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Public Health Interventions Applications for Public Health Nursing Practice March 2001 Minnesota Department of Health Division of Community Health Services Public Health Nursing Section Public Health Interventions Applications for Public Health Nursing Practice March 2001 Public Health Nursing Practice for the 21st Century Project Director: Mary Rippke, RN, MA Project Coordinator: Laurel Briske, RN, MA, CPNP Project Staff: Linda Olson Keller, RN, MS, CS, and Sue Strohschein, RN, MS Administrative Assistant: Jill Simonetti Development of this document was supported by federal grant 6 D10 HP 30392, Division of Nursing, Bureau of Health Professions, Health Resources and Service Administration, United States Department of Health and Human Services. Minnesota Department of Health Division of Community Health Services Public Health Nursing Section Acknowledgments Public Health Interventions: Applications for Public Health Nursing Practice acknowledges the tremendous contribution made by practicing public health nurses (PHNs) and educators from Iowa, Minnesota, North Dakota, South Dakota, and Wisconsin. Special thanks go to the graduate students who identified and analyzed relevant intervention literature. Forty-six practice experts and educators from those same states volunteered to serve on review panels, devoting hours of their time and, more importantly, their practice wisdom. An additional 150 preceptors and participants from the Public Health Nursing Practice for the 21st Century project provided invaluable input for clarification and richness of the content. This document could not have happened without them. Gratitude also goes to LaVohn Josten and Sharon Cross, School of Nursing, University of Minnesota for their insight and evaluation expertise. The interventions also reflect the talents and skills of many Minnesota Department of Health staff. In particular we want to acknowledge our colleagues in the Section of Public Health Nursing, Marie Margitan, Terre St. Onge, and Karen Zilliox; Diane Jordan and the library services’ staff; and Lisa Patenaude, former administrative assistant. We are interested in learning more about how the model is being used or adapted. If you have comments or questions, please contact us. Linda Olson Keller 651/296-9176 [email protected] Sue Strohschein 320/650-1078 [email protected] Suggested citation: Public Health Nursing Section: Public Health Interventions–Applications for Public Health Nursing Practice. St. Paul: Minnesota Department of Health, 2001. Literature Search Managers Mary Jo Chippendale, University of Minnesota Jennifer Deschaine, Bethel College Kathy Lammers, Winona State University Deborah Meade, Augsburg College Jackie Meyer, University of Iowa Dolores Severtson, University of Wisconsin-Madison Victoria Von Sadovszky, University of Wisconsin-Madison Expert Panelists Iowa Elaine Boes, Palo Alto County Community Health Service Nancy Faber, Worth County Public Health Marti Franc, Des Moines Visiting Nurse Services Penny Leake, Winneshiek County Public Health Therese O’Brien, Lee County Health Department Janet Peterson, Iowa Department of Health Jane Schadle, Wellmark Community Health Improvement Lu Sheehy, Skill Medical Center Jenny Terrill, Iowa Department of Health Minnesota Mary Kay Haas, Minnesota Nurses Association Bonnie Brueshoff, Dakota County Public Health Terre St. Onge, Minnesota Department of Health Jean Rainbow, Minnesota Department of Health Karen Zilliox, Minnesota Department of Health Barb Mathees, Minnesota State University-Moorhead Cecilia Erickson, Minneapolis Public Schools Ane Rogers, Cass County Public Health Rose Jost, Bloomington Health Department Dorothea Tesch, Minnesota Department of Health Nancy Vandenberg, Minnesota Department of Health Ann Moorhous, Minnesota Department of Health Mary Sheehan, Minnesota Department of Health Penny Hatcher, Minnesota Department of Health North Dakota Ruth Bachmeier, Fargo Cass Public Health Nancy Mosbaek, Minot State University Cheryl Hagen, Fargo Cass Public Health Kelly Schmidt, First District Health Unit–Minot Debbie Swanson, Grand Forks Public Health Department Barb Andrist, Upper Missouri District Health Unit South Dakota Nancy Fahrenwald, South Dakota State University Darlene Bergeleen, South Dakota Department of Health Joan Frerichs, Grant County–Milbank Paula Gibson, South Dakota Department of Health Wisconsin Judy Aubey, Madison Department of Public Health Elizabeth Giese, Division of Public Health-Wisconsin Barbara Nelson, St. Croix Health & Human Services Department Tim Ringhand, Chippewa County Department of Public Health Marion Reali, Eau Claire City/County Health Department Gretchen Sampson, Polk County Health Department Vicki Moss, Viterbo College Joan Theurer, Wisconsin Department of Health & Family Services Julie Willems Van Dijk, Marathon County Health Department Public Health Nursing Interventions Public health nurses (PHNs) work in schools, homes, clinics, jails, shelters, out of mobile vans and dog sleds. They work with communities, the individuals and families that compose communities, and the systems that impact the health of those communities. Regardless of where PHNs work or whom they work with, all public health nurses use a core set of interventions to accomplish their goals. Interventions are actions that PHNs take on behalf of individuals, families, systems, and communities to improve or protect health status. This framework, known as the “intervention model,” defines the scope of public health nursing practice by type of intervention and level of practice (systems, community, individual/family), rather than by the more traditional “site” of service, that is, home visiting nurse, school nurse, occupational health nurse, clinic nurse, etc. The intervention model describes the scope of practice by what is similar across settings and describes the work of public health nursing at the community and systems practice levels as well as the conventional individual/family level. These interventions are not exclusive to public health nursing as they are also used by other public health disciplines. The public health intervention model does represent public health nursing as a specialty practice of nursing. (See The Cornerstones of Public Health Nursing, Appendix A) An enlarged black and white copy of the wheel can be found in Appendix B. Section of Public Health Nursing Public Health Minnesota Department of Health 1 Interventions The Intervention Wheel The model, or the “intervention wheel,” as it has come to be known, integrates three distinct and equally important components: 1. The population-basis of all public health interventions 2. The three levels of public health practice: Community Systems Individual/family 3. The 17 public health interventions: Surveillance Disease and Health Threat Investigation Outreach Screening Case-Finding Referral and Follow-up Case Management Delegated Functions Health Teaching Counseling Consultation Collaboration Coalition Building Community organizing Advocacy Social Marketing Policy Development and Enforcement The model itself consists of a darkened outside ring, three inner rings and seventeen “slices.” Each of the inner rings of the model are labeled “population-based,” indicating that all public health interventions are population- based. A population is a collection of individuals who have one or more personal or environmental characteristics in common.1 A population-of-interest is a population that is essentially healthy, but who could improve factors that promote or protect health. A population-at-risk is a population with a common identified risk factor or risk-exposure that poses a threat to health. 1. Public health interventions are population-based if they focus on entire populations possessing similar health concerns or characteristics. This means focusing on everyone actually or potentially impacted by the condition or who share a similar characteristic. Population-based interventions are not limited to only those who seek service or who are poor or otherwise vulnerable. Population-based planning always begins by identifying 1Williams, C. A., Highriter, M. E. (1978). Community health nursing–population and practice. Public Health Reviews, 7(4), 201. Section of Public Health Nursing Public Health Minnesota Department of Health 2 Interventions everyone who is in the population-of-interest or the population-at-risk. For example, it is a core public health function to assure that all children are immunized against vaccine-preventable disease. Even though limited resources may compel public health departments to target programs toward those children known to be at particular risk for being under or unimmunized, the public health system remains accountable for the immunization status of the total population of children. 2. Public health interventions are population-based if they are guided by an assessment of population health status that is determined through a community health assessment process. A population-based model of practice analyzes health status (risk factors, problems, protective factors, assets) within populations, establishes priorities, and plans, implements, and evaluates public health programs and strategies.2 The importance of community assessment cannot be emphasized enough. All public health programs are based on the needs of the community. As communities change, so do community needs. This is why the core function of assessment is so important.3 Public health agencies need to assess the health status of populations on an ongoing basis, so that public health programs respond appropriately to new and emerging problems, concerns, and opportunities. 3. Public health interventions are population-based if they consider the broad determinants of health. A population-based approach examines all factors that promote or prevent health. It focuses on the entire range of factors that determine health, rather than just personal health risks or disease. Examples of health determinants include income and social status, housing, nutrition, employment and working conditions, social support networks, education, neighborhood safety and violence issues, physical environment, personal health practices and coping skills, cultural customs and values, and community capacity to support family and economic growth.4 4. Public health interventions are population-based if they consider all levels of prevention, with a preference for primary prevention. Prevention is anticipatory action taken to prevent the occurrence of an event or to minimize its effect after it has occurred.5 A population approach is different from the medical model in which persons seek treatment when they are ill or injured. Not every event is preventable, but every event does have a preventable component. Thus, a population-based approach presumes that prevention may occur at any point–before a problem occurs, when a problem has begun but before signs and symptoms appear, or even after a problem has occurred. 2 Population-based practice assessment, planning and evaluation model. (1999). CHS planning guidelines. Minnesota Department of Health (attached as an Appendix). 3 Institute of Medicine. (1988). The future of public health. Washington DC: National Academy Press. 4See, for instance, Evans, R. G., & Stoddard, G. L. (1990). Producing health, consuming health care. Social Science and Medicine, 31, 1347-1363, or, Wilkinson, R., & Marmot, M. (1998). Social determinants of health: The solid facts. World Health Organization. Available http://www.who.uk/document/e59555.pdf. 5Turnock, B. (1997). Public health: What it is and how it works. Gaithersburg, MD: Aspen Publishers. Section of Public Health Nursing Public Health Minnesota Department of Health 3 Interventions Primary prevention both promotes health and protects against threats to health. It keeps problems from occurring in the first place. It promotes resiliency and protective factors or reduces susceptibility and exposure to risk factors. Primary prevention is implemented before a problem develops. It targets essentially well populations. Primary prevention promotes health, such as building assets in youth, or keeps problems from occurring, for example, immunizing for vaccine-preventable diseases. Secondary prevention detects and treats problems in their early stages. It keeps problems from causing serious or long-term effects or from affecting others. It identifies risks or hazards and modifies, removes, or treats them before a problem becomes mroe serious. Secondary prevention is implemented after a problem has begun, but before signs and symptoms appear. It targets populations that have risk factors in common. Secondary prevention detects and treats problems early, such as screening for home safety and correcting hazards before an injury occurs. Tertiary prevention limits further negative effects from a problem. It keeps existing problems from getting worse. It alleviates the effects of disease and injury and restores individuals to their optimal level of functioning. Tertiary prevention is implemented after a disease or injury has occurred. It targets populations who have experienced disease or injury. Tertiary prevention keeps existing problems from getting worse, for instance, collaborating with health care providers to assure periodic examinations to prevent complications of diabetes such as blindness, renal disease failure, and limb amputation. Whenever possible, public health programs emphasize primary prevention. 5. Public health interventions are population-based if they consider all levels of practice. This concept is represented by the inner three rings of the model. The inner rings of the model are labeled community-focused, systems-focused, and individual/family-focused. A population-based approach considers intervening at all possible levels of practice. Interventions may be directed at the entire population within a community, the systems that affect the health of those populations, and/or the individuals and families within those populations known to be at risk. Population-based community-focused practice changes community norms, community attitudes, community awareness, community practices, and community behaviors. They are directed toward entire populations within the community or occasionally toward target groups within those populations. Community-focused practice is measured in terms of what proportion of the population actually changes. Population-based systems-focused practice changes organizations, policies, laws, and power structures. The focus is not directly on individuals and communities but on the systems that impact health. Changing systems is often a more effective and long-lasting way to impact population health than requiring change from every single individual in a community. Section of Public Health Nursing Public Health Minnesota Department of Health 4 Interventions Population-based individual-focused practice changes knowledge, attitudes, beliefs, practices, and behaviors of individuals. This practice level is directed at individuals, alone or as part of a family, class, or group. Individuals receive services because they are identified as belonging to a population- at-risk. Interventions at each of these levels of practice contribute to the overall goal of improving population health status. Public health professionals determine the most appropriate level(s) of practice based on community need and the availability of effective strategies and resources. No one level of practice is more important than another; in fact, most public health problems are addressed at all three levels, often simultaneously. Consider, for example, smoking rates, which continue to rise among the adolescent population. At the community level of practice, public health nurses coordinate youth led, adult supported, social marketing campaigns intending to change the community norms regarding adolescents’ tobacco use. At the systems level of practice, public health nurses facilitate community coalitions that advocate city councils to create stronger ordinances restricting over-the-counter youth access to tobacco. At the individual/ family practice level, public health nurses tach middle school chemical health classes that increase knowledge about the risks of smoking, change attitudes toward tobacco use, and improve “refusal skills” among youth 12-14 years of age. The interventions are grouped with related interventions; these “wedges” are color coordinated to make them more recognizable. For instance, in practice, the five interventions in the red (pink) wedge are frequently implemented in conjunction with one another. Surveillance is often paired with disease and health event investigation, even though either can be implemented independently. Screening frequently follows either surveillance or disease and health event investigation and is often preceded by outreach activities in order to maximize the number of those at risk who actually get screened. Most often, screening leads to case-finding, but this intervention can also be carried out independently or related directly to surveillance and disease and health event investigation. The green wedge consists of referral and follow-up, case management, and delegated functions–three interventions which, in practice, are often implemented together. Similarly, health teaching, counseling, and consultation (the blue wedge) are more similar than they are different; health teaching and counseling are especially often paired. The interventions in the orange wedge –collaboration, coalition building, and community organizing–while distinct, are grouped together because they are all types of collective action and all most often carried out at systems or community levels of practice. Similarly, advocacy, social marketing, and policy development and enforcement (the yellow wedge) are often interrelated when implemented. In fact, advocacy is often viewed as a precursor to policy development; social marketing is seen by some as a method of carrying out advocacy. Section of Public Health Nursing Public Health Minnesota Department of Health 5 Interventions Where did this model come from? Health care reform in the 1990s challenged public health nurses to define their contribution to improving population health. In response, the Section of Public Health Nursing at the Minnesota Department of Health constructed a set of interventions that public health nurses use in their practice. The model began as a set of examples of PHN practice collected in 1994 from over 200 experienced Minnesota PHNs. A panel of practice experts from the section identified the common themes within those examples–and the initial set of interventions (Public Health Interventions: Examples from Public Health Nursing, October 1997) was created, depicted as spokes of a wheel. Hundreds of copies of the interventions were distributed within the state and throughout the nation. Reports from PHNs using Interventions I suggested the framework could be quickly adopted to both teach and enrich practice.6 The initial interventions framework was practice-based. In July 1998, the Section began intensive work to determine the evidence underlying the interventions. With the award of a grant from the federal Division of Nursing, current public health nursing, nursing, public health, and related literature were explored to identify the theory, research, and expert opinion supporting and enhancing the interventions. In June 1999, forty-six public health nursing practice experts and academics from Iowa, Minnesota, North Dakota, South Dakota, and Wisconsin participated in a consensus meeting and created the bases of the revised intervention set. The recommendations of the regional experts were reviewed and critiqued by a national panel of public health nursing experts. The model withstood the challenge of rigorous examination with only a few changes to the original set of 17. The results of that process are presented in this document. (See Appendix C) What Is the Relationship Between the Interventions Wheel and the Core Public Health Functions/Essential Services?7 Public health nurses fulfill the public health’s essential services by implementing interventions to address public health problems and opportunities identified through a community assessment. The specific set of interventions selected and implemented will vary from community to community, from population to population, from problem to problem, and from department to department. Additionally, PHNs will most often accomplish these as part of a team with members from other public health disciplines and other community partners. 6Keller, Strohschein, Lia-Hoagberg, & Schaffer. (1998). Population-based public health nursing interventions: A model from practice. Public Health Nursing, 15(3), 207-215. 7Harrell, J. A. & Baher, E. L. (1994). The essential services of public health. Leadership in Public Health, 3(3), 27-31. Section of Public Health Nursing Public Health Minnesota Department of Health 6 Interventions