U.S. Health Care Delivery System
© 2010 Jones and Bartlett Publishers, LLC
Basic Concepts of the U.S. Health Care Delivery System: Student Activity Workbook
Chapter 4
Public Health Role
Nancy J. Niles
Introduction: Two Definitions
Charles Winslow (1920) defined public health as the science and art of preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts for the sanitation of the environment, control of community infections, education of individuals regarding hygiene to ensure a standard of living for health maintenance.
The Institute of Medicine in its’ 1988 Future of Public Health report defined public health as an organized community effort to address public health by applying scientific and technical knowledge to promote health .
Introduction
Public health specialists view health from a collectivistic and preventive care viewpoint—to protect as many citizens as possible from health issues and to provide strategies to prevent health issues from occurring.
Public health concepts were in stark contrast to traditional medicine which focused on the sole relationship between a provider and patient.
Private practitioners held an individualistic viewpoint—citizens more often would be paying for their services from their health insurance or from their own pockets.
Physicians would be providing their patients guidance on how to cure their diseases, not preventing disease.
What Is Health?
The World Health Organization defines “health” as the state of complete physical, mental and social well-being and not merely the absence of disease or infirmity .
The Institute of Medicine defines “health” as a state of well being and the capability to function in the face of changing circumstances. It is a positive concept emphasizing social and personal resources as well as physical capabilities.
According to the Society for Emergency Medicine (SAEM), health is a state of physical and mental well-being that facilitates the achievement of individual and societal goals.
How would you define the concept of health?
Determinants of Health
Health has several determinants or influences that impact the status of an individual’s health.
The physical environment would include pollutants, hazardous exposure at work, water contamination, etc.
The social environment would include socioeconomic status which relates directly to quality of health
An individual’s lifestyle or behavior includes diet, exercise, sexual activity, stressful job, which all have an impact on health.
Also, genetic factors or a person’s biology predispose individuals to certain diseases.
Primary, Secondary And Tertiary Prevention Of Public Health
Primary prevention activities focus on reducing disease development. Smoking cessation programs and immunization programs are examples.
Secondary prevention activities refer to early detection and treatment of diseases. The goal of secondary prevention is to stop the progression of disease such as blood pressure screenings, colonoscopies, and mammograms.
Primary, Secondary And Tertiary Prevention Of Public Health
Tertiary prevention activities focus on activities to rehabilitation and monitoring of individuals from disease progression. Activities may also include patient behavior education to limit disease impact and further progression.
Although public health professionals may participate in each area of prevention activities, they focus primarily on primary and secondary prevention.
Origins Of Public Health
During the 1700s-1800s, the concept of public health was born. Edwin Chadwick, Dr. John Snow, and Lemuel Shattuck in their reports demonstrated a relationship between the environment and disease which established the foundation of public health.
In 1842, Edwin Chadwick published the General Report on the Sanitary Condition of the Labouring Population of Great Britain. His report highlighted the relationship between unsanitary condition and disease.
Origins of Public Health
Dr. John Snow, a famed British anesthesiologist, is more famous for investigating the cholera epidemics in London in the 1800s. He made the connection between contaminated water and the spread of disease—cholera.
Dr. Snow surveyed local London residents and discovered that those who were ill had retrieved water from a specific neighborhood pump on Broad Street.
When the pump handle was removed, the disease ceased.
Origins of Public Health
In the United States, Lemuel Shattuck in his Census of Boston report discussed high mortality rates among lower income and unsanitary living conditions.
In 1850, he published a plan for health promotion to combat unsanitary conditions. He was considered the American advocate for environmental health.
As a result of their work, public health law was enacted and by the 1900s’, public health departments were focused on the environment and its relationship to disease outbreaks.
What Is Public Health?
In 1945, the American Public Health Association issued a set of guidelines for the basic functions of the local health department:
Vital statistics – data management of the essential facts births, deaths, and reportable diseases;
Communicable disease control – management of tuberculosis, venereal disease, and malaria;
Sanitation- management of the environment including milk, water and dining;
Laboratory services;
Maternal and child health – management of school aged children’s health; and
Health education of the general public.
What is Public Health?
These functions remained the cornerstone of public health until the 1960s when the American Public Health association (APHA), reacting to cultural and political changes, revised the definition of the core public health functions. The APHA issued the following guidelines for the core public health functions:
Health surveillance, planning and program development;
Health promotion of local health activities;
Development and enforcement of sanitation standards; and
Health services provisions.
What is Public Health?
The Institute of Medicine (1988), as a result of an in-depth study of public health, stated that the three core public health functions of public health are:
Assessment which includes surveillance, identifying problems, data collection and analysis;
Policy development which includes developing policies to address public problems;
Assurance which includes evaluation of policies meeting program goals .
Public Health Functions
In 1994, the Public Health Steering Committee, as part of the U.S. Public Health Service, issued a list of essential public health services that provided specific information on the implementation of the core public health functions and how they should be implemented.
The following slides lists essential public health services:
Essential Public Health Services
monitor community health status;
diagnose and investigate community health issues;
educate people;
develop community partnerships;
develop public health policies;
enforce public health laws and regulations;
sustain a competent health care workforce;
evaluate the effectiveness, access and long term sustainability of community health services;
link people to needed health services.
What is Epidemiology?
Epidemiology is the study of disease distribution and patterns among populations. Epidemiologists search for the relationship of those patterns of disease to the causes of the disease.
The epidemiology triangle which consists of the host, which is the population that has the disease; the agent or organism which is causing the disease, and the environment, or where the disease is occurring (see Figure 4-2) is the foundation of epidemiology.
What is Epidemiology?
Public health workers attempt to assess each factor’s role in why a disease occurs. Public health workers develop prevention strategies to alter the interaction between the host, disease and the environment, so the disease occurrences will be less severe or will not occur again
Epidemiologic Surveillance
An important component of epidemiology is surveillance which is the monitoring of patterns of disease and investigating disease outbreaks to develop public health intervention strategies to combat disease.
A new form of surveillance involves biosurveillance which focuses on early detection of unusual disease patterns that may be due to human intervention.
What is Environmental Health?
Since the discovery of John Snow who linked disease with environmental factors, the field of environmental health is an integral component of public health.
Environmental health workers often are responsible for investigating environmental hazards in the community and monitoring and enforcing environmental regulations.
Both state and local health departments have environmental health.
Emergency Preparedness
Public health emergency preparedness is a term used for planning protocols that are in place to manage a large scale event such as a natural disaster such as a hurricane or massive flooding or man-made disaster such as a terrorist attack like September 11, 2001.
During a public health emergency such as Hurricane Katrina in Louisiana and recent food contamination outbreaks in 2008 with salmonella cases nationwide, risk communication protocols are implemented to inform the public regarding the health issue.
Emergency Preparedness
The federal government may intervene in a disease outbreak.
If not, state and local public health departments are responsible for monitoring the disease threat.
Since the terrorist attacks in 2001, simulating public health emergencies have been staged across vulnerable areas of the United States like large urban areas such as New York City and Las Vegas.
Public health funding for state activities such as these are largely from Centers for Disease Control and Prevention grants and budget allocations
Department of Homeland Security
As result September 11, 2001, the federal Department of Homeland Security (DHS) was created from 23 federal agencies, programs and offices to coordinate an approach to emergencies and disasters. Several public health functions were transferred into the DHS in 2003.
The Emergency Preparedness and Response Directorate coordinates emergency medical response in the event of a public health emergency.
National Response Framework
The National Response Framework (NRF), created by the Department of Homeland Security, presents the guiding principles that enable all response partners to prepare for and provide a unified national response to disasters and emergencies.
The National Response Framework describes how communities, states, the federal government, private-sectors, and nongovernmental partners collaborate to coordinate national response and describes “best practices” for managing incidents.
State And Local Response To Disasters
Incident Command Systems and Public Health
Incident command systems (ICS) are used by police, fire and emergency management agencies. ICS eliminates many communication problems, spans of control, organizational structures and differences in terminology when multiple agencies respond to emergency events (www.fema.gov).
The ICS is a coordinator for an emergency event. They are in control of a situation and make decisions about how to manage an emergency. They coordinate all responders to the event which increases management effectiveness.
Bioterrorism: A New Public Health Threat
According to the Centers for Disease Control and Prevention, bioterrorism is an attack on a population by deliberately releasing viruses, bacteria or other germs or agents that will contribute to illness or death in people.
Homeland Security, American Red Cross, the American Medical Association and the Environmental Protection Agency have developed educational campaigns regarding the U.S. response to bioterrorism.
Bioterrorism
More than 20 federal departments and agencies have roles in preparing for a bioterrorist attack. In 2002, the Public Health Security and Bioterrorism Preparedness and Response Act provided grants to hospitals and public health organizations to prepare for bioterrorism as a result of September 11, 2001.
The Food and Drug Administration also has additional responsibilities in the detection of food as a threat to community health.
Public Health Functions And Administration
Accreditation of Public Health Departments
The 2003 IOM Report discussed earlier recommends a national accreditation system for public health agencies because there is no national accrediting body to institute standards.
In 2004, the Centers for Disease Control and Prevention and the Robert Wood Johnson Foundation funded a study, the Exploring Accreditation Project, to assess accreditation of public health agencies.
Public Health Functions And Administration
Mobilizing for Action through Planning and Partnership (MAPP)
This cooperative agreement, between the CDC and the NACCHO, is a strategic plan for community health
Based on the needs assessment of the community, a long range plan is developed that establishes goals and a set of actions to accomplish these goals.
The Influence of the Institute of Medicine Reports on Public Health Functions
Published in 1988, the Institute of Medicine published a report, the Future of Public Health, which indicated that although the health of the American people has been accomplished through public health measures such as consumer food regulations, water safety standards; epidemic control of disease, the public has come to take public health measures for granted.
There was poor collaboration between public health and private medicine, no strong mission statement and weak leadership, and politicized decision making. Three core public health functions were identified: assessment, policy development and assurance.
Three Core Public Health Functions
Assessment was recommended because it focused on systematic continuous data collection of health issues which would ensure that public health agencies were vigilant in protecting the public.
Policy development was also mentioned but the recommendation was to ensure that any policies were based on valid data to avoid any political decision making.
Assurance focuses on evaluating any processes that have been put in place to assure that the programs are being implemented appropriately
Healthy People Reports
The Healthy People series is a federal public health planning tool that assesses the most significant health threats and sets objectives to challenge these threats.
The first major report, published in 1979, Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention discussed 5 goals of public health: reduce mortality rates among children, adolescents, young adults and adults, and increase independence among older adults.
Objectives were set for 1990 to accomplish these goals.
Healthy People Reports
The Healthy People 2000 report, the National Health Promotion and Disease Prevention Objectives, released in 1990, was created to implement a new national prevention strategy with 3 major goals: increase life expectancy, reduce health disparities, and increase access to preventive services.
An evaluation report in 2002 indicated that only 21% of their objectives was met with an additional 41% indicating progress.
Unfortunately, in the critical areas of mental health, there were significant reversals in any progress.
There was also minor progress in the areas chronic diseases and diabetes
Healthy People Reports
The Healthy People 2010 report, Understanding and Improving Health, based on the previous Healthy People reports and their progress, was released in 2000.
The report contained a health promotion and disease prevention focus to identify preventable threats to public health and to set goals to reduce the threats.
Like Healthy People 2000, its major goals were to increase quality and life expectancy and to reduce health disparities. The goals for these reports are consistent with both Winslow’s and the IOM’s report’s definition of public health.
Federal Government
The major federal agency responsible for public health activities is the Department of Health and Human Services. They are responsible for the following activities:
data gathering and analysis, and surveillance and control;
conducting and funding research;
providing assistance to state and local government programs;
formulating health policy;
ensuring food and drug safety;
ensuring access to health services for the poor and elderly; and
providing direct services to special populations
State Government
The major key feature of state agencies is their relationship with their local public health agencies which are responsible for implementing state policy and regulations.
Most states have public health activities distributed across many agencies which include environmental protection, human services, labor, insurance, transportation, housing and agriculture.
Local Government
Local government agencies are directly responsible for performing the majority of community public health services.
On November 1, 2005, NACCHO released the operational definition of a local health department which is defined as the “public health government entity at a local level including a locally governed health department, state-created district, department serving a multi-county area or any other arrangement with governmental authority and responsibilities for public health at the local level”.
Nongovernmental Public Health Activities
Community hospitals have been important to public health. The Hill-Burton Act of 1943 which financed hospital construction projects required them to provide charitable services which established a tradition of charitable services among community hospitals.
Hospitals may operate primary care clinics, sponsoring health education programs, and health screening fairs. The Joint Commission requires hospitals to participate in community health assessment activities
Ambulatory or outpatient care providers such as physician practices also contribute to community public health.
Nongovernmental Public Health Activities
Physicians may serve on local public health organizations or provide services to the uninsured for reduced fees.
Health insurers and managed care providers also make important public health contributions. All types of health care providers cooperate with state and local health departments by providing immunizations and offering patient education.
Nongovernmental Public Health Activities
Nonprofit agencies such as the American Cancer Society, American Heath Association and American Lung Association have active health promotion and health screening programs at the national, state, and local levels.
United Way is a civic organization that is active in identifying health risks and implementing community public health programs to target these risks.
Rotary International, is responsible for efforts to eradicate polio through vaccine programs throughout the world.
Robert Wood Johnson Foundation (RWJ) have provided funding for public health activities such as community education and intervention programs.
Public Health Education And Health Promotion
Public health educational strategies are a crucial component to public health interventions.
Health education focuses on changing health behavior through educational interventions such as multi-media education and classes.
Health promotion is a broader intervention term in public health that encompasses not only educational objectives and activities but also organizational, environmental and economic interventions to support activities conducive to healthy behavior
Public Health Education Campaign
There are several steps to planning and developing a successful public health educational campaign.
The first step in implementing a public health education campaign is to perform a community assessment.
The second step is collaborating with the community for their input on prioritizing their target health issues.
The third step is performing surveillance activities for specific data.
Public Health Education Campaign
The fourth step is to develop a pilot study to assess the effectiveness of the proposed campaign.
The fifth step is to revise the campaign based on the pilot study.
The sixth step is to implement the chosen campaign for a period of time.
The seventh step is to perform an evaluation of the impact of the campaign and revise, if needed
Health Promotion
Health promotion focuses on a comprehensive coordinated approach to long term health behavior changes by influencing the community through educational activities.
Examples of health promotion include nutritional, genetic or family counseling which would include health education activities
Public Health Marketing
According to the CDC, health marketing is an innovative approach to public health practice. Public health marketing draws from the business discipline of marketing theory and adds science-based health strategies of promotion and prevention.
It involves creating, communicating and delivering health information and interventions using customer-oriented and science-based strategies to protect and promote health in diverse populations
Summary of Chapter 4
Public health is challenged by its very success because consumers now take public health measures for granted.
When some major event occurs like anthrax or SARS, people immediately think that public health will automatically control these problems. The public may not realize how much effort and dedication and research takes place to protect the public.
Summary of Chapter 4
It is important to recognize as a health care consumer, the role public health plays in our health care. Public health surrounds consumers with educational opportunities to change a health condition or behavior.
You can visit the federal organization Centers for Disease Control’s website that is discussed in several chapters, which provides information about different diseases and health conditions. You can also visit your local health department.
