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2019v1.0
 Tenth Edition

Health
Promotion
THROUGHOUT THE LIFE SPAN
Carole Lium Edelman, MSN, GCNS-BC, CMC
Private Practice
Professional Geriatric Care Management
Westchester County, New York

Elizabeth Connelly Kudzma, DNSc, MPH, WHNP-BC, CNL

Professor Emeritus
School of Nursing
Curry College
Milton, Massachusetts
Elsevier
3251 Riverport Lane
St. Louis, Missouri 63043
HEALTH PROMOTION THROUGHOUT THE LIFE SPAN,
TENTH EDITION ISBN: 978-0-323-76140-6

Copyright © 2022 by Elsevier, Inc. All rights reserved.

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To our wonderful families, friends, students, and colleagues —
that they promote health in themselves and others.
CONTRIBUTORS

Erin Bompiani, PT, DPT, PCS June Andrews Horowitz, PhD, RN, PMHCNS-BC, FAAN
Assistant Professor Associate Dean for Graduate Programs & Research & Professor
Physical Therapy and Athletic Training College of Nursing
College of Health Professions University of Massachusetts Dartmouth
Pacific University Dartmouth, Massachusetts;
Hillsboro, Oregon Professor Emeritus
William F Connell School of Nursing
Michael Bridges, DPT Boston College
Associate Professor Chestnut Hill, Massachusetts
School of Physical Therapy and Athletic Training
Pacific University Susan Rowen James, PhD, RN
Hillsboro, Oregon Professor Emeritus
School of Nursing
Kevin K. Chui, PT, DPT, PhD, GCS, OCS, CEEAA, FAAOMPT Curry College
Chair and Professor Milton, Massachusetts
Waldron College of Health and Human Services
Radford University Marni B. Kellogg, PhD, RN, CPN, CNE
Roanoke, Virginia Assistant Professor
Community Nursing
Donna M. Dello Iacono, NP, PhD, CNL University of Massachusetts Dartmouth
Senior Lecturer North Dartmouth, Massachusetts
Nursing
Curry College Debora Elizabeth Kirsch, RN, MS, CNS, CNE
Milton, Massachusetts; Clinical Assistant Professor Retired
Nurse Practitioner College of Nursing
Nursing/Anesthesia SUNY Upstate Medical University
Brigham and Women’s Hospital Syracuse, New York
Boston, Massachusetts
Carolyn Cable Kleman, PhD, MHA, RN
Miriam Ford, PhD, FNP-BC Assistant Professor
Chief Nurse Administrator School of Nursing
Nursing University of North Carolina Wilmington
Mercy College Wilmington, North Carolina
Dobbs Ferry, New York
Louise LaFramboise, PhD, RN
Cassandra Marie Godzik, PhD, RN, PMHNP-BC, CNE Associate Professor and Interim Assistant Dean
Assistant Professor College of Nursing
Graduate School of Nursing University of Nebraska Medical Center
Regis College Omaha, Nebraska
Weston, Massachusetts
Kimberly L. Malin, BA, MS, DHSc
Susan A. Heady, PhD, RN
Assistant Professor
Professor
School of Physical Therapy and Athletic Training
Nursing Department
Pacific University
Webster University
Hillsboro, Oregon
St. Louis, Missouri
Amber S. McIlwain, MS
Jeremy E. Hillard, DPT
Assistant Professor
Associate Professor, Director of Clinical Education
School of Healthcare Administration and Leadership
School of Physical Therapy and Athletic Training
College of Health Professions
College of Health Professions
Pacific University
Pacific University
Hillsboro, Oregon
Hillsboro, Oregon

iv
 CONTRIBUTORS v

Staci Nix McIntosh, MS, RD Yvonne M. Smith, PhD, APRN-CNS

Assistant Professor (Lecturer) Assistant Professor
Director of Teaching and Learning College of Nursing
Department of Nutrition and Integrative Physiology Kent State University
University of Utah Kent, Ohio
Salt Lake City, Utah
Jody A. Spiess, PhD, RN, GCPH
Susan Moscou, FNP, MPH, PhD Assistant Professor
Associate Professor Webster University
Nursing Program St. Louis, Missouri
Mercy College
Dobbs Ferry, New York Lynnette Leeseberg Stamler, PhD, DLitt, RN, FAAN
Professor and Associate Dean for Academic Programs
Susan Natale, PhD, RN, NEA-BC College of Nursing
Associate Professor University of Nebraska Medical Center
School of Nursing Omaha, Nebraska
Curry College
Milton, Massachusetts Frank Tudini, PT, DSc, OCS, FAAOMPT
Associate Professor
Karen Goyette Pounds, PhD, PMHCNS, BC Department of Physical Therapy
Clinical Associate Professor College of Health, Education and Professional Studies
College of Nursing and Health Sciences The University of Tennessee at Chattanooga
University of Massachusetts Dartmouth Chattanooga, Tennessee
New Bedford, Massachusetts;
Psychiatric Clinical Nurse Specialist Diane Marie Welsh, DNP, APRN, CNE
Department of Psychiatry Dean
Boston Medical Center Young School of Nursing
Boston, Massachusetts Associate Professor of Nursing
Regis College
Emily Quinn, PhD, CCC-SLP Weston, Massachusetts
Assistant Professor of Pediatrics
School of Medicine Stacy Wong, PT, DPT, PCS
Oregon Health & Science University Associate Director of Clinical Education and Assistant Professor
Portland, Oregon School of Physical Therapy and Athletic Training
College of Health Professions
Anne Rath Rentfro, PhD, MSN, BSN Pacific University
Professor (retired) Portland, Oregon
College of Nursing
The University of Texas Sheng-Che Yen, PhD
Brownsville, Texas Associate Clinical Professor
Department of Physical Therapy, Movement and
Susan Scott Ricci, APRN, MSN, MEd, CNE Rehabilitation Sciences
Nursing Faculty Northeastern University
College of Nursing Boston, Massachusetts
University of Central Florida
Orlando, Florida

Leslie Kennard Scott, PhD, APRN, PPCNP-BC, CDE, MLDE

Associate Professor
College of Nursing
University of Kentucky
Lexington, Kentucky
CE
R OVNITERWI B
EUR ST O R S

Jessica Barkimer, PhD, RN, CNE Arlene McGuane, RN, MSN-Ed

Assistant Professor Assistant Professor of Practice
School of Nursing Nursing
MSOE University Russell Sage College
Milwaukee, Wisconsin Troy, New York

Brenda A. Battle, RN, BSN, MBA Susan Natale, PhD, RN, NEA-BC
Vice President, Urban Health Initiative and Chief Diversity, Associate Professor
Inclusion and Equity Officer School of Nursing
Office of Community Affairs and Diversity, Inclusion Curry College
and Equity Milton, Massachusetts
University of Chicago Medicine
Chicago, Illinois Maria Pratt, PhD, MScN, BScN, BA, RN
Assistant Professor
Karin L. Ciance, RN, BSN, MSN, DNP School of Nursing
Assistant Professor of Nursing McMaster University
Nursing Hamilton, Ontario, Canada
Anna Maria College
Paxton, Massachusetts Carol Rossman, DNP, FNP-BC, PPCNP-BC
Professor
Janice A. Edelstein, EdD, MSN, RN, PHCNS-BC, ANEF School of Nursing
Associate Professor Andrews University
Nursing Berrien Springs, Michigan
Marian University of Fond du lac
Fond du Lac, Wisconsin Felisa Smith, RN, BSN, MSA, MSN/Ed, CNE
Accelerated BSN Program Coordinator
Lisa Jaurigue, PhD, RN, CNE Nursing and Allied Health
Clinical Assistant Professor Norfolk State University
Edson College of Nursing and Health Innovation Norfolk, Virginia
Arizona State University
Phoenix, Arizona

Wendy Manetti, PhD, FNP

Assistant Professor
Nursing
University of Scranton
Scranton, Pennsylvania

vi
 P R E FA C E

PURPOSE OF THE BOOK

The mission within this vision was improving health through
The case for promoting and protecting health, and preventing strengthening policy. Healthy People 2020 goals moved forward to:
disease and injury, was established by accomplishments in the • Identify nationwide health improvement priorities.
20th and 21st century. Americans and global populations want • Increase public awareness and understanding of the determi-
better care; public concerns about physical fitness, good nutri- nants of health, disease, and disability and the opportunities
tion, and avoidance of health hazards such as environmental for progress.
pollution have been adopted in the lifestyles of global citizens. • Provide measurable objectives and goals that can be used at
Encouraging positive health changes has been a major effort of the national, state, and local levels.
individuals; the local, state, and federal governments; health • Engage multiple sectors to take action that are driven by the
professionals; and society in general. In the United States, public best available evidence and knowledge.
and private attempts to improve the health status of individuals • Identify critical research and data collection needs.
and groups traditionally have focused on reducing communica- These overarching goals for Healthy People 2020 continued
ble diseases and health hazards. These include the delivery and the tradition of earlier Healthy People initiatives of advocating
best practices to improve access to and reduce costs of health for improvements in the health of every person in our country.
services and to improve the overall quality of life for all people. They addressed the environmental factors and placed particular
Americans increasingly recognized that the health of each per- emphasis on the determinants of health:
son is influenced by the health environments of all individuals • Eliminate preventable disease, disability, injury, and prema-
worldwide. ture death.
Throughout the history of the United States, the public health • Achieve health equity, eliminate disparities, and improve the
community has assessed the health of Americans. In 1789, the health of all groups.
Reverend Edward Wigglesworth developed the first American • Create social and physical environments that promote good
mortality tables through his study in New England. Population health for all.
statistics gathered in England and America, including those of • Promote healthy development and healthy behaviors across
Florence Nightingale, proved that scientific data could change every stage of life.
health outcomes. The Report of a General Plan for the Promotion As this edition was undergoing revision and in the midst of the
of Public and Personal Health was completed by Lemuel Shat- COVID-19 pandemic, new goals and objectives were proposed
tuck in 1880. Healthy People, The Surgeon General’s Report on and formed for the next decade in Healthy People 2030. Healthy
Health Promotion and Disease Prevention, was first published in People 2030 reduced the number of objectives to avoid overlap
1979, and was followed by Healthy People 2000, 2010, and 2020. and emphasize public health priorities. The vision statement for
The history of Healthy People is described comprehensively in Healthy People 2030 is “a society in which all people can achieve
Chapter 1. their full potential for health and well-being across the life span.”
Professionals who undertake health-promotion strategies • The major goals of Healthy People 2030 are:
need to understand the basics of health protection and disease • Attain healthy, thriving lives and well-being free of pre-
and injury prevention. Health protection is directed at popu- ventable disease, disability, injury, and premature death.
lation groups of all ages and involves adherence to standards, • Eliminate health disparities, achieve health equity, and
outcomes, infectious disease control, and governmental regu- attain health literacy to improve the health and well-being
lation and enforcement. These activities emphasize reducing of all.
exposure to various sources of hazards, including those related • Create social, physical, and economic environments that
to air, water, foods, drugs, motor vehicles, and other physical promote attaining the full potential for health and well-
agents. Health care providers present individuals, families, and being for all.
communities with disease- and injury-prevention services, • Promote healthy development, healthy behaviors, and
which include immunizations, screenings, health education, well-being across all life stages.
and counseling. To implement prevention strategies effectively, • Engage leadership, key constituents, and the public across
it is essential to develop activities targeted to and tailored for all multiple sectors to take action and design policies that
age groups in various settings including schools, industries, the improve the health and well-being of all.
home, the health care delivery system, the larger community, Healthy People 2030 objectives are matched with data from
and the world. earlier objectives of Healthy People so that objective data and
Healthy People 2020 reflected earlier assessments of major investigations may be compared across decades. Healthy People
risks to health, changing public health priorities, and emerging 2030 objectives are also arranged for easier search into major
issues related to national and global health preparedness and topic areas:
prevention. The following vision statement was established: A • Health conditions
society in which all people live long healthy lives. • Health behaviors
vii
viii PREFACE

• Populations needs as well as related implications for research and practice in

• Settings and systems the 21st century. Throughout the text, research abstracts have
• Social Determinants of Health been added to highlight the science of nursing practice and to
The databases within Healthy People continue to indicate demonstrate to the reader the relationship among evidence,
targets and assessments of health status and risk for evalua- practice, and outcomes.
tions and future planning, not only for health policymakers Throughout these units, the evolving health care profes-
and health care providers but also for individuals, families, and sions and the changing health care systems, including future
communities at the local, regional, national, and global levels. challenges and initiatives for health promotion, are described.
Emphasis is placed on the current concerns of reducing health
care costs while increasing life expectancy and improving the
APPROACH AND ORGANIZATION quality of life for all Americans. This promotes the reader’s
This edition presents health data with related theories and skills immediate interest in thoughts about the content of the chapters.
that are needed to understand and practice when providing care.
This book focuses on primary prevention intervention; its three Key Features
main components are (1) health promotion, (2) specific health • A full-color design, including color photos and enhanced
protection, and (3) prevention of specific diseases. Primor- graphics, is implemented throughout for better accessibility
dial prevention is an earlier piece of primary prevention, which of content and visual enhancement.
addresses policy interventions to decrease risky lifestyle behav- • Each chapter starts with a list of objectives to help focus the
iors. Health promotion is the intervention designed to improve reader and emphasize the content the reader should acquire
health, such as providing adequate nutrition, a healthy environ- through reading the book.
ment, and ongoing health education. Specific protection and pre- • Key Terms including quality and safety terms are listed at the
vention strategies, such as massive immunizations (for example, front to acquaint readers with the important terminology of
COVID-19–related), periodic examinations, and safety features in the chapter.
the workplace, are the interventions used to protect against illness. • Each chapter’s narrative begins with a Think About It sec-
In addition to primary prevention, this book discusses tion, the presentation of a clinical issue or scenario that
secondary prevention interventions, focusing specifically on relates to the topic of the chapter, followed by critical think-
screening and education. Such programs include blood pres- ing questions. This promotes the reader’s immediate interest
sure, cholesterol, and diabetes screening and referral (the in and thought about the chapter.
acute components of secondary prevention are generally not • Evidence-Based Practice boxes provide brief synopses on
addressed in this book). current health-promotion research studies that demonstrate
This text is presented in five parts, each forming the basis for the links between research, theory, and practice.
the next. • Health and Social Determinants/Health Equity boxes offer
Unit 1, Foundations for Health Promotion, describes the cultural perspectives on various aspects of health promotion.
foundational concepts of promoting and protecting health and • Quality and Safety boxes provide information regarding
preventing diseases and injuries, including diagnostic, thera- specific scenarios to improve health.
peutic, and ethical decision-making. • Genomics boxes explore current genetic issues, controver-
Unit 2, Assessment for Health Promotion, focuses on individ- sies, and dilemmas with respect to health promotion, provid-
uals, families, and communities and the factors affecting their ing an opportunity for critical analysis of care issues.
health. The functional health pattern assessments developed • Best Practice/Innovative Practice boxes highlight inventive
by Gordon serve as the organizing framework for assessing the and resourceful projects, programs, and research studies that
health of individuals, families, and communities. draw upon new ways of implementing health promotion.
Unit 3, Interventions for Health Promotion, discusses theo- • Healthy People 2030 boxes present a list of selected objec-
ries, methodologies, and case studies of nursing interventions, tives that are relevant to each chapter’s topic.
including screening, health-education counseling, stress man- • The Case Study highlights a realistic clinical situation rel-
agement, and crisis intervention. evant to the chapter topic.
Unit 4, Application of Health Promotion, also uses Gor- • Study Questions are located on the book’s website to offer
don’s functional health patterns, emphasizing developmental, additional review and self-study practice.
cultural, ethnic, and environmental variables in assessing the
developing person. The intent is to address the health concerns New Features
of all Americans regardless of gender, race, age, or sexual orien- 1. An increased focus on social determinants, health equity, in-
tation. Although most human development theories discussed clusion, and vulnerable populations
may be based on the research of male subjects, newer theories 2. Recommendations provided in updated sources and evi-
based on female subjects are included. The hope is to describe dence throughout the text
human development that more accurately reflects the complex- 3. An increased focus on genomics reflects increasing scientific
ity of human experiences throughout the life span. evidence supporting the health benefits of using genetic in-
Unit 5, Emerging Global Health Issues, presents a single chap- formation and family health history to guide public health
ter that discusses changing population groups and their health interventions
 PREFACE ix

4. Next-Generation NCLEX® (NGN) Examination–Style Case For Instructors

Studies for Health Promotion added to Evolve help guide in- • Next-Generation NCLEX® (NGN) Examination–Style Case
structors on the new question formats on the NCLEX® Studies for Health Promotion
5. The latest information on updates in The Patient Protection • TEACH for Nurses including Nursing Curriculum Stan-
and Affordable Care Act dards, Teaching Activities, and Case Studies
6. Expanded discussion of QSEN competencies related to health • Image Collection with all images from the book
promotion • Lecture Slides in PowerPoint
7. Updated photos and graphics bring a fresh look and feel to • Test Bank: 700 questions in NCLEX® examination format
the text The current trend to emphasize the developing health of peo-
ple mandates that health care professionals understand the many
Evolve Resources issues that surround individuals, families, national and world com-
The expanded website for this book provides materials for both munities in social, work, and family settings, including biological,
students and faculty and is accessible at http://evolve.elsevier inherited, cognitive, psychological, environmental, and sociocul-
.com/Edelman/. tural factors that can put their health at risk. Most important is that
they develop interventions to promote health by understanding
For Students the diverse roles these factors play in the person’s beliefs and health
Study Questions: Multiple choice NCLEX® examination format practices, particularly in the areas of disease and injury prevention,
protection, and health promotion. Achieving such effectiveness
requires collaboration with other health care providers and the
integration of practice and policy while developing interventions
and considering the ethical issues within individual, family, and
both national and world communities’ responsibilities for health.

Carole Lium Edelman

Elizabeth Connelly Kudzma
ACKNOWLED GMENTS

We had the good fortune of receiving much assistance and support from many friends, relatives,
and associates. Our colleagues read chapters, gave valuable advice and constructive suggestions,
helped clarify concepts, and provided case examples.
We also acknowledge the contributions of all the authors. In developing this text, they gave the
project their total commitment and support. Their professional competence aided greatly in the
development of the final draft of the manuscript. Elizabeth Kudzma and I worked and learned
from each other during the planning and development of this book; throughout the entire pro-
cess, close contact prevailed.
Many thanks to the Elsevier editorial and production team: Elizabeth McCormick, Rachel
McMullen, and Heather Bays-Petrovic. We appreciate and thank them for their ongoing help and
support. It was a true pleasure working with them.
I am fortunate to have faith in the Lord, who gives me courage and strength to face life’s dif-
ficulties in a positive manner. In particular, over the past year, for my ability to successfully avoid
getting COVID-19 and continue to successfully work on this 10th edition. My children, John and
Megan Gillespie, Tom and Heather Gillespie, and Deirdre O’Brien, and my grandchildren, Ryan,
Caroline, Meredith, and Colleen, continue to bring joy to me as a mother and grandmother. Their
patience and love continue. Fredric Edelman provides much encouragement and support. Both
my brother and sister-in-law, John and Marilyn Lium, are inspirational to me and a remind me
that every day in life is precious.
Carole Lium Edelman

The insights and clinical experiences of Curry College traditional, accelerated, and master’s stu-
dents have provided commentary and a source of rich experience on which to draw. My faculty
colleagues also have assisted me in identifying important innovations in digital processes, testing,
education, and practice. These chapter manuscripts were assembled during the COVID-19 pan-
demic; I thank all the contributors who set aside time to write and update chapters while manag-
ing remote teaching and the concerns of their students about the spread of the virus. I also thank
the world-wide teachers and educators who use the book and who request separate editions and
language translations. My sister, Mary Draper, my brother Mark Connelly, and my daughter Kath-
erine, keep me grounded and informed of political and economic changes. And, thanks go most
of all to my husband, Daniel, who has provided support, wise discussion, and insight throughout
the phases of this endeavor.
Elizabeth Connelly Kudzma

x
 CONTENTS

UNIT 1 Foundations for Health Promotion Arab Americans, 31

Health Care Issues of Arab Americans, 32
1 Health Defined: Health Promotion, Protection, and Selected Health-Related Cultural Aspects, 33
Prevention, 1 Asian Americans, 33
Carolyn Cable Kleman, Yvonne M. Smith Health Care Issues of Asian Americans, 34
Exploring Concepts of Health, 2 Selected Health-Related Cultural Aspects, 35
Models of Health, 3 Native Hawaiians and Other Pacific Islanders, 36
Wellness-Illness Continuum, 5 Native Hawaiians/Pacific Islander Health Issues, 37
Strategies to Address Health Disparities Among
High-Level Wellness, 5
Native Hawaiians/Pacific Islanders, 38
Health Ecology, 5
Latino/Hispanic Americans, 39
Functioning, 5
Health Issues of Latino/Hispanic Americans, 39
Health, 6
Selected Health-Related Cultural Aspects, 40
Illness, Disease, and Health, 6
Black/African Americans, 40
Planning for Health, 6
Health Issues of Black/African Americans, 40
Healthy People 2020/2030, 7
Selected Health-Related Cultural Aspects, 41
Goals, 7
American Indians/Alaska Natives, 42
Healthy People 2030, 9
Health Care Issues of American Indians/Alaska
Levels of Prevention, 10
Natives, 42
Primordial Prevention, 10
Selected Health-Related Cultural Aspects, 43
Primary Prevention, 10
Lesbian, Gay, Bisexual, and Transgender People, 43
Secondary Prevention, 13
LGBT Health Issues, 44
Tertiary Prevention, 14
Strategies to Reduce Health Disparities in LGBT
Quaternary Prevention, 14
Populations, 45
Levels of Prevention Strategies, 14
Homelessness: A Continuing Saga, 45
The Intersectionality of Public Health, Population
The Nation’s Response to the Health Challenge, 48
Health, and Health Promotion, 14
Nursing’s Response to Vulnerable Populations and
The Nurse’s Role, 14
Health, 50
Nursing Roles in Health Promotion and Protection, 15
3 Health Policy and the Delivery System, 59
Improving Prospects for Health, 16
Debora Elizabeth Kirsch
Population Effects, 16
The Health of the Nation, 62
Shifting Problems, 17
Healthy People 2030, 63
Moving Toward Solutions, 17
Health Indicators of a Nation, 64
Tying It All Together Using the Nursing Process, 18
Historical Role of Women in Health Promotion, 68
Problem Identification, 18
A Safer System, 68
Planning Interventions, 19
Global Health, 69
What Was the Actual Cause of Frank’s Problem?, 20
Historical Perspectives, 69
Evaluation of the Situation, 20
History of Health Care, 70
2 Vulnerable Populations and Health, 25
Early Influences, 70
Kimberly L. Malin, Amber S. Mcllwain, Frank Tudini, Sheng-Che Yen,
Industrial Influences, 70
Kevin K. Chui
Socioeconomic Influences, 70
Social Determinants of Health and Health Equity, 25
Public Health Influences, 70
Vulnerable Populations in the United States, 27
Scientific Influences, 71
Ethnicity, Ethnic Group, Minority Group, Race, and
Political and Economic Influences, 72
Racism, 28
Split Between Preventive and Curative Measures, 72
Culture, Values, and Value Orientation, 28
Organization of the Delivery System, 72
Cultural and Linguistic Competency, 28
Private Sector, 72
Immigrants/Refugees, 30
Move to Managed Care, 73
Health Issues of Immigrants/Refugees, 30
Public Sector, 77
Strategies to Reduce Health Disparities in
Financing Health Care, 83
Immigrant/Refugee Population, 30
Costs, 83
Folk Healing and Nursing Care Systems, 31
Sources, 84

xi
xii CONTENTS

Employer Health Benefits, 84 Ethics of Health Promotion: Cases, 141

Mechanisms, 86 Case 1: Addressing Health Care System Problems—
Managed Care Issues, 87 Elissa Needs Help, 141
Health Insurance, 88 Case 2: She’s My Client!—Lilly and “Jake”
Pharmaceutical Costs, 90 (a.k.a. Paul), 142
The Uninsured: Who Are They?, 91 Case 3: Don’t Touch My Things! Ms. Smyth and
Health Care Systems of Other Countries, 92 Autonomy, 142
Canadian Health Care System, 92
4 The Therapeutic Relationship, 96 UNIT 2 Assessment for Health Promotion
June Andrews Horowitz, Karen Goyette Pounds
Values Clarification, 97 6 Health Promotion and the Individual, 145
Definition, 97 Anne Rath Rentfro
Values and Therapeutic Use of Self, 98 Gordon’s Functional Health Patterns: Assessment of
The Communication Process, 99 the Individual, 148
Function and Process, 101 Functional Health Pattern Framework, 148
Types of Communication, 102 The Patterns, 151
Effectiveness of Communication, 103 Health Perception–Health Management Pattern, 152
Interprofessional Communication and Nutritional-Metabolic Pattern, 152
Teamwork, 105 Elimination Pattern, 154
Factors in Effective Communication, 105 Activity-Exercise Pattern, 155
Health Literacy, 107 Sleep-Rest Pattern, 157
The Helping or Therapeutic Relationship, 107 Cognitive-Perceptual Pattern, 157
Characteristics of the Therapeutic Relationship, 108 Self-Perception–Self-Concept Pattern, 159
Ethics in Communicating and Relating, 109 Roles-Relationships Pattern, 160
Therapeutic Techniques, 109 Sexuality-Reproductive Pattern, 160
Barriers to Effective Communication, 112 Coping–Stress Tolerance Pattern, 161
Setting, 114 Values-Beliefs Pattern, 162
Stages, 114 Individual Health Promotion Through the Nursing
5 Ethical Issues Related to Health Promotion, 121 Process, 163
Yvonne M. Smith, Carolyn Cable Kleman Collection and Analysis of Data, 163
Health Promotion as a Moral Endeavor, 122 Planning Care, 165
Health Care Ethics, 123 Implementation, 165
Origins of Applied Ethics in Moral Philosophy, 123 Evaluation, 165
Types of Normative Ethical Theories, 123 7 Health Promotion and the Family, 170
Limitations of Moral Theory, 124 Anne Rath Rentfro
Feminist Ethics and Caring, 127 The Nursing Process and the Family, 172
Professional Responsibility, 128 The Nurse’s Role, 173
Accountability to Individuals and Society, 128 Family Theories and Frameworks, 173
Codes of Ethics, 128 The Family from a Developmental Perspective, 173
Advocacy, 129 The Family from a Structural-Functional
Problem-Solving: Issues, Dilemmas, Moral Distress, Perspective, 175
and Moral Injury, 129 The Family from a Risk-Factor Perspective, 175
Preventive Ethics, 130 Gordon’s Functional Health Patterns: Assessment of
Ethical Principles in Health Promotion, 131 the Family, 178
Autonomy as Civil Liberty, 132 Health Perception–Health Management Pattern, 178
Autonomy as Self-Determination, 132 Nutritional-Metabolic Pattern, 179
Exceptions to Autonomous Decision-Making, 134 Activity-Exercise Pattern, 179
Confidentiality, 135 Sleep-Rest Pattern, 180
Veracity, 136 Cognitive-Perceptual Pattern, 180
Nonmaleficence, 137 Self-Perception–Self-Concept Pattern, 180
Beneficence, 138 Roles-Relationships Pattern, 181
Justice, 139 Sexuality-Reproductive Pattern, 186
Strategies for Ethical Decision-Making, 139 Coping–Stress Tolerance Pattern, 187
Locating the Source and Levels of Ethical Values-Beliefs Pattern, 187
Problems, 139 Environmental Factors, 188
Values Clarification and Reflection, 140 Nursing Analysis, 189
Use a Decision-Making Framework, 140 Analyzing Data, 189
 CONTENTS xiii

Planning With the Family, 194 Environment-Dependent Factors, 238

Goals, 195 National Guidance and Health Care Reform, 238
Implementation With the Family, 195 The Nurse’s Role, 241
Evaluation With the Family, 197 Racial and Ethnic Approaches to Community Health, 241
8 Health Promotion and the Community, 202 10 Health Education, 245
Anne Rath Rentfro Susan A. Heady, Jody A. Spiess
The Nurse’s Role, 206 Nursing and Health Education, 246
Influencing Health Policy, 206 Definition, 247
The Nursing Process and the Community, 208 Goals, 247
Methods of Data Collection, 209 Learning Assumptions, 250
Sources of Community Information, 211 Family Health Teaching, 250
Community from a Systems Perspective, 211 Health Behavior Change, 250
Structure, 211 Ethics, 251
Function, 212 Genomics and Health Education, 252
Interaction, 213 Diversity and Health Teaching, 252
Community from a Developmental Perspective, 213 Community and Group Health Education, 253
Community from a Risk-Factor Perspective, 213 Teaching Plan, 254
Gordon’s Functional Health Patterns: Assessment of Determining Expected Learning Outcomes, 254
the Community, 214 Selecting Content, 255
Health Perception–Health Management Pattern, 214 Designing Learning Strategies, 256
Nutritional-Metabolic Pattern, 214 Evaluating the Teaching-Learning Process, 257
Elimination Pattern, 215 Referring Individuals to Other Resources, 257
Activity-Exercise Pattern, 215 Teaching and Organizing Skills, 258
Sleep-Rest Pattern, 215 11 Nutrition Counseling for Health Promotion, 261
Cognitive-Perceptual Pattern, 216 Staci Nix McIntosh
Self-Perception–Self-Concept Pattern, 216 Nutrition in the United States, 262
Roles-Relationships Pattern, 216 Classic Vitamin-Deficiency Diseases, 262
Sexuality-Reproductive Pattern, 216 Nutrition-Related Health Status, 262
Coping–Stress Tolerance Pattern, 216 Dietary Inadequacy, 263
Values-Beliefs Pattern, 217 Dietary Excesses, 263
Analysis With the Community, 217 Food and Nutrition Recommendations, 264
Organization of Data, 217 Healthy People Initiative: Nutrition Objectives, 264
Guidelines for Data Analysis, 217 Dietary Guidelines for Americans, 265
Community Analysis, 219 MyPlate Guidelines, 266
Planning With the Community, 220 Dietary Reference Intakes, 266
Purposes, 220 Dietary Supplements and Herbal Medicines, 268
Planned Change, 221 Micronutrient Toxicity, 269
Implementation With the Community, 221 Circumstances When Nutrient Supplementation Is
Evaluation With the Community, 222 Indicated, 271
Food Safety, 271
Food-Borne Illness, 271
UNIT 3 Interventions for Health Promotion Common Food-Borne Pathogens, 272
Food Safety Practices, 272
9 Screening and Health Promotion, 226
Food, Nutrition, and Poverty, 273
Elizabeth Connelly Kudzma
Poverty and Income Distribution, 273
Advantages and Disadvantages of Screening, 228
Food Assistance for Low-Income Individuals, 273
Advantages, 228
Nutrition Screening, 276
Disadvantages, 229
Nutrition-Related Chronic Disease, 277
Selection of a Screened Disease, 229
Cardiovascular Disease, 277
Significance of the Disease for Screening, 229
Nutrition Intervention for Atherosclerosis, 277
Detection, 231
Epidemiology, 279
Should Screening for the Disease Be Done?, 234
Nutrition Intervention for Hypertension, 280
Ethical Considerations, 235
Dietary Approaches to Stop Hypertension, 280
Borderline Cases and Cutoff Points, 235
Cancer, 280
Economic Costs and Ethics, 235
Osteoporosis, 282
Selection of Screenable Populations, 236
Calcium, 282
Person-Dependent Factors, 236
Vitamin D, 283
xiv CONTENTS

Obesity, 283 Assertive Communication, 345

Diabetes Mellitus, 284 Empathy, 346
Human Immunodeficiency Virus and Acquired Healthy Pleasures, 347
Immunodeficiency Syndrome, 287 Spiritual Practice, 347
12 Physical Activity, 293 Clarifying Values and Beliefs, 347
Frank Tudini, Kevin K. Chui, Michael Bridges, Jeremy E. Hilliard, Setting Realistic Goals, 348
Sheng-Che Yen Humor, 349
Defining Physical Activity in Health, 293 Engaging in Pleasurable Activities, 349
Healthy People 2020 and 2030 Objectives, 294 Effective Coping, 349
Physical Activity Objectives: Making Progress, 294 14 Complementary, Integrative, and Alternative
Aging, 296 Strategies, 354
Effects of Exercise on the Aging Process, 297 Donna M. Dello Iacono
Cardiac Risk Factors, 298 Background, 355
High-Density Lipoprotein and Serum Some Known Facts, 355
Triglyceride Levels, 298 What Is the Difference Between Holism and
Hypertension, 298 Allopathy?, 355
Hyperinsulinemia and Glucose Intolerance, 300 Person-Centered Care, 356
Obesity, 301 Health and Wellness, 357
Osteoporosis, 302 Health Policy, 357
Arthritis, 303 Interventions, 360
Low Back Pain, 306 Whole Medical Systems, 360
Immune Function, 307 Biologically Based Practices/Natural Products, 361
Mental Health, 308 Manipulative and Body-Based Practices, 361
Exercise Prescription, 309 Mind-Body Medicine, 362
Aerobic Exercise, 310 Energy Therapies, 363
Warm-Up and Cool-Down Periods, 311 Nursing Presence, 365
Flexibility, 312 Safety and Effectiveness, 366
Resistance Training, 312
Exercise the Spirit: Relaxation Response, 312
Monitoring the Inner and the Outer Environment, 313 UNIT 4 Application of Health Promotion
Hydration, 314
Special Considerations, 314 15 Overview of Growth and Development Framework, 370
Coronary Heart Disease, 314 Elizabeth Connelly Kudzma
Diabetes, 315 Overview of Growth and Development, 371
Building a Rhythm of Physical Activity, 316 Growth, 371
Adherence and Compliance, 316 Concept of Development, 379
Creating a Climate That Supports Exercise, 318 Theories of Life Span Development, 380
13 Stress Management, 330 Psychosocial Development: Erikson’s Theory, 381
June Andrews Horowitz, Marni B. Kellogg Cognitive Development, 381
Sources of Stress, 331 Cognitive Development: Piaget’s Theory, 381
Physical, Psychological, Sociobehavioral, and Cognitive Development: Vygotsky’s Theory, 382
Spiritual/Homeodynamic Consequences of Moral Development: Kohlberg’s Theory, 383
Stress, 333 Moral Development: Gilligan’s Theory, 383
Physiological Effects of Stress, 333 Behavioral Biological Development, 384
Psychological Effects of Stress, 334 16 The Childbearing Period, 387
Sociobehavioral Effects of Stress, 335 Susan Scott Ricci
Spiritual Effects of Stress, 335 Biology and Genetics, 388
Health Benefits of Managing Stress, 335 Duration of Pregnancy, 388
Assessment of Stress, 336 Fertilization, 388
Stress-Management Interventions, 337 Implantation, 388
Developing Self-Awareness, 338 Fetal Growth and Development, 388
Nutrition: Healthy Diet, 342 Placental Development and Function, 389
Physical Activity, 342 Maternal Changes, 389
Cognitive-Behavioral Restructuring, 343 Changes During Transition From Fetus to
Affirmations, 345 Newborn, 397
Social Support, 345 Nursing Interventions, 397
 CONTENTS xv

Apgar Score, 397 Health Services/Delivery System, 465

Sex, 398 Nursing Application, 465
Race and Culture, 398 18 Toddler, 471
Genetics, 399 Diane Marie Welsh, Cassandra Marie Godzik
Gordon’s Functional Health Patterns, 399 Biology and Genetics, 472
Health Perception–Health Management Pattern, 399 Gordon’s Functional Health Patterns, 474
Nutritional-Metabolic Pattern, 400 Health Perception–Health Management
Elimination Pattern, 403 Pattern, 474
Activity-Exercise Pattern, 403 Nutritional-Metabolic Pattern, 474
Sleep-Rest Pattern, 404 Elimination Pattern, 476
Cognitive-Perceptual Pattern, 405 Activity-Exercise Pattern, 477
Self-Perception–Self-Concept Pattern, 407 Sleep-Rest Pattern, 477
Roles-Relationships Pattern, 407 Cognitive-Perceptual Pattern, 478
Sexuality-Reproductive Pattern, 409 Self-Perception–Self-Concept Pattern, 481
Coping–Stress Tolerance Pattern, 410 Nursing Interventions for Self-Perception/Self-
Values-Beliefs Pattern, 410 Concept Pattern, 481
Environmental Processes, 411 Roles-Relationship Pattern, 482
Physical Agents, 411 Sexuality-Reproductive Pattern, 483
Biologic Agents, 411 Coping–Effective/Ineffective Stress
Chemical Agents, 416 Tolerance Pattern, 483
Mechanical Forces, 419 Values-Beliefs Pattern, 484
Radiation, 420 Environmental Processes, 484
Determinants of Health, 420 Physical Agents, 484
Social Factors and Environment, 420 Biological Agents, 486
Levels of Policy Making and Health, 421 Chemical Agents, 486
Health Services/Delivery System, 423 Levels of Policy Making and Health, 488
Nursing Application, 423 Health Services/Delivery System, 488
17 Infant, 429 Nursing Application, 489
Susan Scott Ricci 19 Preschool Child, 492
Biology and Genetics, 430 Erin Bompiani, Stacy Wong, Emily Quinn, Kevin K. Chui
Developmental Tasks, 430 Biology and Genetics, 494
Concepts of Infant Development, 433 Gender, 496
Sex, 435 Race, 496
Race, 435 Genetics, 496
Genetics, 436 Gordon’s Functional Health Patterns, 496
Gordon’s Functional Health Patterns, 437 Health Perception–Health Management
Health Perception–Health Management Pattern, 437 Pattern, 496
Nutritional-Metabolic Pattern, 437 Nutritional-Metabolic Pattern, 497
Elimination Pattern, 442 Elimination Pattern, 498
Activity-Exercise Pattern, 443 Activity-Exercise Pattern, 499
Sleep-Rest Pattern, 444 Sleep-Rest Pattern, 500
Cognitive-Perceptual Pattern, 446 Cognitive-Perceptual Pattern, 502
Self-Perception–Self-Concept Pattern, 448 Self-Perception–Self-Concept Pattern, 508
Roles–Relationships Pattern, 448 Roles-Relationships Pattern, 509
Sexuality–Reproductive Pattern, 450 Sexuality-Reproductive Pattern, 510
Coping–Stress Tolerance Pattern, 450 Coping–Stress Tolerance Pattern, 510
Values–Beliefs Pattern, 451 Values-Beliefs Pattern, 512
Environmental Processes, 452 Environmental Processes, 512
Physical Agents, 452 Physical Agents, 512
Biological Agents, 454 Biological Agents, 515
Chemical Agents, 456 Chemical Agents, 516
Motor Vehicles, 459 Determinants of Health, 519
Radiation, 460 Social Factors and Environment, 519
Determinants of Health, 460 Levels of Policy Making and Health, 520
Social Factors and Environment, 460 Health Services/Delivery System, 521
Levels of Policy Making and Health, 464 Nursing Application, 521
xvi CONTENTS

20 School-Age Child, 528 22 Young Adult, 588

Leslie Kennard Scott Susan Natale
Biology and Genetics, 529 Biology and Genomics, 589
Elevated Blood Pressure, 529 Gordon’s Functional Health Patterns, 590
Physical Growth, 530 Health Perception–Health Management
Gordon’s Functional Health Patterns, 531 Pattern, 590
Health Perception–Health Management Nutritional-Metabolic Pattern, 595
Pattern, 531 Elimination Pattern, 596
Nutritional-Metabolic Pattern, 533 Activity-Exercise Pattern, 597
Elimination Pattern, 535 Sleep-Rest Pattern, 598
Activity-Exercise Pattern, 536 Cognitive-Perceptual Pattern, 598
Sleep-Rest Pattern, 536 Self-Perception–Self-Concept Pattern, 599
Cognitive-Perceptual Pattern, 537 Roles-Relationships Pattern, 600
Self-Perception–Self-Concept Pattern, 541 Sexuality-Reproductive Pattern, 602
Roles-Relationships Pattern, 542 Coping–Stress Tolerance Pattern, 606
Sexuality-Reproductive Pattern, 544 Values-Beliefs Pattern, 607
Coping–Stress Tolerance Pattern, 544 Environmental Processes, 608
Values-Beliefs Pattern, 546 Physical Agents, 608
Environmental Processes, 546 Biological Agents, 609
Physical Agents, 546 Chemical Agents, 609
Accidents, 546 Determinants of Health, 611
Biological Agents, 549 Social Factors and Environment, 611
Chemical Agents, 550 Levels of Policy Making and Health, 611
Cancer, 551 Health Services/Delivery System, 611
Determinants of Health, 552 Nursing Application, 612
Social Factors and Environment, 552 23 Middle-Age Adult, 619
Levels of Policy Making and Health, 554 Susan Moscou, Miriam Ford
Health Services/Delivery System, 555 Biology and Genetics, 620
Nursing Application, 556 Life Expectancy and Mortality Rates, 621
21 Adolescent, 562 Gender and Relationship Status, 623
Susan Rowen James Social Determinants of Health, 623
Biology and Genetics, 563 Genetics, 623
Sex and Puberty, 563 Gordon’s Functional Health Patterns, 623
Gordon’s Functional Health Patterns, 566 Health Perception–Health Management
Health Perception–Health Management Pattern, 623
Pattern, 566 Habits, 623
Nutritional-Metabolic Pattern, 568 Health Indicators, 624
Elimination Pattern, 569 Nutritional-Metabolic Pattern, 624
Activity-Exercise Pattern, 569 Oral Health, 626
Sleep-Rest Pattern, 570 Elimination Pattern, 627
Cognitive-Perceptual Pattern, 570 Activity-Exercise Pattern, 627
Self-Perception–Self-Concept Pattern, 571 Sleep-Rest Pattern, 628
Roles-Relationships Pattern, 572 Cognitive-Perceptual Pattern, 628
Sexuality-Reproductive Pattern, 573 Skill Acquisition, 628
Coping–Stress Tolerance Pattern, 575 Perceptual Changes, 629
Values-Beliefs Pattern, 577 Self-Perception–Self-Concept Pattern, 630
Environmental Processes, 577 Roles-Relationships Pattern, 631
Physical Agents, 577 Caring for Aging Parents, 633
Biological Agents, 579 Divorce and Separation, 634
Chemical Agents, 581 Death, 634
Determinants of Health, 582 Sexuality-Reproductive Pattern, 634
Social Factors and Environment, 582 Coping–Stress Tolerance Pattern, 636
Levels of Policy Making and Health, 583 Stress and Heart Disease, 636
Health Services/Delivery System, 583 Values-Beliefs Pattern, 637
Nursing Application, 584 Environmental Processes, 637
 CONTENTS xvii

Physical Agents, 637 Environmental Processes, 665

Biological Agents, 638 Physical Agents, 665
Chemical Agents, 638 Biologic Agents, 668
Tobacco, 638 Chemical Agents, 669
Determinants of Health, 638 Social Determinants of Health, 670
Social Factors and Environment, 638 Social Factors and Environment, 670
Nursing Application, 640 Levels of Policy Making and Health, 674
24 Older Adult, 647 Health Services/Delivery Systems, 675
Miriam Ford, Susan Moscou Nursing Application, 675
Poverty, 648
Healthy People 2020 and Healthy People 2030, 649 UNIT 5 Emerging Global Health Issues
Biology and Genetics, 650
Theories of Aging, 651 25 Health Promotion for the 21st Century: Throughout the Life
Gordon’s Functional Health Patterns, 652 Span and Throughout the World, 680
Health Perception–Health Management Lynnette Leeseberg Stamler, Louise LaFramboise
Pattern, 652 Introduction, 681
Nutritional-Metabolic Pattern, 653 Air Pollution and Climate Change, 683
Elimination Pattern, 655 Noncommunicable Diseases, 685
Activity-Exercise Pattern, 656 Communicable Diseases, 686
Sleep-Rest Pattern, 657 COVID-19 Pandemic, 686
Cognitive-Perceptual Pattern, 658 Fragile and Vulnerable Settings, 688
Self-Perception–Self-Concept Pattern, 661 Antimicrobial Resistance, 689
Roles-Relationships Pattern, 662 Vaccine Hesitancy, 690
Sexuality-Reproductive Pattern, 663 Weak Primary Care and Poor Access, 691
Coping–Stress Tolerance Pattern, 664
Values-Beliefs Pattern, 665
UNIT 1 Foundations for Health Promotion

1
Health Defined: Health Promotion,
Protection, and Prevention
Carolyn Cable Kleman, Yvonne M. Smith

http://evolve.elsevier.com/Edelman/

OBJECTIVES
After completing this chapter, the reader will be able to: • Differentiate between health, illness, disease, disability, and
• Analyze concepts and models of health as used historically premature death.
and as used in this textbook. • Compare the four levels of prevention (primordial,
• Evaluate the consistency of Healthy People 2020/2030 goals primary, secondary, and tertiary) with the levels of service
with various concepts of health. provision available across the life span.
• Analyze the progress made in this nation from the original • Critique the role of research and evidence as well as the nurse's
Healthy People document to the foci in Healthy People role in health education and research for the promotion and
2020. protection of health for individuals and populations.

KEY TERMS
Adaptive model of health Eudaimonistic model of health Person-centered care
Applied research Evidence-based practice Qualitative studies
Asset planning Functional health Quality of life
Clinical model of health Health Quantitative studies
Community-based care Health disparities Role performance model of health
Cultural competence Health in all Policies Social determinants of health
Disease Health promotion Social ecological model of health
Ecological model of health Health-related quality of life (HRQoL) Specific protection
Empathy High-level wellness Well-being
Epidemiology Illness Wellness
Ethnocentrism Interprofessional practice Wellness-illness continuum
Eudaimonistic Levels of prevention

THINK ABOUT IT
Use of Complementary and Alternative Therapies
One of the biggest challenges to health care providers is the blending of Western • What information should you know about the benefits or limitations of using
medicine and health practices with the health practices from other cultures and complementary therapies, such as acupuncture, spiritual healing, herbal rem-
ethnic groups. The federal government formed the National Center for Comple- edies, or chiropractic?
mentary and Alternative Medicine (NCCAM; http://nccam.nih.gov) to conduct • What resources should you trust for information on the efficacy and use of
and support basic and applied research and training and to disseminate informa- herbal remedies relative to prescription medications?
tion on complementary and alternative medicine to practitioners and the public. • Which ideas of health would be most compatible with the use of alternative
As demographics of the United States shift, more people use a combination of therapies?
therapies in self-care and for the treatment of specific illnesses. • How can alternative therapies be integrated into the newer Healthy People
• What questions should you ask to obtain information from people about their 2030 objectives?
use of nontraditional therapies?

1
2 UNIT 1 Foundations for Health Promotion

Health is a core concept in society. This concept is modified extent of Rogers (1970) and Reed (1983); Murdaugh and col-
with qualifiers such as excellent, good, fair, or poor, on the basis leagues (2019) and Allen and Warner (2002) state that health
of a variety of factors. These factors may include age, sex, race is an outcome of ongoing patterns of person and environment
or ethnic heritage, comparison group, current health or physical interactions throughout the life span. Research within this
condition, past conditions, social or economic situation, geo- paradigm seeks to address the dynamic whole of the health
graphical location, or the demands of various roles in society. experience through behavioral and social mechanisms over
In addition, there is growing evidence that larger societal and time. Health can be better understood if each person is seen
environmental concerns determine health outcomes. This chap- as a part of a complex, interconnected biologic and social
ter will discuss health as a concept and related concepts such system. Research based on this paradigm conforms primar-
as wellness, illness, disease, disability, and functioning. These ily to constructivist scientific methods that seek to describe
concepts are frequently embedded in theories, such as theories and understand health experiences in more depth (Orchard &
of health behavior or health planning (Gehlert & Ward, 2019). Mahler, 2018).
Some motivating factors behind the move to disease preven- The social ecological model of health (Bronfenbrenner,
tion and health promotion in society will be examined with 1977; Shelton, 2019) is a comprehensive developmental
an introduction to Healthy People, the federal government’s approach and is useful for promoting health at individual,
health objectives for the nation. The implementation of these family, community, and societal levels (Fig. 1.1). This model
concepts as nursing actions will also be addressed from ideal emphasizes the social determinants of health—those factors
and pragmatic standpoints. Research and evidence supporting in society that have an influence on health and the options
these concepts, and recommendations for further research, will available to people to improve or maintain their health, and
be presented. how they impact people at all environmental levels from indi-
Nurses understand the pivotal role they play in promot- vidual to the policy level. In this way, the ecological model of
ing health and preventing disease, the important role of health is more compatible with Smith’s descriptions of health
research in the knowledge of what is “healthy,” and the cen- as adaptation and eudemonia (self-actualization). The social
tral role of epidemiology (the study of health and disease in determinants of health also form the basis for Healthy People
society) and public health theories in the everyday practice 2020 and the newer 2030 Healthy People objectives (US Depart-
of nursing. ment of Health and Human Services, Office of Disease Preven-
tion and Health Promotion, 2020). Each of these ideas will be
examined in more detail throughout this chapter.
EXPLORING CONCEPTS OF HEALTH People involved in health promotion must consider the
Definitions of health in the nursing literature can be classi- meaning of health for themselves and for others. Recogniz-
fied broadly within two major paradigms. The first paradigm ing differences in the meaning of health can clarify outcomes
is the wellness-illness continuum, a dichotomized portrayal and expectations in health promotion and enhance the qual-
of health and illness ranging from high-level wellness at the ity of health care (Svalastog, Donev, Kristoffersen, & Gafovic,
positive end to depletion of health at the negative end. High- 2017). Because health is used to describe a number of entities,
level wellness is further conceptualized as a sense of well- including a philosophy of care (health promotion and health
being, life satisfaction, and quality of life. Movement toward maintenance), a system (health care delivery system), practices
the negative end of the continuum includes adaptation to dis- (evidence-based health practices), behaviors (personal health
ease and disability through various levels of functional ability behaviors), costs (health care costs), and insurance (uninsured
(Newman, 2003; Travis & Ryan, 2004; de Hond, Bakx, & Ver- health care), the reason that confusion continues regarding the
steegh, 2019). The wellness-illness conceptualization was the use of the term “health” becomes clear. People’s use of the term
focus of early research and is consistent with some of the cat- “health” and its incorporation into these various entities have
egories Smith (1983) identified in her philosophical analysis of also changed over time.
health. Research based on this paradigm conforms primarily Americans born before 1940 experienced the greatest
to scientific methods that seek to control contextual effects, changes in how health is defined. Because infectious diseases
provide the basis for causal explanations, and predict future claimed the lives of many children and young adults at that
outcomes (Hardin & Kaplow, 2017). time, health was viewed as the absence of disease. The physi-
The second paradigm characterizes health as a perspec- cian in independent practice was the primary provider of health
tive developmental phenomenon of unitary patterning of the care services, with services provided in the private office. The
person-environment. The developmental perspective of health federal government was only beginning to establish its role in
has been present in the nursing literature since 1970, but it was working with states to address public health and welfare issues
not identified clearly with health until the late 1970s and early (Barr et al., 2003).
1980s. It has been conceptualized as expanding conscious- As the national economy expanded during and after World
ness, pattern or meaning recognition, personal transformation, War II in the 1940s and 1950s, the idea of role performance
and, tentatively, self-actualization. This shift toward a develop- became a focus in industrial research and entered the health
mental perspective has had clear implications for the way in care lexicon. Health became linked to a person’s ability to fulfill
which health is conceptualized (Newman, 2003; Endo, 2017). a role in society. Increasingly, the physician was asked to com-
Although not endorsing the developmental perspective to the plete physical examination forms for school, work, military, and
 CHAPTER 1 Health Defined: Health Promotion, Protection, and Prevention 3

FIG. 1.1 Social Ecological Model. (Adapted from Bronfenbrenner, U. [1977]. Toward an experi-
mental ecology of human development. America Psychologist, 32[7], 513–531.)

insurance purposes, while physician practice became linked USDHHS, Office of Disease Prevention and Health Promo-
more directly to hospital-based services. The federal govern- tion, 2020). Multiple tools are available for measuring quality
ment expanded its role through funding for hospital expansion of life, including a general measure established by the World
and establishment of the new Department of Health, Education, Health Organization (WHO, 2004) (World Health Organiza-
and Welfare, currently the Department of Health and Human tion Quality of Life, WHOQOL-BREF) and the Revised McGill
Services (Barr et al., 2003). It was recognized that a person Quality of Life Questionnaire (Cohen et al., 2017) for use at the
might recover from a disease yet be unable to fulfill family or end of life (Box 1.1: Quality and Safety Scenario). There is also
work roles because of residual changes from the illness episode. an acknowledgment of the importance of resiliency as a factor
Concepts of disability and rehabilitation entered the health care that contributes to health. Resilience is one’s ability to deal with
arena. The work or school environment was viewed as a possible stressful or traumatic life events. The Resilience Scale has been
contributor to health, illness, disability, and death. used to quantitatively measure resilience in many populations
From the 1960s to the present, there have been incredible (The original Resilience Scale, 2020).
changes in the health care delivery system while federal and
state governments attempted to control spending and health Models of Health
care costs escalated (Barr et al., 2003; Badash et al., 2017). Throughout history, society has entertained a variety of con-
Primary care providers, including nurse practitioners and other ceptual models of health. Smith (1983) describes four distinct
advanced practice nurses, now attempt to involve individuals models in her classic work.
and their families in the delivery of person-centered care, and
teaching individuals about individual responsibilities and life- Clinical Model
style choices has become an important part of their job. Health In the clinical model, health is defined by the absence of signs
care became an interdisciplinary endeavor even while managed and symptoms of disease and illness is defined by the presence
care companies limited the health-promotion options available of signs and symptoms of disease. People who use this model
under insurance plans. During this time the idea of adaptation may not seek preventive health services or they may wait until
had an important influence on the way Americans view health. they are very ill to seek care. The clinical model is the conven-
Increasingly, health became linked to individuals’ reactions to tional model of the discipline of medicine.
the environment rather than being viewed as a fixed state. Adap-
tation fit well with the self-help movement during the 1970s and Role Performance Model
with the progressive growth in knowledge from research of dis- The role performance model of health defines health in terms
ease prevention and health promotion at the individual level. of individuals’ ability to perform social roles. Role performance
Emphasis is being placed on the quality of a person’s life includes work, family, and social roles, with performance based
as a component of health (USDHHS, Public Health Service, on societal expectations. Illness would be the failure to perform
2020; USDHHS, Office of Disease Prevention and Health Pro- roles at the level of others in society. This model is the basis for
motion, 2020). Research on self-rated health and self-rated occupational health evaluations, school physical examinations,
function (Bombak, 2013; Gyasi & Phillips, 2018) indicates and physician-excused absences. The idea of the “sick role,”
that there are multiple factors contributing to a person’s per- which excuses people from performing their social functions,
ception of his or her health, sometimes referred to as func- is a vital component of the role performance model. It is argued
tional health (Gordon, 2020) or health-related quality of that the sick role is still relevant in health care nowadays (Davis
life (HRQoL) (Andresen et al., 2003; Karimi & Brazier, 2016; et al., 2011; Burnham, 2012).
4 UNIT 1 Foundations for Health Promotion

BOX 1.1 QUALITY AND SAFETY SCENARIO

Fall Prevention in the Home
Falls in the home are a common yet preventable source of both fatal and nonfatal need for supports such as grab bars and railings. Again, watching the person
injuries. In 1 year, 2016, falls resulted in more than 29,000 deaths and 3.2 million navigate through the home is helpful in recognizing potential trip hazards and
emergency department visits. In the year 2030 the number of estimated falls areas where additional supports are needed. Adequate hydration is another
will be 49 million, with 12 million fall injuries. The Stopping Elderly Accidents, consideration, especially if the person is taking medications that contribute to
Deaths & Injuries Program by the Centers for Disease and Prevention is a pro- dehydration without regular fluid replacement or if the temperature of the home
gram that addresses coordination of fall prevention activities in primary care and and environment is too high.
implementation of fall prevention programs (www.cdc.gov/homeandrecreation- Health outcomes for the person can be significant. Falls can cause minor
alsafety/falls/index.html). injury and embarrassment, but they can also cause life-threatening injuries such
There are specific factors that contribute to fall risk, including changes to the as fractures and head injuries. If a fall has occurred, it is helpful to do a root
person attributable to age, medication use, and environmental hazards. Nurses cause analysis to determine those factors that contributed to the fall. Ask per-
are in key roles to work with older adults to assess fall risks and help them to mission before attempting to make any alteration to the home, because items
gain control over this aspect of their health. The National Center for Injury Pre- and their placement may have sentimental importance to the person. Address
vention and Control at the Centers for Disease Control and Prevention provides medication changes with the person, pharmacist, and/or primary care provider.
guidelines for fall prevention in older adults at https://www.cdc.gov/homean- Some medication habits may be hard for the person to change.
drecreationalsafety/falls/index.html. The nursing implications of fall risk are many and varied. Assessment skills
Risk factors attributable to the aging process include visual, hearing, and must be practiced in a variety of settings so that the nurse is vigilant for potential
functional limitations. Although pets have proven to be a benefit for older adults hazards and individual factors that might precipitate a fall. Older adults should
by providing companionship and comfort, they can also scamper underfoot or be routinely observed performing their daily routines to identify visual, hearing,
the older adult may trip over the pet because the pet is not seen or heard. Loss and functional decline. In addition, if a person reports a fall, that report should
of night vision and depth perception can also contribute to falls when lighting trigger a more extensive evaluation of that individual because falls may be indic-
is poor or when a person is moving from room to room. Older adults should be ative of future fall risk.
encouraged to always wear prescribed vision and hearing aids when moving Falls are a frequent but preventable occurrence, especially for older adults.
about the house or apartment. Loss of upper and lower body strength can also Falls also contribute millions of dollars each year to the cost of health care as a
contribute to fall risk. Lower body strength is needed to lift the legs and feet high result of personal injury and disability. That is why fall prevention is a key feature
enough to navigate stairs and changes in texture of flooring. Upper body strength of quality and safety education for nurses.
allows the use of supports when a person is moving about. Watch the person
maneuver about the living space, and note the use of furniture, walls, and other Questions
objects for support. • Can you identify at least four items in your own environment that may contrib-
Medications can contribute to disequilibrium. A careful review of currently ute to your fall risk?
used medications, both prescribed and over-the-counter medications, can help • How would you structure an interview with an older adult to determine the
identify medications that could possibly contribute to fall risks. Environmental presence of fall risks in that person’s home?
risks include clutter, too much furniture for the room, placement of items in typi- • What evidence and arguments would you use to encourage an older adult to
cal walkways, lighting problems, needed repairs to flooring and walls, and the modify the home environment to decrease the risk of a fall?

From Johnston, Y. A., Bergen, G., Bauer, M., Parker, E. M., Wentworth, L., McFadden, M., et al. (2019). Implementation of the stopping elderly accidents, deaths, and in-
juries initiative in primary care: An outcome evaluation. The Gerontologist, 59(6), 1182–1191. Centers for Disease Control and Prevention, Home and Recreational Safety,
Older Adult Falls. Retrieved from https://www.cdc.gov/homeandrecreationalsafety/falls/index.html.

Adaptive Model aspects of the eudaimonistic model predate the clinical model
In the adaptive model of health, people’s ability to adjust posi- of health. This model is also more congruent with integrative
tively to social, mental, and physiologic change is the measure modes of therapy (National Institutes of Health, National Cen-
of their health. Illness occurs when the person fails to adapt ter for Complementary and Alternative Medicine, 2019), which
or becomes maladaptive to these changes. As the concept of are used increasingly by people of all ages in the United States
adaptation has entered other aspects of American culture, this and the rest of the world. In this eudaimonistic model, people
model of health has become more accepted. For example, par- dying of cancer may still consider themselves healthy if they are
ticipating in goal-directed activities can be useful in adapting finding meaning in life.
to a decreased level of functioning in older adults (Carpentieri, These ideas of health provide a basis for how people view health
Elliott, Bret, & Deary, 2017). and disease and how they view the roles of nurses, physicians, and
other health care providers. For example, in the clinical model
Eudaimonistic Model of health, a person may expect to see a health care provider only
In the eudaimonistic model, exuberant well-being indicates when there are obvious signs of illness. Personal responsibility for
optimal health. This model emphasizes the interactions between health may not be a motivating factor for this individual because
physical, social, psychological, and spiritual aspects of life and the provider is responsible for dealing with the health problem
the environment that contribute to goal attainment and create and returning the person to health. Therefore attempts to teach
meaning. Illness is reflected by a denervation or languishing, a health-promoting activities may not be effective with this person.
lack of involvement with life. Although these ideas may appear On the other hand, those who adopt a eudaimonistic model of
to be new when compared with the clinical model of health, health may find that practitioners working under a clinical model
 CHAPTER 1 Health Defined: Health Promotion, Protection, and Prevention 5

do not address their more comprehensive health needs. They favorability of the person’s environment for health and wellness
may instead seek out a practitioner of alternative medicine or the (see Fig. 1.2). Adding this second dimension to the health-ill-
counsel of a priest, rabbi, or minister to complement the services ness continuum created a matrix in which a favorable environ-
of the more traditional health provider. ment allows high-level wellness to occur and an unfavorable
environment allows low-level wellness to exist. Social and phys-
Wellness-Illness Continuum ical environmental factors can positively or negatively influence
The wellness-illness continuum, as stated earlier, is a dichoto- wellness.
mous depiction of the relationship between the concepts of With this addition, it became possible to combine the clini-
health and illness. In this paradigm, wellness is a positive state cal model of health with models based on social and environ-
in which incremental increases in health can be made beyond mental parameters. The concept demonstrates that a person
the midpoint (Fig. 1.2). These increases involve improved physi- can have a terminal disease and be emotionally prepared for
cal and mental health states. The opposite end of the continuum death, while acting as a support for other people and achieving
is illness, with the possibility of incremental decreases in health high-level wellness. High-level wellness involves progression
beyond the midpoint. This depiction of the relationship of well- toward a higher level of functioning, an open-ended and ever-
ness and illness fits well with the conceptual and clinical model expanding future with its challenge of fuller potential and the
of health (McMahon & Fleury, 2012). This paradigm is useful integration of the whole being (Ardell, 2007). This definition
when thinking about the transitions between wellness and ill- of high-level wellness contains ideas similar to those in the
ness (Polacsek, Boardman, & McCann, 2019). eudaimonistic model of health. In addition, high-level well-
ness emphasizes the interrelationship between the environ-
High-Level Wellness ment and the ability to achieve health on both a personal and
From a dichotomous representation of health and illness as a societal level.
opposites, Dunn (1961) developed a health-illness continuum
that assessed a person not only in terms of his or her relative Health Ecology
health compared with that of others but also in terms of the An evolving view of health recognizes the interconnection
between people and their physical and social environments.
Newman (2003) expressed this interconnection within a devel-
opmental framework, and the work of Gordon (2020) applies
this interconnection to functional health patterns as presented
in subsequent chapters. Health from an ecological perspective is
multidimensional, extending from the individual into the sur-
rounding community, and including the context within which
the person functions. It incorporates a systems approach within
which the actions of one portion of the system affect the func-
tioning of the system as a whole (Institute of Medicine, 2003,
2010). This view of health expands on high-level wellness by
recognizing that there are social and environmental factors that
can enhance or limit health and healthy behaviors. For example,
most people can benefit from physical activity such as walk-
ing, and people are more likely to walk in areas where there
are sidewalks or walking paths and where they feel safe. Nurses
can encourage people to walk but may also need to advocate
safe areas for people to walk and work with others to plan for
people-friendly community development.

Functioning
One of the defining characteristics of life is the ability to func-
FIG. 1.2 Wellness-illness continuum with high-level wellness tion. Functional health can be characterized as being present
added. Moving from the center to the right demonstrates or absent, having high-level or low-level wellness, and being
movement toward illness. Moving from the center to the left influenced by neighborhood and society. Functioning is inte-
demonstrates movement toward health. Moving above the line gral to health. There are physical, mental, and social levels of
demonstrates movement toward increasing wellness. Moving function, and these are reflected in terms of performance and
below the line demonstrates movement toward decreasing
social expectations. Function can also be viewed from an eco-
wellness. (Modified from US Department of Health and Human
Services, Public Health Service [1982]; McMahon, S., & Fleury,
logical perspective, as in the example of walking used previ-
J. [2012]. Wellness in older adults: A concept analysis. Nursing ously. Loss of function may be a sign or symptom of a disease.
Forum, 47[1], 39–51. Becker, C. M., Glascoff, M. A., Felts, W. For example, sudden loss of the ability to move an arm or leg
M., & Kent, C. [2015]. Adapting and using quality management may indicate a stroke. The inability to leave the house may
methods to improve health promotion. Explore, 11[3], 222–228.) indicate overwhelming fear. In both cases the loss of function
6 UNIT 1 Foundations for Health Promotion

is a sign of disease, a state of ill health. Loss of function is a present balance is not working. Within this definition, illness
good indicator that the person may need nursing interven- has psychological, spiritual, and social components. A per-
tion. Research in older adults indicates that decline in physical son can have a disease without feeling ill (e.g., asymptomatic
function is a sentinel event and may indicate the future loss of hypertension). A person can also feel ill without having a diag-
physical function and death (Boltz et al., 2012; Greiner et al., nosable disease (e.g., as a result of stress). Our understanding
1999; Gyasi & Phillips, 2018). of disease and illness within society, overlaid with our under-
standing of the natural history of each disease, creates a basis
for promoting health.
HEALTH
Health, as defined in this text, is a state of physical, mental, spiri-
tual, and social functioning that realizes a person’s potential and
PLANNING FOR HEALTH
is experienced within a developmental context. Although health Public health has always had the prevention of disease in society
is, in part, an individual’s responsibility, health also requires col- as its focus. However, during the past 30 years, the promotion
lective action to ensure a society and an environment in which of health and individual responsibility moved to the forefront
people can act responsibly to support health. The culture and within public health, becoming a driving force in health care
beliefs of people can also influence health action. This definition reform.
is consistent with the WHO definition of health as the state of A key milestone in promoting health was the advent of
complete physical, mental, and social well-being and not merely Healthy People (US Department of Health, Education, and Wel-
the absence of disease and infirmity (WHO, 2020a) but moves fare, Public Health Service, 1979), the first Surgeon General’s
beyond this definition to encompass spiritual, developmen- report on health promotion and disease prevention issued in
tal, and environmental aspects over time. The physical aspect the later years of President Carter’s administration.
includes one’s genetic makeup, which when combined with the The document identified three causes of the major health
other aspects influences one’s longevity. This broader definition issues in the United States as allowing careless habits, environ-
is applicable across the life span, as well as in situations where mental pollution, and harmful social conditions (e.g., hunger,
illness may be a chronic state. For example, in this broader poverty, and ignorance) to persist that destroy health, especially
definition of health, a person with diabetes may be considered for infants and children.
healthy if he or she is able to adapt to his or her illness and live a Healthy People was a call to action and an attempt to set
meaningful, spiritually satisfying life. Health is considered to be health goals for the United States for the next 10 years. Each
part of the metaparadigm for nursing (Fawcett & Garity, 2009), decade overarching goals are identified for Healthy People
which includes the four components of person, health, environ- (Table 1.1). Unfortunately, a change in political leadership, a
ment, and nursing. As can be seen in the discussion thus far, lack of political and social willpower, and the spiraling costs
health can be viewed in a variety of ways. of hospital-based health care intervened. The need to report
progress toward these national objectives led a larger, renewed
effort in the form of The 1990 Health Objectives for the Nation:
ILLNESS, DISEASE, AND HEALTH A Midcourse Review (USDHHS, Public Health Service, 1986).
It is easy to think of health or wellness as the lack of disease This midcourse review noted that, although many goals were
and to consider “illness” and “disease” as interchangeable terms. achievable, the unachieved goals were hindered by current
However, “health” and “disease” are not simply antonyms and health status, limited progress on risk reduction, difficulties in
“disease” and “illness” are not synonyms. Disease literally means data collection, and a lack of public awareness.
“without ease.” Disease may be defined as the failure of a per- Healthy People 2000 (USDHHS, Public Health Service,
son’s adaptive mechanisms to counteract stimuli and stresses 1990) and Healthy People 2000 Midcourse Review and 1995
adequately, resulting in functional or structural disturbances. Revisions (USDHHS, Public Health Service, 1996) were land-
This definition is an ecological concept of disease, which uses mark documents in that a consortium of people representing
multiple factors to determine the cause of disease rather than national organizations worked with US Public Health Service
describing a single cause. This multifactorial approach increases officials to create a more global approach to health. In addition,
the chances of discovering multiple points of intervention to a management-by-objectives approach was used to address each
improve health. problem area. These two documents became the blueprints for
Illness is composed of the subjective experience of the each state as funding for federal programs became linked to
individual and the physical manifestation of disease (Holling- meeting these national health objectives. While the objectives
sworth & Didelot, 2005). Both are social constructs in which became more widely implemented, methods for collecting data
people are in an imbalanced, unsustainable relationship with became formalized, and the data flowed back into the system to
their environment and are failing in their ability to survive form the revisions set in 1995. The core of these health objec-
and create a higher quality of life. Illness can be described as tives remained: that is, prevention of illness and disease was the
a response characterized by a mismatch between a person’s foundation for health.
needs and the resources available to meet those needs. In addi- Healthy People 2010 (USDHHS, Public Health Service, 2000)
tion, illness signals to individuals and populations that the introduced two overarching goals (see Table 1.1).
 CHAPTER 1 Health Defined: Health Promotion, Protection, and Prevention 7

TABLE 1.1 Current and Historical Overarching Goals of Healthy People

GOALS OF HEALTHY PEOPLE
1990 2000 2010 2020 2030
1 To continue to improve infant Increase the span of Increase quality and years Attain high quality, longer Attain healthy, thriving
health and to reduce infant healthy life. of healthy life. lives free of preventable lives and well-being, free
mortality. disease, disability, injury, of preventable disease,
and premature death. disability, injury, and
premature death.
2 To improve child, adolescent, Reduce health disparities. Eliminate health Achieve health equity, Eliminate health
and young adult health and disparities. eliminate disparities, and disparities, achieve
reduce deaths among these improve the health of all health equity, and attain
groups. groups. health literacy to improve
the health and well-being
of all.
3 To improve the health of Create access to preventive Create social and physi- Create social, physical, and
adults and reduce deaths services for all. cal environments that economic environments
among this group. promote good health that promote attaining
for all. full potential for health
and well-being for all.
4 To improve the health and Promote quality of life, Promote healthy
quality of life for older healthy development, and development, healthy
adults, and to reduce the healthy behaviors across behaviors, and well-being
average annual number of all life stages. across all life stages.
days of restricted activity
attributable to acute and
chronic conditions.
5 Engage leadership, key
constituents, and the
public across multiple
sectors to take action
and design policies that
improve the health and
well-being of all.

These goals addressed the issues of longevity and quality in a variety of areas has clearly indicated that health disparities
of life. Both longevity and quality of life address the concern are directly and indirectly linked to longevity and quality-of-
that people are living longer but frequently with numerous life issues (Clay et al., 2018; Xu et al., 2018). For example, the
chronic health problems that interfere with the quality of their American Cancer Society reports that Black men die of prostate
lives. However, quality of life is also an issue for people who are cancer more frequently than any other racial or ethnic group,
unable to achieve a long life. Combining these two ideas placed with their death rate almost 2.4 times higher than that of White
an emphasis on both longevity and quality of life as areas that men (American Cancer Society, 2016) (Box 1.2: Health and
need improvement. Social Determinants/Health Equity).
Eliminating health disparities addressed the continuing The Healthy People 2020 topic areas include adolescent
problems of access to care; differences in treatment based on health; blood disorders and blood safety; dementias, includ-
race, gender, and ability to pay; and related issues such as urban ing Alzheimer disease; early and middle childhood; genomics;
versus rural health, insurance coverage, Medicare and Medicaid global health; health care–associated infections; HRQoL and
reimbursement for care, and satisfaction with service delivery. well-being; lesbian, gay, bisexual, and transgender health; older
adults; preparedness; sleep health; and social determinants of
health. These topic areas are an expansion on previous areas and
HEALTHY PEOPLE 2020/2030 incorporate recent evidence more directly in each area.
The detailed objectives can be found at https://www.healthy-
Goals people.gov/2020/topics-objectives. These topic areas span age
For Healthy People 2020, there are four overarching goals (see categories from conception to death and incorporate preven-
Table 1.1). These four goals established the territory in which tion, access, treatment, and follow-up at the individual, family,
health promotion and disease prevention efforts occur. Research provider, work site, and community levels. The 42 topical areas
8 UNIT 1 Foundations for Health Promotion

BOX 1.2 HEALTH AND SOCIAL BOX 1.3 BEST PRACTICE/INNOVATIVE

DETERMINANTS/HEALTH EQUITY PRACTICE
Influence of Personal Cultural Values on Health Care Process for Assessing, Evaluating, and Treating
Delivery Overweight and Obesity in Adults
Culture influences every aspect of human life, including beliefs, values, and Overweight and obesity are major concerns in public health because they
customs regarding lifestyle and health care. As health care providers, nurses contribute to other health problems such as high cholesterol level, high blood
need to be aware of their own beliefs, values, and customs and how these pressure, diabetes mellitus, heart disease, functional limitations, and disabil-
ideas translate into behavior. It is easy to assume that an individual’s own per- ity. As part of the National Heart, Lung, and Blood Institute’s (2020) obesity
spective is correct and shared by others. This is especially true when one is education initiative, titled Aim for a Healthy Weight, nurses have an important
working with other health care providers who share the same culture. This con- role to play in health education related to obesity prevention and control. More
cept is referred to as ethnocentrism and can lead to a devaluing of the beliefs, complete information and guidelines can be obtained from https://www.nhlbi
values, and customs of others. It can be associated with racism, leading to so- .nih.gov/health-topics/overweight-and-obesity.
cial inequities, discrimination, and prejudice. Although it is impossible for any Make the Most of the Individual’s Visit and Set an Effective Tone for
person to ignore the cultural influences on their lives, nurses and other health Communication: Nurses ask individuals about their weight history, weight-
care providers have a special obligation to be aware of their own social and related health risks, and desire to lose weight. The approaches used need to
cultural biases. Our focus as nurses must be on the cultural influences in the be respectful of a person’s lifestyle, habits, and cultural influences. Discus-
daily lives of individuals through the development of cultural competence sions need to be nonjudgmental and goal directed.
and cultural humility. The ability to view other people’s situations from their Assess the Individual’s Motivation/Readiness to Lose Weight:
perspective is known as empathy. Diversity awareness will continue to chal- Nurses explain body mass index and why it is the preferred method of deter-
lenge providers to lifelong learning about the people for whom they provide mining overweight and obesity in adults. Individuals need to understand the
care as the racial and ethnic mix in society changes. methods of data collection and measurement of height and weight, as well as
waist circumference, risk factors, and comorbidities. Nurses develop skill in
determining readiness and motivation to lose weight in their patients.
Build a Partnership With an Individual: Nurses work with individuals
to determine what each person is willing to do to achieve a lower weight.
lead to specific objectives for each topical area. One example is This approach includes knowing the best practices in weight management
used here for illustration. and weight loss. Fad diets, dietary supplements, and weight loss pills may
Objective PA-2.1. Increase the proportion of adults who engage be inappropriate for most people, and formal weight loss programs may be
in aerobic physical activity of at least moderate intensity for at too expensive for low- and moderate-income families. Use recommended diets
least 150 minutes/week, or 75 minutes/week of vigorous intensity, that restrict caloric intake, set activity goals with your patients, encourage the
or an equivalent combination. This objective directly addresses person to keep a weekly food and activity diary, and provide information on
each of the overarching goals, either directly or indirectly. Phys- diet and activity. Be sure to record individual goals and the treatment plan,
ical activity can contribute to the maintenance or improvement including a health-education plan. Nurses are knowledgeable about current
treatment options and their success. Holistic approaches are needed because
in mobility, which improves the quality of life and prevents dis-
food behaviors are influenced by many factors. Listen to individuals’ stories
ability. It is something in which most people can participate. It about food and its role in their lives. Therapies should fit the individual’s goals
enhances positive mental health through stress reduction and and lead to lifestyle change.
physical fitness, which contribute to the development of healthy
behaviors. However, it takes social action and awareness to
address the need for social and physical environments that sup-
port physical activity across the life span. age and encouraging young adults to be actively engaged in
Access to health care to obtain a complete physical examina- exercise. How might this objective be adjusted to the needs of
tion before starting to exercise and the quality of the work or an older adult population? The target for this objective is that
neighborhood environment available for exercise can contrib- 47.9% of adults engage in aerobic physical activity of at least
ute to success or failure of this objective. This objective is related moderate intensity for at least 150 minutes per week, or vigor-
to other objectives such as nutrition, obesity, and stroke preven- ous intensity for 75 minutes per week, or an equivalent com-
tion (Box 1.3: Best Practice/Innovative Practice). bination. This target represents a 10% increase over the 2008
In addition, current knowledge of physical activity and spe- baseline. This approach emphasizes personal responsibility but
cific populations was considered when the Healthy People 2020 now includes society’s role in addressing the social and physical
objectives were being created. Women, low-income popula- environments within which those choices are made (USDHHS,
tions, Black and Hispanic people, people with disabilities, and National Institutes of Health, National Heart, Lung, and Blood
those older than 75 years exercise less than do White men with Institute, 2020; https://www.nhlbi.nih.gov/health-topics/heart
moderate-to-high incomes (USDHHS, National Institutes of -healthy-living).
Health, National Heart, Lung, and Blood Institute, 2020). These The latest Healthy People 2020 progress update on the goals
health disparities can influence the number of people in these of increasing access to health care services, addressing social
groups who develop high cholesterol levels or high blood pres- determinants of health, and increasing the health-related qual-
sure, which further increases their risk of heart disease and ity of health for people indicates small improvements.
stroke. Although this objective addresses adults, other objectives The two leading health indicators for access to health care
address the need for beginning exercise activities at an early services of persons with medical insurance (<65 years old)
 CHAPTER 1 Health Defined: Health Promotion, Protection, and Prevention 9

and persons with a usual primary care provider showed little dation (http://www.agingblueprint.org). The project engaged
or no detectable change (USDHHS, 2014). The latest figure for older adults in walking programs, line dancing, gardening, and
the improvement in the rate of persons with medical insur- low-impact exercise programs, including programs from the
ance was 89% (2018), the baseline rate was 83% (2008), and National Arthritis Foundation (http://www.arthritis.org/).
the goal is 100%. In 2016, 76.4% of people had a usual primary Another approach to partnerships is to have providers serve
care provider, the baseline rate was 76.3% (2007), and the goal as active participants on community boards and advisory com-
is 83.9%. Social determinants of health are represented by the mittees, which allows providers to become aware of the service
leading health indicator of students who graduate with a regular needs in the community and the resources available to meet
diploma 4 years after starting 9th grade. There has been an over- those needs.
all increase from 79% (2010–11) to 85% (2016–17), although Work sites and communities need to become partners in
there are dramatic differences in graduation rates according to providing opportunities for people to lead healthy lives through
race and ethnicity (National Center for Education Statistics: flexible work schedules, work site wellness programs, accessibil-
www.nces.ed.gov). Improving the HRQoL and well-being of ity of safe parks, and availability of exercise facilities. Convert-
adults is considered by measurement of the proportion of adults ing empty lots into community gardens provides beautification
who self-report good or better physical and mental health. In of the area, an opportunity for exercise in caring for the garden,
2010, men reported good or better physical health at a rate of and a source of fresh vegetables. The availability of bike paths
82.5%, with women trailing at a rate of 75.4%, and 81.1% of men encourages physical activity.
report good or better mental health compared with 77.3% of Churches, temples, and mosques can be vital partners in
women. Education is related to good or better health. The more meeting Healthy People objectives. Faith communities can break
educated one is, the higher the level of reported good or better economic, social, racial, and gender barriers, making them an
health (USDHHS, 2014). excellent source for sharing information on health promotion
Health care providers need to be responsible for offering and disease prevention. Parish nurses and Faith Community
health promotion, providing preventive health services, and Nurses are becoming increasingly prevalent, and they incor-
monitoring behaviors. Unfortunately, many of the financial porate Healthy People objectives into their activities (Westberg
incentives for providers are to perform tasks and procedures Institute, 2020).
rather than to counsel and help individuals choose between Public health officials at all levels are necessary partners in
various behaviors. The Patient Protection and Affordable Care meeting Healthy People objectives. As part of the core public
Act (US Congress, 2010) now requires primary care providers health functions of assessment, policy development, and assur-
to provide free wellness services to older adults and others and ance, the US Public Health Service and all state, county, and
to provide person-centered care. Providers need to take the time local health departments need to collect data, make informa-
to discuss behaviors that may improve the quality of life and tion available to the public, create policies that support Healthy
extend the number of years of life. For example, the addictive People objectives, and ensure that needed services are available
nature of tobacco products, including e-cigarettes, and its effect from a competent workforce.
on the development and course of a variety of chronic health Healthy People can form the basis for planning, service deliv-
conditions are now well recognized. Providers should be asking ery, evaluation, and research in every aspect of the health care
every person if they use tobacco products and should be provid- system. The nurse needs to be familiar with this document and
ing them with ways to quit smoking, including economic and its intent. Nurses should compare their practices with the objec-
social incentives. tives of Healthy People. In addition, the nurse needs to be aware
Providers also need to look for partnership in the commu- of the research and practice changes that occur as a result of the
nity through which they can better serve the needs of individu- work toward these objectives.
als. Healthy People 2020 emphasizes that person-centered care
is essential to health promotion. One approach to person-cen-
tered care to build partnerships is the use of community nursing
HEALTHY PEOPLE 2030
centers as partnering organization. The Health Promotion Cen- The current process of updating Healthy People 2020 to Healthy
ter operated by Fairfield University School of Nursing in Fair- People 2030 is underway. With each iteration of Healthy People,
field, Connecticut, was one example. The nurses and nursing the goals and topic areas of the previous decade are evaluated
students who provided health education, screening, and referral and topic areas are changed, added, or removed based on the
services at the Health Promotion Center worked with existing current vision and mission of Healthy People. Objectives spe-
community organizations to better meet the health care needs cific to those topic areas are developed by experts from mul-
of underserved people. The Health Promotion Center worked tiple lead federal agencies, the Secretary’s Advisory Committee
with senior housing and senior centers to provide compre- on National Health Promotion and Disease Prevention Objec-
hensive cardiovascular screenings and medication review. As tives for 2030, and the public. There are three levels of objec-
an extension of this work, funding was secured for a program tives proposed for Health People 2030. Core objectives are
called Step Up to Health, a project to increase physical activity based on established data found in registries, national surveys,
in this population through interactive planning and consumer US Census, etc. Developmental objectives are around high pri-
ownership of the activities. The project was part of the National ority areas that may not have any associated data but do have
Blueprint Project supported by the Robert Wood Johnson Foun- evidence-based interventions. Research objectives can address
10 UNIT 1 Foundations for Health Promotion

BOX 1.4 HEALTHY PEOPLE 2030 Some confusion exists in the interpretation of these concepts;
therefore a consistent understanding of primordial, primary,
Proposed Planning Activities
secondary, tertiary, and quaternary prevention is essential. The
• Set national goals and measurable objectives to guide evidence-based poli- levels of prevention operate on a continuum but may overlap in
cies, programs, and other actions to improve health and well-being. practice. The nurse must clearly understand the goals of each
• Provide data that are accurate, timely, and accessible and can drive tar-
level to intervene effectively in keeping people healthy.
geted actions to address regions and populations with poor health or at
high risk for poor health in the future.
• Foster impact through public and private efforts to improve health and well-
Primordial Prevention
being for people of all ages and the communities in which they live. “Primordial” refers to the time frame before a risk factor devel-
• Provide tools for the public, programs, policy makers, and others to evaluate ops and before disease occurs. Primordial prevention can begin
progress toward improving health and well-being. as early as childhood or even prenatally and is closely linked to
• Share and support the implementation of evidence-based programs and the determinants of health and the environment in which one
policies that are replicable, scalable, and sustainable. lives (Salama, n.d.). Determinants of health include income,
• Report biennially on progress throughout the decade from 2020 to 2030. education, literacy, employment, working conditions, social
• Stimulate research and innovation toward meeting Healthy People 2030 and physical environment, health practices, genetic makeup,
goals, and highlight critical research, data, and evaluation needs. health services, gender, and culture (Association of Faculties of
• Facilitate development and availability of affordable means of health pro-
Medicine of Canada, n.d.). Primordial interventions are aimed
motion, disease prevention, and treatment.
at determinants of health. For example, if the social environ-
From US Department of Health and Human Services, Public Health ment one grows up in discourages exercise or encourages eating
Service. (2020). Healthy People 2030. https://www.healthypeople high-fat food, that environment could be targeted for primor-
.gov/2020/About-Healthy-People/Development-Healthy-People-2030
dial prevention. Healthy eating and activity school-based pro-
/Framework.
grams, reduction of sodium in the food supply, and creation of
areas that do not have evidence-based interventions. These safe places to ride bikes and walk are examples of primordial
three levels of objectives are currently being identified and will prevention. Most health-promoting primordial prevention
reflect the five overarching 2030 goals in Table 1.1. The three occurs at the national, state, and community levels.
levels of objectives are a new addition to Healthy People, as well The Healthy People proposed goals for 2030 that include 7
as the overarching goal of engaging leadership, key constituents, core, 7 developmental, and 10 research objectives related to
and the public to design polices that will advance Healthy Peo- improving the public health system, where many primordial
ple 2030 objectives. Because public health is complex, Healthy health prevention programs are housed (USDHHS, Office of
­People 2030 is also placing an emphasis on complex systems sci- Disease Prevention and Health Promotion, 2020).
ence and modeling to help transform the fields of health promo-
tion and disease prevention (Secretary’s Advisory Committee Primary Prevention
for Healthy People 2030, 2019) (Box 1.4: Healthy People 2030 Primary prevention precedes disease or dysfunction. However,
Proposed Planning Activities). primary prevention is therapeutic in that it includes health as ben-
eficial to well-being, it uses therapeutic treatments, and, as a pro-
cess or behavior toward enhancing health, it involves symptom
LEVELS OF PREVENTION identification when stress reduction techniques are being taught.
Prevention, in a narrow sense, means averting the development Primary prevention intervention includes health promotion, such
of disease. In a broad sense, prevention consists of all measures as health education about risk factors for heart disease, and specific
that limit disease progression. Leavell and Clark (1965) defined protection, such as immunization against hepatitis B. Its purpose
three levels of prevention: primary, secondary, and tertiary is to decrease the vulnerability of the individual or population to
(Fig. 1.3). Although the levels of prevention are related to the disease or dysfunction. Interventions at this level encourage indi-
natural history of disease, they can be used to prevent disease and viduals and groups to become more aware of the means of improv-
provide nurses with starting points for making effective, positive ing health and the actions they can take at the primary preventive
changes in the health status of the persons for whom they provide health level and the optimal health level. People are also taught to
care. Primordial prevention, the earliest form of prevention, has use appropriate primary preventive measures. However, primary
been added as a type of prevention that reflects policy-level inter- prevention can also include advocating policies that promote the
vention aimed at affecting health before at-risk lifestyle behaviors health of the community and electing public officials who will
are chosen or become habit. Within the four levels of prevention, enact legislation that protects the health of the public.
there are five steps. These steps include health promotion and
specific protection (primordial and primary prevention); early Health Protection
diagnosis, prompt treatment, and disability limitation (second- Primordial and primary prevention activities focus on the
ary prevention); and restoration and rehabilitation (tertiary pre- reduction of threats and negative influences on health. Both
vention). A fifth level of prevention has recently been introduced types of prevention can occur at an individual level and at the
and is being discussed as the quaternary level of prevention; this community, state, national, and even global levels. Ensuring safe
level considers the potential for overmedicalization (Martins, and adequate food, water, and medical therapies for all people
Godycki-Cwirko, Heleno, & Brodersen, 2018). and protecting them against workplace and environmental haz-
 CHAPTER 1 Health Defined: Health Promotion, Protection, and Prevention 11

FIG. 1.3 The three levels of prevention developed by Leavell and Clark with primordial prevention
added. (Modified from Leavell, H., & Clark, A. E. [1965]. Preventive medicine for doctors in the
community. New York: McGraw Hill; Ali, A., & Katz, D. L. [2015] Disease prevention and health
promotion: How integrative medicine fits. American Journal of Preventive Medicine, 49[5], S230–
S240; D’Ascenzi, F., Sciaccaluga, C., Cameli, M., Cecere, A., Ciccone, M. M., Di Francesco, S.,
Ganau A., et al. [2019]. When should cardiovascular prevention begin? The importance of ante-
natal, perinatal and primordial prevention. European Journal of Preventive Cardiology, December
16, 2019, 1–12. doi:10.1177/2047487319893832.)

ards are regional and global objectives. Ruger and colleagues in an article commissioned by the US Public Health Service. They
(2015) suggest the formation of a global health fund that would stated that health promotion is “the process of advocating health
unite efforts to ensure adequate protection of all the world’s to enhance the probability that personal (individual, family, and
people concerning AIDS, tuberculosis, and malaria in recogni- community), private (professional and business), and public (fed-
tion of the global responsibility for social protection. eral, state, and local government) support of positive health prac-
tices will become a societal norm.” Healthy People has adopted
Health Promotion the definition of health promotion as “any planned combination
The definitions of health promotion differ. O’Donnell (1987) has of educational, political, regulatory, and organizational supports
defined health promotion as “the science and art of helping peo- for actions and conditions of living conducive to the health of
ple change their lifestyle to move toward a state of optimal health.” individuals, groups, or communities” (Secretary’s Advisory Com-
Kreuter and Devore (1980) proposed a more complex definition mittee for Healthy People 2030, 2019).
12 UNIT 1 Foundations for Health Promotion

The Theoretical Basis of Health Promotion. The theoretical

TABLE 1.2 Transtheoretical Model Stages
underpinnings for health promotion have evolved since the
of Change
early 1980s. Most of these theories are behaviorally based, de-
rived from the social sciences, and extensively researched. These Precontemplative Not considering change
theories include the theory of reasoned action by Ajzen and Contemplative Aware of but not considering change soon
Fishbein (1980), theories of behavior by Bandura (1976, 1999, Preparation Planning to act soon
2004), the health belief model by Rosenstock (Champion & Action Has begun to make behavioral change (recent)
Skinner, 2008), Pender’s health-promotion model (Murdaugh, Maintenance Continued commitment to behavior (long term)
Parsons, & Pender, 2019), and stages of change theories by Relapse Reverted to old behavior
Prochaska (Prochaska et al., 2015). Internet searches on each
of these theories will provide numerous websites where more
detailed information is available. active and passive strategies is best for making an individual or
society healthier. This text is concerned almost entirely with
The Social Nature of Health Promotion. Health promotion
active strategies and the nurse’s role in these strategies. Some
goes beyond providing information. It is also proactive deci-
passive strategies are presented, but they are presented with the
sion-making at all levels of society as reflected in the Healthy
implicit belief that each individual must take responsibility for
People 2020 objectives. Health promotion holds the best prom-
improving health. It is undeniable that passive strategies also
ise for lower-cost methods of limiting the constant increase in
have a valuable role, but they must be used within a context of
health care costs and for empowering people to be responsible
encouraging and teaching individuals to assume more respon-
for the aspects of their lives that can enhance well-being. Based
sibility for their health.
on the need for health-promotion activities within the health
care system, efforts must be made to identify the multiple deter-
An Application of Theory to the Practice of Health Promo-
minants of health, determine relevant health-promotion strate-
tion. The Transtheoretical Model (TTM) is an excellent ex-
gies, and delineate issues relevant to social justice and access
ample and can be applied to this case study. TTM incorporates
to care. Individuals, families, and communities must be active
stages of change (readiness to take action), decisional balance
participants in this process so that the actions taken are socially
(benefits to and detractors from changing a behavior), self-
relevant, economically feasible, and supportive of changes at the
efficacy (personal confidence in making a change), and pro-
individual level.
cesses of change (cognitive, affective, and behavioral activities
The Active and Passive Nature of Health Promotion. Health- facilitating change). The bases of TTM are the stages of change;
promotion efforts, unlike those efforts directed at specific these are six stages that people spiral through on a path toward
protection from certain diseases, focus on maintaining or im- making and sustaining a behavioral change to promote health.
proving the general health of individuals, families, and com- See Table 1.2.
munities. These activities are conducted at the public level (e.g., Each stage offers opportunities for the nurse to provide
government programs promoting adequate housing or reducing information and support behavioral change. Encouraging peo-
pollutants in the air), at the community level (e.g., Habitat for ple and suggesting changes to their environment that support
Humanity or community health centers), and at the personal behavioral change can increase individuals’ self-efficacy and
level (e.g., voting to offer low-income housing or to elect public their chances of maintaining a change. This model also recog-
officials who recognize the need for public oversight). Nursing nizes that people need multiple opportunities to make behav-
interventions are actions directed toward developing people’s ioral change before achieving success and that relapse should be
resources to maintain or enhance their well-being—a form of expected (Prochaska et al., 2015).
assets-based planning. Although health promotion would seem to be a practical and
Strategies of health promotion that involve the individual effective mode of health care, the major portion of health care
may be either passive or active. Passive strategies involve the delivery is geared toward responding to acute and chronic dis-
individual as an inactive participant or recipient. Examples of ease. Preventing or delaying the onset of chronic disease and
passive strategies include public health efforts to maintain clean adding new dimensions to the quality of life are not as easy
water and sanitary sewage systems to decrease infectious dis- because they take time to implement and evaluate and require
eases and improve health, and efforts to introduce vitamin D personal action. These actions are more closely associated with
in all milk to ensure that children will not be at high risk of everyday living and the lifestyles adopted by individuals, fami-
rickets when living in areas where sunlight is scarce. These pas- lies, communities, and nations. Habits such as eating, resting,
sive strategies must be used to promote the health of the public exercising, and handling anxieties appear to be transmitted
when individual participation might be low but the benefit to from parent to child and from social group to social group as
society is high. part of a cultural, not a genetic, heritage. These activities may
Active strategies depend on the individual becoming per- be taught in subtle ways, but they influence behavior and have
sonally involved in adopting a proposed program of health pro- as much of an influence on health as does genetic inheritance.
motion. Two examples of lifestyle change are performing daily Although the public may not appreciate the causal relationships
exercise as part of a physical fitness plan and adopting a stress- between behavior and health, they should be apparent to health
management program as part of daily living. A combination of professionals. Arguably, the concept of risk is the most basic of
 CHAPTER 1 Health Defined: Health Promotion, Protection, and Prevention 13

all health concepts, because health promotion and disease pro- Health promotion is an important concept for nursing
tection are based on this concept. because it embodies many other concepts that nursing is con-
Health-promotion strategies have the potential of enhanc- cerned with nowadays. As stated earlier, much of the nursing
ing the quality of life from birth to death. For example, good role is involved with health teaching. Standard 5B of Nursing:
nutrition is adjusted to various developmental phases in life to Scope and Standards of Practice (American Nurses Association
account for rapid growth and development in infancy and early [ANA], 2015b) includes a full section on the practice imple-
childhood, physiologic changes associated with adolescence, mentation of health teaching and health promotion. Nurses
extra demands during pregnancy, and the many changes occur- are expected to demonstrate professional role competence
ring in older adults. Good nutrition is known to enhance the throughout their careers. Health education is clearly an impor-
immune system, enabling individuals to fight infections that tant nursing role.
could lead to disabling illnesses. Other individual activities are
adapted to the person’s needs for optimal personality develop- Specific Protection
ment at all ages. As seen in Unit 4, much can be done on a per- This aspect of primary prevention focuses on protecting people
sonal or group basis, through counseling and properly directed from injury and disease, for example, by providing immuniza-
parent education, to provide the environmental requirements tions and reducing exposure to occupational hazards, carcino-
for the proper personality development of children. Commu- gens, and other environmental health risks. These hazards and
nity participation is also an important factor in promoting indi- risks include not only protection of adults from work-related
vidual, family, and group health (see Chapters 6–8). injuries (e.g., back injuries in nurses, dismemberment in
Personal health promotion is usually provided through health machinists, exposure to chemicals used in boat repair or expo-
education (see Chapter 10). An important function of nurses, sure to inhaled sawdust by carpenters) but also protection of
physicians, and allied health professionals, health education is infants and children from potential carcinogens (e.g., exposure
principally concerned with eliciting useful changes in human of children to diesel emissions, damage to a fetus caused by
behavior on the basis of current research. The goal is to inculcate radiation).
a sense of responsibility in individuals for their own health and Primary prevention interventions are considered health pro-
a shared sense of responsibility for avoiding injury to the health tection when they emphasize shielding or defending the body
of others. For example, encouraging child-rearing practices that (or the public) from specific causes of injury or disease. Imple-
foster normal growth and development (personal, social, and menting nursing interventions that prevent a specific health
physical) addresses both the individual parent and the needs of problem may seem easier than promoting well-being among
society. Health education nurtures health-promoting habits, val- individuals, groups, or communities because the variables are
ues, and attitudes that must be learned through practice. These delineated more clearly in prevention than in promotion and
must be reinforced through systematic instruction in hygiene, the potential influences are less diverse.
bodily function, physical fitness, and use of leisure time. Another
Examples. Two examples may help demonstrate these dif-
goal is to understand the appropriate use of health services. For
ferences. Immunization against influenza is recommended by
example, a semiannual visit to a dentist may teach a child better
the Centers for Disease Control and Prevention (CDC) and
oral health habits and to visit the dentist regularly, although this is
has become a regular health preservation activity for peo-
not the primary purpose of the visit. Parents, teachers, and care-
ple at risk each fall https://www.cdc.gov/flu/prevent/flushot
givers play a vital role in health education. In addition to teaching
.htm). Nurses can participate in this specific protection role
individuals, nurses need to develop skills in group teaching and
by giving the influenza injections in clinics and offices. An-
in providing education within community organizations.
other example is the creation of nut-free schools to protect
Available research clearly shows an increase in longevity, a
hypersensitive children from life-threatening allergic reac-
decrease in mortality and morbidity, and an improvement in
tions to peanuts and nut products. Such initiatives have large-
the quality of life for individuals who have been involved in
ly been the result of grassroots parent organizations working
health-promotion activities such as physical activity and avoid-
with formal community organizations to adopt policies that
ance of smoking (Snedden et al., 2019). It must be emphasized
protect the health of these children. Nurses may be involved
that health promotion requires lifestyle change. Once a lifestyle
in the parent organizations or the school or public health
change has been adopted, vigilance is needed to ensure that the
boards that review the proposed policies. In addition, nurses
lifestyle change is maintained and modified to fit developmental
must be able to address the need to protect specific portions
and environmental changes.
of the population at risk.
Empirical data linking risk factors, health-promotion activi-
ties, and outcomes are sufficient to drive the development of
the Healthy People 2020 objectives and to be incorporated into Secondary Prevention
quality improvement measures in managed care. One of the Although primary prevention measures have decreased the haz-
challenges posed in Healthy People 2020 is the development of ards of chronic diseases such as cardiovascular disease, condi-
measurable outcome objectives that are based on more realistic tions that preclude a healthy quality of life are still prevalent.
economic models. Early reports on Healthy People 2030 have Secondary prevention ranges from providing screening activi-
decreased the number of objectives into order to focus on the ties and treating early stages of disease to limiting disability by
most important outcomes for investigation. averting or delaying the consequences of advanced disease.
14 UNIT 1 Foundations for Health Promotion

Screening is secondary prevention because the principal goal ease). These interventions or programs are focused at the pri-
is to identify individuals in an early, detectable stage of the dis- mordial, primary, and secondary levels of prevention. At the
ease process. However, screening provides an excellent oppor- level of tertiary prevention, programs focus on intervention and
tunity to offer health teaching as a primary preventive measure. maintenance (Hawkins et al., 2015).
Screening activities now play an important role in the control of
diseases such as heart disease, stroke, and colorectal cancer. In The Intersectionality of Public Health, Population
addition, screening activities provide early diagnosis and treat- Health, and Health Promotion
ment of nutritional, behavioral, and other related problems. Public health is population-based focusing on the determinants
Nurses play an important role in screening activities because of health for defined populations. It is also grounded in social
they provide clinical expertise and educationally sound health justice, focused on health promotion and disease prevention,
information during the screening process. and driven by the science of epidemiology, and it organizes com-
Delayed recognition of disease results in the need to limit munity services (Keller et al., 2016). Population health is the out-
future disability in late secondary prevention. Limiting dis- comes (i.e., length of life, HRQoL, function) of a population that
ability is a vital role for nursing because preventive measures are influenced by patterns of health determinants, policies, and
are primarily therapeutic and are aimed at arresting the disease interventions (Kindig & Stoddart, 2003). Population is a group
and preventing further complications. The paradox here is that defined by a geographic area, or employees, ethnic groups, pris-
health education and disease prevention activities seem similar oners, or disabled people. It is not defined as a clinical care recipi-
to those used in primary prevention but are applied to a per- ent group like individuals with heart failure. A clinical population
son or population with an existing disease. Modifications to the focus may be an example of population health management or
teaching plan must be made on the basis of the individual’s cur- population medicine (Kindig, 2015). Because determinants of
rent health status and ability to modify behavior. health are what drive health outcomes, they are considered in
population health and public health. Determinants include medi-
Tertiary Prevention cal care, public health interventions, aspects of the social and
Tertiary prevention occurs when a defect or disability is perma- physical environment, genetics, and individual behavior (Kindig
nent and irreversible. The process involves minimizing the effects & Stoddart, 2003). Health promotion efforts empower people to
of disease and disability by surveillance and maintenance activi- have control over their own health. These efforts involve advo-
ties aimed at preventing complications and deterioration. Ter- cating for and/or supplying supports for actions and conditions
tiary prevention focuses on rehabilitation to help people attain that can lead to positive health practices. The WHO describes
and retain an optimal level of functioning regardless of their five key areas for work related to health promotion: good gov-
disabling condition. The objective is to return the affected indi- ernance, health literacy, healthy cities, health-promoting schools,
vidual to a useful place in society, maximize remaining capacities, and social mobilization. Health in All Policies is a collaborative
or both. The responsibility of the nurse is to ensure that persons attempt to consider social determinants that influence the health
with disabilities receive services that enable them to live and work of communities when creating and enacting any policy (Rudolph
according to the resources that are still available to them. When et al., 2013). Gathering and using health information that sup-
a person has a stroke, rehabilitating this individual to the high- ports healthy decisions requires health literacy. Urban planning
est level of functioning and teaching lifestyle changes to prevent that promotes health requires strong leadership and commitment.
future strokes are examples of tertiary prevention. School health programs to promote health and prevent disease
are important for children and the community. Socially mobiliz-
Quaternary Prevention ing groups and communities to create sustainable resources and
Quaternary prevention is a concept developed by Jamoulle and services that will enhance health is also an important factor of
colleagues (2013) that describes the potential for the overmedi- health promotion. All three of these concepts of health, public
calization of care recipients. The prevention of doing harm, by health, population health, and health promotion, are interwoven
overdiagnosing or overtreating and the commercialization of together to meet the needs of groups of people at various ecologic
disease, is the objective of this level of prevention. This process levels.
of prevention requires providers to make ethical and socially
responsible diagnostic and treatment suggestions and include
the care recipient in shared decision-making (Pandve, 2014;
THE NURSE’S ROLE
Martin, 2018). Evolving demands are placed on the nurse and the nursing
profession as a result of changes in society. Emphasis is shift-
Levels of Prevention Strategies ing from acute, hospital-based care to preventive, community-
According to the National Academy of Medicine, there are based care, which is provided in nontraditional health care
three program levels of prevention interventions. Universal pro- settings in the community. This demand for community-based
grams are directed toward an entire population and are aimed services, with the home as a major community setting for care,
at preventing or delaying the behavior of concern. Selective is closely related to the changing demographics of the United
prevention strategies target specific groups that are at risk for States. While the home and community become the existing
the behavior. Indicated programs are designed to prevent risk sites for care, nurses must assume more blended roles, with a
behaviors (or symptoms) becoming the actual behavior (or dis- knowledge base that prepares them to practice across settings
 CHAPTER 1 Health Defined: Health Promotion, Protection, and Prevention 15

using evidence-based practice. Within these roles, nurses practice, such as in gerontology, women’s health, or community/
assume a more active involvement in the prevention of disease public health, and they are equipped to provide information as
and the promotion of health. Nurses can be more independent consultants in these areas of specialization (ANA, 2015b). A
in their practice and place a greater emphasis on promoting and gerontologic nurse specialist might be on a community plan-
maximizing health, and more than ever nurses are accountable ning board offering advice about what types of health-promo-
morally, ethically, and legally for their professional behavior. tion activities should be considered in planning a new senior
housing development. All nurses need to develop consultation
Nursing Roles in Health Promotion and Protection skills that can be integrated into practice and allow the individ-
Although nurses often work with people on a one-to-one basis, ual nurse to take advantage of opportunities to provide support
they seldom work in isolation. Within the current health care on an individual level or for future development at the organi-
system, nurses collaborate with other nurses, physicians, social zational level (Drury, 2016).
workers, nutritionists, psychologists, therapists, individuals,
and community groups. In this interprofessional practice, Deliverer of Services
nurses play a variety of roles. The core role of the nurse is the delivery of direct services such
as health education, influenza vaccinations, and counseling in
Advocate health promotion. Visible, direct delivery of nursing care is the
As advocates, nurses help individuals obtain what they are enti- foundation for the public image of nursing. The public demands
tled to receive through the health care system, try to make the that nurses be knowledgeable and competent in their delivery of
system more responsive to individual and community needs, services. This role is clearly expressed in Nursing’s Social Policy
and help people develop the skills to advocate for themselves. In Statement (ANA, 2010) and in the Code of Ethics for Nurses with
the role of an advocate, the nurse strives to ensure that all per- Interpretive Statements (ANA, 2015a).
sons receive high-quality, appropriate, safe, and cost-effective
care. The nurse may spend a great deal of time identifying and Educator
coordinating resources for complex cases. Health practices in the United States are derived from the theory
that health components such as good nutrition, industrial and
Care Manager highway safety, immunization, and specific drug therapy should
The nurse acts as a care manager to assist the individual in be within the grasp of the total population. Even with its rich
navigating the complexities of health care and health decision- resources, society falls far short of attaining the goal of maximal
making. Primary roles of the care manager include preventing health for all. The problem is not a lack of knowledge, but rather
duplication of services, maintaining quality and safety, provid- the lack of application; therefore it is incumbent on nurses to be
ing education and advocacy, facilitating self-management, and excellent health educators. To teach effectively, the nurse must
reducing costs (Luther, Barra, & Martial, 2019). Information know essential facts about how people learn and the teaching-
gathered from reliable data sources enables the care manager learning process. Health literacy is an important component of
to help individuals avoid care that is unproven, ineffective, or successful teaching and learning. (see Chapter 10).
unsafe. Reliable sources of information on best practices, evi- In addition to their storehouse of scientific knowledge,
dence-based practices, and standard protocols are available from nurses who are committed to their teaching role know that
websites sponsored by the federal government (e.g., https://www. individuals are unique in their response to efforts to change
nih.gov; https://www.cdc.gov), specialty organizations (e.g., their behavior. Teaching may range from a chance remark by
http://www.arthritis.org; http://www.nursingworld.org; http:// the nurse, based on assessment coupled with perception of
www.aginglifecare.org), and private foundations (e.g., http:// desirable individual behavior, to structurally planned teaching
www.rwjf.org; http://www.johnahartford.org). Successful care according to individual needs. Selection of the methods most
management depends on a collaborative relationship among the likely to succeed involves the establishment of teacher-learner
care manager, other nurses and physicians, the individual and goals. Health promotion and protection rely heavily on the
his or her family, the insurance provider, and other care provid- individual’s ability to use appropriate knowledge. Health edu-
ers who work with the person. A key aspect of this collaborative cation is one of the primary prevention techniques available to
relationship is educating and engaging the individual and family avoid the major causes of disability and death nowadays and is
members (Witwer & Wallenstein, 2019). Without engagement, a critical role for nurses.
individuals assume a passive role in their health care. The wishes
of the individual and the family need to be clear to the care man- Healer
ager as part of person-centered care provision. Facilitating com- The role of healer requires the nurse to help individuals inte-
munication among parties and engaging the individual in the grate and balance the various parts of their lives (Quinn, 2016).
process are two of the care manager’s most important functions. The concept of patient centeredness requires nurses to learn
from the individual or family what is required for healing. The
Consultant nurse understands that healing resides in the ability to glimpse
Nurses may provide knowledge about health promotion and or intuit the “interior” of an individual, to sense and identify
disease prevention to individuals and groups as a consultant. what is important to that other person, and to incorporate the
Some nurses have specialized areas of expertise or advanced specific insight into a care plan that helps that person to develop
16 UNIT 1 Foundations for Health Promotion

his or her own capacity to heal. It requires a mindful blending BOX 1.5 EVIDENCE-BASED PRACTICE
of science and subjectivity (Benner et al., 2010; Siegel, 2007).
Evidence-Based Programming for Older Adults
Nurses have a special ability to help people heal. The art of nurs-
ing is the extraordinary ability to manage a broad array of infor- The National Council on Aging (NCOA) encourages the use of evidence-based
mation to create something meaningful, sensible, and whole programs to enhance health and prevent injuries and disability in older adults.
(see Chapter 14). Evidence-based programs are composed of interventions that have been rig-
orously studied and found to be helpful. These programs are translated into
Researcher practice using content that has been tested. Three example programs are: Self-
Management Resource Center Programs for chronic disease self-management
In the current health care environment, nurses are constantly education, A Matter of Balance for falls prevention, and Healthy IDEAS for
striving to understand and interpret research findings that will depression management. All three of these resources have met the evidence-
enhance the quality and value of individual care. To provide based quality criteria of the NCOA. Those standards involve demonstrated
optimal health care, nurses need to use evidence-based findings program effectiveness through experimental or quasi-experimental research,
as their foundation for clinical decision-making. When nurses published results, translated in at least one community site, and have dis-
or other clinicians use research findings and the best evidence semination products that are available to the public. Once a program has been
possible to make decisions, the outcome is termed evidence- selected, it must be followed consistently to ensure that the tested interven-
based practice. Evidence-based practice is defined as the con- tions are properly being applied.
scientious, explicit, and judicious use of current best evidence From National Council on Aging (n.d.). About evidence-based programs.
in making decisions about the care of individuals. The practice Retrieved from https://www.ncoa.org/center-for-healthy-aging/basics-of
of evidence-based nursing means integrating individual clinical -evidence-based-programs/about-evidence-based-programs/.
expertise with the best available external clinical evidence from
systematic research (ANA, 2015b). individuals through the Outcome and Assessment Information
The National Institute of Nursing Research (NINR) serves Set (OASIS) and Minimum Data Set (MDS) assessment tools.
as the focal point in developing research themes for the future These data are used as part of the quality improvement process
of the profession. NINR supports research to establish a scien- to indicate areas for improvement in care, thereby contribut-
tific base for the care of individuals throughout the life span, ing to nursing protocols. Nurses in hospital settings are asked to
from the management of individuals during illness and recov- participate in research as part of the Magnet Hospital designa-
ery to the reduction of the risks of disease and disability. The tion process.
four “investment” themes NINR has identified are promoting The book chapters contain specific health-promotion
personalized health strategies using symptom science, promot- research studies. Time should be taken to review these studies
ing health and preventing disease, improving the quality of life and explore the relationship between behavior and disease, to
for individuals with chronic disease through self-management, identify which population groups are at risk, and to discover
and end-of-life and palliative care through compassion (NINR, what types of health-promotion programs work and why they
2016). Notice how the Healthy People 2020 objectives match work. Through knowledge of research, nurses can strengthen
many of these themes. their confidence in making daily decisions about quality care
Evidence-based practice involves searching for the best (Box 1.5: Evidence-Based Practice).
evidence with which to answer clinical research questions.
Research evidence can be gathered from quantitative studies IMPROVING PROSPECTS FOR HEALTH
that describe situations, correlate different variables related to
care, or test causal relationships between variables related to Population Effects
care. Such studies become incorporated into screening and Cultural and socioeconomic changes within the population
treatment standards such as those from the US Preventive Ser- unequivocally influence lay concepts of health and health pro-
vices Task Force (2014). Research evidence can also be gath- motion. Currently there are areas of the United States where the
ered from qualitative studies that describe phenomena or Hispanic population is larger than any other population group.
define the historical nature, cultural relevance, or philosophi- By the 2050, it is predicted that the majority of people in the
cal basis of aspects of nursing care. Applied research is done United States will not be of White European descent (US Cen-
to directly affect clinical practice (Burns & Grove, 2017). Sack- sus Bureau, 2015). Taken together as a portent for future health-
ett and colleagues (1996) stressed the use of the best evidence promotion strategies, these predictions about the population
available to answer clinical questions and explore the next best indicate that current knowledge of and approaches to health
evidence when appropriate. The next best evidence may include promotion may not meet the needs of the future US population
the individual clinical judgment that nurses acquire through (see Chapter 2).
clinical experience and clinical practice and other qualitative In addition to changes in the ethnic and racial distribution
approaches to research. within the population, the projected changes in age distribu-
Nurses need to recognize that research is important as tion will affect health-promotion practice. Considerable growth
a basis for their practice and that they need to participate in is expected in the proportion of the population that is aged 25
the research process. For example, both home health nurses years or older. For example, the post–World War II baby boom
and nurses in long-term care facilities are required to collect will increase the number of people in the 65 years and older
extensive data on the cognitive and physical functioning of age group between 2010 and 2030 (US Census Bureau, 2014).
 CHAPTER 1 Health Defined: Health Promotion, Protection, and Prevention 17

Although there was a drop in births after 1960, this decrease BOX 1.6 GENOMICS
has been offset by an increase in immigration, both legal and
Genetic research is primarily concerned with discovering, detecting, and treat-
illegal. More-restrictive immigration rules related to homeland
ing illnesses related to specific abnormal genetic sequences (Khoury, 2011;
security have limited legal immigration since 2002 (US Depart-
World Health Organization, 2020b). Genomics, as a research focus, involves
ment of Homeland Security, 2016). Analysis of these population the study of all human genes, which are collectively called the human genome.
trends and projections helps health professionals determine The study and practice of genomics are concerned with how genes express
changing needs. In addition, analysis of the social and economic themselves and how they interact with each other and the environment to
environment is necessary for the development of social policy encourage or discourage disease (Allen et al., 2014). Genomic interests range
concerning health. from an individual level to a population-based level similar to health-promoting
activities. Genomics at an individual level is concerned with an individual’s
risks related to that person’s genomic profile and environmental stimuli. At the
SHIFTING PROBLEMS population level, genomics is concerned with large-scale patterns of genomic
The provision of personal health services must be influenced risk and how that plays out in the public arena. Therefore population-based
public health genomics is involved with policy development, prioritizing useful
by current information regarding environmental health. Envi-
genomic information, and ensuring that genomic information is discovered and
ronmental pollution is a complex and increasingly hazardous
used ethically and responsibly (Khoury, 2011).
problem. Diseases related to industry and technology, includ- Lifestyle, environment, and genetics and the interaction among the three are
ing asthma and trauma, have become important threats to determining factors of disease. Currently the focus of much intervention is on
health. the lifestyle and environmental contributors to disease. Because we are just
The physical and psychological stresses of a rapidly changing beginning to look at the genomic components of disease and how they inter-
and fast-paced society present daily problems, such as psycho- act with lifestyle and environment, the current scientific discussion revolves
social and spiritual poor health habits. Posttraumatic stress dis- around the ethical implications of private and public genomic interventions.
order is becoming a more common diagnosis and suicide is on Current debate surrounding population genomics focuses on the public’s “right
the rise (American Foundation for Suicide Prevention, 2020). not to know” (Edge & Coop, 2020). Genomic information can be used to formu-
Terrorism is also affecting the mental health of our families late public health information and initiatives. There are potential social justice
ramifications in sharing large-scale genomic information, which may accentu-
(National Academies of Sciences, Engineering, and Medicine,
ate discrimination and worsen stigma. If the information is too complex or dif-
2017; Comer, Furr, & Gurwitch, 2019). Obesity, partly attrib-
ficult to comprehend, it may demotivate people from making needed positive
uted to a lack of exercise and increasing food portion size, is a changes. For example, if there is a health behavior that is linked to a particular
growing health issue. The ingestion of potentially toxic, non- genomic profile, knowing that could help those who do not have the genomic
nutritious, high-fat foods is another contributing factor (see profile become motivated to change their behavior, whereas people with the
Chapter 11). The abuse of tobacco products, drugs, and alcohol genetic profile might become demotivated to change their behavior. Because
also negatively affects health. it is a combination of factors that cause disease, just because a person has
The emphasis on treating disease through the application the genetic profile does not mean it is an absolute that the person will get the
of complex technology not only is costly but also contrib- disease, so sharing this information incautiously may be a disservice to public
utes minimally to the improvement of health. An orientation health as opposed to a service. Careful consideration of the risks and benefits
toward illness clearly focuses on the effects rather than the of sharing public genomic-related information is essential.
causes of disease. During epidemics and pandemics, which From Allen, C., Senecal, K., & Avard, D. (2014). Defining the scope of
are rare but still occur, basic prevention activities are needed. public engagement: Examining the “right not to know” in public health
Washing hands and physical distancing will help prevent the genomics. Public Health Genomics, 42(1), 11–18; Khoury, M. J. (2011). Pub-
spread of these rare and lethal infectious diseases. A medi- lic health genomics: The end of the beginning. Genetics in Medicine, 13(3),
206–209. Edge, M., & Coop, G. (2020). Attacks on genetic privcacy
cal model will not suffice in these cases, and following public via uploads to genealogical databases. eLife, 9: e51810. https://doi
health standards are essential. Testing, contact tracing, symp- .org/10.7554/eLife.51810.
tom monitoring, isolation, and treatment are all important
activities that need to occur to curtail the spread of these rare
infectious diseases.
MOVING TOWARD SOLUTIONS
A substantial change in wellness patterns is occurring. Infec-
tious and acute diseases were the major causes of death in the Solutions are neither simple nor easy, but they can be focused
early part of the 20th century, whereas chronic conditions, in two major directions: individual involvement and govern-
heart disease, cerebrovascular accident (stroke), and cancer are ment involvement. The first direction concentrates on actions
currently the major causes. An emphasis on the diagnosis and of the individual, especially actions related to lifestyle choices
treatment of disease, which were highly successful in the past, across the life span. The learning and the inherent changes that
is not the answer for today’s needs, which are closely related to are involved require the adoption of a new set of skills by people
and affected by the individual’s biochemical functioning, genet- who will need the assistance of nurses to make those changes.
ics, environment, and personal choices (Box 1.6: Genomics). Approximately 40% of the US population has difficulty securing
The Patient Protection and Affordable Care Act (US Congress, the basic necessities of housing, food, utilities, and health care.
2010) was enacted to begin the process of paying for health pro- These difficulties are most prevalent among adults with lower
motion by providing insurance coverage for more people and by incomes but not limited to this group. They are experienced
covering preventive health services. by families with working members and by those above the
18 UNIT 1 Foundations for Health Promotion

poverty line (Karpman, Zuckerman, & Gonzalez, 2018). Levy governmental intervention. Health ecology and planning are
(2016) found that there is a definite link between health status important areas for government involvement in the future. The
and hardship. The sicker an older American is, the more likely redirection of the existing health care delivery system, putting
he or she is to suffer hardships of food insecurity, medication more emphasis on primary prevention, is probably the most dif-
reduction, and difficulty paying bills. (Levy, 2016). Motivational ficult and the most far-reaching goal; however, an emphasis on
factors play a large role in influencing attitudinal change. As dis- a wellness system is necessary to improve the health of the US
cussed in Chapter 10, programs for health promotion and health population.
education are only part of the answer. Financial incentives for
prevention may be another motivating factor, and health advo-
cacy by professionals in the health field is critical. In addition, TYING IT ALL TOGETHER USING THE
private and public action at all levels is needed to reduce social NURSING PROCESS
and environmental health hazards. Toxic agents in the environ-
ment such as particles from diesel emissions and social condi- Problem Identification
tions such as school overcrowding can present health hazards How many problems are present in Frank’s situation? The
that may not be detected for years; therefore it is necessary for answer depends on who is asked the question and his or her
individuals and the government to play a role. position in relation to Frank. Each point of view focuses on
Legislation and financing that relate to primary prevention different aspects of Frank’s life. His physician, using a clinical
are discussed in Chapter 3. Government activity, in the form model of health, might say that Frank has coronary heart dis-
of legislation, is currently increasing in this area. For example, ease with an acute myocardial infarction, hypertension, hyper-
increasing the activity time in schools, mandating seat belt use, lipidemia, chronic bronchitis, and obesity. But Frank’s problems
and implementing taxes on gasoline use are specific areas for also represent a failure to meet several of the Healthy People

CASE STUDY
Health Assessment: Frank Thompson and Family
Frank Thompson’s large brick home is located off a rural country road. A few of his career. Frank’s primary care provider, whom Frank visited regularly, said
yards away stands the small house where Frank was born at the start of the Frank’s blood pressure and serum lipid levels were both higher than normal and
Korean War. Frank was raised knowing the odds that he faced as a poor tenant that he had chronic bronchitis. The physician urged Frank to take the actions that
farmer. He helped his father, Ben, with their small tobacco and corn crops. They Frank already recognized: reduce smoking, drinking, and intake of saturated fats
were unaware that the hazardous chemicals in the pesticides they used would and calories; get more exercise; and find ways to relax. However, Frank’s life was
later affect Ben’s life. As his father often reminded him, Frank had to do better too busy for exercise. He had to work harder because he had been promoted, but
than others in school so he would not be doomed to the tenant farmer’s life. he also had to appear in control and relaxed, which was an essential character-
However, Frank’s school attendance was erratic because it was interrupted by istic for a prospective vice president. To meet these goals, Frank tended to drink
the frequent demand of tending field crops. Thin and often tired, Frank had recur- and smoke more. He also refused to take medication for problems he could not
rent infections. Rural health care services were insufficient or not accessible. see. Without the outward signs of disease, Frank believed he was out of shape
The school nurse helped the Thompson family obtain the necessary medication but generally healthy. Then Sada noted that his chance for promotion might actu-
for Frank’s initial infection, but the family was never able to afford the penicillin ally improve if he lost some weight; therefore Frank registered for a physical
that was necessary to prevent recurrent infections. fitness program that he could attend on Sunday mornings and before work during
Inspired by the early work of Martin Luther King, Jr., Frank was intent on the week. At his first workout, the classic sharp pain gripped his chest and Frank
helping at home and building something better for his future. Frank managed to had a massive heart attack.
more than compensate for his lost time at school. He passed his college entrance Weeks later, Frank was convalescing at home after being released from the
examinations and was awarded one of the new equal opportunity grants, which local hospital’s coronary care facility. He was lucky to survive the heart attack,
offered him a choice of attending any of the Ivy League schools in the North- and he was also fortunate to have most of the health care services covered by
east. Instead, he chose the prestigious public Southern University and eventually his medical insurance plan; in addition, 80% of his earnings were protected by
earned a master of business administration degree. He married Sada, his long- the company’s disability program. (Most people in the United States do not have
time girlfriend, and the two planned their future. this protection.)
With a good job in a large local sales firm, Frank built his house and started However, Frank’s dreams of promotion were shattered. For many months he
a family. He moved from being a salesman to being a division head and often could go to the office only two or three times a week at most, simply to deal with
traveled to regional meetings, sometimes accompanied by Sada and their three routine matters. He could not travel, for business or otherwise, for a long time.
children. Frank’s dream of sharing his success with his family included using part He was also skeptical about his cardiac rehabilitation program because his heart
of his earnings to help his brothers and sisters with their education. attack happened during exercise.
This new way of life meant Frank had little time for relaxation and frequently Reflective Questions
had to attend business luncheons and career-promoting social events. Frank kept • As a nurse, how would you explain to Frank that his heart attack was not
late hours and worked long weekends. Food, alcoholic beverages, and cigarettes caused by his exercise?
helped Frank relax before and after important business and social encounters; • How might a family approach to diet and exercise work with this family, given
these softened the edges of hard bargaining and were status symbols. its structure and background?
Not surprisingly, Frank gained weight. He had a persistent cough, which was • Are there things you do to cope with stress that may be making your health
probably a result of the smoking habit that developed during the early years worse?
 CHAPTER 1 Health Defined: Health Promotion, Protection, and Prevention 19

2020/2030 objectives on a personal level. Reducing illness, dis- at this level means examining how to move Frank back into his
ability, and death related to tobacco use and reducing chronic work role without further jeopardizing his health. Frank and
disease risk through the consumption of healthful diets and Sada also need to examine if he could continue in this position,
achievement of healthy body weights are two examples. His given its potential effect on his health.
nurse can add that he has paid little attention to his lifestyle, Frank and his family used a broader perspective than
even after changes were recommended. He continues to overeat, the medical personnel or the corporation. They knew that to
drink too much, smoke, not exercise, and live a stressful life. achieve the family’s economic and educational goals and still
Frank’s employer sees a man who has potential but who is now spend time together they had to make decisions that would ulti-
too disabled to take on new responsibilities and perhaps unable mately affect Frank’s health. Similar to many Americans, they
to continue performing his previous duties. Frank’s children had been willing to live with Frank’s job pressures and stress-
might feel that he can no longer take them on trips or play with ful lifestyle caused by the economy. The family members were
them. His wife, Sada, knows that their plans for educating their aware of their impoverished roots and had no wish to return to
children, and for travel and enjoyment, might suffer. The human them. However, they also recognized that the strength of their
resource personnel who manage Frank’s health insurance and family, their ability to work together to achieve goals, and their
retirement program would say that he has an expensive disease, faith were assets that could be used for support.
and the state health planner would point out that Frank’s prob- Frank’s social network of friends, relatives, and church mem-
lem is only one of a growing number of disabling illnesses that bers became an additional asset. They helped the family through
result from preventable causes. A reviewer for Healthy People the difficult initial weeks at home by delivering meals, taking
2020 might see Frank as part of the aggregated data on heart care of the yard work and laundry, and providing companion-
disease, indicating a continuing increase in the incidence of ship so Sada could shop and have time alone. As Frank recov-
heart disease among Black non-Hispanic men. ered, they would provide support for the social and lifestyle
To Frank, his health problems are multidimensional. His ini- changes that Frank and his family needed to make.
tial fear of dying, pain, dependence, and frustration decreased The nurse-led cardiovascular rehabilitation group played
as he began to feel better, but Frank is haunted by his realization a vital role in Frank’s recovery. As the physician continued to
that he might never be able to achieve his dreams for himself monitor Frank’s cardiac status, the nurse began the long process
and his family. Although theoretically in his prime, Frank sud- of working with Frank to modify his habits. He had stopped
denly sees himself as far older than his years, both in body and smoking while in the hospital, but with more free time than
in social achievement. He believes he has reached his limit and usual, he was craving to smoke again. Using an asset planning
that he will never again have the freedom to choose his future. approach and Gordon’s (2020) functional health patterns, the
He and his family needed to evaluate their situation and make nurse identified the changes that Frank needed to make to
alternative plans based on asset planning. decrease the risk of a second heart attack. A plan was developed
to help Frank begin to take control of his life through behav-
Planning Interventions ior changes. These changes included relaxation techniques, diet
Rather than emphasizing the chronic health issues and related modification, smoking cessation, and mild chair exercises. The
problems, the nurse can begin with asset planning within the support of the family was enlisted to reinforce the changes Frank
family. Asset planning is a planning approach that, given the was willing to make, because social support and environmental
realities of the present, helps to focus the family members and changes are shown to enhance personal decision-making. His
their providers on the building blocks for their future. It focuses employer was contacted and agreed to a plan enabling Frank
on the assets or strengths of the individual, the family, and the to work from home via Internet while the workplace became
community, applying those assets to improve or maintain the smoke free. Frank became an asset to the workplace, serving
current level of functioning. as a spokesperson for the benefits of lifestyle change. He was
Frank’s physician and nurse can begin with the fact that Frank enlisted to talk with other employees about stress management,
survived his first myocardial infarction. The coronary damage exercise, weight reduction, and smoking cessation based on his
resulting from this event becomes the baseline for determin- personal experiences.
ing future change in the lives of Frank and his family. Earlier, Health planners and public health officials used the broadest
Frank’s physician had taken a broader time perspective when perspective in asset planning by viewing Frank as an example
he advised Frank to reduce his cigarette smoking, which was of a person whose potential shifted as a result of a preventable,
contributing to both his bronchitis and his hypertension, and disabling illness. The planners looked to public and private
to change his high-fat diet and sedentary habits, which contrib- community patterns and policies that increase healthful hab-
uted to his weight problem and his high blood pressure. These its and living conditions. Work schedules and work load; stress
lifestyle changes now become tools for Frank’s recovery and for and safety in work environments; affirmative action programs
change within his family. His cardiac event also becomes a risk for jobs and wages; availability of public transportation sys-
factor for heart disease in the lives of his children. tems, recreational facilities, and economically accessible hous-
Looking at the immediate future, Frank’s employer saw the ing; farm price subsidies for food and tobacco crops that affect
effect of the event on Frank’s position within the company. buying patterns; excise taxes and regulation of health-damaging
Frank would have a long recovery that could be successful if he drugs such as alcohol and nicotine were all taken into consid-
adhered to his cardiac rehabilitation program. Asset planning eration (Richmond, Virginia: Health in all Policies, n.d.; Grzy-
20 UNIT 1 Foundations for Health Promotion

wacz & Fuqua, 2000). The asset planning approach emphasized limited than they were before his heart attack, but his family
the positive actions that could be made at the personal, employ- responded by seeking tuition support from community organi-
ment, community, and societal levels to minimize the effects of zations. Frank found that his contacts in both the corporate and
Frank’s illness and related diseases, thereby addressing all levels the nonprofit sectors increased his value to his new employer.
of the ecological model of health. Frank’s entire life, internal and external, had changed. He had
learned to adapt to his health problems and had developed a
What Was the Actual Cause of Frank’s Problem? more eudaimonistic approach to health and life.
It is not possible to separate one cause from another because Frank’s situation illustrates how causes and effects in life and
heart disease is a multifactorial disease. In Frank’s case the health tend to merge into constant, inseparable interconnections
sources of illness were found in the many interrelationships in between individuals and their worlds. A person’s health status is a
his life. Attempting to treat or change each factor as a separate reflection of a web of relationships that characterize that person’s
entity can have only a limited effect on the improvement of over- life. Health is not an achievement or a prize but a high-quality
all health. Frank’s health problems were numerous. In addition interaction between a person’s inner and outer worlds that pro-
to a poor diet, weight gain, lack of exercise, and smoking, his vides the capacity to respond to the demands of the biologic, psy-
hyperlipidemia, an adaptive biologic response to the pressures chological, and environmental systems of these worlds.
in his life, further debilitated him. It eventually led to clogged Which of the Healthy People 2030 proposed objectives listed
coronary vessels, and his responses became maladaptive. His in Box 1.7 apply to the promotion of Frank’s health?
hypertension, resulting from his diet and time-constrained life- Clearly, the area of heart disease and stroke is most applica-
style, complicated by the buildup of plaque secondary to hyper- ble. The Healthy People 2030 website (https://www.healthypeo-
lipidemia, was also a biologic attempt to adjust to a situation ple.gov/sites/default/files/ObjectivesPublicComment508.pdf)
that contributed to an imbalance between his personal resources has a number of objectives that relate directly to the prevention
and the demands of his family and the economic world. Frank’s of heart disease, hypertension, and hyperlipidemia, including
smoking was a psychosocial means to help him relieve some objectives that relate to treatment options and training the pub-
of the emotional pressures. It may have served this short-term lic to recognize and respond to nutrition and weight (Box 1.7:
purpose but only at a silently rising cost to his health. Cigarette Selected Healthy People 2030 Objectives). From the information
use by persons who have hypertension or high serum choles- about Frank and his experience, determine what his children
terol levels multiplies their risk of coronary heart disease (Zhu, should be taught on the basis of the Healthy People 2030 objec-
Nelson, Toth, & Muscat, 2019). tives in this focus area.

Evaluation of the Situation

The health status of an individual or population depends on a
SUMMARY
sustainable balance of the complex responses between physi- The ways individuals define health and health problems are
ologic, psychological, and social and environmental factors. important because definitions influence attempts to improve
Health was initially conceived as a biologic state, with genetic health and care delivery. In the case study, Frank Thompson’s
endowment as the starting point. However, health involves psy- health was affected by obvious, immediate, and personal factors,
chological and social aspects and is interpreted within the con- such as his diet and employment pressures. Nevertheless, his
text of the immediate environment. problems had their roots in the social and economic conditions
The interconnections between biophysical, psychological, of his parents; in his own early history of illness, education, and
and environmental causes and consequences did not end with work; and in his and his family’s hopes and aspirations. His phy-
Frank’s heart attack. His heart attack was only the most dra- sician defined Frank’s problem in immediate biomedical terms.
matic sign that health-damaging responses outweighed health- Public health planners, who saw Frank’s problem on a longer-
promoting ones. The “tip of the iceberg” analogy is frequently term population basis, sought policy solutions to the problem
used to illustrate the importance of identifying individuals with of preventing cardiovascular disease.
subclinical symptoms. High blood lipid levels, high blood pres- The view taken in this text is that a broad and longer-term
sure, obesity, smoking, and persistent worrying were no less perspective of health is the best guide to promoting health more
important than the infarction in shaping the status of Frank’s effectively, even as nurses deal with individual problems on a
health. Repairing the damage to Frank’s heart without chang- daily basis. Health is a sustainable balance between internal and
ing his lifestyle, habits, and work environment would only buy a external forces. Health allows people to move through life free
brief amount of time before further damage would occur. from the constraints of illness and promotes healing.
The infarction and resulting disability also permanently Illness represents an imbalance that human choices (inter-
reshaped Frank’s environment. After a few months of working twined social, political, spiritual, professional, and personal
full-time, Frank realized that he needed to find a less stressful choices) contribute to. In the United States, communities may
job. He recognized that his sales administration skills were an still have time to reduce the onslaught of chronic disability and
asset and began interviewing in the nonprofit sector. Ultimately, shift the direction, slow the pace, and humanize the scope of
he landed a job at half his previous salary but with excellent economic and social life.
benefits and a flexible work environment. His reduced income Shifting directions in current health care patterns may be
meant that his children’s educational opportunities were more possible only when nurses and other health professionals do
 CHAPTER 1 Health Defined: Health Promotion, Protection, and Prevention 21

BOX 1.7 SELECTED HEALTHY PEOPLE 2030 OBJECTIVES

Access to Health Services • SDOH-2030-03 Reduce the proportion of persons living in poverty.
Core Objectives • SDOH-2030-04 Reduce the proportion of all households that spend more than
• AHS-2030-01 Increase the proportion of persons with medical insurance. 30% of income on housing.
• AHS-2030-02 Increase the proportion of persons with dental insurance. Research Objectives
• AHS-2030-05 Reduce the proportion of persons who are unable to obtain or • SDOH-2030-R01 Increase the proportion of federal data sources that collect
delay in obtaining necessary medical care. country of birth as a variable.
• AHS-2030-08 Increase the proportion of adults who receive appropriate evi-
dence-based clinical preventive services. Nutrition and Weight Status
Core Objectives
Research Objectives • NWS-2030-01 Reduce household food insecurity and in doing so reduce
• AHS-2030-R01 Increase the capacity of the primary care and behavioral health hunger.
workforce to deliver high quality, timely, and accessible patient-centered care • NWS-2030-02 Reduce the portion of adults who have obesity.
• AHS-2030-R02 Increase the use of telehealth to improve access to health • NWS-2030-04 Increase the proportion of physician office visits made by adult
services care recipients who have obesity that include counseling or education related
to weight reduction, nutrition, or physical activity.
Social Determinants of Health • NWS-2030-06 Increase consumption of total vegetables in the population
Core Objectives aged 2 years and older.
• SDOH-2030-01 Increase the proportion of children aged 0–17 years living • NWS-2030-09 Reduce the consumption of calories from added sugars in the
with at least one parent employed year round, full time. population aged 2 years and older.

US Department of Health and Human Services. [Internet]. Healthy People 2030. Office of Disease Prevention and Health Promotion. Retrieved from https://health.gov
/healthypeople/objectives-and-data/browse-objectives.

what is expected of them as leaders in the care of health: to individuals, the public, other professionals, and other nations.
work with others through open processes; to provide leadership Responsibility also means evaluating the social and individual
in finding the vision and the path; and to inform, educate, and consequences, the long-term and short-term effects, and the
reeducate themselves, their colleagues, the media, and the gen- public and private interests that are involved when one is decid-
eral public using research findings and evidence-based practice ing on the set of tools to use in the care of health.
methods.
The responsibility of nurses as health professionals today is
to see the health problem in new ways and help others to do the EVOLVE CHAPTER FEATURES
same. Responsibility means developing new roles and examin- http://evolve.elsevier.com/Edelman/
ing the problem through others’ viewpoints, including those of • Study Questions

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 2
Vulnerable Populations and Health
Kimberly L. Malin, Amber S. Mcllwain, Frank Tudini, Sheng-Che Yen, Kevin K. Chui

http://evolve.elsevier.com/Edelman/

OBJECTIVES
After completing this chapter, the reader will be able to: • Native Hawaiians/Pacific Islanders
• Differentiate among ethnicity, ethnic group, race, and • Refugees
minority group. • Describe health concerns and issues of vulnerable populations.
• Describe demographic data relative to vulnerable • Discuss selected cultural factors that may have an impact
populations: on the health and well-being of vulnerable populations.
• American Indians/Alaskan Natives • Contrast the folk healing system with the professional care
• Arab Americans system.
• Asian Americans • Explain strategies for health care professionals to meet the
• Black/African Americans needs of vulnerable populations
• Homeless persons • Identify tools available to help meet the health care needs
• Immigrants of immigrants.
• LGBTQ community members • Describe initiatives to address the health care concerns of
• Latino/Hispanic Americans vulnerable populations.

KEY TERMS
Chi Gender expression Race
Complementary alternative and Gender identity Racism
integrative medicine (CAM) Gender transition Refugees
Cultural and linguistic competence Harm reduction Sexual orientation
Culturally congruent practice Health disparities Social determinants of health
Cultural respect Health equity Taoism
Culture Homelessness Transcultural nursing
Ethnic groups Hot and cold concept of disease Transgender
Ethnicity Immigrants Value orientations
Ethnocentric perspective Intersectionality Values
Female genital alteration (FGA) Jing Vulnerable populations
Female genital mutilation/cutting Minority group Yang
(FGM/C) Nurse care systems Yin
Folk healing system Professional care systems

SOCIAL DETERMINANTS OF HEALTH AND conditions, gender discrimination, racism, globalization,

HEALTH EQUITY and urbanization contribute to health disparities and ineq-
uity worldwide. These factors, termed social determinants
Social factors contribute significantly to health disparities of health, contribute to an individual’s capability to attain
within the United States and across countries. Factors such good health, which is a function of one’s ability to access and
as employment conditions, social exclusion, public health receive quality health care (US Department of Health and
25
Another random document with
no related content on Scribd:
“But Wealthy’s testimony, linking my presence at the upper door of
uncle’s room with the person she heard tampering with the glass
believed by all to have held the draught which was the cause of his
death?”
“Mr. Bartholomew, are you sure she saw your figure fleeing down the
hall?”
I was on the point of saying, “Whose else? I did rush down the hall,”
when he sharply interrupted me.
“What we want to know and must endeavor to find out is whether,
under the conditions, she could see your shadow or that of any other
person who might be passing from front to rear sufficiently well to
identify it.”
Greatly excited, I stared at him.
“How can that be done?”
“Well, Mr. Bartholomew, fortunately for us we have a friend at court.
If we had not, I judge that you would have been arrested on leaving
the court-house.”
“Who? Who?” My heart beat to suffocation; I could hardly articulate.
Did I hope to hear a name which would clear my sky of every cloud,
and make the present, doubtful as it seemed, a joy instead of a
menace? If I did, I was doomed to disappointment.
“The Inspector who was the first to examine you does not believe in
your guilt.”
Disappointment! but a great—a hopeful surprise also! I rose to my
feet in my elation, this unexpected news coming with such a shock
on the heels of my despair. But sat again with a gesture of apology
as I met his steady look.
“I know this, because he is a friend of mine,” he averred by way of
explanation.
“And will help us?”
“He will see that the experiment I mention is made. Poison could not
have got into that glass without hands. Those hands must be
located. The Police will not cease their activities.”
“Mr. Jackson, I give you the case. Do what you can for me; but—”
I had risen again, and was walking restlessly away from him as I
came to this quick halt in what I was about to say. He was watching
me, carefully, thoughtfully, out of the corner of his eye. I was aware
of this and, as I turned to face him again, I took pains to finish my
sentence with quite a different ending from that which had almost
slipped from my unwary tongue.
“But first, I want your advice. Shall I return to the house, or go to the
hotel and send for my clothes?”
“Return to the house, by all means. You need not stay there more
than the one night. You are innocent. You believe that the house and
much more are yours by your uncle’s will. Why should you not return
to your own? You are not the man to display any bravado; neither
are you the man to accept the opinion of servants and underlings.”
“But—but—my cousin, Orpha? The real owner, as I look at it, of
everything there?”
“Miss Bartholomew has a just mind. She will accept your point of
view—for the present, at least.”
I dared not say more. I was never quite myself when I had to speak
her name.
He seemed to respect my reticence and after some further talk, I left
him and betook myself to the house which held for me everything I
loved and everything I feared in the world I had made for myself.

XXXIII
During the first portion of this walk I forced my mind to dwell on the
astonishing fact that the Inspector whom I had regarded as holding
me in suspicion was the one man most convinced of my innocence.
He had certainly shown no leaning that way in the memorable
interview we had held together. What had changed him? Or had I
simply misunderstood his attitude, natural enough to an amateur
who finds himself for the first time in his life subject to the
machinations of the police.
As I had no means of answering this query, I gradually allowed the
matter, great as it was, to slip from my mind, and another and more
present interest to fill it.
I was approaching the Bartholomew mansion, and its spell was
already upon me. An embodiment of beauty and of mystery! A
glorious pile of masonry, hiding a secret on the solution of which my
honor as a man and my hope as a lover seemed absolutely to
depend.
There was a mob at either gate, dispersing slowly under the efforts
of the police. To force my way through a crowd of irritated,
antagonistic men and women collected perhaps for the purpose of
intercepting me, required not courage, but a fool’s bravado. Between
me and it I saw an open door. It belonged to a small shop where I
had sometimes traded. I ventured to look in. The woman who usually
stood behind the counter was not there, but her husband was and
gave me a sharp look as I entered.
“I want nothing but a refuge,” I hastily announced. “The crowd below
there will soon be gone. Will it incommode you if I remain here till the
street is clear?”
“Yes, it will,” he rejoined abruptly, but with a twinkle of interest in his
eye showing that his feelings were kindlier than his manner. “The
better part of the crowd, you see, are coming this way and some of
them are in a mood far from Christian.”
By “some of them,” I gathered that he meant his wife, and I stepped
back.
“People have such a way of making up their minds before they see a
thing out,” he muttered, slipping from behind the counter and
shutting the door she had probably left open. “If you will come with
me,” he added more cheerfully, “I will show you the only thing you
can do if you don’t want a dozen women’s hands in your hair.”
And, crossing to the rear, he opened another door leading into the
yard, where he pointed out a small garage, empty, as it chanced, of
his Ford. “Step in there and when all is quiet yonder, you can slip into
the street without difficulty. I shall know nothing about it.”
And with this ignominious episode associated with my return, I finally
approached the house I had entered so often under very different
auspices.
I had a latch-key in my pocket, but I did not choose to use it. I rang,
instead. When the door opened I took a look at the man who held
the knob in hand. Though he occupied the position of butler in the
great establishment, and was therefore continually to be seen at
meals, I did not know him very well—did not know him at all; for he
was one of the machine-made kind whose perfect service left
nothing to be desired, but of whose thoughts and wishes he gave no
intimation unless it was to those he had known much longer than he
had me.
Would he reveal himself in face of my intrusion? I was fully as
curious as I was anxious to see. No; he was still the perfect servant
and opened the door wide, without a gleam of hostility in his eye or
any change in his usual manner.
Passing him, I stepped into the court. The fountain was playing. The
house was again a home, but would it be a home to me? I resolved
to put the question to an immediate test upstairs. Hearing Haines’
steps passing behind me on his way to the rear, I turned and asked
him if Mr. Bartholomew had returned. Then I saw a change in the
man’s face—a flash of feeling gone as quickly as it came. It had
always been, “Does Mr. Edgar want this or Mr. Edgar want that?”
The use of his uncle’s name in designating him, seemed to seal that
uncle forever in his tomb.
“You will find him in the library,” was Haines’ reply as he passed on;
and looking up, I saw Edgar standing in the doorway awaiting me.
Without any hesitation I approached him, but stopped before I was
too near. I was resolved to speak very plainly and I did.
“Edgar, I can understand why with this hideous doubt still unsettled
as to the exact person who, through accident we hope, was
unfortunate enough to be responsible for our uncle’s death, you
should find it very unpleasant to see me here. I have not come to
stay, though it might be better all around if I were to remain for this
one night. I loved Uncle. I am innocent of doing him any harm. I
believe him to have made me the heir to this estate in the will thus
unhappily lost to sight, but I shall not press my claim and am willing
to drop it if you will drop yours, leaving Orpha to inherit.”
“That would be all right if the loss of the will were all.”—Was this
Edgar speaking?—“But you know and I know that the loss of the will
is of small moment in comparison to the real question you mentioned
first. The verdict was murder. There is no murder without an active
hand. Whose hand? You say that it was not yours. I—I want to
believe you, but—”
“You do not.”
His set expression gave way; it was an unnatural one for him; but in
the quick play of feature which took its place I could not read his
mind, one emotion blotting out another so rapidly that neither heart
nor reason could seize satisfactorily upon any.
“You do not?” I repeated.
“I know nothing about it. It is all a damnable mystery.
“Edgar, shall I pack up my belongings and go?”
He controlled himself.
“Stay the night,” he said, and, turning on his heel, went back into the
library.
Then it was that I became aware of the dim figure of a man sitting
quietly in an inconspicuous corner near the stairway.
It needed no perspicacity on my part to recognize in him a police
detective.
I found another on the second floor and my heart misgave me for
Orpha. Verily, the police were in occupation! When I reached the
third, I found two more stationed like sentinels at the two doors of my
departed Uncle’s room. This I did not wonder at and I was able to
ignore them as I hurried by to my own room where I locked myself in.
I was thankful to be allowed to do this. I had reached the point where
I felt the necessity of absolute rest from questioning or any thought
of the present trouble. I would amuse myself; I would smoke and
gradually pack. The darkness ahead was not impenetrable. I had a
friend in the Inspector. Edgar had not treated me ill—not positively ill.
It would be possible for me to appear at the dinner-table; possibly to
face Orpha if she found strength to come. Yet were it not well for her
to be warned that I was in the house? Would Edgar think of this?
Yes, I felt positive that he would and then if she did not come—
But nothing must keep her from the table. I would not go myself
unless summoned. I stood in no need of a meal. In those days I was
scarcely aware of what I ate. On this night it seemed simply
unbelievable that I should ever again crave food.
But a smoke was different. Sitting down by the window, I opened my
favorite box. It was nearly empty. Only a part of the lower layer
remained. Taking out a cigar, I was about to reach for a match when
I caught sight of a loose piece of paper protruding from under the
few cigars which remained. It had an odd, out-of-the-way look and I
hastened to pull it forth. Great Heaven! it appeared to be a note. The
end of a sheet of paper taken from my own desk had been folded
once and, on opening it, I saw this:
The kEy which MR. BARTH olomew ALWAYS WORE ON A
STRING ABOUT His neck wAs not there WHEN they Came to
Undress HIM BURN THIS aT Once
No signature; the letters, as shown above, had been cut carefully
from some magazine or journal. Was it a trap laid by the police; or
the well meant message of a friend? Alas! here was matter for fresh
questioning and I was wearied to the last point of human endurance.
I sat dazed, my brain in confusion, my faculties refusing to work. One
thing only remained clear—that I was to burn this scrawl as soon as
read. Well, I could do that. There was a fireplace in my room,
sometimes used but oftener not. It had not been used that day,
which had been a mild one. But that did not matter. The draught was
good and would easily carry up and out of sight a shred of paper like
this. But my hand shook as I set fire to it and watched it fly in one
quick blaze up the chimney. As it disappeared and the last spark was
lost in the blackness of the empty shaft, I seemed to have wakened
from a dream in which I was myself a shadow amongst shadows, so
remote was this incident and all the rest of this astounding drama
from my natural self and the life I had hoped to live when I crossed
the ocean to make my home in rich but commonplace America.
 XXXIV
“Miss Bartholomew wishes me to say that she would be glad to see
you at dinner.”
I stared stupidly from the open doorway at Haines standing
respectfully before me. I was wondering if the note I had just burned
had come from him. He had shown feeling and he had not shown me
any antagonism. But the feeling was not for me, but for the master
he had served almost as long as I was years old. So I ended in
accepting his formality with an equal show of the same; and
determined to be done with questions for this one night if no longer, I
prepared myself for dinner and went down.
I found Orpha pacing slowly to and fro under the glow of the colored
lamps which illuminated the fountain. Older but lovelier and nobler in
the carriage of her body and in the steady look with which she met
my advance.
Suddenly I stopped dead short. It was the first time I had entered her
presence without a vivid sense of the barrier raised between us by
the understanding under which we all met, that we were cousins and
nothing more, till the word was given which should release us to be
our natural selves again.
But the lift of one of her fingers, scarcely perceptible save to a lover’s
eye, brought me back to reason. This was no time for breaking down
that barrier, even if we were alone, which I now felt open to doubt,
and my greeting had just that hesitation in it which one in my position
would be likely to show to one in hers. Her attitude was kindly,
nothing more, and Edgar presently relieved me of the
embarrassment of further conversation by sauntering in from the
conservatory side by side with Miss Colfax.
Remembering the scene between them to which I had been a
witness on the night of the ball, I wondered at seeing them thus
together; but perceiving by the bearing of all three that she was
domiciled here as a permanent guest, this wonder was lost in
another: why Orpha should not sense the secret with which, as I
watched them, the whole air seemed to palpitate.
But then she had not had my opportunities for enlightenment.
A little old lady whom I had not seen before but who was evidently a
much esteemed relative of the family made the fifth at the dinner
table. Formality reigned. It was our only refuge from an
embarrassment which would have made speech impossible. As it
was, Miss Colfax was the only one who talked and what she said
was of too little moment to be remembered. I was glad when the
meal was at an end and I could with propriety withdraw.
Better the loneliest of rooms in the dreariest of hotels than this.
Better a cell—Ah, no, no! my very soul recoiled. Not that! not that! I
am afraid that I was just a little mad as I paused at the foot of the
great staircase on my way up.
But I was sane enough the next moment. The front door had
opened, admitting the Inspector. I immediately crossed the court to
meet him. Accosting him, I said in explanation of my presence, “You
see me here, Inspector; but if not detained, I shall seek other
quarters to-morrow. I was very anxious to get back to my desk in
New York, if the firm are willing to receive me. But whether there or
here, I am always at your call till this dreadful matter is settled. Now
if you have no questions to ask, I am going to my room, where I can
be found at any minute.”
“Very good,” was his sole reply, uttered without any display of
feeling; and, seeing that he wished nothing from me, I left him and
went quickly upstairs.
I always dreaded the passage from the second floor to the third,—to-
night more than ever. Not that I was affected by the superstitious
idea connected by many with that especial flight of steps—certainly I
was too sensible a man for that, though I had had my own
experience too—but the dread of the acute memories associated
with the doors I must pass was strong upon me, and it was with relief
that I found myself at last in my own little hall, even if I had yet to
hurry by the small winding staircase at the bottom of which was a
listening ear acquainted with my every footfall.
Briskly as I had taken the turn from the main hall, I had had time to
note the quiet figure of Wealthy seated in her old place—hands in
lap—face turned my way—a figure of stone with all the wonted good
humor and kindliness of former days stricken from it, making it to my
eyes one of deliberate accusation. Was not this exactly what I had
feared and dreaded to encounter? Yes, and the experience was not
an agreeable one. But for all that it was not without its
compensations. Any idea I may have had of her being the one to
warn me that the key invariably carried by my uncle on his person
was not to be found there at his death, was now definitely eliminated
from my mind. She could not have shown this sympathy for me in my
anomalous position and then eye me as she had just done with such
implacable hostility.
My attention thus brought back to a subject which, if it had seemed
to lie passive in my mind, had yet made its own atmosphere there
during every distraction of the past hour, I decided to have it out with
myself as to what this communication had meant and from whom it
had come.
That it was no trap but an honest hint from some person, who, while
not interested enough to show himself openly as my friend but who
was nevertheless desirous of affording me what help he could in my
present extremity, I was ready to accept as a self-evident truth. The
difficulty—and it was no mean one, I assure you—was to settle upon
the man or woman willing to take this secret stand.
Was it Clarke? I smiled grimly at the very thought.
Was it Orpha? I held my breath for a moment as I contemplated this
possibility—the incredible possibility that this made-up, patched-up
line of printed letters could have been the work of her hands. It was
too difficult to believe this, and I passed on.
The undertaker’s man? That could easily be found out. But why such
effort at concealment from an outsider? No, it was not the
undertaker’s man. But who else was there in all the house who
would have knowledge of the fact thus communicated to me in this
mysterious fashion? Martha? Eliza? Haines? Bliss? The chef who
never left his kitchen, all orders being conveyed to him by Wealthy or
by telephone from the sick room?
No, no.
There was but one name left—the most unlikely of all—Edgar’s.
Could it be possible—
I did not smile this time, grimly or otherwise, as I turned away from
this supposition also. I laughed; and, startled by the sound which
was such as had never left my lips before, I rose with a bound from
my chair, resolved to drop the whole matter from my mind and calm
myself by returning to my task of looking over and sorting out my
effects. Otherwise I should get no sleep.

XXXV
What was it? It was hardly a noise, yet somebody was astir in the
house and not very far from my door. Listening, I caught the sound of
heavy breathing in the hall outside, and, slipping out of bed, crossed
to the door and suddenly pulled it wide open.
A face confronted me, every feature distinct in the flood of moonlight
pouring into the room from the opposite window. Alarm and
repugnance made it almost unrecognizable, but it was the face of
Edgar and no other, and, as in my astonishment I started backward,
he spoke.
“I was told—they said—that you were ill—that groans were heard
coming from this room. I—I am glad it is not so. Pardon me for
waking you.” And he was gone, staggering slightly as he
disappeared down the hall. A moment later I heard his voice raised
further on, then a door slam and after that, quiet.
Confounded, for the man was shaken by emotion, I sat down on the
edge of the bed and tried to compose my faculties sufficiently to
understand the meaning of this surprising episode.
Automatically, I looked at my watch. It was just three. I had
associations with that hour. What were they? Suddenly I
remembered. It was the hour I visited my uncle’s door the night
before his death, when Wealthy—
The name steadied the rush and counter-rush of swirling, not-to-be-
controlled thoughts. Mr. Jackson had spoken of an experiment to be
made by the police for the purpose of determining whether the
shadow Wealthy professed to have seen about that time flitting by on
the wall further down would be visible from the place where she
stood.
Had they been trying this?
Had he been the one—
There was no thoroughfare in this direction. And wearied to death, I
sank back on my pillow and after a few restless minutes fell into a
heavy sleep.

XXXVI
Next day the thunderbolt fell. Entering Mr. Jackson’s office, I found
him quite alone and waiting for me. Though the man was almost a
stranger to me and I had very little knowledge of his face or its play
of expression, I felt sure that the look with which he greeted me was
not common to him and that so far as he was concerned, my cause
had rather gained than lost in interest since our last meeting.
“You did not telephone me last night,” were his first words.
“No,” I said, “there was really no occasion.”
“Yet something very important happened in your house between
three and four in the morning.”
“I thought so; I hoped so; but I knew so little what, that I dared not
call you up for anything so indefinite. This morning life seems normal
again, but in the night—”
“Go on, I want to hear.”
“My cousin, Edgar, came to my door in a state of extreme agitation.
He had been told that I was ill. I was not; but say that I had been, I
do not see why he should have been so affected by the news. I am a
trial to him; an incubus; a rival whom he must hate. Why should he
shiver at sight of me and whirl away to his room?”
“It was odd. You had heard nothing previously, then?”
“No, I was fortunate enough to be asleep.”
“And this being a silent drama you did not wake.”
“Not till the time I said.”
He was very slow, and I very eager, but I restrained myself. The
peculiarity observable in his manner had increased rather than
diminished. He seemed on fire to speak, yet unaccountably
hesitated, turning away from my direct gaze and busying himself with
some little thing on his desk. I began to feel hesitant also and
inclined to shirk the interview.
And now for a confession. There was something in my own mind
which I had refused to bare even to my own perceptions. Something
from which I shrank and yet which would obtrude itself at moments
like these. Could it be that I was about to hear, put in words, what I
had never so much as whispered to myself?
It was several minutes later and after much had been said before I
learned. He began with explanations.
“A woman is the victim of her own emotions. On that night Wealthy
had been on the watch for hours either in the hall or in the sick room.
She had seen you and another come and go under circumstances
very agitating to one so devoted to the family. She was, therefore,
not in a purely normal condition when she started up from her nap to
settle a question upon which the life of a man might possibly hang.
“At least this was how the police reasoned. So they put off the
experiment upon which they were resolved to an hour approximately
the same in which the occurrence took place which they were
planning to reproduce, keeping her, in the meantime, on watch for
what interested her most. Pardon me, it was in connection with
yourself,” he commented, flashing me a look from under his shaggy
brows. “She has very strong beliefs on that point—strong enough to
blind her or—” he broke off suddenly and as suddenly went on with
his story. “Not till in apparent solitude she had worked herself up to a
fine state of excitement did the Inspector show himself, and with a
fine tale of the uselessness of expecting anything of a secret nature
to take place in the house while her light was still burning and her
figure guarded the hall, induced her to enter the room from which
she might hope to see a repetition of what had happened on that
fatal night. I honor the police. We could not do without them;—but
their methods are sometimes—well, sometimes a little misleading.
“After another half hour of keen expectancy, during which she had
not dozed, I warrant, there came the almost inaudible sound of the
knob turning in the upper door. Had she been alone, she would have
screamed, but the Inspector’s hand was on her arm and he made his
presence felt to such a purpose that she simply shuddered, but that
so violently that her teeth chattered. A fire had been lit on the hearth,
for it was by the light thus given that she had seen what she said she
had seen that night. Also, the curtains of the bed had been drawn
back as they had not been then but must be now for her to see
through to the shelf where the glass of medicine had been standing.
Her face, as she waited for whomever might appear there, was one
of bewilderment mingled with horror. But no one appeared. The door
had been locked and all that answered that look was the impression
she received of some one endeavoring to open it.
“As shaken by these terrors, she turned to face the Inspector, he
pressed her arm again and drew her towards the door by which they
had entered and from which she had seen the shadow she had
testified to before the Coroner. Stepping the length of the passage-
way intervening between the room and the door itself, he waited a
moment, then threw the latter open just as the shadow of a man shot
through the semi-darkness across the opposite wall.
“‘Do you recognize it?’ the Inspector whispered in her ear. ‘Is it the
same?’
“She nodded wildly and drew back, suppressing the sob which
gurgled in her throat.
“‘The Englishman?’ he asked again.
“Again she nodded.
“Carefully he closed the door; he was himself a trifle affected. The
figure which had fled down the hall was that of the man who had just
been told that you were ill in your room. I need not name him.”

XXXVII
Slowly I rose to my feet. The agitation caused by these words was
uncontrollable. How much did he mean by them and why should I be
so much more moved by hearing them spoken than by the
suppressed thought?
He made no move to enlighten me, and, walking again to the
window, I affected to look out. When I turned back it was to ask:
“What do you make of it, Mr. Jackson? This seems to place me on a
very different footing; but—”
“The woman spoke at random. She saw no shadow. Her whole story
was a fabrication.”
“A fabrication?”
“Yes, that is how we look at it. She may have heard some one in the
room—she may even have heard the setting down of the glass on
the shelf, but she did not see your shadow, or if she did, she did not
recognize it as such; for the light was the same and so was every
other condition as on the previous night, yet the Inspector standing
at her side and knowing well who was passing, says there was
nothing to be seen on the wall but a blur; no positive outline by which
any true conclusion could be drawn.”
“Does she hate me so much as that? So honest a woman fabricate a
story in order to involve me in anything so serious as crime?” I could
not believe this myself.
“No, it was not through hate of you; rather through her great love for
another. Don’t you see what lies at the bottom of her whole conduct?
She thinks—”
“Don’t!” The word burst from me unawares. “Don’t put it into words.
Let us leave some things to be understood, not said.” Then as his
lips started to open and a cynical gleam came into his eyes, I
hurriedly added: “I want to tell you something. On the night when the
question of poison was first raised by the girl Martha’s ignorant
outbreak over her master’s casket, I was standing with Miss
Bartholomew in the balcony; Wealthy was on her other side. As that
word rang up from the court, Miss Bartholomew fainted, and as I
shrieked out some invective against the girl for speaking so in her
mistress’ presence, I heard these words hissed into my ear. ‘Would
you blame the girl for what you yourself have brought upon us?’ It
was Wealthy speaking, and she certainly hated me then. And,” I
added, perhaps with unnecessary candor, “with what she evidently
thought very good reason.”
At this Mr. Jackson’s face broke into a smile half quizzical and half
kindly:
“You believe in telling the truth,” said he. “So do I, but not all of it.
You may feel yourself exonerated in the eyes of the police, but
remember the public. It will be uphill work exonerating yourself with
them.”
“I know it; and no man could feel the sting of his position more
keenly. But you must admit that it is my duty to be as just to Edgar as
to myself. Nay, more so. I know how much my uncle loved this last
and dearest namesake of his. I know—no man better—that if what
we do not say and must not say were true, and Uncle could rise from
his grave to meet it, it would be with shielding hands and a
forgiveness which would demand this and this only from the beloved
ingrate, that he should not marry Orpha. Uncle was my benefactor
and in honor to his memory I must hold the man he loved innocent
unless forced to find him otherwise. Even for Orpha’s sake—”
“Does she love him?”
The question came too quickly and the hot flush would rise. But I
answered him.
“He is loved by all who know him. It would be strange if his lifelong
playmate should be the only one who did not.”
“Deuce take it!” burst from the irate lawyer’s lips, “I was speaking of
a very different love from that.”
And I was thinking of a very different one.
The embarrassment this caused to both of us made a break in the
conversation. But it was presently resumed by my asking what he
thought the police were likely to do under the circumstances.
He shot out one word at me.
“Nothing.”
“Nothing?” My face brightened, but my heart sank.
“That is, as I feel bound to inform you, this is one of those cases
where a premature move would be fatal to official prestige. The
Bartholomews are held in much too high esteem in this town for
thoughtless attack. The old gentleman was the czar of this
community. No one more respected and no one more loved. Had his
death been attributed to the carelessness or aggression of an
outsider, no one but the Governor of the state could have held the
people in check. But the story of the two wills having got about,
suspicion took its natural course; the family itself became involved—
an enormity which would have been inconceivable had it not been
that the one suspected was the one least known and—you will
pardon me if I speak plainly, even if I touch the raw—the one least
liked: a foreigner, moreover, come, as all thought, from England on
purpose to gather in this wealth. You felt their animosity at the
inquest and you also must have felt their restraint; but had any one
dared to say of Edgar what was said of you, either a great shout of
derisive laughter would have gone up or hell would have broken
loose in that court-room. With very few exceptions, no one there
could have imagined him playing any such part. And they cannot to-
day. They have known him too long, admired him too long, seen him
too many times in loving companionship with the man now dead to
weigh any testimony or be moved by any circumstance suggestive of
anything so flagrant as guilt of this nature. The proof must be
absolute before the bravest among us would dare assail his name to
this extent. And the proof is not absolute. On the contrary, it is very
defective; for so far as any of us can see, the crime, if perpetrated by
him, lacks motive. Shall I explain?”
“Pray do. Since we have gone thus far, let us go the full length. Light
is what I want; light on every angle of this affair. If it serves to clear
him as it now seems it has served to clear me, I shall rejoice.”
Mr. Jackson, with a quick motion, held out his hand. I took it. We
were friends from that hour.
“First, then,” continued the lawyer, “you must understand that Edgar
has undergone a rigid examination at the hands of the police. This
may not have appeared at the inquest but nevertheless what I say is
true. Now taking his story as a basis, we have this much to go upon:
“He has always been led to believe that his future had been cut out
for him according to the schedule universally understood and
accepted. He was not only to marry Orpha, but to inherit personally
the vast fortune which was to support her in the way to which she is
entitled. No doubt as to this being his uncle’s intention—an intention
already embodied in a will drawn up by Mr. Dunn—ever crossed his
mind till you came upon the scene; and not then immediately. Even
the misunderstanding with his uncle, occasioned, as I am told, by Mr.
Bartholomew learning of some obligations he had entered into of
which he was himself ashamed, failed to awaken the least fear in his
mind of any change in his uncle’s testamentary intentions, or any
real lessening of the affection which had prompted these intentions.
Indeed, so much confidence did he have in his place in his uncle’s
heart that he consented, almost with a smile, to defer the
announcement of what he considered a definite engagement with
Orpha, because he saw signs of illness in his uncle and could not
think of crossing him. But he had no fear, as I have said, that all
would not come right in time and the end be what it should be.
“Nor did his mind change with the sudden signs of favor shown by
his uncle towards yourself. The odd scheme of sharing with you, by
a definite arrangement, the care which your uncle’s invalid condition
soon called for, he accepted without question, as he did every other
whim of his autocratic relative. But when the servants began to talk
to him of how much writing his uncle did while lying in his bed, and
whispers of a new will, drawn up in your absence as well as in his
began to circulate through the house, he grew sufficiently alarmed to
call on Mr. Dunn at his office and propound a few inquiries. The
result was a complete restoration of his tranquillity; for Mr. Dunn,
having been kept in ignorance of another lawyer having visited
Quenton Court immediately upon his departure, and supposing that
the will he had prepared and seen attested was the last expression
of Mr. Bartholomew’s wishes, gave Edgar such unqualified
assurances of a secured future that he naturally was thrown
completely off his balance when on the night which proved to be Mr.
Bartholomew’s last, he was summoned to his uncle’s presence and
was shown not only one new will but two, alike in all respects save in
the essential point with which we are both acquainted. Now, as I am
as anxious as you are to do justice to the young man, I will say that if
your uncle was looking for any wonderful display of generosity from
one who saw in a moment the hopes of a lifetime threatened with
total disaster, then he was expecting too much. Of course, Edgar
rebelled and said words which hurt the old gentleman. He would not
have been normal otherwise. But what I want to impress upon you in
connection with this interview is this. He left the room with these
words ringing in his ears, ‘Now we will see what your cousin has to
say. When he quits me, but one of these two wills will remain, and
that one you must make up your mind to recognize.’ Therefore,” and
here Mr. Jackson leaned towards me in his desire to hold my full
attention, “he went from that room with every reason to fear that the
will to be destroyed was the one favoring himself, and the one to be
retained that which made you chief heir and the probable husband of
Orpha. Have we heard of anything having occurred between then
and early morning to reverse the conclusions of that moment? No.
Then why should he resort to crime in order to shorten the few
remaining days of his uncle’s life when he had every reason to
believe that his death would only hasten the triumph of his rival?”
I was speechless, dazed by a fact that may have visited my mind,
but which had never before been clearly formulated there! Seeing
this, the lawyer went on to say:
“That is why our hands are held.”
Still I did not speak. I was thinking. What I had said we would not do
had been done. The word crime had been used in connection with
Edgar, and I had let it pass. The veil was torn aside. There was no
use in asking to have it drawn to again. I would serve him better by
looking the thing squarely in the face and meeting it as I had met the
attack against myself, with honesty and high purpose. But first I must
make some acknowledgment of the conclusion to which this all
pointed, and I did it in these words.
“You see! The boy is innocent.”
“I have not said that.”
“But I have said it.”
“Very good, you have said it; now go on.”
This was not so easy. But the lawyer was waiting and watching me
and I finally stammered forth:
“There is some small fact thus far successfully suppressed which
when known will change the trend of public opinion and clarify the
whole situation.”
“Exactly, and till it is, we will continue the search for the will which I
honestly believe lies hidden somewhere in that mysterious house.
Had he destroyed it during that interval in which he was left alone,
there would have been some signs left in the ashes on the hearth;
and Wealthy denies seeing anything of the sort when she stooped to
replenish the fire that night, and so does Clarke, who, at Edgar’s
instigation, took up the ashes after their first failure to find the will
and carefully sifted them in the cellar.”
“I have been wondering if they did that.”
“Well, they did, or so I have been told. Besides, you must remember
the look of consternation, if not of horror, which crossed your uncle’s