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Public Health Interventions

Applications for Public Health

Nursing Practice

• Interventions are actions that PHNs take on
behalf of individuals, families, systems, and
communities to improve or protect health
• “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 model, or the “intervention wheel,” as it has come to be known, integrates three distinct and equally important
1. The population-basis of all public health interventions
2. The three levels of public health practice:
3. The 17 public health interventions:
Disease and Health Threat Investigation
Referral and Follow-up
Case Management
Delegated Functions
Health Teaching
Coalition Building
Community organizing
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.
• This means focusing on everyone actually or
potentially impacted by the condition or who
share a similar characteristic.
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.
• 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
• Prevention is anticipatory action taken to
prevent the occurrence of an event or to
minimize its effect after it has occurred.
• 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.
• Primary prevention both promotes health
and protects against threats to health.
• It promotes resiliency and protective factors
or reduces susceptibility and exposure to risk
factors. Primary prevention is implemented
before a problem develops.
• 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 more serious.
• Secondary prevention is implemented after a
problem has begun, but before signs and
symptoms appear.
• 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.
• Tertiary prevention keeps existing problems from
getting worse, for instance, collaborating with
health care providers to assure periodic
examinations to prevent complications
• 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-
• 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
• The focus is not directly on individuals and
communities but on the systems that impact
• Changing systems is often a more effective and
long-lasting way to impact population health than
requiring change from every single individual in a
• 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
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
• 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.
• Surveillance describes and monitors health
events through ongoing and systematic
collection, analysis, and interpretation of
health data for the purpose of planning,
implementing, and evaluating public health
• Disease and other health event investigation systematically
gathers and analyzes data regarding threats to the health of
populations, ascertains the source of the threat, identifies cases
and others at risk, and determines control measures.
• The threats may be actual or potential.
• While investigation traditionally focuses on contagious diseases, it
also may be used with chronic diseases, injury, and other health
• The investigative process consists of identifying and verifying the
source of the threat; identifying cases, their contacts, and others at
risk, determining control measures, and communicating with the
public, as needed.
• Outreach locates populations-of-interest or
populations-at-risk and provides information about
the nature of the concern, what can be done about it,
and how services can be obtained.
• Outreach activities may be directed at whole
communities, targeted populations within those
communities, and/or systems that impact the
community’s health. It includes risk communication.
• Outreach success is determined by the proportion of
those considered at risk who receive the information
and act on it.
• Case-Finding locates individuals and families with
identified risk factors and connects them to
• Case-finding is a one-to-one intervention and,
therefore, operates only at the individual/family level.
As such, case-finding serves as the individual/family
level of intervention for surveillance, disease and other
health event investigation, and outreach.
• Case-finding is frequently implemented to locate those
most at risk.
• Screening identifies individuals with unrecognized health risk factors or
asymptomatic disease conditions in populations.
• Three types of screening are described in the literature:
– mass: a process to screen the general population for a single risk–such as
cholesterol screening in a shopping mall–or for multiple health risks–such as
health fairs at work sites or health appraisal surveys at county fairs
(community level)
– targeted: a process to promote screening to a discrete sub-group within the
population–such as those at risk for HIV infection (individual/family level)
– periodic: a process to screen a discrete, but well, sub-group of the population
on a regular basis, over time, for predictable risks or problems; examples
include breast and cervical cancer screening among age-appropriate women,
well-child screening, and the follow-along associated with early childhood
development programs (individual/family level)
• Referral and follow-up assists individuals,
families, groups, organizations, and
communities to utilize necessary resources to
prevent or resolve problems or concerns.
• Referral may include developing resources that
are needed, but unavailable to the population.
• The key to successful referral is follow-up; making
a referral without evaluating its results is both
ineffective and inefficient.
• Case management optimizes self-care capabilities of
individuals and families and the capacity of systems and
communities to coordinate and provide services.
• Case management is characterized by:
– focus on development of the self-care capabilities of
communities, systems, individuals, and families
– promotion of the efficient use of resources
– stimulation of the creation of new services where needed
– assurance of quality care along a continuum of service delivery
– decrease in the fragmentation of care across settings
– enhancement of clients’ quality of life
– cost containment
• Delegated functions are direct care tasks a
registered professional nurse carries out
under the authority of a health care
practitioner, as allowed by law.
• Delegated functions also include any direct
care tasks a registered professional nurse
entrusts to other appropriate personnel to
• Health teaching communicates facts, ideas, and skills that change knowledge,
attitudes, values, beliefs, behaviors, and practices and skills of individuals,
families, systems, and/or communities.
– Knowledge is familiarity, awareness, or understanding gained through experience or study.
– Attitude is a relatively constant feeling, predisposition, or set of beliefs directed toward an
object, person, or situation, usually in judgment of something as good or bad, positive or
– Value is a core guide to action.
– Belief is a statement or sense, declared or implied, intellectually and/or emotionally accepted
as true by a person or group.
– Behavior is an action that has a specific frequency, duration, and purpose, whether conscious
or unconscious.
– Practice is the act or process of doing something; performance or action or doing or
performing habitually or customarily; making a habit of.
– Skill is proficiency, facility, or dexterity that is acquired or developed through training or
• Counseling establishes an interpersonal
relationship with a community, system,
family, or individual intended to increase or
enhance their capacity for self-care and
• Counseling engages the community, system,
family, or individual at an emotional level.
• Consultation seeks information and
generates optional solutions to perceived
problems or issues through interactive
problem-solving with a community, system,
family or individual.
• The community, system, family or individual
selects and acts on the option best meeting
the circumstances.
• Collaboration commits two or more persons
or organizations to achieving a common goal
through enhancing the capacity of one or
more of them to promote and protect health.
• Coalition building promotes and develops
alliances among organizations or
constituencies for a common purpose. It
builds linkages, solves problems, and/or
enhances local leadership to address health
• Community organizing helps community
groups identify common problems or goals,
mobilize resources, and develop and
implement strategies for reaching the goals
they collectively have set
• Advocacy pleads someone’s cause or acts on
someone’s behalf, with a focus on developing
the community, system, individual, or
family’s capacity to plead their own cause or
act on their own behalf.
• Social marketing utilizes commercial
marketing principles and technologies for
programs designed to influence the
knowledge, attitudes, values, beliefs,
behaviors, and practices of the population-of
• Policy development places health issues on
decision-makers’ agendas, acquires a plan of
resolution, and determines needed resources.
• Policy development results in laws, rules and
regulations, ordinances, and policies.
• olicy enforcement compels others to comply
with the laws, rules, regulations, ordinances,
and policies created in conjunction with policy


Population-Based Relationship-Based
Grounded in Social Justice Grounded in an Ethic of Caring
Relies on the Science of Epidemiology Holistic
Focus on Health Promotion and Prevention
Sensitivity to Diversity
Long-term Commitment to the Community
Independent Practice

Public health nursing practice is population based, that is, based on a process that
determines the health status of the community, identifies populations at risk, and
determines the priority health problems of the community; and plans, implements,
and evaluates public health strategies accordingly at community, systems, or
family/individual levels. The selection of these strategies are based in the science of
• Public health nurses’ commitment to the
communities, families, and individuals they
serve emanates from a combination of the
passion underlying their social justice beliefs
that all persons, regardless of circumstances,
are entitled equally to a basic quality of life,
their ethic of caring and compassion, and their
sensitivity to and respect for the worth of all
people, especially those persons who are
• Public health nursing practice is relationship-
based, that is, all public health nursing
interventions are provided in the context of a
relationship. The relationships that public
health nurses establish with the communities,
families, individuals, and systems they serve
are grounded in personal integrity, honesty,
consistency, and trustworthiness.
• Public health nursing is committed long term
to promoting and maintaining health and
preventing illness, injury, and disability. The
interventions that public health nurses utilize
for health promotion and prevention
encompass a holistic approach that includes
the inter-relationship of mind, body, spirit as
well as the dynamic relationships between
people and their physical and social
• Public health nurses use their extensive
knowledge of the community to organize
community resources to collaboratively meet the
health needs of community, families, and
individuals. As do all public health professionals,
public health nurses can and will work alone if
others are unable or choose not to work on an
issue. Most public health nursing interventions
are independent nursing functions as outlined in
the Nurse Practice Act.