women (National Academies of Sciences, Engineering, and Medicine [NASEM], 2021).
  • Reduction in Smoking Rates: The prevalence of smoking in the United States has significantly decreased in recent decades. This decline can be attributed to comprehensive tobacco control policies, public health campaigns, and increased awareness about the harmful effects of smoking. In addition, reducing smoking has resulted in improved cardiovascular health and decreased smoking-related diseases (NIH, 2022b). Preventing smoking initiation among youth and young adults remains a challenge. Despite progress, some young individuals are still drawn to tobacco products due to factors like peer pressure, social influences, and aggressive marketing tactics by the tobacco industry. Smoking can be influenced by broader societal factors such as stress, mental health challenges, and socioeconomic disparities. Smoking rates continue to be higher among certain populations, including those with lower education levels and lower income. Addressing these disparities requires targeted interventions and tailored approaches. Addressing these underlying issues is critical for effective smoking cessation efforts (Chaiton et al., 2016).
  • Vaccinations: Vaccinations have led to a decline in vaccine-preventable diseases. Immunization efforts, including childhood vaccination programs and targeted campaigns for specific populations, have contributed to controlling and eliminating diseases such as smallpox (Figure 35.3). However, globally, coverage has plateaued over the last decade, with an estimated 25 million children under the age of 1 year not receiving essential vaccines in 2021, which is six million more children than before the beginning of the COVID-19 pandemic in 2019. Additionally, there were 18 million children who did not receive any vaccines, called “zero-dose,” which is the highest this number has been since 2005 (CDC, 2023).
A person in military fatigues injects a needle into the thigh of a small child. The child sits on an adult’s lap while two other adults look on in the background.
Figure 35.3 Globally, childhood vaccination rates have plateaued over the last decade, with an estimated 25 million children under the age of 1 year not receiving essential vaccines, the highest number since before the start of the COVID-19 pandemic in 2019. (credit: “A Sailor gives a child a vaccine at the Angaur Community Center, Sept. 27, 2019” by Haley McMenamin/U.S. Marine Corps/Flickr, CC BY 2.0 DEED)
  • Advances in Medical Technology: Advancements in medical technology have improved the diagnosis, treatment, and management of various health conditions in the United States. Innovations such as minimally invasive surgeries, precision medicine, telemedicine, and electronic health records have enhanced client care and health outcomes (Thomas, 2022). However, underserved communities face numerous challenges in accessing advanced medical technologies, including financial constraints, inadequate health care infrastructure, and the digital divide. The digital divide refers to the gap between individuals, communities, or groups who have access to and use digital technologies, such as computers, smartphones, and the internet, and those who do not. To ensure that everyone has equal access to quality health care, these challenges must be addressed. Additionally, culturally sensitive care and effective communication are essential to promote equitable health care for all (Saeed & Masters, 2021).
  • Expanded Health Insurance Coverage: The ACA is a comprehensive U.S. health care reform law enacted in March 2010. It represents one of the most significant changes to the country’s health care system in recent history. Its primary goals were to increase access to health care coverage, improve the quality of care, and control health care costs. Although the ACA expanded health insurance coverage to millions of previously uninsured individuals and improved access to care, several gaps and challenges persist. For example, the ACA provides subsidies to help individuals and families afford health insurance, but some people, especially those with moderate incomes who do not qualify for subsidies, still face challenges affording premiums, deductibles, and other out-of-pocket costs.
  • Increased Access to Health Care Services: Increased access has resulted in improved preventive care, early diagnosis, and management of chronic conditions (Antonisse et al., 2022). However, access to mental health and substance misuse continues to be an issue. For example, although the ACA required insurance plans to cover mental health and substance use disorder services, barriers to accessing timely and comprehensive care and disparities in coverage still exist. Additionally, some rural areas still face challenges in accessing health care services due to limited provider availability, lack of specialists, and health care facility closures. The ACA explicitly excluded undocumented immigrants from accessing its benefits, including health insurance marketplaces and Medicaid. This has resulted in a lack of coverage options for this population, which can lead to barriers in accessing timely and preventive care.
  • Health Equity Initiatives: There has been a growing recognition of health disparities and efforts to address them. Initiatives focused on health equity aim to reduce differences in health outcomes across different racial, ethnic, and socioeconomic groups. This includes targeted interventions, community-based programs, and policy changes to address the social determinants of health (CDC, 2020). Despite efforts to improve access to care, barriers such as lack of insurance, geographic location, language barriers, and cultural factors continue to limit health care access for marginalized communities. Health equity initiatives often focus on health care delivery, but addressing the social determinants of health, such as income, education, housing, and employment, is crucial for achieving lasting improvements in health outcomes.

Challenges to Improving Health Outcomes

While progress has been made in improving U.S. health outcomes, several ongoing challenges and disparities contribute to differences in health outcomes among different populations. Efforts to improve health further will require investing in public health infrastructure (organizational structures and functions that support health equity), addressing social determinants of health, expanding access to health care, and promoting health equity for all populations (CDC, 2020). Looking ahead to the future, the United States is poised to confront significant health care challenges in the coming decade. These issues include access to care, health care disparities, an aging population, chronic illnesses, mental health, substance misuse, and a shortage of health care professionals. A comprehensive and collaborative approach that involves public health agencies, health care providers, policymakers, community organizations, and individuals is needed to address these challenges. Such collaboration will improve population health and promote equity in health care.

Access to Care

Despite expanding health insurance coverage through the ACA, some individuals and communities still need affordable health insurance. Lack of insurance can result in delayed or inadequate health care, leading to poorer health outcomes. Even with insurance coverage, individuals may face limitations in the services covered. Some plans may restrict specific treatments, medications, or procedures, creating barriers to accessing necessary care.

Health insurance plans often have networks of contracted health care providers. These networks may vary by state, and coverage may be limited to providers within a specific geographic area. When individuals travel or need care outside their insurance network’s coverage area, they may face out-of-network costs or have limited access options. Individuals may also have limited access to certain specialists or health care facilities. Limited coverage networks can also restrict access to preferred health care providers or specialists, particularly in rural or underserved areas.

Rural communities often face challenges accessing health care due to distance, provider shortages, and limited infrastructure. This can lead to delayed or inadequate care, resulting in poorer health outcomes for rural populations. Attracting and retaining health care professionals in rural areas can be challenging, leading to a lack of health care providers. Limited transportation options can hinder individuals from reaching health care facilities, particularly in emergencies. Rural populations may have lower income levels and limited health insurance coverage, impacting their ability to afford health care services. Many rural communities have aging populations with unique health care needs, including chronic disease management and geriatric care (Teo et al., 2009). Improving rural health care requires strategic investments and innovations in nurse-led clinics, nurse-managed health centers, and mobile health care units to reach underserved areas. Public and community health nurses play a transformative role in enhancing the health and well-being of residents.

Administrative complexities, such as paperwork requirements, annual renewals, or frequent changes in coverage options, can act as barriers to obtaining and maintaining health insurance coverage. Individuals may find it challenging to navigate bureaucratic processes, leading to gaps in coverage or delays in accessing care. For some clients, limited health literacy and inadequate health education contribute to challenges in understanding and navigating the health care system, making informed health decisions, and adopting healthy behaviors. Addressing health literacy gaps and promoting health education is essential for improving health outcomes.

Health Disparities and Social Determinants

Disparities in health outcomes exist across various demographic groups, including racial and ethnic minorities, low-income populations, rural communities, and marginalized groups such as members of the LGBTQIA+ community. The social determinants of health, such as socioeconomic status, education, access to health care, and structural racism, influence these disparities. Eliminating social inequities promotes social justice and creates a healthier environment for all. For example, maternal and infant health disparities persist, with higher rates of preterm birth, low birth weight, and infant mortality among certain racial and ethnic groups. Improving access to care, addressing social determinants of health, and promoting health equity are crucial in addressing these disparities.

Policy and legislative changes can address social determinants of health and promote health equity. This includes policies that reduce health disparities and improve health outcomes among marginalized populations. For instance, policies may target poverty reduction, education reform, affordable housing, and employment opportunities to address the root causes of health inequities. Legislation can also support programs and services targeting underserved communities and providing resources to address their unique health care needs. For example, the American Hospital Association (2016) considers these health care services essential to address heath disparities:

  • Primary care
  • Psychiatric and substance use treatment services
  • Emergency department and observation care
  • Prenatal care
  • Transportation
  • Diagnostic services
  • Home care
  • Dentistry services
  • A robust referral structure to provide all individuals in the community with access to the full spectrum of health care services

Policy and legislative changes are critical in driving population health improvements. They provide a framework for allocating resources, guiding health care delivery, and addressing systemic factors influencing health outcomes. By implementing effective policies and enacting supportive legislation, governments can create an environment that fosters better health for populations, promotes health equity, and addresses the social, economic, and environmental determinants of health.

Chronic Diseases

Chronic illnesses, such as heart disease, diabetes, and certain types of cancer, significantly impact overall health, mortality rates, and health care expenses. The aging population will undoubtedly lead to a surge in the need for health care to manage chronic diseases. The management and extensive care required for age-related health issues, including cardiovascular diseases, dementia, and diabetes, will pose a considerable challenge.

A crucial step in tackling the burden of chronic diseases is shifting attention toward prevention rather than treatment. This involves targeting risk factors, promoting healthy behaviors, and implementing early detection strategies to reduce the occurrence and impact of chronic conditions. The challenge lies in prioritizing this shift toward prevention and health promotion. Investing in preventive measures, such as promoting healthy lifestyles, early detection, and screening programs, can significantly reduce the burden of chronic diseases and enhance overall population health outcomes.

Regular screenings and early detection programs play a role in preventing and managing chronic diseases. These screenings help identify potential risk factors and detect diseases in their initial stages when they are more treatable. Examples of effective screening programs include mammograms for breast cancer, colonoscopies for colorectal cancer, and blood pressure checks for hypertension. The goal is to prevent the development of chronic diseases by creating supportive environments and enabling healthy choices. Adopting a preventive approach can impact entire populations, reducing health disparities and improving the overall health of communities.

Preventing chronic diseases requires a comprehensive approach that targets high-risk individuals, promotes health among the general population, and creates supportive environments for healthy choices. This approach necessitates improving health care systems, public health initiatives, education, policy changes, and technological advancements at each of the three prevention levels: primary, secondary, and tertiary (Table 35.2).

Enhancing Primary Prevention
  • Health Education and Promotion: Invest in widespread health education campaigns using innovative digital platforms, social media, and interactive apps to reach diverse populations and promote healthy lifestyles.
  • Early Childhood Interventions: Focus on early childhood nutrition, education, and development to establish a strong foundation for lifelong health. Implement policies that ensure access to quality early childhood education and health care.
  • Environmental Policies: Advocate for policies that improve air quality, promote physical activity, and encourage healthy eating by creating walkable communities, green spaces, and healthier food environments.
Strengthening Secondary Prevention
  • Innovative Screening Technologies: Invest in advanced screening technologies that enable earlier detection of diseases with higher accuracy, reducing false positives and unnecessary interventions.
  • Telehealth and Remote Monitoring: Utilize telehealth for remote monitoring of high-risk individuals, ensuring timely interventions and reducing the burden on health care facilities.
  • Personalized Risk Assessment: Develop algorithms that use individual health data to identify personalized risk factors, enabling targeted early interventions.
Advancing Tertiary Prevention
  • Home-Based Care: Expand home health care services and incorporate telemedicine to monitor and support clients with chronic conditions, reducing hospital readmissions.
  • Palliative and Hospice Care: Increase access to high-quality palliative and hospice care services for individuals with advanced and terminal illnesses, focusing on improving their quality of life.
  • Rehabilitation and Support Services: Invest in advanced rehabilitation technologies and therapies to help clients regain functionality and independence after surgeries or injuries.
Table 35.2 Preventing Chronic Diseases: Three Prevention Levels

Mental Health and Substance Use Disorders

As noted in Caring for Populations and Communities in Crisis, the increasing number of individuals experiencing mental health and substance use disorders poses a challenge to the health care system. Mental illnesses, such as depression, anxiety disorders, bipolar disorder, and schizophrenia, are characterized as chronic diseases because they are typically long-term and persistent, impact an individual’s daily functioning and quality of life, and require continual management (Park et al., 2008). Ongoing public health concerns include access to mental health care, the stigma associated with mental illness, and integrating mental health services within the broader health care system.

Improving mental health care requires a thorough approach that involves policy changes, increased funding, public education, and better access to care. Several strategies can be implemented, such as expanding insurance coverage for mental health services, providing supportive housing, increasing funding for mental health programs and workforce development, providing telehealth services to improve access, reducing stigma through education and awareness campaigns, and promoting integration between mental health and primary care services (Mental Health America, 2023).

The U.S. opioid epidemic is another persistent challenge. Prescription opioid misuse and overdose fatalities are widespread, and substance misuse issues, including alcohol and illegal drug use, pose significant risks to individuals and communities (Mental Health America, 2023). Community/public health nurses are on the front lines of responding to opioid overdoses.

Naloxone is used to rapidly reverse the effects of opioid overdose and is the standard treatment for overdose cases. To increase access to naloxone products, the U.S. Food and Drug Administration (FDA) has taken several measures, including approving a 4 milligram (mg) naloxone hydrochloride nasal spray for over-the-counter (OTC) and nonprescription use. This is the first naloxone product approved for use without a prescription (FDA, 2023). Nurses working within community settings must be trained to administer naloxone (Narcan) and be prepared to provide immediate care to individuals who have overdosed. Ensuring timely access to naloxone and educating the community on its use is a necessity to prevent overdose deaths.

Community and public health nurses can conduct outreach programs and educational sessions to increase awareness about the availability of naloxone over the counter and the importance of calling 911 after administering the medication. Timely access to naloxone and educating the community on its use is crucial in preventing death from opioid overdoses. For example, using naloxone nasal spray on individuals dependent on opioids may result in severe withdrawal symptoms. These symptoms include body aches, diarrhea, increased heart rate, fever, runny nose, sneezing, goosebumps, sweating, yawning, nausea or vomiting, nervousness, restlessness or irritability, shivering or trembling, abdominal cramps, weakness, and increased blood pressure. Nurses must be prepared to handle and support these symptoms in a community setting. See Table 35.3.

Challenges Nursing Implications
Shift to Synthetic Opioids: As the opioid landscape changes, synthetic opioids like fentanyl are becoming more prevalent. These substances are highly potent and pose a higher risk of overdose (Drug Enforcement Administration, 2021). Nurses must be aware of the latest opioid-use trends, including the rise of synthetic opioids. They should be trained to recognize the signs of opioid overdose and be prepared to administer naloxone (Narcan), an opioid reversal medication, as needed.
Access to Treatment and Recovery Services: Many individuals struggling with opioid use disorder face barriers in accessing treatment and recovery services due to limited availability, stigma, and financial constraints (AACN, 2021a). Nurses can advocate for increased funding and resources for addiction treatment and recovery programs. They can also play a role in connecting individuals to available services, providing education about treatment options, and offering support throughout the recovery process.
Co-occurring Mental Health Disorders: Opioid use disorder often co-occurs with mental health disorders such as depression and anxiety, making treatment more complex (Substance Abuse and Mental Health Services Administration, 2023). Nurses should be skilled in assessing both substance use disorders and mental health conditions. Integrated care that addresses both aspects of a client’s health is crucial for effective treatment.
Neonatal Abstinence Syndrome (NAS): Pregnant individuals who use opioids can give birth to babies with NAS, which requires specialized care (AACN, 2021a). Nurses caring for pregnant individuals with opioid use disorder must collaborate closely with obstetricians, neonatologists, and addiction specialists to provide comprehensive care that supports the parent’s well-being and the newborn’s health.
Stigma and Discrimination: Stigma surrounding opioid use disorder can hinder individuals from seeking help and can affect their overall well-being. Nurses should provide nonjudgmental, compassionate care to individuals with opioid use disorder, focusing on reducing stigma and creating a safe environment where clients feel comfortable discussing their needs.
Harm Reduction Strategies: Harm reduction approaches, such as supervised injection sites and needle exchange programs, are debated but may be essential in preventing overdose deaths and the spread of infections (Thakarar et al., 2020). Nurses can be advocates for harm reduction strategies, engaging in public health discussions, educating communities about their benefits, and supporting initiatives that provide safe spaces for substance use.
Interdisciplinary Collaboration: Addressing the opioid epidemic requires collaboration across health care disciplines, law enforcement, public health agencies, and community organizations (The Overdose Response Strategy, 2018). Nurses are well-positioned to serve as advocates and leaders in interdisciplinary teams. They can foster communication and cooperation among various partners to develop comprehensive prevention, treatment, and recovery strategies.
Education and Prevention: Educating the public, health care professionals, and policymakers about the risks of opioid misuse, proper pain management, and available resources is essential to curb the epidemic (AACN, 2021a). Nurses can engage in public awareness campaigns, educate clients and families about safe medication use, and participate in policy discussions to promote evidence-based opioid prescribing practices.
Table 35.3 Challenges and Nursing Implications of the Opioid Epidemic (See Mental Health America, 2023.)

Addressing these challenges and disparities requires a multi-faceted approach that includes improving access to health care, addressing social determinants of health, promoting health equity, expanding preventive services, and investing in public health infrastructure. Collaboration among health care providers, policymakers, community organizations, and individuals is needed to create meaningful, sustainable change (Mental Health America, 2023).

Health Care Workforce Shortages

The scarcity of health care professionals, including doctors, nurses, and allied health workers, will escalate in the coming years. A workforce shortage arises when the availability of skilled workers in a specific location at the required time is inadequate to meet the target audience’s demands (Lopes et al., 2015). These shortages could easily overload the health care system’s ability and significantly restrict health care access, particularly in underprivileged regions. It is, therefore, imperative to boost the health care workforce, enhance recruitment and retention efforts, and explore innovative care delivery models to address this pressing issue.

According to the Association of American Medical Colleges (AAMC) (2021), the United States will face a shortage of up to 124,000 physicians by 2034. A workforce analysis of registered nurses (RNs) projects a shortage throughout the United States through 2030. The analysis shows that almost 30 states will face a significant deficit of RNs (American Association of Colleges of Nursing [AACN], 2022). California, Florida, and Texas will have the highest shortage in terms of RN job numbers. In contrast, New Mexico, Arizona, and Nevada will have the most substantial shortages based on the ratio of RNs per 100,000 individuals. Massachusetts and South Dakota are the only states projected to show an RN surplus in 2030 (Juraschek et al., 2019; World Health Organization [WHO], 2023).

Shortages in the health care workforce can result from factors such as demographics, education, training, work environment, and economics. The aging population significantly contributes to the increased demand for health care services, as older individuals need more medical care and chronic disease management. The limited number of qualified educators can create a bottleneck in education, leading to fewer health care professionals (AACN, 2021b). Shortages are usually more prominent in specific specialties or geographic locations, resulting in disparities in access to care (AAMC, 2021). High-stress environments and heavy workloads can cause burnout and attrition among health care professionals. Public health emergencies can also strain health care systems, leading to workforce shortages as health care professionals face increased demands (NASEM, 2019).

The nursing shortage can lead to errors and higher morbidity and mortality rates. In medical facilities with a high client-to-nurse ratio, nurses often experience burnout and dissatisfaction, and clients face increased mortality and failure-to-rescue rates compared to facilities with lower ratios. Although a few states have implemented laws to limit client-to-nurse ratios, when staffing is insufficient, ratios tend to rise to meet demand (Haddad et al., 2023).

The COVID-19 pandemic revealed a lack of adequate public health infrastructure and workforce in several regions (Pittman & Park, 2021). The decline in RNs employed in clinic- and non-clinic-based community/public health jobs undoubtedly impacted the lack of a public health workforce. Clinic-based jobs fell from 3.5 percent (76,127) in 2000 to 1.6 percent (53,084) in 2018. At the same time, non-clinic-based community/public health jobs dropped from 3.2 percent (69,837) in 2000 to just 1.4 percent (47,226) in 2018 (Pittman & Park, 2021). Figure 35.4 illustrates the drop in employment among RNs working in community and public health sectors.

A line graph shows the percent of all RNs in community or public health in the United States from 2000 to 2018. The number of RNs who worked in clinical community/public health jobs decreased from 3.5% in 2000 to about 1.75% in 2018, with the biggest drop occuring between 2000 and 2004. The number of RNs who worked in non-clinical community/public health decreased from 3.25% in 2000 to ~1.4% in 2018, with the biggest drop occuring between 2000 and 2004.
Figure 35.4 This graph demonstrates the drops in employment among RNs working in community public health sectors. (data source: National Center for Health Workforce Analysis, 2018; attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Diversity in the nursing workforce is crucial for effective health care delivery. Recruiting and retaining nurses from diverse backgrounds, including different races, ethnicities, cultures, genders, sexual orientations, and socioeconomic statuses, can help establish client trust and enhance cultural competency, ultimately reducing health care disparities. Per the U.S. Census Bureau, nursing supply and demand aligns with demographic changes in the population. Notably, there has been a significant increase in the supply of Hispanic nurses, meeting the demand for nursing care for Hispanic clients among both registered nurses (RNs) and licensed practical nurses (LPNs) (Health Resources and Services Administration, 2017).

The Roots of Health Inequities

The Need for a More Diverse Nursing Workforce

The lack of diversity in the nursing workforce can lead to disparities in health care access, quality, and outcomes for marginalized and underserved populations, contributing to health inequities. This is especially true for underrepresented minority groups facing poorer health and higher mortality rates.

  • A diverse nursing workforce is crucial for providing culturally competent care that considers diverse client populations’ unique needs, beliefs, and practices.
  • Clients from marginalized communities often have higher trust in health care providers who share their cultural backgrounds and experiences.
  • A diverse nursing workforce can help bridge language gaps between clients and health care providers, improving communication and understanding.
  • Diverse nursing teams provide a broader perspective on client needs and experiences, leading to more client-centered care.
  • Nursing professionals from diverse backgrounds can advocate for policies that address health disparities and promote health equity.

(See AACN, 2023.)


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