13COMPETENCY #11Shows Evidence of Commitment to Social Justice, the Greater Good, and the Public Health Principles

n  Patricia M. Schoon with Noreen Kleinfehn-Wald and Colleen B. Clark

Erica is a new public health nurse (PHN) in a large urban county where 40% of the children live in pov-erty. During Erica’s home visit to a young family, the mother states that the 2- and 3-year-old children have become “slow to get things and were tripping and falling more than usual.” A year ago, the family had moved from a newer apartment building into a 70-year-old building when the husband lost his job. Erica notices paint chips on the floor and is concerned that they are from lead-based paint. She advises the mother to have her children’s blood lead levels checked. The mother says she does not have health insurance and cannot afford a trip to the doctor. Erica tells the mother the paint should be replaced, but the mother is concerned that the landlord will not listen to her. Erica consults with her public health nursing supervisor about what else can be done.

ERICA’S NOTEBOOKCOMPETENCY #11 Shows Evidence of Commitment to Social Justice, the Greater Good, and the  Public Health Principles

A. Appliesprinciplesofsocialjusticetopromoteandmaintainthehealthandwell-beingofpopulations

B. Understandstheimpactofthesocialdeterminantsofhealthonvulnerableandat-riskpopulations

C. Advocatesforthedisadvantagedandunderserved

D. Participatesincollaborativesocialactionstoreducehealthdisparitiesandinequities

Source: Henry Street Consortium, 2017




Civic Engagement:Workingwithcommunitymemberstoimprovetheciviclifeofthecommunitythroughsocialandpoliticalactionsbasedonanunderstandingofthecommunity,itsdiversity,assets,andproblems(Gehrke,2008).



Copyright 2018. Sigma.

All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law.

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252 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

Health Disparities:Preventable,population-specificdifferencesinhealthanddisease(incidenceandpreva-lence),healthoutcomes,oraccesstocarethatplacesomepopulationsatgreaterriskthanothersandthatareprimarilytheresultofthesocialdeterminantsofhealth.

Health Equity:“Wheneverypersonhastheopportunitytorealizetheirhealthpotential—thehighestlevelofhealthpossibleforthatperson—withoutlimitsimposedbystructuralinequities.Healthequitymeansachievingtheconditionsinwhichallpeoplehavetheopportunitytoattaintheirhighestpossiblelevelofhealth”(MDH,2014,p.11).

Human Rights:Individualandfamilyrightstoliveanindependent,fulfilling,healthylifeandearnalivingwageforfood,clothing,housing,andasafeenvironment;self-determinationandautonomy.Humanrightsarerightsinherenttoallhumanbeings.Theyareuniversalandinalienable,interdependentandindivisible,equalandnon-discriminatory,entailingbothrightsandobligations(OfficeoftheHighCommissionerforHumanRights,n.d.).

Institutionalized Racism:Historicalandsystematicdiscriminationthatresultsinnormalizationandacceptanceofdifferencesinhowminoritypopulationsofraceandethnicityareperceivedandtreatedthatresultsinedu-cational,social,economic,andhealthinequities(Blodern,O’Brien,Cheryan,&Vick,2016;Feagin&Bennefield,2014;Gordon-Burns&Walker,2015).

Market Justice:Personalresourcesandchoicesprovidethebasisforuseanddistributionofhealthcareservicesbasedonconceptsofindividualism,self-interest,andindividualeffort;nocollectiveobligationofsocietyorgovernmentexiststoprovideforhealthcare(Budetti,2008).



Social Determinants of Health:Thesocialdeterminantsofhealtharethecircumstancesinwhichpeopleareborn,growup,live,work,andage,aswellasthesystemsputinplacetodealwithillness.Thesecircumstancesareinturnshapedbyawidersetofforces:economics,socialpolicies,andpolitics(WorldHealthOrganization[WHO],n.d.).

Social Justice (syn., distributive justice):Theconceptthatindividualshavetherighttoreceiveresourcesbasedontheirneedsandthatacollectivesocialobligationexiststoprovideforbasichumanneeds,includinghealthservices(Budetti,2008).


Taking Action for What Is Right—Applying Principles of Social JusticeProfessional nurses have a social contract with their clients and the public to ensure that the healthcare needs of indi-viduals, families, populations, and communities are met in a caring, nonjudgmental, just, and equitable manner. Nurses as professionals and as private citizens are guided by the rule of law that protects basic human rights and by ethical principles that undergird basic human rights and social justice, a core principle of public health. Nurses in

public health are confronted with ethical issues or moral challenges surrounding human rights and social justice on a daily basis. Moral challenges are situations in which a nurse’s ethical beliefs are challenged and require critical thinking to arrive at a solution that protects the rights of individuals, families, and communities. The integration of caring (a core component of nursing) and social justice (a core component of public health), in conjunction with the moral challenge resulting when PHNs witness their clients experiencing health disparities and social injustice, propel PHNs to become involved in social and political advocacy (Falk-Rafael & Betker, 2012).

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253CHAPTER 13  n  Competency #11

Article 25 also speaks to many of the social determinants of health that have both societal and individual origins (see Table 13.1).

Respect for human rights is a basic tenet of ethical nurs-ing practice (American Nurses Association [ANA], 2015, 2016; Fowler, 2015). The International Council of Nurses (ICN, 2011) views healthcare as a basic right for all individ-uals; they state that nurses are obligated to provide fair and equal treatment and have a responsibility to safeguard client rights at all times and are held accountable for both their actions and their inactions. The ANA Code of Ethics identi-fies the obligations of nurses to support both human rights and principles of social justice for all:

A fundamental principle that underlies all nursing practice is respect for the inherent dignity, worth, unique attributes, and human rights of all individu-als. The need for and right to health care is universal, transcending all individual differences. Nurses con-sider the needs and respect the values of each person in every professional relationship and setting; they provide leadership in the development and implemen-tation of changes in public and health policies that support this duty (ANA, 2015, p. 1).

In addition, the ANA code stipulates that nurses are obligated as individuals and as a profession to act at the community and systems levels of practice to reduce health disparities. n Provision 8: “The nurse collaborates with other

health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities” (p. 31).

n Provision 9: “The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy” (p. 35).

As students, you will be challenged and at times conflicted by the decisions you face that require choosing between two important and good things. For example, do you decide to respect individual autonomy and confidentiality, or do you find it necessary to enforce a public health law? This chapter provides guiding principles for social justice, information about population health disparities that confront PHNs, and a framework for public health advocacy interventions to help prepare you for the difficult situations you may encounter as a student and as a professional nurse.

Guiding Principles for Taking Actions for What Is RightMatwick and Woodgate (2016) report that social justice is considered a core value of nursing present since the late 19th century and evident in the actions of public health nursing leaders such as Nightingale and Wald. It is central to the practice of public health nursing. The two key attributes of social justice in nursing practice are equitable distribu-tion of resources and helping relationships that occur when those with social advantage and power help those with less social advantage and power. Matwick and Woodgate believe that in order to practice social justice, nurses need to rec-ognize and acknowledge social oppression and inequities, which then lead nurses to take caring actions toward social reform. They propose the following definition of social jus-tice (p. 182):

Social justice in nursing is a state of health equity characterized by both the equitable distribution of services affecting health and helping relationships.

Principles of social justice and human rights provide a framework for the ethical principles of public health prac-tice. The principles of social justice that are key to the health and well-being of populations include: n Collective social responsibility for community membersn Responsibility of government to ensure the basic human

rights and healthcare needs of its citizensn Equitable allocation of healthcare resources based

on needn Protection of the rights of individuals and families to

live safe, healthy, and fulfilling lives

The United Nations published The Universal Declara-tion of Human Rights detailing 30 articles defining human rights (UN, 1948). The Preamble states, “Whereas inherent recognition of the inherent dignity and of the equal and inalienable rights of all members of the human family is the foundation of freedom, justice, and peace in the world… a common understanding of these rights and freedoms is of the greatest importance.” Articles 1 and 25 provide an international standard for health as a basic human right.

TABLE 13.1 Selected Human Rights From the UN’s Universal Declaration of Human Rights

Article 1. All human beings are born free and equal in dignity and rights. They are endowed with reason and conscience and should act towards one another in a spirit of brotherhood.

Article 25. (1) Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing, and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control. (2) Motherhood and childhood are entitled to special care and assistance. All children, whether born in or out of wedlock, shall enjoy the same social protection.

Source: United Nations, 1948

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254 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

For example, at the individual/family level of practice, a PHN would arrange to have an interpreter present when providing health education and counseling to an immigrant family who cannot speak English. At the community level, PHNs could create a social marketing campaign to help the community understand and respond to the challenges English language learners have in understanding English language signage posted throughout the community. At the systems level, PHNs could work with interprofessional teams to improve access to healthcare services for immi-grants and English language learners. Figure 13.1 depicts the three levels of practice.

Nurses have a social contract with the public. The Ameri-can Nurses Association Guide to Nursing Social Policy State-ment (Fowler, 2015) outlines the social contract that nurses have with the public. The contract involves 16 elements of reciprocal expectations between nursing and the public (p. 19). The ninth expectation, Promotion of the Health of the Public, stipulates that nurses have a social responsibility to address health disparities at all levels of society:

Promotion of the Health of the Public: It is expected that nurses will address the problems faced by indi-vidual patients including issues of health disparities and that nursing will be involved with and lead in health-related issues important to society. In some instances, nursing will be in the vanguard of emerging health-related issues. Nursing will participate in the promulgation of healthcare policy at regional, state, national, and global levels. Protection of the public through advocacy also includes whistleblowing (p. 21).

The World Health Organization (WHO) considers the human right to healthcare from a very holistic perspective (2015).

The right to the highest attainable standard of health requires a set of social criteria that is conducive to the health of all people, including the availability of health services, safe working conditions, adequate housing, and nutritious foods (WHO, 2015, para. 1). Achieving the right to health is closely related to that of other human rights, including the right to food, housing, work, education, non discrimination, access to information, and participation. The right to health includes both freedoms and entitlements. n Freedoms include the right to control one’s health and

body (e.g., sexual and reproductive rights) and to be free from interference (e.g., free from torture and from non-consensual medical treatment and experimentation).

n Entitlements include the right to a system of health protection that gives everyone an equal opportunity to enjoy the highest attainable level of health.

WHO also identifies principles and standards of human rights that provide guidance to address the causes of human

rights inequities. These principles and standards are out-lined in Table 13.2 (2015, para 7).

These human rights, especially those emphasizing access to living conditions that encourage health, guide much of the work that PHNs do. Sometimes advocating for the human rights of individuals and concurrently advocating for social justice for vulnerable individuals, families, or populations results in ethical conflicts. Nurses have ethical responsibil-ities to protect the rights of individuals and to protect the health and welfare of the community. Consequently, some actions, such as mandated reporting of specific communi-cable disease incidents, require nurses to identify an ethical rationale for whether they choose to protect the individual or the community when protecting both simultaneously is not possible. Public health professionals have a code of ethics (Public Health Leadership Society, 2002) that directs them to act to protect vulnerable and at-risk populations and to work to eliminate health disparities. (See Table 13.3 for principles and examples of PHN actions.)

FIGURE 13.1 How a PHN Can Practice at All Three Levels

Individual/FamilyArrange to have an interpreterpresent when providing healtheducation and counseling to animmigrant family who cannotspeak English

Community Create a social marketing campaign to help the community understand and respond to the challenges English language learners have in understanding English language signage postedthroughout the community

SystemWork with interprofessionalteams to improve access to healthcare services for immigrants andEnglish language learners

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255CHAPTER 13  n  Competency #11

PHNs have both a moral and a legal obligation based on human rights to secure and provide public health services to those who need them. However, because resources are finite, PHNs are faced with the difficult situation of setting priori-ties to determine which at-risk populations and who among these populations will receive services. PHNs employed by governmental agencies work with community partners to identify need, available resources, and service gaps. A human rights approach presented by Gruskin and Daniels (2008, p. 1573) provides a framework for these decisions:

n Direct concern with equity in the utilization of resources.

n Examination of the factors that may constrain or sup-port planned interventions, including the legal, policy, economic, social, and cultural context.

n Participation and negotiation between all stakeholders, even as primary responsibility rests with government officials to facilitate these processes and to determine which interventions may have the biggest impact on health.

n Government responsibility and accountability for the manner in which decisions are made, resources are allo-cated, and programs are implemented and evaluated, including the impact on these decisions on health and well-being.

TABLE 13.2 Human Rights–Based Approaches

Nondiscrimination: The principle of nondiscrimination seeks “…to guarantee that human rights are exercised without discrimination of any kind based on race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth or other status such as disability, age, marital and family status, sexual orientation and gender identity, health status, place of residence, economic and social situation.”

Availability: A sufficient quantity of functioning public health and healthcare facilities, goods and services, as well as programs.

Accessibility: Health facilities, goods, and services should be accessible to everyone. Accessibility has four overlapping dimensions: nondiscrimination; physical accessibility; eco-nomic accessibility (affordability); information accessibility.

Acceptability: All health facilities, goods, and services must be respectful of medical ethics and culturally appropriate as well as sensitive to gender and life-cycle requirements.

Quality: Health facilities, goods, and services must be scientifically and medically appropriate and of good quality.

Accountability: States and other duty-bearers are answerable for the observance of human rights.

Universality: Human rights are universal and inalienable. All people everywhere in the world are entitled to them.

Source: WHO, 2015

TABLE 13.3 Ethical Principles That Guide Public Health Professionals in Confronting Health Disparities

Principles PHN Practice Examples

Public health should address principally the fun-damental causes of disease and requirements for health, aiming to prevent adverse health outcomes.

n Focusing on primary prevention with individuals, families, and communities

n Assessing the social determinants of health as part of the community assessment process

n Sharing the data on the social determinants of health that adversely affect the health of community members

Public health should advocate and work for the empowerment of disenfranchised community mem-bers, aiming to ensure that the basic resources and conditions necessary for health are accessible for all.

n Targeting services to vulnerable and at-risk populations experiencing the greatest levels of health disparities

n Advocating through the political process for funding and services for vulnerable and at-risk populations

n Using an assets-based approach to collaborate with community members to empower them to manage their own healthcare needs

Public health programs and policies should be implemented in a manner that most enhances the physical and social environments.

n Providing services to the uninsured and underinsured in homes and in community and mobile clinics

n Creating and providing culturally sensitive servicesn Collaborating with community organizations that provide safety-net


Source: Public Health Leadership Society, 2002

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256 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

EVIDENCE EXAMPLE 13.1Social Justice and Human Rights Issues Identified by Practicing PHNs

Afocus-groupprocesswasusedtoidentifysocialjusticeandhuman rights issues that cause staff PHNs to confront ethi-cal dilemmas on a daily basis. Sixteen nurses working in asuburban-ruralcountypublichealthagencyusedstorytellingtodrawoutexamplesof thesocial justice issuesandhumanrightsprinciplesthatwerebeingviolatedwhichresultedinneg-ativehealthoutcomes.Allfourexamplesidentifiedresultedinreducedhealthoutcomesforindividualsandfamilies.  Right to self-determination (human right)—Clientsareinneedofservicesbutdonotqualifyforexistingprograms.Forexample,anelderlypersonmayneedpersonalcareattendantservices but does not qualify for medical assistance, so theclientremainsatriskforplacementinalong-termcarefacility.  Right to a standard of living adequate for the health and well-being  of  individuals  and  families  (human  right)—Theworkingpooroftenworkinentry-leveljobsandearnsalaries

thatmakethemineligibleforpublicservices,eventhoughtheirincomeisnotenoughtoadequatelysupporttheirfamilies.  Autonomy  (human  right)  versus  greater  good  (social justice)—A client with a communicable disease chooses tobreakhomeisolationandexposesmanypeoplebygoingoutinpublic.Parentschoosenottovaccinatetheirchild,whothenbecomesillwithpertussisandexposesanentireclassroomofchildren,includingonechildwhoisimmune-compromised.  Inequitable  distribution  of  power,  money,  and  resources (social  justice)—Legal immigrants arriving in the state havereceivednohealthexaminationintheirhomecountryandarenotprovidedwithahealthscreeninguponarrivalintheUnitedStates.Otherforeignersseekingadmissiontothecountryasrefugeeshaveahealthexaminationandhaveahealthscreen-inguponarrivalintheircountyofresidence.

Source: Kleinfehn-Wald, 2010

Market Justice Versus Social JusticeGlobally, healthcare systems vary but are generally based on principles of market justice, social justice, or a combination of the two. The U.S. healthcare system, like the rest of the U.S. economy, is based on free enterprise and the principles of market justice. An alternative healthcare system, based on social justice, is embodied in the nonprofit and govern-mental healthcare systems. See Chapter 7 for a discussion of the U.S. healthcare system. Advocates of social justice believe that the government has a role to play in the provi-sion of and assurance of basic health services to its citizens. Advocates of market justice believe that individuals and the private sectors are better prepared to meet the healthcare needs of private citizens. Social justice requires that the gov-ernment be responsible and accountable for the health and well-being of its citizens. Market justice requires that indi-viduals be responsible for their own health and well- being. Table 13.4 compares the concepts of market and social jus-tice relative to healthcare.

The United States has a dominant and enduring cul-tural value of individualism—a belief that individuals are able to create their own destiny and that individual rights are more important than society’s rights (Ludwick & Silva, 2000). This cultural belief presents a significant barrier to the development of a social justice model of healthcare. It is important for nurses in the United States to understand the cultural values of our society to determine how health equity might be achieved.

Social Determinants of HealthSocial determinants of health are the conditions and cir-cumstances that vulnerable populations experience over their life span in their homes, neighborhoods, work places, schools, and the larger community. The social determinants of health include access to healthcare and the systems put in place to deal with their ongoing health status and illness. These circumstances are in turn shaped by a wider set of economic, social, and political forces at the local, national, and global levels (WHO, n.d.). These social determinants of health have a significant impact on the health status of populations—often a negative one. Research has shown that interventions that address social determinants of health well in advance of identified health problems or concur-rently with medical care improve health and reduce health disparities (Williams, Costa, Oduniami, & Mohammed, 2008). The social determinants of health (social and eco-nomic factors and physical environment) account for 40% of the health determinants that influence health outcomes, as illustrated in Figure 13.2.

Examples of social determinants of health identified by Healthy People 2020 are outlined in Table 13.5. Both the cat-egories of social determinants and physical determinants in the table are considered social determinants of health.

Healthy People 2020 has identified objectives for the social determinants of health in the following categories: economic stability, education, neighborhood and built environment, and social and community context (, n.d.).

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TABLE 13.4 Market Justice Versus Social Justice in the United States

Market Justice Social Justice

People are entitled only to those valued ends, such as status, income, and happiness, that they acquire by individual efforts, actions, or abilities. The focus and beliefs include:

n Individual rights and responsibilityn Death and disability as individual responsibilities and

problemsn Minimal collective action n Freedom to act with minimal obligations for the

common goodn Respect for the rights of individualsn Individuals and the local private and public sector having

responsibility and control over health and healthcaren Local short-term goals that are treatment-orientedn Government infringement on individual rights, its

inefficiency, and mistrust of itn Support for the medical model of healthcare

People in society receive benefits by belonging to a community, and the burdens and benefits of society should be fairly and equitably distributed. The focus and beliefs include:

n Individual rights as members of the communityn Death and disability as collective responsibilities and

problemsn Collective action for the common goodn General obligation to protect individuals against disease

and injuryn Quality of life; stewardship of futuren Private business’s obligation to the community as a wholen Global, long-term goals that are prevention-orientedn Government obligation and responsibility to protect citizens

and trust that it will do the right thingn Support of a universal or single-payer model of healthcare

Sources: Based on work by Keller, 2010, & Beauchamp, 2013

It is important to note that the list of the social deter-minants of health does not include culture or ethnicity. Nor is the category of race considered a health determinant that results in poorer health outcomes. In order to organize public health data in a way that identifies populations with poorer health outcomes and health disparities, governmen-tal agencies report health outcomes by specific categories of people (grouping people by a set of defined biological, cultural, and ethnic characteristics). The purpose of this categorization is to identify and target specific population groups for specific interventions to reduce health disparities (Cloos, 2015; Smedley & Smedley, 2005). This categorization is referred to as racialization in that these categories lead to stereotyping individuals by racial, ethnic, and cultural categories. PHNs must be careful that, when developing interventions for specific population groups (immigrants, Native Americans, etc.), they are able to set aside data-driven stereo types and develop services that meet the needs of unique individuals.

FIGURE 13.2 Determinants of HealthSource:MDH,2014,p.12


and biology

40%Social and

economic factors





10%Clinical care

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258 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

TABLE 13.5 Healthy People 2020 Social Determinants of Health

Social Determinants of Health Examples

Social n Availability of resources to meet daily needs (e.g., safe housing and local food markets)n Access to educational, economic, and job opportunitiesn Access to healthcare servicesn Quality of education and job trainingn Availability of community-based resources in support of community living and opportunities for

recreational and leisure-time activitiesn Transportation optionsn Public safetyn Social supportn Social norms and attitudes (e.g., discrimination, racism, and distrust of government)n Exposure to crime, violence, and social disorder (e.g., presence of trash and lack of cooperation in a

community)n Socioeconomic conditions (e.g., concentrated poverty and the stressful conditions that accompany it)n Residential segregationn Language/literacyn Access to mass media and emerging technologies (e.g., cellphones, the Internet, and social media)n Culture

Physical n Natural environment, such as green space (e.g., trees and grass) or weather (e.g., climate change)n Built environment, such as buildings, sidewalks, bike lanes, and roadsn Worksites, schools, and recreational settingsn Housing and community designn Exposure to toxic substances and other physical hazardsn Physical barriers, especially for people with disabilitiesn Aesthetic elements (e.g., good lighting, trees, and benches)

Source:, n.d.

Impact of Social Determinants of HealthIn the United States, the social determinants of health of social status (e.g., education, income, place of residence, his-torical discrimination based on perceptions of race and eth-nicity) and the ability to control one’s life and health have a significant impact on health outcomes of both individuals and populations.

A comparison of life expectancy among different social groups in the United States illustrates both health dispar-ities and health inequities. For example, the gap in life expectancy between the rich and the poor and those with more education versus those with less education is widening (Isaacs & Choudhury, 2015). Although gaps in life expec-tancy might be partially explained by lifestyle decisions and biological factors, societal factors also play a role. Those who are poor or live in poor neighborhoods have less access to healthy food, parks and public spaces, jobs, and education

(California Newsreel, 2008, p. 2). Children from low-income families are about seven times as likely to be in poor or fair health compared to children in the highest-income families (p. 1). In a study of 40,000 children, obesity rates for all U.S. children ages 10 to 17 increased 10% from 2003 to 2007, while the rate increased 23% for low-income children (Singh, Siahpush, & Kogan, 2010). Social determinants of health have a significant impact on early childhood development that persists into adulthood. Poverty, language differences, and vocabulary skills all have an effect on high school gradu-ation rates, which have an impact on adult earning potential and health status across the life span (Robinson et al., 2017).

Infant mortality rates are considered a gold standard of health worldwide. The U.S. infant mortality rate, esti-mated at 5.80/1,000 live births for 2017, ranks 170th glob-ally ( Central Intelligence Agency [CIA], 2017). Education, income, and access to prenatal care are all causative factors. A review of African-American infant deaths in Milwaukee

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259CHAPTER 13  n  Competency #11

from 2008 to 2010 demonstrated that many of the mothers received late or no prenatal care (Salm Ward, Mazul, Ngui, Bridgewater, & Harley, 2013). Infant mortality rates in the U.S. continue to decrease, but significant gaps among racial groups are noted in Figure 13.3 (Matthews & Driscoll, 2017).

Life expectancy trends, although improving, also demon-strate health disparities, with Black males consistently

having the lowest life expectancy over a 14-year period from 1999 to 2013 (see Figure 13.4).

Although Figure 13.4 only includes the racial categories of Black and White, there are data of years of potential lives lost before age 75 (death of individuals before their expected life span) that demonstrate disparities across multiple racial categories from 1990 to 2015 (see Table 13.6).

FIGURE 13.3 Infant Mortality in the United States, 2005–2014Source: Matthews&Driscoll,2017

FIGURE 13.4 U.S. Life Expectancy by Race and Sex, 1999–2013 Source: Kochanek,Arias,&Anderson,2015

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260 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

housing, employment, social power, and opportunity) and spatial (e.g., geographic locations within neighborhoods, cities, counties, states, and areas of the country and concen-tration of poverty and race in specific neighborhoods) social determinants are the major causes of health disparities.

Institutionalized racism is a significant social determi-nant of health that provides multiple and complex pathways to poor health (Ramaswamy & Kelly, 2015). PHNs need to be educated about the social determinants of health embed-ded in society in order to advocate effectively to reduce the effects of institutionalized racism and work to change the systems that perpetuate it. An explanation of the multiple and often hidden causes of institutionalized racism that result in health disparities for African Americans is illus-trated in Figure 13.5.

Progress is being made in reducing the health disparities between identified racial groups in the United States, but gaps do remain. The gap in life expectancy between African Americans and Whites is decreasing; however, the remain-ing gap is most pronounced between Black and White males. The reduction of the gap for Black males was related to decreased death rates for cancer, HIV, and unintentional injuries. For Black females, the reduced gap was due to decreased death rates for heart disease, HIV, and cancer.

The burden of excess deaths of the five leading causes of death (heart disease, stroke, chronic respiratory disease, cancer, and unintentional injury) is greater for those who

It is important to note that health disparities represented by racial comparison mask the actual causes of the health disparities. Race is primarily a social construct rather than a genetic marker. So, although health data comparisons by racial categories historically and socially defined in the United States demonstrate correlation, these data do not demonstrate causation. Structural (e.g., income, education,

TABLE 13.6 U.S. Years of Potential Life Lost Before Age 75 by Sex, Race, and Hispanic Origin, 1990 & 2015 (Age adjusted per 100,100 under age 75)

Category by Race 1990 2015

All 9,085.5 6,757.7

American Indian or Alaskan Native

9,506.2 7,176.2

Asian or Pacific Islander 4,705.2 3,049.7

Black (non-Hispanic) 16,583.0 9,702.3

Hispanic or Latina 7,963.3 4,750.4

White 8,159.5 6,514.8

Source: National Vital Statistics System (NCHS), 2016

FIGURE 13.5 Impact of Institutionalized Racism on Health Outcomes of African AmericansSource: Doede,2015,p.152


Labor market, housing,land ownership,




Lack of pension,paid leave, or


Fresh food, prescriptions,safe housing, exercise






No healthinsurance

Poor workingconditions andsafety policies



Education, health,transportation









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261CHAPTER 13  n  Competency #11

collaboration, and implement programs to promote health equity at the state and local level (see the upcoming Fig-ure 13.6). The idea is to move from a fragmented planning approach to an integrated approach that deals with all of the factors that can improve population health status: imple-menting policies that can improve health across all health, political, economic, and social sectors; developing an under-standing of what health is and valuing it; and empowering communities to have the capacity to improve the health of their citizens (ASTHO, 2016).

Nurses represent the largest segment of healthcare pro-fessionals with more than 3.6 million nationwide. The Gal-lup annual honesty and ethics survey has recognized the nursing profession as the most trusted profession for the last 16 consecutive years (Brenan, 2017). With this acknowledge-ment comes privilege: advantages, power and authority, and a mandate to promote health equity and social justice by tak-ing actions to reduce health disparities (Reutter & Kushner, 2010). Health disparities are preventable, population-specific differences in health and disease (incidence and prevalence), health outcomes, or access to care that place some popu-lations at greater risk than others and that are primarily the result of the social determinants of health. PHNs know from experience that the populations they serve experience different levels of health status and have differing abilities to achieve their health potential. These disparities in health status are often the result of social determinants of health that negatively affect individual and family health outcomes and are not within the control of individuals and families to change. PHNs work to eliminate the social determinants of health that lead to health inequalities or health inequities: n Health inequalities are differences in health disparities

based on social conditions that reflect the level of depri-vation of one group versus another group.

n Health inequities are systematic disparities in health and in the major social determinants of health between diverse populations with different social positions that persist over time (e.g., race; class; and advantages or disadvantages such as wealth, power, and prestige).

The Commission on the Social Determinants of Health, established by the WHO in 2005, recommends that the focus be on creating the conditions in which health and well-being can flourish (Baum, Gollust, Goold, & Jacobson, 2007). The Commission made three recommendations for action: (1) improving daily living conditions in which peo-ple are born, grow, live, work, and age; (2) tackling the ineq-uitable distribution of power, money, and resources; and (3) measuring and understanding the problems of health inequities and assessing the impact of action (Baum et al., 2007). In 2015, the UN General Assembly adopted resolu-tion 70/1. Transforming Our World: The 2030 Agenda for Sustainable Development (2015). This resolution addresses the social determinants of health at a global level and sets out an action plan for people, the planet, prosperity, peace, and partnership. This action plan identifies 17 Sustainable Development Goals (SDG) (see Chapter 1).

live in rural areas than in urban areas (Garcia et al., 2017). The excess death rate for unintentional injury was 50% higher in rural versus urban populations.

Health Equity and Health Disparities A major goal of public health is to achieve health equity; health equity exists when all people have the right and abil-ity to reach their health potential regardless of their social positions or social circumstances (Brennen Ramirez, Baker, & Metzler, 2008). Reutter and Kushner (2010, p. 272) outline the requirements of health equity as follows:n Resources should be allocated equitably and fairly. n Human rights perspective includes the right to health

and its prerequisites, the right to participate fully in society, and the right to nondiscrimination.

n Access to healthcare and the social determinants of health (social, economic, material, cultural, and political structures) should be equitable.

n Health equity is shaped by politics and achieved through the political process.

n Achieving health equity requires an intersectional approach (beyond the healthcare sector).

Many initiatives across the United States focus on devel-oping solutions to health inequities at the local and state lev-els. The National Academy of Science in partnership with the Robert Wood Johnson Foundation (2017) published a report detailing how communities working collaboratively with diverse partners could identify and implement solu-tions to achieve health equity. The initiatives described in this report are based on several beliefs (National Academies of Sciences, Engineering, and Medicine, 2017): n Health equity is crucial for the well-being and vibrancy

of communities.n Health is a product of multiple social, economic,

environmental, and structural factors.n Health inequities are mainly a result of poverty,

structural racism, and discrimination.n Communities have the ability or agency to promote

health equity.n Supportive public and private policies and programs

at all levels facilitate community action.n Collaboration and engagement of new and diverse

(multi-sector) partners is essential to promoting health equity.

Their report provides a roadmap for community-based solutions.

Another initiative, A Triple Aim of Health Equity, was established by the Association of State and Territorial Health Officials (ASTHO) to empower state and territorial health agencies to develop policies, develop cross-sector

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262 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

EVIDENCE EXAMPLE 13.2Food Insecurity

Food insecurityreferstotheUSDA’smeasureoflackofaccess,at times, to enough food for an active, healthy life for allhousehold members and limited or uncertain availability ofnutritionally adequate foods. Food-insecure households arenot necessarily food insecure all the time. Food insecuritymay reflect a household’s need to make trade-offs betweenimportantbasicneeds,suchashousingormedicalbills,andpurchasingnutritionallyadequatefoods.Thelackofaccessattimes to enough food to provide for a healthy, active life forall familymembers isasignificanthealthdeterminantrisk intheUnitedStates.In2015,42,238,000peoplewereidentifiedasfoodinsecure.Ofthesepeople,26%wereabovethe185%ofpovertylevel($45,510annualincomeforafamilyoffour),whichmadethemineligibleforalmostallgovernmentalnutri-tion assistance programs. In some states, the Supplemental

NutritionAssistanceProgram(SNAP)hasraisedtheeligibilityto200%ofpoverty(FeedingAmerica,2017). SNAPusestheThriftyFoodPlan(TFP)tocalculatethecosttoprovideanutritiousdietthatmeetsminimumdailydietaryrequirements as a means to determine the amount of SNAPfamilycashfoodbenefits.Asystematicreviewofmarketbas-ketsurveys(MBS)usingactualgrocerystorefoodpriceswasconductedbyHorningandFulkerson(2014).TheyfoundthatSNAPcashallotmentsbasedonTFPcalculationsmaynotbesufficienttomeetanutritiousfamilydietbasedontheactualcostofgroceries.Theabilityoflow-incomefamiliestochangetheirbehaviorstoeatahealthierdietmaybecostprohibitive.Nursesneedtoadvocateforincreasesinfoodassistanceandtheaffordabilityofhealthyfoods.

Native Diabetes Wellness Program 

GOAL 10 PovertyandfoodinsecurityhavebeenidentifiedasriskfactorsforobesityanddiabetesinNativeAmericans.TheNativeDiabetesWellnessProgram(NDWP)wasestablishedin2004toreducehealthinequitiesintribalcommunities.Principlesofpracticeincludedculturalhumilityandcommuni-ty-ledparticipation.TheEagle Books series foryoungchildren,highlighting thewisdomof traditionalwaysofhealth,andaK–12curriculum,HealthIsLifeinBalance,wereinstitutedin2006.TheinteractiveDiabetesEducationinTribalSchoolscurriculumincludedengagement,exploration,explanation,elab-oration, and evaluation. The Traditional Foods Project for American Indian and Alaska Native Com-munitieswasinstitutedbytheCDCin2008.Theprojectincludedsustainable,ecologicalapproaches

totraditionalfoodsandphysicalactivity, increasedaccesstolocalfoods,andrevivedandsharedstoriesofhealthytraditionalpractices.Communitymemberswereengagedtotracktheprogressoftheproject.In2012and2013,TraditionalFoodsProjectpartnersandNDWPstaffwereinvitedtopresenttotheCDCTribalAdvisoryCommittee,whichrecommendedcontinuingtheTraditionalFoodsProjectforayearbeyondthe5-yearcycle.Partnersappliedforasixthyearoffundingfor2014bydemonstrat-ingtheirevaluationresultsandplanstosustaintheirnativefoodsystems.Factorsidentifiedasimportantforthesuccessoftheprogram included: thesignificanceof land; interest inNativeAmerican foodpathwaysand foodsheds; respect for traditionalknowledge;consistencywithtraditionalvalues;theroleofeldersasteachersoftraditionalknowledgefosteredintergenerationalrelationships;traditionalfoodsfacilitatedialogueabouthealth;emphasisonplanning;theimportanceofcommunity-drivenplan-ning;andsustainedeffortsbeyondtheproject’send(CDC,2016).

Advocacy: PHN Advocacy for Population HealthAdvocacy is considered a fundamental basis of nursing (Curtin, 1979; Gadow, 1999; MacDonald, 2006), while social justice is considered the fundamental basis of public health. The ANA (2013) directs PHNs to advocate for the protection of the health, safety, and rights of populations (Standard 16). In public health nursing, a primary focus of advocacy is health equity.

PHNs most often work with vulnerable individuals and families—those who are oppressed, marginalized, disen-franchised, or underserved and therefore at greater risk for disease, disability, and premature death. Although it is pos-sible to improve the health status of individuals and families one by one, it is more effective, when possible, for PHNs to take actions to improve the health status of vulnerable pop-ulations as a whole.

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263CHAPTER 13  n  Competency #11

The Journey to PHN AdvocacyCaring leads to advocacy, and PHNs care passionately about those experiencing health disparities. PHNs enter into the practice of “critical caring” when they recognize health dis-parities in individuals and families and work to change the context of people’s lives to improve their health (Falk-Rafael, 2005a). It is not always easy to advocate for clients, either at the individual or the population level of public health prac-tice. Social justice dilemmas are part of the everyday lives of nurses. What is different for PHNs is that they often have to confront and resolve these dilemmas when they are out in the community by themselves. In an acute care setting, eth-ics committees can usually help resolve ethical issues related to autonomy, rights to self-determination, rights to refuse treatment, and rights to a safe and comfortable death. In the home and community setting, PHNs are often practicing alone, although they consult with other health team mem-bers when faced with challenging situations. Sometimes ethical decisions related to social justice and human rights need to be made during a home visit, such as reporting unsafe “garbage” homes to the county sanitarian, contact-ing animal control about a client’s pet that has just bitten a young child, or requesting court-ordered Directly Observed Therapy (DOT) for a client with active TB who is not adher-ing to the medication regime. Sometimes PHNs carry out advocacy interventions by themselves, and sometimes they are part of a group advocating for change.

The pervasive barriers to advocacy are economic, polit-ical, and public opinion obstacles. Shankardass, Lofters, Kirst, and Quinonez (2012) believe that political will is shaped by public awareness and opinion. The ability of PHNs to create awareness of health inequities in their com-munities at the local or national level is key to influencing the health equity agenda of both the public and the politi-cians. Advocacy messaging generally needs to be tailored to the specific human rights or social justice theme and tai-lored to the targeted audience. The key messaging themes that should be considered when developing an advocacy message include: health as a value and social justice; human rights and governmental policies; environmental sustain-ability; economic cost of health inequities; and self-interest, in that inequities may lead to economic and social instability and may risk the health of others. Effective messaging strat-egies include: cooperative approaches; social mobilization and building a broader base of support; empowering dis-advantaged groups; forming coalitions and networks with business, scientists, and policymakers; engaging the media; involvement in the political process; and taking advantage of windows of opportunity (Shankardass et al., 2012).

Advocacy for health equity is defined as “a deliberate attempt to influence decision makers and other stake-holders to support or implement policies that contribute to improving health equity using evidence” (Farrer, Mari-netti, Cavaco, & Costongs, 2015, p. 394). The types of data analysis that are useful include: program evaluation data,

particularly an analysis of cross-sector initiatives that show the impact on health disparities; cost-benefit analysis to assure policymakers that resources are not being wasted; analysis of the differential impact of specific policies to determine expected and unexpected outcomes; and presen-tation of narratives and stories.

It is important to consider how data is collected and when and where it is presented. Effective data is recent, timely, and local (Farrer et al., 2015). The data collection and eval-uation process should include participation of community members. Disadvantaged and vulnerable populations have less voice and less power in shaping public policy. Finding ways to include community members who do not normally have a voice is important. Strategies to include community members are discussed in Chapter 8.

Advocacy and EmpowermentTo foster self-determination, facilitate empowerment, and promote self-advocacy, nurses need to create an atmosphere that supports and respects the rights of the populations they advocate for (Mallik, 1997). Nurses also need to feel and be empowered to take action (Cawley & McNamara, 2011). Table 13.7 outlines an empowerment framework for nurses.


Critical caring is a theory that is linked in the social activ-ismofNightingaleandgrounded inWatson’shumancar-ing theory and creative health promotion processes, andin feminist theory. Critical caring provides a frameworkfor PHNs to engage in empowered caring (Falk-Rafael &Betker, 2012). Falk-Rafael and Betker interviewed expertCanadianPHNsusingamultimodalresearchdesign.Theirresearch identifiedthreeoverarchingthemesfrompartic-ipants’ reports: 1) the moral imperative and difficulty inarticulatinganethicalframeworkforpractice,2)pursuingsocialjusticebyadvocatingforhealthequity,and3)expe-riencingbarrierstotheirmoralagency(i.e.,beingunabletodowhattheirmoralsenseimpelledthemtodo)andmoraldistress.Thepremisethat“criticalcaringisacaringethicthroughwhichsocial justicemaybeexpressed”wassup-portedbyFalk-RafaelandBetker’sresearch(p.110).Caringisalsoarelationalethicbasedontheexperientialaspectsof PHN practice. The critical caring theory supports theimportanceofcreatingandmaintainingsupportivephysi-cal,social,economic,andpoliticalenvironmentsforclientsandnurseshavingacriticalroleincreatingtheseenviron-ments(p.110).

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264 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

TABLE 13.7 A Framework for Becoming Empowered and for Empowering Others

Definition Components Empowerment Strategies

Personal power is the power you acquire and exercise through your informal and formal roles in your family and community.

n Personal roles: family and friendsn Community roles: neighborhood,

volunteer, elected officialn Cultural and ethnic tiesn Organizational membership:

religious, political, other

n Become involved as a citizen with an issue you are passionate about.

n Get to know your neighbors and community.n Identify yourself to family, friends, neighbors, com-

munity members, and stakeholders as a professional who is committed to improving the health of the community.

n Participate in community or organizational meetings. Share your knowledge about healthcare.

n Form linkages and networks between different groups and organizations that share common beliefs and goals.

n Know your elected and appointed officials.

Professional power is the power you acquire and exer-cise through your formal role as a professional nurse.

n Legitimacy through licensuren Social contract with publicn Professional expertise and

competenciesn Membership in professional

organizationsn Professional networks

n Find a professional and career mentor.n Join a professional nursing organization.n Attend conferences and meetings.n Embrace the concept of lifelong learning through

continuing education, certification, and formal higher education.

n Strive to provide evidence-based care.n Develop strategies for monitoring quality and safety

of care.n Role-model professional nursing practice. n Become a mentor for novice nurses.

Organizational power is the power you acquire and exercise through your formal and informal roles in your workplace and the healthcare system.

n Position and job descriptionn Organizational communication n Coordination of caren Dispersed power of nursing

throughout your organization and society

n Become involved in the work of the organization beyond patient care.

n Become a member of a practice committee.n Collaborate with people in other disciplines,

management, and administration.n Join an interdisciplinary group whose goal is

improvement in patient care or population health.n Work with a consumer group to improve healthcare

in your community.n Be politically active at the local level. Be GLOCAL:

Think global, act local. At some point, you may wish to become involved at the state and national levels.

Source: Schoon, Miller, Maloney, & Tazbir, 2012, p. 188

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265CHAPTER 13  n  Competency #11

about abuse, and then the nurses can effectively intervene and advocate for safety (Hughes, 2010; Vanderburg, Wright, Boston, & Zimmerman, 2010). Home visiting by itself has been identified as a nursing intervention that reduces health disparities (Abbott & Elliott, 2016). See Chapter 10 for more information on caring relationships.

PHNs are aware that they can take actions to advocate for specific health needs of families that are related to both indi-vidual health determinants and social health determinants. They know that individuals and families can only change health determinants that are related to their own biological, behavioral, and life circumstances. They generally cannot change the health determinants that are societal in nature, or the social determinants of health. See Chapter  1 for a discussion of health determinants, protective factors, and risk factors. Table 13.8 illustrates the diverse individual and social determinants of health confronting a young family at risk for elevated blood lead levels at the individual/family, community, and systems levels.

Advocacy at the Individual/Family Level of Public HealthNurses advocate for individuals and families by safeguard-ing their autonomy, acting on their behalf, and champi-oning social justice in the provision of healthcare (Bu & Jezewski, 2006). Advocacy is aimed at building the capacity of individuals or families to manage their own healthcare needs. PHNs recognize the inequalities that exist within social determinants of health and challenge the status quo to change the social environment.

When PHNs advocate for individuals and families, they often do so within trusting relationships (MacDonald, 2006). For example, over time, nurses working with abused children or women often become aware of the abusive situa-tions when they are providing trustworthy care for common physical health conditions. Trusting relationships make it possible for the clients to disclose very personal information

TABLE 13.8 Erica’s Clients: Health Determinant Analysis—Risk for Elevated Blood Lead Levels in Children

Protective Factors Risk Factors

Individual/family health determinants

n Mother exhibits health-seeking behaviors and accepts assistance from the PHN and public health resources.

n Children are healthy except for increased lead levels.

n Apartment owner is concerned about the tenants’ health and willing to apply for funding for lead abatement.

n Exposure to lead-based paint in home n Children’s developmental stages and agesn Children’s liver and kidneys unable to excrete

excess leadn Family’s inability to afford safe housingn Lack of medical insurance

Social determinants of health—Community level

n Community volunteer resources for transportation

n Faith-based resourcesn Community health priorities of child health

and environmental health

n Older, substandard housing with lead-based paint

n Lack of safe, affordable housingn High poverty level due to poor economyn Downsizing of local businesses

Social determinants of health—System level

n Taxpayer funding of public health services n Public health nursing services availablen Environmental health services availablen Medicaid and CHIP funds for healthcare

available for low-income, uninsured familiesn Local clinic willing to admit Medical

Assistance clients n Public health clinic able to arrange for blood

lead level testing. n Lead-abatement funding available

n Lack of affordable private or public health insurance

n Limited access to affordable healthcare n Fewer medical clinics accepting Medical

Assistance clients

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266 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies



owner to a state program that provides financial assistance for lead abatement. The apartment owner is relieved to know that he can get financial assistance for lead abate-ment to provide a safer environment for his tenants.

Erica reflects on the positive health outcome for the two children with increased lead levels and the lead abatement of the apartment building that is scheduled for next month. She remembers that she had been in a hurry on the home visit and was impatient when the mother started talking about her children rather than responding to the questions Erica was asking. Luckily, Erica managed to focus on the mother’s concerns rather than her own. She knows that if she had not taken the time to listen carefully, she might have missed the mother’s comments about the children’s symptoms and might not have noticed the paint chips. Erica renews her commitment to listen to clients telling her what their priorities and needs are. She decides she will be more observant when assessing the homes and neighborhoods of children in her caseload. Erica knows that collecting data and reporting her findings are the first steps in advocating for change.

Advocacy at the Community and Systems Levels of Public HealthTo reduce health disparities, PHNs need to be engaged in interventions at both community and systems levels of prac-tice. PHNs spend most of their time working with individ-uals and families to modify their health determinants (i.e., reduce their risk factors and strengthen their protective factors) and empower them to manage their own healthcare needs. PHNs are interested in reducing health disparities among populations as well. To do this, PHNs must under-stand the multiple causes or health determinants that influ-ence populations’ health statuses. Individuals and families within populations that experience health disparities suffer consequences even if their personal behaviors and biolog-ical/genetic factors encourage health. Thus, PHNs must advocate for change in the societal causes of population health disparities by working at the community and systems levels of practice. Working with individuals and families to help them change their own behaviors and risk factors can-not by itself eliminate health disparities at the population level. In a perfect world, health resources would be infinite, and everyone would have access to all the healthcare they need. Unfortunately, this is not the case, and much of the time people cannot even agree on the type of healthcare that is needed. It is important for PHNs to work with other com-munity members to create a sustainable community part-nership to work to achieve health equity. Table 13.9 provides

Erica receives a phone call from the mother of the children with suspected high lead levels. She has been able to enroll her children in a state-run healthcare plan and is looking for a medical clinic on a bus line. The clinic she finds is no longer taking patients on government assistance. Erica knows that not many medical clinics are in the mother’s neighborhood and cannot think of one on a bus line. She checks the county’s database on medical clinics and the metropolitan transportation agency website to investigate bus service routes. She contacts the American Red Cross and faith-based and charitable organizations in the neigh-borhood for transportation assistance. These searches take an entire afternoon, but Erica is successful in finding a clinic that accepts people on government assistance and a local church that has a volunteer transportation program. Erica tells the mother that she will make a home visit to draw blood from the children to screen them for high lead levels.

Erica asks her supervisor how to code these hours on her time sheet, as she is not providing direct nursing care. Her supervisor tells Erica that she is carrying out the nurs-ing interventions of Advocacy and Case Management by finding resources that can help her client become more self-sufficient.

Erica returns to the family and draws blood from the children. Environmental Health staff has visited the fam-ily’s apartment to determine whether the paint and paint chips are lead-based. Two weeks later, Erica, her PHN supervisor, and the Environmental Health staff meet to review their findings. Both children have increased blood lead levels, and a significant amount of lead-based paint has been found throughout the apartment. Erica arranges for the mother and children to be seen in the county pub-lic health clinic. Chelation therapy is recommended for the children, but the county does not provide that service. Lead abatement is recommended for the apartment building, but the owner says that he cannot afford it.

Erica knows that the human rights of the families in the apartment complex are at risk because of their exposure to lead-based paint and inability to change their living sit-uation because of poverty and lack of affordable and safe housing. She knows that the human rights of the children cannot be met if they do not receive the medical care they need. Realizing that the individual rights of the apart-ment owner are in conflict with the social justice rights of the apartment residents, Erica tries to find just solutions. Erica refers the family to a social worker to apply for the state Medicaid/Medical Assistance program and Children’s Health Insurance Program (CHIP) services. She thinks funding is available for medical treatment for the children through these programs. Erica also refers the apartment

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267CHAPTER 13  n  Competency #11

Determining Public Health PrioritiesPHNs need to identify the social justice and human rights issues they encounter in their practice to determine what actions they need to take and what their agencies’ priori-ties should be. Dealing with the issue of health disparities often appears overwhelming. Tools to identify the dispari-ties in specific populations and their causes help PHNs and their partners develop targeted interventions. One exam-ple is a Health Equity Assessment Tool (HEAT) developed in New Zealand (Signal, Martin, Cram, & Robson, 2008) that provides a planning and intervention process to iden-tify and reduce health disparities in the Maori population. Table 13.10 provides a list of 10 questions that guides the pro-cess from assessment through intervention.

TABLE 13.9 Public Health Nursing Interventions at the Community and Systems Levels of Practice That Include and Support Advocacy

Advocacy: Florence Nightingale demonstrated advocacy throughout her nursing career. As superintendent of a London hospital for impoverished women, she successfully had the hospital policy changed from admitting only those who belonged to the Church of England to admitting women of all faiths. Her nursing leadership of 38 nurses in Ottoman, Turkey, during the Crimean War was directed primarily at improving the plight of the wounded (Selanders & Crane 2012).

Community Organizing: A community action model was used in California to increase the community’s capacity to address the social health determinants of tobacco-related health disparities and to develop local policies to eliminate or weaken smoking-related social health determinants (Lavery et al., 2005).

Collaboration: PHNs in Alberta, Canada, were concerned about the incidence of postpartum depression. They initiated a demonstration project in which they collaborated with a group of obstetricians and a group of midwives to have preg-nant women referred to PHNs for psychosocial screening, health education, referral, and follow-up. Of the 150 women assessed, 37% had a history of postpartum depression, and 33% had a family history of depression. They accessed 93 services. Of the 75 women who participated in the program evaluation, 68% reported that the PHN intervention was helpful. The outcomes were so positive that the collaborative program was continued (Strass & Billay, 2008).

Policy Development and Policy Enforcement: Barriers that limit access to healthcare in the uninsured elderly popu-lation were explored in a journal article in a special health policy feature. Key barriers were lack of transportation, lack of insurance, complexity of the healthcare system, poverty, lack of family support, culture, communication, and race and ethnicity. Recommendations included improvements to health insurance coverage, use of the case management model of care, outreach services, improvements to transportation, and cultural competency and communication. Many of these recommendations were directed toward needed changes in federal healthcare policy (Horton & Johnson, 2010).

examples of how advocacy at the community and systems level can lead to improved population health status.

Lathrop (2013) believes that nurses can take a leadership role in advocating for health equity at the local, national, and global levels of society. The areas targeted for advocacy are: structural change at the national and global levels; liv-ing and working conditions at the national and local levels; community interventions such as health fairs at the local levels; and individual and family interventions.

EVIDENCE EXAMPLE 13.3National Association of School Nurses— Speaking Up for Children

TheNationalAssociationofSchoolNurses(NASN)advo-catesforchildhealthandtheresourcesneededtopromotehealth and safety among school children. School nursesareawareofthesignificantnumberofchildrencomingtoschoolwithpreventablephysicalandmentalhealthcondi-tions.Schoolnursesworkhardtoobtaintheneededhealthandsocialservices for thesechildren,but theyknowthatthey cannot solve the problem of inadequate resourcesbyworkingonenursetoonechildata time.NASNhasahistory of lobbying for school health resources to meetchildren’sneeds.Tomoreeffectivelylobbyatthenationallevel, NASN moved its headquarters to Washington, DC,in 2005. The NASN Annual Conference in 2005 broughthundreds of school nurses to Washington, DC; preparedthem for lobbying efforts; and provided opportunities forthenursestomeetwiththeirelectedrepresentativestotalkaboutchildandschoolhealthissues,explaintheroleoftheschoolnurse,anddiscussthepositiveimpactschoolnurseshaveonchildhealth.TheNASN2007policyagenda,Capi-talInvestmentforChildren,wasanefforttosecureaplaceatthenationalpolicymakingtableforschoolnursessothattheycouldadvocateforchildrenwithunmethealthneeds.NASN continues its efforts to work with national, state,and local officials to achieve its goal of achieving a ratioofschoolnursestostudents ineachschoolthatcanade-quatelymeettheirhealthneeds(Denehy,2007).

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268 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

Reducing Health Disparities—Downstream Versus Upstream ApproachEvidence has shown that the medical model alone, based on market justice, will not eliminate health disparities. Social determinants of health have been identified as a major cause of health disparities; however, the medical model deals pri-marily with individual causes of morbidity and mortality, such as genetics, healthcare access and quality, and indi-vidual health knowledge and behaviors. When the focus of healthcare is on the individual experiencing disease (sec-ondary and tertiary prevention), this is called the down-stream approach. Interventions aimed at reducing these causes, although important, will not by themselves allevi-ate health disparities. Individuals and families do not have equal access to private healthcare systems, governmental supports, or societal resources.

When the focus of healthcare is on modifying the social determinants of health to prevent disease and disability (primary prevention), this is called the upstream approach. Beauchamp (2013) argues that collective societal and govern-mental action based on social justice is necessary to protect the health of the public and that the burdens and benefits of

TABLE 13.10 The Ten HEAT Planning Process Questions to Reduce Health Disparities Among Maori

1. Which inequalities exist in relation to the health issue under consideration?

2. Who is most advantaged and how?

3. How did the inequities occur? What are the mechanisms by which the inequalities were created, maintained, or increased?

4. Where/how will you intervene to tackle the issue?

5. How will you improve Maori health outcomes and reduce health inequalities experienced by the Maori?

6. How could this intervention affect health inequalities?

7. Who will benefit most?

8. What might the unintended consequences be?

9. What will you do to make sure the intervention does reduce inequalities?

10. How will you know whether inequalities have been reduced?

Source: Signal et al., 2008

FIGURE 13.6 A Framework for Health EquitySource: AlamedaCountyPublicHealthDepartment,2008,p.4

DiscriminatoryBeliefs (ISMS)

• Race• Class• Gender• Immigration status• National origin• Sexual orientation• Disability


• Corporations• Business• Government agencies• Schools


• Neighborhood conditions – Social – Physical• Residential segregation• Workplace conditions


Socio-Ecological Model

Social Factors

Medical Model















• Smoking• Nutrition• Physical activity • Violence

Disease andInjury

• Infectious disease• Chronic disease• Injury

Mortality• Infant mortality• Life expectancy

Health Status



ss t






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269CHAPTER 13  n  Competency #11

these efforts should be shared equally except in situations where health disparities exist. However, there is no consen-sus within U.S. society for this position. Iton (2008) advo-cates a dual upstream-downstream approach (Figure 13.6). The dual approach involves taking an upstream approach to prevent disease and improve the health of populations while maintaining the downstream approach that treats individu-als’ diseases and disabilities. Figure 13.6 illustrates the dual upstream-downstream approach.

The collective social action that is needed to integrate the upstream and downstream approaches and to create inter-sectoral partnerships among governmental and pri-vate institutions is a journey that the United States has just begun. However, until there is an integrated system of healthcare that addresses all of the determinants of health, there will be little of the social change required to achieve health equity. A community partnership model that could be implemented at the local, national, and global levels to achieve health equity is presented in Figure 13.7.

ActivityRead the following story and reflect upon upstream versus downstream thinking:   Two people were walking by a river. Suddenly, they observed babies floating down the river. They ran to the river to pull out as many babies as they could possibly reach. One of the rescuers yelled, “I’m going upstream to find out how these babies are getting into the river.” This rescuer climbed the pathway up the side of the river, found where the babies were being thrown into the river, and immediately prevented more babies from being thrown into the water. This is upstream thinking and action in contrast to downstream action. Falk-Rafael (2005b) explains how downstream approaches that are aimed at meeting the needs of individuals and families must be paired with upstream approaches that aim to change power in societal relationships and structures to give voice to those with poor health and social disadvantages.   Think of a health disparity you would like to see decreased in a specific population. How would you use upstream thinking to achieve your goal? Do you think a dual approach of combining upstream and downstream strategies might work? What would you propose?

FIGURE 13.7 Community Partnership Model to Achieve Health EquitySource: ModifiedfromPhases of a Social Determinants of Health Initiative,BrennenRamirezetal.,2008,p.33

Achieving HealthEquity

AssessPopulation Health

Focus on SocialDeterminants

Map Community Assets

Develop Mission,Goals, Objectives

Build CommunityCapacity


and ChangeStrategies





Identify Consequences



Modify Plan

Maintain Partnership


Create orEnhance


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270 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

outcomes of societal inequities and health disparities. Civic engagement involves more than charity: It is a means to achieve social justice through upstream actions—changing the social structure that creates health disparities. It involves social and political advocacy. Like others, you might tend to prefer to carry out acts of charity and avoid political engage-ment (Gehrke, 2008; Iton, 2008). However, it is important that you participate in civic engagement at some point in your nursing education and career. Civic engagement may occur at the local, national, and international levels.

Participating in the Political ProcessProfessional nurses are expected to advocate for popula-tions experiencing health disparities by using the political process. The role of a political advocate is embedded in the social contract that the profession of nursing has with

Civic Engagement as Social Justice InterventionAs advocates for social justice, PHNs by necessity must be involved in the civic life of their communities to have an impact on the social determinants of health. Nurses have both professional and citizenship obligations to the com-munities in which they work and live as part of the collec-tive responsibility for social action to improve population health. Civic engagement involves working to improve the civic life of communities in partnership with community members. Nursing students who participate in civic engage-ment develop knowledge, skills, values, and motivations to make a difference (Gehrke, 2008, p. 53–54). Many nursing students are comfortable volunteering in their communities as a form of charity. These actions are commendable, but volunteering is not considered civic engagement. Charity is downstream action—an adaptive response to ameliorate the

TABLE 13.11 Political Process Activities

Stages of the Political Process Examples of Civic Engagement

Electoral processCandidate selection, endorsement, and support in the primary and general elections.

Work for a candidate by making phone calls, knocking on doors, assembling mailings, putting up yard signs, donating money, and attending rallies and other campaign activities for candidates who support your political health agenda. Participate in candidate screening through your local nurses’ association.

Legislative processWriting, introducing, passing the bill, and enabling legisla-tion for funding. Both houses of Congress (one or two at state level) must pass the bill, and the bill must then be signed by the governor.

Contact your legislators about bills you want legislators to sup-port; write letters and emails or go to the Hill for a face-to-face meeting and attend hearings on the bill. Testify at conference hearings, write letters to the editor of the local newspaper, post blog entries, and call in to radio programs.

Budgeting processThe omnibus reconciliation bill at the end of each legislative session provides funding. A government department is given “budget authority,” or the right to implement the legislation and allocate the funding.

Lobby for a bill’s funding. Find out which state agency has budget authority to enact and fund the legislation. Provide testimony on the best way to fund programs, and discuss who is going to benefit.

Regulatory processThe department with budget authority holds hearings to deter-mine the rules and regulations that need to accompany the bill.

Attend hearings about the rules and regulations that are going to enable the bill to be implemented and monitored for cost, quality, and access. Ask to be put on an email list to receive notice of meetings and actions taken.

Evaluation processLegislation that is enacted is usually evaluated at the end of the 2-year budget cycle of the legislature. Every program funded and implemented has to be evaluated and a report sent to the legis-lative auditor’s office. The evaluation of the success of a project is a significant factor in determining whether the program is continued or renewed.

Testify and present reports about the effectiveness and impact of programs. Download a copy of the report and meet with a legislator’s staff person or the “budget authority” agency to dis-cuss the evaluation and make recommendations for continuing or modifying the program.

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271CHAPTER 13  n  Competency #11

TABLE 13.12 Strategies for Working With Legislators

n Get to know legislators well—their districts and constituencies, voting records, personal schedules, opinions, expertise, and interests. Be sure to have a good understanding of the legislator and his/her concerns, priorities, and perspectives.

n Acquaint yourself with the staff members for the legislators, committees, and resource officials with whom you will be working. These people are essential sources of information and have significant influence in some instances in the development of policy.

n Identify fellow advocates and partners in the public health community to better understand the process, monitor legislation, and assess strengths and weaknesses. Finding common ground on an issue sometimes brings together strange bedfellows but makes for a stronger coalition.

n Identify the groups and other legislators with whom you may need to negotiate for changes in legislation. Do not dismiss anyone because of previous disagreements or because you lack a history of working together. Yesterday’s opponent may be today’s ally.

n Foster and strengthen relationships with allies and work with legislators who are flexible and tend to keep an open mind. Don’t allow anyone to consider you a bitter enemy because you disagree.

n Be honest, straightforward, and realistic when working with legislators and their staff. Don’t make promises you cannot keep. Never lie or mislead a legislator about the importance of an issue, the opposition’s position or strength, or other matters.

n Be polite, remember names, and thank those who help you—both in the legislature and in the public health advocacy community.

n Learn the legislative process and understand it well. Keep on top of the issues and be aware of controversial and contentious areas.

n Be brief, clear, accurate, persuasive, timely, persistent, grateful, and polite when presenting your position and communicating what you need/want from the legislator or staff member.

n Be sure to follow up with legislators and their staff. If you offer your assistance or promise to provide additional information, do so in a timely and professional manner. Be a reliable resource for them today and in the future.

Source: APHA, 2018

society (Des Jardin, 2001). Nurses who have personal and professional senses of empowerment are able to work within their communities to improve population health through the political process (Carnegie & Kiger, 2009). PHNs are uniquely suited to participate in the political process, as they are confronted daily with the social determinants of health that often negatively affect their clients’ health.

PHNs often participate in the Policy Development and Enforcement process, which requires an understanding of how the political process works and the critical points in moving forward. Taking the time to understand the policy-making process is essential if you want to advocate for vulnerable populations with your elected officials (e.g., leg-islators, mayor, city council, county commissioners, school board). After you understand how laws, regulations, and ordinances are made, you can be more confident about par-ticipating in the process. Your knowledge of healthcare and

the health needs of your community makes you an expert in the eyes of elected officials. Developing a trusting rela-tionship with your legislators can help you influence health policy development (Deschaine & Schaffer, 2003).

Nurses need to be involved in the political process from the electoral process to the legislative audit process. How-ever, most citizens, nurses included, have no experience actively participating in the political process. So, it is time to start! Table 13.11 can guide you through the stages of the political process and provide examples of how you can become involved.

The American Public Health Association (APHA, 2018) has identified ten key points of advocacy that might be helpful to you as you think about approaching your leg-islators (see Table 13.12). Which of these strategies would you feel comfortable using? Think about your authentic leadership style.

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272 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies


Erica is going to attend a Nurses Day on the Hill event at the state capitol. She wants to talk with her senator and rep-resentative about the need for funding programs to rehab older homes to remove lead paint. She asks the mother of the children with lead paint poisoning if it would be okay to share her family’s story. She knows that real-life stories are more effective than statistical data. Erica attends Nurses Day on the Hill and talks with her senator and represen-tative. She provides them with a one-page handout on the dangers of lead-based paint to young children. She is sur-prised at how receptive they are to her and that they treated her as an expert! More than 1,000 nurses are at the event. Erica is surprised that so many nurses took the time to attend. She feels proud to be part of such a large group that advocates for the health needs of the community. She real-izes that nursing requires more than just working a shift. Erica knows that if she is going to make a difference as a public health nurse, she needs to advocate for her clients at both the systems and the community levels of practice.

Erica has been with the county public health agency for a year. She is committed to social justice and wants to improve her ability to advocate for vulnerable individuals and families. She wants to be able to support agency ini-tiatives to improve population health in her community.

TABLE 13.13 Erica’s List of Agency Initiatives

Opportunities Taken Opportunities Missed

Brief conversation with a county health board member. Told a client story about a teenage mom who benefitted from the exis-tence of a Healthy Families Collaborative. (Coalition Building)

In the past legislative session during a debate on a ruling regard-ing preservatives in vaccines, I could have written a personal letter to my legislator. (Policy Development)

Articulated several “talking points” from the state department of health policy on vaccines and autism at the early childhood meeting for parents to encourage other parents to have their children vaccinated. (Community Organizing)

Did not attend a meeting organized by city hall regarding hiking and biking trails in my community. I could have been a voice for obesity prevention in my community. (Community Organizing)

Led a focus group with Cambodian immigrants on cultural competency in services for the elderly in their community. Provided a summary report to the Cambodian community and service providers. (Collaboration)

Missed an opportunity for PHN team case study discussion to identify unmet health needs among their caseloads. I could have learned how my caseload was similar to or different from other PHNs’ caseloads and how this influences our decision-making and priority-setting processes. (Collaboration)

Represented the agency on a task force organized by the state health department to develop guidelines on blood lead and healthy housing. (Policy Development)

Missed a meeting with a senior coalition to lobby county com-missioners to extend green light walking time to allow seniors to walk across streets safely. I could have learned more about this health risk for the elderly. (Coalition Building)

Met with the OB nurse manager, the Newborn Nursery nurse manager, and the Infection Control nurse at the local hospital to discuss Tdap vaccination of staff as a means to prevent pertussis in newborn infants. (Collaboration)

Did not return a survey regarding vending machine policies in the school district. I could have helped with the data-collection process. (Policy Development)

Erica has noticed that agency nurses in management positions frequently carry out community-organizing, coalition-building, and policy-development interventions. Sometimes she supported these agency initiatives. Erica makes a list of the opportunities she participated in and the opportunities she missed.

Table 13.13 lists the opportunities that Erica put together.

Ethical Application for Social Justice and Nursing AdvocacyPHNs often make ethical decisions related to social justice and human rights. Most of the time these decisions are related to the health status of individuals and families, but sometimes they are clearly related to the health status and health disparities of diverse populations. You need to be able to identify and describe the ethical principles based on social justice and human rights that guide you. It is also import-ant to understand how your ethical beliefs and the ethical beliefs of others affect your capacity to act when confronted with health disparities. You need to have a strong sense of your own ethical beliefs. All PHNs bring personal biases to

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273CHAPTER 13  n  Competency #11

ethical decision-making, and they have differing abilities and skills to take action. Consider your level of moral cour-age, the ability to confront moral challenges based on stead-fast commitment to fundamental ethical principles despite potential risks (Edmonson, 2010; Gallagher, 2011; Lachman, 2010; Murray, 2010). Think about the ethical environment that surrounds you, the social environment consistent with principles of human rights and social justice that is support-ive of individual or collective actions of moral courage. Do you have the personal and professional resources you need as a student and future nurse to be the advocate you want to be?

ActivityReflect on the experiences you and your peers have participated in or observed as part of your community clinical. Were any of these ethical principles demonstrated in PHN practice? 

Activity Consider the following case study: A PHN making a home visit to a recently paroled inmate of the local jail notes on the referral that the man is PPD positive on repeat testing and needs to start antiviral medications for TB. The man has the medication with him but is not taking it. The PHN considers her options: 

n Should she encourage him to resume treatment for latent TB infection?

n Should she notify his physician or his parole agent of his noncompliance? 

n What is the ethical problem, and how would you resolve it? 

n Review the ethical principles listed in Table 13.14, and use them to resolve the ethical dilemma.

TABLE 13.14 Ethical Principles and Actions in Advocacy

Ethical Perspectives Examples

Rule ethics (principles) n Public health resources and services are allocated based on need, so they might be distributed unequally—maximizing utility.

n Identify individuals, families, populations, and communities who are vulnerable and experiencing health disparities.

n Provide public health nursing services to those who are most vulnerable, at greatest health risk, and experiencing health disparities and health inequities, focusing on equal access to goods.

Virtue ethics (character) n Make ethical decisions based on social justice and human rights.n Focus on fair procedures rather than outcomes.n Provide support for individuals, families, populations, and communities who advocate for

themselves.n Be caring and compassionate.n Select advocacy goals and actions that are culturally congruent with the racial and ethnic

diversity of individuals, families, and populations within the community.

Feminist ethics (reducing oppression)

n Advocate for the health and well-being of individuals, families, populations, and communities.n Include and partner with clients in priority setting, goal setting, and advocacy actions.n Empower clients to manage their own healthcare needs.n Increase capacity of individuals, families, populations, and communities to manage their

healthcare needs.n Take actions to address social injustice at all levels of public health nursing practice.n Focus on ensuring equal access to resources.n Focus on traditions and practices in a community.

Sources: Table based on work by Racher, 2007, and Volbrecht, 2002

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274 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

 4.  PHNs advocate for health equity and justice for indi-viduals, families, populations, and communities at all three levels of practice—individual/family, community, and systems.

 5.  PHNs bear professional accountability to advocate for vulnerable individuals, families, populations, and com-munities experiencing health disparities.

 6.  It is important for students and PHNs to become involved in civic engagement and the political process to help create social and structural change for health equity.


 1.  Social justice and human rights serve as the foundation for public health nursing advocacy.

 2.  Public health priorities and actions are directed at vul-nerable populations experiencing health disparities and health inequities.

 3.  To reduce health disparities at the local, national, and global levels, it is necessary to eradicate the social determinants of health that create negative health outcomes.


It is difficult to think about the bigger picture on a daily basis when providing nursing care to vulnerable individu-als and families. The annual review period is a good time to compare your professional goals with actual practice to determine the congruence between goals and practice and to identify future opportunities for professional growth and development.

Think about your experiences in your public health nurs-ing clinical and the advocacy competencies you developed during it:n Which vulnerable populations have you worked with

as a student nurse? n How did you know whether an individual, family,

or population was experiencing a health disparity? n Which health disparities did you identify in your

community? n How did you explore the causes of health disparities

in your community?n Which unmet health needs did you identify in your

community?n Which clients did you advocate for as part of your

public health clinical?n Which advocacy actions did you observe or participate

in during your public health nursing clinical?



n What worked and what did not? What would you do differently?

n If you were going to develop an intervention at the com-munity or systems level of practice for an unmet health need, what would it be? How would you start?

Refer to the Cornerstones of Public Health in Chap-ter 1. Which of these cornerstones support the social justice approach of achieving health equity through community partnerships? Does this cornerstone also support social jus-tice as a foundation of public health nursing?

Erica is preparing for her annual review with her super-visor. She decides that one of her goals for the following year will be to develop her advocacy skills at the commu-nity and systems levels of practice. She believes that her values and perspectives are consistent with social justice and the mission and goals of the county public health agency. She believes that she has been effective in advo-cating for individuals and families, such as the family whose children had increased blood lead levels. She now understands that she has to intervene at all three levels of practice to create change sufficient to improve popu-lation health. Erica is ready to work on her ACTIONS!

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Think about how Erica developed and demonstrated public health nursing advocacy competencies as she worked with the two young children with increased blood lead levels and their mother, analyzed her own practice, and set the goal of developing additional advocacy competencies. Discuss the following questions with your classmates:

 1.  Which values and perspectives motivated Erica to act in a socially just manner?

 2.  Which aspects of the situation required Erica to take actions for this family?

 3.  Which ethical conflict between social justice and indi-vidual human rights did Erica have to resolve? How did she resolve it?

 4.  Why was it important for Erica to include others and work as part of a team?

 5.  Which health determinants required Erica to take actions at the systems level of practice?

 6.  Which advocacy actions did Erica take to help the family and owner of the building?

 7.  What were the health outcomes of her actions and the team’s actions?

 8.  Which future civic engagement or community engage-ment actions might Erica participate in to protect children from environmental hazards?

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Salm Ward, T. C., Mazul, M., Ngui, E. M., Bridgewater, F. D., & Harley, A. E. (2013). “You learn to go last”: Perceptions of pre-natal care experiences among African-American women with limited incomes. Journal of Maternal Child Health, 17, 1753–1759. doi:10.1007/s10995-012-1194-5

Schoon, P. M., Miller, T. W., Maloney, P., & Tazbir, J. (2012). Power and politics. In P. Kelly & J. Tazbir (Eds.), Essentials of leadership and management (pp. 186–208). Clifton Park, NJ: Delmar/Centage.

Selanders, L. C., & Crane, P. C. (2012). The voice of Florence Nightingale on advocacy. Online Journal of Issues in Nursing, 17(1), 1–10. doi:10.3912/OJIN.Vol17No01Man01

Shankardass, K., Lofters, A., Kirst, M., & Quinonez, C. (2012). Public awareness of income-related health inequalities in Ontario, Canada. International Journal of Equity Health, 11(26). Retrieved from track/pdf/10.1186/1475-9276-11-26?site=

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Kochanek, K. D., Arias, E., & Anderson, R. N. (2015). Leading causes of death contributing to decrease in life expectancy gap between black and white populations: United States, 1999–2013. National Center for Health Statistics Data Brief 218. Centers for Disease Control and Prevention.

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Lathrop, B. (2013). Nursing leadership in addressing the social determinants of health. Policy, Politics, and Nursing Practice, 14(1), 41–47. doi:10.1177/1527154413489887

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278 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

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