NURS 434-001: public / community lecture- unit 2

Janis Barner

global burden of disease

A metric that quantifies the health loss caused by diseases, injuries, and risk factors in all regions of the world.

DALYs (Disability-Adjusted Life Years):

• One DALY = 1 year of healthy life lost due to illness, disability, or premature death

• QUALYs, HALE, and other health expectancy/gap measures reflect both length and quality of life.

• These tools help assess population health, inform research and clinical priorities, and guide policy decisions.

GBD by Cause

• Noncommunicable Diseases (NCDs): 64% of global burden

• Communicable, Maternal, Neonatal, and Nutritional Diseases (CMNNDs): 26%

• Injuries: 10%

Low-income countries 

• bear a higher burden of CMNNDs (60%), while high-income countries experience a much greater burden of NCDs (86%).

• face a "double burden"—the ongoing fight against infectious diseases while also confronting rising NCDs (like heart disease, diabetes, cancer).

public health disaster response

General Structure

• All disasters start locally → Local health departments = first responders

• Coordinate with state & federal agencies

• Health Alert Network (HAN) → nationwide alerts, surveillance, communication

• Provide public info: health threats, evacuation routes, shelters, medical care

Scope & Command

• Disasters may be rapid (terrorism) or slow (pandemic like COVID-19)

• Coordinate: triage, transport, mental health, body recovery, food/water/shelter

• Use Incident Command System (ICS) + Emergency Operations Plans (EOPs)

Key Nursing Actions

• Collaborate with hospitals, healthcare teams, MRC/CERT volunteers

• Ensure PPE & responder safety

• Maintain documentation

• Monitor resources & activate mutual aid

• Plan for special populations

• Manage specimen testing & media communication

Federal & Volunteer Role

• Federal teams may deploy in large-scale events

• Unvetted volunteers handled per policy

• Nurses = key in monitoring, education, coordination

Post-Acute Phase

• Contaminant ID & lab analysis

• Ongoing public/responder health monitoring

• Water/food safety education

• Veterinary services important (impacts evacuation)

• Pets Evacuation and Transportation Standards Act (PETS Act) supports pet-inclusive evacuation planning

Risk Communication

• Exchange of reliable info to empower & reduce panic

• Designated team + clinical spokesperson

• Use simple, calming, repeated messaging

• Adapt for diverse populations & multiple languages

• Provide fact sheets (CDC biologic/chemical/radiologic info)

• Build trust: listen, acknowledge emotions, clarify misinformation

blast injuries

Common Injuries

Multisystem trauma:

Mutilation, shrapnel wounds

Bone, soft tissue, and vascular damage

Dismemberment

High risk of blunt trauma, open wound infections, and hearing loss due to blast force.

Effective Response Measures

Rapid on-site first aid and immediate transport to trauma centers save lives.

Tourniquet use has proven effective in controlling bleeding.

Coordination among emergency services and hospitals is critical.

Boston Marathon Bombing – A Success Story

Pre-positioned first responders enabled rapid care.

Presence of Level I trauma centers in the area reduced deaths.

Community training exercises (e.g., Operation Urban Shield with 71 drills) significantly improved response effectiveness.

Volunteers and runners contributed heroically on the scene.

Field Response Considerations (CDC):

Explosions in confined spaces = more severe injuries.

Victims may have temporary deafness, complicating communication.

Life-threatening injuries must be prioritized; don’t delay triage for fear of a “dirty bomb.”

Avoid detailed on-site assessments—focus on quick lifesaving measures.

radiologic disasters

What Is Radiation?

Radiation is energy in the form of particles or waves (e.g., light, heat, x-rays).

Ionizing radiation is high-energy and can be harmful in large doses.

Exposure vs. Contamination:

Exposure: Contact with a radioactive source (external or internal).

Contamination: Radioactive material is deposited where it doesn’t belong (e.g., on skin or clothes).

Dirty Bombs (Radiologic Dispersal Devices):

Combine explosives + radioactive material.

Have limited blast range, but cause exposure via inhalation, skin, and ingestion.

Can result in cancer, genetic issues, reproductive harm.

Biggest concerns: public fear and economic impact due to cleanup, not necessarily mass casualties.

disasters

overwhelm the community, requiring outside assistance.

Types of Disasters:

Pandemics:

• The COVID-19 pandemic of 2020 was the first major pandemic in the U.S. since 1918. It exposed gaps in preparedness, such as PPE shortages and communication issues. However, it also led to rapid vaccine development, expanded remote work, and normalized virtual healthcare and meetings.

Natural Disasters:

• floods, hurricanes, tornadoes, mudslides, avalanches, and wildfires cause major harm to life and property.

• All-hazards planning (assessing vulnerabilities and preparing resources) can reduce harm. Displacement of people is a major concern during such events.

Human-Made Disasters:

• radiation leaks, chemical spills, accidents, acts of terrorism, school shootings, and lone-wolf attacks in public places

• social human-made: genocide, warfare

Terrorism:

• acts that endanger human life and violate criminal laws, with the intent to intimidate civilians, influence government policy, or disrupt government actions. Its primary goals are to instill fear, cause harm, and disrupt the use of targeted areas or systems.

• Traditional terrorism includes violent acts causing casualties and destruction.

• Cyberterrorism targets digital infrastructure to disrupt or control computing systems

CDC Classification of Bioterrorism Agents

Category A (highest priority):

Easily spread.

High mortality.

Major public health impact.

Potential for mass panic.

Requires special preparedness measures.

Categories B and C include agents with lower risk or emerging threats.

nursing steps to dealing with chemical disaster!

Immediate Responsibilities:

1. Don Personal Protective Equipment (PPE) before any interaction with victims.

2. Assess Victims: Airway and breathing are top priorities. Help victims sit upright and loosen or remove tight clothing to ease breathing. If lying down, elevate the torso.

3. Decontamination Procedures: Remove outer layers of clothing to reduce chemical exposure. Separate victims from the unaffected population to prevent cross-contamination.

4. Washing: Use soap and water or at least water to cleanse exposed skin. Temporary decontamination tents may be set up in the field.

5. Severely Affected Victims: Transport to hospitals after field triage. Hospitals perform secondary decontamination outside before allowing entry into emergency departments.

Final Step:

Ensure that all personnel involved in the decontamination process are themselves thoroughly decontaminated before leaving the site.

evacuation

Evacuation is required during:

Massive explosions, fires, or flooding

Long-duration emergencies

Loss of essential infrastructure (e.g., water, electricity)

Natural disasters (e.g., wildfires, hurricanes)

Industrial accidents

Types of Movement:

Evacuation: Leaving homes or areas to move to a safer location.

Invacuation: Moving to a safer location within a building or facility (e.g., another floor in a hospital).

Blended Approach:

Some situations require both evacuation and shelter in place, depending on location:

Downwind of chemical releases: shelter in place.

Upwind or farther away: evacuate in case wind direction shifts.

Evacuation Guidelines:

•Wear long sleeves, pants, and sturdy shoes.

•Take pets with you.

•Lock your home before leaving.

•Bring your disaster supplies kit.

•Follow official travel routes—avoid shortcuts.

•Stay away from downed power lines.

sheltering in place

used during short-duration emergencies when:

Evacuating would be more dangerous.

It is not feasible to leave.

It’s a protective measure to reduce exposure to hazardous agents (chemical, biologic, or infectious).

When to Shelter in Place:

Chemical spills or toxic releases

Bioterrorism events

Infectious disease outbreaks (e.g., pandemics)

Box 20.11 Guidelines for Sheltering in Place:

•Stay indoors (home, office, or nearest building).

•Shut off HVAC systems and fans.

•Close and lock windows and doors.

•Seal doors with towels and tape; use plastic sheeting on vents and windows.

•Close fireplace dampers.

•Go to an interior, above-ground room (avoid basements).

•Bring your disaster supplies kit.

•Monitor news via radio or TV until cleared to exit.

Infectious Disease Events (e.g., pandemics):

May include social distancing orders:

Stay home, avoid gatherings.

Public events are canceled.

Drive-thru clinics may be used for medication or immunization (POD/EDS events).

chemical disasters

Agencies involved:

OSHA: Develops programs to prevent chemical incidents.

EPA: Requires risk management plans for facilities handling hazardous chemicals.

Chemical Agent Characteristics

Persistence is key in classifying and responding to chemical threats:

Nonpersistent agents (e.g., chlorine gas): Dissipate within hours.

Persistent agents (e.g., nerve and blister agents like sarin or VX): Remain for weeks; harder to clean.

Exposure can occur through:

Inhalation

Ingestion (food, water, medication)

Skin contact or contaminated objects

Chemical vs. Biologic Agents

Some nonliving toxins (e.g., ricin, botulinum) are classified as chemical agents under international law.

Chemical weapons include:

Nerve agents (sarin, VX)

Blister agents (mustard gases)

Choking agents (phosgene)

Agent Orange used in Vietnam caused long-term genetic and cancer-related effects.

FEMA

the lead federal agency, offering resources, coordination, and leadership.

Phases of Disaster Management

1. Preparation

   1. developing action plans, assessing risks, and identifying hazards before disasters occur.

   2. Tools like historical data, GPS, aerial imagery, and hazard modeling help communities design effective emergency plans.

   3. Public health nurses (PHNs) can join MRCs/CERTs, completing training, and preparing emergency kits.

2. Mitigation-All-Hazards Vulnerability Planning

   1. A proactive process that identifies common needs across disaster types (e.g., shelter, food, water, medical care).

   2. Involves mutual aid agreements and partnerships with healthcare, police, fire departments, volunteer groups, and local leaders.

3. Response

   1. Begins at the local level, with local officials and agencies being the first responders.

   2. Activation of emergency plans includes opening Points of Distribution (PODs) or Emergency Dispensing Sites (EDS) for distributing supplies like food, water, and medications.

   3. Drills and response coordination are often supported by MRCs, CERTs, and school/public health nurses.

4. Recovery

   1. Involves restoring essential services and supporting long-term community rebuilding.

   2. PHNs and local leaders help assess health needs and ensure equitable access to services during recovery.

5. Evaluation

   1. Post-disaster review of response efforts helps refine future preparedness plans.

   2. Includes analyzing what worked, identifying gaps, and updating emergency plans accordingly.

All-hazards vulnerability plan:

An integrated approach to emergency preparedness that addresses a wide spectrum of emergencies.

• identifies who’s affected in the community & the resources the community has to deal w disasters

invacuation

Moving people from one area to another within the same facility

Tabletop exercise (TTX)

An emergency-planning exercise that involves key personnel discussing simulated scenarios in an informal setting. It is used to assess plans, policies, and procedures and resolve issues before an actual disaster occurs.

Informal, discussion-based sessions where key personnel walk through simulated disaster scenarios.

Used to assess and refine plans, policies, and procedures.

Helps identify gaps and areas for improvement before real emergencies occur.

public health nursing competencies

Domain 1

Preparation and planning (actions taken before any specific emergency to increase readiness and confidence in actions to be taken during an event)

Domain 2

Communication (approaches to conveying essential information within one’s place of work or emergency assignment and documenting decisions made)

Domain 3

Incident management systems (the structure of disaster/emergency response and actions to make them effective)

Domain 4

Safety and security (assuring that nurses, their colleagues, and patients do not add to the burden of response by unsafe practices)

Domain 5

Assessment (gathering data about assigned patients/families/communities on which to base subsequent nursing actions)

Domain 6

Intervention (clinical or other actions taken in response to assessment of patients/families/communities within the incident management of the disaster event)

Domain 7

Recovery (any steps taken to facilitate resumption of pre-event individual/family/community/organization functioning or moving it to a higher level)

Domain 8

Law and ethics (the legal and ethical framework for disaster/emergency nursing)

Sustainable Development Goals (SDGs):

a global plan to end poverty, protect the planet, and ensure well-being for all. Includes 100+ specific goals

SDG 3: Good Health and Well-being

• Goal: Ensure healthy lives and promote well-being for all at all ages.

Key areas of focus include:

• Reducing maternal and child mortality

• Combating communicable and noncommunicable diseases

• Strengthening health systems & train workforce

• Achieving universal health coverage (UHC)

climate change & global health

Climate Change: long-term changes in:

• Temperature

• Precipitation

• Weather patterns

Effects include:

• Rising global temperatures

• Extreme weather (hurricanes, wildfires, floods)

• Air pollution & ozone depletion

• Rising sea levels

Health Impacts

According to the World Health Organization, climate change is one of the greatest threats to human health.

It affects:

• Public health systems

• Food & water security

• Migration/displacement

• Global peace & security

Disproportionate Burden

• Richest 10% → >50% of carbon emissions

• Poorest 50% → only 7%

• Yet vulnerable populations suffer most

Most affected:

• Low- & middle-income countries

• Low-income groups

• Communities of color

• Indigenous peoples

• Women, children, elderly

🌱 Climate Action – SDG 13

United Nations Sustainable Development Goal 13:

• Calls for urgent global climate action

• Focuses on reducing vulnerability

• Builds resilience to climate-related health risks

👩‍⚕ Nursing Relevance:

• Increased heat-related illness

• Respiratory conditions (asthma, COPD)

• Disaster response & emergency preparedness

• Advocacy for vulnerable populations

• Addressing social determinants of health

What can we do?

• Adaptation = Adjusting to climate impacts (flood defenses, climate-smart infrastructure)

• Mitigation = Reducing climate change causes (cutting emissions (public transit), recycling, reducing fossil fuel use)

social ecological model

A framework to understand the dynamic interconnectedness between health, personal, and environmental factors.

Health is shaped by multiple layers of influence:

• Individual factors: genetics, behaviors, psychological traits

• Social factors: family, peers, cultural norms

• Community factors: physical and social environments (schools, neighborhoods, workplaces)

• Policy factors: laws, regulations, and policies affecting health

social determinants of health (SDOH)

SDOH build upon the ecological model by focusing on nonmedical conditions that impact health. These are grouped into five key domains:

Economic stability

Education access and quality

Healthcare access and quality

Neighborhood and built environment

Social and community context

Demographic and Epidemiologic Transitions

Demographic Transition. (a long time ago, the US had a lot of kids. But today we have few kids bc we live longer so we don’t need to replace us as fast. NOT focused on disease.)

• “high fertility and high mortality, resulting in slow population growth; improvement in hygiene and nutrition, leading to a decreased burden of infectious disease; decline in mortality and later decline in fertility.”

• A population shifts from:

➡ High birth & death rates
to
➡ Low birth rates & longer life expectancy

💡 Why this happens:

• Better sanitation

• Improved healthcare access

• Vaccines

• Safer childbirth

• Improved nutrition

👩‍⚕ Nursing Relevance:

• More older adults → ↑ need for geriatric care

• Increased chronic disease management

• Focus on long-term care & prevention

• More education on healthy aging

Epidemiologic Transition

• “high and fluctuating mortality, due to poor health, epidemics, and famine.”

• Shift in the main causes of illness and death:

➡ From infectious diseases (TB, pneumonia)
to
➡ Chronic diseases (NCDs) like:

• Heart disease

• Diabetes

• Cancer

💡 Why this happens:

• People live longer

• Lifestyle factors (diet, smoking, inactivity)

• Environmental and policy influences

👩‍⚕ Nursing Relevance:

• Emphasis on health promotion & disease prevention

• Managing chronic conditions

• Patient education on lifestyle changes

• Monitoring long-term medication adherence

• Addressing social determinants of health

3 types of preventions

Primary Prevention-

• Maximizing health and wellness before illness or injury is present.

• Target: Healthy individuals or populations with no signs of illness

• Examples: Immunizations, seat belt use, handwashing, healthy eating, exercise.

  • vaccines: active immunity (Antibodies produced by the body after exposure to a pathogen (via infection or vaccine)

  • passive immunity (Temporary protection through external antibodies (e.g., from the placenta or immune globulin).

  • Herd immunity: Community-wide resistance due to a high proportion of immune individuals, reducing disease spread.

• Tertiary prevention- Maximizing health and wellness through strategies that are set in place at the palliation and end stage of disease and injury trajectories.

Secondary Prevention- (secondary screening)

• Maximizing health and wellness at the early and active chronic stages of illness and injury to minimize the impact of a disease or injury

• focuses on detecting and addressing disease or physical / emotional challenges early, to minimize their impact and prevent progression to more severe stages.

• Goal: Identify conditions at an early stage to allow timely intervention and better outcomes.

• examples - PT after a stroke, early screening programs

Tertiary Prevention- (Tertiary Treating an existing disease)

• focuses on the long-term care and management of individuals living with chronic, progressive, or incurable conditions, aiming to maintain quality of life, reduce complications, and support emotional well-being.

• for- Ongoing treatment, Rehabilitation, Palliative care, Support for comorbidities, Holistic support (emotional, spiritual, social), Monitored exercise programs, Nutrition counseling, Smoking cessation, Stress reduction (e.g., yoga, meditation), Weight management, Lifestyle coaching

• Tertiary prevention helps reduce the physical, psychological, and financial burdens of serious illness.

• maximizing function and dignity for those living with chronic illness while minimizing further health decline and complications.

climate change

Climate change is already disrupting health, agriculture, water, and ecosystems.

It causes natural disasters, changes in disease patterns, worsens air quality, and threatens food and water security.

Vector-borne diseases like malaria and dengue are spreading due to changing climates.

Between 2030 and 2050, climate change is expected to cause 250,000 additional deaths per year, largely from heat, diarrhea, malaria, and undernutrition

Children’s Health and the Environment

Why Children Are More Vulnerable

• Rapid body system development

• Higher intake of air, food, and water per body weight

• Hand-to-mouth behaviors (crawling, mouthing objects)

• Immature detoxification systems

• Closer to ground-level contaminants

• Time spent in schools, daycare, and outdoor environments

Lead Exposure

• High risk in older housing and contaminated areas

• Exposure via soil, dust, and objects placed in mouth

Mercury Exposure

• Metallic mercury from old devices can be mishandled

• Vapor is highly toxic, even at low levels

• Spills are costly; some schools have closed due to contamination

Unsafe Play Areas

• Lack of safe recreation spaces increases injury and contamination risk

• Teens may trespass on abandoned/polluted sites

environmental health risk assessment

I-PREPARE

investigate

present work

residence

environmental concerns

past work

activities

referrals & resources

educate

Key Components of Exposure Assessment:

1. Source of Contamination: Where the contaminant originates. It can be a point source (e.g., a spill) or nonpoint source (e.g., widespread pollution from cars).

2. Environmental Media and Transport: Contaminants travel through media like air, water, soil, or living organisms. Transport mechanisms explain how they move from the source to people.

• understand point of exposure, route of exposure, & receptor population.

Understanding whether an exposure pathway is complete is vital. If any link in the pathway is missing, exposure—and thus risk—is unlikely. For example, being near a contaminant doesn’t automatically mean someone is exposed or at risk.

bioavailability key terms

• Bioavailability: The amount of a substance that is absorbed or becomes available at the site of physiologic activity.

• Biomonitoring: Process of measuring environmental chemicals or their breakdown products (metabolites) in human tissues and fluids such as blood and urine.

• Exposure pathway: Describes how people are exposed to an environmental contaminant that originates from a specific source.

• Precautionary principle: If something has the potential to cause harm to humans or the environment, then precautionary measures should be taken even if there is a lack of scientific evidence for cause and effect.

• Toxicology: The study of the adverse effects of chemicals on people, animals, and the environment.

exposure pathway

Source= particles & vapors in plant

Environmental medium= rain, air, clouds

Point of exposure= where the animals are drinking the water / eating plants that have absorbed the harmful chemicals

Route of exposure= ingesting the contamination

Receptor pop= anyone living in the area

coalition

Group of consumers, health professionals, policymakers, and others working together to improve community health status or to solve a specific community health problem.

• An alliance for combined action

• ESSNTIAL - bringing together diverse stakeholders to address health issues collaboratively.

• For a coalition to succeed, it must have-

• A clear mission, goals, and expectations, Strong leadership and accountability, Respect for members’ time, roles, and expertise.

• Also- Engaging members with relevant expertise and diverse perspectives, Ensuring mutual respect and collaboration among members, Understanding that members expect more than goodwill—they often seek professional or organizational benefits, Selecting members based on past experience, community standing, and ability to influence others

health vs well-being

health - not simply the absence of disease, but rather a resource and capacity that enables individuals and communities to adapt, cope, and function in daily life.

well-being- A subjective perception of full functional ability as a human being. health as a dynamic and complex relationship between the individual and their environment. People and communities can face illness or even death while still maintaining dignity and a high level of human functioning

Nurses play a key role in four of the ten essential public health activities by:

1.Contributing to interdisciplinary efforts that monitor and respond to public health threats.

2.Analyzing health trends and helping prioritize interventions for at-risk populations.

3.Collaborating with communities to shape policies and targeted prevention programs.

4.Evaluating healthcare services to ensure awareness and use of available resources

The Healthy People (HP) initiatives

U.S. national health objectives aimed at improving the health and well-being of individuals, families, and populations. Led by the Centers for Disease Control and Prevention (CDC), HP 2030 provides a strategic framework to guide public health professionals, including nurses, in tackling the most pressing health issues.

Key goals of HP 2030 include:

• Increasing quality and years of healthy life, and

• Eliminating health disparities and barriers to care.

types of diseases

• Noncommunicable diseases: Chronic or non-infectious (e.g., obesity, depression, substance use, genetic disorders).

• Communicable diseases: Caused by pathogens (e.g., HIV, flu, malaria) and capable of spreading between hosts.

levels of disease prevention

prepathogenic period : health & wellness : primary prevention

Early pathogenic period : disease identified : secondary prevention

Pathogenic period : chronic illness : also secondary prevention

Late pathogenic period : physical . Emotional challenges : tertiary prevention

Motivational Interviewing (MI):

A client-centered, goal-directed communication technique 

Designed to help individuals resolve ambivalence about behavior change.

Motivation must come from the client, not be imposed.

Avoids arguments, unsolicited advice, diagnostic labeling, or coercion.

Emphasizes autonomy, active decision-making, and health literacy.

Behavior models guide health professionals in understanding and facilitating meaningful behavior change

The Learning Model

Learning theories view health behavior change as a step-by-step process toward a final goal, where behavior is shaped through reinforcement:

• Skinner says behaviors are shaped incrementally toward a health goal.

• Reinforcement—external (extrinsic) or internal (intrinsic)—is key to motivation:

• Extrinsic rewards (e.g., praise, prizes) help initiate behavior change.

• Intrinsic rewards (e.g., personal satisfaction, improved health) support long-term adherence.

Ex-

Weight Watchers uses both extrinsic (stars, public praise) and intrinsic (sense of achievement, leadership roles) reinforcement.

Nurses apply this model in chronic illness management (e.g., diabetes, CHF, hypertension) through teaching, monitoring, and encouraging behavior changes.

Limitations:

Long-term success depends on intrinsic motivation, which can be undermined by external social and economic barriers.

Example: In marginalized communities with limited access to healthy food (“food deserts”), maintaining healthy behaviors like dietary control for diabetes becomes difficult, despite initial success.

health behavior model

*Do know / care about this healthy behavior?

explains that individuals, families, or communities are more likely to engage in health-promoting behaviors based on four key beliefs:

-Perceived Severity of the illness or condition

-Perceived Susceptibility of getting

-Perceived Benefits – The expected advantages of taking preventive action.

-Perceived Barriers – The obstacles (real or imagined) to taking that action.

Cues to Action (reminders or prompts): are used to encourage healthy behaviors.

Individual cue: A note saying “Don’t overdo it at dinner.”

Family cue: “Let’s do one thing tonight not related to a television.”

Community cue: A “Got Milk?” billboard.

But these cues only work if people believe the behavior is possible and worthwhile.

- Age impacts perception:

Younger people may feel invincible and ignore risks.

Older adults may feel it's too late or discouraging to act.

The Transtheoretical Model

*I’m ready to TRANSform - NO REWARDS

behavioral change depends on an individual’s or group’s readiness to change

• Precontemplation – No intention to change or start a behavior. (idc that I smoke, I’m not quitting)

• Contemplation – Considering change, aware of it (eh maybe I’ll quit one day but I’m not ready)

• Preparation – Taking steps toward change, planning. (I’ll plan to cut back & examine how to stop)

• Action – Actively engaging in the new behavior. (I’m stopping)

• Maintenance – Sustaining the behavior over time. (I’ve stopped & I will not restart)

There is also the possibility of relapse, where a behavior stops but the intention to restart exists.

The Theory of Reasoned Action

*examines the REASON why people perform health actions

explains that a person’s behavior is mainly driven by their intention to perform that behavior. AKA they want to do it. Depends on:

• Attitude toward the behavior — beliefs about the behavior’s outcomes and their value.

• Subjective norms — beliefs about what others think the person should do.

A crucial part of behavior change is the belief in one’s ability to perform the behavior. Social norms influence behavior, but if someone feels incapable (e.g., a smoker who believes they can’t quit), social pressure alone won’t prompt change. People may even hide addictive behaviors to avoid judgment, complicating efforts to promote healthy habits.

Social Learning (Social Cognitive) Theory

explains behavior change through the interaction of environmental factors, personal factors, and the behavior itself.

A key element is self-efficacy—the belief in one’s ability to perform the behavior—and the perception that the benefits outweigh the negatives.

4 essential stages for learning behaviors:

-Attention – noticing the behavior,

-Retention – remembering it,

-Reproduction – being able to imitate it,

-Motivation – having reasons to perform it.

People change behaviors when messages are meaningful, memorable, and personally relevant. Though individuals reflect on their behavior, their environment heavily influences how they learn and act.

Theories of social support

Social support from family, friends, neighbors, and communities plays a crucial role in promoting behavior change. It includes:

-Instrumental support: Practical help like providing transportation or building safe walking spaces.

-Informational support: Sharing useful information, such as how to access community resources.

-Emotional support: Offering comfort, like calling a grieving family.

-Appraising support: Giving positive feedback on new health behaviors.

The relapse prevention model

focuses on maintaining adherence to healthy behaviors by addressing common causes of relapse (ex- negative emotions, poor coping skills, low motivation, stress, and high-risk situations). It distinguishes between a full relapse and a brief lapse, emphasizing the importance of planning strategies to manage high-risk scenarios.

- ex- what causes sobriety relapses?

Ecologic model:

There are a LOT of factors that influence health behaviors.

• intrapersonal attributes, interpersonal dynamics, person/environment interactions, cultural beliefs, and attitudes.

4 levels of influence:

1. ontogenetic (individual)- developmental level, attitudes, beliefs, self-efficacy

2. microsystem (immediate relationships)

3. exosystem (indirect environment)- finances, literacy, employment, insurance, transportation, community resources, food access

4. macrocultural (broader societal culture)- societal norms, gender roles, cultural beliefs, public policy

skills required for health literacy

• Functional Health Literacy: Basic reading and writing skills

• Interactive Health Literacy: Higher-level cognitive and social skills enabling individuals to participate in shared decision-making and self-care

• information, computer, visual, communication literacy

communication practices

Teach-Back Method: Clients repeat back what they’ve learned to ensure understanding.

Show-Me Method: Clients demonstrate a skill (e.g., using a glucometer) to verify they can perform it at home.

Communication Best Practices

Spoken info: Use simple terms, limit to 3–4 main points, reinforce messages, avoid jargon.

Written materials: Use plain language, short sentences, bullet points, visuals, and logical organization.

Three Levels of Health Literacy:

Functional – Basic reading and writing skills to understand health information.

Interactive – Ability to actively engage in healthcare and decision-making.

Critical – Skills to analyze health information and take collective action for health improvement.

key informant

Person knowledgeable about specific aspects of a problem and the community’s current and past attempts to address it.

• ex- mayor, doctor, manager, nurse, pastor. AKA anyone involved in the community as a professional (NOT civilians)

population aggregate

A defined subset of the population such as people with or at risk for a specific health problem or having specific social or demographic characteristics

stakeholder

An individual, organization, or group that has an interest (stake) in a specific community health issue or the outcome of a community-level intervention

Ottawa Charter

• First International Conference on Health Promotion.

• Focus: Health promotion through policy & community empowerment.

  • Build healthy public policy

  • Strengthen community action

  • Develop personal skills

  • Reorient health services

WHO Commission on Social Determinants of Health (2008)

Focus: Health inequities caused by social conditions.

• Key recommendations:

  • Improve living conditions

  • Reduce poverty & inequity

  • Ensure fair distribution of power/resources

  • Monitor & track health disparities

Millennium Development Goals (2000) → Sustainable Development Goals

• MDGs (2000):

  • Reduce disease

  • Improve access to water, education, health care

• SDGs (2015–2030):

  • Also include poverty, gender equality, climate change, health equity

• Progress has been uneven; COVID-19 slowed advancement.

Shanghai Declaration

• Promotes:

  • Innovation & technology in health

  • Health literacy

  • Community engagement

  • Equitable access

• Emphasizes local empowerment for sustainable outcomes

Geneva Charter for Well-Being

• Vision of a “well-being society.”

• Calls for:

  • Fair economies

  • Universal health coverage

  • Digital equity

  • Environmental protection

  • Public policy engagement

Health Planning: National & State Levels (U.S.)

Key Federal Agencies

• Centers for Disease Control and Prevention (CDC)

• U.S. Department of Health and Human Services (HHS)

Major Data Sources

• Behavioral Risk Factor Surveillance System (BRFSS)

• National Health Interview Survey (NHIS)

• Medicare & Medicaid claims data

• Youth Risk Behavior Survey (YRBS)

• NHANES

• Disease surveillance systems

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Role of State Departments of Public Health

• Align state plans with Healthy People 2030

• Coordinate with:

  • Federal agencies

  • Local health departments

  • Community stakeholder

community health assessment (CHA)

a structured process used to identify priority health issues and available resources within a community. It involves methods such as:

• Key informant interviews

• Health data analysis

• Community surveys

• Direct observation

Aims to uncover both health problems and needs, as well as community assets and strengths. It also assesses the community's readiness and capacity to address identified issues. This foundational process informs targeted interventions and resource planning.

systems theory

a community as a complex, interconnected network of systems—such as families, schools, workplaces, and neighborhoods—each with its own structure, boundaries, and purpose.

These systems:

• Overlap and interact, meaning individuals are often part of multiple systems.

• Exchange information, energy, resources, and services in a reciprocal way.

• Are interdependent, so a change in one system affects others.

• To create effective community change, it's often necessary to influence multiple systems

social ecological model (SEM)

-a framework for health promotion that recognizes health as the result of multiple, interacting influences—individual, family, work, community, and broader societal factors

helps public health professionals design multi-level intervention

health impact pyramid

- a framework that illustrates the population-level impact of different types of public health interventions, organized into five tiers. As you move from top to bottom, interventions require less individual effort and generally have a greater impact on population health.

Pyramid Levels (Bottom to Top):

• Socioeconomic Factors (Base of the Pyramid)

Interventions that improve education, income, housing, water, and sanitation.

These have the greatest population impact but are often politically and financially challenging to implement.

• Changing the Environmental Context

Makes healthy choices the default or easier option (eliminating trans fats, smoke-free laws, iodized salt).

Broad reach with sustainable population-wide benefits that don’t rely on individual behavior change.

• Protective Interventions

Examples include immunizations and screenings (e.g., colonoscopy).

Long-term benefits but require some individual participation.

• Clinical Interventions

Treat individual health conditions like hypertension or diabetes.

Effective for individuals but have limited population impact due to access, adherence, and cost issues.

• Counseling and Education (Top of the Pyramid)

Includes health education and behavior counseling.

Requires the most individual effort and typically has the least population-level impact, though useful when repeated and consistent.

Types of Intervention Levels:

• Upstream: Societal, environmental, or policy level (laws, social reforms). Keeping your head UP above water before a problem occurs

• Mainstream: Community or population level (neighborhood programs, local initiatives)

• Downstream: Individual level (one-on-one counseling, clinical care). Your health issue let you DOWN

Upstream and mainstream interventions have greater, more sustainable impacts on population health by shaping social norms, environments, and policies.

Downstream efforts (e.g., treating individuals) are limited in reach and must be repeated continuously as new people experience the health issue.

True behavioral change is difficult to sustain without structural and cultural changes (e.g., through law, organizational policies, or community norms

social determinants of health (SDOH)

-the conditions in which people are born, live, work, and age—shaped by larger economic, political, and social systems

-influence health outcomes across individuals and communities.

• Obesogenic environments- promote unhealthy behaviors and contribute to obesity (e.g., poor food availability, lack of physical activity spaces).

• Salutogenic environments- foster health by making healthy choices the norm (e.g., schools offering nutritious meals and regular physical activity).

Built Environment & Community Health:

The built environment (infrastructure, land use, transportation, etc.) strongly influences eating, activity, and overall health. (ex- if there’s a trail nearby, people will be encouraged to take walks)

Lewin’s Model of Change

A foundational theory for planned change. 3 stages:

1. Unfreezing:

Purpose: Prepare the community to recognize the need for change.

How it works: Raise awareness, challenge current behaviors, and highlight the gap between the current state and desired health outcomes.

Role of Nurses: Act as change agents by motivating the community and creating a sense of urgency.

2. Changing (Transition):

Purpose: Begin implementing the change.

Identify how change will occur.

Help the community visualize the desired outcome.

3. Refreezing:

Purpose: Stabilize and sustain the change.

Goal: Make new behaviors or norms part of the community’s systems and culture.

Sustainability:

Requires planning for ongoing support after a program ends.

Community ownership is essential—engagement throughout the process is key.

force field analysis

a change management tool that helps assess the balance of forces driving and resisting change in a given situation.

• Forces Driving Change: Support or push toward the desired change.

• Forces Resisting Change: Act as barriers or restraints against the change.

• Equilibrium: When driving and restraining forces are equal, no change occurs.

Purpose of Force Field Analysis:

To visualize the dynamic forces in a situation that appears stuck or resistant to change.

To identify factors within a community or organization that can be:

Strengthened (driving forces)

Weakened (restraining forces)

levers of change

• Strategies that create large health impact with minimal effort or resources.

• Used to increase driving forces and reduce restraining forces (Force Field Analysis).

Examples (Tobacco Control)

• Smoke-free public laws, Bans on sales to minors, Higher tobacco taxes, Social marketing (secondhand smoke campaigns, smoke-free homes)

Community Readiness for Change

-how willing and prepared a community is to accept and implement a proposed change. Assessing this readiness is crucial for effective intervention planning.

-members must be full partners in the change process.

logic model

*LOGICALLY, how will this program work?

A visual framework showing how a community health program will achieve its desired outcomes.

Key Components

• Inputs – Resources needed (staff, funding, materials)

• Activities – What the program does

• Outputs – Direct products of activities

• Outcomes – Short-, mid-, and long-term results

• Target Population – Who is served

• Timeline – When activities/results occur

• Program Theory – Why it should work (evidence-based)

Uses

• Planning – Organizes resources, budgets, timelines

• Evaluation – Defines how success is measured

• Communication – Clarifies goals for stakeholders

• Customization – Adaptable to community needs

Bottom line: A logic model links resources → actions → results in a clear, organized way

SMART objectives

When you make a program goal, it should be SMART:

-Specific, Measurable, Achievable, Relevant, and Time-bound.

• Specific: What behaviors, knowledge, skill, change in health status indicators, or outcome will result from the program?

• Measurable: How will the outcome be measured and how will one know if the objective is achieved? Are the data available?

• Achievable: Is it realistic to reach the desired outcome with the resources and time available to the program?

• Relevant: Is the objective related to the program’s goals and activities?

• Time-bound: When will the objective be achieved?

Not SMART: The program will reduce teen pregnancy.

SMART: The number of births to girls aged 19 and younger in Springfield will be reduced by 20% from 40 births in 2025 to 32 or fewer in 2030.

Not SMART: Fewer teens will start smoking.

SMART: The proportion of high school sophomores in the state of Georgia who report having ever smoked a cigarette on the Youth Behavioral Risk Factor Survey in 2025 will be no more than 7%.

RE-AIM Framework

An evaluation model used to assess effectiveness and sustainability of health programs

Components:

• Reach – % and number of target population engaged

• Effectiveness – Impact on behaviors, health outcomes, quality of life (including negatives)

• Adoption – Extent organizations/providers implement the program

• Implementation – How consistently and accurately it’s delivered

• Maintenance – Long-term sustainability for participants and organizations

Funding Community-Level Intervention Programs

Sustainability

• Funders expect clear plans to continue programs after funding ends.

• Plan early and secure partner commitments.

• Program replication tests if success can be reproduced in other communities (shows strength of intervention).

Funding Sources

• Government agencies – Competitive, often disease-specific grants; usually flow through states or universities.

• Private foundations – Fund projects aligned with their mission; require strict proposal guidelines.

• Local resources – Banks, businesses, faith/civic groups; provide seed money, matching funds, or in-kind support.

Bottom line: Long-term success requires early sustainability planning, strong partnerships, and diverse funding sources.

social marketing

Promotes social change in public health by raising awareness and driving actual personal behavior change.

Effective in areas like:

• Obesity prevention, Smoking cessation, Alcohol reduction, Cancer screening, Healthy eating, breastfeeding, fall prevention, Safer behaviors

Social Marketing vs. Social Media

• Social marketing → Targets specific behaviors and defined audiences.

• Social media → Broad messaging to wide audiences.