Public Health Nursing

A Textbook for Health Visitors, School Nurses and Occupational Health Nurses

Greta Thornbory

• Publisher: Wiley-Blackwell
• Year: 2013
• ISBN:
  9781118699461
• Edition: 1
• Topic: Medicine
• Subtopic: Nursing

Public Health Nursing is an essential resource for all health visiting students, school nursing students, and occupational health nursing students, that reflects the current key changes in community public health nursing. It is a key textbook for specialist practitioner programmes, and those new to the public health arena.

Written by relevant experts in the field, this practical textbook uniquely explores the three main specialties of Public Health Nursing: Health Visiting, School Nursing and Occupational Health Nursing. A particular strength of the book is the way it shows the diversity of each discipline and how they each address Public Health in vastly different ways according to the needs of their relevant population.

This will be essential reading for all students on the Specialist Community Public Health Nursing (SCPHN) programmes offered across the UK.

Key features:

• Focuses on the specialist community public health nursing part of the NMC register
• Multidisciplinary, with contributors from all three specialisms
• Concerned with improving the health of the population, rather than treating the diseases of individual patients
• Focuses on practice and competencies

Chapter 1

What Is Public Health?

Cécile Knai

Learning objectives

After reading this chapter you will be able to:

• Discuss the meaning of public health
• Describe the changing approaches to public health over time
• Discuss some of the current debates within public health
• Comment on some of the implications of health practitioners

Introduction

This chapter attempts to answer the question ‘What is public health?’ and at one level, the answer is simple and straightforward: public health aims at preventing health problems before they occur and focuses on populations rather than on individuals. As we will see in the chapter, there are different ways of going about this task. The more convenient linear, two-dimensional way holds that there is a cause and there is a disease, and to address the disease one needs to address the cause. According to this line of thought, disease is brought about by specific aetiological agents which affect the body’s structure and function, with illness a separate ‘subjective experience of dysfunction’ [1]. This biomedical model has been argued as being narrow: the reality is that achieving public health is a complex task with an ill-defined scope. This is not for lack of effort on behalf of public health practitioners. Indeed, as discussed below, an enormous amount of effort and debate and political commitment have converged over time so that the field of public health is a field in its own right, with educational and professional specialisations. The approach to health has shifted from a relatively narrow approach to a broader conception of what health means, as expressed by the World Health Organization (WHO) definition which has not been amended since 1948: ‘Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’ [2]. Moreover, the understanding of public health and the extent to which governments should intervene to support population health will vary according to the sociopolitical stance of countries [3, 4].

This chapter introduces the various meanings and applications of public health, placing it in a historical context to help the reader to understand the development of modern public health. We highlight some of the major achievements of the past century, and discuss the current challenges we face. The discussion of these challenges provides an opportunity to understand some of the underlying philosophical and practical debates in public health. Finally, we suggest some of the implications for health practitioners. Although many of these arguments are universal, this chapter mainly draws on European context and highlights the experience and development of public health in Britain.

The development of modern public health

An early definition of public health, variations of which have informed later definitions, is that of Winslow from the 1920s. Winslow proposed that public health was ‘the science and art of preventing disease, prolonging life, and promoting mental and physical health and efficiency through organised community efforts for the sanitation of the environment, the control of communicable infections, the education of the individual in personal hygiene, the organisation of medical and nursing services for the early diagnosis and preventive treatment of disease, and the development of social machinery to ensure to every individual a standard of living adequate for the maintenance of health, so organising these benefits as to enable every citizen to realise his birthright of health and longevity’ [5].

Although the wording is slightly dated, the meaning still holds. Importantly, it demonstrates the many overlapping disciplines comprising public health, adapted according to time and context. The modern field of public health is highly varied and encompasses many academic disciplines including the fundamental tools of epidemiology, biostatistics, health education, advocacy, policy analysis and health services management applied to various fields such as environmental health, food and nutrition, tobacco and alcohol abuse, and the health of different age groups across the life course. Increasingly, a crucial facet of public health research and practice has been to factor in as thoroughly as possible factors such as social, economic, cultural, psychological and political considerations since they characterise the diverse aspects of health risk in different ways and to different degrees of importance according to context [6].

The question of whether public health should confine itself to individual risk factors for disease or rather be increasingly concerned with the more ‘upstream’ sources of health (or ill health) such as employment, housing, transport, food and nutrition and global trade concerns is central to public debates and in many ways defined by the political and economic stance of those on either side of the debate. Beaglehole and Bonita [7] argue that ‘the central challenge for public health practitioners is to articulate and act upon a broad definition of public health which incorporates a multidisciplinary and intersectoral approach to the underlying causes of premature death and disability’.

Origins and history of public health

Understanding the historical development of the public health movement provides perspective on current health issues and on the wider significance and impact of health interventions [8]. Writing for the journal Public Health in 1928, Wood notes that above and beyond the great achievements of public health in Britain, there were ‘adverse circumstances still requiring attention’, citing, for example, the appalling conditions in newly industrialising cities and stating that ‘in the forefront I would place one of our last remaining problems of environmental hygiene, the smoke pollution of the atmosphere, with its direct and indirect effects on physical well-being’ [9]. Many of the discussions of the past resonate with contemporary ones.

The ideology and concept of public health and how it is organised and implemented have undergone important changes over time. The history of public health stretches back to ‘remote times’ [10], by some accounts as far as the ancient Greeks [11]. The growing involvement of ‘authorities’ in addressing the health problems of citizens progressively increased with the approach of the modern era [10], many examples of which have been documented (read, for example, Occupational Health and Public Health: Lessons from the Past – Challenges for the Future [4] and Public Health at the Crossroads: Achievements and Prospects [11]). George Rosen’s A History of Public Health [12] provides an in-depth account of the development of public health over time and throughout the world. For the purposes of this chapter, we focus on developments in Europe and particularly Britain and step into the history of public health at the time of industrialisation, particularly its consequences on the health of urban populations, and the debates and policy decisions it engendered.

The nineteenth century saw an increasingly systematic approach to public health, taking root throughout European countries, with considerable scientific advances and a growing consciousness of the impact of life in industrial cities on the health of populations.

In Britain the sanitary movement was launched in the 1820s, emphasising the need for government-level expertise in health [13]. It is argued that the sanitary movement was motivated and led by the work of social reformers rather than medical practitioners [11]. During his travels through Britain in the 1830s, the French political thinker Alexis de Tocqueville commented on the abject conditions of urban centres, noting that here ‘. . . humanity attains its most complete development and its most brutish; here civilization works its miracles, and here civilized man is turned back almost into a savage’ [14].

During the 1840s, public health emerged as a field in its own right in Britain. A key player in the ‘meshing of medicine with the moral and political economy’ [15] was Edwin Chadwick. His seminal 1842 report on the sanitary conditions of the working class revealed the dangerous conditions in which labourers lived and worked [11]. This report was the first such national investigation and pointed to a number of now widely accepted phenomena about economic development, urbanisation and health within industrial urban areas [15]. Chadwick supported the principle that the people’s health was a matter of public concern and thus one of the responsibilities of the state [16]. He highlighted through his report how modern circumstances could contribute to a health schism between social groups [15]. One of the conclusions of this report was that‘. . . the various forms of epidemic, endemic, and other disease caused, or aggravated, or propagated chiefly amongst the labouring classes by atmospheric impurities produced by decomposing animal and vegetable substances, by damp and filth, and close and overcrowded dwellings prevail amongst the population in every part of the kingdom, whether dwelling in separate houses, in rural villages, in small towns, in the larger towns – as they have been found to prevail in the lowest districts of the metropolis’ [17]. This document was not only a survey of the social and environmental condition of towns and cities, but in effect an act to bring together formerly isolated health and sanitary domains, and to create public health policy [15]. The subsequent Public Health Act of 1848 was a legislative attempt to impart social and health equity in Britain [11]. It was built upon the assumption that implementation of the sanitary reform would address and remove causes of illness and early death, and allow labourers to live longer and healthier lives and thus contribute to the economy [18]. Then, as now, however, the battle was to convince government that these ideas were viable, particularly in the light of the great costs related to sanitary measures [18]. It saw the establishment of the Board of Health, though reportedly unpopular and short-lived because it challenged powerful vested interests: it faced strong opposition from the medical profession and local government officials reluctant to yield to a central authority. It is reported that by the 1870s the medical profession dominated public health in Britain; this dominance continues in most European countries including the United Kingdom [11, 19].

The Public Health Act was shaped by the prevailing miasmic medical notions, or the idea that disease is associated with noxious odours, impure air and poor sanitation [15] (miasma translates as ‘bad air’ in Greek). This was of course subsequently refuted, as described below. But by the 1850s, as a result of the Public Health Act there were better sewers, cleaner water and streets less polluted with decaying animals and human excrement. Disease did in fact decline, providing empirical evidence for these disease theories [18]. However, at this time great scientific advances contributed to the understanding of how disease was caused and spread. It was the French microbiologist Louis Pasteur who ‘dealt the final blow to [. . .] miasma as the cause of infectious diseases’ [18]. In short, Pasteur is credited with reframing disease by demonstrating what eventually came to be known as the ‘germ theory’, namely, that specific microbes caused specific diseases, an unthinkable concept until then. Towards the end of the nineteenth century, the German scientist Robert Koch devised a series of proofs or criteria to establish a causal relationship between a microbe and a disease, now referred to as ‘Koch’s postulates’, and these supported the germ theory [11, 13]. One of Chadwick’s contemporaries, John Snow, was a strong supporter of the germ theory. He is credited with carrying out one of the first epidemiological study in 1854, now commonly referred to as the study of the Broad Street Pump: while investigating a local cholera epidemic in London, Snow linked all cases to a single contaminated well. He convinced authorities to remove the pump handle and the spread of the disease was rapidly reduced. Snow isolated what would eventually be identified as the bacterium responsible for cholera.

By the turn of the century there was no longer any question that certain microbes caused specific diseases, and slowly but surely major cities were building sewages systems and providing cleaner water for their inhabitants. These advances provided a solid foundation for contemporary measures for communicable diseases control and laid the scientific basis for vaccination [18, 20].

The early twentieth century saw the rise of preventive medicine, characterised by its focus on the concept of hygiene, supporting the previous developments in several ways [20]: it took into account the concept of disease vectors; it highlighted the importance of nutrition and the role of nutrient deficiencies in impairing optimal health (thus leading to the development of vitamins); and it emphasised the particular needs of ‘high-risk’ population groups such as schoolchildren, pregnant women and older people [21]. Advances in housing, education, road and other infrastructure enabled rapid economic progress to take place across Europe during this period and this undoubtedly did much to improve the health of those populations.

The assumption of scientific rationality where disease aetiology follows a relatively linear pathway [1] was increasingly challenged by many as failing to capture all factors pertinent to disease: broad social conditions must be addressed by all relevant sectors to bring about long-term and meaningful improvements in population health [22, 23]. These principles were supported and developed by a series of important policy commitments at the national and international level. The 1974 Lalonde Report by the Canadian Government proposed the health field concept wherein genetic predisposition, individual behaviour and lifestyle, health services and environmental circumstances all contribute to population health [24]. A focus on healthy public policy and intersectoral action was then laid out in 1978 by the WHO’s ‘Health for All by the Year 2000’ movement [25], the key principles of which were (1) global cooperation and peace as important aspects of primary health care; (2) recognition that primary health care should be adapted to the particular circumstances of a country and the communities within it; (3) recognition that health care reflects broader social and economic development; (4) primary health care as the backbone of a nation’s health strategy, with an emphasis on health promotion and disease prevention strategies; (5) achievement of equity in health status; and (6) involvement of all sectors in the promotion of health [26].

These principles were enshrined in the 1986 Ottawa Charter for Health Promotion which called for building healthy public policy, creating supportive environments, strengthening community actions, developing personal skills, reorienting health services and demonstrating commitment to health promotion [24]. The conference participants challenged the WHO and other international organisations ‘to advocate the promotion of health in all appropriate forums and to support countries in setting up strategies and programmes for health promotion’ [27]. These commitments continue to be renewed by WHO and are increasingly cross-disciplinary to ensure a broad enough scope of action and influence.

Moreover, the ecological approach to public health is increasingly accepted. In public health, an ecological model refers to people’s interactions with their physical and sociocultural surroundings [28], incorporating many influences at multiple levels [29, 30] including biological, psychological, cultural, physical (built and natural environment) and policy [31]. Although there are ongoing debates about whether this is an appropriate approach or not, the ecological approach is supported by influential public health publications such as the WHO/FAO report Diet, Nutrition and the Prevention of Chronic Disease [32] and by the WHO Global Strategy for Diet and Physical Activity [33].

Successes and challenges in public health

The advances in public health over the past century, due in part to the convergence of scientific progress and political commitment, have improved our quality of life [34]. In 1999, the US Centre for Communicable Disease Control published a list of the twentieth century’s ten greatest public health achievements [35]. These are summarised below. As noted in an article by Gray et al., these achievements are all applicable to the United Kingdom where they have significantly contributed to considerable, long-term increases in life expectancy [36, 37]:

(1) Vaccination resulted in the eradication of smallpox; elimination of polio (in the Americas); and control of measles, rubella, tetanus, diphtheria and Haemophilus influenzae type b

(2) Motor-vehicle safety led to substantial reductions in motor vehicle-related deaths due to engineering improvements in vehicles and highways, and changes in personal behaviours such as using seat belts and other safety devices, and reductions in drinking and driving

(3) Safer workplaces due to a focus on occupational health and environments led to, e.g., the control of pneumoconiosis and silicosis and a reduction in fatal occupational injuries

(4) Reduction of infectious diseases was achieved through the control of typhoid and cholera by focusing on improving water and sanitation, and the control of tuberculosis and sexually transmitted diseases (STDs) by education and the advent of antibiotics

(5) A decline in deaths from coronary heart disease and stroke was attained from changing high-risk behaviours, such as smoking cessation and blood pressure control, and improved access to early detection and treatment

(6) Safer and healthier foods contributed to nearly eliminating nutritional deficiency diseases such as rickets, goitre and pellagra, and were achieved by decreasing microbial contamination and increasing nutritional content

(7) Advances in maternal and child health came about through better hygiene and nutrition, availability of antibiotics, access to health care and technological advances in neonatal and maternal medicine

(8) Family planning contributed to improved maternal and child health and supported a more important socioeconomic role of women, reduced family size, and increased birth intervals; barrier contraceptives also reduced unwanted pregnancies and transmission of STDs

(9) Fluoridation of drinking water contributed to reducing tooth decay and tooth loss

(10) Recognition of tobacco use as a health hazard resulted in changes in social norms, reduced prevalence of tobacco smoking and mortality and morbidity from smoking-related diseases

Although these have certainly been important successes in population health due to public health strategies and the role of public health is increasingly recognised, implementation is more often than not difficult to achieve [38]. Philosophical debates continue on who holds the responsibility for action in health, as well as how best to translate scientifically independent and comparable data into effective public health policy. The following section addresses some of these challenges.

The responsibility for health

Individuals and nation states will have different understandings of how to achieve a population which benefits from ‘a state of complete physical, mental and social well-being’. These differe...

Table of contents

• Cover
• Content
• Title Page
• Copyright
• Dedication
• Contributors
• Forewords
• Preface
• Acknowledgements
• Abbreviations
• Chapter 1: What Is Public Health?
• Chapter 2: Public Health Nursing
• Chapter 3: Theoretical Perspectives of Health Visiting
• Chapter 4: Health Visiting in Practice
• Chapter 5: The Development of School Nursing
• Chapter 6: School Nursing and School Health Practice
• Chapter 7: What Is Occupational Health?
• Chapter 8: Occupational Health Nursing Practice
• Chapter 9: Education and Continuing Professional Development of Public Health Nurses
• Appendix
• Index