Chapter 12 Population-Based Public Health Nursing Practice The Intervention Wheel Part 1

The Intervention Wheel: Use and Development

  • The Intervention Wheel is a conceptual framework that defines population-based public health practice and explains how PHNs contribute to improving population health.
  • It provides a graphic illustration of population-based practice and shows interventions with communities, individuals/families, and the systems that affect community health.
  • It was originally introduced as the Public Health Intervention Model and was nationally known as the "Minnesota Model"; it is now commonly referred to as the “Wheel.”
  • The Wheel depicts how public health improves population health through interventions across three spheres: communities, individuals/families, and systems.
  • It originated from the practice of public health nurses (PHNs) and is intended to support their work by offering a common language for describing the full scope of PHN practice.
  • The Wheel is a conceptual model that serves as a catalog of general actions used by PHNs across settings, framed by a set of assumptions or relations among concepts.
  • It creates a structure for identifying and documenting interventions performed by PHNs and captures the nature of their work.
  • The Public Health Nursing: Scope and Standards of Practice includes the Intervention Wheel as a framework used in practice today (ANA, 2013; 2022).
  • Although centered on PHN, the Wheel is applicable to other public health professionals (nutritionists, health educators, planners, physicians, epidemiologists) who use these interventions.
  • The Wheel emphasizes population-based practice and is intended to adapt across changes in the public health system.
  • Key historical references: Keller et al. introduced the Wheel (1998; 2004a; 2004b); it has since been revised and updated (e.g., 2019 edition by MDH).
  • Origins and evolution highlighted the Wheel’s development through a grounded theory process in Minnesota in the mid-1990s, with workshops across the state, analysis of 200 practice scenarios, and identification of 17 common actions across three levels of practice. The graphic was updated in $2019$ (Fig. 12.1).
  • Adoption has been rapid and worldwide since first publication in $1998$; it has informed curricula, practice in state/local health departments, and inquiries into topics like school nursing, breast cancer screening coalitions, and fall case management.
  • Updating the Wheel (Box and figures): In $2017$, MDH requested an evidence update; evidence gathering used CINAHL (2000–2018) and other sources (CDC, NACCHO, WHO, USDHHS, state health departments). The Johns Hopkins Nursing Evidence-Based Practice model guided evidence strength. Box 12.1 presents evidence levels, and Fig. 12.2 outlines the evidence pipeline from sources to consensus to field testing.

Origins and Evolution

  • The mid-$1990$s: Minnesota PHN consultants faced reform debates and uncertainty about PHN contributions to population health. Workshops across Minnesota highlighted core PHN functions.
  • Across 200 practice scenarios from home care, school health, home visiting, to corrections health, 17 common actions were identified as universal to PHN work, regardless of setting.
  • A wheel-shaped graphic was developed to illustrate the set of interventions and levels of practice, later updated in $2019$ with an evidence update (Fig. 12.1).

Assumptions Underlying the Intervention Wheel

  • Learning objective: Describe the assumptions underlying the Intervention Wheel.
  • The Wheel rests on 10 core assumptions guiding PHN practice:
Assumption $1$: Public Health Nursing Practice Requires Knowledge and Skills in Both Nursing and Public Health
  • Public health nursing is defined as "the practice of promoting and protecting the health of populations using knowledge from nursing, social, and public health sciences" (APHA, 2013, p. 2).
  • A PHN is a licensed RN with educational preparation in both public health and nursing. Primary focus: promote health and prevent disease for entire population groups by working with individuals, families, communities, and/or systems.
Assumption $2$: Public Health Nursing Practice Focuses on Populations
  • Distinguishes PHN from other nursing by focusing on populations rather than only individuals.
  • Definitions:
    • Population: a group with one or more shared characteristics (geographic, risk factors, etc.).
    • Population at risk: a population with a common identified risk factor or exposure threatening health (e.g., overweight adults with hypertension).
    • Population of interest: a population essentially healthy but with potential health improvements (e.g., healthy adolescents for social competency training).
Assumption $3$: Public Health Nursing Practice Considers the Determinants of Health
  • Determinants of health include: (1) social/economic environment, (2) physical environment, (3) individual characteristics/behaviors (WHO, 2017).
  • Emphasis on Social Determinants of Health (SDOH) domains: economic stability, education access and quality, health care access and quality, neighborhood and built environment, social and community context (Fig. 12.3).
  • Specific health disparities examples include racial/ethnic disparities in preterm birth and infant mortality (NCHS, 2022):
    • Preterm birth by race/ethnicity: Black women $12.8 ext{ extperthousand}$; Asian $7.29 ext{ extperthousand}$ (interpret as percentages where applicable). In population terms: % figures cited: $12.8 ext{%}$, $7.29 ext{%}$; Puerto Rican $11.37 ext{%}$; Cuban $9.00 ext{%}$.
    • Infant mortality rates (2018): overall $5.67$ per $1000$ live births; highest among non-Hispanic Black infants $10.75$; Native Hawaiian/Other Pacific Islander $9.39$; American Indian/Alaska Native $8.15$; Hispanic $4.86$; non-Hispanic White $4.63$; non-Hispanic Asian $3.63$.
Assumption $4$: Public Health Nursing Practice Is Guided by Priorities Identified Through an Assessment of Community Health
  • Community defined as a group sharing culture/values/interests based on social identity or territory, with a means to recognize and act on these commonalities.
  • Community health status assessment requires ongoing collection/analysis of quantitative and qualitative data, including determinants of health.
  • Priority setting requires balancing data-driven needs with community beliefs, attitudes, readiness for change, and resource constraints; PHNs provide key insights during priority setting.
Assumption $5$: Public Health Nursing Practice Emphasizes Prevention
  • Prevention is anticipatory action to prevent occurrence or minimize effects after occurrence (Turnock; Turnock's continuum).
  • Levels of Prevention (definitions with examples):
    • Primary Prevention: promotes health and protects against threats; prevents problems before they occur; targets essentially well populations. Examples: immunization; building developmental assets in youth.
    • Secondary Prevention: detects and treats problems early; reduces severity; identifies risks and modifies/treats before they become serious. Examples: screening for hypertension, obesity, hyperglycemia, hyperlipidemia.
    • Tertiary Prevention: limits further negative effects once a disease/injury has occurred; restores functioning. Examples: directly observed therapy (DOT) for active TB.
  • Public health nursing emphasizes health promotion and disease prevention, prioritizing primary prevention when possible.
Assumption $6$: Public Health Nurses Intervene at All Levels of Practice
  • PHNs work at three levels of practice—community, systems, and individual/family—often sequentially and/or simultaneously to improve population health.
  • Community-level practice changes community norms/attitudes/awareness/practices/behaviors; example: social marketing to discourage underage drinking at high school graduation parties (primary prevention).
  • Systems-level practice changes organizations, policies, laws, power structures within communities; example: compliance checks to restrict alcohol access to minors (secondary prevention).
  • Individual-level practice changes knowledge, attitudes, beliefs, practices, and behaviors of individuals; example: teaching refusal skills to adolescents (secondary prevention).
Assumption $7$: Public Health Nursing Practice Uses the Nursing Process at All Levels of Practice
  • The nursing process (assessment, priority problem, planning, implementation, evaluation) is applied at all levels but customized to community, systems, and individual/family practice.
  • Table 12.1 (not reproduced here) outlines the nursing process for each level of practice.
Assumption $8$: Public Health Nursing Practice Uses a Common Set of Interventions Regardless of Practice Setting
  • The Intervention Wheel includes $17$ interventions:
    • Surveillance
    • Disease and other health event investigation
    • Outreach
    • Screening
    • Case finding
    • Referral and follow-up
    • Case management
    • Delegated functions
    • Health teaching
    • Consultation
    • Counseling
    • Collaboration
    • Coalition building
    • Community organizing
    • Advocacy
    • Social marketing
    • Policy development and enforcement
  • Interventions are grouped with related interventions into wedges and color-coded for recognition (Fig. 12.4).
  • Examples of how interventions relate: surveillance paired with disease investigation; screening often follows surveillance/investigation and may be preceded by outreach; screening often leads to case finding but can be independent.
  • The Green wedge includes: referral and follow-up, case management, delegated functions (often used together).
  • The Blue wedge includes: health teaching, counseling, consultation (often paired).
  • The Orange wedge includes: collaboration, coalition building, community organizing (types of collective action; used at systems or community levels).
  • The Yellow wedge includes: advocacy, social marketing, policy development and enforcement (often interrelated; advocacy can precede policy; social marketing can carry out advocacy).
  • Interventions on the right side (red/green/blue) are commonly used by PHNs focused on individuals/families; Orange and Yellow wedges are more commonly used by PHNs focusing on systems/communities.
  • No PHN is required to perform every intervention at all three levels, but workforce capacity to do so is recommended for organizational planning.
Assumption $9$: Public Health Nursing Practice Contributes to the Achievement of the 10 Essential Services
  • Implementing the 17 interventions contributes to achieving the 10 essential public health services (as described in Chapter 1).
  • Interventions are the means by which PHNs implement the 10 essential services; they are the ‘how’ of practice (MDH, 2019; CDC, 2021b).
Assumption $10$: Public Health Nursing Practice Is Grounded in a Set of Values and Beliefs
  • The Cornerstones of Public Health Nursing (Box 12.2) accompany the Intervention Wheel; they synthesize values/beliefs from public health and nursing.
  • The Cornerstones inspire and guide PHN practice, shaping the rationale for how interventions are chosen and applied (Keller et al., 2011).

Components of the Model

  • Learning objective: Identify the components of the Intervention Wheel.
  • The model has three components: a population basis, three levels of practice, and 17 interventions.
Component 1: The Model Is Population Based
  • All levels of practice (community, systems, individual/family) are population-based.
  • PHN practice identifies a focus on populations of interest or populations at risk through a community health status assessment and priority setting.
  • Services to individuals/families are population-focused only if they meet both criteria:
    • Individuals receive services because they are members of an identified population.
    • Services to individuals clearly contribute to improving the overall health status of the identified population.
Component 2: Three Levels of Practice
  • Community level: targets entire populations within a community or at-risk populations; aims to change norms/behaviors; example: social marketing campaign against underage drinking.
  • Systems level: changes organizations, policies, laws, and power structures to influence health outcomes; example: regulatory compliance checks to prevent service to minors.
  • Individual/family level: changes knowledge, attitudes, beliefs, practices, and behaviors of individuals (or families); example: teaching refusal skills to adolescents.
Component 3: 17 Interventions
  • The 17 interventions are the core actions used across levels:
    • Surveillance
    • Disease and health event investigation
    • Outreach
    • Screening
    • Case finding
    • Referral and follow-up
    • Case management
    • Delegated functions
    • Health teaching
    • Consultation
    • Counseling
    • Collaboration
    • Coalition building
    • Community organizing
    • Advocacy
    • Social marketing
    • Policy development and enforcement
  • The Wheel emphasizes that these interventions are used in various combinations (wedges) to address population health needs.

Adoption and Dissemination

  • Adoption of the Wheel was rapid and worldwide after its first publication in $1998$.
  • It has been integrated into public/community health coursework in undergraduate and graduate curricula and used as an organizing framework in multiple countries and contexts (Mexico, New Zealand, Norway, Poland, Hungary, Namibia, Kazakhstan, Japan).
  • It has supported inquiries into school nursing practice (Schaffer et al., 2016; Anderson et al., 2017), nursing curriculum reviews (Schoneman et al., 2014), building breast cancer screening coalitions (Depke & Onitilo, 2011), and fall case management and prevention (Leahy-Warren et al., 2018).
  • The Wheel’s strength lies in providing a common language for PHNs to discuss their work (Keller et al., 1998).

Updating the Wheel (Box 12.1 and Box 12.2 context)

  • In $2017$, MDH requested an update on Wheel evidence.
  • Evidence sources: primarily CINAHL for $2000$–$2018$; additional evidence from CDC, NACCHO, WHO, USDHHS, state health departments; classic texts; Johns Hopkins Nursing Evidence-Based Practice Model guided strength levels.
  • Evidence levels (Box 12.1):
    • Level $1$: Experimental studies (randomized controlled trials) or systematic reviews of RCTs
    • Level $2$: Quasi-experimental designs; systematic reviews of mixed RCTs/quasi-experimental designs; pretest-posttest evaluations
    • Level $3$: Nonexperimental designs; qualitative studies and surveys; systematic reviews of nonexperimental studies
    • Level $4$: Clinical practice guidelines; consensus panels; position statements
    • Level $5$: Literature reviews; quality improvement, program evaluation, case reports; expert opinion
  • The evidence update showed representation of all five levels, with many interventions supported by $4$ and $5$ level evidence.
  • The update also provides "evidence-based practice tips" and assigns evidence levels to each practice tip.
  • Box 12.1 explicitly documents the evidence levels used to categorize Wheel updates.
  • Figure references: Fig. 12.2 depicts the development process (systematic critique, expert panels, Delphi rounds) and the flow from literature to practice recommendations.
  • Box 12.1 and Fig. 12.2 illustrate the evidence-based development of the Wheel and its applications.

Evidence Base and Practical Implications

  • The Wheel’s evidence base combines trial-based, quasi-experimental, and nonexperimental evidence, with many items supported by Level $4$–$5$ evidence, reflecting public health practice realities.
  • The framework is designed to translate evidence into practical interventions across population groups and levels of practice.
  • The Johns Hopkins Nursing Evidence-Based Practice model provides structure for appraising and applying evidence in Wheel-based practice.

Social Determinants of Health (SDOH) – Figure 12.3

  • The Wheel emphasizes that population health is shaped by SDOH domains:
    • Economic stability
    • Education access and quality
    • Health care access and quality
    • Neighborhood and built environment
    • Social and community context
  • Visual representation (Fig. 12.3) shows the five determinants around the health status of populations.
  • The SDOH domains connect to health disparities; examples include differences in infant gestational age and life expectancy across racial/ethnic groups, and the impact of pandemic-related mortality on life expectancy (NCHS data):
    • Overall U.S. life expectancy at birth declined from $78.8$ years in $2019$ to $77.3$ years in $2020$; disparity between men and women widened from $5.1$ to $5.7$ years.
    • Non-Hispanic Black infants had the highest infant mortality rate in $2018$ at $10.75$ per $1000$ live births; other groups ranged from $3.63$ (non-Hispanic Asian) to $9.39$ (Native Hawaiian/Other Pacific Islander).
  • The NCHS $2021$ reports continued disparities in life expectancy by race/ethnicity and sex.
  • Resolving health inequities and addressing determinants of health are core distinguishing characteristics of PHN.

Population Health Priorities and Community Assessment (Assumption $4$; Box context)

  • Community health assessment requires ongoing data collection and analysis to identify deviations from expected rates of disease, injury, death, disability, or risk factors.
  • Priority setting requires balancing data with community beliefs, attitudes, and readiness for change; PHNs contribute important insights during priority setting.
  • The community is defined as a group sharing culture/values/interests and having recognizable commonalities (Gregory et al., 2009).

Levels of Practice, Nursing Process, and Interventions – Connections to Practice

  • PHN practice uses the nursing process at all three levels (community, systems, individual/family) with the same components: assessment, priority problem, planning, implementation, evaluation.
  • The Wheel’s 17 interventions are applied across levels to address health determinants and outcomes.
  • The Wheel aligns with the 10 Essential Public Health Services by providing the practical actions (interventions) that achieve those services.

Practical Takeaways and Connections to Practice

  • The Wheel provides a common language for PHNs and interprofessional teams to discuss population-based interventions.
  • It emphasizes prevention (primary, secondary, tertiary) and the use of multiple levels of practice to affect population health.
  • It supports priority setting through population-based assessment and consideration of SDOH.
  • The Wheel’s evidence-based evolution shows a commitment to grounded practice, ongoing updating, and flexible application across settings and countries.

Key Terms to Remember

  • Advocacy, case finding, case management, coalition building, collaboration, community, community-level practice, community organizing, consultation, counseling, delegated functions, determinants of health, health teaching, intermediate goals, interventions, levels of practice, outcome health status indicators, outreach, policy development, policy enforcement, population, population at risk, population of interest, prevention (primary/secondary/tertiary), public health nursing (PHN), referral and follow-up, surveillance, screening, social determinants of health, social marketing, systems-level practice, wedges.

Summary Connections to Foundational Concepts

  • The Intervention Wheel integrates PHN foundations with a practical set of actions (17 interventions) that can be applied at different population levels to achieve public health goals.
  • It emphasizes population health, determinants of health, prevention, and the interdependence of community, systems, and individual/family interventions.
  • The Wheel is anchored in evidence-based practice, with ongoing updates to reflect current research, guidelines, and best practices.

Quick Reference: 17 Interventions (for study)

  • Surveillance
  • Disease and health event investigation
  • Outreach
  • Screening
  • Case finding
  • Referral and follow-up
  • Case management
  • Delegated functions
  • Health teaching
  • Consultation
  • Counseling
  • Collaboration
  • Coalition building
  • Community organizing
  • Advocacy
  • Social marketing
  • Policy development and enforcement

Quick Reference: Levels of Practice (PHN)

  • Community-level practice: targets whole communities or populations at risk to change norms and behaviors; example: social marketing campaigns to change norms around underage drinking.
  • Systems-level practice: targets organizations, laws, policies, and power structures; example: compliance checks to ensure liquor stores do not sell to minors.
  • Individual/family-level practice: targets individuals or families; example: teaching refusal skills to adolescents.

The 3 Core Model Elements in Practice

  • Population basis: focus on populations and priority populations identified through community assessment.
  • Three levels of practice: community, systems, individual/family.
  • 17 interventions: actions used to influence population health at any level.

Box and Figure References (Contextual, not reproduced here)

  • Fig. 12.1: The Intervention Wheel graphic showing population-based interventions.
  • Fig. 12.2: Evidence-based development flow (literature → expert panels → Delphi → field-testing).
  • Fig. 12.3: Social determinants of health diagram.
  • Fig. 12.4: Visual wedges of interventions (color-coded): red, green, blue, orange, yellow.
  • Box 12.1: Evidence levels (1–5) for Wheel evidence.
  • Box 12.2: Cornerstones of Public Health Nursing (foundational values).