community health nursing 7th ed. - j. allender, et. al., (lippincott, 2010)

Community Health Nursing
Promoting and Protecting
the Public’s Health
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Community Health Nursing
Promoting and Protecting
the Public’s Health
7th Edition
Judith A. Allender, EdD, MSN, MEd, RN
Professor Emerita of Nursing
Department of Nursing, College of Health and Human Services
California State University, Fresno
Fresno, California
Cherie Rector, PhD, MSN, RN
Professor
Department of Nursing
California State University, Bakersfield
Bakersfield, California
Kristine D. Warner, PhD, MPH, RN
Associate Professor
School of Nursing
California State University, Chico
Chico, California
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7th edition
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins.
Copyright © 2005 and 2001 by Lippincott Williams & Wilkins. Copyright © 1996 by Barbara Walton Spradley
and Judith Ann Allender. Copyright © 1990, 1985, and 1981 by Barbara Walton Spradley. All rights reserved.
This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by
any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information
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request permission, please contact Lippincott Williams & Wilkins at 530 Walnut Street, Philadelphia, PA
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987654321
Printed in China
Library of Congress Cataloging-in-Publication Data
Allender, Judith Ann.
Community health nursing : promoting and protecting the public’s health / Judith A. Allender, Cherie
Rector, Kristine D. Warner. — 7th ed.
p. ; cm.
Includes bibliographical references and index.
ISBN-13: 978-0-7817-6584-8
ISBN-10: 0-7817-6584-6
1. Community health nursing. 2. Public health nursing. I. Rector, Cherie L. II. Warner, Kristine D.
III. Title.
[DNLM: 1. Community Health Nursing. 2. Health Promotion. WY 106 A425c 2010]
RT98S68 2010
610.73Ј43—dc22

2008045578
Care has been taken to confirm the accuracy of the information presented and to describe generally accepted
practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any
consequences from application of the information in this book and make no warranty, expressed or implied,
with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this
information in a particular situation remains the professional responsibility of the practitioner; the clinical
treatments described and recommended may not be considered absolute and universal recommendations.
The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set
forth in this text are in accordance with the current recommendations and practice at the time of publication.
However, in view of ongoing research, changes in government regulations, and the constant flow of
information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each
drug for any change in indications and dosage and for added warnings and precautions. This is particularly
important when the recommended agent is a new or infrequently employed drug.
Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA)
clearance for limited use in restricted research settings. It is the responsibility of the health care provider to
ascertain the FDA status of each drug or device planned for use in his or her clinical practice.
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To my husband Gil, with love and thanks.
Judy Allender
To my husband—my greatest supporter—and to my children and grandchildren,
who make it all worthwhile.
Cherie Rector
To my son Sean and his wife Angela, my daughters Erin and Kathleen Whalen,
and the best mom in the world, Dolores Warner—thank you for your
unwavering love and support.
Kris Warner
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About the Authors
❂Dr. Judith A. Allender has been a nurse for more than 45
years. For 30 of those years, she taught nursing—first at
Good Samaritan Hospital in Cincinnati, Ohio, and later at
California State University, Fresno where she retired as a
Professor Emerita. Her nursing practice experiences were
varied. She worked with surgical patients, in intensive care
units, as a school nurse, in-patient hospice, home care, and
community health nursing. She has authored five nursing
textbooks in addition to this one. During her long career, she
received several awards. She was voted RN of the Year in
Education for the Central Valley of California in 1998. The
fourth edition of this textbook received a Robert Wood John-
son award in 2001 for the end-of-life care content. In 2005,
she was inducted into the Central San Joaquin Valley, Cali-
fornia Nursing Hall of Fame. Presently, Dr. Allender con-
sults for a nonprofit immigrant and refugee center and
writes a weekly health column for a local newspaper. She
received her undergraduate nursing degree from the State
University of New York in Plattsburgh; a master’s degree in
guidance and counseling from Xavier University in Cincin-
nati, Ohio; a master’s in nursing from Wright State Univer-
sity in Dayton, Ohio; and a doctorate of education from the
University of Southern California. When not busy at home,
she can be found traveling around the world. She and her
husband have a blended family with five children, 14 grand-
children, and two great-grandchildren.
Dr. Cherie Rector is a native Californian who is cur-
rently a Professor at California State University, Bakers-
field Department of Nursing, where she teaches community

health nursing. She served as director of the School Nurse
Credential Program and the RN to BSN Program there and
was formerly the coordinator of the School Nurse Creden-
tial Program at California State University, Fresno, where
she also taught community health nursing. She has served
as the director of Allied Health and the Disabled Students
Program at College of the Sequoias. She has consulted with
school districts and hospitals in the areas of child health,
research, and evidence-based practice and has practiced
community health and school nursing, as well as neonatal
nursing in the acute care setting. She has taught undergrad-
uate and graduate level courses in community health, vul-
nerable populations, research, and school nursing. Her
grants, research, publications, and presentations have
focused largely on child and adolescent health, school nurs-
ing, nursing education, and disadvantaged students. She
earned an associate’s degree in nursing from the College of
the Sequoias more than 30 years ago, and a bachelor of
science in nursing degree from the Consortium of the Cali-
fornia State Universities, Long Beach. She has a master’s
degree in nursing (clinical specialist, community health)
and a School Nurse Credential from California State Uni-
versity, Fresno. Her doctorate of philosophy in educational
psychology is from the University of Southern California.
Dr. Rector and her husband have three grown sons, five
grandsons, and a granddaughter.
Dr. Kristine Warner, also a native Californian, is an
associate professor at California State University, Chico
with a specialization in public/community health nursing.
With more than 3 decades of experience in the field of pub-

lic/community health, she has taught in nursing programs in
both Pennsylvania and California. Undergraduate and grad-
uate courses she has taught include community health nurs-
ing, nursing research, program planning and development,
and health policy. Her nursing career began in adult and
pediatric acute care, and she has practiced home care and
public health in rural and urban settings. Her current profes-
sional interests include evidence-based practice, nursing
education, emergency preparedness, and health needs of
vulnerable populations. Her grants, research, publications,
and presentations have focused on emergency preparedness,
poverty, chronic illness, and nutrition. Dr. Warner is a retired
Navy Nurse Corps Captain, having ended a 29-year career
of both active and reserve service in 2002. She was recalled
to active duty and stationed in the Saudi Arabian desert dur-
ing the first Gulf War as Assistant Charge Nurse of a 20-bed
medical unit. She received her bachelor of science in nurs-
ing from Harris College of Nursing, Texas Christian Univer-
sity; master of public health (community health nursing) and
master of science (community health nursing and nursing
education) from the University of South Florida; and doc-
torate of philosophy in nursing from the University of Penn-
sylvania. Dr. Warner has three grown children and one
daughter-in-law. She was a resident of Germany for 2 years
in the early 1980s and has traveled extensively in Europe.
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Elizabeth M. Andal, CNS, PhD, FAAN
Professor

Department of Nursing
California State University, Bakersfield
Bakersfield, California
Margaret Avila, MSN, MS, PHN, RN/NP
Assistant Professor
Mt. St. Mary’s College
Los Angeles, California
Barbara J. Blake, RN, PhD, ACRN
Associate Professor
Kennesaw State University
WellStar School of Nursing
Kennesaw, Georgia
Lydia C. Bourne, BSN, RN, MA
Legislative Advocate
Bourne & Associates
Sacramento, California
Marie P. Farrell, EdD, MPH, RN, FAAN, ACC
Professor
Fielding Graduate University
Santa Barbara, California
Sheila Hoban, EdD, RN
Licensed Clinical Psychologist
Associate Professor
School of Nursing
California State University, Chico
Chico, California
Sheila M. Holcomb, EdD(c), RN, MSN
Clinical Faculty
Department of Nursing
Sacramento State University

Sacramento, California
School Nurse
Folsom Cordova Unified School District
Folsom, California
Mary Lashley, PhD, RN, APRN-BC
Professor
Community Health Nursing
Towson University
Towson, Maryland
Karin Lightfoot, MSN(c), RN-BC, PHN
Public Health Nurse II
Public Health Branch
Shasta County Department of Health & Human Services
Shasta County, California
Filomela A. Marshall, RN, EdD
Consultant
School of Nursing
Thomas Edison State College
Trenton, New Jersey
Erin D. Maughan, RN-BC, MS, PhD
Assistant Professor
College of Nursing
Brigham Young University
Provo, Utah
Debra Millar, MSN, RN
Senior Health Advisor
CHF International
Silver Spring, Maryland
Mary Ellen Miller, PhD, RN
Assistant Professor

Department of Nursing and Health
DeSales University
Center Valley, Pennsylvania
Cherie Rector, PhD, RN
Professor
Department of Nursing
California State University, Bakersfield
Bakersfield, California
Kathleen Riley-Lawless, RN, PhD, PNP-BC
Assistant Professor
School of Nursing
University of Delaware
Newark, Delaware
Pediatric Nurse Practitioner
Nemours/Alfred I. duPont Hospital for Children
Wilmington, Delaware
Phyllis G. Salopek, MSN, FNP
Assistant Professor
School of Nursing
California State University, Chico
Chico, California
Contributors
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Christine L. Savage, RN, PhD, CARN
Associate Professor
Director, Public Health Nursing Masters Program
College of Nursing
Associate Professor
Master of Public Health Program, College of Medicine

University of Cincinnati
Cincinnati, Ohio
Karen Smith-Sayer, RN, MSN
Immunization Coordinator and Communicable
Disease Control PHN
Nevada County Public Health Department
Nevada County, California
Mary E. Summers, PhD, MSN, RN, PHN
Professor Emeritus
Department of Nursing
Sacramento State University
Sacramento, California
Gloria Ann Jones Taylor, DSN, RNc
Professor
Kennesaw State University
WellStar School of Nursing
Kennesaw, Georgia
Rose Utley, PhD, RN, CNE
Associate Professor
Director, Nurse Educator Graduate Programs
Missouri State University
Springfield, Missouri
Kristine D. Warner, PhD, MPH, RN
Associate Professor
School of Nursing
California State University, Chico
Chico, California
Frances Wilson, RNC, MSN, OCN, PHN
Clinical Nurse Specialist
Acute Care Services/Telemetry

Kern Medical Center
Bakersfield, California
Joyce Zerwekh, EdD, RN
Director
Bachelor of Science Nursing Degree Program
College of Health & Human Services
Concordia University
Portland, Oregon
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❂
Contributors
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JoAnn Abegglen, APRN, MS, PNP
Brigham Young University
Provo, Utah
Joseph Adepoju, PhD, MA, BSN
Delaware State University
Dover, Delaware
Dolores Aguilar, RN, MS, APN
University of Texas, Arlington
Arlington, Texas
Jo Azzarello, PhD, RN
University of Oklahoma Health Science Center
Oklahoma City, Oklahoma
Margaret Bassett, MPH, MS, RN
Radford University
Radford, Virginia
Joyce Begley, BSN, MA, MSN
Eastern Kentucky University
Richmond, Kentucky

Carol Beltz, MSN, RN
Kent State University
Kent, Ohio
Anne Bongiorno, PhD, RN
SUNY Plattsburgh
Plattsburgh, New York
Cindy Bork, EdD, RN
Winona State University
Winona, Minnesota
Mary Bouchaud, RN, MSN
Thomas Jefferson University
Philadelphia, Pennsylvania
Kathleen Brewer, PhD, APRN, BC
Kansas State University Medical Center
Kansas City, Kansas
Alice Brnicky, MS, RN, BS
Texas Woman’s University
Denton, Texas
Kathryn Burks, PhD, RN
University of Missouri, Columbia
Columbia, Missouri
Bonnie Callen, PhD, MA
University of Tennessee, Chattanooga
Chattanooga, Tennessee
Wilma Calvert, PhD, RN, BSN, MPE
University of Missouri, St. Louis
St. Louis, Missouri
JoAnne Carrick, RN, MSN
Penn State University
State College, Pennsylvania

Deborah Chaulk, MS, APRN, BC
University of Massachusetts, Lowell
Lowell, Massachusetts
Mary Clark, PhD, RN, BSN
University of Iowa
Iowa City, Iowa
Nancy Donovan
University of Pittsburgh School of Nursing
Pittsburgh, Pennsylvania
Mary Gallagher Gordon, MSN, RN, CNE
Drexel University
Philadelphia, Pennsylvania
Anita Hansberry
Southern University Baton Rouge
Baton Rouge, Louisiana
Sheila Hartung, PhD, RNC, BSN, MSN
Bloomsburg University of Pennsylvania
Bloomsburg, Pennsylvania
Margaret Kaiser, RN, PhD
University of Nebraska Medical Center
Omaha, Nebraska
Vicky Kent, PhD, RN
Towson University
Towson, Maryland
Reviewers
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Judith Keswick
California State University Stanislaus
Turlock, California

Cheryl Krause-Parello,
PhD, RN
Kean University
Union, New Jersey
Lynette Landry, PhD, MS, BSN
San Francisco State University
San Francisco, California
Mary Lashley, RN, PhD
Towson University
Towson, Maryland
Sandra Leh, MSN, BSN, DNS
Cedar Crest College
Allentown, Pennsylvania
Sherill Leifer, PhD, RN
Milwaukee School of Engineering
Milwaukee, Wisconsin
Shelly Luger, BSN, BA
Indiana State University
Terre Haute, Indiana
Beth Luthy, APRN, FNP-C
Brigham Young University
Provo, Utah
Carolyn Mason, MS, RN
Miami University of Ohio
Oxford, Ohio
Terran Mathers, RN, DNS
Spring Hill College
Mobile, Alabama
Erin D. Maughan, RN-BC, MS, PhD
College of Nursing

Brigham Young University
Provo, Utah
Susan McMarlin, RN, BSN, MSN, EdD
University of North Florida
Jacksonville, Florida
Phyllis More
Bloomfield College
Bloomfield, New Jersey
Nancy Mosca, PhD, RN, CS
Youngstown State University
Youngstown, Ohio
Ruth Mullins-Berg, PhD, RN, CPNP
California State University, Long Beach
Long Beach, California
Carol Ormond, MS
Georgia College & State University
Milledgeville, Georgia
DeAnne Parrott, BSN, MS
Oklahoma City University
Oklahoma City, Oklahoma
Cindy Parsons,
BSN, MSN
University of Tampa
Tampa, Florida
Jenny Radsma,
RN, MN
University of Maine at Fort Kent
Fort Kent, Maine
Rebecca Randall, MS, RN, BA
South Dakota State University

Brookings, South Dakota
Delbert Raymond, BSN, MSN, PhD
Wayne State University
Detroit, Michigan
Bobbie Reddick, EdD, MSN, PhD
Winston Salem State University
Winston Salem, North Carolina
Jerelyn Resnick, RN, PhD
University of Washington
Bothell, Washington
Will Anne Ricer
New Mexico State University, Las Cruces
Las Cruces, New Mexico
Carol Sapp, RN
Georgia College & State University
Milledgeville, Georgia
Charlotte Schober
Union College
Lincoln, Nebraska
xii
❂
Reviewers
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Lauren Smith
Oakland University
Rochester, Michigan
Robbie South, MSN,
APRN, BC, CS
Lander University
Greenwood, South Carolina

Ruth Stephenson
Queens University of Charlotte
Charlotte, North Carolina
Sharon Stoffels
Boise State University
Boise, Idaho
Mary Ann Thompson, RN, DrPH
McKendree College, Louisville
Louisville, Kentucky
Patricia Thompson,
PhD, RN
Winona State University
Winona, Minnesota
Anna Wehling Weepie, BSN, MSN, (CNE)
Allen College
Waterloo, Iowa
Jane Weilert
Newman University
Wichita, Kansas
Reviewers
❂
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❂The seventh edition of Community Health Nursing:
Promoting and Protecting the Public’s Health continues in
the tradition of the previous editions of this text, begin-
ning with Barbara Spradley’s initial publication in 1981.
The purpose of this textbook is to introduce undergradu-
ate nursing students to the stimulating world of nursing

outside the acute care setting—whether at a public health
department, community health agency, school, or other
setting. We hope to share our enthusiasm and devotion to
this population-focused, community-oriented form of
nursing. Compared with acute care nurses, those working
in public or community health are often more autonomous
and exert a greater influence on the overall health of their
communities by being political advocates for their clients
and aggregates.
This book is designed to give students a basic ground-
ing in the principles of public health nursing and introduce
them to key populations they may engage while working in
the community setting. Entry-level public health nurses may
also find it a helpful resource as they begin to familiarize
themselves with their unique practice settings and target
populations. The nexus of public health nursing lies in the
utilization of public health principles along with nursing
science and skills in order to promote health, prevent dis-
ease, and protect at-risk populations. We use the term com-
munity health nurse interchangeably with public health
nurse to describe the practitioner who does not simply “work
in the community” (physically located outside the hospital
setting, in the community), but rather one who has a focus
on nursing and public health science that informs their com-
munity-based, population-focused nursing practice.
ABOUT THE SEVENTH EDITION
This textbook has always strived to be a user-friendly
resource for nursing students who are new to public health
nursing, and this new edition is no exception. We have
attempted to write in a style that is accessible to students,

with a conversational quality and minimal use of unneces-
sary jargon and dry narrative. Throughout the book, we have
made liberal use of case studies and highlighted student,
practitioner, and instructor perspectives on pertinent issues.
This is done to help students more readily grasp and apply
necessary information to their real clients and better under-
stand the common issues and problems they will face in this
new area of nursing study. At the same time, our goal is to
provide the most accurate, pertinent, and current informa-
tion for students and faculty. We have sought out experts in
various fields and specialty areas of public health nursing in
order to provide a balanced and complete result. With the
addition of more than 20 new contributors from across the
country, the content reflects a broad spectrum of views and
expertise.
ORGANIZATION OF THE TEXT
The seventh edition has five fewer chapters than the sixth
edition, having been reorganized to combine some related
topics while reducing duplication in other areas. We have
chosen to continue the emphasis on Healthy People 2010
goals and objectives throughout the text and to maintain a
research emphasis by providing examples of evidence-based
practice where applicable.
The book is now organized into eight units, with revised
unit titles to better reflect content covered. In addition, some
content has shifted to better align with the new units. The
eighth unit was added to encompass the various settings for
public health nursing practice or community-based nursing.
Unit 1, Foundations of Community Health Nursing,
describes the core public health functions (Chapter 3), as

well as the basic public health concepts of health, illness,
wellness, community, aggregate, population, and levels of
prevention (Chapter 1). Leading health indicators are intro-
duced, along with Healthy People 2010 goals and objectives
(Chapter 1). The rich history of public health nursing is
examined, along with social influences that have shaped our
current practice (Chapter 2). Educational preparation is dis-
cussed, as well as the roles and functions of public health
nurses (Chapters 2 and 3). Common settings for public
health nursing are introduced (Chapter 3), and values, ethi-
cal principles, and decision making are also considered
(Chapter 4). Evidence-based practice and research princi-
ples relating to community health nursing are discussed,
along with the nurse’s role in utilizing current research
(Chapter 4). Cultural principles are defined and the impor-
tance of cultural diversity and sensitivity in public health
nursing are highlighted, as well as cultural assessment and
folk remedies (Chapter 5).
Unit 2, Public Health Essentials for Community
Health Nursing, covers the structure of public health within
the health system infrastructure, along with a basic overview
of the economics of health care (Chapter 6). Epidemiology
and communicable disease are examined, and principles of
disease investigation and surveillance are explored from
both an historical and practical perspective (Chapters 7 and
8). Chapter 9 focuses on issues of environmental health with
particular attention to areas of concern to community health
nursing practice. Emphasis is placed on prevention and
using an ecological approach when addressing issues of
environmental health and safety.

Unit 3, Community Health Nursing Toolbox, examines
tools used by the public health nurse to ensure effectiveness
in his or her practice. Communication and collaboration,
as well as contracting with clients, are essential skills
that must be mastered by all community health nurses
(Chapter 10). Health promotion is examined in Chapter 11
with particular emphasis on achieving behavioral change
Preface
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through educational methodologies. Chapter 12 focuses on
planning and developing community health programs with
attention to the practical steps needed to achieve successful
outcomes. Social marketing as an emerging tool in commu-
nity health programs and grant funding are also explored.
The community health nurse is an advocate for clients, and a
basic knowledge of policy-making, political advocacy, and
client empowerment strategies is needed (Chapter 13).
Unit 4, The Community as Client, examines the theo-
retical basis for public health nursing (Chapter 14). Moving
the student’s focus from the individual patient to the com-
munity as their client is emphasized in Chapter 15, as are
community assessment strategies and resources. Chapter 16
describes the global community in which we now live, and
provides examples of international health problems and
practices. The timely topics of disaster and terrorism are
covered in Chapter 17, with emphasis on the role of the
community health nurse in emergency preparedness, both
personally and professionally.
Unit 5, The Family as Client, introduces theoretical

frameworks for promoting family health and better under-
standing and working with family dysfunctions (Chapter
18). Family assessment and application of the nursing
process are included in Chapter 19. Chapter 20 examines
family violence, spousal and child abuse, and effective
measures that can be utilized by the community health nurse
to provide resources and education.
Unit 6, Promoting and Protecting the Health of
Aggregates with Developmental Needs, provides informa-
tion about client groups as they are often delineated by pub-
lic health departments—maternal–child and infants (Chapter
21), children and adolescents (Chapter 22), adult women’s
and men’s health (Chapter 23), and the elderly (Chapter 24).
These particular chapters can be very helpful in targeted
health efforts for select population groups and build upon
the content presented in Unit 5.
Unit 7, Promoting and Protecting the Health of Vul-
nerable Populations, examines theoretical frameworks, basic
principles of vulnerability, and effective methods of working
with vulnerable clients (Chapter 25). Clients with chronic
illnesses and disabilities are also included (Chapter 26), as
well as those with behavioral health problems, such as men-
tal health and substance abuse (Chapter 27). The homeless
client and the impact of poverty on these individuals and
families are discussed in Chapter 28. Chapter 29 covers the
unique challenges of rural and urban health care in terms of
health care needs and types of service delivery options. The
particular needs of migrant populations and issues of social
justice are also explored.
Unit 8, Settings for Community Health Nursing,

examines public (Chapter 30) and private (Chapter 31) set-
tings in more depth. These chapters provide overviews of a
number of practice options available to both new and expe-
rienced nurses. There is a vast array of opportunities for
practice in public/community health, and this section is
designed to enhance understanding of some of those
options. Finally, the important roles of home health and hos-
pice nursing are discussed in Chapter 32. With the aging of
our population, many nurses are finding this practice area a
challenging and satisfying option.
NEW AND REVISED CHAPTERS
Each of the chapters maintained from the sixth edition has
been rigorously updated to provide clear and accurate infor-
mation. Some content has been maintained, but reorganized
into the new chapter format to keep the textbook to a man-
ageable length and to enhance student learning. We are par-
ticularly pleased to present seven chapters that have been
completely rewritten to reflect changes in nursing knowledge
and to provide a fresh approach to valuable content.
Chapter 12, on planning and developing community pro-
grams, now emphasizes the need for rigorous collaboration
with community groups to both identify and solve health
problems. Unit 7 contains three completely new chapters
focusing on vulnerable populations, including how to work
with vulnerable clients (Chapter 25), the unique aspects of
behavioral health in the community (Chapter 27), and the
homeless (Chapter 28). Chapter 26, dealing with disabilities
and chronic illness, was new to the sixth edition, and has been
updated and expanded here. Unit 8 is entirely new, with Chap-
ters 30 and 31 focusing on practice settings in the public and

private sector. Chapter 32 continues with the vital role of
home care and hospice nursing in the aging of our population.
KEY FEATURES
The seventh edition of Community Health Nursing: Promot-
ing and Protecting the Public’s Health includes key features
from previous editions as well as new ones. Features contin-
ued from previous editions include:
◆ An emphasis on aggregate-level nursing and the commu-
nity health nurse’s opportunity and responsibility not
only to serve individuals and families, but also to
promote and protect the health of communities and
populations.
◆ An emphasis on health promotion, health protection, and
illness prevention. This, in addition to the aggregate
emphasis, reflects the view set forth in this text that
community health nursing is the amalgamation of nurs-
ing science with public health science. Public health phi-
losophy, values, knowledge, and skills are an essential
part of all community health nursing practice.
◆ A balance of theory with application to nursing practice.
The seventh edition continues the presentation of
theoretical and conceptual knowledge to provide an
understanding of human needs and a rationale for nurs-
ing actions. At the same time, the text presents practical
information on the use of theory to undergird practice.
◆ A Summary of highlights at the end of each chapter pro-
vides an overview of material covered and serves as a
review for study.
◆ References and Selected Readings at the end of each
chapter provide you with classic sources, current research,

and a broad base of authoritative information for further-
ing knowledge on each chapter’s subject matter.
◆ A student-friendly writing style has been a hallmark of
this text since the first edition. Topics are expressed and
concepts explained to enhance understanding and capture
interest. Writing style remains consistent throughout the
xvi
❂
Preface
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text (including contributed chapters) to promote an unin-
terrupted flow of ideas and enhance learning.
◆ Internet Resources have been improved and are included
in nearly every chapter for quick and easy student
reference.
◆ Learning Objectives and Key Terms sharpen the reader’s
focus and provide a quick guide for learning the chapter
content.
◆ Activities to Promote Critical Thinking at the close of
each chapter are designed to challenge students,
promote critical-thinking skills, and encourage active
involvement in solving community health problems.
They include Internet activities, where appropriate.
◆ Recurring displays, tables, and figures throughout the
text highlight important content and create points of
interest for student learning.
◆ Levels of Prevention Pyramid boxes enhance understand-
ing of the levels of prevention concept, basic to commu-
nity health nursing. Each box addresses a chapter topic,
describes nursing actions at each of the three levels of

prevention, and is unique to this text in its complexity
and comprehensiveness.
◆ Additional assessment tools can be found throughout the
chapters. They are added to enhance assessment skills of
aggregates, families, or individuals in unique situations.
FEATURES NEW TO THIS EDITION
Additional recurring displays new to this edition include:
◆ Evidence-based Practice—this feature incorporates cur-
rent research examples and how they can be applied to
public/community health nursing practice to achieve
optimal client/aggregate outcomes.
◆ From the Case Files—presentation of a scenario/case
study with student-centered, application-based questions.
Emphasizing nursing process, students are challenged
to reflect on assessment and intervention in typical yet
challenging examples.
◆ Perspectives—this feature is included in most chapters
and provides stories (viewpoints) from a variety of
sources. The perspective may be from a nursing
student, a novice or experienced public health nurse,
a faculty member, a policy maker, or a client. These
short features are designed to promote critical
thinking, reflect on commonly held misconceptions
about public/community health nursing, or to
recognize the link between skills learned in this
specialty practice and other practice settings,
especially acute care hospitals.
◆ New art has been added throughout the text to clarify
important concepts and enhance interest in and
understanding of material.

RESOURCES FOR INSTRUCTORS
A set of tools to assist you in teaching your course is avail-
able at thePoint* is Lip-
pincott Williams & Wilkins’ web-based course and content
management system that provides every resource instructors
need in one easy-to-use site.
If, as an instructor, you want help structuring your lessons…
We’ve provided PowerPoint slides, which condense the
material into bulleted lists, figures, and tables.
If you’d like your students to engage in further study of the
material, beyond what’s provided in the textbook…
We’ve provided journal articles and a listing of internet
resources to facilitate research.
If you’d like your students to start applying what they’ve
learned…
We’ve provided a set of case studies associated with units of
the book to get students thinking about how their nursing
knowledge works in real-world scenarios.
If you’re concerned about preparing your students for the
NCLEX exams…
We’ve provided a Test Generator that includes unique
questions for each chapter. These questions are presented
in traditional and in alternate-form NCLEX style, so stu-
dents will become familiar with the format of the exams.
Preface
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❂We are grateful to those who helped with the writing and
publication of this text. To the contributors who brought
their wealth of knowledge and experience to bear in writing
their chapters, we acknowledge our debt and gratitude. We
also thank former contributors whose work may remain, in
part, in this edition. We appreciate the assistance of many
other colleagues and friends who served as “sounding
boards” and cheerleaders, and those who contributed ideas
and suggestions, among them Linda Olsen Keller from the
University of Minnesota; Dr. Linda Hewett from the
University of California San Francisco and the Alzheimer’s
& Memory Center; Lieutenant Commander A. Karen Bryant
from the U.S. Public Health Service; and Travis Hunter, RN,
from the Utah State Prison.
To our managing editors, Katherine Burland and Betsy
Gentzler, and acquisitions editor, Margaret Zuccarini, along
with other staff at Lippincott Williams & Wilkins, we
express our thanks.
We are in debt to our family and friends who “suffered”
through this experience with us. We appreciate your flexi-
bility and encouragement.
Acknowledgments
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Contents
Unit 1
Foundations of Community Health Nursing
Chapter 1
The Journey Begins: Introduction to Community

Health Nursing
2
Cherie Rector
Community Health 3
The Concept of Community
6
The Concept of Health
9
Components of Community Health Practice 14
Characteristics of Community Health Nursing 17
Chapter 2
History and Evolution of Community Health
Nursing
25
Kristine D. Warner
Historical Development of Community Health
Nursing 26
Societal Influences on the Development of
Community Health Nursing 36
Preparation for Community Health Nursing 39
Chapter 3
Setting the Stage for Community Health
Nursing
43
Kristine D. Warner
Core Public Health Functions 44
Standards of Practice 46
Roles of Community Health Nurses 47
Settings for Community Health Nursing Practice 54
Chapter 4

Evidence-based Practice and Ethics
in Community Health Nursing
60
Cherie Rector
Asking the Question 63
Quantitative and Qualitative Research 64
Steps in the Research Process 65
Impact of Research on Community Health and
Nursing Practice 71
The Community Health Nurse’s Role in Research 73
Ethics 77
Chapter 5
Transcultural Nursing in the Community 91
Cherie Rector
The Meaning of Culture 92
Characteristics of Culture 95
Ethnocultural Health Care Practices 98
Selected Cultural Communities 101
Transcultural Community Health Nursing
Principles 112
Unit 2
Public Health Essentials for Community
Health Nursing
Chapter 6
Structure and Economics of Community Health
Services
122
Cherie Rector
Historical Influences on Health Care 123
Public Health Care System Development in the

United States 124
Health Organizations in the United States 127
International Health Organizations 134
Significant Legislation 136
The Economics of Health Care 136
Sources of Health Care Financing: Public
and Private 145
Trends and Issues Influencing Health Care
Economics 151
Health Care Reform Possibilities 157
Effects of Health Economics on Community Health
Practice 160
Implications for Community Health Nursing 163
Chapter 7
Epidemiology in Community Health Care 172
Kristine D. Warner
Historical Roots of Epidemiology 173
Concepts Basic to Epidemiology 176
Sources of Information for Epidemiologic
Study 186
Methods in the Epidemiologic Investigative
Process 191
Conducting Epidemiologic Research 195
Chapter 8
Communicable Disease Control 200
Karen Smith-Sayer
Basic Concepts Regarding Communicable
Diseases 201
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Primary Prevention 207
Secondary Prevention 219
Major Communicable Diseases in the United
States 220
Global Issues in Communicable Disease Control 234
Using the Nursing Process for Communicable
Disease Control 235
Ethical Issues in Communicable Disease Control 236
Chapter 9
Environmental Health and Safety 242
Kristine D. Warner
Concepts and Theories Central to Environmental
Health 243
Evolution of Environmental Health 245
Major Global Environmental Concerns 247
Strategies for Nursing Action in Environmental
Health 269
Unit 3
Community Health Nursing Toolbox
Chapter 10
Communication, Collaboration, and
Contracting
276
Cherie Rector
Communication in Community Health Nursing 277
Collaboration and Partnerships in Community
Health Nursing 288
Contracting in Community Health Nursing 291
Chapter 11
Health Promotion: Achieving Change Through

Education
300
Kristine D. Warner, Debra Millar
Health Promotion Through Change
302
Change Through Health Education
310
Domains of Learning
310
Learning Theories
314
Health Teaching Models
316
Teaching at Three Levels of Prevention
320
Effective Teaching
320
Chapter 12
Planning and Developing Community Programs
and Services
332
Mary E. Summers, Kristine D. Warner
Program Planning: The Basics
333
Identifying Group or Community Health
Problems
334
Evaluation of Outcomes 341
Models Useful in Program Evaluation 344
Social Marketing 346

Grants 348
Chapter 13
Policy Making and Community Health
Advocacy
353
Lydia C. Bourne
Evolution and Effects of Current U.S. Health
Policies 354
Foundations of Political Action and Advocacy 355
Current Public Health Nursing Advocacy 357
Policy 358
Politics as Usual 364
Power and Empowerment 364
Influencing Policy 365
UNIT 4
The Community as Client
Chapter 14
Theoretical Basis of Community Health
Nursing
374
Kristine D. Warner, Karin Lightfoot
When the Client Is a Community: Characteristics of
Community Health Nursing Practice 375
Theories and Models for Community Health
Nursing Practice 376
Principles of Public Health Nursing 382
Societal Influences on Community-Oriented,
Population-Focused Nursing 383
Chapter 15
Community as Client: Applying the Nursing

Process
390
Filomela A. Marshall
What Is a Healthy Community? 392
Dimensions of the Community as Client 392
The Nursing Process for the Community as
Client 399
Nursing Process Characteristics Applied to
Community as Client 400
Community Assessment Methods 406
Sources of Community Data 407
Data Analysis and Diagnosis 408
Planning to Meet the Health Needs of the
Community 410
Implementing Plans for Promoting the Health
of the Community 413
Evaluating Implemented Community Health Plan 414
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Chapter 16
Global Health and International Community
Health Nursing
422
Marie P. Farrell
A Framework for Global Community Health
Nursing 423
The Context 425
The Population 430

Providers of Health Care 437
The Procedures/Interventions 440
Community Health Nursing Opportunities 447
Chapter 17
Being Prepared: Disasters and Terrorism 453
Kristine D. Warner, Sheila Hoban
Disasters 454
Terrorism 468
Unit 5
The Family as Client
Chapter 18
Theoretical Bases for Promoting Family
Health
476
Kathleen Riley-Lawless
Universal Characteristics of Families 477
Attributes of Families as Social Systems 477
Family Culture 480
Family Structures 481
Family Functions 485
Family Life Cycle 486
Emerging Family Patterns 487
Chapter 19
Working with Families: Applying the Nursing
Process
494
Phyllis G. Salopek
Nursing Process Components Applied to Families
as Clients 495
Planning to Meet the Health Needs of Families

During Home Visits 497
Effects of Family Health on the Individuals 501
Characteristics of Healthy Families 502
Family Health Practice Guidelines 506
Family Health Assessment 509
Guidelines for Family Health
Assessment 513
Education and Health Promotion 519
Evaluating Implemented Family Health
Plans 519
Chapter 20
Violence Affecting Families 524
Sheila M. Holcomb
Dynamics and Characteristics of a Crisis
525
History of Family Violence
527
Family Violence Against Children 530
Partner/Spousal Abuse 537
Mistreatment of Elders 541
Other Forms of Family Violence 543
Levels of Prevention: Crisis Intervention and Family
Violence 544
Families Facing Violence from Outside the Family 552
Methods of Crisis Intervention 552
Role of the Community Health Nurse in Caring
for Families in Crisis 553
Unit 6
Promoting and Protecting the Health of
Aggregates with Developmental Needs

Chapter 21
Maternal–Child Health: Working with Perinatal,
Infant, Toddler, and Preschool Clients
560
Cherie Rector
Health Status and Needs of Pregnant Women and
Infants 562
Infants, Toddlers, and Preschoolers 577
National Perspective on Infants, Toddlers,
and Preschoolers 577
Health Services for Infants, Toddlers, and
Preschoolers 586
Role of the Community Health Nurse 592
Chapter 22
School-age Children and Adolescents 606
Cherie Rector
School—Child’s Work 607
Health Problems of School-age Children 607
Adolescent Health 623
Health Services for School-age Children and
Adolescents 634
Chapter 23
Adult Women and Men 650
Barbara J. Blake, Gloria Ann Jones Taylor
Demographics of Adult Women and Men 651
Life Expectancy 652
Health Disparities 652
Health Literacy 652
Major Health Problems of Adults 653
Contents

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