NRSG 780 - HEALTH PROMOTION AND

POPULATION HEALTH
Module 1: Overview of Population/Public Health
INTRODUCTION
This course is designed to address the American Association of Colleges of Nursing
(AACN) Essentials of Master’s Education in Nursing and the AACN Essentials of
Doctoral Education for Advanced Practice Nursing in the category Clinical Prevention
and Population Health for Improving the Nation’s Health. The course is also designed to
address components of the Association for Prevention Teaching and Research (APTR)
Healthy People Curriculum Task Force’s Clinical Prevention and Population Health
Curriculum Framework.
For information on the AACN Essentials click
on http://www.aacnnursing.org/Portals/42/Publications/MastersEssentials11.pdf a
nd http://www.aacnnursing.org/Portals/42/Publications/DNPEssentials.pdf. For
information on the ATPR Healthy People Curriculum Task Force’s Clinical Prevention
and Population Health Curriculum Framework click
on http://www.aptrweb.org/?page=HPC_Taskforce.
O VERVIEW
The purpose of this module is to provide an overview of Population and Public Health. It
emphasizes the fact that improvements in the quality of life and the longevity of
Americans since the late 19th century have been accomplished largely through public
health measures. The modern era of public health is highlighted and future goals for
improved population health, reduction of health disparities and disease prevention
strategies are introduced.
O BJECTIVES
At the conclusion of this module, the learner will be able to:
 Explain the need to establish health care priorities for the population
 Discuss the history of the modern era of public health
 Indicate the key determinants of health
 Identify a Healthy People 2020 Topic Area of interest
R EQUIRED R EADINGS
 Institute of Medicine (IOM). (1988). A History of the Public Health System. In The
Future of Public Health (pp. 56-72).Retrieved
from http://www.nap.edu/openbook.php?record_id=1091&page=56
This report is the first in a series of three IOM reports on public health. The next
two are The Future of the Public’s Health in the 21st Century (2002) and For the
Public’s Health Investing in a Healthier Future (2012).
D IRECTIONS
Read the module and suggested readings within the module. Then complete the
assignment for the module.

NRSG 780 - HEALTH PROMOTION AND

POPULATION HEALTH
Module 1: Overview of Population/Public Health
INTRODUCTION TO POPULATION HEALTH
Many of the major improvements in the quality of life and longevity of Americans since
the late 19th century have been accomplished through successful public health
measures. Examples include:
 Immunization for infectious disease
 Safe food and water
 Population-based screening and follow-up programs for infectious and chronic
diseases
Much of this progress is taken for granted, and public health is sometimes referred to in
the field as “what we don’t see”. As a result, funding and critical services may not be
sufficient to address public health crises. Health professionals and the population-at-
large need to recognize the importance of maintaining and, in many cases, enhancing
current preventive efforts to meet continuing and emerging threats to the public’s health.
The IOM Report (The Future of Public Health, 1988) defined public health as “what we
as a society do collectively to assure the conditions in which people can be healthy”.
Population-based health care focuses on reducing morbidity and mortality. It
emphasizes the availability and accessibility of adequate health care resources for the
population-at-large, vs. care for a special few. The organizational mechanism for
achieving the best population health, the public health system, encompasses activities
undertaken within the formal structure of government and the associated efforts of
private and voluntary organizations and individuals.
SETTING PRIORITIES FOR THE POPULATION
In most cases, because resources are limited, it is necessary to establish health care
priorities for the population. What becomes a priority is often the result of social policies
and politics as well as science. Priorities are extremely responsive to politics as the
majority of public health programs are funded by public dollars in the form of federal,
state, and local taxes.
Given the limited resources we have to spend and the consequences of treating or not
treating certain diseases or reducing risk for certain diseases, it is important to carefully
consider how public health priorities are established. As a society and as health
professionals, we need to begin thinking about which areas should be selected for
public intervention, the time it takes to effectively implement public health programs and
the impact of shifting priorities.

NRSG 780 - HEALTH PROMOTION AND

POPULATION HEALTH
Module 1: Overview of Population/Public Health
MODERN ERA OF PUBLIC HEALTH
Two main factors have shaped our modern public health system:
 Growth of scientific knowledge
 Growth of public acceptance of disease control as both a possibility and a public
responsibility
Throughout recorded history, major outbreaks or epidemics such as the plague, cholera
and smallpox evoked sporadic public efforts to isolate or quarantine victims in an
attempt to protect citizens from becoming infected. As scientific knowledge regarding
sources of contagion and means of controlling disease became more refined, public
authorities expanded measures for containing specific diseases beyond quarantine to
take on new tasks including sanitation, immunization, regulation, health education and
personal health care.
FIVE PHASES OF MODERN ERA (1850- PRESENT)
A History of the Public Health System summarizes the five phases of the modern era
of public health.
P HASE 1 - M IASMA (1850 - 1880)
The first phase was based on the Miasma Theory - a theory based on the belief
that disease originated from rotting organic matter. Although the scientific basis of
disease was poorly understood, personal and environmental hygiene gained attention
as keys to mitigate spread of disease and improve health.
Two early proponents of sanitation, Chadwick in England and Shattuck in the U.S., are
considered to be founders of the modern era of public health. They produced landmark
data-driven reports and gained both public and government attention. Their work lead
western societies and later developing countries to recognize the importance of public
approaches to solving or preventing health problems. For more information,
view Chadwick’s and Shattuck’s reports.
P HASE 2 - B ACTERIOLOGY (1880 - 1920)
The second phase is identified as the rise of bacteriology. The work of Pasteur, Koch
and others in this rapidly growing field dramatically improved the scientific
understanding of the origins of disease. During the early 20th century, many
communicable diseases were checked and science became a vehicle for desired social
change. The average American lifespan was extended from 47 years in 1900 to nearly
70. This shift in mortality is now termed the first public health revolution.
Despite improvement in mortality, by the 1920s it became clear that significant disability
continued to exist in the population. With the draft for WWI, 34% of young men were
rejected for service due to physical or mental health disabilities. Physicians and public
health experts reviewed the surprising data from the draft and recognized that while
communicable diseases were well under control, other risk factors were being neglected
and these resulted in chronic physical and mental health problems. Studies of disease
registries and mortality and morbidity data also showed higher than expected rates of
death and disability among children and the poor.

P HASE 3 - H EALTH R ESOURCES (1920 - 1960)

During the third phase, the nation believed disparities could be addressed
by improving individual access to care. From 1920 to 1960 many state and county
health departments established TB and child health clinics to provide medical care.
Additional efforts supported health education and mass immunization programs.
Significant new funding supported hospital construction, healthcare manpower, and
biomedical research and resulted in:
 establishment of the National Institutes of Health (NIH) in 1930
 passage of the Hill-Burton Act in 1947 which provided funding for hospital
construction that was tied to the delivery of a percentage of free care
 increased presence of voluntary organizations like the American Heart Association
(AHA)
Despite these initiatives and the proliferation of hospitals, mortality and morbidity rates
did not declined significantly by 1960.

P HASE 4 - S OCIAL E NGINEERING (1960 - 1975)

During the fourth phase, leading health authorities attributed the lack of improvement in
morbidity and mortality rates by 1960 to the fact that medical resources were still
inaccessible to many, particularly the poor, elderly and isolated populations. From 1960
to 1975, the nation targeted social engineering strategies to provide services to
populations identified as high risk.
The Social Security Amendments of 1965, PL 89-97, 79 Stat. 286, enacted July 30,
1965, resulted in the creation of Medicare and Medicaid. The legislation provided
federal health insurance for the elderly (over 65) and for poor families. Click here to
watch President Johnson sign the bill into law. Additional outreach services were
designed to serve groups including immigrants, Native American, and migrant workers.
As in previous periods, despite strategies to improve resource allocation and access to
services, dramatic changes in morbidity and mortality did not occur. Rates of heart
disease, cancer and stroke, the 3 leading causes of death, followed by accidents,
COPD, cirrhosis, suicide and homicide did not change appreciably. What did change
was the per capita cost of health care.
P HASE 5 - H EALTH P ROMOTION (1975 - P RESENT )
By the mid-1970s, developing new approaches to preventing premature death (before
age 75) became a priority.
These landmark reports concluded that health is largely attributable to the four factors in
approximate percentages as noted below.

Environmental Lifestyle Human Biology Health Care

System

Percentage 20% 50% 20% 10%

Examples  occupational  unhealthy  age  access to

of factors exposures diet  gender health
 environmental  smoking  race care
exposures  physical  genetics services
 radiation inactivity  quality of
 poverty  stress health
 alcohol care
misuse services
received
 drug
misuse
 reckless
driving
 non-use of
seatbelts

Perspective Communities can exert Many of these Little can be done Heavily funded,
tremendous influence factors are self- to alter these often very late in
 over these factors imposed risks factors the disease
process

Based on Healthy People, the Department of Health and Human Services (DHHS)
works under the premise that further improvements in the health of Americans will
not be achieved through greater health expenditures for increasing the number of
medical services but through greater efforts designed to change lifestyles to
promote health, reduce risk and prevent disease.

NRSG 780 - HEALTH PROMOTION AND

POPULATION HEALTH
Module 1: Overview of Population/Public Health
HEALTHY PEOPLE REPORTS
Since the first Healthy People report in 1979, the Surgeon General has issued
Objectives for the Nation every 10 years. These reports identify our health promotion
and disease prevention priorities and outline objectives in focus areas that are to be
achieved within the decade. The objectives serve as a critical component of the health
policy agenda for the U.S.

Reassessment of the scientific evidence for each of the Health People reports is a
critical component of the process. In 2011, one outcome of the scientific review lead to
a revision of the weights of the four key determinants of health-- environment, lifestyle,
human biology and health care system-- that contribute to premature mortality, placing
an even greater emphasis on lifestyle (an increase from 50 to 70%).
 Click here to watch the launch video (3:28) for Healthy
People 2020, “Preparing for the Next Decade: A 2020 Vision for Healthy People.”
E XERCISE
With “Healthy People 2020” as a foundation, the course will focus on understanding the
scientific basis and developing strategies for increasing longevity and quality of life,
decreasing disparities and creating health promoting environments.
Go to Healthy People 2020 and find the four overarching goals for the current decade.
Practice explaining them to a peer or colleague:
Overarching Goals
 Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death.
 Achieve health equity, eliminate disparities, and improve the health of all groups.
 Create social and physical environments that promote good health for all.
 Promote quality of life, healthy development, and healthy behaviors across all life stages.

Review the Healthy People 2020 Topic Areas. Begin thinking of a topic area that you
will concentrate on for the course paper.
 About Healthy People

Healthy People provides science-based, 10-year national objectives for improving the health of all
Americans. For 3 decades, Healthy People has established benchmarks and monitored progress
over time in order to:
 Encourage collaborations across communities and sectors.
 Empower individuals toward making informed health decisions.
 Measure the impact of prevention activities.
Introducing Healthy People 2020
Healthy People 2020 continues in this tradition with the launch on December 2, 2010 of its
ambitious, yet achievable, 10-year agenda for improving the Nation’s health. Healthy People 2020 is
the result of a multiyear process that reflects input from a diverse group of individuals and
organizations. Read the press release for the Healthy People 2020 launch. [PDF - 149 KB]
Vision
A society in which all people live long, healthy lives.

Mission
Healthy People 2020 strives to:

 Identify nationwide health improvement priorities.

 Increase public awareness and understanding of the determinants of health, disease, and disability
and the opportunities for progress.
 Provide measurable objectives and goals that are applicable at the national, State, and local levels.
 Engage multiple sectors to take actions to strengthen policies and improve practices that are driven
by the best available evidence and knowledge.
 Identify critical research, evaluation, and data collection needs.