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Community Nursing Quiz #1 Guide

Introduction to Community Health

Week 1: Textbook Chapter 1, 3, 4


Target population
o specific aggregate to study
Assessment (p. 108-111, Box 1-1 p.6)
o establish a professional relationship with selected aggregate, clarify nursing position
o meeting with the aggregate on a regular basis allows for in-depth assessment
o gather sociodemographic information from observations and data/charts
o a key informant from community may give data based on knowledge
o systems analysis of community: the subsystem, the system, and the suprasystem
o the system is the group, the subsystem is the individuals, and the suprasystem is the
resources/services that are available
o a literature review to compare the aggregate with the norm
o identify and prioritize specific aggregates health problems and needs, related directly to the
assessment and the literature review
o Needs assessment: expressed need from the target population, normative (lack, deficit, or
inadequacy) determined by health care professional, perceived need by audience, relative
need (gap showing the health disparities)
o priorities can be analyzed by way of preference, number of individs, severity of health
condition, availability to solution, time limitations/resources
o Regular collection, analysis, and information sharing about health conditions, risks, and
resources in a community from Box 1-1 on Core Public Health Functions
Assurance (Box 1-1, p. 6)
o Focuses on the availability of necessary health services throughout community. It includes
maintaining the ability of both public health agencies and private providers to manage dayto-day operations and the capacity to respond to critical situations and emergencies from
Box 1-1 on Core Public Health Functions
Community (p. 3-4)
o group or collection of individuals interacting in social units and sharing common interests,
characteristics, values, and goals

Public health (p. 6)
o organized efforts made through
governmental agencies such as health
departments, which are authorized by
legislation, serve all people, and are
supported by taxes
o community health: extends the realm of
public health to include organized health
efforts at the community level through
both government & private efforts
Prevention (p. 7-9, 114)
o disease prevention activities protect
people from disease and the effects of
Policy development (15, Box 1-1 p.6)
o Places health issues on decision makers
agendas, acquires a plan of resolution, and
determines needed resources, resulting in
laws, rules, regulations, ordinances, and
o Use of information gathered during
assessment to develop local and state
health policies and to direct resources
toward those policies. from Box 1-1 on
Core Public Health Functions
Population (p. 4)
o typically used to denote a group of people having common personal or environmental
o can also refer to all of the people in a defined community
Population-focused practice (p. 11, 13t)
o nursing practice that concentrates upon specific groups of people, focusing on health
promotion and disease prevention, regardless of geographic location
o community/public health nurses must use a population focused approach to move beyond
providing direct care to individuals and families
o Population-focused practice, in-short:
focuses on the entire population
is based on assessment of the populations health status
considers the broad determinants of health
emphasizes all levels of prevention
intervenes w/ communities, systems, individuals, and families
Primary prevention (p. 7)
o relates to activities directed at preventing a problem before it occurs by altering susceptibility
or reducing exposure for susceptible individuals
o consists of two elements: general health promotion and specific protection
Secondary prevention (p. 7)
o refers to early detection and prompt intervention during the period of early disease
o implemented after a problem has begun but before S&S appear and targets those
populations that have risk factors
Tertiary prevention (p. 8)
o targets populations that have experienced disease or injury and focuses on limitation of
disability and rehabilitation
o aims to keep health problems from getting worse, to reduce the effects of disease and injury,
and to restore individuals to their optimal level of functioning
Public health mission (ppt)

social justice, which entitles all people to basic necessities such as adequate income and
health protection and accepts collective burdens to make this possible
Public health vision
o Epidemiologic studies provide the basis for public health practice and policymaking, by
attempting to find out what causes disease, how does disease spread, what prevents disease,
and what works in controlling disease?

1. Leading Causes of preventable deaths in US (pg 59)
From Page 4:
o Tobacco (~20%)
o Poor Diet & Physical Inactivity (~16.6%)
o Alcohol Consumption (in association w/ accidents, suicides, homicides, cirrhosis, liver
o Microbial Agents
o Toxic Agents
o Motor Vehicle Accidents
o Firearms
o Sexual Behavior
o Illicit Use of Drugs
From Page 59:
o Diseases of heart
o Malignant neoplasms
o Chronic lower respiratory diseases
o Cerebrovascular diseases
o Accidents
o Alzheimers disease
o Diabetes Mellitus
o Influenza and pneumonia
o Nephritis, nephrotic syndrome, and nephrosis
o Suicide
2. Understanding what upstream thinking entails (pg 8, 37)
Upstream thinking actions focus on modifying economic, political, and environmental factors that
are the precursors of poor health throughout the world
orientation to viewing a problem that emphasizes variables that precede or play a role in the
development of health problem

3. Core

The concepts of
prevention and
populationfocused care figure
prominently in a
orientation to
nursing practice
referred to as
o This
orientation is
derived from
an analogy of
falling into a
upstream and
by health
with the
struggle of
to disease and
o The river as
an analogy for
the natural
history of illness
was first
coined by
(1979), with a
charge to
health providers
to refocus
their efforts
preventive and
o In a
description of
the daily
challenges of
providers to
address health
from a
curative focus,
consequences of
from its
The author then charges health providers to critically examine the relative
weight of their activities toward illness response versus the prevention of
A population-based perspective on health and health determinants is critical to
understanding and formulating nursing actions to prevent disease.
o By examining the origins of disease, nurses identify social, political, environmental,
and economic factors that often lead to poor health options for both individuals and
o The call to refocus the efforts of nurses upstream, where the real problems lie
(McKinlay, 1979) has been welcomed by community health nurses in a variety of
practice settings
Manufacturers of illness are what push clients into the river => i.e. cigarette companies
downstream endeavors are characterized by short term, individual bases interventions
o They take place in the ED, ICU, & other units focused on illness care
Functions of Public Health (pg 6)
o regular collection, analysis, and information sharing about health conditions, risks, and
resources in a community
Policy Development:

Use of information gathered during assessment to develop local and state health policies
and to direct resources toward those policies
o Focuses on the availability of necessary health services throughout community. It includes
maintaining the ability of both public health agencies and private providers to manage
day-to-day operations and the capacity to respond to critical situations and emergencies
4a. Understand fundamental goals of community-oriented (vs. community-based) nursing.
The goal of community-based nursing & community-oriented nursing are different
o Community health nursing emphasizes preservation & protection of health
o Community-based nursing emphasizes managing acute or chronic conditions
Community-based nursing refers to application of the nursing process in caring for individuals,
families and groups where they live, work or go to school or as they move through the health care
o setting-specific
o emphasis is on acute & chronic care
o includes such practice areas as: home health nursing & nursing in outpatient or ambulatory
o primary clients are the individual and the family
o Services in community based nursing are largely direct
Community health nursing:
o primary client is the community
o services in community health nursing are both direct & indirect
4b. Understand levels of intervention (p.14)
The public health intervention wheel: become increasingly recognized as the framework for
community & public health nursing practice
Intervention wheel contains three important elements:
o it is population based
o it contains three levels of practice (community, systems, and individual/family)
o it identifies and defines 17 public health interventions
The levels of practice & interventions are directed at improving population health
Within the intervention wheel, the 17 health interventions are grouped into five wedges
o Theses interventions are actions taken on behalf of communities, systems, individuals, and
families to improve or protect health status

4c. Understand fundamental values of public health.

Fundamental values of public health (ppt slide 8-9, pg 6)
o Mission of public health is social justice, which entitles all people to basic necessities such as
adequate income and health protection and accepts collective burdens to make this possible.
o Public Health is the science and art of
1) preventing disease
2) prolonging life
3) promoting health and efficiency through organized community effort for:
sanitation of the environment
control of communicable infections
education of the individual in personal hygiene
organization of medical and nursing services for the early diagnosis and
preventive treatment of disease

development of the social machinery to
ensure everyone a standard of living
adequate for the maintenance of health, so
organizing these benefits as to enable every
citizen to realize his birthright of health and
5. Levels of prevention (vs. levels of care) (p.7)
Levels of Care =>
o Primary Care
Primary care: has to do with going in for your
annual check-up
Check and see if things are going okay
Catch the problem early & refer to a
Prevention & population focused prevention => occurs before primary care b/c
primary care is more about early detection
o Specialty Care
provider is trying to dx a condition that exists and provide treatment. & also try to
minimize the negative & long term effects of the condition
o Tertiary Care
same goal as specialty care
Levels of Prevention [Inversion of triangle represents focus/funding in the U.S. Should cause you to
think about this further!]
o Primary Level of Prevention:
Prevention of disease or condition before it
I.e.: Flouridation of water, immunizations is
the best example, birth control & STD
health educ for high schoolers, nutrition
counseling, CD educ & surveillance, Educ
about health/hygiene to spec grps ie day
care or restaurant workers, prenatal
classes, advocating for resolution of health
probs ie healthy environments
o Secondary Level of Prevention:
Early detection & intervention of a disease
or condition
I.e.: mammos, BP, Diabetes, TB, Genetic
disorders in newborns, cancer-cervical,
testicular, colorectal screenings, dental assessment of red/swollen gums, BMI and
follow up prn to groups who are at risk the follow up could be tertiary, HIV screen,
vision and hearing screening for adults and/or sr centers, scoliosis screening in middle
school, organized health screenings/fairs for specific populations, treatment STDs &
TB, control outbreaks of CD
o Tertiary Level of Prevention:
Treatment to improve quality of life and reduce complications severity, progression of
a disease or condition
Post stroke exercise and PT/DM/MI, AA and drug rehab for addicts, shelter and
relocation post-earthquakes, case management of chronic illness, mental illness,
o Levels of Prevention can occur at the individual, family, group or aggregate, or community &
population levels

6. Relationship between income and health (pg 8)

The real determinants of health, are prevention efforts that provide education, housing, food, a
decent minimal income, and safe social and physical environments
in industrialized countries, life expectancy at birth is not related to the level of health care
expenditures; in developing countries, longevity is closely related to the level of economic
development and the education of the population
7. Microscopic vs. Macroscopic approach to health (p. 38)
Microscopic: individual patient
o Examines individual, and sometimes family, responses to health and illness
o Often emphasizes behavioral responses to individuals illness or lifestyle patterns
o Nursing interventions are often aimed at modifying an individuals behavior through
changing his or her perceptions or belief system
o When the individual is the focus, the microscopic focus contains the health problem of
interest (i.e. pediatric exposure to lead compounds)
Macroscopic: society or social economic factors influencing health status
o Examines interfamily and intercommunity themes in health and illness
o Delineates factors in the population that perpetuate the development of illness or foster
the development of health
o Emphasizes social, economic, and environmental precursors of illness
o Nursing interventions may include modifying social or environmental variables (i.e.
working to remove care barriers and improving sanitation or living conditions)
o May involve social or political action
8. Understand how Public Health is at odds with U.S. healthcare delivery system, Market
justice vs. Social justice, etc.
market justice: the principle that people are entitled to valued ends (status, income) when they
acquire them through fair rules of entitlement
social justice: principle that all citizens bear equitably in the benefits and burdens of society
in context of community health nursing, health and healthcare in considered a right rather than
a privilege. Certain citizens, by virtue of their income, race, health care needs, are unable to
access health care, the society suffers. Nurses must act on behalf of justice in healthcare
access for all citizens.

The Art and Science of Community

Week 2: Textbook Chapter 5, 6, 7


o a group or collection of individuals interacting in social units and sharing common interests,
characteristics, values, and goals
Aggregate (p. 93)
o subgroups or subpopulations that have some common characteristics or concerns
o a community composed of people who have common characteristics
i.e. members of a community may share residence in the same city, membership in
the same religious organization, or similar demographic characteristics such as age
and ethnic background; pregnant teens within a school district
o The who: personal characteristics and risks [major feature of a community]
Health (WHO) (p. 3)
o the definition of health is evolving
o the early, classic definition of health by WHO set a trend toward describing health in social
terms rather than in medical terms
1958 WHO definition: a state of complete physical, mental, and social well-being and
not merely the absence of disease or infirmity
1986 WHO definition: the extent to which an individual or group is able, on the one
hand, to realize aspirations and satisfy needs; and, on the other hand, to change or
cope with the environment. Health is, therefore, seen as a resource for everyday life,
not the objective of living; it is a positive concept emphasizing social and personal
resources, and physical capacities.
Rate (p. 74)
o arithmetic expressions that help practitioners
consider a count of an event relative to the size of
the population from which it is extracted (i.e. the
population at risk)
o population proportions or fractions in which the
numerator is the number of events occurring in a specified period of time & the denominator
consists of those in the population at the specified time period (e.g., per day, per week, or
per year)
This proportion is multiplied by a constant (k) that is a multiple of 10, such as 1000,
10,000, or 100,000.
The constant usually converts the resultant number to a whole number, which is
larger and easier to interpret
Thus, a rate can be the number of cases of a disease occurring for every 1000,
10,000, or 100,000 people in the population.
Prevalence (p. 75)
o prevalence rate is the number of all cases of a
specific disease or condition (i.e. deafness) in a
population at a given point in time relative to
the population at the same point in time
o When prevalence rates describe the number of
people with the disease at a specific point in time, they are sometimes called point
o factors that influence prevalence rates: the number of people who experience a particular
condition (i.e., incidence) and the duration of the condition
o A nurse can derive the prevalence rate by multiplying incidence by duration (P = I D).
An increase in the incidence rate or the duration of a disease increases the prevalence

rate of a disease.
Incidence (p. 74)
o incidence rates describe the occurrence of new
cases of a disease (i.e. tuberculosis, influenza) or
condition (i.e. teen pregnancy) in a community
over a period of time relative to the size of the
population at risk for that disease or condition
during that same time period
o The denominator consists of only those at risk for the disease or condition; therefore, known
cases or those not susceptible (e.g., those immunized against a disease) are subtracted from
the total population
o The incidence rate may be the most sensitive indicator of the changing health of a
community because it captures the fluctuations of disease in a population
particularly useful for detecting short-term acute disease changessuch as those that
occur with infectious hepatitis or measleswhen the duration of the disease is
typically short
Morbidity (p. 74)
o Rates of illness
o Two types of morbidity rates in public health:
incidence rates
prevalence rates
Mortality rates (p. 75)
o Rates of death
Sensitivity (p. 80)
o sensitivity is the tests ability to do what its
supposed to correctly
o For a given test, the sensitivity and specificity
tend to be inversely related to each other.
o When a test is highly sensitive, individuals
without disease may be labeled positive.
These false-positive tests may cause
stress and worry for clients and require
further diagnostic testing to confirm a diagnosis.
Specificity (p. 80)
o extent to which a test can correctly identify those who do not have disease
o With a highly sensitive test, specificity may be lower and the test may not detect disease in
some clients.
These false-negative test results mean that some individuals may receive false
reassurance and will not receive follow-up care.
Disease surveillance (p. 81)
o surveillance is a mechanism for the ongoing collection of community health information (in
addition to screening)
o Monitoring for changes in disease frequency is essential to effective and responsive public
health programs
o Identifying trends in disease incidence or identifying risk factor status by location and
population subgroup over time allows the community health nurse to evaluate the
effectiveness of existing programs and implement interventions targeted to high-risk groups.
Relative risk ratio (p. 78)
o measure of the excess risk caused by a factor
o calculated by dividing the incidence rate of disease in the exposed population by the
incidence rate of disease in the non-exposed population
a relative risk of 5 indicates that an exposed individual has a fivefold greater risk than
a non-exposed individual
o relative risks are valuable indicators of the excess risk incurred by exposure to certain factors



1a. Understand the basic premise of Orems Self-care Deficit Theory.

Orems Self-care Deficit: individual can change need for nursing care
o the individual is the focus of change (I.e. microscopic)
Orem stated that this theory is a composite of the following constructs:
o The theory of self-care deficits, which provides criteria for identifying those who need nursing
o The theory of self-care, which explains self-care & why it is necessary
o The theory of nursing systems, which specifies nursings role in the delivery of care and how
nursing helps people
theory based on the assumption that self-care needs and activities are the primary focus of
nursing practice. Nursing is a response to a sick person's inability to administer self-care .
1b. Understand the basic premise of Milios framework for prevention.
Milios Framework for prevention: health needs and available resources must align for health
education to be effective => health may be lost if there is a health need but no available resources
o Thinking upstream: society is the focus of change (i.e. macroscopic)
Provides a complement to the HBM (health belief model) and a mechanism for directing attention
upstream and examining opportunities for nursing intervention at the population level
o Milo outlined 6 propositions that relate to an individuals ability to improve healthful behavior
to a societys ability to provide accessible and socially affirming options for healthy choices
o She used these propositions to move the focus upstream by challenging the notion that a
main determinant for unhealthful behavior choice is lack of knowledge
plays into nursing by assessing the personal and societal resources of individual patients and to
analyze social and economic factors that may inhibit healthy choices in populations
1c. Understand the basic premise of Critical Social Theoretical perspective
Critical Social Theoretical perspective: exposes inequalities that keep people from reaching
perspective used often in CHN
o Thinking upstream: society is the focus of change (i.e. macroscopic)
uses societal awareness to expose social inequalities that keep people from reaching their full
used to understand linkages between health care system and broader political, economic, and social
systems of society.
Applied when health care is used as a form of social control, get patients to adhere to a norm of
behavior (medicalization for medical treatment and intervention)
2. Understanding techniques and purpose of Community Assessment
A community health nurse must define a community and describe its characteristics before applying
the nursing process
o Then the nurse can launce the assessment and diagnosis phase of the nursing process at the
aggregate level and incorporate epidemiological approaches
The community health nurse participates in assessing the communitys health and its ability to deal
with health needs
o With sound data, the nurse makes valuable contribution to health policy development
Major features of a community:
o Aggregate of people
The who: personal characteristics and risks
o Location in Space & time
The where & when: physical location frequently delineated by boundaries and
influenced by the passage of time

Social system
The why & how: interrelationships of
aggregates fulfilling community functions
Diagram of assessment parameters =>
o Suggests assessment parameters that can help a nurse
develop a more complete list of critical community
o i.e.: recreation, physical environment, education, safety
& transportation, politics & government, health & social
services, communication, economics
Assessing the Community
o Windshield survey:
Organized observations of the community
gain understanding of the environment layout
geographic features, and location of
agencies, services, businesses, industries
locate areas of environmental concern
o Analysis of Demographic Information:
Analysis of demographic info and statistical data provides descriptive info about the
Epidemiology involves
analysis of health data to discover the patterns of health and illness distribution
in a population
conducting research to explain nature of health problems and identify the
aggregates at increased risk
Examples of some sources of data:
Census Data: every 10 yrs survey of all American families, MSAs (Metropolitan
statistical areas) central cities with more than 50,000 people and suburbs
surrounding totaling in 100,000 people, in order to demographic variables such
as age, sex, race, and ethnicity
Vital Statistics
o The official registration records of births, deaths, marriages, divorces,
and adoptions for the basis of data in vital statistics
o Every year, city, county, & state health departments aggregate and
report these events for the preceding year
o Provide indicators of population growth or reduction (when compared to
data of previous years)
Local, regional, and state government reports
o Needs Assessment:
the nurse must understand the communitys perspective on health status, the services
it uses or requires, and its concerns
most official data do not capture this type of information
data collected directly from an aggregate may be more insightful and accurate;
therefore, community health nurses sometimes conduct community needs
What/who is key informant?
Interview key community informants
Use community forums, focus groups, and/or surveys
Steps in the needs assessment process
1. Identify aggregate for assessment.
2. Identify required information.
3. Select method of data gathering.
4. Create questionnaire or interview questions.
5. Develop procedures for data collection.
6. Train data collectors.
7. Arrange for sample representative of aggregate.

8. Conduct needs assessment.

9. Tabulate and analyze data.
10. Identify needs suggested by data.
11. Develop an action plan.
12. Establish evaluation measures




3. Things a nurse
can do to make community diagnosis & plan successful (p. 102)
specify the nature and cause of an actual or potential community
health problem and direct the community health nurses plans to
resolve the problem
consists of four components: (1) identification of the health problem
or risk, (2) aggregate or community affected, (3) etiological or causal
statement, and (4) evidence or support for the diagnosis
o the problem represents a synthesis of all assessment data
o the among phrase specifies the aggregate that will be the
beneficiary of the nurses action plan and whose health is at risk
o the related to phrase describes the cause of the health problem and directs the focus of the
all plans and interventions will be aimed at addressing this underlying cause
o the health indicators are the supporting data/evidence from the completed assessment
With a clear statement of the problem in the form of a diagnosis, the nurse is ready to begin the
planning phase of the nursing process
Inherent in this phase is a plan for the intervention and its evaluation
Epidemiological data can be useful as a basis for determining success
o By comparing baseline data, national and local data, and other relevant indicators, the nurse
can construct benchmarks to gauge achievement of program objectives
This step may entail calculation of incidence rates, if the goal is to reduce the
development of disease, or primary prevention
Comparing data with national rates or with prevalence rates found in local community
may be other indicators of success

Reducing the presence of risk factors and documenting patterns of healthy behavior
are other objective indices of successful programs
4. Purpose & methodology of a windshield survey (p. 95)
Community health nurses often perform a windshield survey by driving through a community and
making organized observations
Nurse can gain an understanding of the environmental layout, including geographic features and the
location of agencies, services, businesses, and industries, and can locate possible areas of
environmental concern through sight, sense, and sound


Windshield survey offers the nurse an

opportunity to observe people and their role
5. Purpose of evaluation (p. 112)
Evaluation is an important component for
success or failure of a project and
factors that contributed to its success or
The evaluation should include participants
feedback and the nurses detailed analysis
Evaluation includes reflecting on each
determine the plans strengths and
(process/formative evaluation)
o The process/formative evaluation
evaluate both positive and negative
experience honestly and
and whether the desired outcome was
(product/summative evaluation)
6a. Health Planning Model (nursing process)
Health Planning Model: aims to improve
and applies nursing process to the larger
systems framework
o Several considerations affect how nurses
aggregate for study.
The community may have
opportunities appropriate for
o Additionally, each community offers
for health intervention.
For example, an urban area might

in the community
determining the
understanding the
verbal or written
previous stage to
allows one to
aspects of each
aggregate health
aggregate within a
choose a specific
extensive or limited
nursing involvement.
different possibilities
have a variety of

industrial and business settings that need assistance, whereas a suburban community may
offer a choice of family-oriented organizations such as boys and girls clubs and parentteacher associations that would benefit from intervention.
A nurse should also consider personal interests and strengths in selecting an aggregate for
For example, the nurse should consider whether he or she has an interest in teaching
health promotion and preventive health or in planning for organizational change, whether
his or her communication skills are better suited to large or small groups, and whether he
or she has a preference for working with the elderly or with children.
Thoughtful consideration of these and other variables will facilitate assessment and


6b. Health Belief Model (working w/ a persons beliefs

about their own behavior). (p. 40-41, 53-56)
Focuses on the individual as the locus of change, based
on the assumption that the major determinant of
preventative health behavior is disease avoidance (the
actions taken to prevent a disease)
o Limitation is that it places the burden of action
exclusively on the client
o Also, it assumes that only those clients who have
negative perceptions of the specified disease or
recommended health action will fail to act
Evolved from the premise that the world of the perceiver
determines action
o Developed to attempt to explain why the public
failed to participate in screening for tuberculosis

7. Concepts of risk (modifiable and non-modifiable) and risk reduction. (p. 56-58)
Risk: the probability that a specific event will occur in a given time frame
Risk factor: an exposure that is associated with a disease
Modifiable risk factors: aspects of a persons health risk over which he or she has control
o smoking, leading a sedentary or active lifestyle, type and amount of food eaten, and the type
of activities in which he or she engages (skydiving is riskier than bowling)
Non-modifiable risk factors: aspects of ones health risk over which one has no or little control
o genetic makeup, gender, age, environmental exposures
Risk reduction: a proactive process in which individuals participate in behaviors that enable them to
react to actual or potential threats to their health
% of
smokin HighSedent High
Elevate Obesit
8. Read over: Health Determinants,
Leading Health Indicators, objectives &
topic areas [textbook and Healthy People
2020 website]
Health determinants: leading health
indicators are used to track progress for
meeting Healthy People 2020 Goals
o Biology & Genetics: genetic
makeup, family history,
physical/mental health problems,
aging, diet, physical activity,
smoking, stress, alcohol/drug use
(can change an individuals
o Individual
Healthy People 2020 Leading Health
Indicator Topics (p. 5)
response to
access to health services
internal stimuli
clinical preventative services
person with
exercise and eat
environmental quality
o Social
injury & violence
and relationships
maternal, infant & child health
coworkers, social
mental health
o Physical
nutrition, physical exercise, &
with the senses,
o touched, heard,

oral health
o Policies &
reproductive & sexual health
Services): ex:
social determinants
substance abuse

and external conditions (ex:

hypertension chooses to
more healthfully)
Environment: interactions
with family, friends,
Environment: experienced
what is smelled, seen,
Interventions (Health
against smoking in public

o access to quality healthcare
when the national health objectives for healthy people 2020 were being made, a total of 12 leading
health indicators were identified that reflected the major public health concerns in the US =>
o each of these indicators can affect the health of individuals and communities and can be
correlated with leading causes of morbidity & mortality
Healthy people 2020: the 4th version of the nations health objectives
o Divided into 42 topic areas & contains numerous new objectives
9. Person-Place-Time model (pg 70)
Person-Place-Time Model
o "who" factors, such as demographic characteristics, health, and disease status
o "where" factors, such as geographic location, climate and environmental conditions, and
political and social environment
o "when" factors, such as time of day, week, or month, and secular trends over months and
Use of the person-place-time model organized epidemiologists investigations of the disease pattern
in the community
o This study of the amount and distribution of disease constitutes descriptive epidemiology
o Identified patterns frequently indicate possible causes of disease that public health
professionals can examine with more advanced epidemiological methods
10. Epidemiological triangle (p. 70)
Defined: an organized method of inquiry to derive an explanation of
disease, which analyzes three elements: (1) agent, (2) host, and (3)
The development of disease depends on the extent of the hosts
exposure to an agent, the strength or virulence of the agent, and
the hosts genetic or immunological susceptibility
Disease also depends on the environmental conditions existing at
the time of exposure, which include the biological, social, political
and physical environments
The model implies that the rate of disease will change when the
balance among these three factors is altered
By examining each of the three elements, a community health nurse can methodically assess a
health problem, determine protective factors, and evaluate the factors that make the host
vulnerable to disease
Conditions linked to clearly identifiable agents, such as bacteria, chemicals, toxins, and other
exposure factors, are readily explained by the epidemiological triangle
11. Goals of epidemiology (ppt 20)
Epidemiology: the study of the distribution and determinants of health and disease in human
o The principal science of public health
o It entails a body of knowledge derived from epidemiological research and specialized
epidemiological methods and approaches to scientific research.
o Community health nurses use epidemiological concepts to improve the health of population
groups by identifying risk factors and optimal approaches that reduce disease risk.
o Epidemiological methods are important for accurate community assessment and diagnosis and in
planning and evaluating effective community interventions
Goals of epidemiology:
1. Describe disease patterns
2. Identify etiological factors in disease development
3. Identify and take the most effective prevention measures
12. Understand how epidemiology can be applied to the levels of prevention (ppt 21, 22)

Primary: when interventions occur before disease development; relies on epidemiological information to
indicate those behaviors that are protective or those that will not contribute to an increase in disease,
and those that are associated with increased risk

Health promotion: actions that are general in nature and designed to foster healthful lifestyles and
a safe environment
o Specific protection: actions aimed at reducing the risk of specific diseases
Secondary: occurs after pathogenesis; measures designed to detect disease at its earliest stage, namely
screening and physical examinations that are aimed at early diagnosis
o Interventions that provide for early treatment and cure of disease are also in this category.
o Epidemiological data and clinical trials determining effective treatments are crucial in disease
o Mammography, guaiac testing of feces, and the treatment of infections and dental caries are all
examples of secondary prevention.
o Early identification
Tertiary: includes the limitation of disability and the rehabilitation of those with irreversible disease such
as diabetes and spinal cord injury.
o Epidemiological studies examine risk factors affecting function and suggest optimal strategies in
the care of patients with chronic advanced disease.
o Limitation of disability/disease progress

13. Understand what is needed to establish causality (as opposed to correlation) (ppt 25)
Establishing causality depends on 6 criteria: (The following 6 criteria are needed to establish
the existence of a cause-and-effect relationship)
1. Strength of association: rates of morbidity or mortality
2. Dose-response relationship
3. Temporally correct relationship
4. Biological plausibility
5. Consistency with other studies
6. Specificity
Strength of association: must be higher in the exposed group than in the non- exposed group. Relative
risk ratios, or odds ratios, and correlation coefficients indicate whether the relationship between the
exposure variable and the outcome is causal. For example, epidemiological studies demonstrated an
elevated relative risk for heart disease among smokers compared with nonsmokers (Doll and Hill, 1956).
Dose-response relationship: An increased exposure to the risk factor causes a concomitant increase in
disease rate. The risk of heart disease mortality is higher for heavy smokers compared with light smokers

Temporally correct relationship: Exposure to the causal factor must occur before the effect, or

disease. For heart disease, smoking history must precede disease development.
Biological plausibility: The data must make biological sense and represent a coherent explanation for
the relationship. Nicotine and other tobacco-derived chemicals are toxic to the vascular endothelium. In
addition to raising low- density lipoprotein (LDL) and decreasing high-density lipoprotein (HDL)
cholesterol levels, cigarette smoking causes arterial vasoconstriction and platelet reactivity, which


contributes to platelet thrombus formation.

Consistency with other studies: Varying types of studies in other populations must observe similar

associations. Numerous studies of different designs have repeatedly sup- ported the relationship between
smoking and heart disease.
Specificity: The exposure variable must be necessary and sufficient to cause disease; there is only one
causal factor. Although specificity may be strong causal evidence, this criterion is less important today.
Diseases do not have single causes; they have multifactorial origins.

Causality is largely a matter of judgment (pg 79)

Smoking is not specific to heart disease alone it is a causal factor for other diseases such as lung and
oral cancers
Additionally, smoking is not necessary and sufficient to the development of heart disease because
there are nonsmokers who also have coronary heart disease
o Therefore, the causal criterion of specificity more frequently pertains to infectious diseases