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Community
Health and Wellness
Principles of primary health care
6e
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Community
Health and Wellness
Principles of primary health care
6e
Jill Clendon & Ailsa Munns
Elsevier Australia. ACN 001 002 357
(a division of Reed International Books Australia Pty Ltd)
Tower 1, 475 Victoria Avenue, Chatswood, NSW 2067
This edition © 2019 Elsevier Australia.
All rights reserved. No part of this publication may be reproduced or transmitted in any form
or by any means, electronic or mechanical, including photocopying, recording, or any
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and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/
permissions.
This book and the individual contributions contained in it are protected under copyright by
the Publisher (other than as may be noted herein).
ISBN: 978-0-7295-4274-6
Notice
Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds or experiments described
herein. Because of rapid advances in the medical sciences, in particular, independent verifi
cation of diagnoses and drug dosages should be made. To the fullest extent of the law, no
responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or
damage to persons or property as a matter of products liability, negligence or otherwise, or
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material herein.
National Library of Australia Cataloguing-in-Publication Data
Content Strategist: Natalie Hunt

Content Development Specialist: Liz Coady
Senior Project Manager: Karthikeyan Murthy
Edited by Jo Crichton
Proofread by Melissa Faulkner
Design by Natalie Bowra
Index by Innodata Indexing
Typeset by Toppan Best-set Premedia Limited
Printed in China by 1010 Printing International Ltd
Dedication
This book is dedicated to all community health practitioners;
for the visionary contribution they make to the health and wellbeing of people,
families and communities.
Jill Clendon, Ailsa Munns

September 2018
vi
Contents
Foreword xi
Preface xii
About the Authors xiv
Acknowledgements xv
Reviewers xv
Section 1
Principles of primary health care 1
CHAPTER 1 Fundamentals of creating and maintaining a healthy community 3

The ecological multilayered perspective of community health 4
What is health? 4
What do we mean by community? 5
Wellness 6
The social determinants of health (SDH) 7
The social gradient 8
Community health 9
Primary health care 11
Primary health care principles 13
Accessible health care 14
Appropriate technology 14
Increased emphasis on health promotion 15
Intersectoral collaboration 15
Cultural sensitivity, cultural safety 15
Community participation 16
Social capital 18
Research to practice: social capital and health 18
Health literacy 18
Health promotion 20
What’s the point? 21
Promoting global health 22
Health education 23
Primary, secondary and tertiary prevention 25
Health promotion evaluation 26
CHAPTER 2 Healthy policies for healthy communities 34

The Australian health care system 35
The New Zealand health care system 39
Politics, policy making and health care 44
Contents vii
Policy action at the national level: think global, act local 48

Connecting policies with the social determinants of health 51
Policy making and primary health care 53
Health care: building a better system 55
CHAPTER 3 Communities of place 63

The global community 64
Families 67
Urban communities 67
Rural communities 70
Contemporary issues within distinctive communities 72
Virtual communities 72
Fly-in fly-out communities 72
Communities of affiliation 73
Migrant and refugee communities 74
Indigenous populations 75
Promoting health in communities of place 75
Health promotion in the city 76
Health promotion in hospitals 76
Rural health promotion 76
Health promotion in schools 77
Health promotion through virtual technologies 78
Section 2
Primary health care in practice 85
CHAPTER 4 Primary health care in practice 87

An interdisciplinary primary health care approach 88
Types and categories of health care practitioners 90
Advanced practice nurses 90
Community health practice 92
School health nursing practice 94
Community mental health nursing practice 96
Community midwifery practice 98
Paramedicine practice 99
Rural and remote area practice 101
Practice strategies—ways of working 103
Working with groups 103
Reflective practice 105
Leadership 106
CHAPTER 5 Assessing the community 114

Community assessment tools 115
Epidemiological assessment 115
Methods that support epidemiology 118
Challenges of the epidemiological approach 119
viii Contents
The evolution of community assessment tools in nursing 120

Asset mapping 125
Community-based participatory research (CBPR) 126
Assessment tools specific to health education planning 127
Social epidemiology, CBPR, primary health care and the SDH 129
Streamlining community assessment—the McMurray Community Assessment Framework 130
1. ENGAGE with the community 131
2. MAP community strengths, resources and risks 131
3. ANALYSE the information in collaboration with community members using a strengths,
weaknesses, opportunities and threats (SWOT) analysis 132
4. EMPOWER the community by sharing the findings with community members
and working with them to develop intervention strategies for improvement or
measures that sustain positive community life 133
Sources of assessment information 133
CHAPTER 6 Planning for intervention 139

Overview 139
Guiding approaches for effective planning 140
Strengths-based approaches 141
Primary health care principles 141
Planning for intervention: steps 141
Assessment with individuals and families 141
Development of objectives 144
Implementation 145
Evaluation 150
Disability 152
Advocacy groups 152
Section 3
Health and wellness throughout the lifespan 159
CHAPTER 7 The early years 161

Part 1: Healthy families 162
What are families? 162
Family developmental pathways 164
Family functions 165
Contemporary issues within distinctive families 168
Goals for healthy families 173
Part 2: Healthy children 175
Biological embedding and genetics 175
Preconceptual and antenatal care 176
Resilience and critical pathways to child health 178
Obesity 182
Child poverty 184
Goals for healthy children 184
Contents ix
CHAPTER 8 Transitions to adulthood and beyond 193

Part one: Healthy adolescence 195
Context 195
Social determinants of adolescent health, risk-taking, resilience, and decision making 195
Part two: Healthy adulthood 203
Context 203
Work 206
The sandwich generation 208
Goals for healthy adulthood 209
Part three: Healthy ageing 210
Context 210
Health in older age 211
Ageist attitudes 213
Retirement 214
Challenges in older age 215
Supporting transitions to and within older adulthood 218
The future 220
Section 4
Evidence to support primary health care 229
CHAPTER 9 Inclusive communities 231

Part one: Inequality, social exclusion, gender, culture and power 232
Women’s health issues 235
Men’s health issues 238
Men’s and women’s health policies 241
Gender issues among sexually diverse populations 241
Intimate partner violence 244
Goals for gender-inclusive communities 246
Part two: Culture and health 247
Culture 248
Culture conflict 249
Cultural safety 251
Multiculturalism 253
Ethnocentrism, racism and differential health care 253
Aboriginality, culture and health 255
Indigenous people’s relationships between health and place 256
The health of Indigenous Australian people and New Zealand Māori 256
Health and healing 257
Goals for Indigenous health 259
Inclusive migrant communities—the Pacific experience in New Zealand 259
CHAPTER 10 Inclusive research 266

Researching the social determinants of health—globally, nationally and locally 268
Evidence, to education, to child-health practice in preventing SIDS/SUDI—
case study 271
x Contents
Evidence-based practice 273

Systematic reviews, literature reviews, integrative reviews and meta-analyses 275
Randomised controlled trials 277
Evidence for practice: home visiting 278
Big data 279
Paradigms 279
Translational research: knowledge translation and knowledge transfer (KT) 281
Community-based participatory research (CBPR) 282
Action research 283
Mixed methods research 284
Researching culture 284
Researching with Indigenous people 286
Culturally safe research 286
Researching the future 288
APPENDIX A The McMurray Community Assessment Framework 298
APPENDIX B Calgary Family Assessment Model 305
APPENDIX C HEEADSSS Assessment Tool for use with Adolescents 306
Index 311
xi
Foreword
This text is based on the foundational principles of primary health care, which guide the reader to consider the
health of individuals and populations in their personal, family and community environments. Health professionals
engaging with communities use these principles as a basis for implementing a range of strategies to assist
people in their journey towards better health. The primary health care mindset recognises that health is socially
determined, and the book unpacks the social and structural elements that sometimes enable and at other times
compromise health. For the learner, this edition of the text has been streamlined on the premise that evidence
for practice is increasingly accessible on the internet and through other electronic means of sharing information.
The text therefore provides not only a guided tour through the most important elements of health care knowledge
for practice, but also inspires the reader’s appetite for further learning by signposting other sources of knowledge.
Together this information can be used to tailor practice strategies to individual ages and stages in the context
of community resources and needs. A strength of the text lies in the practice applications of knowledge through
case studies, while drawing attention to the fundamental points contained in each chapter, and encouraging the
reader to reflect on situations, needs, goals and strategies.
Our trans-Tasman societies are multilayered and the authors outline a broad range of caring approaches that
can be adapted for different populations and social geographies. Community health and wellness depends on
comprehensive assessment, and this is addressed extensively as the first step in any of these approaches.
Moving forward from a base of assessment data relies on understanding features of the health care system as
well as government policies, which are constantly changing. These features and policies are presented as a
point of departure for planning inclusive, equitable, adequate, culturally appropriate and accessible pathways to
health, despite occasional roadblocks. By situating this information in the context of different types of communities
and different locations for care, the authors have attempted to instil a sense that health goals can be achieved,
and that by working in partnership with nurses and other health professionals, people can be empowered to
change unhealthful lifestyles. Another notable feature of the text is its focus on evidence-based practice, including
evaluation of current practice. The authors underline the need for all of us to help generate new evidence to fill
the gaps in our knowledge. Researching communities is unique; it relies on deep understanding of the dynamics
of a community and the cultural conventions that determine how its citizens interact with health care. This is
captured in the text to whet the reader’s appetite for what should be a lifelong journey in the evolution of knowledge
for practice. I am pleased to recommend this edition of Community Health and Wellness to you with best wishes
for your learning enjoyment and scholarly fulfilment.
Emeritus Professor Anne McMurray AM

xii
Preface
This book is intended to guide the way nurses and other health practitioners work with people as they seek to
maintain health and wellbeing in the context of living their normal lives, connected to their families, communities
and social worlds. Life is lived in a wide range of communities, some defined by socio-cultural factors such as
ethnicity or Indigenous status, some defined by geography of ‘place’, others by affiliation or interest, and some
by relational networks such as social media. Because most people live within multiple communities it is important
to understand how their lives are affected by the combination of circumstances that promote or compromise
their health and wellbeing. Knowing a person’s age, stage, family and cultural affiliations, employment, education,
health history, and recreational and health preferences has an enormous effect on the way we, as health practitioners,
interact with them. Likewise, our guidance and support are heavily influenced by the environments of their lives:
the physical, social and virtual environments that contribute to the multilayered aspects of people’s lives. Knowing
how, why and where people live, work, play, worship, shop, study, socialise and seek health care, and understanding
their needs in these different contexts, underpins our ability to develop strong partnerships with people and
communities to work together as full participants, in vibrant, equitable circumstances to achieve and enable
community health and wellness.
This edition of the text represents contemporary thinking in community health and wellness from local, trans-Tasman
and global communities. We have condensed much of the book from previous editions to reflect the growing
accessibility of information online. Access to up-to-date information is available today at the push of a button,
so we have therefore focused on the fundamental principles of primary health care that underpin community
health and wellness. Using these principles as a foundation, the reader can then use the internet to investigate
other, specific areas of interest while maintaining a core understanding of what comprises community health and
wellness. We have signposted many areas where readers may want to explore further and we encourage you
to also access the supplementary material available online.
Primary health care continues to be an integral approach to promoting health and wellness throughout the world
and we apply the principles of primary health care to our practice in this part of the world. These principles are
outlined in Chapter 1 and elaborated on throughout the text. A primary health care approach revolves around
considering the social determinants of health (SDH) as we work in partnership with individuals, families and
communities. The text examines the interrelatedness of the SDH throughout the various chapters, to examine
where such things as biological factors, employment, education, family issues and other social factors that
influence health and the way we approach our role in health promotion and illness prevention. As partners our
role is to act as enablers and facilitators of community health, encouraging community participation in all aspects
of community life. Another foundational element that guides our consideration of community health is the notion
that health is a socio-ecological construct. As social creatures, we are all influenced by others and by our environ-
ments, sometimes with significant health outcomes. The relationship between health and place is therefore crucial
to the opportunities people have to create and maintain health. Interactions between people and their environments
are also reciprocal; that is, when people interact with their environments, the environments themselves are
energised, revitalised and often changed. Analysing these relationships is therefore integral to the process of
Preface xiii
assessing community strengths and needs as a basis for health promotion planning. The first two sections of
the text focus on the principles and practice of primary health care. A new element of this edition is a section
on project planning, equipping the practitioner with the skills to plan projects in and with communities to achieve
wellness.
Our knowledge base for helping communities become and stay healthy is based on understanding the structural
and social determinants of health that operate in both global and local contexts. We also know that what occurs
in early life can set the stage for whether or not a person will become a healthy adult and experience good
health during the pathways to ageing. Along a person’s life pathway, it is helpful to know the points of critical
development and age-appropriate interventions, particularly in light of intergenerational influences on health and
wellbeing. We outline some of these influences and risks in Section 3 of the book, which addresses healthy
families, healthy children, adolescents, adults and older people. We provide a set of goals in each chapter for
achieving health and wellbeing.
Maintaining an attitude of inclusiveness is the main focus of Section 4. Within the chapters of this section, we
suggest approaches that promote cultural safety and inclusiveness in working with Indigenous people and those
disadvantaged or discriminated against. To enable capacity development within communities, we need to use
knowledge wisely, which means that we need evidence and innovation for all of our activities. Clearly, our profes-
sional expertise rests on becoming research literate and developing leadership skills for both personal and
community capacities to reach towards greater levels of health, vibrancy and sustainability for the future.
As you read through the chapters you will encounter the Mason family in Australia and the Smiths in New Zealand.
Their home lives revolve around their respective communities and the everydayness of busy families. Throughout
the chapters you will see how each family deals with their lifestyle challenges and opportunities as they experience
child care, adult health issues, and some of the characteristics of their communities that could potentially
compromise their health and wellbeing. We hope you enjoy working with them and develop a deeper sense of
their family and community development, and how nurses can help enable health and wellness.
Throughout the text, we have included boxes that will encourage you to stop and think on the content (key
points and points to ponder) and direct you to find further information (‘where to find out more on…’). We have
also included group exercises and questions that can be used in practice or tutorial groups to help add depth
to your conversations on how to improve community health and wellness.
xiv
About the Authors
Jill Clendon is a registered nurse and member of the College of Nurses, Aotearoa.
She is currently Acting Chief Nursing Officer at the Ministry of Health in New Zealand.
Jill is also an Adjunct Professor in the Graduate School of Nursing and Midwifery at
Victoria University, Wellington. Jill spent the 18 years previous to her current position in
nursing policy, research, and child and family health. Jill’s research has examined issues
with contemporary nursing workforces, the efficacy of community-based nurse-led clinics,
and nursing history. Jill has taught at both undergraduate and postgraduate levels with
a specific interest in primary health and the contemporary context of community-based
well child care in New Zealand. Jill’s qualifications include a PhD in Nursing and a Masters
of Philosophy in Nursing from Massey University, and a Bachelor of Arts in Political
Studies from Auckland University. She also holds a Diploma in Career Guidance and
Certificate of Adult Teaching from the Nelson Marlborough Institute of Technology. She
has held a range of community positions including Chairperson of Victory Community
Health in Nelson, and as a member of the Nelson Bays Primary Health Care Nurse
Advisory Group. Jill has a clinical background in public health nursing and paediatrics.
Ailsa Munns is a registered nurse, registered midwife, and child and adolescent health
nurse. Ailsa has practised in a range of hospital and community health settings in
metropolitan, rural and remote health settings in Western Australia. She is currently
working at the School of Nursing, Midwifery and Paramedicine at Curtin University in
Western Australia as a Lecturer, Course Coordinator of the Postgraduate Child and
Adolescent Health Nursing Programs and Coordinator of the Community Mothers Program
(Western Australia). Ailsa has a range of research interests including exploration of current
practice for child health nurses, Aboriginal community-based antenatal care, peer-led
home visiting support for Aboriginal and non-Aboriginal families, community nurse-led
grief and loss strategies in primary school aged students and prevention of childhood
iron deficiency anaemia in rural and remote Aboriginal communities. Her academic
qualifications include a PhD in Nursing from Curtin University, Master of Nursing from
Edith Cowan University and Bachelor of Applied Science (Nursing) from Curtin
University.
xv
Acknowledgements
We offer our appreciation to colleagues, students and friends who supported and encouraged us in the writing
of this book; sharing their stimulating ideas, stories and photos have made community health come alive in the
hearts and minds of readers. We are grateful to our reviewers who helped strengthen the book, and the team
at Elsevier who provided invaluable assistance in producing this work. Bringing a trans-Tasman perspective to
the book has been both challenging and rewarding, showing how community health practice underpins health
and wellbeing across international communities. Being able to bounce ideas off one another and melding together
the various perspectives we bring has been both inspirational and enjoyable. We hope that communities on both
sides of the Tasman will benefit from the insights that have come from working together. We would also like to
thank and acknowledge our families for their support and patience.
Reviewers
Sandra Bayliss RN, BN, MN

Programme Leader and Lecturer, Nurse Education Team, Faculty of Health and Sciences, Universal College
of Learning, Palmerston North Campus, New Zealand
Leah East RN, BN(Hons), PhD, GradCertAP
Associate Professor in Nursing (Primary Health Care), School of Health, University of New England, Armidale,
NSW, Australia
Steve Goldsmith MPET, RN, BN, BN(Psychiatric)
Registered Nurse and Educator, School of Nursing, Faculty of Health Science Youth & Community Studies,
Holmesglen Institute, Vic, Australia
Anne McMurray BA (Psych), MEd, RN, PhD, AM, FACN
Emeritus Professor of Nursing, Griffith University, Principal Research Fellow, Centre for Health Economics,
Menzies Health Institute, QLD, Australia
Patricia (Trish) Thomson RN, MEd(merit), CTLT
Senior Nurse Lecturer, Te Hoe Ora, Department of Nursing, Midwifery and Allied Health, Ara Institute of
Canterbury, Christchurch, New Zealand
Section 1
Principles of primary
health care
CHAPTER 1 Fundamentals of creating and maintaining a healthy community

CHAPTER 2 Healthy policies for healthy communities
CHAPTER 3 Communities of place
Introduction to the section
The three chapters that introduce this text provide a foundation to help frame what we
understand about communities in contemporary society, and how community health and
wellness is achieved and maintained. Chapter 1 defines ‘community’ and the principles and
foundations for creating and maintaining community health. The overall goal for those working
with communities is to nurture health within a primary health care philosophy; that is, providing
care for the community and its people in a way that is socially just. This overarching goal is
guided by an understanding of the social determinants of health (SDH). The SDH outlined in
Chapter 1 explain that health is a product of social and environmental factors, which underlines
the importance of place in health.
Chapter 2 provides an overview of the health systems in Australia and New Zealand, providing
the context within which primary health care is provided. The chapter also discusses the way
policy is formed and how nurses and other health practitioners can be involved in developing
policy to achieve healthy communities. Our discussion culminates in a list of characteristics of an
ideal health system, so that we can all strive beyond today, to create a better policy
environment, more responsive systems and healthier communities for tomorrow.
In Chapter 3 we address communities of place, beginning with the global community and
examining features of urban and rural communities in Australia and New Zealand. The chapter
then examines relational communities of people bound together virtually through electronic
and social media, and communities of affiliation, which create a bond based on occupation,
religious or cultural characteristics. At the end of each chapter, we revisit the Smith and Mason
families, demonstrating how many of the concepts we have learned are played out in the
realities of their lives.
CHAPTER 1
Fundamentals of creating and

maintaining a healthy community
INTRODUCTION
For most people, ‘community’ is a friendly term, conjuring up a sense of place, a sense of
belonging. Healthy communities are where people are empowered to come together to improve
their communities for individuals, families and the whole community (Health and Human
Services 2017). This is essentially an ecological relationship. Ecology embodies the idea that
everything is connected to everything else. Health is both a social and ecological phenomenon,
in that it is created and maintained in the context of community life. Although as individuals
we can experience relative states of health or ill health because of our biological make-up,
these are manifest within the supporting or challenging social ecology of a community. Health
is therefore dynamic, changing as a function of the myriad interactions between biology and
our genetic predispositions, and the psychological, social, cultural, spiritual, physical and
political environments that surround us. We explore the socio-ecological model of health in
relation to models of care further in Chapter 6.
As health practitioners, our role in working with communities is quite different from that
of working within a health care institution. Whereas institutional care is focused on an episode
of illness, the community role ranges from preventing illness to protecting people from harm
or worsening health once they have experienced illness, to recovery and rehabilitation. To
undertake this type of role requires extensive knowledge of people in the many contexts of
their lives. Community practice also revolves around caring for the community itself. It is
multilayered in that it can include protecting communities from harm or stagnation, helping
its citizens to enhance their existing capacity for future development by fostering health literacy
(that is, knowledge that contributes to health and wellbeing), and working in partnership with
them to become empowered to make decisions that will maintain the community’s viability
and capability to cope with any future challenges.
We start this chapter by defining ‘community’ and the principles and foundations for creating
and maintaining health. We explore a range of definitions and differing interpretations of
health, wellness, community, the social model of health, public health and the social determinants
of health (SDH), and introduce readers to the fundamental principles underpinning primary
health care.
4 Section 1 Principles of primary health care
OBJECTIVES
By the end of this chapter you will be able to:
1 explain health, wellness and community 4 explain the concept of health literacy and
health in socio-ecological terms how it enhances health capacity for
2 identify the SDH and discuss how they individuals, families and communities
impact on individuals, families and 5 describe the differences between health
communities education and health promotion and the
3 define the principles of primary health care significance of each in community health
and explain how they guide community practice.
health practice
THE ECOLOGICAL MULTILAYERED PERSPECTIVE OF

COMMUNITY HEALTH
What is health?
The concept of health can be varied and difficult to define. The World Health Organization
(WHO) definition of health encompasses a holistic approach where health is not seen as one
half of a dichotomy of health and illness, but ‘a state of complete physical, mental and social
wellbeing and not merely the absence of disease or infirmity’ (WHO 1974:1). In subsequent
years, recognising increasing rates and lifelong impacts of chronic disease, Huber et al. (2011)
highlighted health as being the capacity of people to adapt and self-manage within social,
physical and emotional environments.
Health itself is multifaceted. Each of us brings a number of factors influencing our health
which are unique to us alone, including:
■ a personal history
■ our biology as it has been established by heredity and moulded by early
environments
■ previous events that have affected our health, including past illnesses or injuries
■ our nutritional status as it is currently, and its adequacy in pregnancy and early
infancy
■ stressors; both good and bad events in our lives that may have caused us to respond in
various ways.
Biological factors provide the foundation for an individual to develop into a healthy person,
but these are shaped by the environments or conditions of their lives. Becoming and staying
healthy depends on our ability to reduce the environmental risks to health, with 23% of global
deaths and 26% of deaths among children under five being influenced by modifiable environ-
mental factors (Prüss-Ustün et al. 2016). Biological factors provide the foundation for an
individual to develop as a relatively healthy person, which is an adaptive process. Personal
development and wellbeing occurs when an individual is positively engaged with their physical,
social, political, economic and structural environments (Keleher & MacDougall 2014). Reciprocal
exchanges between people and their environments, therefore, build the capacity for individual,
family and community health.
Concepts of health are not uniform with contrasting understandings between groups and
individuals. People’s understandings of health are influenced by a wide range of experiences,
social norms and contexts. As health practitioners, we need to be aware of these different
cultural interpretations and what it means for individuals, families and communities to be
ill or well (AIHW 2017). For example, Indigenous Australian and New Zealand people have
very holistic definitions reflecting the importance of social, emotional, spiritual and cultural
wellbeing of individuals and whole communities, along with their physical environment, dignity,
self-esteem and justice (National Aboriginal Health Strategy Working Party 1989). It is also
important to recognise that these meanings may vary between specific Indigenous environments.
This differs from the Western mainstream biomedical approach, emphasising a community
perspective.
The inclusion of cultural perspectives within health frameworks highlights issues of
health governance for the delivery of services. Supportive government policies for resources
and models of care are essential for health service provision across a wide domain (Bod-
dington & Raisanen 2009), which will be explored more extensively in the following
chapter.
What do we mean by community?

The meaning of ‘community’ can be varied. It is usually explained as being geographical
or functional, where members interact and share both a sense of identity and resources
(Talbot & Verrinder 2014). Communities can be defined by culture or issues of interest
(Hampton & Toombs 2013), accommodating a dynamic diversity of ethnicities, strengths
and needs. Of growing interest across age groups is the emergence of virtual communities,
which involve members using a range of communication technologies to interact as groups
(Demiris 2006).
Feelings of connectedness have been positively associated with higher levels of physical
and mental health, social support and having control over issues affecting their lives
(Talbot & Verrinder 2014). A community is often seen as a context for action, par-
ticularly in the areas of health and social wellbeing. These are impacted by members’
varying beliefs, traditions, feelings of collective identity and determinants of health.
There are many contextual meanings for community, and its influence on the capac-
ity of individuals and families to interact meaningfully will be explored throughout
this text.
POINTS TO PONDER
What is Community?
• A place we share with others?
• A network of like-minded people?
• A group who lives, works and plays together?
• An interdependent group of people inhabiting a common space?
• A context for action?
Wellness
Health influences the sense of wellness of individuals and communities. Healthy people’s lives
are characterised by balance and potential. A wellness perspective reduces the focus on illness
prevention alone. Wellness is individually constructed dynamic relationships between people
and their many everyday environments, and how they can maintain purposeful connections
in the social, emotional, physical, intellectual, spiritual, occupational and environmental
dimensions of their lives (Roscoe 2009). In a balanced state of health and wellness, there are
feelings of life purpose, optimism and cohesion (Adams et al. 2000). When these dimensions
are part of a healthy community there are opportunities for the community as a whole to
develop high levels of health or wellness, thereby supporting individuals and families. This
socio-ecological connectivity between people and their environments embodies community
health and wellness in that people feel supported and able to develop health capacity. For
example, they may feel they have lifestyle choices, and if they choose, they will be able to
exercise or relax in safe spaces. They have access to nutritious foods; students balance study with
recreation; young families immunise their children and have time out from work to socialise.
Older people are valued for their contribution to the community and inclusive policies promote
opportunities for all citizens to participate fully in the community and lead a high-quality,
happy life.
KEY POINT
Health and wellness are ecological.

Biological factors provide the foundation for an individual to develop into a healthy person,
but these are shaped by the environments or conditions of their lives.
THE SOCIAL DETERMINANTS OF HEALTH (SDH)

From birth, individuals are programmed through experiences to develop certain biologically
preset behaviours at critical and sensitive developmental periods. This is called ‘biological
embedding’, and it is influenced by how people interact with the genetic, social and economic
contexts of their lives. Early life adversity within these environments increases the risk for a
range of physical and psychosocial health problems later in life (Ehrlich et al. 2016). Overlapping
family, cultural, community and political characteristics and aspects of the wider society can
be termed SDH, creating opportunities or threats to lifelong health and wellness, and associated
areas such as learning, behaviour and resilience (Hertzman 2012).
A World Health Organization report (Wilkinson & Marmot 2003) identified ten SDH which
impact on people’s ability to adopt healthy lifestyles.
1 The social gradient
2 Stress
3 Early life
4 Social exclusion
5 Work
6 Unemployment
7 Social support
8 Addiction
9 Food
10 Transport
Source: Reprinted from Wilkinson, R., Marmot, M. (Eds.), 2003. Social determinants of
health: The solid facts, 2nd edition. Geneva, Switzerland, World Health Organization.
Fig. 1.1 demonstrates the determinants.
The WHO (2017a) has more recently recognised the influence of genetics and access to
and use of health services as being further determinants influencing health. Within the SDH
are a number of structural conditions. For example, in order to improve a community’s develop-
ment, employment opportunities and environments supporting healthy physical and psychosocial
development are needed. Food security in relation to accessible and nutritious foods at a reason-
able cost is an ongoing national and international issue (PMSEIC 2010). People also need to
have reasonable working conditions with adequate transport and spaces for recreation so they
can achieve a work–life balance. Other structures within the community supporting the
maintenence of health and wellbeing include hospitals, medical practitioners, nurses, non-
govenmental organisations and allied health practitioners who are accessible where and when
they are needed.
SDH strongly influence healthy child development. Parenting support and skills, family
stability and adequate physical and socio-economic resources are integral to health and well
being. Interactions between individuals, families and communities, such as having healthy and
supportive neighbourhoods, accessible services for child health and child care are additional
Healthy
child
development Social
Biology, genetic support
characteristics networks
Gender, Education,
culture literacy
Social
determinants
of health
Health
Employment
services,
and working
resources
conditions
Health
Social
practices,
environments
coping skills
Physical
environments
Figure 1.1 The social determinants of health
supports for families and children. Employment conditions such as parental leave without loss
of promotional opportunities, flexible working hours and income protection in the case of
unemployment all support healthy growth and development. On-site and out-of-hours child
care underpin contemporary working conditions that facilitate economic and family security.
The social gradient

The SDH create advantages and disadvantages for individuals, families and groups,
with some members of society having reduced chances of reaching their full health potential
(Guzys & Petrie 2014). Those who earn income at successively higher levels have better health
than those who are unemployed or have lower levels of income. Research studies have shown
there is a ‘social gradient’ in health, whereby those employed at successively higher wealth-
producing levels of employment have better psychosocial health than those on lower levels
(Kendall et al. 2017). This inequity creates disadvantage from birth for some children. A child
born into a lower socio-economic family for example, may be destined for an impoverished
life, creating intergenerational ill health. This child lives in a situation of ‘double-jeopardy’,
where interactions between the SDH conspire against good health. Without external community
supports, the family may spiral into worsening circumstances, affecting their child’s opportunities
for the future. This is the case for many Indigenous people, whose parents have not had access
to adequate employment or community supports that would sustain their own health, much
less that of their children. They become caught in a cycle of vulnerability where the SDH
interact in a way that creates disempowerment across generations. Political decisions governing
employment opportunities may hamper the parents’ ability to improve finances. A less than
optimal physical environment may deprive both parents and the child of a chance to access
social groups or gatherings. There may be few opportunities for education, health care or
transportation to access services. Parenting skills may be absent for a range of reasons, including
younger age, a lack of role modelling, geographic disadvantage or illness.
Reducing the impact of inequities requires people, communities and governments to take
action on the SDH. Many of these determinants are influenced by the social, political and
economic environments in which people live. People may have very limited opportunities to
exert control over their SDH. As such, attributing blame or a lack of commitment to decision
making in relation to these particular situations further disadvantages people (WHO 2017a).
Global, national and local policy decisions such as employment strategies and public health
priority setting affect the ability of people and communities to influence their own health
decisions. Any marginalisation of individuals and families through adverse SDH prevents
them from fully interacting with community assets, leading to social exclusion (WHO 2017b).
Social exclusion leaves many members of society without the support and resources they need
for health and wellbeing. In contrast, social inclusion creates social capital, trust, norms of
reciprocity and cohesion: the essence of a healthy community.
Community health
SDH help determine strengths and challenges in community health. When people are asked
to define community health, their responses usually reflect a blending of community, public
health and population health characteristics. Public health focuses on promoting and sustaining
the health of populations (Fleming & Parker 2015), with programs involving measurement
and surveillance with development of evidence-based strategies to prevent or overcome diseases.
The field of community health concentrates on the self-identified needs of individuals and
families within communities. Health practitioners may use aspects of public health research
and strategies in partnership with communities when working towards the shared goal of
improving health (Goodman et al. 2014). Population health is similar to public health in that
its focus is health and disease in the community, but population health programs tend to
address disparities in health status between different groups.
KEY POINTS
Public health focuses on promoting and sustaining the health of populations.

Population health aims to address disparities in health status between different groups.
Healthy communities are the synthesis or product of individual people interacting with
their environments with their unique understandings of what it is to be healthy, working
collaboratively to shape and develop the community in a way that will help them achieve
positive health outcomes.
Our definition of community health is as follows:
Community health is characterised by the presence of strong social capital, engaged and empowered
community members, a dynamic and healthy physical, social and spiritual environment, accessible,
affordable and equitable services and resources, and a system of governance that is inclusive and
responsive to community members in addressing the SDH.
This and other definitions of community health embody an ideal where all community
members strive towards a common state of health. Of course, in real life, communities and
societies are neither consistent nor stable, which reflects the variability among individuals and the
dynamic changes that occur in people’s social lives. Social conditions are particularly important
to community health, because social environments provide the context for interactions in all
other environments. Social support fostering positive connections, feelings of trust and social
inclusion enables people to feel empowered, and have greater control over their lives and their
health (Leach 2014). We call this social inclusion. On the other hand, if their social situation is
plagued by civil strife, an oppressive political regime, crime, poverty, unemployment, violence,
discrimination, food insecurity, diseases or a lack of access to health and social support services
they may be disempowered, leaving them less likely to become healthy or recover from illness
when it occurs. As Talbot and Verrinder (2014:58) explain, ‘empowerment is about increasing
people’s power over things influencing their lives’, and needs to occur through community
development activities. The community health practitioner can be an advocate for community
empowerment, facilitating and encouraging transforming strategies that take into account SDH
(Fleming & Parker 2015). When people live in situations of disadvantage or disempowerment
they are unable to access the same resources for health as those who live in more privileged
situations, and their lives and potential for the future are compromised. This is called social
exclusion. Chapter 9 explores these themes in more detail.
The role of health practitioners in community health is to recognise enabling and challenging
features within a range of cultural, economic, social, and health environments, working with
KEY POINTS
The characteristics of an enabling community health practitioner include:

• promoting health and providing care where people live, work and play
• advocating for the community, its people and its physical, social and spiritual environments
• promoting equity, access, social inclusion and adequate resources by assessing community
needs and disadvantage and then lobbying for change where required
• encouraging empowerment and health literacy to promote citizen participation in decisions
for health and wellbeing
• generating the evidence base relative to community health needs.
individuals, families, groups and political entities to collectively identify issues and strategies
to enhance health and wellbeing. One of the challenges is the development of relevant, acceptable
and sustainable approaches that take into account the complexities and impacting social
determinants of communities (Goodman et al. 2014). Community health practitioners need
to step outside traditional models of practice and work within an increasingly recognised
social model of health, incorporating a primary health care approach.
PRIMARY HEALTH CARE

When working with communities, nurses are aware of the need to address goals for social
justice, along with promoting equity and access to health resources (Hepner et al. 2014). The
‘social determinants’ approach to health resonates with the notion of human rights and social
justice, which underpins the social model of health (Guzys & Arnott 2014). As such, nurses
have an obligation to identify unfairness and health inequities and their predisposing social
determinants, facilitating extra resources for disadvantaged individuals, families and communities
(Guzys 2014).
Primary health care is a set of principles and an organising framework to guide nurses and
other health practitioners in facilitating socially just, equitable conditions for good health.
The International Conference on Primary Health Care was held in Alma Ata in 1978, where a
resolution was passed calling on the international community to protect and promote the health
of all people (WHO & UNICEF 1978). Primary health care is defined in the 1978 Declaration of
Alma-Ata as:
Essential health care based on practical, scientifically sound and socially acceptable methods and
technology made universally accessible to individuals and families in the community through their full
participation and at a cost that the community and country can afford to maintain at every stage of their
development in the spirit of self-reliance and self-determination. It is the first level of contact with
individuals, the family and community with the national health systems bringing health care as close as
possible to where people live and work and constitutes the first element of a continuing care process
Reprinted from World Health Organization (1978) Declaration of the Alma-Ata,

http://www.who.int/publications/almaata_declaration_en.pdf
Primary care is a term which is often used instead of primary health care, however there
are several differences. Primary care typically relates to medical and allied health management
of conditions with an emphasis on the medical model of care, focusing on early diagnosis,
treatment and screening (Keleher & MacDougall 2011, Talbot & Verrinder 2014). General
practice is often described as primary care. However, in terms of improving overall health
outcomes, a broader primary health care approach that addresses SDH such as housing,
employment and food security is necessarily more encompassing and more likely to address
the inequities that leave some population groups disadvantaged. Primary care, while an important
aspect of care provided within the health sector, comprises part of a primary health care
system, not the entirety of the system (Keleher & MacDougall 2011).
Where to find out more on…

The differences between primary care and primary health care
The following online discussions are valuable in reviewing differences in primary care and
primary health care.
• http://blogs.crikey.com.au/croakey/2010/06/10/
primary-care-vs-primary-health-care-and-who-cares/
• http://blogs.crikey.com.au/croakey/2010/06/17/
primary-care-vs-primary-health-care-who-cares-part-2/
BOX 1.1
PRACTICE PROFILE: PRACTICE NURSE
Hi. My name is Carter and I’m a Practice Nurse.

What the role entails:
The role of a Practice Nurse involves working closely with patients to support them with
their health needs whatever these may be. A typical day may include immunising a baby,
working through a diet plan with a person newly diagnosed with diabetes, managing an
acute asthma attack, following up on lab results or removing a set of stitches. I work hard
to improve population health, meet my responsibilities under the Treaty of Waitangi and
address inequity in a community-based way.
How I came to be in the role:
I came to practice nursing within a year of graduating from my education. Practice nursing
is not a traditional place for male nurses to find themselves but I wanted to work closely
with people in the community and I have an active interest in healthy living and lifestyle.
Practice nursing seemed an ideal place to be able to support people achieve healthy lives.
What I find most interesting about the role:
I enjoy the ongoing interaction and relationship development with my patients that a general
practice allows. It is rewarding to help people of all ages maintain good health and
successfully manage chronic conditions. The generalist setting and multidisciplinary team
approach helps me advocate for patients and guide them through the system. Sometimes,
it is simply the honour of listening to people share their fears and to help them find context,
meaning and acceptance.
Advice for anyone wanting to become a Practice Nurse:
Build your skills and knowledge of working in the community by taking relevant courses on
smoking cessation, cardiovascular risk assessment and immunisations. Consider courses
on motivational interviewing, advanced assessment and prescribing. Talk with other Practice
Nurses and spend a day working with one to see what they do.
PRIMARY HEALTH CARE PRINCIPLES

The principles of primary health care guide our activities in illness prevention, health promotion,
and structural and environmental modifications that support health and wellness. These are
identified as:
■ Accessible health care
■ Appropriate technology
■ Health promotion
■ Cultural sensitivity and cultural safety
■ Intersectoral collaboration
■ Community participation
These principles are a framework to guide us to work towards equitable social circumstances,
equal access to health care, and community empowerment through public participation in
all aspects of life. The literature on primary health care includes cultural inclusiveness as a
common thread in each of these principles. However, we include cultural sensitivity as a
separate principle. This acknowledges the important work on cultural safety that has been
done over the past two decades, particularly in New Zealand. Being culturally sensitive and
enabling culturally appropriate health care that protects cultural safety is one of the most
important factors in achieving primary health care. The principles are interconnected, but they
are examined separately below to underline the importance of each to the overall philosophy
of primary health care (see Fig. 1.2).
Access
Equity
Empowerment
Appropriate Health literacy
technology Community
participation
Primary
health
care
Cultural
Health sensitivity
promotion Cultural safety
Intersectoral
collaboration
Figure 1.2 Primary health care principles

Accessible health care

In many countries of the world, including those considered highly developed, there is a
widening gap in access to health services between population groups such as Indigenous and
non-Indigenous people, and those living in urban and rural or remote areas (Ware 2013).
These factors cause disparity between rich and poor, which is inequitable and socially unjust.
The major objective of providing equity of access is to eliminate disadvantage, whether it is
related to social, economic or environmental factors. Barriers to access include areas such as
unemployment, lack of education and health literacy, age, gender, functional capacity and
cultural or language difficulties. These factors inhibit the development of capacity for individuals
and families. Barriers to community capacity include geographical features that isolate people
from services or opportunities, civil conflict or inadequate supporting structures and services.
KEY POINTS
Inequity
Unfair distribution of resources and support (e.g. lack of health practitioners in rural areas)
Inequality
Disparity in health status or capacity (e.g. poorer health among Indigenous people than
non-Indigenous people)
As the OECD (2016) reports, evidence has shown that in any country, the greater the income
gap between rich and poor, the worse the health status of all its citizens. This occurs unevenly,
as health is distributed differently among different groups. Analysis of population data from
OECD countries has confirmed that the health of any society is better when wealth is more
equally distributed (Devaux 2015). Various interactions among the different influences also
produce different levels of health and illness, and there are also variations in the way different
generations respond to events in their social world. Some inequities also affect the community
itself. Global warming, food security, disease outbreaks and the harmful effects of globalised
industrial processes hinder a community’s ability to maintain healthy environments (Spickett
et al. 2008). Decisions for community health should therefore be based on simultaneous assess-
ments of the impact on individuals, families and communities, future generations and the global
community. Social justice, or equitable access for all, needs to ensure the least advantaged people
in a community receive equal opportunity, education, care and service as those who are advantaged
by virtue of both tangible (finances) and intangible (knowledge) resources.
Appropriate technology
The failure of health care systems to address inequities in health is due, in part, to the use of
inappropriate technologies in health care. Primary health care requires efficiency, effectiveness
and acceptability; that is, ‘methods that are practical, scientifically sound and socially acceptable’
(Keleher & MacDougall 2011:6). Although progress has been made in community management
of health and wellbeing, health systems continue to revolve around services with a medical-
technical focus rather than those that support community empowerment and ‘distributional
equity’ (Talbot & Verrinder 2014). Not all communities can afford the latest and most expensive
technologies, so health expenditure on technological supports can sometimes be a barrier to
less expensive but adequate, sustainable care for more people.
Increased emphasis on health promotion

Health promotion is a capacity-building process, focusing on broad social, environmental and
cultural impacts of health, with a primary health care approach being a key requirement
(Talbot & Verrinder 2014). The principles of health-promotion activities guide advocacy,
mediation and enablement, with global and local strategies incorporating a capacity-building,
comprehensive framework as outlined in the Ottawa Charter (Guzys et al. 2014, WHO 2017c).
These will be discussed in more detail later in the chapter. Health promoting or primary health
care activities that are limited to a particular group are considered ‘selective’ rather than
‘comprehensive’ primary health care. Selective primary health care does not focus on SDH
and equity, tending to adopt an individualised health practitioner-led medical technology
approach (Keleher & MacDougall 2011:7). Comprehensive primary health care adopts a
whole-of-community approach and an empowerment framework, where community members
work in partnership with health practitioners to facilitate social, political, environmental and
economic determinants of health for the entire community (Erickson & Andrews 2011, Keleher
& MacDougall 2011). Table 1.1 captures the differences between selective and comprehensive
Intersectoral collaboration
Intersectoral collaboration requires cooperation between different community sectors, including
(but not limited to) those managing health, education, social services, housing, transportation,
environmental planning and local government. Tapping into the expertise of different sectors
and different alliances enables more holistic, flexible and collaborative responses to certain
needs. Another advantage of intersectoral collaboration is promoting acceptance of the need
for a health initiative when all parties involved work together for its success. Collaborative
alliances encourage efficient and effective use of resources, with economies achieved from less
duplication, improved quality and continuity of health and wellbeing activities (Talbot &
Verrinder 2014). However, in addressing the allocation of economic resources to health budgets
it is important to lobby for national primary health care policies that support decentralised
control so that communities themselves can participate in health planning.
Cultural sensitivity, cultural safety

Culture is the accumulation of beliefs, norms and practices of particular groups that are learned
and shared, guiding thinking, decisions, actions and social behaviour (Petrie & Guys 2014).
SDH and health practitioner cultural reflexivity have an impact on the development of culturally
Table 1.1 Selective and comprehensive PHC
Characteristic Selective primary health care Comprehensive primary health care

Main aim Reduction of specific disease Improvement in overall health of
the community and individuals
Strategies Focus on curative care, with some Comprehensive strategy with
attention to prevention and curative, rehabilitative, preven-
promotion tive and health promotion that
seeks to remove root causes of
health
Planning and External, often ‘global’, programs Local and reflecting community
strategy develop- with little tailoring to local priorities: professional ‘on tap
ment circumstances not on top’
Participation Limited engagement, based on Engaged participation that starts
terms of outside experts and with community strengths and
tending to be sporadic the community’s assessment of
health issues, is ongoing and
aims for community control
Engagement with Professional and claims to be Acknowledges that primary
politics apolitical health care is inevitably political
and engages with local political
structures
Forms of evidence Limited to assessment of Complex and varied research
disease-prevention strategy methods including epidemio-
based on traditional epidemiology and qualitative and
logical methods, usually con- participatory methods
ducted out of context and
extrapolated to situation
Source: Reproduced with permission of Taylor & Francis Ltd. From Baum, F. 2003. ‘PHC: can the dream be
revived?’ Development in Practice 13(5), 515–519.
safe practice. Ramsden (1993) first developed the concept of cultural safety within the New
Zealand health care system. Cultural awareness is the first step, where health practitioners
learn about cultural diversity. Self-reflection on knowledge and clinical practice relates to
attainment of cultural sensitivity, becoming more responsive to the way an individual or group’s
cultural mores shape health and health behaviours. Cultural safety is where health interactions
promote feelings of safety for individuals and families (Nguyen 2008). Importantly, it is not
the nurse, midwife or other health practitioner who determines whether practice is culturally
safe, but the recipient of care (Richardson & Carryer 2005). We will explore these concepts
further in Chapter 9.
Community participation
Community participation is a central tenet of a primary health care approach with improved
health outcomes the result (Bath & Wakerman 2015). Effective partnerships see health care
practitioners and community members having equal status, both actively working to plan and
implement health and wellness activities (Talbot & Verrinder 2014). Community partnerships
are not only empowering but they enhance capacity for developing social capital with mutual
trust and reciprocity as well as cooperative networks for better health. However, it is imperative
that funding support for participatory mechanisms in primary health care is available for
sustainable health services, particularly for Aboriginal Controlled Community Health Services
which are grounded in a community participation approach (Bath & Wakerman 2015). The
major goal of community participation is empowerment, which facilitates more socially just,
inclusive environments (Talbot & Verrinder 2014).
KEY POINTS
Primary health care in practice

Access and equity: working to alleviate the barriers that prevent equal access to health for all
members of the community—identifying any disparities in access to education, health services,
employment or other SDH.
Appropriate technology: advocating for the right care for the right person or community at
the right time, to maximise efficiency and equity rather than the most expensive technologies
for all communities.
Health promotion: encouraging community capacity through comprehensive promotion of
health for the whole-of-community; promoting selective care for those most in need of specific
care.
Cultural sensitivity and cultural safety: being aware of your own and others’ cultural beliefs,
values and knowledge and how these shape health and health decisions.
Intersectoral collaboration: working in partnership with health, disability services,
transportation, education, environment and other sectors to respond to all the SDH.
Public participation: ensuring that community members are able to participate fully in
making decisions for their health and wellbeing.
Primary health care is focused on redressing social disadvantage by promoting healthy

social and structural conditions for good health. We achieve this within an enabling role, acting
in partnership with people who are empowered to make informed choices to develop their
personal and community capacity. The aim of these community partnerships is to enable better
health, equity, justice and governance in health services, including appropriate, effective and
efficient use of available technologies. However, these outcomes are only achievable where
there is the political will to support and sustain good health for all members of the community,
which is integral to the notion of social capital.
SOCIAL CAPITAL
When the health of the community is defined from a social perspective, we acknowledge its
social capital. Social capital relates to the quality of the social norms and values and how these
associations link and benefit people within different types of communities. Health and wellbeing
are enhanced through strong social capital (Talbot & Verrinder 2014).
Internationally, social capital can have different concepts and dimensions, such as bonding,
bridging and linking approaches. These are outlined in Chapters 1 and 3 of the OECD document
found at www.oecd.org/site/worldforum/33703702.pdf (OECD 2001).
The importance of understanding social capital in a community is in knowing where and
how to implement health promotion programs that will have a greater chance of success. For
example, where communities have developed a sense of coherence and commitment to one
another there is a greater likelihood of mutual support in achieving health goals.
KEY POINT
Involving community members in activities or projects to pursue common goals will help build
social capital.
Research to practice: social capital and health

Communities with high social capital have a better chance of coping with adversity and limita-
tions, as well as being able to build a positive sense of place. Murayama et al. (2012) conducted
a systematic review to investigate relationships between social capital and individual health.
They reported that both individual social capital and area/workplace social capital had positive
effects on health outcomes. These associations led them to conclude that health promotion
programs should include consideration of the level and type of social capital in the place they
are being conducted. Equally as important is the finding that health promotion and social
capital have reciprocal effects. Social capital enhances, and is enhanced by, health promotion
interventions and therefore has a continuing impact on the community.
Community health capacity can be supported or weakened by the presence or lack of
organisational structures, such as schools, workplaces and community planning mecha-
nisms that include participatory decision making. When such organisational structures are
present, communities can work together to respond to the SDH, sharing common attitudes,
goals and activities to address inequalities and work towards a more inclusive society
(Talbot & Verrinder 2014).
HEALTH LITERACY
Health literacy is the ability to make sound health decisions in everyday life and is a function
of the SDH, such as education and employment (Keleher 2011). Some decisions may be related
to health care, but others may be lifestyle choices, decisions that improve quality of life, or
that help in understanding civic responsibilities or opportunities. Health literacy is an important
element in addressing health inequities, as those at the lower levels of health literacy are often
the ones who live in socio-economically disadvantaged communities. Being unaware of
information relevant to improving their health, or how to access health resources, creates
higher levels of disadvantage and stress, with a commensurate inability to manage both preventa-
tive and complex health needs (Keleher 2011). New Zealand and Australian research shows
that less than half of all New Zealanders and Australians meet the minimum health literacy
requirements for making effective health care decisions (ABS 2011, Keleher 2011, NZMOH
2010). This emphasises the need for health practitioners to work in partnership with individuals,
families and communities to facilitate effective health communication and decision making.
KEY POINT
There are three levels of health literacy: functional, communicative (or interactive) and critical
Three levels of health literacy have been identified by Nutbeam (2000) and are shown in
Table 1.2. Functional health literacy means that individuals have received sufficient factual
information on health risks and health services, which they also understand, and which allows
them to function effectively in a health context (Nutbeam 2000). Individuals need to be able
to read essential materials such as medication administration labels, particularly for children,
and when to cease medications. They also need to be able to understand and act on test results,
know how to complete health-related forms and participate in shared decision making (Patient
Safety Network & AHRQ 2017). At a second level, communicative or interactive health literacy
develops personal skills to the extent that community members participate in community life,
influencing social norms and helping others develop their personal health capacity. This involves
understanding how organisations work, and communicating with others in the context of
self-help or other support groups, as well as knowing how to get the services they need. The
third level of literacy, critical health literacy, is where people use cognitive skills to improve
individual resilience to social and economic adversity. This paves the way for community
leadership structures to support community action and to facilitate community development
(Nutbeam 2000). Zarcadoolas et al. (2005) further propose cultural literacy, which enables
people to identify and use cultural understandings within their health information communication
strategies.
Table 1.2 Health literacy: A continuum of knowledge and skill development
Functional Communicative/interactive Critical

Knowledge to choose Ability to influence Skills for action
Critical health literacy enables community members to develop capacity for confident,
empowered interactions with others, including members of the health professions, working
together to overcome structural barriers to health (Nutbeam 2008). Examples of outcomes
include workers exerting pressure on workplaces to reduce hazardous risks, or lobby groups
gathering support for environmental preservation, or supportive resources for parenting practices
or health services.
For health practitioners, the focus of promoting health literacy is to provide information,
education and advocacy to ensure consumers’ understanding of health information in a sup-
portive environment, along with health systems provision of services to accommodate consumer
needs and abilities (PHABC 2012). To help people read, understand, evaluate and use health
information requires an understanding of how people learn. This varies according to age, class,
cultural group, gender, beliefs, preferences and coping strategies and experience with the health
system. These individual and group differences draw into clear focus how communities differ
in their populations, resources and capacity to support health and wellness, which is the subject
of chapters to follow.
HEALTH PROMOTION
Health promotion is a significant feature of primary heath care (Guzys et al. 2014) and is
described by the WHO (2017d:1) as:
the process of enabling people to increase control over, and to improve, their health. It moves beyond a
focus on individual behaviour towards a wide range of social and environmental interventions.
Health promotion is essentially a political, ecological and capacity-building process, aimed

at arranging the social and structural determinants of health in a way that facilitates health.
To help people build health capacity requires awareness of both global and local conditions
that affect health. As such, health promotion actions achieve the best outcomes for health
when they involve intersectoral collaboration.
Specific health promotion actions begin with community assessment. From this basis of
knowledge, plans are developed in partnership with community members to maximise assets,
reduce risks to health and plan for a sustainable future for current and future generations. The
role of nurses and other health practitioners in promoting community health includes advocating,
teaching and enabling health based on local knowledge and understanding of the community’s
health goals. Central to this type of analysis is assessing the interplay of SDH, how these are
interacting with the environment in the local context, and what influences are exerting pressures
on the community and its residents along their social, cultural and developmental pathways.
This is a more inclusive, comprehensive view of health promotion than simply seeing the
community in terms of a single issue or health problem at a discrete moment in time. Com-
munity assessment is discussed in Chapter 5.
Health promotion should be focused on the community’s assets and strengths with a focus
on advocacy, mediation and enabling to facilitate improved health and wellbeing outcomes
(Guzys et al. 2014). Health promotion actions may be aimed at different population subgroups,
such as creating daycare centres for the elderly to prevent them from being socially isolated,
or working with new parents to ensure they have information and the support systems they
need. What these have in common is a commitment to enabling capacity through participation,
empowerment and health literacy.
The historical context of health promotion is closely aligned with the historical phases of
the public health movement. The Old Public Health movement (1975 to mid-1980s) was based
on the biomedical model of health, focusing on factors impacting on individual health and
environmental issues. The New Public Health approach (early 1980s to late 1990s) recognised
the need for health promotion, highlighting the tension between the biomedical model and
promotion and prevention in health care. During this period, the World Health Organization’s
Health for All by the Year 2000 statement was published (WHO 1981), influenced by the
Lalonde Report, published in 1974, which highlighted the need for health promotion. The
World Health Organization’s Ottawa Charter, developed in 1986, has been one of the most
influential frameworks for health promotion and primary health care. The Ecological Public
Health movement emerged from the year 2000, recognising ecological and environmental
issues, along with the necessity for sustainable use of resources. Multidisciplinary strategies
have been highlighted to deal with health promotion in these areas due to complexity of health
issues, including ongoing chronic diseases (Fleming & Parker 2015). In 2012, Health 2020:
the European Policy for Health and Well-being was developed (WHO 2017e), complemented
by the global health-promoting Sustainable Development Goals in 2015 (United Nations 2017).

Health promotion charters and declarations
The five key strategies for the Ottawa Charter for Health Promotion:
• Build public health policy
• Create supportive environments
• Strengthen community action
• Develop personal skills
• Re-orient health services
http://www.who.int/healthpromotion/conferences/previous/ottawa/en/
These can be compared with the Health 2000 key components and strategies (http://www.euro.
who.int/en/health-topics/health-policy/health-2020-the-european-policy-for-health-and-well-
being/about-health-2020) and the Sustainable Development Goals where each of the 17 goals is
interconnected and challenged by ecological and environmental factors (http://www.undp.org/
content/undp/en/home/sustainable-development-goals.html).
Source: Reprinted from World Health Organization (1986) The Ottawa Charter for Health Promotion, http://www.who.
int/healthpromotion/conferences/previous/ottawa/en/
What’s the point?

The Ottawa Charter and other health promotion statements since that time are aimed at
overcoming inequalities (bias and disadvantage) and inequities (unfair distribution of health
care and other resources) through action on the SDH at all levels of society. The ultimate goal
is social justice for health and wellbeing.
In 2008 the WHO and the Commission on the SDH commemorated the 30th anniversary
of the Declaration of Alma-Ata by recommitting to the primary health care agenda in the
report: ‘Primary health care—now more than ever’ (CSDH 2008). ‘Now more than ever’ referred
to the state of global health care, which continues to this day to be plagued by inequitable
access, impoverishing costs and erosion of people’s trust in governments. Together, these
factors constitute a threat to social stability. The report underlined the need for primary health
care at a time when the global financial crisis was compromising people’s quality of life, and
when our failure to create an equitable world impinges on human rights (WHO 2008). The
WHO statement clearly refocused our attention to the original Declaration of Alma-Ata and
the Charters that followed to consider progress in meeting their goals.
All of the declarations and charters have highlighted causal pathways linking social factors
to health and wellbeing, in addition to health effects of widespread inequalities (bias and
disadvantage) and inequities (the moral aspect of health inequality, in terms of policies and
decisions taken on health care and the distribution of resources) (Arcaya et al. 2015). These
important statements and the declarations from subsequent international meetings and policy
deliberations have been unequivocal in their goal to address SDH, and they have been extremely
powerful in shaping primary health care thinking today. Contemporary mainstream thinking
in the promotion of health takes the view that without equal access to education, health care,
transportation, nutritious food and social support, the world will never have health for all. In
2012, Professor Ilona Kickbusch, who convened the group that developed the original Ottawa
Charter for Health Promotion, declared that all societies need to address ‘the political, the
commercial, the social, the environmental and the behavioral determinants of health’ (Kickbusch
2012:427), emphasising a global primary health care approach.
PROMOTING GLOBAL HEALTH

Global health promotion is central to global development, and a core government responsibility
(Labonté 2016). Labonté (2016) suggests that promoting health at the global level requires
major changes in how we deal with globalisation to manage social risks, particularly with
an ever-increasing imbalance between people holding the majority of the world’s health,
resources and political power and resources and those without these enabling SDH. Many
crises are created by global forces and affect the most vulnerable disproportionately. A major
element of shifting goals and shifting focus is to blunt the negative impact of the global
marketplace by critically appraising the health problems that have inherent global causes and
consequences, such as changes to the global labour market, increasing under-employment
in high-income countries and economic insecurity elsewhere (Labonté & Stuckler 2016).
In Labonté’s view, health improvements need to start at the national level of any country,
supported by advocacy from health and non-health professionals as the risk of lack of action
on the structural determinants of oppression, injustice and environmental crises remains
(Labonté 2016).
The political orientation of a country can also determine the outcomes of health promotion
rhetoric. Raphael (2013a, 2013b) has found that despite a country’s explicit commitment to
health promotion in public policy, this commitment does not necessarily result in implementation
of such concepts in practice. Liberal welfare states such as Canada, Australia and the UK have
all been seen to provide leadership in health promotion, yet are less successful at providing
the prerequisites for health and addressing the SDH than conservative countries such as France,
where health-promoting public policy is less apparent. Social democratic nations such as
Finland, Norway and Sweden have achieved the greatest success in both articulating health
promotion concepts in policy, implementing these in communities, and improving health
outcomes. These examples demonstrate the importance for those involved in health promotion
to understand that health promotion is inherently a political activity and that gaining knowledge
of the broad policy-making process is essential, especially given that not all health-promoting
public policy is identified as such (Raphael 2013a). Advocacy is required in many different
places within the health system and other sectors.
Promoting global health clearly requires both diplomatic and evidence-based persuasive
advocacy, based on the need for ethical, rights-based public good, development and policies
that promote security for all people (Labonté 2016). Policies that create employment or other
conditions that improve the impacts of the SDH at the population level are critical. Previously
unconsidered contributors include union density and the presence of collective employment
agreements that help preserve human rights in the workplace. Countries that have employment
policies that support union membership and/or collective bargaining have better population
health outcomes (Raphael 2013a). These population level policies are shaped by three key
forces that need ongoing attention (Kickbusch 2012). They include the power of markets and
business, particularly the transnational companies that have emerged from globalisation, the
strong voice of civil society and financial pressures being experienced by many countries
and agencies. As health practitioners, we should have a say in the type of decisions made by
governments and health planners. We can also encourage our respective nations to invest in
the health literacy of parliamentarians as well as the citizens who elect them (Kickbusch 2012).
How we can have a say in policy formation is examined more closely in Chapter 2.
HEALTH EDUCATION
Health education is an integral strategy in community health promotion. It can be described
as combinations of planned or opportunistic learning experiences designed to improve health
for individuals, families and communities by increasing their knowledge and shaping their
attitudes (Keleher 2011). The process begins by building the knowledge base, then working
with community members to identify strengths, weaknesses, assets, inequities, vulnerabilities
or other aspects of community life that may impinge on health. This knowledge is gained
through assessment, and maintaining a receptive and resourceful attitude towards new ideas
and local approaches to thinking about problems or areas that need to be strengthened.
Building health literacy is an important aspect of practice, using a range of health education
activities to help people to make informed health promoting decisions (Talbot & Verrinder
2014). Health education facilitates empowerment by showing people where to access appropriate,
relevant information on health, and how to use it to build health capacity.
Keleher (2011:236–7) has identified four models of health education: the traditional medical
model, the client-centred model, the behaviour-change model and the empowerment model.
■ Traditional medical model
This is a professional-patient approach, focusing on compliance, awareness of health risk
and encouraging behaviour change rather than empowerment. It is used commonly in
self-care in chronic disease management.
■ Client-centred model
This is an empowerment approach, strengthening client autonomy and encouraging
active participation in their disease and lifestyle management.
■ Behaviour-change model
The focus of this model is the transmission of health information, designed to promote
personal responsibility for healthy choices. A common strategy is the use of social
media.
■ Empowerment model
This model recognises the impacts of the SDH, assisting people to increase control over
the determinants affecting their health and wellbeing.
Improving health is complex, due to the underpinning SDH which need to be recog-
nised within health education activities. Four commonly used evidence-based health
education models that support individuals with planning their health behaviours are: the
Precede-Proceed Model; the Health Belief Model, the Theory of Reasoned Action and
Planned Behaviour Model and the Transtheoretical (Stages of Change) Model (as cited in
Talbot & Verrinder 2014).

The Precede-Proceed Model
The Precede-Proceed Model of health promotion is commonly used in practice. It is valuable to
consider the socio-ecological model on which the framework is based and the stages and phases
used, along with reviewing comparisons with the Health Belief Model, the Transtheoretical Model,
and the Theory of Planned Behaviour. For further reading see Porter (2016).
Chapter 5 also contains further information on the model.
The approach of knowledge plus capacity is the contemporary approach to health education.
This approach is oriented towards improving self-efficacy and individual capacity to change
(Talbot & Verrinder 2014), which is essential for developing and using health literacy. Health
education can provide people with substantive information and processes for accessing health
knowledge, including the structures and processes that help them use this knowledge for
self-management (functional health literacy), helpful techniques for influencing determinants
in their local community and society (communicative health literacy), skills and mechanisms
for developing coalitions and networks for change (critical health literacy), and political skills
to engage in community action and work with others for health capacity building. Partnership
approaches with health practitioners such as shared decision making, client-centred care and
self-management place greater incentive on people to be well informed and take an active
part in decision making about their health care.
Primary, secondary and tertiary prevention

As one of the major elements of health promotion and health education, preventing ill health
or injury is an instrumental goal of primary health care. Three levels of prevention, or preventative
health, are widely accepted as encompassing the range of activities involved in preventing
illness or injury. These levels, primary prevention, secondary prevention and tertiary prevention,
distinguish between strategies aimed at maintaining health and wellbeing and preventing
illness (primary), treating and limiting illness or injury (secondary), and rehabilitative or
restorative actions (tertiary) (Guzys et al. 2014). The aim of primary prevention is to promote
health by removing the precipitating causes and determinants of ill health or injury. These are
also known as upstream strategies as they focus on healthy public policy and programs such
as vaccination, tobacco control and promoting healthy lifestyles in areas such as nutrition,
exercise and psychosocial environments. Secondary prevention includes screening for early
detection and treatment of disease, often before symptoms are detected—for example, cervical
and testicular cancer screening and treatment. Tertiary prevention is restorative, focusing on
rehabilitation in a supportive community environment, such as cardiac and renal rehabilitation
programs (Couzos & Murray 2003, Fleming & Parker 2015, Guzys et al. 2014).
Conceptualising health practitioners’ activities across these three levels indicates a holistic,
primary health care approach that can be applied across the lifespan. The metaphor of a waterfall
illustrates this concept. Primary prevention activities at the community level are ‘upstream’
actions, such as developing educational materials to portray the benefits of nutrition or regular
exercise to help individuals become health literate and make healthy choices. Besides offering
encouragement for healthy individual choices, primary prevention includes lobbying the local
council or government agencies to create the conditions that support these choices. This type
of activity might include helping secure cost-effective foods or safe spaces for children to play.
Secondary, or ‘midstream’, prevention includes such preventative activities as screening for skin
cancer, conducting mammography clinics, or establishing drop-in centres for adolescents or
isolated older people. Tertiary prevention occurs ‘downstream’ and typically involves providing
assistance or information to help people cope with a potentially disabling condition. This could
involve the establishment of walking programs for those who have had a cardiac incident,
support groups for family members coping with a loss, or any measure that helps ensure
continuity of care and health literacy, such as access to timely health advice (see Fig. 1.3).
Nurses typically play an important role at all three levels of prevention. At the primary
prevention level, it is common to see community and practice nurses immunising children
and public health or community nurses working with a community to secure funding for a
safe playground. At the secondary prevention level, a nurse practitioner may be seen running
MULTILEVEL HEALTH PROMOTION
Upstream
Promoting, maintaining health (improving conditions)
Midstream
Appropriate treatment, protection from
harm or disability after illness/injury
Downstream
Rehabilitation, coping
(managing health and illness)
Figure 1.3 Primary, secondary and tertiary prevention
a youth drop-in centre (see for example, http://evolveyouth.org.nz/), while a practice nurse
may be found undertaking Pap smear tests to screen for cervical cancer. At the tertiary level,
a specialist nurse may run a ‘cardiac club’ for people who have suffered a heart attack or a
district nurse may do the same for people who have leg ulcers. These roles exemplify how
health promotion is both a core skill and a theoretical underpinning of nursing practice.
HEALTH PROMOTION EVALUATION

Evaluation of the effectiveness of health promotion activities is an essential step to ensure
effectiveness and appropriateness of interventions. The principles of primary health care guide
the evaluation. Where change is expected, evaluation strategies help to provide mutual feedback
to all involved so that barriers and facilitating factors are identified, as well as whatever lessons
can be taken away from one situation and applied to another.
Evaluation continues to be problematic in developing the evidence base for practice. Chal-
lenges include difficulties in measuring complex issues with contributing social determinants
of health. Many programs and projects simply conduct an internal review of general and
immediate outcomes, without sustainability indicators or breaking information down for
different segments of the population according to social or cultural characteristics (Hartman
et al. 2015). Careful, thorough evaluative information on processes and outcomes can be
invaluable to future planning by indicating which groups or contexts are receptive to various
health education strategies, how best to access community resources, and how partnerships
can be developed to help build community capacity. Evaluation is being increasingly mandated
by funding bodies and should be integral to all health promotion practice.
POINTS TO PONDER
• How would you measure the effectiveness of health promotion messages online?
• Have you ever accessed health information on the web that is incomplete or incorrect?
• How do you think you could help community members judge the adequacy and
appropriateness of the information they access electronically?
When developing evaluation plans, it is important to remember to use multiple research

methods, including the voices of participants. Different types of evaluation include:
■ Process evaluation, which is a formative evaluation reviewing ways in which strategies
were implemented.
■ Impact evaluation, where the program’s objectives are assessed to see if the primary
effects have been achieved.
■ Outcome evaluation, where the long-term program effects are reviewed to ensure the
project aim has been achieved (Talbot & Verrinder 2014).

Health promotion evaluation
The Rural Health Information Hub:
https://www.ruralhealthinfo.org/community-health/health-promotion/4/types-of-evaluation
Australian Indigenous Health Info Net:
http://www.healthinfonet.ecu.edu.au/health-infrastructure/health-workers/resources/
health-planning-evaluation-tools
Conclusion
Health and wellness are understood in different ways by different people and influenced by a multitude
of environmental, contextual, ecological and social factors. In order to achieve good health and
wellness we must base our practice on the principles of primary health care as a means of addressing
the SDH, achieving equity, equality and inclusion, and promoting good health. It can be challenging
for community health nurses to ensure they have the appropriate knowledge and skills to respond
to the range of complex, socially determined issues. However, addressing health inequities through
strengthening people’s capacity to enhance their own health and wellbeing is a worthwhile and
effective practice strategy. In the following chapter we will explore the impact of policy on practice,
and the way in which policy contributes to creating the context within which we are able to bring
a PHC approach to our practice. But first, we want to introduce to you the Smiths and the Masons.
Two families who will join you on your journey through this book.
CASE
STUDY Introducing the Smiths and the Masons
1a:
Australian family: The Masons

The Mason family lives in Maddington, a suburb of Perth, Western Australia (population 9136). The
family consists of Colin (husband, age 44), Rebecca (wife, age 41), Emily (age 6), Caleb (age 4), Joe
and Gemma (18-month-old twins). Emily goes to Maddington Public School, Caleb is about to start
pre-primary, and Joe and Gemma go to day care two mornings a week. Rebecca attends a mothers’
group organised through the twins’ day care centre. They live in one of the older neighbourhoods, but
on a street with several migrant families. Rebecca’s mother lives in the wheatbelt, three hours’ drive
from Perth. Colin, who was previously a bricklayer, flies to a Pilbara mining site every six weeks for
four weeks, works 12-hour shifts while he is in the mine, then returns home for two weeks. A
downturn in the resource economy means Colin’s work future is uncertain. He is facing redundancy
and finds himself in a precarious work situation. Rebecca has struggled with her weight since giving
birth to the twins and the child health nurse referred her to the GP, where she was diagnosed with
metabolic syndrome. She is working with the practice nurse on a program of dietary management and
activity. She goes to the gym two mornings a week while the twins are in day care and the rest of the
time manages the home and family. Colin is relatively healthy but suffers from poor sleep habits
related to his work and lifestyle. He enjoys a drink with the boys. Emily and Caleb are healthy, but
Emily is having some difficulties coping with her first year of school. The twins are active but Gemma
has eczema, which requires intermittent specialist treatment. Rising day care costs are making it
difficult to keep the children in day care, which may impact on Rebecca’s ability to get to the gym.
New Zealand family: The Smiths

The Smiths live in Papakura, South Auckland. The family consists of Jason (husband, age 34), Huia
(wife, age 31), John (age 12), Aroha (age 8), Jake (age 4). Jason works in the city as a senior advisor
for a small Māori Land Trust. Huia works full time as a Māori liaison teacher. John attends the local
kura kaupapa (Māori language primary school) where he enjoys kapa haka (Māori dance). John has
recently been diagnosed with a learning disability. Aroha also attends kura kaupapa. John and Aroha
catch the bus to kura most days but Huia drops them off when she can. Jake is 4 and attends a local
Kohanga Reo (Māori language preschool). He is eligible for 20 hours of free preschool education
available to all children aged 3 and 4 in New Zealand. Jake also has asthma for which he has been
hospitalised several times. Huia spends a lot of her free time at the local marae where she helps run a
fitness program for elders. Jason struggles with his weight and has high blood pressure.
CASE
STUDY Promoting health for the Smiths and Masons
1b:
Strategies for promoting health in the three communities of the Smiths and the Masons are planned
around the Ottawa Charter; that is, promoting healthy public policies, creating supportive
environments, strengthening community action, developing personal skills and reorienting health
services. For example, in the mining community we may want to debate the creation of wealth from
the mining companies that provide employment versus the distribution of resources and services that
may disadvantage some members of the community. The mining camp has a dearth of supportive
services for Colin’s health and wellbeing, especially as he suffers from isolation and a lack of work–life
balance. Colin is also not included in the local community, and in some cases when he goes to town
he is made to feel the resentment of the locals. Colin needs support for healthy ways of coping while
he is up at the site, which involves some personal skill development and support from the mine site
health service.
Maddington has assets and resources to support families, and several social networks for miners’
wives. However, there is considerable stress on family life, with Rebecca having to get the children to
child care, school and the child health nurse. Rebecca enjoys the social support of a group of FIFO
(Fly In Fly Out) wives.
Like Maddington, Papakura has a range of services available for families but not all are considered
culturally appropriate. The family struggles with finding appropriate child care and before and after
school care to match their needs with both Jason and Huia working full time. Jason has trouble
accessing primary health care services due to the long hours he works and there is no workplace
health program due to the small size of the trust he works for.
Reflecting on the Big Issues
This chapter outlined several ‘big issues’ including the following:

■ Health is a state of balance between individual, social and environmental factors; the SDH.
■ Being healthy includes wellbeing and happiness.
■ Being healthy in any community means having equitable access to resources, empowerment,
cultural inclusiveness, healthy environments and participation in decision making.
■ SDH have a significant role in determining the health status of people. These include biology/
genetics; healthy child development; social supports; education/literacy; employment/working
conditions; social environments; physical environments; health practices/coping skills; health
services/resources; gender/culture.
■ Healthy communities are the synthesis or product of people interacting with their environments
when they work collaboratively to shape and develop the community in a way that will help them
achieve positive health outcomes and capacities.
■ Primary health care is a philosophy aimed at promoting social justice through the principles of
accessible health care, appropriate technology, health promotion, cultural sensitivity and cultural
safety, intersectoral collaboration and public participation.
■ Primary health care principles focus on capacity building and empowerment of communities and
those who reside in them.
■ Social capital is created when people feel connected with others, developing mutuality and trust.
■ Health literacy is empowering and a vital element of achieving equity in community health.
■ Health practitioners undertake primary, secondary and tertiary prevention, using health promotion,
appropriate technology and intersectoral collaboration.
■ Health promotion is a combination of health education and helping people arrange the social and
structural circumstances of their lives to maintain health.
■ A range of charters and frameworks provide guidelines for health promotion across all communities.
Reflective Questions: How would I use this knowledge in practice?
1 Explain the link between climate change, social disadvantage and sustainable communities.
2 What is the difference between bonding and bridging social capital?
3 Create a brief map with an overview of the SDH that affect the health and wellbeing of the Smith and Mason
families.
4 Identify one research question that would help inform your work with either the Mason or the Smith family.
5 How would you deal with the tensions in the mining town in such a way that would promote the health of
both the townspeople and the mining employees?
6 What do you see as your role in: building healthy public policy, creating supportive environments, strengthening
community action, developing personal skills and reorienting health services in each of these communities?
7 Do you think the five strategies of the Ottawa Charter can yield health improvements for the host communities
of Papakura and Maddington?
8 What level of advocacy could you engage in to make visible the need for community resources in the mining
community?
9 How will you know if your strategies for health promotion are helpful?
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CHAPTER 2
Healthy policies for

healthy communities
INTRODUCTION
Growing healthy communities does not occur in isolation from the political and eco-
nomic drivers that influence our societies—local, national and global. This chapter out-
lines the Australian and New Zealand health care systems and the way in which policy
is formed. This provides the basis from which we can situate primary health care within
the current political context, enabling nurses and other health practitioners to engage in
policy formation with their communities and understand how policy drivers influence
practice.
The Australian and New Zealand health care systems both exist as part of a wider system
of government. These wider systems comprise representative democracies whereby elected
officials represent a group of people and make decisions on their behalf. The types of policies
that drive both Australian and New Zealand health systems often depend on who the elected
government is. An elected government that has a stronger neoliberal approach (for example,
advocates policies that revolve around privatisation, free trade, deregulation and fiscal austerity)
may prefer a different approach to health policy than a government that has a more social
democratic approach (for example, prefers policies that support economic and social intervention
to achieve social equity). Australian and New Zealand health policies often sit somewhere in
the middle of this spectrum. Further detail on policy making is found later in the chapter, but
it is important to understand the approach of the government currently in power as this gives
us greater understanding of what health policies may be more likely and what approaches may
be more effective when advocating change. As a matter of course, nurses and other health
practitioners working in primary health care should have a good understanding of who the
government of the day is, what impact their policies may have on practice, and how they can
influence these policies. In order to do this, it is important to understand how a health system
works.
OBJECTIVES
1 describe the Australian and New Zealand 4 analyse the successes, failures and policy
health systems gaps that have occurred in your national
2 explain the impact of policy on primary health policies
health care practice 5 discuss the role of the nurse and other
3 describe the features of a primary health health practitioners in policy planning and
care system that contribute to better health implementation.
and wellbeing
THE AUSTRALIAN HEALTH CARE SYSTEM

The system of health care in Australia is built on the principle of universal care for all citizens
paid for by their taxes. Australia has a total annual expenditure on health of 10% of Australia’s
gross domestic product (GDP) (Australian Institute of Health and Welfare 2016). Health
services are funded through Medicare, the national insurance scheme that provides each
member of society with the ability to attend any one of a number of services at no cost, or, in
the case of private providers such as general practitioners, by paying an additional surcharge
or co-payment. Many people also have private health insurance, which covers them, and their
family, for a wider range of services than are paid for by Medicare, including dental health
care, massage, optometry and other services. Private health cover is subsidised through the
Private Health Insurance Rebate and can be used for care in a public or private hospital.
Because insurance costs are high, especially for families, having additional coverage advantages
the most affluent, leaving the poor further disadvantaged. Means testing for private insurance
subsidies were introduced in 2013 and will hopefully address some of these inequities, however
the rationale for public subsidisation of private insurance remains unclear (Hall 2015).
KEY POINT
Medicare is Australia’s publicly funded universal health care system that provides all Australians
with the ability to attend many health care services at no cost or at an affordable cost.
The Commonwealth Department of Health (DoH) (www.health.gov.au) has overall respon-

sibility for health care in Australia, working through 17 statutory agencies and commissions.
Box 2.1 describes some examples of these agencies. The DoH is responsible for national health
BOX 2.1
AUSTRALIAN STATUTORY AGENCIES
• Australian Commission on Safety and Quality in Health Care (ACSQHC) (www.

safetyandquality.gov.au)
• Australian Aged Care Quality Agency (www.aacqa.gov.au)
• Australian Institute of Health and Welfare (AIHW) (www.aihw.gov.au)
• Australian Digital Health Agency (www.digitalhealth.gov.au)
policy, subsidisation of public hospitals, the Medicare Benefits Schedule, the Pharmaceutical
Benefits Scheme and the Therapeutic Goods Administration, which monitors and regulates
medicines, blood and tissue (Willis et al. 2016). The DoH also oversees a range of national
health programs including those in ageing and aged care, mental health, Aboriginal and Torres
Strait Islander health, primary and ambulatory care and health protection. Health protection
includes public health surveillance, emergency preparedness and responses, food policy, chronic
and communicable disease control, health promotion and harm reduction related to substance
abuse (Willis et al. 2016).
The Australian system is monitored through the National Health Performance Framework
(NHPF) which measures health status, determinants of health and health system performance.
The health performance reporting framework comprises a total of 48 indicators (17 hospital
indicators and 31 indicators for primary care).
State and territory governments are responsible for hospital and community care, including
private hospitals, even though the funding for these services is provided jointly, through
cooperative arrangements between Commonwealth, state and territory governments. In some
state-based health and hospital services, restructuring is a regular occurrence. Various admin-
istrative bodies take responsibility for individual hospitals, or district-level services. In most
cases, a health service district will include both general and specialist hospitals, some specialising
in certain populations (women and children) and others specialising in certain types of treatment
(cancer care, various surgical specialties).
Certain hospitals are designated as state trauma centres, able to accommodate a wide range
of emergencies, while others have the capacity for only minor emergency treatments, and are
usually bypassed in emergencies of any substance. In addition to hospital services, patients in
most health service districts have access to specialised drug and alcohol treatment services,
state-based ambulance services, aged care, mental health hostels, the Australian Red Cross
Blood service and the Royal Flying Doctor Service, which provides air transportation for
health practitioners to attend to people in remote areas and for patient access to tertiary care.

Information on Australia’s overall health performance:
• www.aihw.gov.au/reports-statistics/health-welfare-overview/health-care-quality-performance/
about-health-performance
Information on Australia’s primary care performance:
• http://www.myhealthycommunities.gov.au/
Information on Australia’s hospital performance:
• https://www.myhospitals.gov.au/
Although comparisons between different health systems are difficult because of variable reporting,
among OECD countries, Australia compares well on such indicators as tobacco smoking, life
expectancy and mortality from cardiovascular disease. Where we compare less favourably is
on national indicators of infant mortality, obesity and alcohol consumption (OECD 2015).
Most of these less favourable indicators are improving, but there remains a need to continue
addressing inequities between different population groups to improve the overall health indicators.
In the areas of alcohol consumption and obesity, the country is among the worst third of
OECD countries (OECD 2015).
The Commonwealth Government appears to have moved away from establishing national
health priorities for the people of Australia, and is using local data to inform local priorities
based on data provided by the Australian Institute of Health and Welfare (AIHW). Although
priorities can change according to a particular political agenda as noted earlier, the priorities
for population health are generally non-partisan, and based on strong research evidence. The
website www.myhealthycommunities.gov.au is an excellent example of how local area data
can help communities identify their own priority areas for intervention. In recent years, the
government has also been working towards equitable distribution of digitally mediated com-
munication and information. Access to digital technologies is an important equity issue, with
those living in disadvantaged circumstances having the least access to health information. The
National Digital Health Strategy (www.digitalhealth.gov.au) is intended to help people become
empowered partners in care, and to assist health practitioners interact with them and with
one another.
One of the most challenging aspects of the Australian health system is that responsibility
for health services is distributed through Commonwealth, state, territory and local jurisdictions,
and this can cause some duplication of effort, and a lack of clarity in reporting mechanisms
as well as cost-shifting (Krassnitzer & Willis 2016). Competition between acute and community
services adds another layer of complexity. Community nursing services such as district nursing
services are funded either directly through Regional Health Services, or through contracts
with public hospitals to provide specified services, or through state or territory health
departments. A large proportion of aged care services are provided through joint Commonwealth–
state-funded Home and Community Care (HACC) and Aged Care Assessment Team (ACAT)
programs, or, in the case of veterans, through the Commonwealth Department of Veterans’
Affairs (DVA) (Warburton & Mahoney 2016). MyAgedCare is the primary portal for information
related to aged care in Australia, linking policy, practice, referrals and resources. Further
information can be found at www.myagedcare.gov.au.
For Australians under 65 with disability, the National Disability Insurance Scheme (NDIS)
is a new way of providing support for them, their families and their carers. The NDIS supports
people with disability to receive the support they need to meet their needs including access
to mainstream services, access to community services and support, maintain informal support
arrangements and receive reasonable and necessary funding. The NDIS takes a lifetime approach
to support, investing early in lives to make a difference in the longer term. Further information
can be found on the NDIS website at www.ndis.gov.au. Disability is discussed further in
Chapter 6.
Community nurses and other health practitioners can be employed by any of these agencies,
attached to Commonwealth programs such as the HACC, ACAT or DVA programs, state or
territory public health or education departments, district community services such as Silver
Chain Nursing, Blue Care, Royal District Nursing Services, or a range of agencies responsible
for specific population groups or those with a unique focus, such as the not-for-profit centres
to help victims of violence, or torture and trauma survivors. In any context, health practitioners’
registration to practice is governed by the National Registration and Accreditation Scheme,
which has oversight for accreditation, regulation and monitoring of all health practitioners.
Professions in the scheme include chiropractors, dental practitioners, medical practitioners,
nurses and midwives, optometrists, osteopaths, pharmacists, physiotherapists, podiatrists,
psychologists, Aboriginal and Torres Strait Islander health practitioners, Chinese medicine
practitioners and medical radiation practitioners, each with their own accrediting body, such
as the Nursing and Midwifery Board of Australia.
KEY POINT
Australian nurses are registered with the Nursing and Midwifery Board of Australia and
regulated through the Australian Health Practitioners Registration Authority (AHPRA).
Most Australian medical practitioners are self-employed general practitioners (GPs) or

consultants, who practise on a contractual basis in public, and sometimes private, hospitals.
Allied health practitioners and paramedics are typically employed by hospitals or health districts,
and some can charge a fee-for-service, including acupuncturists, podiatrists and naturopaths.
Paramedics may also be employed by not-for-profit organisations such as the St John Ambulance
service. St John provides an air ambulance and ground ambulance service, and there are
subsidised helicopters for beach patrols and surf rescues. There are also volunteer ambulance
officers in rural ambulances and in attendance at metropolitan and rural events. Nurses and
midwives can be employed in hospitals or health agencies, with many being appointed to
government agencies either at the state, territory, regional or local level. Some nurse practitioners
and other nurse entrepreneurs have established clinics, and there are also midwives who work
privately or in group practices to provide homebirthing services, or other consultations. Based
on their insights into both the ‘business’ of health and the many dimensions of achieving
better health for the population, these nurses are expected to play an expanding role in policy
development (Burke 2016).
Integrated care is a growing systems response in both Australia and New Zealand to increasing
numbers of people living with long-term conditions. Integrated care has a number of definitions,
but for the purposes of this discussion we will use a process-based definition that describes
integrated care as the ‘…connectivity, alignment and collaboration within and between the
cure and care sectors…[designed] to enhance quality of care and quality of life, consumer
satisfaction and system efficiency for people by cutting across multiple services, providers and
settings…’ (World Health Organization 2016:4).
KEY POINT
Integrated care is a new approach to ensuring people’s care is coordinated, accessible and
appropriate.
New models of care built around the concept of organising and managing health services
so that people get the care they need, when and where they need it, and in ways that meet
their needs in the most appropriate and effective ways are still in the formative stages. The
Gold Coast Integrated Care Model (GCIC) is one example of a multilevel program designed
to improve patient-centred care in a complex system. Fourteen general practices volunteered
to take part in an initial trial in which multidisciplinary teams based in a coordination centre
collaborated with patients and the general practitioner to complete a holistic assessment of
needs and risks. An individual management plan was developed and actioned in collaboration
with the patient with a live care plan managed and monitored through a shared care health
information system (Cooper et al. 2015). Communication, partnership and health promotion
were essential elements of the program with the patient, general practice and public health
service all playing key roles (Cooper et al. 2015).
THE NEW ZEALAND HEALTH CARE SYSTEM

Health and disability services in New Zealand are delivered by a complex network of people
and organisations. Overall responsibility for the delivery of health services lies with the Minister
of Health. The holder of this post is elected through the democratic process to government,
and subsequently appointed to the role of Minister. The Minister of Health then works with
the Ministry of Health to provide overall leadership, direction and stewardship for the health
care system. The New Zealand Health Strategy (NZMOH 2016) provides the direction for
the current system of health care in New Zealand. The strategy can be found online at:
www.health.govt.nz/publication/new-zealand-health-strategy-2016.
KEY POINT
The New Zealand Health Strategy published in 2016 provides a guiding framework for the New
Zealand health system.
The Strategy provides a framework and context for District Health Boards (DHBs), as the
majority providers of public health services, to develop services for their identified populations.
There are currently 20 DHBs in New Zealand. DHBs plan, manage, provide and purchase
services for the population of their district. This includes funding for public health services,
primary health care services (through primary health organisations (PHOs), discussed later
in the chapter), aged care, and services provided by other non-government health providers
including Māori and Pacific providers (www.health.govt.nz/new-zealand-health-system/
overview-health-system). Māori and Pacific providers play a particularly important role in
the provision of services to their own population groups, emphasising culturally appropriate
services as significant in achieving improved outcomes.
A number of other strategic health documents also contribute to the provision of health
care services in New Zealand. He Korowai Oranga: Māori Health Strategy (NZMOH 2001
[updated 2013/14]), and ‘ ’Ala Mo’ui: Pathways to Pacific Health and Wellbeing’ (NZMOH
2014) both provide strategic direction and actions to improve health outcomes for Māori and
Pacific people in New Zealand who experience significant disparities in health compared with
non-Māori and non-Pacific people. The Healthy Ageing Strategy (Associate Minister of Health
2016) and the New Zealand Disability Strategy (Office for Disability Issues 2016) provide
further specific guidance in the areas of ageing and disability.
POINT TO PONDER
What differences can you identify between the Australian and New Zealand health systems?
DHBs employ a range of health practitioners to provide services including medical doctors,
nurses and allied health staff, such as physiotherapists and occupational therapists. However,
long waiting lists to receive care from public health services have seen the development of a
robust private health care sector in New Zealand, particularly for the provision of surgical
care. Many individual New Zealanders who can afford it choose to purchase their own health
insurance policies to ensure they have access to surgical care quickly if they need it. However,
for those people who cannot afford health insurance, poor access to surgical care can mean
prolonged suffering and disability that is easily preventable. Many medical specialists work in
both private and public health systems, potentially increasing the risk of long public health
waiting lists and the inequities this creates. Improving access to elective surgery is one of six
government targets designed to improve efficiency and care across the health sector, although
strategies designed to achieve this target are not addressing the discrepancies in private/public
surgical provision. The other five targets are: shorter stays in emergency departments (six-hour
target), faster cancer treatment, increased immunisation, better help for smokers to quit, and
raising healthy kids (www.health.govt.nz/new-zealand-health-system/health-targets). New
Zealand continues to have significant disparities in health within its population—in particular
Māori, Pacific people (as noted earlier) and those on lower incomes (NZMOH 2015). Child
poverty is a significant concern in New Zealand with approximately 28% of children living in
low-income households (New Zealand Child and Youth Epidemiology Service 2014) and
approximately 21.5% of 0–14 year olds having unmet needs for primary care (NZMOH 2015).
At the time of writing, the most recent figures are available at www.nzchildren.co.nz. The New
Zealand health strategy recognises the importance of health inequalities, the SDH, and active
participation by communities as key contributors to the health of the New Zealand population.
Using new approaches to target high-need populations—particularly children—it is hoped
many inequities can be addressed.
KEY POINT
District Health Boards (DHBs) are responsible for planning, managing, providing and
purchasing health services for New Zealanders.
DHBs also have responsibility for funding primary health care, and this is done primarily
through Primary Health Organisations (PHOs). There are currently 32 PHOs throughout New
Zealand, funded by DHBs to provide primary health care services to an enrolled population.
PHOs vary in size and structure, are not-for-profit, and either provide services directly by
employing staff or through provider members. Most general practices are members of PHOs
and provide the bulk of primary care services in New Zealand (NZMOH 2017).
General practices charge a fee-for-service on top of the funding they receive through the
PHO. Most general practices are run as businesses by the general practitioner, who then
employs staff such as nurses within the business. This business model creates difficulties for
practice nurses seeking to extend their practice, due to power imbalances inherent in employee
and employer relationships, and traditional models of practice. It was hoped that population-
based funding and the advent of PHOs would go some way towards addressing this issue, but
to date there has been limited progress. With the business model being the predominant model
of care in primary health care settings, nurses’ ability to develop more effective models of care
for patients has been stymied, although some are now challenging this. Growing population
demands and the retirement of older GPs from rural areas have seen nurses stepping up to
offer nurse-led clinics and, in some cases, buying into general practices. Extended practice
roles, substitution, delegation, innovation and liaison with other specialist practitioners are
enabling nurses in primary care settings greater opportunities than ever before (Walker et al.
2015). The government has also recently improved access for nurses to direct funding for
services provided to high-need populations rather than requiring GP sign-off as has traditionally
been the case. New models of care including the Health Care Home and Integrated Family
Health Centres also have the potential to provide new opportunities for nurses and other
health practitioners, but caution is required as the models remain largely GP-centric.
In 2016, legislative changes enabled registered nurses working in primary health and specialty
teams with appropriate qualifications to prescribe medicines and for nurse practitioners to
become authorised prescribers (full prescribing rights). Other changes amending the terminology
used in numerous pieces of legislation from medical practitioner to health practitioner has
also addressed a number of barriers to practice. For example, nurse practitioners can now sign
medical certificates and certify death. These incremental changes in policy and legislation are
slowly enabling nurses to practise to the full extent of their scope, improving access to health
care for many despite the persistence of the business model in primary care.
POINT TO PONDER
Nurse-led clinics and nurses buying into general practices as business owners are increasingly
common. What barriers currently exist that still limit nurses working in these areas?
Aged and residential care in New Zealand is provided through a mix of privately and
publicly funded services. Large business conglomerates have bought out many of the aged and
residential care providers in New Zealand that were traditionally run by charitable trusts. The
New Zealand Government funds providers to deliver services to those in need, yet standards
of care in aged and residential care facilities are frequently poor with a lack of appropriately
skilled staff identified as one of the primary contributors to this (New Zealand Human Rights
Commission 2012, New Zealand Labour Party and the Greens with Grey Power New Zealand
2010). Low pay rates and difficult working conditions in the sector make it difficult to attract
and retain nursing staff (Ravenswood et al. 2014) and many providers rely on an internationally
qualified nursing workforce to provide care (Walker 2015). Complaints regarding standards
of care in aged and residential care are higher than in all other areas (visit www.hdc.org.nz to
review case notes on complaints regarding aged care in New Zealand). Given the significant
levels of funding provided by government, further work is required to improve standards of
care across the sector.
A unique feature of the New Zealand health system is the Accident Compensation Corporation
(ACC). The ACC was established in 1974 and is, in effect, an insurance scheme that provides
personal injury cover for all New Zealanders and some visitors. The ACC is funded through
a mixture of levies from people’s earnings, businesses, petrol and vehicle licensing fees and
government funding. This means that if a person has an accident in New Zealand, the majority
of costs associated with this will be covered by the ACC at no cost to the person. In return
for this injury cover, an individual is unable to sue another person or company for personal
injury except for exemplary damages (ACC 2017). There are inequities associated with ACC
funding. For example, if an accident results in a person becoming permanently disabled, the
ACC will fund all the care and equipment that person requires on an ongoing basis. On the
other hand, if a person is permanently disabled due to a congenital abnormality or a medical
condition, all costs associated with the disability are borne by the individual with limited
financial support.
A further unique element of the New Zealand health system is the Pharmaceutical Manage-
ment Agency or PHARMAC. PHARMAC is an agency of the New Zealand Government that
decides, on behalf of District Health Boards, which medicines and related products are subsidised
for use in the community and public hospitals. PHARMAC was established in 1973 as an
attempt to control the spiralling costs of medicines in New Zealand. Its role is to get better
value and better health outcomes for New Zealanders for the money spent on medicines.
Between 2005 and 2016 PHARMAC saved DHBs nearly $6 billion (PHARMAC 2017). Further
information on PHARMAC and how it works can be found in a series of fact sheets available
online at www.pharmac.govt.nz/about/your-guide-to-pharmac/.
Paramedic care is provided largely by the St John Ambulance Service. Exceptions include
the Wellington Free Ambulance Service covering the greater Wellington area, and air ambulance
and rescue helicopter services, which are provided privately through a mix of government,
philanthropic funding and corporate sponsorship. The St John Ambulance Service has a significant
volunteer base with volunteers providing the majority of ambulance services in rural areas. This
has both advantages and disadvantages. Volunteerism is known to increase social capital in a
community; however, increasing demands on volunteer ambulance officers and limited funding
to employ full-time officers is increasing health risks for rural populations.
Primary maternity care in New Zealand is provided by Lead Maternity Carers (LMCs). A
woman selects an LMC to provide her maternity care throughout the duration of the pregnancy,
birth and first weeks following birth. An LMC may be a midwife, general practitioner with a
Diploma in Obstetrics, or an obstetrician. Midwifery as a profession in New Zealand has its
own distinct body of knowledge, scope of practice, standards of practice and code of ethics.
The Health Practitioners Competence Assurance Act (HPCA Act) 2003 provides the legal
framework governing the competency of health practitioners to practise in New Zealand. The
HPCA Act is designed to protect public safety. A number of titles are protected under the Act,
and only health practitioners registered under the Act are entitled to use these. Regulated
professions include nursing, midwifery, medicine, pharmacy, physiotherapy and a range of
other allied health professions. Registration of health practitioners is undertaken by the respective
profession’s council or board. For example, the Nursing Council of New Zealand is the statutory
body that governs the practice of nurses, monitors and sets standards for practice, and maintains
the register of nurses. The Health Practitioner Disciplinary Tribunal (a separate but linked
entity under the Act) is responsible for hearing and determining disciplinary proceedings
brought against registered health practitioners under the HPCA Act.
Despite a number of inequities in the system, at present all New Zealanders have access to
universal health care. New Zealand spends approximately $15.6 billion on health every year,
representing approximately 9.5% of GDP (New Zealand Treasury 2016, OECD 2015). Current
thinking suggests this expenditure is unsustainable, and that consolidation of spending, reducing
demand for health services and developing new models of health care provision need to be
considered (NZMOH 2016).
A focus on fiscal restraint has been a hallmark of New Zealand health policy over the past
15 years. The risk of focusing on fiscal savings is that those most disadvantaged are likely to
continue to miss out on vital health care. A study of Capital and Coast DHB’s decision making
around equity and primary health care following the increased focus on fiscal restraint found
that hospital expenditure grew relative to primary health care expenditure, inequitable access
to primary care persisted, and unplanned hospital admissions increased (Matheson 2013).
Further evidence of the risks associated with focusing on fiscal restraint is to be found in the
UK. An inquiry into reports of poor care and increased mortality rates at the Mid Staffordshire
NHS Foundation Trust found that a focus on targets and fiscal restraint were among the primary
causes (Francis 2013). There are important lessons to be learnt from these reports and both
underline the importance of the role health practitioners have in advocating for a continued
focus on social equity, the impact of the SDH and community participation in future policy.
KEY POINT
A focus on fiscal savings in health systems may result in poor outcomes for those people who
are at greatest risk, including those who live in low socio-economic areas, come from ethnic
minority populations or who have existing long-term conditions or disability.
POLITICS, POLICY MAKING AND HEALTH CARE

Policy making for community health is basically a political process in which those in positions
of power make decisions on how best to allocate resources. As health practitioners, it is our
responsibility to be aware of how these decisions are made, and to advocate for equity in
allocations to the communities we assist. This can take us into unfamiliar territory, carefully
examining the needs and priorities of the community, while, at the same time, understanding
the constraints on services and resources. Policymaking is an important step in health promotion.
Without policies, decisions for resource allocation could be made based on the loudest voices,
the highest population, or the desires of those best able to articulate their requests. To work
towards equitable distribution of resources requires policies that are fair. Fairness means that
there is advocacy for those who are most in need, whose voices are often silent. Fairness also
means that those born to privilege are not overlooked, but their needs are carefully considered
alongside those of the wider population. Guided by the principles of primary health care, we
consider how policies and systems of health service are able to balance needs and services on
the basis of social justice at the global, national, regional and local levels.
KEY POINT
A policy is a statement of intent that is implemented within an organisation or system as a

procedure or protocol. A primary health care policy should result in equitable resource
allocation.
National health policies are usually informed by, and responsive to global priorities and local
conditions. Ideally, state or regional priorities would also be designed to follow or complement
the directions of national policies. However, where political agendas differ, this may not always
be the case. So, for example, it is possible that in one Australian state or territory, policymakers
could place a high priority on environmental issues in its health planning, whereas another
might see child health as its greatest priority. Both states would be governed by the goal of better
health, but they may change the distribution of resources according to their respective priorities.
In countries such as New Zealand, where there is a single health department, policy making is
more consistent across the country, even though there may be some differences in the way
different DHBs implement policies. Yet, even in this environment, there is a need for constant
vigilance, to ensure that policy making is inclusive, and results in all members of the community
having equity of access to what they need to maintain good health.
Because of the complexity of health policy making, it is important to understand how
decisions are made. Optimally, decisions would be bi-directional: bottom-up and top-down.
Local citizens’ groups, health practitioners, town councils and city planners would convey the
needs of local communities upward, to the regional, state and national levels, where they would
participate in informed debates about health and health care. Policy makers would hear their
voices and preferences, and attempt to accommodate multiple perspectives in the way they
allocate resources for health. In this context, debates and decisions would be approached on
the basis of equal partnerships, and expedient information systems, so that all policy decisions
would also be evidence-based; or informed by the latest research and demographic data. Once
considerations were aired and consensus was achieved, the policy-making group would com-
municate with the wider community, gathering further data and/or responses, which would
instigate further cycles of input for decision making. As a result, the policy would achieve
three main outcomes. First, it would have a significant effect in improving the health of the
population. Second, it would be fair. Third, it would be administered through efficient governance
structures, with transparent goals, expectations, financial accountability and evaluation strategies.
Yet, impediments to achieving this type of system remain for reasons that are often political
and financial. Too often, political positions dictate the terms or targets of health decisions,
especially if there are vested interests involved.
KEY POINT
In an ideal world, policy making would be bi-directional: bottom-up and top-down, with local
groups and individuals having a say in how health systems are structured and services are
provided.
The main goal of health policy making should be to improve and enhance health. This
requires a strong health care system, and decisive leadership to guide the way policies are
developed. The ideal health care system is ethical, fair and strategic in its endeavour to meet
the needs of current and future communities; transparent in communicating its goals and
capabilities; oriented towards community empowerment for informed choices, and resourced
to the extent that it can support those choices. But the health system alone cannot create or
sustain health. This is why there has been an urgent call from global health policy makers to
incorporate health in all policies. Health in all policies (HiAP) is an approach to public policy
making that systematically considers the implications of all public policy decisions on health,
the determinants of health and health systems, identifies synergies across policy sectors, and
seeks to avoid the harmful health effects of poor policies (De Leeuw & Peters 2015). HiAP
also aims to improve the accountability of policy makers for health impacts at all levels of
policy making, and is based on the fundamental health-related human rights of populations,
social justice and on the obligations of governments to uphold those rights (WHO 2014). If
health was included in all policies our governments would ensure health and safety in education,
transportation, media advertising, food services and the environment. Community planning
would include health considerations in their plans for housing, infrastructure and public
works. Health planners would participate in policies for safe neighbourhoods, community
policing and disaster planning. There would be health considerations in decisions made by
departments of immigration and multicultural affairs, and health plans for primary industry
development and innovation, workplace and industrial relations. Health issues are embedded
in each of these aspects of daily life, and affect people at all stages of the life course from family
planning, safe maternity care, child protection and care, illness and injury prevention and
management at all ages, healthy ageing and end-of-life care.
KEY POINT
The health system alone cannot create or sustain health. Health must be considered in all
policy development activities.
As mentioned above, the defining purpose of a health care system lies in the provision of
accessible, appropriate, equitable health care that is responsive to people’s expectations. When
equity is achieved, the health care system, its policies, and the policies of other government
departments are inclusive, and aligned with the SDH. The fact that we live in conditions of
inequity indicates that equity continues to be elusive, yet it is a worthy goal for our actions.
To some extent, this may be due to the complexity of policy making and all the competing
interests that influence the outcome. However, some inequities persist because of events in
the global and/or local environment. When global markets decline, there is a profound impact
on countries that depend on these markets to sustain their population. If trade declines,
unemployment increases, and there is a major effect on family health and wellbeing. When
families are unable to purchase goods and services, domestic trade suffers, and more people
become unemployed. When unemployment is high, there is a dramatic drain on public resources,
and supports for those most in need are unavailable. This is a classic ‘butterfly effect’ where
we can see the inherently complex and ecological perspective of policy making.
Ambrose Bierce (1842–1914), a US author and satirist, once described politics as a ‘strife
of interests masquerading as a contest of principles’. In health policy making there has always
been a strife of interests, between rich and poor, urban and rural, young and old, sick and
well, and those with competing biomedical or health promotion needs. Health care decisions
revolve around distributive justice: who gets what. Ethically, the poor and disadvantaged should
receive the lion’s share of resources, as this would bring them up to the same level of opportunity
as the rest of the population. However, no country in the world has achieved equity in resource
allocation, leaving many people living impoverished lives. At the global level, the United
Nation’s Report on the World Social Situation indicates a need for all governments to focus
on addressing poverty through inclusion and sustainability (United Nations Department of
Economic and Social Affairs 2016). While levels of poverty have improved globally, this
improvement has not been achieved equally (United Nations Department of Economic and
Social Affairs 2016). Age, gender, disability, race, ethnicity, and economic and migration status
continue to influence the experience of poverty with many disadvantaged due to poorly paid,
precarious, insecure or lack of employment (United Nations Department of Economic and
Social Affairs 2016). Alleviating global poverty is the first of the 17 goals and 169 targets
outlined in the UN’s 2030 Agenda for Sustainable Development (United Nations 2015). The
17 sustainable development goals (SDG) (discussed in detail in Chapter 3) provide a platform
for the social, economic and environmental development of the planet. The SDGs include a
focus on universal access to health and wellbeing, universal education and sustainable approaches
to production and consumption (United Nations 2015).
KEY POINT
Globally, all governments must increase their efforts to address poverty through inclusion and
sustainability.
The UN calls on governments to implement a universal approach to social policy supported

by targeted strategies to address the distinct barriers faced by disadvantaged groups; improve
data collection through effective statistical strategies to identify groups that are left behind;
and promote inclusive institutions that have identifiable anti-discrimination policies that are
enacted (United Nations Department of Economic and Social Affairs 2016). This is a balanced
approach to alleviating poverty, urging governments and employers to work collaboratively
towards equitable, sustainable opportunities in areas such as employment, income and housing.
In each country, inclusive policies for better health should measure and understand local
problems in the context of these global issues (United Nations Department of Economic and
Social Affairs 2016). From this foundation, policy makers can then assess the impact of action
and inaction on community health in terms of the principles of primary health care: accessible
health care, appropriate technology, health promotion and health education, cultural sensitivity
and cultural safety, intersectoral collaboration and community participation.
POLICY ACTION AT THE NATIONAL LEVEL:

THINK GLOBAL, ACT LOCAL
As health practitioners, we can be conscious and concerned about global issues and the failure
of the global community to create equity. For those who wish to become global advocates
there are many lobby groups that welcome our participation. For others, becoming involved
at the global level may not be possible; however, acting at a local level can encourage community
participation in the policy arena, and ensure that professional knowledge and skills are used
to the community’s advantage. Box 2.2 provides examples of how nurses and other health
practitioners can become engaged with policy formation. To prepare for this type of advocacy
it is important to be aware of global policies. Human rights policies such as the UN Convention
on the Rights of the Child, their Declarations on the Elimination of Violence Against Women
and the Rights of Indigenous Peoples, and WHO policies on women’s and men’s health, workplace
equity and health and environmental protection can translate to local actions. Each of these
policies bring together the main issues surrounding equity, cultural inclusion and family life.
These policy areas therefore rely heavily on input from nurses and other health practitioners
who are present, visible and working with people where they live, work and play (NZMOH
2016). By working towards connecting the global policy agenda vertically (at different levels)
and horizontally (through different services) we can promote better care across the life course
from pregnancy to the end of life, incorporating maternity care, early childhood education,
adolescent and adult physical and mental health, care of the homeless and vulnerable, and
healthy ageing. Of significant concern is the decrease in the number of nurses holding senior
policy positions globally. Nurses hold only 0.6% of senior or professional positions within
WHO, and the UK National Health Service (NHS) recently announced the disbanding of the
nursing, midwifery and allied health professions policy unit (Nelson 2016). If nurses are to
continue to have a key role in policy development globally, we must advocate for nurses to
hold senior positions within these settings. Fortunately, both Australia and New Zealand
currently have nurses at senior executive levels within their respective departments of health;
however, as a profession, we must be vigilant to ensure these roles continue.
BOX 2.2
ENGAGING WITH THE POLITICAL SYSTEM AND POLICY FORMATION
Having a say in the political process and the formation of policy is an essential role for
nurses and other health practitioners. The practice experience of nurses and other health
practitioners can help inform the development of robust policy and there are many different
levels and ways in which nurses and other health practitioners can be involved in the
process. Some simple ways to engage in the policy process are as follows:
• comment on or contribute to the development of a guideline or publication written by
your workplace or professional organisation
• contribute to or comment on a proposed policy in your workplace or community
• join a group that is working on new policies or practices
• write or contribute to a submission during a policy consultation process
• make an oral submission to a workplace committee or a parliamentary select
committee
• sign a petition, participate in a campaign or go on strike as part of union action
• send an email or letter to a manager, policy analyst or member of parliament.
(Clendon 2013:1)
Using examples from everyday practice that reflect the knowledge, skill and impact nurses
have on patient care is a useful approach to take in writing or making a submission. These
real-life examples are helpful in informing policy makers of the reality of clinical practice and
the potential impact of a proposed policy change.
Source: Adapted from Clendon, J., 2013. The value of engaging with the political process, New Zealand
Nurses Association, Wellington, New Zealand.
KEY POINT
Clinical input is necessary in all policy areas from consultation and development to evaluation.
When frontline practitioners coordinate the implementation of policies, they undertake an

invaluable part of policy making, particularly if they are able to send evaluative information
and practitioner-informed evidence back to political decision makers (Burke 2016). Policies
governing adult health such as the anti-tobacco strategies, women and men’s health, family-
friendly workplaces, climate change adaptation, food security, national chronic disease strategies,
falls prevention, healthy ageing, rural health, social inclusion and mental health have been
developed this way, with specific input, for example, from nurses in Australia and New Zealand.
Where there are difficulties generating research evidence for change, health practitioners can
provide informal information to policy makers in the context of community advocacy. The
Healthy Ageing Strategy (Associate Minister of Health 2016) in New Zealand is an example
of an important family policy initiative that has relied heavily on input from nurses and other
health practitioners prior to and during development. In these and other policy areas we are
often seen as guardians of the community, ensuring health, protection from harm, and cultural
safety. Advocacy and involvement in policy is a competency requirement for nurse practitioners
in Australia and New Zealand (Nursing and Midwifery Board of Australia 2013, Nursing
Council of New Zealand 2012) and advocacy is a requirement of all registered nurses (Nursing
and Midwifery Board of Australia 2016, Nursing Council of New Zealand 2016). Each of these
policy areas continue to offer important opportunities to enact our social contract with society
to promote health and social justice. Equally as important is the need for us to ensure that
policies are framed within a caring discourse, especially those that have been developed with
an emphasis on economics and the market. The central policy theme is equity, and the strategies
for achieving equity must revolve around the SDH.
KEY POINT
Advocacy and involvement in policy is an important competency for nurse practitioners in

Australia and New Zealand but all nurses, along with other health practitioners, have an
important role to play as well.
Although we may not all be involved in formal policy development, there is a major role
for nurses and other health practitioners in examining how existing policies affect health, and
in identifying the issues that require new or modified policies to maintain health and community
capacity. Health impact assessment (HIA) is a useful tool for in-depth analysis of the impact
of a policy on health outcomes and is advocated by the World Health Organization as an
important method for maximising health promotion at the local, national and global levels
(Winkler et al. 2013).

Health impact assessment:
There are a range of resources in New Zealand and Australia to support people who wish to
undertake HIA.
• www.health.govt.nz/our-work/health-impact-assessment
• http://hiaconnect.edu.au/old/other_australian_initiatives.htm
Connecting policies with the social determinants of health

Poverty is pervasive and persistent in some countries of the world, but it is social injustice
that kills people: unjust social structures, unfair distribution of society’s benefits and responsibili-
ties, poor policies, unfair economic arrangements and bad politics (Yanicki et al. 2015). Equitable
social policies emanate from outside the health care system, in the economic environments
of a nation or region (Browne et al. 2016, Marmot 2016). However, health care systems play
three important roles in maintaining equity: by ensuring universal access to high-quality care;
by advocating for health in all policies and actions related to the SDH; and by creating, managing
and evaluating the evidence on health equity and the SDH in other policies (Fisher et al. 2016,
Marmot et al. 2012).
Australia and New Zealand boast universal access to high-quality care for most people,
but we do not achieve the other two criteria to the extent that we could, although action is
increasing. Although policies that address the SDH are present in health, this is less evident in
social policy (Fisher et al. 2016). The somewhat sporadic mention of health in the context of
developing social policies may be due to the fact that our policy research is still at an early stage of
development, without the longevity or level of evidence to mount cogent arguments for changes.
Translating existing evidence into practice is challenging and ideas must be defended on the
basis of expert opinion, political sensitivities, organisational constraints, and the possibility that
policy development processes can become eroded by the time the evidence is presented (Dwan &
McInnes 2013). The other problems lie in bureaucratic systems and the cultural divide between
researchers and policy makers. Policy makers tend to rotate through government positions
before evidence becomes accepted, and those who generate evidence are not always privy to
policy discussions. An exploration of how evidence is incorporated into policy making in New
Zealand found an inconsistent range of practices and attitudes across government agencies
(Gluckman 2013). These problems could be partially solved with the use of knowledge brokers
or science advisors, who have the time, resources and position to build positive relationships
between producers and users of research knowledge (Dwan & McInnes 2013, Gluckman 2013).
KEY POINTS
Equity in health care systems means:

• ensuring universal access
• advocating for health in all policies
• generating evidence for equity and the SDH in all policies.
Another issue concerns the type of evidence that is acceptable by government decision
makers who may be unaware of the impact of local case studies that could provide exemplars
for good and best policies elsewhere. Process evaluations, for example, provide evidence of
what works well, where and why (Moore et al. 2014), yet funding for this essential element of
the policy process is frequently trimmed or diverted (Gluckman 2013). Evaluation of health
policies themselves is also important—asking how well a policy worked and what the outcome
was is an important feedback loop to inform future policy. Dutch researchers have found
placing a continence nurse specialist within a general practice resulted in a saving of $585 per
patient seen over a three-year period (Holtzer-Goor et al. 2015), however comparing community-
based nurse-led care with rheumatologist-led care for a group of stable patients found higher
costs among the nurse-led care group (Watts et al. 2015). This type of data is important to
policy makers, but it also suggests that without concurrently demonstrating the preventative
value added by community nursing services, decision makers may consider the costs prohibitive.
To date, health service managers have been quick to adopt biomedical evidence, and, because
the political power rests with the medical, technological and pharmaceutical industries, this
is where the greatest level of funding is allocated. Public demand for scientific information
also plays a role in maintaining the dominance of biomedical, technological and pharmaceutical
services. Health care is not responsive to the business principles of supply and demand because
cost-effectiveness is not something people generally seek. When a person is ill, they want the
best, rather than the most economical health care. As a result, politicians and decision makers
find it easier to provide expensive medical care in urban environments, where demand is
greatest. However, privileging hospital services over preventative, primary health care programs
and concentrating health care in urban environments, deprives many segments of the population
from access to appropriate care and prevention of illness and injury.
KEY POINT
Evaluation of health policies is important to ensure they achieve what they set out to achieve
with no unintended negative consequences.
Rural and remote area health practitioners face a range of challenges that policy makers need
frontline guidance to address.
Policy making and primary health care

An inclusive approach to policy development resonates with a careful balance of comprehensive
and selective primary health care. Equitable services can be provided from comprehensive
primary health care systems that also accommodate selective care based on prioritised needs.
Yet the logic of this type of policy environment has yet to be acknowledged by the ‘strife of
interests’ among those competing for limited resources. Marginalised communities remain
unable to control key processes that control their lives and their health or to select what they
need. They are subjected to inadequate services, and difficult living conditions that prevent
them from being able to challenge power brokers, or work towards building local capacity. A
classic example is seen in the context of preventative interventions that benefit the affluent,
subsequently widening disparities (Hanson et al. 2016). Another barrier to primary health
care lies in policy decisions that see staff appointed to rural and remote areas for short periods
of time, which are insufficient for community engagement and, ultimately, problem solving.
In some cases, they arrive in the community to find that they are expected to live in substandard,
sometimes unsafe housing. The death of outback nurse Gayle Woodford in 2016 also highlighted
the risks many nurses face when working in solo, remote positions. Despite policy changes
requiring nurses in sole positions to be accompanied on home visits and after-hours call outs
in the Northern Territory, South Australia has so far failed to implement such requirements
(Henson & Jean 2016). Nurses and other health practitioners in rural and remote positions
have few opportunities for professional interaction or continuing education. In addition, with
so many regional, state and national employers making decisions about their role in health
and community development, there are mixed messages and variable expectations of their
role. An example is seen in the policies governing the schedule of child health assessments,
which can vary according to whether the child health nurse is employed by local, regional,
state, national or Aboriginal services. These factors make it difficult to maintain the focus on
primary health care. When communities and the people who care for them live in disadvantaged
or unpredictable situations, their predominant focus is on day-to-day survival, which not only
causes substandard health, but erodes social capital. Without political leadership that is com-
mitted to addressing the inequities of disadvantage, this situation will remain unchanged. The
policy ‘problem’ is that, rather than try to mitigate the consequences of powerless groups,
policy makers tend to shy away from restructuring health care, redefining labour relations or
unemployment arrangements, or imposing regulations on environmental pollution, or taxes
on alcohol or junk food that affect the poor disproportionately. Instead, spurred on by economic
goals, social and health policies have continued to concentrate wealth in the hands of the
powerful, which has left the poor and voiceless with a disproportionate amount of health-
damaging experiences (Fisher et al. 2016, Marmot et al. 2012).
Clearly, change is necessary, but it does not occur spontaneously. What is needed is an overt
process of inviting community input, then an ongoing level of support. This would produce
a combination of perspectives from the public, health practitioners, health planners, and
intersectoral policy makers to encourage multilevel, multidimensional approaches for better
health. The key to success in accommodating such a breadth of opinions is authentic com-
munication between all participants and particularly local stakeholders (Hanson et al. 2016).
KEY POINTS
Issues for policy makers:

• Focusing on creating wealth rather than fair distribution of wealth
• Inadequate evidence for local policy implementation
• Dominance of biomedical rather than social evaluations
• Poor and disadvantaged are voiceless
But first, those in charge of health care have to extend the invitations, then practitioners need
to become active and persistent advocates for communities, engaging with people to gain their
support and input. In this era there is room for optimism, as the centrality of community
engagement is being acknowledged in the contemporary policy environments of both Australia
and New Zealand.
New Zealand’s strong commitment to primary health care was reflected firstly in their
Primary Health Care Strategy (King 2001), and latterly with the integration of primary health
care into the New Zealand health strategy (NZMOH 2016). Australia has now begun to follow
suit, at least in the rhetoric surrounding primary health care. The National Health Reform
Agreement of 2011 was developed to commit the Commonwealth and the states and territories
to work together on preventative health strategies and system-wide policy and state-wide
planning for general practice and primary health care. Medicare Locals were subsequently
established to coordinate primary health care delivery, address local health care priorities,
support health practitioners and improve access to primary care (see www.phcris.org.au/guides/
medicare_locals.php). In 2014, Medicare Locals were disbanded (many had barely been operating
a year) and were replaced with Primary Health Networks which have a similar, mesolevel role,
albeit are fewer in number (Robinson et al. 2015). The National Primary Health Care Strategic
Framework of 2013 identified future policy directions and priorities including:
1 building a consumer-focused integrated primary health care system
2 improving access and reducing inequity
3 increasing the focus on prevention, screening and early intervention
4 improving quality, safety, performance and accountability (Australian Government 2013).
Critics of the government policy argue that there is too much emphasis on general practice
and Medicare, rather than investment in comprehensive primary health care, a lack of guidance
from government, and limited incentives to facilitate change (Donato & Segal 2013, Oster et al.
2016). These are legitimate criticisms, given that government documents in both countries
confuse primary care with primary health care, which has diluted the primary health care agenda.
In both Australia and New Zealand, attempts to devolve services traditionally provided in
hospital settings to community settings have had mixed results. One of the primary issues has
been the introduction of charges by some providers for services that were provided for free
in hospitals. For example, the treatment of cellulitis (a common bacterial infection) usually
requires intravenous antibiotics. In the past, a person was admitted to hospital for two to three
days for treatment. Now, the person is treated in the community either at home or at their
general practice. Although funding for the service has devolved to general practice, because
general practice is run as a business, a consultation fee can be charged to the person in addition
to the government funding. This can have major implications for low-income individuals and
families and actually contribute to a delay in seeking treatment rather than improve access.
It is essential that policy development in relation to devolution of services ensures equitable
access to services is maintained.
Health care: building a better system

Three decades ago, few health care planners were concerned with the SDH. Yet gradually, as
more evidence came to light, policymakers throughout the world came to realise that good
health evolves from equity and the social aspects of people’s lives, supported by an accessible
health care system. Resources and good management practices play an important role, but
there are other critical elements of a health system that contribute to the health of any given
population. These are listed as health system features in Box 2.3. The outcome of good stewardship
should be achieving the goals for a healthy society as listed in Box 2.4. Since the health
communities of the world began to focus on the SDH, we have had a closer global connection
BOX 2.3
HEALTH SYSTEM FEATURES
• Health care systems should be fair, not focused on privileging hospital care funding at
the expense of prevention or community care.
• Universal care, along with universal systems of health insurance can help reduce the
disadvantage experienced by those already disadvantaged by socio-economic status
and health status.
• A health system should provide appropriate, adequate and culturally acceptable care
for the most vulnerable.
• The majority of health care needs are in chronic disease and disability management
and these must be met with continuity of care between acute and home and
community settings.
• Service decisions should be made in partnership with health-literate end users of the
system.
• Efficiencies in the system should carefully balance technological and biomedical care
with community care.
Continued
BOX 2.3
HEALTH SYSTEM FEATURES—cont’d
• Health information systems are integral to efficient and effective services.

• Effective systems are client-oriented, so they deal with waiting lists and the patient
journey through hospital to home and community from a client, rather than a service-
provider perspective.
• A self-regulating system monitors and addresses threats to patient quality and safety.
• Adequate service provision relies on sufficient health practitioners, educated
appropriately for their scope of practice and employed across all settings to practise
at their level of competence.
• A robust health care system is based on research evidence as a basis for good and
best practice.
• A health care system should include best practice in health promotion to strengthen
capacity.
BOX 2.4
GOALS FOR HEALTHY SOCIETIES
1 Inclusivity and fairness—through a values-based commitment to equity, freedom,

social inclusion and capacity development.
2 Equality—where men and women and members of minority groups are treated
equally for common needs.
3 Cultural safety—through culturally competent management and clinical systems to
ensure that all care processes acknowledge diversity, difference and ability, with an
ultimate aim of empowerment.
4 Responsive health systems—with timely, affordable, safe, coordinated care.
5 Support for healthy behaviours—by arranging structural features of the environment
to support people in achieving and maintaining health.
6 Sustainable eco-systems—through public awareness and action on preserving the
environment.
7 Evidence-based, evidence-informed management of health and health care, where
research, interventions and policy analysis are interlinked and translated into better
health.
BOX 2.4
GOALS FOR HEALTHY SOCIETIES—cont’d
8 Democratic citizen participation—where all voices are heard.

9 Social capital is valued—human, spiritual, cultural and social capital is seen as equal
to economic capital.
10 Adequate and appropriate resources—there is congruence between needs and
resources.
11 Well managed for best processes, best practices—good stewardship and strong
community leadership is rewarded and supported.
12 Development of goals and strategies on the basis of multiple levels of influence by
an appropriate, well-educated and satisfied workforce.
to those things that help, and those that hinder our quest for health and wellness. Rapid
communication brings into our consciousness the cold, hard reality of health inequalities. We
are responding to a wider breadth of knowledge on the quality as well as the quantity of life,
and as a backlash against the failures of the market to improve health in the population. Given
the financial, demographic, environmental and epidemiological threats of modern society, it
will take great leadership to nurture our communities and render our health care systems safe,
effective and efficient. As health practitioners, we must remain in our imperfect health care
systems to improve, rather than abandon, our roles as purveyors of health. Every nurse and
every health practitioner has a certain sphere of influence, which can be used to build the
capacity of a human community to shape its culture and its future (Burke 2016). This is leader-
ship. It grows from a dialogue between people, between those of us in the health care professions,
and those who need us. We must use our leadership and our ability to generate evidence for
practice to advance the goals of primary health care with a common language and the wisdom
gleaned from community engagement.
Conclusion
In this chapter we have explored the way in which health systems and policy create the environment
in which we work. Understanding how policies drive health practice enables us to be fully engaged
with the policy formation process and contribute our frontline knowledge to policy development.
In Chapter 3 we will continue our exploration of community and examine the notion of communities
of place but before we do, we return to our case study to consider policies affecting the lives of the
Smith and Mason families.
CASE
STUDY Policy implications for the Smith and Mason families
:
The occupational health nurses at the Pilbara mine where Colin is employed, work within national
occupational health and safety policies, which are meant to protect workers. There are few
discrepancies in workplace practices given the high-risk environment of the mine.
Families in both countries are affected by global economic policies. Government policies that affect
both families include those addressing financial matters, including government spending on early
childhood education, social service provision, women’s health policy, men’s health policy and
children’s policies such as the Healthy Schools policy. Global policy affects the Mason family in
particular in terms of generating wealth from the resources of Western Australia, but the uncertainty of
the resources boom and the demise of the mining tax may have an unexpected impact on Colin’s
employment.
In New Zealand, Huia has taken up a new position as Māori teacher liaison officer. Even before she
was employed, she had to undergo a safety check to ensure she is safe to work with children. This is
a compulsory requirement of the new Vulnerable Children’s Act 2014. The Whānau Ora policy has
enabled new wrap-around services to be offered in the Papakura community as well, and this appears
to be making a difference for some of the families in the community. Aroha, who is 8, had been
complaining of a sore throat and was able to get this checked out at the sore throat clinic offered by
the school nurse, which is funded by the government to prevent rheumatic fever.
■ Policy making is a political process of deciding how resources are allocated.

■ Many local policies are linked to global and regional goals.
■ All policies influence health, and most policies are linked with one another, which means there is a
need for health to be considered in all policy making.
■ Community members should have a voice in policy making.
■ Nurses, midwives and other health practitioners can help communities develop a level of health
literacy that would facilitate their participation in policy development.
■ Health care systems continue to privilege hospital and high-tech care over community care.
■ Some inequities persist in access to care, with the most disadvantaged often excluded from the
services they need.
■ Primary health care can provide the fairest systems of health care.
■ An ideal health care system is based on the social determinants of health.
1 Internationally, population health policies can vary according to factors such as culture, economics, political
systems and the environment. Find and review the Australian and New Zealand population health policies
available on the websites listed below and reflect on the enabling and challenging factors for population health
approaches in each country: www.aihw.gov.au/ and www.health.govt.nz
2 Identify the factors influencing policy development in your health service district or primary health
organisation.
3 Explain why policy development is guided by the mantra ‘think global, act local’.
4 What strategies would you use to ensure Rebecca’s level of health literacy is adequate for caring for her
family?
5 How can a country’s primary health care system promote access and equity in services?
6 What steps could you take to support ongoing development of an effective primary health care system in
Australia or New Zealand?
7 Group exercise: Policy making and nurses
Break into groups of two or three and consider the following questions:
a What is policy and why is it important for nurses to have a good understanding of this?
b What role do nurses have in the policy-making process?
Share your thoughts with the wider group.
8 Policy action exercise: Australian and New Zealand successes and gaps
Some consider the following policies a success, others a work in progress and still others consider some of the
policies a failure or even a complete gap. Search out these policy areas and reflect on how successful they
are and why.
Success? Gaps Work in progress

Employment policies
Food safety, security
Tobacco legislation
Affordable child care
Mandatory seatbelts
Healthy schools, workplaces
Healthy ageing
Disability insurance policies
Drug and alcohol policies
Social inclusion
Distribution of health
practitioners
Success? Gaps Work in progress

Migration policy
Mental health policy
Rural health policy
Women’s and men’s health
policies
Indigenous health policies
Climate change policies
References
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overview-of-acc/introduction-to-acc/index.htm; 29 October 2017.
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Australian Government, 2013. National primary health care strategic framework. Commonwealth of Australia,
Canberra.
Australian Institute of Health and Welfare (AIHW), 2016. Health expenditure Australia 2014–15. AIHW,
Canberra.
Browne, G.R., Davern, M.T., Giles-Corti, B., 2016. An analysis of local government health policy against state
priorities and a social determinants framework. Aust. N. Z. J. Public Health 40 (2), 126–131.
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CHAPTER 3
Communities of place
INTRODUCTION
The notion of reciprocal determinism, whereby people affect and are affected by their environ-
ments, epitomises the relationship between health and place. Place is not just a location,
referring to spaces that are meaningful for human and non-human interactions for individuals,
families and communities. Place is shaped through the impacts of the SDH. A primary health
care lens highlights how communities within places, or communities of place, can promote
health and wellbeing through ongoing interactions with their environments. In so doing, place
has the potential to be adapted through community knowledge and action, expanding the
concept and management of health and wellbeing beyond traditional institutional organisations
(Neely & Nading 2017).
Places can affect physical, social and emotional aspects of health and wellbeing. In today’s
world, where there is an increasing concern about our global and local places, there is a need
to look more closely at the intersection of health, place and our personal geographies and how
we transit through multiple contexts along the pathways to good health. It is important for
health practitioners to understand how micro- and macro-level influences can affect people’s
ability to develop enabling pathways and resilience or can further exacerbate issues. Micro
OBJECTIVES
1 explain how knowledge of health and place 4 identify strengths and challenges to
can be used to promote health across a sustaining health and wellness in urban,
range of community settings rural and remote communities
2 discuss how local, national and global 5 describe the importance of the sustainable
factors combined with the social determi- development goals (SDGs) on primary
nants influence primary health care practice health care practice in Australian and New
3 explain how the health of people across the Zealand communities.
age range is influenced by virtual
communities
level relates to factors affecting families at home and at community level while macro-level
considerations result from wider economic, social and political government and non-government
institutions (Solar & Irwin 2010).
In this chapter, we will explore how place impacts on health disparities between different
groups within our communities and how these groups are able to sustain their health and
wellbeing. We start by looking closely at the relationships between global, national and local
communities. We also consider the Sustainable Development Goals and the relationship between
these and primary health care practice, virtual communities and their growing importance in
a digital world, and a range of existing unique communities including rural/remote, fly-in
fly-out (FIFO), migrant and refugee and Indigenous communities. We finish the chapter with
an exploration of promoting health in communities of place.
THE GLOBAL COMMUNITY

As part of the global community we need to be mindful that what occurs in one country
affects all others. We depend on our natural ecosystems to provide life support throughout
the world, and this affects our health and that of our communities (WHO 2017a). The macro
factors affecting the global community have a profound impact on our social world, particularly
in terms of economic capabilities and our ability to access the social and cultural supports
that help conserve our communities. Globalisation is therefore relevant to family life across
the age continuum and across generations, from birth and child care to education, employment,
recreation and a comfortable retirement. Our globalised world has brought significant changes
to community life. Global technology has enhanced knowledge for many people, providing
instant electronic access to a wealth of information, including health information and research
data; however, it has also created inequities.
The term ‘globalisation’ refers to ‘the movement across national boundaries of people, ideas,
money, goods and services, resulting in the world becoming politically, economically and culturally
interconnected and interdependent’ (Fleming & Parker 2015:334). Integration of economic
capabilities means that economic decisions affecting people in all corners of the world are
influenced by global conditions. Initially, a globalised world held the promise of increased
markets for goods, borders through which people could pass freely, greater sharing of cultures,
and economies of scale where goods might become cheaper because they could be bought and
sold efficiently by large business concerns. Economic arrangements since globalisation have
added wealth to various nations, reducing absolute poverty, a term that measures deprivation
in relation to the amount of money needed to address basic needs of daily living (UNESCO
2017). However, inequities have become evident from the fact that global markets privilege those
in control of trade relationships, who have profited enormously from worldwide commercial
endeavours at the expense of social, environmental and health concerns.
Globalisation has also led to increased spread of infectious diseases and pandemics such
as the Ebola virus disease, HIV-AIDS and avian influenza subtypes A(H5N1), A(H7N9), and
A(H9N2) infections. Chronic disease management has needed to take a global perspective.
For example, international food supply and advertising along with tobacco production and
distribution contribute significantly to chronic respiratory diseases and obesity, diabetes and
renal disease. An alternative perspective is the rise of medical tourism where cheaper costs
and enhanced technologies encourage people to travel to other countries for treatments and
procedures (Fleming & Parker 2015). Further social health impacts are emerging in relation
to unlawful income generation through illicit drug production and distribution, child and
adult prostitution, unauthorised organ harvesting, smuggling of migrants and sale of fake
medications, all targeting vulnerable people and communities (Reynolds & McKee 2010).
KEY POINT
Globalisation
Integration of the world economy through the movement of goods and services, capital,
technology and labour.
In 2000, a global macro initiative coordinated by the United Nations developed the Millenium
Development Goals (MDGs). A global partnership between participating countries agreed on
eight targets to reduce extreme poverty and associated social issues by 2015. The goals were
to: eradicate extreme poverty and hunger; achieve universal primary education; promote gender
equality and empower women; reduce child mortality; improve maternal health; combat HIV/
AIDS, malaria and other diseases; ensure environmental sustainability and develop a global
partnership for development (United Nations Development Programme 2017). The MDGs
achieved many successes with their targets; however, they did not address public health chal-
lenges such as acute epidemic diseases, non-communicable diseases, mental health disorders
and global inequalities. In 2015, a further global development strategy was adopted by the
United Nations. The Sustainable Development Goals (SDGs) are built on the successes of the
MDGs with 17 goals addressing three broad dimensions of sustainable economic, social and
environmental development through an intersectoral approach, aiming to make positive changes
for people, the planet, prosperity, peace and partnerships by 2030. The goals are underpinned
by universal, integrated and interrelated approaches that enhance sustainable strategies to
global challenges (Boerma et al. 2015). Box 3.1 outlines the full list of SDGs.
Nurses and other health practitioners have an important role to play in achieving the SDGs.
The International Council of Nurses advocates for nurses to become leaders, raise their voice
at the policy table, work with their professional associations to provide leadership in the health
sector, and work in partnership with the multidisciplinary team to achieve change (ICN 2017).
The SDGs are not just about people in low-income countries, they affect everyone. Achieving
the targets will improve the health of everyone, including ourselves.
Despite the global attention to poverty in developing countries, another effect of globalisation
has been the loss of cultural identities, languages and the right to choice in securing the best
level of health for the most number of people. The reality is that even as countries of the West
BOX 3.1
SUSTAINABLE DEVELOPMENT GOALS
Goal 1. End poverty in all its forms everywhere.

Goal 2. End hunger, achieve food security and improved nutrition and promote
sustainable agriculture.
Goal 3. Ensure healthy lives and promote wellbeing for all at all ages.
Goal 4. Ensure inclusive and equitable quality education and promote lifelong learning
opportunities for all.
Goal 5. Achieve gender equality and empower all women and girls.
Goal 6. Ensure availability and sustainable management of water and sanitation for all.
Goal 7. Ensure access to affordable, reliable, sustainable and modern energy for all.
Goal 8. Promote sustained, inclusive and sustainable economic growth, full and
productive employment and decent work for all.
Goal 9. Build resilient infrastructure, promote inclusive and sustainable industrialisation
and foster innovation.
Goal 10. Reduce inequality within and among countries.
Goal 11. Make cities and human settlements inclusive, safe, resilient and sustainable.
Goal 12. Ensure sustainable consumption and production patterns.
Goal 13. Take urgent action to combat climate change and its impacts.
Goal 14. Conserve and sustainably use the oceans, seas and marine resources for
sustainable development.
Goal 15. Protect, restore and promote sustainable use of terrestrial ecosystems,
sustainably manage forests, combat desertification, and halt and reverse land
degradation and halt biodiversity loss.
Goal 16. Promote peaceful and inclusive societies for sustainable development,
provide access to justice for all and build effective, accountable and inclusive
institutions at all levels.
Goal 17. Strengthen the means of implementation and revitalise the Global Partnership
for Sustainable Development.
* Acknowledging that the United Nations Framework Convention on Climate Change is the
primary international, inter-governmental forum for negotiating the global response to climate
change.
Source: Reprinted from World Health Organisation (2015). Health in 2015: from MDGs, Millenium
Development Goals to SDGs, Sustainable Development Goals. World Health Organisation, Geneva.
celebrate new wealth, we are all aware that wealth is distributed unequally. So as the global
community has continued to develop, there have been greater disparities between rich and
poor countries, and between the rich and poor within most countries. Clearly, globalisation
has wreaked havoc with the SDH. The effects of decisions cascade throughout society, affecting
the poor and vulnerable, including women workers, migrants, different cultural groups, rural
and urban dwellers and families.
Families
Positive family environments are integral to the development of children’s lifelong physical
and psychosocial development. Family structure and function underpin each member’s ability
to maintain their health and wellbeing. However, families frequently experience health and
psychosocial challenges which are optimally addressed through holistic, place-based approaches.
These focus primarily on a community bio-ecological and resources approach rather than on
the problems faced by the individuals. This approach enables the community, social and physical
environments supporting families to be reviewed and adapted according to need, along with
accessibility of the accompanying service systems (RCH 2011). As health practitioners, we
work in partnership with families, advocating through a respectful and culturally sensitive
approach, helping them to engage with their chosen community and develop sustainable
outcomes in the face of social adversities such as poverty, lack of transport and economic and
social marginalisation.
Urban communities
Globally, there is a greater proportion of people living in urban areas compared with those in
rural areas. Urban communities, consisting of cities and smaller population groups, accounted
for 54% of the world’s population (approximately 3.9 billion people) in 2014. This is anticipated
to rise to 66% by 2050 (United Nations, Department of Economic and Social Affairs, Population
Division 2014a).
Across the global spectrum, many cities have experienced explosive growth through reasons
such as personal choice, greater economic and employment opportunities or environmental
degradation of rural areas. At the beginning of the twentieth century, there were 16 cities with
populations of one million or greater, compared with 500 such cities in 2015. Although urban
expansion can bring economic benefits, there are also population groups subject to inequitable
living conditions, poverty and inequality due to rapid and often unplanned growth (United
Nations, Department of Economic and Social Affairs, Population Division 2014b). The subsequent
need for resources and infrastructure to combat issues such as crowded housing, food and
water security, air pollution and inadequate social services places pressure on countries both
at national and community levels to manage sustainable and socially inclusive environments
for individuals, families and communities. Additional threats are higher incidences of com-
municable diseases from overcrowding such as tuberculosis and non-communicable diseases
from urbanised unhealthy lifestyles (WHO 2016). Homelessness, the ultimate marker of
disadvantage and inequality in society, is a particular concern, as inadequate shelters struggle
to keep up with demand for food, clothing or safety. Many homeless people are the mentally
ill who have been left on the streets by deinstitutionalisation and the inadequacy of mental
health support services. Among the homeless is a growing number of adolescents and young
families experiencing social disadvantage such as poverty and unemployment (AIHW 2016a).
KEY POINTS
Up side, down side to the city

• More services, more jobs, more people
• Higher costs, poverty
• Inequities
• Substandard housing, crowding
• Fewer family supports
• Crime, pollution
Cities can also be seen as a community of place, supporting health environments where
people have choices that can help them reach their maximum potential. The Healthy Cities
initiative is a strategy supported by the World Health Organization, with an intersectoral approach
involving people such as health practitioners, and representatives of recreation, police, social
services, voluntary organisations and community members of all ages. The model of Healthy
Cities is to create awareness of the importance of place in achieving and maintaining health,
with community participation being a high priority. Healthy Cities initiatives have instigated
actions to reduce crime and environmental degradation, increase recreational spaces and promote
connectedness between people for health, education and quality of life (WHO 2017b).
An extension of the Healthy Cities movement is the WHO Age-Friendly City concept,
designed to provide optimal opportunities for health, participation, security and quality of
life for older citizens. Eight initiatives to support city and community structures and services
that optimally address the needs of older people have been identified: the built environment,
transport, housing, social participation, respect and social inclusion, civic participation and
employment, communication, and community support and health services (WHO 2017c).
Each of these initiatives will need to be developed on a local or regional basis to ensure they
are responsive to the specific needs and resources of various geographical areas.
The Healthy Cities program and WHO Age-Friendly City concepts promote micro-level
equity for families and communities, but rely on macro-level political commitment and support.
Government policies in Australia and New Zealand seek to facilitate universal publicly funded
health care systems for hospitals and primary health care in addition to social support systems
that support enabling SDH (Australian Government 2017, NZMOH 2017). Both governments
also liaise with non-government organisations to diversify the planning and delivery of health
and social services. These policies extend from urban communities to rural communities.
BOX 3.2
PRACTICE PROFILE: FLIGHT NURSE
Hi. My name is Kate and I am a Flight Nurse.

What the role entails
Flight Nurses (FNs) have specialised training in critical care nursing and midwifery. They
deliver all-encompassing critical, emergency and pre-hospital care for patients of all kinds
aboard an aircraft. They also provide community-based health care such as child health
services and diabetes clinics.
Perhaps the most visible part of the FN’s job is the primary retrievals that treat trauma
victims. These patients have usually been injured in a remote location and standard ground
transportation may not be accessible or it might take considerable time to reach the patient.
FNs stabilise these patients, administering emergency care and preparing the patient for
treatment at a tertiary facility. Duties range from basic first aid to starting IVs, administering
medication, or performing advanced resuscitation techniques.
Another common scenario involves inter-hospital patient transfers. Patients might need to
be transferred to a tertiary centre to obtain lifesaving treatment that is unavailable at the
original facility, such as an angioplasty. Secondary to patient comfort and safety during the
flight, an FN’s role is to liaise with medical practitioners at the transferring and receiving
facilities, ensuring that all pertinent information, patient files and belongings are received and
delivered into the right hands.
How I came to be in the role
I did my graduate year in rural WA and got to work in the local hospital’s emergency and
high dependency units. Many of these patients needed transfer to a tertiary hospital in
Perth for further and ongoing treatment. The majority of these patients were flown to Perth
with the Royal Flying Doctor Service (RFDS). I was fortunate to accompany patients in the
ambulance from the hospital to the RFDS hangar for transfer to Perth. I got to meet some
of the FNs transferring the patients and I admired their confidence, knowledge base and
autonomy. One of the FNs noted my enthusiasm and took the time to show me around the
aircraft, its equipment and inside the local base. She also gave me some advice on some
courses that would help me get to my goal of being an FN. That experience, and that FN’s
kindness and patience, started me on the path to become a Flight Nurse.
What I find most interesting about the role
There are so many interesting aspects of this role! The fact that you don’t know what type
of patients you are going to get each day—it could be a premature baby requiring
ventilation, an elderly patient with a fractured hip needing surgery, a woman in pre-term
labour or being first on scene to a patient in a remote location involved in a motor vehicle
accident. The excitement, variety and autonomy in the role, combined with the amazing
views from your office window, makes it a fabulous experience.
Continued
BOX 3.2
PRACTICE PROFILE: FLIGHT NURSE—cont’d
Advice for anyone wanting to become a Flight Nurse

Go for it! You need to hold a dual registration in nursing and midwifery, as well as previous
critical care experience in Emergency or ICU. Ideally a postgraduate qualification in critical
care will increase your chances of getting a job. While gaining clinical experience and
consolidating your practice in these areas, there are a few courses to consider including:
Advanced Life Support, Advanced Life Support Obstetrics, Advanced Paediatric Life
Support, Pre Hospital Life Support and Trauma Nursing Care Course. It also pays to get
rural and remote nursing experience.
Rural communities
Rural communities have a number of unique challenges that have left many more people
disadvantaged by poorer health than city dwellers. The most glaring challenge is a lack of
appropriate services, and this is the case in both Australia and New Zealand. As we discuss
later in the chapter, globalisation has meant much health service planning is no longer undertaken
on the basis of need alone; instead many decisions are made on the basis of economic considera-
tions, and this has seen a net outflow of services to those living in rural and remote communities
(AIHW 2016b, Cumming et al. 2014).
KEY POINTS
Up side, down side to rural life

• Strong sense of community
• Stable family home
• Few health, social services
• Social, cultural isolation
• Family burden of caring
• Few education, employment, recreational opportunities
• Declining economy
Although the issue of access to care in rural and remote areas has been addressed through
a number of innovations, in Australia these have primarily been aimed at flying in health
practitioners who conduct clinics or community assessments, but are then not able to provide
the long-term attention the community needs. As a result, many rural people have less preventative
care, such as screening, than urban residents, and ongoing poorer health outcomes (Onnis
2016). There are challenges for chronic disease management related to lower numbers of health
practitioners providing care, and this affects a wide range of preventable or modifiable conditions,
thereby creating a cycle of ongoing ill health (National Rural Health Alliance 2016). This
reduces people’s confidence to attain sustainable health and wellbeing. Of note, is the urgent
need for mental health assistance across Australia and New Zealand. People are experiencing
a unique range of economic and health stressors, and rates of suicide increase with remoteness
(National Rural Health Alliance 2017).
Rural communities also have high levels of disadvantage because of restricted access to the
range of goods and services that their urban counterparts enjoy. With shrinking economic
resources, many services such as banks and commercial outlets have closed down, and this
has led to a decline in the infrastructure for those who remain. Other problems include the
lack of educational, employment and recreational opportunities that would enhance health
literacy and social interaction. These factors all contribute to higher morbidity and mortality
rates for rural people, compared with those who live in cities, which is evident in the significant
and unacceptable gradient in health and wellbeing that worsens with distance from capital
cities (AIHW 2017). Population ageing has affected a growing number of rural residents, and
many of these people have chronic diseases. A lack of culturally appropriate services means
that these people are not only underserved but often unable to communicate with the health
practitioners who do make sporadic visits to the community (AIHW 2017, Erny-Albrecht &
Bywood 2016). Similarly, those needing mental health services and guidance often have difficulty
accessing services (National Rural Health Alliance 2017).
Sustainable health outcomes in rural communities are not achievable without a primary
health care approach. Issues such as affordable and accessible housing, fuel, healthy food,
education and culturally secure health and social services underpin health care provision
for rural individuals, families and communities (Springer & Smith 2016) and need to be
integral to an intersectoral approach for nursing care planning. Factors in the global envi-
ronment may also impact on policies to achieve sustainable health outcomes across rural
and urban environments and within distinctive communities. We turn our attention to
these now.

Rural health
There are a wide range of health and social challenges for individuals, families and communities
in rural areas of Australia and New Zealand. Fact Sheets on a variety of these issues are available
through the National Rural Health Alliance: http://ruralhealth.org.au/factsheets/thumbs in
addition to New Zealand’s proposed Rural Health Road Map http://www.rhaanz.org.nz/
wp-content/uploads/2017/07/Rural-Health-Road-Map-2017-A4.pdf
CONTEMPORARY ISSUES WITHIN

DISTINCTIVE COMMUNITIES
Within global, national and local communities there are distinctive and special populations.
In this next section of the chapter, we will explore some specific examples and circumstances,
and review the impact of the SDH and primary health care approaches to the health and
wellbeing of people within these communities.
Virtual communities
A contemporary perspective of health and place sees ‘place’ as internet networks, where social
relationships are created and maintained (Woo et al. 2015). This approach is appropriate to
today’s lifestyles where most of us influence and are influenced by multiple places on the
web through our virtual networks with others. These places can be described as ‘relational’,
as compared with the conventional view of ‘place’ as a specific geographical location. In our
technological world, the various forms of internet networks that bind people together can
also be considered as communities, albeit as virtual places. From this perspective, people can
enjoy membership in multiple communities that are settings for health promotion through
social media tools such as Facebook, Twitter, blogs, smart phones, SMS messaging, telephone-
assisted devices and self-tracking devices (Fleming & Parker 2015:319). Electronic devices and
social media that expedite communication are instrumental to health and wellness because
they act as conduits for people to develop health literacy, exchange knowledge on health,
become socially engaged with others, and receive information from health practitioners or
other sources when they need guidance or support. Social and electronic media therefore
play an important role in enhancing health promotion and health education, and ultimately
social capital for individuals, families and communities (Fleming & Parker 2015). Virtual
networks can therefore be seen as enabling places for health. Examples of virtual communities
include private Facebook groups for families of children with a rare disease, gaming communi-
ties or special interest communities such as people with an interest in mountain biking or
needlework.
However, virtual spaces can also create risks to health in similar and novel ways to physical
communities. Such risks may include cyber bullying and sexual predation. Other risks are related
to eyesight damage from the constant connection to screens, and behavioural effects that see
some people become socially isolated or depressed from interacting almost exclusively with
online sites rather than individuals. These risks must be managed to ensure virtual networks
remain safe environments for all those who choose to use them.
Fly-in fly-out communities

FIFO or, in some cases, drive-in drive-out (DIDO) refers to the type of work arrangements
that have become common in the mining and health professions. Under the influence of macro
global economic forces, resource-based FIFO employment has spread throughout Australia
and New Zealand, with workers flying to the exploration and mining or related infrastructure
sites for several weeks at a time, then returning home for a short break (ABS 2014). While
they are away, working hours are long with minimal time off. Leave can be unpredictable, as
it is predominantly dictated by workplace need, sometimes leaving little room for negotiation
by workers. Families of workers in urban and rural areas need support from health practitioners
and their communities to cope with parents’ and partners’ absences, tiredness and stress.
Relationship issues and parenting support are also challenges for these families (AIFS 2014).
There is evidence of challenges for community life in terms of sustainability and growth
for local communities adjacent to FIFO communities. Cost pressures are placed on infrastructure
and community development. There are challenges for policy makers, resource companies
and health practitioners to work with local communities to facilitate socio-economic wellbeing
(Chapman et al. 2015).
KEY POINTS
The potential effects of FIFO employment are:

• substantial wages
• compressed work schedules
• intermittent parenting
• low sense of community
• accommodation difficulties
• lifestyle risks for workers
• isolation of partners
• marital pressures, stress
• fly-over effects on community
• low social capital
• inadequate community services
• destruction of Indigenous land
• pressure on infrastructure.
Communities of affiliation
Some people are bound by occupation to communities such as FIFO families, and this can affect
health and social behaviours. Other occupations connect people together by virtue of shared
values and attitudes, and this is evident for many nurses who travel throughout the world.
Our own experiences have shown that meeting another member of the profession often results
in an instant connection based on a common commitment to health and wellbeing. Other
occupations may have less of a community connection, and some people prefer to maintain
their distance rather than develop a connected relationship with co-workers. So the ties that
bind members of an occupational community fall along a continuum of connectedness from
very little to very strong linkages. On the other hand, members of religious or faith communities
tend to have a strong sense of community, based, again, on a common commitment. Cultural
groups may also feel a strong sense of community, but this varies with the particular culture
and subgroups within that culture. Community bonds may be based on such things as age,
gender, family structure and whether or not people are bound together by social, occupational
or religious affiliation. For example, a group of Pacific Island elders who live in a particular
neighbourhood and attend a common church may share a close social bond, while another
group of seniors from the same region may have a separate, distinctive sense of community
outside the group. The children and grandchildren of both groups may not feel part of either
community, and instead may create their social bonds in communities bound together by study,
sports or recreational activities. These differences caution us against making generalisations
about people and their community memberships on the basis of ethnicity, which is important
to consider when working with migrant or refugee populations.
Migrant and refugee communities

International migration is a feature of globalisation, with economic, political and social inequities
and conflict underlying short- and long-term movements of people between countries. The
term migrant can be politically defined and redefined and is a current topic of interest worldwide.
For example, the designations of migrant and refugee can be categorised differently between
countries in terms of people moving voluntarily for economic, lifestyle and family reasons as
compared to refugees forced from their home countries through conflict and persecution
(Geddes & Scholten 2016). This is supported by the United Nations High Commissioner for
Refugees (UNHCR 2016) which highlights the deadly consequences for people who are denied
asylum when governments conflate the two terms, effectively removing legal protections for
refugees (see Box 3.3). Further categories include temporary workers who may have entered
a country under specific employment and education programs; and undocumented persons,
BOX 3.3
THE CONVENTION RELATING TO THE STATUS OF REFUGEES
The Convention Relating to the Status of Refugees was adopted by the UNHCR in
1950–51. Information on the Convention and the updated 1967 Protocol Relating to the
Status of Refugees can be located at: http://www.unhcr.org/3b66c2aa10.html.
The basic minimum standards for the treatment of refugees are highlighted.
UNHCR (2010)
who have no status in their new country because their visitor or temporary work status has
lapsed (Dickie et al. 2016).
It is estimated that 244 million people were classified as international migrants in 2015.
Approximately 58% migrated to developed countries compared with 42% to developing countries.
Between 1990 and 2015, the 10 countries accommodating the largest number of international
migrants were the United States of America, Germany, Russia, Saudi Arabia, the United Kingdom,
United Arab Emirates, Canada, France, Australia and Spain (United Nations, Department of
Economic and Social Affairs 2015, 2016). Migrants enrich communities through economic
development and cultural diversity but need transitory or ongoing support with their
resettlement.
The SDH impact on migrant and refugees’ ability to engage with health systems and maintain
their own health and wellbeing. Enabling factors such as awareness of language difficulties
between health practitioners, migrants and refugees, and building the capacity of multidisciplinary
health care teams to respond to both overt and hidden client trauma are crucial to reducing
social inequities for these vulnerable populations (Yelland et al. 2016). A primary health care
approach by community health nurses and other health practitioners is needed to promote
socially inclusive, accessible policies and strategies.
Research has demonstrated cumulative stressors for migrant individuals and families can
impact significantly on their physical and psychosocial health (McClure et al. 2015), with
toxic stress having adverse lifelong effects on learning, behaviour and health. Young children’s
growth and development is particularly vulnerable to these damaging effects (Centre on the
Developing Child 2017). Chapter 9 explores the refugee experience in the context of inclusive
communities.
Indigenous populations
Australian Aboriginal and Torres Strait Islander and New Zealand Māori families and com-
munities have a richness in their family lives and relationships to their communities. The
original inhabitants of both countries enjoy strong family and cultural ties that positively
influence their relationships and sense of wellbeing. However, historical and contemporary
public social and health policies have had negative influences on their ability to maintain
healthy families and communities (Springer & Smith 2016). Culturally reflexive health care
provision is needed from nurses and other health practitioners, working in partnership with
these vulnerable populations to investigate their self-perceived needs and pathways forward.
This area of practice will be explored in greater detail in Chapter 9.
PROMOTING HEALTH IN COMMUNITIES OF PLACE

People’s most immediate environment is significant for maintaining their health and wellbeing.
Planning for health promotion and health education activities needs to reflect a settings approach
and communities of place, recognising that health is shaped and is ‘where people live, love,
work and play and where they shop, google and travel’ (Kickbusch 2008:10). Effective health
promotion plans begin with knowledge of the local context, the SDH that either enhance or
constrain health and wellbeing in that environment, and individual or family factors that may
be influencing personal choices. As noted earlier in the chapter, place is where people share
meanings and understandings of their lives based on experiences and the extent to which they
can engage with others in that particular place (Nykiforuk et al. 2012). Some places are more
conducive to good health than others. For example, some communities enable and sustain
health and wellbeing through social connectedness and spaces for physical activity (Talbot &
Verrinder 2014). Relative disadvantage may include disempowering settings where there is a lack
of employment opportunities and victim blaming for poor social circumstances. Contemporary
settings affecting health and behaviour include the internet and a range of social networking sites
(MacDougall 2011). Examples of settings approaches are explored in the following paragraphs;
however, you may encounter more settings in your varied practice situations.
Health promotion in the city

As discussed earlier in the chapter, promoting the health of urban communities begins with
the global commitment to healthy cities, where community participation and empowerment,
intersectoral partnerships and participant equity are integral features of health in numerous
cities throughout the world (WHO 2017b). Locally, many Healthy Cities initiatives begin at the
neighbourhood level, particularly in those neighbourhoods where there is a high concentration
of poor and socially excluded people due to unemployment, low education or fear of crime.
Research has identified creation of trust and social integration between neighbours as being a
highly prioritised safety feature (Kullberg et al. 2013) along with the quality of a city’s environments
and enabling political, economic and social connections (Kullberg et al. 2013, WHO 2017b).
Health promotion in hospitals

Throughout the past two decades the Health Promoting Hospitals (HPH) concept has been used
to encourage acute care staff to engage in health promotion and health education. However,
HPH has been more popular in Europe than in Australia, where only 11 Australian health
services are registered (McHugh et al. 2010) or in New Zealand where none are registered.
International standards for these programs include having a management policy for promoting
health among staff, patients and families, including health promotion as an aspect of patient
assessment, providing patients with health education materials, promoting a healthy workplace
and collaborating with other health services, organisations and sectors to promote health. There
is also growing evidence that health promotion for those providing health care is also essential
to ensure optimal messages regarding health are given (Groene & Garcia-Barbero 2005).
Rural health promotion

Like health promotion in the city, promoting health in rural communities is dependent on
understanding people and place factors. Rural culture can provide a structure for higher levels
of social capital and cohesiveness; for example, higher rates of volunteering (AIHW 2017).
This is not to imply a homogeneous culture in rural and regional areas, but there are shared
cultural norms among rural people that need to be recognised for the development of effective
health promotion activities. Health outcomes are poorer outside major cities, with common
issues being diabetes, coronary heart disease and motor vehicle accidents. Multifactorial
determinants of health impact on rural and remote populations that contribute to these outcomes,
such as availability of fresh fruit and vegetables, differences in access to services and factors
associated with driving (AIHW 2017).
POINT TO PONDER
People who live in rural or remote regions frequently have poorer access to health promotion
programs. What specific role could you see a nurse undertaking to improve access to health
promotion for rural families?
In many rural and regional areas, there is often closer collaboration between acute and
primary health care services, both with an interest in integration of services (Humphreys
& Gregory 2012). In some cases it is important to develop selective and comprehensive
primary health care programs. In many rural areas one of the greatest needs for engaging
local communities is in enabling mental health literacy and supports. With the decline of
the rural economy, young people often feel isolated from their peers at a time when social
connections are most important. Adolescents may be receptive to health education messages
that encourage responsible alcohol consumption, or other healthy behaviours, but in rural
areas even when programs or services are available, they may not access these because of
the stigma of the entire community knowing their reasons for attending a clinic or service.
McMichael (2011) suggests that school-based mental health programs, often developed as part
of the Healthy Schools initiatives in urban areas, should be adapted for use in rural schools.
Valuable sources of information for rural and regional communities are the Australian National
Rural Health Alliance (www.nrha.org.au) and in New Zealand, the Institute for Rural Health
(www.nzirh.org.nz).
Health promotion in schools

Health Promoting Schools (HPS) are also place-based settings for health promotion, developed
around a whole-of-school approach to engage students and staff in promoting their health and
that of their school. Nurses in both Australia and New Zealand are actively engaged in promoting
health in schools (Lovell et al. 2011), but not always in the context of an HPS program or the
associated MindMatters program (McCluskey 2015). In those schools that do work within the
HPS framework, there have been some successes in engaging school members to work towards
improving children and adolescents’ physical and mental health. The HPS model begins with
healthy policies that promote a healthy physical and social environment, which can support
the development of healthy individual skills and actions for health in the context of providing
both health and education services (Senior 2012, WHO 2017d). HPS is also closely linked to the
external community and home environment, to provide an integrated set of values for mental
and physical health, respect for learning and social justice (WHO 2017d).
An increasing contemporary issue, identified by McCluskey (2015), highlights the role of
school health nurses in promoting awareness of mental health issues, particularly for adolescents.
A great deal of the school nurse’s practice is spent helping students with mental health and
psychosocial issues, including the safe use of technology, as online support and care plays a
significant role in management of mental health and wellbeing (Fleming et al. 2017).
Health promotion through virtual technologies

The internet is increasingly becoming a valid tool for health promotion with a wide variety
of tools that can be used by health practitioners and community members for information,
mass communication, peer interaction and community engagement (Fleming & Parker 2015).
However, access to computers can be a problem for people experiencing disadvantage which
creates barriers to participation (Van Dijk 2017). In some cases, a lack of access to readily
understood information can affect culturally and linguistically disadvantaged (CALD) people
and those with low literacy. The ‘digital divide’ can therefore be a cause of social exclusion,
exacerbating existing inequalities (Van Dijk 2017). Although 79% of Australians enjoy home
internet, there is a digital gradient, similar to the gradient effect on health, whereby disadvantaged
groups, particularly rural and Indigenous people, have less access than those at the higher
end of the socio-economic scale (Park 2017). There is also a caution for nurses in using the
internet for health education. Because information placed on the internet is publicly accessible
in perpetuity, nurses must be careful that any postings maintain client confidentiality, and that
they are accurate and represent best available knowledge at the time they are disseminated
(Nursing Council of New Zealand 2013).
KEY POINTS
Trends in health promotion and health education include:

• social media for health information
• smart phones
• addressing the digital divide
• online peer support.
One of the challenges of health promotion and education is to help maintain integrity in
the type, level and appropriateness of information people are accessing from the internet. As
health practitioners, we can fulfil an enabling role by providing access to expertise, research
evidence and contextual information that will assist people in making healthy choices and
finding the resources they need, along with providing guidance on accessing credible and
reliable information.
Conclusion
The implications of these discussions on communities of place are twofold. Firstly, they indicate that
place is very important to health. Secondly, as professional advocates, we have an obligation to stay
abreast of new knowledge and strategies that will help us maintain professional competence to
work in partnership with virtual and geographical communities, whether they are located locally,
nationally or globally. These activities are developmental in that by working collaboratively, the
knowledge, skills and self-confidence of individuals, families and communities are developed, ultimately
empowering them in their lifelong health and wellbeing. Facilitating and enabling community
empowerment also helps develop the skills of health practitioners. Every opportunity to work with
a community is unique and yields new information that community health nurses working in partnership
with other health practitioners, families and communities can use to consolidate and refine health
promotion skills. In this respect, advocacy is a deliberate two-way process of mutual development.
In the next chapter we focus on the role of the practitioner and the differing ways they work with
communities and other health practitioners.
CASE
STUDY The Smith and Mason families’ communities
:
Papakura is a working-class suburb of South Auckland with large Māori and Pacific populations.
Jason and Huia have recently built a new home on the outskirts of Papakura, approximately five
minutes’ drive to the local shopping centre and a 40-minute drive to central Auckland where Jason
works. Huia’s family lives in the Papakura area and, although Jason and Huia could afford to move to
more affluent suburbs, she wants to stay close to her extended family.
Maddington is a leafy, older suburb of Perth, with large, comfortable homes and a growing multicultural
population. The suburb contains major residential, retail and industrial sections as well as some
semi-rural areas. Unusual for a large city suburb, Maddington has several vineyards and orchards from a
previous era when it was primarily agricultural. The community has a railway station and is engaged in
transit-oriented development planning. The area also has a large shopping centre and a technical
college, and it is within 10 kilometres of a major university. The Masons live in a three-bedroom home
close to a park and within a short drive to most of the local schools and services. They are only 10
minutes away from the freeway which helps Colin’s commute to the airport.
The mining site where Colin is employed is in the Pilbara region of Western Australia. The mine operates
24 hours, 365 days a year. It is close to several small communities where some of the mine’s service
personnel live. The men live in single men’s quarters in the mining camp where they have some access
to amenities such as a gym, recreation hall and some internet access on most days.
■ Being healthy in any community means having equitable access to resources, empowerment,
cultural inclusiveness, healthy environments and participation in decision making.
■ Global factors have an impact on all types of communities.
■ Place is important to health because it constitutes as well as contains social relations.
■ The reciprocal relationship between health and place means that some places can enhance health
potential, while others may create risks to health.
■ A relational view of health sees health as dynamic, and created through either virtual or visible
networks.
■ Social capital means that communities can accumulate social assets.
■ Distinctive and special populations within our communities need supportive primary health care
approaches to enhance their capacity to maintain their health and wellbeing.
■ The relationship between health and place is a major consideration in promoting health and
advocating for the community.
1 Identify the primary, secondary and tertiary steps that can be taken to promote health in a relational community,
such as one connected by social media.
2 Intersectoral collaboration is essential for addressing the SDGs. Consider the health professional skill mixes
needed in different global communities to address community health challenges.
3 Consider how globalisation may affect your practice. How will globalisation affect job opportunities for new
graduates, and the drive for efficiencies and cost savings within health services.
4 Can you identify any influences on the Mason and Smith families from global factors?
5 Which of these factors are evident in Colin’s (mining) workplace community?
6 Conduct a web search of the two communities of Maddington WA and Papakura, New Zealand. From the
online information describe the relationship between health and place in each community
7 What would constitute social capital in each of these communities?
8 What are the most important assets available to those who live in large cities?
9 Describe a relational community in which you are a member.
10 What are the barriers to empowerment for rural communities?
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Section 2
Primary health care

in practice
CHAPTER 4 Primary health care in practice

CHAPTER 5 Assessing the community
CHAPTER 6 Planning for intervention
While Section 1 outlined the fundamental principles that underpin primary health care practice,
Section 2 shifts our focus to the practicalities of working in communities. Chapter 4 extends our
knowledge of communities by examining the wide range of nursing roles present in
communities and the many ways in which we can enable community capacity. Nurses and other
health practitioners assist communities using a comprehensive primary health care approach,
which supports all aspects of community life, helping to conserve what is special and helpful,
and assisting them in countering what is not. Other activities are aimed at selective primary
health care, which is a more targeted approach, where specific groups or issues are given priority
attention. Because primary health care has become integral to professional practice in both
Australia and New Zealand we examine primary health care roles in the context of various
models of practice and the situations that guide role development, including rural and remote
nursing, child, school and occupational health nursing, community mental health and the more
generic roles of practice nurses and nurse practitioners. In today’s health care environments
nurses undertake a range of these traditional roles and some that have evolved in response to
contemporary lifestyles. We describe some of these new roles and examine their effectiveness in
a range of health service contexts. We also examine the importance of interdisciplinary practice
and the importance of ensuring teamwork in practice.
In Chapter 5 we outline a number of models of assessment to illustrate unique features of each
as well as common elements that provide the foundations for planning. We track the
development of these assessment models, and provide some critique of their usefulness in the
current context where assessment strategies should be informed by knowledge of the social
determinants of health (SDH). We introduce a new framework for community assessment, the
McMurray Community Assessment Framework, as a unique approach to including the SDH in
community assessment, and provide some examples of its appropriateness in assessing families
such as the Smith and Mason families within the context of their communities.
Chapter 6 provides the framework for our work in communities, exploring care planning with
individuals and families, models of care and project planning. Working in and with communities
requires us to work with individuals, families and communities to achieve health, each requiring
different approaches and skill sets. In this chapter, we provide a framework for care planning and
examples of how the framework can be used in practice. Importantly, we extend our discussion
of care planning to project planning in communities. With growing demand for health
promotion in communities, project planning provides us with the skills to manage work in a
structured way, ensuring we miss nothing in our endeavours to achieve social equity. At the end
of each chapter we revisit the Smith and Mason families, using our case study to demonstrate
how nurses can work effectively within communities.
CHAPTER 4
Primary health care in practice
INTRODUCTION
This chapter is aimed at exploring the various roles from which nurses and other health
practitioners promote health and wellbeing in their communities. As you will see throughout
the chapter, despite having common primary health care goals, practitioners use a variety of
approaches to community health that are influenced by the context of community care, the
population they assist, diverse and changing regulations, policy imperatives, employer require-
ments and their specialised preparation for practice. For example, some nurses work in a
particular speciality (gerontology, for example), others as child, school or practice nurses
(PNs), and some are attached to primary health care clinics that may serve a range of popula-
tions, or specifically defined needs (women’s health, family services, aged care, remote area
nursing). Nurse practitioners work in a range of primary health care settings undertaking
diagnosis, treatment and care, while other practitioners such as paramedics and midwives
take yet another approach to primary health care. Despite the differences, initiatives to enable
community health are guided by the principles of primary health care: accessible health care,
appropriate technology, health promotion, intersectoral collaboration, community participation,
cultural sensitivity and cultural safety. Enabling health in any given community is based on
OBJECTIVES
1 discuss the major factors influencing practice and how it can be used by
primary health care practice practitioners to promote health and
2 explore how a variety of nursing and wellbeing
health/non-health practitioners can work in 4 identify the most important elements of
partnership to develop interdisciplinary successful group work
primary health care approaches targeted at 5 explore the influences of practitioner
individuals, families and communities delegation and leadership on primary
3 explain the relevance of the socio- health care practice.
ecological approach to primary health
88 Section 2 Primary health care in practice
an understanding of the social determinants of health (SDH). Practice is holistic, encompassing

the notion that health is created and maintained in the context of the settings of people’s lives,
where they work, play, study, worship, engage in recreational pursuits and access care. In each
of these settings the community itself is at the centre of care, and members of the community
are empowered by knowledge and the expectation that they will be full participants in health
decision making. Because the models and processes of care differ between settings and between
different groups of people, we describe both generalised and specialised practice in response
to changing needs and different contexts. We explore interdisciplinary practice, look at working
in teams and with groups, and leadership within the health care team.
AN INTERDISCIPLINARY PRIMARY HEALTH

CARE APPROACH
Models of practice highlight the need for community health nurses and other health practitioners
to be integral members of interdisciplinary teams to improve both clients’ experiences of care
and health outcomes, within sustainable, economically responsible environments (Salmond
& Echevarria 2017). Partnering with clients to achieve better outcomes is the mandate of all
health practitioners. This demonstrates the need for interprofessional collaboration so that
the requirements of individuals, families and communities within their social contexts determine
care, rather than provider-centric control. Effective, affordable and accessible quality care will
be available if all health practitioners integrate their strengths-based expertise and work in
partnership with clients to facilitate health, wellness and health prevention strategies (Salmond
& Echevarria 2017).
Patterns of engagement between clients and health care providers can generally be described
as uniprofessional, multiprofessional and interprofessional (Casimiro et al. 2015). The terms
multidisciplinary and interdisciplinary can be used synonymously with multiprofessional and
interprofessional. We prefer, and use throughout the book, the term interdisciplinary due to
its integrated approach to caring. Table 4.1 outlines the differences between each approach.
Table 4.1 Practice models
Uniprofessional practice A single health care provider collaborates with a client to address
a health issue.
Multiprofessional or Multiple health care providers from different professions work
multidisciplinary practice with a client to achieve the client’s health objective. There is little
collaboration with other professionals apart from information
sharing.
Interprofessional or Multiple health care providers work with a client, integrating their
interdisciplinary practice knowledge and expertise with that of the client to develop an
integrated strategy to achieve common health objectives.
Source: Adapted from Casimiro, LM., Hall, P., Kuziemsky, C., O’Connor, M., & Varpio, L., 2015. Enhancing
patient-engaged teamwork in healthcare: An observational case study. J. Interprof. Care 29 (1), 55–61.
International contemporary models of practice highlight the value of interdisciplinary

approaches to enhance quality care for individuals, families and the communities in which
they live and work. The combined expertise of professional and non-professional health care
providers can be used to address complex situations impacting on health and wellness, including
physical, psychosocial, cultural and spiritual aspects of client need (Nancarrow et al. 2013).
Combined professional expertise, in collaboration with individuals, families and communities,
can create unique client-centred support strategies to lessen risk and enhance successful outcomes
(Casimiro et al. 2015).
KEY POINT
Interdisciplinary practice in the community is guided by the principles of primary health care:
accessible health care, appropriate technology, health promotion, intersectoral collaboration,
community participation, cultural sensitivity and cultural safety.
A recent systematic review identified 10 characteristics underpinning effective interdisciplinary

team work:
■ positive teamwork and management attributes
■ communication strategies and structures
■ personal rewards
■ appropriate resources and procedures
■ appropriate skill mix
■ supportive team climate and individual characteristics supporting interdisciplinary team
work
■ clarity of vision
■ quality and outcomes of care
■ respect and understanding roles
■ training and development (Nancarrow et al. 2013:1).
Of note is the requirement for team-based ongoing professional development, which is
integral to maintaining frameworks of practice, skill mixes and familiarity of roles, in addition
to collective agreement on integration of evidence-based strategies to achieve acceptable,
meaningful and health-promoting client-centred care. Community health nurses are well
positioned to participate in and coordinate interdisciplinary teams with their strengths-based
emphasis on primary health care, understanding of the SDH and advocacy towards clients’
physical and psychosocial needs, particularly with vulnerable and at-risk families (Fraser et al.
2014, Joyce et al. 2014).
TYPES AND CATEGORIES OF HEALTH CARE

PRACTITIONERS
As we have discussed, interdisciplinary care is undertaken by a range of health care practitioners,
including nurses, doctors and allied health practitioners, such as social workers, occupational
therapists and physiotherapists. Some may be located within hospitals, while others are based
in the community or work between both sectors of practice. Practice models for community-
based nurses, midwives and paramedics are explored in this section while recognising the
need for integration of their expertise with other professional personnel within a socio-ecological
health perspective. At times, non-professional staff, such as peer-support workers and practice
assistants may be team members. Vignettes to further highlight the diversity of community
health practitioners are found throughout the text.
The Director General of the World Health Organization (WHO) recently reiterated the
importance of primary health care strategies to address health issues globally, and unequivocally
identified nursing practice as the critical driver for transforming health service organisation
and health care delivery (WHO 2017a). The impact, range and expertise of community health
nurses is increasing, with their ability to positively influence health care in traditional and
non-traditional settings being increasingly recognised (Arcus et al. 2016). Community nurses
have had a long tradition of working relatively autonomously, with the safety net of supervision
by employers and colleagues who help ensure they are engaging in best practice informed by
the most recent, relevant and rigorous evidence to support their work. Support and mentoring
of community practice can take place through intermittent monitoring of activities, face-to-
face individual or group meetings with peers, supervisors or managers, or online resources.
This is important for all practitioners to enable them to meet the high standards of nursing
practice and ethical professional performance across beginning to advanced practice levels
(ACCYPN 2016).
Advanced practice nurses

Internationally, there is no consistent interpretation of advanced practice nursing. The title
‘advanced practice nurse’ incorporates a number of advanced practice roles where registered
nurses are extending their traditional scope of practice, supported by further education and
research activities. Although advanced practice skills have improved client outcomes, there is
no agreement on the specific criteria for these roles, and regulation of this level of practice
has not been undertaken in most countries. A range of professional designations are used,
such as advanced practice nurse (APN), nurse practitioner (NP), nurse consultant (NC) clinical
nurse specialist (CNS) and nurse anaesthetist (NA) (Carney 2016:106).
In Australia, it is recognised that advanced nursing practice is not a role but specific to an
individual practitioner within their scope of practice, whether they are enrolled nurses, registered
nurses or nurse practitioners. Their higher recognisable levels of competence allow them to
manage clients with complex care needs (Nursing and Midwifery Board of Australia 2016a:1).
Advanced practice has been defined by the Nursing Council of New Zealand as a role that
reflects highly developed clinical skills and judgements acquired through a combination of
nursing experience and education (Roberts et al. 2011).
Within Australia, the three main advanced nursing areas of practice are CNSs, clinical
nurse consultants (CNCs) and NPs (Masso & Thompson 2014). In New Zealand, CNSs and
NPs are recognised as advanced practitioners. Internationally, it is recognised that there is a
need to improve health service delivery to individuals, families and communities, particularly
vulnerable populations. Access to primary health care is vital for issues of health equity and
justice but there are challenges of continuity and fragmentation within current models of care
(Richard et al. 2016). Central to innovative, client-centred care at the advanced practice level
is the evolving role of NPs who employ high levels of interdisciplinary, evidence-based health
promotion and intervention approaches in their clinical practice (Kutzleb et al. 2015).
The first NP was registered in Australia in 2000 (Australian College of Nurse Practitioners
2017) and in New Zealand in 2001 (Nursing Council of New Zealand 2017). The scopes of
practice for New Zealand and Australian nurse practitioners have many similarities, with both
requiring Master’s level educational preparation for the role. They have specific codes of practice
and are able to work autonomously and collaboratively within their legally designated scope
of practice.
POINT TO PONDER
Review the professional requirements for Australian and New Zealand nurse practitioners,
particularly noting both their scopes of practice and competencies.
New Zealand
www.nursingcouncil.org.nz/Nurses/Scopes-of-practice/Nurse-practitioner (Nursing Council of New
Zealand 2017)
Australia
www.nursingmidwiferyboard.gov.au/Registration-and-Endorsement/Endorsements-Notations.
aspx#nurse (Nursing and Midwifery Board of Australia 2016b)
Internationally, the NP role has steadily evolved, gradually gaining acceptance as a viable
contribution to health care systems, with the context of care being an important determinant
of how they practice. There is agreement on the positive enabling impact of NPs in the popula-
tions they serve, particularly in improved family-centred care and client outcomes, and increased
accessibility to health care services (Kooienga & Carryer 2015, Lowe 2017). Of note is the
positioning and expertise of NPs in understanding the impacts of the SDH and translating
this knowledge into effective strategies and policies for change (Davis & Chapa 2015). However,
the need for development of global standards for competencies and scopes of practice has
been highlighted to address discrepancies in NP roles and practice standardisation (Kooienga

& Carryer 2015).
In all levels of practice, community nurses in Australia and New Zealand have forged
important links with the communities they serve, especially in creating models of primary
health care. In rural and remote areas, cities and general practices, all nurses have a
common commitment to health equity through empowering partnerships with their clients.
Roles and responsibilities to strengthen the health and wellbeing of individuals, families
and communities are undertaken within diverse practice positions, a number of which
are discussed below and are supplemented by the practice vignettes found throughout
the text.
Community health practice

General practice nursing
General practice nursing is a rapidly expanding area of community nursing with an increasingly
pivotal role in delivering continuous care to clients, especially to those with chronic diseases.
The role includes organising client care, managing quality and risk activities, solving problems
within the general practice, providing education for clients and staff, and being an agent of
connectivity for interdisciplinary practice (APNA 2017). General practice nurses in Australia
and New Zealand are able to plan and implement client care, health promotion and prevention
activities for a range of population groups including managing emergency situations, lifestyle
education, aged care, women’s health, men’s health, anti-smoking programs, infection control,
chronic disease management including cardiovascular, asthma and other respiratory conditions,
immunisation, cancer management, mental health, maternal and child health, sexual health,
population health, diabetes and wound management (APNA 2017, Heaphy 2017). Legislative
and regulatory amendments have enabled nurses in New Zealand to add prescribing to their
toolkit and many practice nurses are expanding their scope to include this intervention within
their practice.
Many general practice nursing roles revolve around the primary care activities that are
common in general practice, such as chronic illness management. However, there is an increasing
emphasis on the importance of primary health care activities in conjunction with primary
care (Halcomb et al. 2014). Practice nursing in Australia and New Zealand is a specialist strand
of primary health care practice, complementary to the role of the GP (APNA 2017, Halcomb
et al. 2014). The role is expanding and becoming more diverse, with the scope of practice
varying according to the nurse’s expertise and experience, practice arrangements, the GP’s
understanding of the role and the needs and understanding of the role by the local population
(Halcomb & Ashley 2016, McInnes et al. 2017).
Child health nursing practice
Child health nursing is a specialised area of nursing in the community. Working within a
primary health care framework, child health nurses deliver universal and targeted services to
children. In partnership with families, child health nurses facilitate multidisciplinary and
interdisciplinary approaches, to enhance child and family health through primary, secondary
and tertiary activities. However, there are differences in titles for these nurses; for example,
‘health visitors’ in the United Kingdom, ‘Plunket/Well Child/Tamariki Ora/public health nurses’
in New Zealand and an extensive variety within different Australian states and territories
(Fraser et al. 2016:2558) such as community child health nurse (Western Australia and Northern
Territory), child health nurse (Queensland), child and family health nurse (South Australia,
Tasmania and New South Wales) and maternal and child health nurse (Victoria and Australian
Capital Territory). Internationally, there are wide scopes of practice and role descriptions for
child health nurses, with no definitive position description or agreed academic preparation
(Fraser et al. 2014, 2016). Currently, all child health nurses in Australia and New Zealand are
registered nurses, some with midwifery competencies. Across most developed countries such
as Australia, New Zealand, Canada and the United Kingdom, postgraduate studies are generally
required for child health nursing practice (Kruske & Grant 2012).
Child health practice is linked to the complexity of family life. Knowledge of the SDH and
their effect on families are key components of the child health nurse’s role (Fraser et al. 2016).
As a result, contemporary practice has become more aligned with global primary health care
goals, focusing on family strengths and assets as well as risks.
What all child health nurses have in common is working in partnership with parents in a
way that encourages their health literacy and participation in health decisions that will sustain
their family’s health and wellbeing throughout the family life cycle. Additionally, they have
an expanding role in supporting vulnerable families. The New Zealand Well Child Schedule
provides the framework for child health service provision for under-fives in New Zealand
(NZMOH 2013). The schedule outlines a universal service that all New Zealand families can
access and provides for a series of health assessments with a child health nurse up until the
child turns five, also including health promotion and specialist referrals (NZMOH 2013).
Nurses can also work in an interdisciplinary role with vulnerable children and families in
specialist programs such as in Children’s Teams as part of The Children’s Action Plan for
children at risk of abuse or neglect; and Family Start which is intensive home visiting support,
focusing on improving children’s developmental health, parent–child relationships and family
physical and psychosocial environments. In Australia, child health nurse practice is guided
by individual state government policies. However, there is a high degree of commonality of
services, including universal home visits for all families with new babies, facilitation of new
parent groups and provision of well-child clinics for developmental health assessments from
birth to preschool. Enhanced and sustained home visiting for families with additional needs
are available through programs such as Best Beginnings (DCPFS 2015, DoHWA 2017). Some
programs are aimed at assisting families with culturally specific needs (Munns & Walker
2015), while others are part of outreach programs such as the WA, NSW, South Australian
and New Zealand Family Partnership Training programs, all of which are aimed at developing
parenting capacity. Of note, are emerging models of practice incorporating partnerships between
child health nurses and community peers in order to offer universal and targeted parent
support relevant to families’ needs, particularly for vulnerable families (Munns et al. 2016,
Walker 2010).
Another more specialised type of child health practice involves acting as the expert resource
person in special schools for children with disabilities. In this context, the nurse’s health promo-
tion activities extend from primary and secondary care of the child to ongoing tertiary care
for the entire family. On occasion, this includes hospital visiting and grief counselling for
family members and fellow students.
KEY POINTS
Maternal, child and family health nurses, Plunket nurses, Tamariki Ora nurses, public health
nurses provide:
• primary, secondary, tertiary prevention
• child and family case management
• postnatal home visiting
• care coordination
• parenting group work
• telephone support
• interdisciplinary collaboration
• peer support partnerships.
School health nursing practice

School nurses use a primary health care approach to work in partnership with school-age
children and their families to foster the health, wellbeing and learning potential of each child
(CHNWA 2017). Combining primary and secondary prevention, school nurses manage safety
and protective strategies in the educational environment, promoting mental and physical
health, screening children for developmental and health conditions and intervening early
when concerns are detected. They can also provide immunisation services. School nurses can
be based in secondary schools while others engage with a number of primary and pre-schools
to conduct developmental assessments and anticipatory guidance (CHNWA 2017). In New
Zealand, school nurses who work in pre-school, primary and intermediate schools are usually
public health nurses. Children with special needs can be enrolled in mainstream school education
or within education support schools, requiring school nurses in these practice areas to be able
to undertake health procedures such as PEG feeding in addition to their prevention activities.
As part of interdisciplinary teams within schools, they assist in the management of student
health and welfare policies in addition to being an important resource person for parents and
teachers. The school nurse role is therefore complex, a specialised advanced practice role that
revolves around promoting students’ physical and mental wellbeing, which will influence their
academic success and lifelong achievement. The comprehensiveness of the role requires a
broad knowledge and skill set related to child and adolescent development, human behaviour
and learning, accompanied by enhanced communication and assessment skills to strengthen
health-promoting relationships (McCluskey 2015).
KEY POINTS
School nursing roles

• Primary, secondary, tertiary prevention to enable children’s capacity for academic achievement
and their ongoing health and wellbeing.
• Health promotion for students, staff and the school community.
There are several emerging issues impacting on the health and wellbeing of young chil-
dren and youth that are being addressed through interdisciplinary practice with the role
of the school nurse preeminent. Responding to children’s needs for support in relation to
obesity, online and face-to-face bullying, issues related to the home environment and coping
with stress are contemporary areas of need, even in very young children. As an example,
Rainbows is a school nurse facilitated program designed to address grief and loss in primary-
school-aged children in Western Australia which has demonstrated tangible benefits from
a collaborative approach between the nurses, teachers, parents and children (Munns et al.
2015). One of the most important interactions school nurses have with adolescents is in
helping them develop health literacy, particularly with the many challenges associated with
accessing health information through the internet. They need to be able to understand how
to appropriately access, understand and evaluate contextually appropriate health informa-
tion (Jain & Bickham 2014). School nurses are a credible source of information to assist
with the use of appropriate internet sites and guiding students towards making positive
health decisions.
Research is highlighting the importance of health promotion in school health practice,
particularly in relation to mental health. Health promotion using primary and secondary
strategies is vital early in life. Behaviour problems underpinned by complex psychosocial issues
beginning in infancy and childhood are associated with decreased wellbeing and increased
levels of depressive and anxiety symptoms in later adolescence (Kjeldsen et al. 2016). School
nurses are identifying that provision of mental health care is becoming increasingly embedded
in their practice, such as detecting students experiencing mental health issues, raising awareness
of risk factors within the school community and for families, and how to help with accessing
resources (McCluskey 2015).
POINT TO PONDER
Taking a psychosocial history is integral to health assessments for young people as psychosocial
and physical wellbeing are closely linked (RCH 2017). Review the use of the HEEADSSS assessment
tool for psychosocial screening. Consider the questions you could use to introduce each section.
(See also Appendix C.)
The Health Promoting Schools (HPS) framework developed by WHO provides an evidence
framework to strengthen health promotion in schools and provide guidance on key principles
and practical actions for effective outcomes (WHOWPR 2017). The guidelines for health
promotion are based on the socio-ecological approach to health, with school nurses encouraged
to use this framework in their own scope of practice and when working in collaboration with
the school community in planning, implementing and evaluating school health promotion
programs (CAHS n.d.).
School nurses must carefully balance the need to build effective relationships with students
to promote health, responding quickly to any health needs arising in the school. Many see
their role as helping children and young people develop resilience by encouraging them to
develop self-awareness and the ability to find solutions and options to the issues that chal-
lenge them. Their approach is one of deliberate engagement, building trust, taking advantage
of the ‘teachable moments’ and whatever opportunities arise to convey the message that
they are there to help. School nurses engage with students during critical developmental
periods. By working in partnerships with schools, families and community agencies, they
are able to facilitate strengths-based, effective and acceptable primary health care support
(Guzys & Monagle 2014).
Community mental health nursing practice

The prevalence of mental health issues in our societies has created renewed awareness of the
importance of community mental health nursing. Deinstitutionalisation and early discharge
for clients hospitalised with mental illnesses places a focus on the ability of community mental
health nurses to work in partnership with clients, their families and communities to manage
and promote positive mental health (Hercelinskyj & Petrie 2014). They are able to provide
support and care during life crises and transition periods at clients’ homes or residential care,
liaise with interdisciplinary teams and provide client-centred education on self-care and mental
health maintenance (Australian College of Mental Health Nurses 2017). They also provide
acute care as members of community psychiatric response teams, increasingly working col-
laboratively with emergency service personnel in critical events (Heslop et al. 2016, WA Office
of the Chief Psychiatrist 2017).
Community mental health nursing is a complex, specialised, multidimensional role; one
that combines primary, secondary and tertiary prevention with individual and family case
management for all age groups. This breadth of activities and age groups distinguishes the
role of community mental health nurses from that of other community nurses whose practice
is focused on young children in the context of child or school health, or domiciliary services
with a primary responsibility for older people. In some cases, they may be working in an
interdisciplinary role with other health practitioners. They are able to work with community
child health and school nurses to support children and youth with mental health issues and
parents with postnatal depression (Hercelinskyj & Petrie 2014). In Australia and New Zealand,
postgraduate qualifications are required for mental health nursing practice. Importantly, a
credentialling process for nurses working in general practice who wish to include mental
health care in their practice has been established by Te Ao Māramatanga New Zealand College
of Mental Health Nurses Inc (NZCMHN 2017). The Australian College of Mental Health
Nurses has developed a similar accreditation program for nurses specialising in mental health
(Australian College of Mental Health Nurses 2017). Additionally, community mental health
nurses have recognition within legislative acts, and in Australia are registered to act as responsible
clinicians within their scope of practice (Heslop et al. 2016, WA Office of the Chief
Psychiatrist 2017).
In 2016, the Australian Government transitioned an incentive funding package from the
Commonwealth Department of Health to GP Primary Health Networks. The Mental Health
Nurse Incentive Program (MHNIP) was developed in 2007 to provide clients with severe
mental illness timely access to mental health nursing care through general practices, psychiatrists
and Aboriginal Community Controlled Health Services. Evaluation outcomes have highlighted
strong client benefits when credentialled mental health nurses are working in partnership with
eligible medical practitioners. A specialist professional credentialling program for mental health
nurses is required for this area of practice (Australian College of Mental Health Nurses 2016).
KEY POINTS
Community mental health nurses provide:

• primary, secondary, tertiary prevention
• specialised case management
• integration of physical and mental health
• counselling
• care coordination
• home visiting for clients across the lifespan
• family teaching, support, health literacy
• community support for vulnerable people.
Medication management is an important part of the role of community mental health

nurses, especially for those clients with severe mental illness (Evans et al. 2016). Their level of
clinical decision making, especially in relation to medications, is distinctive in being beyond
the scope of practice of most other nurses working in the community. They also work closely
with clients and their families to facilitate understanding on medication treatment regimes, side
effects, precautions and issues of adherence (Evans et al. 2016). Other areas of responsibility
include careful management of chronic mental health disease, with emerging recognition that
physical comorbidities also need to be taken into consideration as part of the community mental
health nurse’s scope of practice (Heslop et al. 2016). One of the major issues for those who
have experienced mental illness is securing affordable, secure housing. Australian specialist
home support services recently reported that, of their clients with a mental health issue, the
18–24-year age group presented with the highest rate of homelessness and supported housing
needs (AIHW 2017). As a social determinant of health, housing security is instrumental in
feelings of wellbeing and ability to build social connections. If the location of housing is not
accessible to transport, employment and support services, people’s vulnerability to further ill
health is compounded (ABS 2016). The coordination role of the nurse is therefore signifi-
cant, with addressing the SDH through primary health care activities part of the continuum
of care.
Community-based child health, school health and mental health nursing are three practice
areas for community nurses. There are many more settings where nurses engage in primary
health care approaches with individuals, families and communities, such as occupational health,
diabetes care and education, district nursing, contact tracing for sexually transmitted diseases,
multiple sclerosis support and Hansen’s Disease guidance in urban, rural and remote areas.
All are underpinned by a primary health care model of care, working in partnerships with
clients to facilitate empowering, sustainable strategies.
Community midwifery practice

Comprehensive midwifery care needs to be responsive to the needs and preferences of women
and their families, including their ability to make informed evidence-based choices in relation
to birthing and care providers in the perinatal period (AHMAC 2016). The perinatal period
describes the time from 22 weeks of gestation to seven days following a baby’s delivery, with
the health and wellbeing of both mother and baby being taken into consideration
(WHO 2017b).
Significant changes to the education, models of care and positioning of midwives in com-
munity practice have been undertaken across Australia and New Zealand in recent years.
Recognition of midwifery as a discrete profession from nursing has been supported by direct
entry Bachelor of Midwifery programs (Hildingsson et al. 2016, Smith 2016). In Australia,
service improvement in the past decade has seen midwives providing continuity of care in
community, home and hospital settings depending on complexity and risk. Continuity of care
models that are led by midwives include three major categories: midwifery group practice
caseload care, team midwifery and private midwifery care. Research has demonstrated a high
degree of interdisciplinary collaboration being initiated by midwives with benefits for women,
midwives and service delivery agencies (Homer 2016). Publicly funded homebirths are also
an option for low-risk women in most states of Australia.
Similar to Australia, New Zealand midwifery practice includes home, community and
hospital settings. Lead Maternity Carers (LMCs), who can be midwives, general practitioners
with specialist education, or obstetricians with specialty qualifications, provide continuity of
care throughout the perinatal period, including birth. Women can birth at home, birthing
centres or in maternity hospitals (NZCOM 2016). Of note, midwives in New Zealand have a
greater primary health care focus than their Australian colleagues and report a greater sense
of professional empowerment (Hildingsson et al. 2016).

The Pregnancy, Birth and Baby website and helpline: www.pregnancybirthbaby.org.au/
The Royal New Zealand Plunket Society: www.plunket.org.nz
Paramedicine practice
Internationally paramedicine is a relatively new health discipline with paramedics working
mainly in community settings such as retrieval and industrial sites. Their role description
encompasses a wide range of primary care and primary health care activities. The following
excerpt from the College of Paramedics (2017) summarises the role:
Paramedics are autonomous practitioners who undertake a wide range of diagnostic, treatment and
management activities for service users across the lifespan, who present in either primary, urgent or
emergency care settings.
Their role is to holistically assess, and if required treat and manage service users presenting with physical
or mental health complaints; either as the result of injury, illness, or an exacerbation of a chronic illness.
They have responsibilities in health promotion and supporting proactive care for service users.
They contribute positively to the local and wider health and care services.
Paramedics work in a multitude of environments and care settings either as a sole clinician or as part of a
wider health and care team.
(College of Paramedics 2017:1)
There is a common set of competency standards for Australian and New Zealand paramedic
practitioners. Their practice reflects an interdisciplinary approach with an understanding of
SDH and the social model of health (O’Meara et al. 2014, Paramedics Australasia 2011). Mining
companies, particularly in Australia, employ paramedics for onshore, offshore and international
operations to provide emergency health responses in addition to health promotion activities
such as health and safety strategies (Acker et al. 2014).
BOX 4.1
PRACTICE PROFILE: PARAMEDIC
Hi. My name is Michelle and I am a Paramedic.

What the role entails
The role of a paramedic mainly entails the assessment and management of patients in the
pre-hospital setting and the transport of these patients to hospitals. It occurs sometimes in
an emergency situation, however it is mostly non-emergency and can even include the
transfer of patients from one hospital to another. Paramedics also attend sporting events
and music concerts, for example, where they are on standby to assist anyone who may
need medical treatment.
How I came to be in the role
I began volunteering for my local ambulance service in a rural area. They provided me with
the training I needed to attend to patients as well as driving the ambulance. Once trained, I
began assisting paramedics on jobs in attending to patients and transporting them to
hospital. I thoroughly enjoyed this role, so applied for a position to become a Student
Ambulance Officer. I was successfully recruited, qualifying as a paramedic once I had
completed my degree.
What I find most interesting about the role
I find the diversity of the people that I meet the most interesting part of the role of a
paramedic. We meet many different people and their families, quite often on what can be
the most stressful day of their lives. The other thing I find interesting is the variety of different
techniques we have available to manage patients with. The role has evolved from being
one that just transferred patients to hospital without much intervention to one where we
currently provide many lifesaving techniques.
Advice for anyone wanting to become a paramedic
Start with some volunteer work with your local ambulance service to get some experience
in the job role. This will give you an insight into what the role entails and how the service
functions. It is also a great opportunity to be involved in the community.
The role of the paramedic is evolving from a historical ambulance retrieval officer to that
of an autonomous practitioner engaged with a wide range of health practitioners and community
members in diverse practice settings. Subspecialities are emerging as their educational and
practice expertise and agency requirements expand. Evidence-based information is needed to
substantiate these areas and their continuing professional development requirements (Acker
et al. 2014).
Rural and remote area practice
Rural and remote area practice can mean working in isolated locations (Jill Clendon)
Although the context may differ, practising in rural and remote areas holds many common
challenges for health practitioners around the world. Most of these challenges are related to
the need to provide primary health care to a geographically defined community that is dis-
advantaged by distance from services and support. The notion of ‘remoteness’ varies, which
is an issue for defining rural and remote practice (Wakerman et al. 2017). The Australian
Bureau of Statistics (2017) utilises a Remoteness Areas framework to identify five classifications
of remoteness across Australia relative to each area’s ability to access services. Some rural and
remote health practitioners reviewed the differences in terms of demographics and SDH,
identifying smaller, more isolated and highly dispersed populations in remote areas. Of note,
socio-economic vulnerability was considered greater, particularly for Aboriginal and Torres
Strait Islander communities (Wakerman et al. 2017). In New Zealand, the definitions of rural
are complex with levels of rurality defined not by population but by how much influence there
is from main or satellite urban areas (NZMOH 2017).
Because of substantial differences in resources and access to other health practitioners,
the degree of remoteness is therefore significant in determining the breadth of nursing,
midwifery and paramedicine roles, which can range from being part of a team to being a
sole practitioner. In order to engage in reflexive, sustainable and client-centred activities,
practitioners engage in a primary health model of care. A recent international literature
review described rural and remote nursing as requiring a broad knowledge and expertise
base, facilitating a generalist approach (Bingham 2016). Additionally, there are competen-
cies needed for specific professional roles and extended scopes of practice, such as maternal
and child health, women and men’s health and chronic disease management. An emerg-
ing recommendation is for credentialling in rural and remote nursing roles (Cliffe &
Malone 2014).
KEY POINT
Rural and remote populations face unique health issues often compounded by a lack of
geographic access to health care services. A lack of appropriately skilled health practitioners to
meet the needs of rural populations adds to the problem.
Internationally, rural and remote area nurses, midwives and paramedics work in a range
of geographical settings for organisations such as government health services, Aboriginal
community controlled health services, primary health care clinics and outreach services,
multipurpose centres, non-government organisations and mining companies. Initiatives such
as the Australian Rural Health Outreach Fund encourage improved access for rural, remote
and regional individuals, families and communities to medical specialists, general practitioners,
community nurses and midwives, and allied health practitioners such as paramedics (Department
of Health, Australia 2014). Increasingly, due to workforce issues and family–life balance, more
community health practitioners are engaging in fly-in-fly-out and drive-in-drive-out employment
to these areas (Bingham 2016, Cliffe & Malone 2014).
Nurses and midwives working for the Royal Flying Doctor Service also undertake primary
health care activities through nurse- and midwife-led clinics and with interdisciplinary teams
(Bishop et al. 2016). A new and useful method for engaging with clients is videoconferencing
or telehealth services, allowing community health nurses and other health practitioners to
support their clients in rural and remote areas when it is not feasible to visit sites through
distance or cost. This tool can also be used for professional development activities to support
staff, especially in their expanded practice roles (Johansson et al. 2017).
The advantages of rural and remote area practice include feeling closely connected with
the community on a social as well as professional level. Relationships with people, groups and
organisations can be interdisciplinary, multi-institutional or intersectoral. However, geographic
remoteness can present challenging issues for nurses and other health practitioners working
in rural and remote areas. Stress, isolation, longer working and on-call hours, reduced opportuni-
ties for professional development and a lack of collegial support are among some of the concerns.
Nurses have also identified role creep through competing professional demands, resulting
from restructuring within government and employer policies and funding models within tight
fiscal environments (Bingham 2016, Cliffe & Malone 2014). Rural and remote practitioners
also have greater role diffusion than those working with non-rural populations, where the
boundaries between personal and professional life can be indistinct. Relationships with colleagues
outside work have an effect on the work dynamic as well as on social relationships. This type
of role diffusion has both negative and positive effects: it can be difficult for the practitioner
to maintain anonymity in the community, which can lead to role strain. On the other hand,
their closeness to the community may also make them more effective because of the level of
trust they have established (Cliffe & Malone 2014).
The health promotion role of rural and remote area nurses and other practitioners ranges
from whole-of-community initiatives to health teaching to foster health literacy for certain
individuals or groups. Indigenous people worldwide remain disadvantaged compared with
non-Indigenous populations (WHO 2017c) meaning the role of rural and remote area prac-
titioners may be to focus on identifying and building on the strengths of these groups to
facilitate health. Contributing to the SDH in rural and remote areas is less access to primary,
secondary and tertiary health services, poor food security, lower education and reduced
employment opportunities (AIHW 2016, SCRGSP 2016). Through their primary health
care approach, rural and remote area practitioners need to recognise the impacts of these
adversities, working in partnership with individuals, families and communities to develop
acceptable, affordable and sustainable strategies. As such, cultural safety is an important
consideration in their role. Developing good relationships and, when appropriate, shared
models of care with other health practitioners, including Aboriginal and Māori health workers
and community volunteers is an enabling approach to effective client outcomes (Munns &
Walker 2015).
PRACTICE STRATEGIES—WAYS OF WORKING

In order to enhance the health and wellbeing of urban, rural and remote area populations,
community nurses and other practitioners employ a variety of evidence-based strategies
either as sole practitioners or within intersectoral and interdisciplinary practice. Professional
practice models and strategies have been influenced by contemporary health evidence,
economic influences, population vulnerabilities and workforce fluctuations. Models such as
progressive universalism have been developed to augment capacity within universal health
service delivery to target the needs of those population members who need enhanced support,
such as parenting skills (AIFS 2016). Strategies are underpinned by approaches that facilitate
client self-determination and empowerment, including culturally safe care and a partnership
approach.
Working with groups

Along with individual and community-level approaches, community health practice includes
group activities to help people create and maintain their health, change their health behaviours
or enhance their community through capacity building. There are several advantages for
undertaking group work as opposed to one-on-one interactions. Linking vulnerable people
into a community’s social networks and groups encourages a sense of belonging, self-esteem
and wellbeing (Talbot & Verrinder 2014). Group work can be rewarding, particularly when
group members energise and support one another, but it can also be challenging, especially
where individuals overwhelm the ideas of others by dominating the group, or when group
members find the topic difficult to share. To meet the goals of the group the facilitator must
accommodate different cultures, attitudes, behaviours, experiences and styles of relating to
other people.
The success of group work depends on two main elements: content and process. In some
cases, the content of the group is pre-determined by the reason it was constituted, which can
be to provide group therapy, mutual support for a common issue or condition, to develop
group or community solutions to problems or a combination of all of these goals. Group topics
can be varied, such as new parent support groups, toddler behaviour and toilet training, sexual
health, anaphylaxis management and drug education. Nurses may decide to be a member of
a community group where political and policy decisions have compromised their ability to
provide equitable, accessible services to the community. This type of action is often influenced
by decisions that have created disadvantage for the most vulnerable in society and is where
nurses use their advocacy skills to articulate to policy makers the difficulties people experience
from decisions such as discontinued rural health services and housing for the mentally ill or
victims of violence.
Contemporary community health nursing practice also includes working with virtual groups
using a number of technologies such as email, teleconferencing, text, Skype, Facebook, Twitter,
blogs, videoconferencing, telehealth and electronic meeting systems to connect with clients
across urban, rural and remote contexts. These interactive tools present opportunities for
people to participate in groups regardless of proximity. However, the nurse facilitator needs
to be aware that not all group members may have the language and technology skills to be
fully involved with the discussion (Coggio & Deveneau 2016, Johansson et al. 2017).
Effective group facilitators understand the importance of group processes, and the need to
develop a sense of shared purpose. They are also able to monitor group progress while maintaining
personal boundaries, understanding what is appropriate in terms of self-disclosure, particularly
when drawing on personal experiences. They create a safe space for conversation, maintaining
a non-judgemental attitude and consistency in the way they approach conflict resolution.
Communication strategies are crucial to effective group processes and problem solving. These
KEY POINTS
Group planning and management needs to be addressed through a range of strategies:

• Establish purpose, goals, leadership.
• Establish rules for confidentiality.
• Set tone for communication.
• Discuss organisational issues.
• Decide tasks and responsibilities.
• Decide on progress markers.
• Conflict resolution.
include launching discussions in ways that are informative but do not preclude others’ ideas,
controlling the fairness and flow of the discussions, ensuring that familiar language is used
and ensuring a balance between guided discussion and self-direction. Understanding and
developing appropriate child- and adult-centred learning needs are important group learning
strategies where the learning environment is structured to enhance interactive opportunities
for participation and learning (Talbot & Verrinder 2014).
Many groups are facilitated by interdisciplinary teams, where the perspectives of other
disciplines can collaboratively address the SDH, enhance problem resolution and promote
holistic views (Talbot & Verrinder 2014). A similar dynamic occurs when groups combine
professionals and peer support workers (PSWs) from the same communities as their clients,
where enabling strategies can be developed through a shared PSW understanding of impacting
SDH and their ability to deliver culturally relevant support and advocacy (Munns et al. 2016).
Reflective practice
As discussed throughout this chapter, therapeutic relationships between community health
nurses and other health practitioners and their clients are vitally important in order to facilitate
community health and wellness. The SDH can present complex issues for both health practitioners
and clients, particularly in rural and remote areas and for clients with vulnerabilities. A high
degree of problem solving and interdisciplinary case management are needed. As such, reflective
thinking and practice are important elements of nursing models of care, allowing for reflections
on philosophies, personal viewpoints and actions in order to improve ongoing delivery of
care. Nurses are encouraged to consider both strengths and challenges within their practice.
This involves a high degree of critical thinking and enhances clinical reasoning. Key considera-
tions are whether clients and communities feel comfortable and engaged with health practitioners
and their health services (Nicol & Dosser 2016, SARRAH 2017, Smith 2016). Additionally,
critical reflection enables interdisciplinary teams to review their performance and decision-
making processes (Guzys et al. 2017, Sims et al. 2015).
Reflective practice can be undertaken through a range of strategies. Private, group and
one-on-one reflections with facilitators are commonly used approaches. Maintaining a reflective
diary or journal is advantageous for documenting events, feelings and reflections. Groups may
comprise nurse-only members or may be interdisciplinary, which has the potential to enhance
deeper understandings of context and practice (SARRAH 2017).
An emerging strategy to support rural and remote community health nurses is the use of
telehealth to link nurses and mentors. During 2016 a trial program was conducted for beginning-
level child health nurses without peer support in rural and remote Queensland to support
their skills and knowledge development. Overall, strong support from the child health nurses
was received for this reflective practice research project, demonstrating that the telehealth
strategy was an acceptable, effective and viable support strategy. Challenges related to identifying
time for the reflective practice sessions and the need for extra phone and email support when
required (State of Queensland, Queensland Health 2016).
POINT TO PONDER
Models of reflection guide health practitioners in reviewing their practice. It is important to

remember that reflections need to consider a primary health care approach and the impact of the
SDH on clients and communities. A strengths-based approach is recommended to enable
consideration of both positive and challenging aspects of models of care.
Please review three commonly used models of reflection: John’s model of reflection (Johns 1994),
Atkins and Murphy’s model of reflection (Atkins & Murphy 1994) and Gibbs’ model of reflection
(Gibbs 1988). These can be found at: http://libguides.scu.edu.au/c.php?g=185038&p=1548939
Leadership
Community health nurses working with individuals, families and communities are seen to
have a leadership role in implementing and sustaining access to primary health care programs
(Nicholas & Breaky 2015). Their ability to recognise the impacts of the SDH particularly in
terms of social and economic justice, recognising diversity and the ability to work in partnership
with clients and interdisciplinary team members, highlights their leadership capabilities to
explore and progress credible health approaches in complex practice environments (Smith
2016). Advanced practice nurses, including nurse practitioners, are well situated within
interdisciplinary models of health to lead change through evidence-based approaches to care,
as are registered nurses and other health practitioners by virtue of their understanding of the
context within which people lead their lives.
Leadership can be described as taking a deliberate, conscientious and committed progres-
sion towards excellence, achieved through careful assessment and rational planning. Good
leaders also facilitate opportunities and ideas for clients, colleagues and interdisciplinary
team members with good timing and good judgement. The theory of Transformational
Leadership (Burns 1978) is recognised as an enabling approach within health practice as it
captures the ideal aspirations of multidisciplinary and interdisciplinary practice. This type of
leadership emphasises inclusiveness and followership as leadership. The theory focuses on
capacity development and building trust and mutual accountability within groups. Ethical
behaviours, integrity and value-based decisions are modelled and fostered by the leader
whose competencies include emotional intelligence, effective communication, collaboration
and mentoring, all of which contribute to the development of positive interpersonal relation-
ships and models of care (Fischer 2016). This type of leadership encourages participation and
empowerment for colleagues and clients rather than creating a culture of disempowerment
and anxiety.
A contemporary issue for community health nurse leaders is changes in role redistribution
from registered nurses to health assistants in nursing. A variety of causes underpin these
changes, including budgetary issues and registered nurse role stress. Internationally, there have
been changes to delegation of traditional registered nurse practice, particularly in the United
Kingdom with health assistants undertaking some of the long-established elements of their
care activities. With the registered nurse remaining accountable for the health assistant’s
competencies, there have been concerns raised in relation to their professional development
and clinical safety (Pringle 2017, Victoria State Government Health and Human Services
2015). In Australia and New Zealand, delegation of care is only undertaken following clinical
decision making involving a risk assessment process and demonstrated clinical competence
by the person to whom the task has been allocated (ANMF 2014). Despite this, concern
remains that health assistants are ‘taking over’ nursing work.
It is therefore vital that community health nurse leaders be at the forefront of the devel-
opment of the health assistant in nursing position in the primary health care context, in
order to establish clear understanding of their role with approved frameworks for delega-
tion of tasks and activities. While acknowledging their role in evolving shared models of
care, it is recommended that legal and professional agreements are developed for health
assistants’ skill sets and competencies, with registered nurses holding responsibility for their
supervision and performance monitoring (Victoria State Government Health and Human
Services 2015).
Community health nurses are integral to helping people achieve their goals for health and
wellness. Their ability to accommodate different cultures, attitudes, behaviours, experiences
and learning styles of varying population groups highlight the nurses’ expertise and leadership
in primary health care practice. Guidance on direction and delegation may be helpful for the
nurse, and the Nursing Council of New Zealand has published information accordingly. This
can be found on their website at: www.nursingcouncil.org.nz/Publications/Standards-
and-guidelines-for-nurses.
Conclusion
Health practitioners span the breadth of a community and can be found in a range of roles and
practice settings. Each practitioner group has its own unique approach to primary health care practice,
yet each is underpinned by the principles of primary health care to ensure equitable care that achieves
social justice. Health practitioners work in interdisciplinary teams to provide leadership and the most
effective care, undertaking group work and reflecting on their practice to ensure it is safe and meets
the needs of the community. We now finish the chapter by examining some of the ways nurses work
with the Smiths and the Masons before continuing on to Chapter 5 which introduces the concept
of community assessment in the context of primary health care practice.
CASE
STUDY Occupational health for the Smiths and Masons
:
The occupational health nurses (OHN) employed by the mining company that employs Colin have
developed several employee programs to support healthy lifestyles. They are experienced nurses who
understand the social and geographic problems faced by the mining community and who work
closely with safety personnel to deal with injuries and risks to wellbeing. Colin has been fortunate in
not requiring any primary care services, but is feeling the effects of isolation after one year of
employment in the mine. Colin remains connected to his family via the internet and has had relatively
stable internet access with few disruptions. Colin attended one of the sessions put on by the OHN for
stress management but didn’t attend a second. He tends to go to the pub when he has a break, but
otherwise stays in the men’s quarters instead of socialising with the others.
The Maddington child and school health nurses are familiar with the difficulties of FIFO families and
run a number of support groups to help enhance families capacity to cope with the lifestyle. Practice
nurses (PN) in the area are also aware of the issues faced by the FIFO families in the communities,
and the PN attached to Rebecca’s GP practice had a discussion with her about her lifestyle the last
time they met, which was at her exercise group, where both are trying to lose weight. Rebecca also
expressed her concern for Colin’s health to the PN.
In Papakura, the local PN has been able to help Huia manage Jake’s asthma. In addition, the exercise
group that Huia volunteers with at the local Marae has been developed by a new Māori nurse
practitioner in the area. She has identified access issues for the local Māori community and has been
contracted by the local primary health organisation to provide services for local Māori. Jason had
previously spent many years working in mining but found the long-distance travel and time away from
his family stressful and his health was suffering. His new job working for a Māori land trust is a
complete change and he now struggles with his weight and blood pressure. There is no OHN Jason’s
new work so he sees his local PN for help with his health.
■ There is considerable overlap in nurses’ and other health practitioners’ roles in the community, with
the need for population and place-based interactions that incorporate physical, mental and social
needs.
■ Primary, secondary and tertiary prevention activities are integral to all community roles.
■ Many aspects of roles are related to the practice setting and the regulatory environment that
determines scope of practice.
■ Population ageing and increasing rates of chronic illnesses have a significant impact on the roles of
nurses and other health practitioners in all community settings.
■ All nursing specialties in the community would benefit from further research that would advance the
knowledge base and help provide role clarity.
■ Models of interdisciplinary collaboration in practice and research can provide better health
outcomes in communities.
■ Nurses’ professional activities could be enhanced by standardising titles and expectations, and
developing evaluation studies of the impact of their practice on community health and wellness.
1 What elements of primary health care are transferable across the range of nursing and other health practitioner
roles?
2 As a practice nurse what would be your role in working with Rebecca to help her, the children and Colin deal
with his occupational situation?
4 As the school nurse, what would be your approach to assessing John’s developmental progress?
5 With family disruption related to her father’s FIFO schedules, what four major elements could Emily’s school
nurse be planning to help Emily become more engaged in her studies?
6 As a practice nurse how could you help Jason keep his blood pressure under control?
7 As the child health nurse, to what resources would you refer Huia to manage Jake’s asthma?
8 How would you research the impact of the OHN role on worker health in the mining community?
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CHAPTER 5
Assessing the community
INTRODUCTION
This chapter discusses the importance of assessment in the context of primary health care
practice. We critique a number of existing assessment tools and introduce a new frame-
work for community assessment based on the social determinants of health (SDH). We also
emphasise the importance of working in partnership with the community in the assessment
process.
Assessment is the foundation for planning to meet the needs of the community. These
needs are identified on the basis of any known risks, hazards and strengths, as well as the
priorities and preferences of community residents. To plan effective, efficient, adequate,
appropriate and acceptable health interventions we need both scientific data gathered by
health planners (top-down information) and community perspectives (bottom-up informa-
tion). As we mentioned in the first two chapters, an ‘assets’ approach to promoting health
focuses on community strengths as well as needs. To generate a list of community assets and
needs it is important to create an assessment ‘map’ of geographic, demographic and social
information. Geographic data indicate what features or hazards exist in the natural and built
environment, the patterns of health and illness among various groups defined by age or
gender, and what social conditions require health promotion interventions for community
residents. Simultaneously, the assessment involves finding out from members of the com-
munity how they assess their health strengths and needs in terms of personal perspectives
and experiences. Once this information has been gathered, the next stage of planning is to
develop intervention strategies for improvement, or measures that can be taken to sustain
positive aspects of community life. The advantage of conducting a comprehensive assessment
is that it allows us to forecast patterns of health or potential changes that may have an
impact on people’s lives or the lives of their children in the future. In the final analysis the
information should produce a snapshot of strengths, weaknesses, opportunities and threats to
community health.
General knowledge of the community has limited usefulness unless it is analysed in terms
of subsequent steps that can be taken in partnership with community members to strengthen
community resources and enable health and wellbeing. Selecting an assessment strategy should
therefore be goal directed, so that the assessment information is linked to promoting and sustaining
community health and wellness.
OBJECTIVES
1 compare a range of assessment approaches 3 identify a range of sources of information

and their usefulness in developing pro- about communities
grams and policies to promote community 4 outline a strategy for assessing a
health community
2 describe the importance of working in 5 assess a community using the McMurray
partnership with communities in the community assessment framework.
assessment process
COMMUNITY ASSESSMENT TOOLS

Community assessment tools have evolved over the years in conjunction with changes in the
way we see communities and our ability to promote health. Many decades ago, community
assessment was predominantly a checklist approach to assessing communities and their ability
to support the needs of residents. A number of tools were developed to ensure that assessments
took into account vital information on personal as well as community health hazards and risks.
This information was then used to predict people’s exposure to diseases or the risk of accidental
ill health from such things as bushfires, drowning or other events common to the area. Many of
these tools focused on the population and age-specific risks (asthma in children, for example),
with only cursory evaluation of the relationship between health and place, or the assets (e.g.
health services) that could help maintain better health. Some of those tools remain useful in
assessing community health and the risk of ill health, but in the context of today’s primary
health care approach, we recognise that people are quite knowledgeable about their needs and
the needs of their communities, and community assessment is incomplete without their input.
One of the earliest approaches to assessment was the epidemiological model, which focused
on the determinants and distribution of health and disease. The epidemiological approach
was embraced by all health professions on the basis that it reflected a whole-of-population
approach and included comprehensive assessment of the person, host and environment, called
the ‘epidemiological triad’. Epidemiological assessments continue to be useful today in developing
a base of scientific evidence on health and its determinants in specified populations.
Epidemiological assessment
Epidemiology can be defined as ‘…the study of the distribution of health and diseases in groups
of people and the study of the factors that influence this distribution’ (Wassertheil-Smoller &
Smoller 2015:83). The classic model of epidemiology is to examine specific aspects of the host
(biology), the agent (a causative factor) and environment (factors that exacerbate or moderate
the effects of the agent on the host), to see how each of these affects the spread of a disease
BOX 5.1
EXAMPLE OF EPIDEMIOLOGICAL RATES
No. of new cases

Incidence = × 1000 (or 100 000 )
Population at risk
No. of existing cases (new and old)

Prevalence =
Population at risk
× 1000 (or 100 000 )
Population at Risk
The group of people who are susceptible to a disease or condition (e.g. non-immunised
children) or who have been exposed to an agent that could cause disease (e.g.
occupational dust).
or ill health in the population. The objective of epidemiological researchers is to collect data
on the incidence of individuals ‘at risk’ of developing a particular disease in order to inform
development of a vaccine or treatment for that disease. Data from epidemiological analyses
are presented in terms of incidence and prevalence. Incidence is calculated by dividing the
number of new cases in a population by the population at risk, then multiplying this by a base
number (1000 or 100 000). This estimates the likelihood that a condition would occur in the
population. The prevalence of a certain condition is the number of new and existing cases
divided by the population at risk multiplied by 1000 or 100 000 (see Box 5.1).
KEY POINTS
Rate
A measure of the frequency of a disease or condition, calculated by dividing prevalence by the
incidence multiplied by a population base number (1000 or 100 000).
Incidence
The number of new cases of a disease or health issue in a specific period of time, divided by
the population at risk multiplied by the base number.
Prevalence
The total number (new plus existing) of cases of a disease or health issue in a population at any
one time, divided by the population at risk multiplied by the base number.
If an occupational group is exposed to a certain toxic substance, a measure of the ‘relative

risk’ of becoming ill from that exposure can be calculated by comparing a group (called a
cohort) who were exposed to the hazard with a cohort who were not exposed. If the group
exposed to the hazard has a higher rate of the illness, that hazard is declared a risk factor. To
confirm that it is a risk factor we would then assess its effect over a longer period of time in
the entire population, which would provide greater insight. An example of relative risk in
relation to adolescent exposure to obesogenic risk factors and depression was outlined in a
systematic review conducted by Australian researchers (Hoare et al. 2014). The researchers
were interested in understanding if there was an association between obesogenic risk factors
(such as physical activity, sedentary behaviour, diet and weight status) and depression in
adolescents. They conducted a systematic review of available literature in the five international
databases that addressed these issues. Analysis of the eligible studies indicated that although
data were typically from non-representative samples, relationships did exist between lack of
physical exercise, heightened sedentary behaviour, poor diet quality, obesity or being overweight
and depression. In other words, young people who lack physical exercise, have heightened
sedentary behaviour, poor diet quality or are obese or overweight, have a greater risk of
depression. The authors recommend addressing obesogenic risk as part of interventions to
address depression.
KEY POINT
Relative risk is a measure of the extent to which a group exposed to a risk has a higher rate of
illness than those not exposed, calculated by dividing the incidence rate among those exposed
by those not exposed. If the rate is higher among those exposed, it is called a risk factor.
The findings from Hoare et al.’s (2014) study are important for providing insight into the
link between obesity and depression among adolescents, but without analysing individual and
group differences, it is difficult to make generalised statements about relative risk and adolescent
behaviours. Still, what can we conclude from this review? In some cases, relative risk is not a
helpful statistic. The studies cited in the review demonstrated differences in demographic
characteristics, ages, stages and ethnicity. Cross-cultural comparisons were limited. Statistical
data and statistical comparisons are important tools in health planning, but they must be used
with caution in planning whole-of-community interventions.
Because traditional epidemiological measurements of an agent, host and environment
are somewhat limited in terms of what we know about the causes of illness, an expanded
model, the web of causation, which includes the interconnections between each of these,
provides a more comprehensive basis for analysis (see Fig. 5.1). The web of causation is
also inclusive of demographic and social features such as age, gender, ethnicity and social
circumstances, which is more closely aligned with a socio-ecological model of health
and the SDH.
ENVIRONMENT
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EXPOSURE
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COFACTORS
COFACTORS NON-INFECTIOUS
•unprotected sex AGENT • malnutrition
• multiple sexual partners HIV Virus • genetics
• needle, syringe sharing • stress
•contaminated blood • age
Av agn IV
di
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ai os n
•
in utero exposure • gender
es e
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INFECTIOUS
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fo nd
as ysi
rm o
co-morbidities
at ms
Ph
(viral infections, STIs)
io ,
n,
Political/economic factors
(unemployment – poverty – tourism)
Figure 5.1 Web of causation
POINT TO PONDER
If the rate of asthma in preschool children was increasing in a community, how would you go
about investigating whether the cause was a risk factor unique to that community, unique to only
certain neighbourhoods, or unique to only certain types of families?
Methods that support epidemiology

Contemporary methods to support epidemiological and other community assessment approaches
enable information to be quickly and accurately compiled, presenting more quantitatively
accurate assessments. For example, geographic information systems (GIS) are being commonly
used to plan, administer and analyse community assessment information. GIS can enable
identification of a population sample and allow for small geographic area analysis of prevalence
data (Pliskie & Wallenfang 2014). The use of GIS is increasingly a requirement in epidemiological
analysis and its use in assessing needs at the community level is growing (Pliskie & Wallenfang
2014). However, the risks of the GIS approach mean that some smaller population cohorts
within a community may not have their needs identified. For example, the different needs of
a small pocket of refugee families in a community or a group of families with children who
have Down syndrome and are spread across a wider geographical area may not have their
particular needs identified. Statistics from the geographic analysis reveal what is typical and
what trends exist in the community, rather than what special needs exist for various segments
of the population. This aggregated information contributes to the risk of ‘ecological fallacy’;
that is, the risk of misunderstanding individual risk in terms of the overall risk to the majority
of the population (Loney & Nagelkerke 2014). To gain a more realistic picture of the community,
a combination of information should be used concurrently, such as combining GIS and traditional
epidemiology. However, GIS can be a useful tool for spatial analysis of communities; for
example, in analysing people’s patterns of public transportation usage. The United States
Environmental Protection Agency’s community-focused exposure and risk screening tool
(C-FERST) is a good example of this type of approach, providing easy access to maps, locally
specific environmental data, and other information in a user-friendly format (https://
www.epa.gov/c-ferst). New Zealand’s Department of Statistics (www.stats.govt.nz.) and Australia’s
Bureau of Statistics (www.abs.gov.au.) provide useful local data but have still to develop the
complexity of the US tool. But like population trends, none of these tools capture the breadth
of variation in human behaviour, which is a limitation of many systematic approaches.
KEY POINT
The ecological fallacy is the risk of misunderstanding individual risk in terms of the overall
population risk. Some people’s health is determined by unique factors rather than those that
are typical of the group or community.
Challenges of the epidemiological approach

Epidemiological approaches to community assessment have traditionally struggled to reconcile
the scientific approach with the broader contextual factors that impact on people’s lives and
contribute to their health status. Some of the challenges include the struggle to integrate
epidemiologically or scientifically determined risk factors with behavioural and social strengths
or risk factors; or an inability to identify risk factors whose origins lie in the interactions
between individuals, or between individuals and their environment. Epidemiological models
are also unable to predict the effects of alternative interventions, which are frequently non-
Western in origin (for example, acupuncture), because all interventions tend to be assessed
on the basis of traditional Western scientific approaches. Epidemiology also struggles to articulate
the experiences of those with multiple co-morbidities, tending once again to focus on an
individual disease rather than the impact of multiple co-morbidities on a person or group.
So, for example, a person who has worked in an occupation with a hazardous exposure to
dust (such as in a flour mill), and who also has lived in a bushfire area, may develop pulmonary
disease. The pulmonary condition may also predispose him or her to a number of other risks
(cardiac, renal, stress-related diseases). In this case it would be difficult to pinpoint the cause
of ill health to the workplace, the natural environment or the lack of preventative programs
that would have provided protection from agents that can cause respiratory problems. The
message is that epidemiological data provides only part of the picture. It is also necessary to
search for causes of ill health in the social and political factors that impact on health (Chauvel
& Leist 2015, Wassertheil-Smoller & Smoller 2015).
KEY POINTS
Limitations of epidemiology
• No contextual information
• Human behaviour
• People’s preferences
• Individual experiences
• Social and political factors ignored
As researchers have become aware of epidemiological limitations, many have become

committed to analysing community input in a way that would capture people’s experience of
certain risks. For example, some epidemiologists have identified that not all people on low
incomes experience their life as deprived. This has led them to conclude that using income
solely as a determinant of health may not be the most appropriate way to judge needs or risks.
In fact, it is more helpful to health promotion planning to understand how people experience
deprivation, and the ways deprivation may impinge on their health, than to simply link low
income to poor health (Gunasekara et al. 2013). These types of studies provide useful information
on population health status contributing to our knowledge of communities and their needs.
THE EVOLUTION OF COMMUNITY ASSESSMENT

TOOLS IN NURSING
Assessment tools to gather information on community health have evolved over past years to
incorporate more appropriate representation of the social characteristics of communities. This
refinement of approaches to assessment is useful in prompting nurses and other health
practitioners to base health policies and programs on knowledge of the SDH and to include
community input. As far back as the 1980s several models of assessment were developed to
be used in combination with epidemiological data. West (1984) devised an assessment tool
based on the interaction between people and their environments in a small community. The
tool included analysis of interactions, actions and awareness, and, although it was comprehensive,
it was somewhat diffuse and was not validated with larger communities. Its strength was that
it was intended to capture extensive information about how people felt about their community,
which was helpful in encouraging the primary health care principle of community participation.
Another community assessment tool of the 1980s was developed to correspond to functional
health assessment of individuals living in the community (Fritsch Gikow & Kucharski 1987).
However, this tool did not reflect a primary health care approach, and instead was focused
on structured assessment of community health patterns that corresponded to personal health
patterns, such as health perception and management, intersectoral role relationships and social
issues. The assessment was very ‘top-down’, and based on health practitioners’ presumptions
about health patterns among the population. Some of these patterns may be relevant to particular
communities, but the assessment approach implied that we could use a ‘one-size-fits-all’ approach
to community assessment. The major limitation of this type of tool is that it is inefficient and
ineffective without valuable community input from which planners could predict the relative
success of their interventions on the basis of community acceptability. In addition, simply
assessing patterns of health and ill health fails to consider inequities between different groups
of people, which is important to achieving the primary health care goal of social justice.
KEY POINT
Simply assessing patterns of health and ill health fails to consider inequities between different
groups of people, which is important to achieving the primary health care goal of social justice.
The assessment tool mentioned above, and other assessment tools of the 1980s, reflected the
commitment of nursing to the systematic approach of the nursing process. The nursing process
revolves around making nursing diagnoses, typically described as ‘deficits’ that nurses can
address. Clark’s (1984) model of assessment is a comprehensive tool specifically aimed at facilitating
a nursing diagnosis. It was originally described as the ‘epidemiologic prevention process model’,
and has more recently been known as the ‘dimensions model of community health nursing’
because of its later focus on the determinants of health and the dimensions of nursing (Bigbee
& Issel 2012:373). Categories of information include general information about the community,
epidemiological information such as population characteristics and health status indicators,
attitudes towards health, environmental factors and community relationships with society. Box
5.2 provides a case study of the development of Clark’s assessment model over time.
Like Clark’s model, Anderson & McFarlane’s (1988, 2014) assessment tool is based on the
nursing process. Their assessment model is based on their philosophy of ‘community as partner’,
which is congruent with primary health care, and a ‘systems’ approach to the community.
Systems approaches are derived from the notion that a community is a living system that is
more than the sum of its parts because of numerous and ongoing internal and external interac-
tions that help maintain homeostasis (Neuman 1982, Neuman & Fawcett 2010). In Anderson
& McFarlane’s (2014) adaptation of Neuman’s systems model, assessment is guided by an
BOX 5.2
THE EVOLUTION OF A COMMUNITY ASSESSMENT TOOL
Clark’s assessment tool arose from having to undertake an assessment of health needs at
a summer day camp in 1995. She began the task by categorising the various needs of
campers, then identifying a set of primary and secondary interventions designed to address
these needs. The process was intended to identify a series of nursing diagnoses that
would illuminate the physical risks and service deficits that could potentially impact on camp
participants. As was accepted practice at the time, there was no dialogue with staff or
campers regarding their perspective on needs and means of addressing these. Nearly 10
years later, Clark (2003:457) critiqued the model in terms of new ideas on community
health, following feedback from a research project she was undertaking, where community
members reported feeling ‘… researched to death’. She and her colleagues recognised the
need for a community engagement process to round out the assessment information (Clark
et al. 2003). By using focus groups with community members, the researchers identified a
range of community health needs and assets. The major needs identified by community
members were housing, environmental and safety needs, followed by access to health
care. The major assets included the proximity of the community to the larger metropolitan
area, its mild climate and recreational opportunities. From the findings of this research, Clark
and her colleagues were able to identify a number of community-led initiatives to address
some of the needs. Clark’s most recent text updates the model further (Clark 2014).
So what does this tell us?
The development of models help guide nursing practice with communities, and this case
study demonstrates how models evolve over time as new knowledge is gained. Being
aware of the history of model development helps nurses understand past practice in the
context of contemporary practice and encourages us to explore new models and practices
based on our previous experiences and knowledge.
What do you see as the next phase in community assessment model development?
(Source: Clark 2003, Clark et al. 2003, Clark 2014)
assessment wheel with eight subsystems, which include similar categories of information to
those used by Clark with some expansion of the areas assessed (see Box 5.3). Despite the
differences, the assessment processes remain the same. Nurses assess each of the categories or
subsystems to diagnose the health of the community in order to inform implementation plans
based on each.
Anderson and McFarlane’s community assessment wheel has been one of the more widely
used models of community assessment in nursing with adaptations of their wheel developed
for Canadian, Australian and New Zealand users (Vollman et al. 2016, Francis et al. 2013).
While providing a useful framework for community assessment, the model is limited by its
BOX 5.3
A COMPARISON OF COMMUNITY ASSESSMENT: ANDERSON AND

MCFARLANE, AND CLARK
Anderson and McFarlane (1988, 2011, 2014)

Physical environment
Economics
Education
Safety and transportation
Health and social services
Politics and government
Communication
Recreation
Clark (1984, 2003, 2014)
Physical
Biophysical
Socio-cultural
Behavioural
Health system
‘top-down’, deficit approach; that is, the identification of community problems rather than
strengths, and seeking community input after problem identification. An existing concern
with many community assessment approaches is a lack of community involvement in the early
stages of the process. Communities should be involved as early as possible, as we underline
throughout the chapter.
POINT TO PONDER
Early assessment models included person–environment interactions and were not always
inclusive of what we now call the SDH. They were also intended to provide a nursing diagnosis as
a basis for systematic health planning.
What are the strengths and weaknesses of these early approaches?
Although the early assessment tools were devoid of community input, they did help
advance nursing’s scientific agenda, by systematising the processes of assessment. Over time,
those using the tools began to recognise the importance of social and interactive factors
that are so important to community health. However, by being prescriptive about categories
of assessment data, sometimes critical information was overlooked, including the need to
assess cultural factors within various community neighbourhoods and groups. Subsequent
community assessment models have contributed to a deeper understanding of the cultural
domain of assessment, following the lead of Leininger (1967) and other nursing theorists
(Tripp-Reimer et al. 1984, Giger & Davidhizar 2002, Ramsden 2002, Jirwe et al. 2006,
Leininger & McFarland 2006). Cultural assessment is now a major focus in community
assessment, integrating cultural information with other assessment information. Cultural
assessment strategies are intended to provide the depth and breadth of locally identified
information that is crucial to ensuring their acceptability in the context of the nurse–client
relationship.
KEY POINT
All cultural assessments must include the perspectives of members of the cultural groups on
their assets, strengths and needs.
Cultural assessment information can include community members’ perspectives on their

worldview, relevant issues related to ethnicity, values, beliefs, history and social orientation.
For refugee and migrant groups, information on pre-movement, migration and post-migration
events is also collected to assess the combination of social, environmental, cultural and medical
factors that determine health. Despite the often traumatic experiences of refugees prior to
resettlement, a strengths-based approach to assessment enables the identification of resilience
in the face of adversity, mediating factors that enable or constrain the ability to cope with
adversity, and the facilitators that enable positive coping (Edge et al. 2014). Comprehensive
assessment of refugee populations, which includes detailed information on family factors,
family reactions to the transition to a new country, the impact of changes, and aspects of the
host community that cause or exacerbate the trauma and stress of dislocation is essential. An
important element of the cultural assessment involves assessing health care providers, as some
researchers have found that accessibility and use of services is dependent upon cultural and
language competencies of staff members (Tyrrell et al. 2016). Including cultural assessment
in all community assessments is congruent with the work of Ramsden (2002) in highlighting
cultural safety in all professional interactions. Cultural information also provides a more realistic
picture of the community and its socio-cultural environment, and shifts the emphasis from
the deficit model of the nursing process to the more positive ‘asset mapping’ model of
assessment.
ASSET MAPPING
KEY POINT
Asset Mapping is the process of assessing community strengths and assets that will help
develop community capacity.
Deficit models of assessment, such as the nursing process, can be helpful in identifying needs
and priorities for health service provision; however, in order to provide a comprehensive
picture of a community, it is essential to include assessment of positive community features
or ‘assets’ (Edge et al. 2014, South et al. 2017). (See Fig. 5.2.) Asset mapping is a more resourceful,
inclusive approach that can help identify health inequities in the community, particularly if
the assessment includes information on the capability of communities to identify problems
and activate solutions. This approach to assessment is therefore responsive to the goals of
primary health care and the SDH. An asset map is intended to build an inventory of community
strengths in relation to the SDH. Data consists of epidemiological information on the population,
their key assets at each stage of life, the physical, environmental and social assets in the
community, and the links between these assets and health outcomes (South et al. 2017). This
Links
Key
between
assets in
assets and
the
health
community
outcomes
Community
epidemiological
information
Figure 5.2 The asset model

assessment information can provide a foundation for planning strategies to reduce health
inequities. Categories of information include primary building blocks (assets and capacities
of residents, their skills, talents and experiences, the presence of community associations under
neighbourhood control); secondary building blocks (assets in the community controlled primarily
by outsiders, such as physical resources, land, waste, energy, public institutions and services);
and potential building blocks (resources outside the community controlled externally, such
as public capital and expenditures) (South et al. 2017). From this base of evidence members
of the community can work with health practitioners to identify actions to improve health
that will be evaluated for their effectiveness. In particular, the use of asset-based community
development can help mobilise a community to address identified need using identified assets
(Mathie et al. 2017).
However, in using this approach to assessment, consideration must be given to the way
data are aggregated. As noted earlier in the chapter, if the information represents an epidemio-
logical approach that focuses only on the total assets within each of these building blocks, it
would be difficult to identify pockets of inequity among subgroups, even within a particular
neighbourhood. As a guide for planning to meet the goals of primary health care, it would
be necessary to ensure that information was stratified, or categorised according to groups such
as the homeless, young people, older citizens and those with disabilities. Examples of how this
can be achieved are growing. For example, researchers in Boston, USA, used asset mapping
to identify a discrepancy between perceptions of community residents with diabetes regarding
available assets and the actual assets in the environment. This enabled implementation of
targeted health interventions to improve understanding of neighbourhood resources that can
help people control their diabetes (Florian et al. 2016).
KEY POINTS
Assets that can be mapped include:

• primary—resident controlled features
• secondary—externally controlled features
• potential—external resources that could be mobilised.
COMMUNITY-BASED PARTICIPATORY
RESEARCH (CBPR)
The strength of asset mapping is that it is a community-based approach to assessment intended
to respond to the SDH, and it continues to evolve. A related assessment approach is encompassed
in community-based participatory research (CBPR), which is designed to equitably involve
all partners in the research process—in particular community members—to assess community
needs from the perspective of residents (Zittleman et al. 2014). CBPR uses a range of processes
including focus groups and individual interviews to foster collaborative identification of com-
munity needs as a basis for plans to improve health and wellbeing (Zittleman et al. 2014). This
type of approach has been shown to be effective in a number of contexts, particularly for
occupational and environmental health planning, but increasingly, as a strategy for conducting
research with cultural groups (Couzos et al. 2015, Katigbak et al. 2016, Tyrrell et al. 2016).
Together, asset mapping and CBPR represent a goal-directed approach to assessment that is
particularly useful for program planning. It is important to remember that most programs
are aimed at addressing a specific health problem, which is important, but they are usually
confined to a particular population group or health issue rather than the whole of the com-
munity. The program planning approach is therefore more closely aligned with selective rather
than comprehensive primary health care.
KEY POINTS
Selective primary health care is aimed at health programs for certain groups.
Comprehensive primary health care is a whole-of-community approach.
One of the key elements of CBPR as an approach to community research is the engagement
of the community at the earliest possible moment in the process. This ensures that community
members are involved in identifying the most appropriate approach to data collection, analysis
and reporting, they have a say in how the information is interpreted, they are encouraged to
share their knowledge and skills with the researchers and can gain increased knowledge and
skills in return. This reciprocal process contributes to community and individual improvements
in health literacy and reflects the primary health care principle of community participation.
Further information on CBPR can be found in Chapter 10.
ASSESSMENT TOOLS SPECIFIC TO HEALTH

EDUCATION PLANNING
Among the most specific, goal-directed tools is the PRECEDE-PROCEED tool for health
education planning (Green & Kreuter 2005) (see Fig. 5.3). The objective of the tool is to provide
a framework for planning and evaluating behaviour change programmes among members of
a community or group (Porter 2016). Like the nursing process models, Green and Kreuter’s
model revolves around gathering diagnostic information. Firstly, a social diagnosis which
includes examining community issues such as crime, population density, education, unemploy-
ment and other aspects that are similar to the SDH. Secondly, an epidemiological diagnosis
is made. This identifies rates of morbidity, mortality, disability and fertility and is aimed at
determining the extent and nature of the determinants of health in the community (Green &
Kreuter 2005). Thirdly, a behavioural and environmental diagnosis is undertaken to identify
PRECEDE
Phase 5 Phase 4 Phase 3 Phase 2 Phase 1
Administrative Educational Behavioural Epidemiological Social
and policy and and diagnosis diagnosis
diagnosis organisational environmental
diagnosis diagnosis
HEALTH
PROMOTION Predisposing
factors
Health
education
Behaviour
Reinforcing and
factors lifestyle
Policy Quality
Health
regulation of life
organisation Enabling
factors Environment
Phase 6 Phase 7 Phase 8 Phase 9

Implementation Process Impact Outcome
evaluation evaluation evaluation
PROCEED
Figure 5.3 PRECEDE-PROCEED model
factors related to actions people might take and how interactions with their physical and social
environments might affect these (Green & Kreuter 2005). Included are preventative actions
such as safe sexual behaviour, self-care indicators, dietary patterns, and coping skills. The
environmental diagnosis includes geographic and economic indicators of community health,
as well as how people connect and relate to health services.
Fourthly, an educational and organisational diagnosis is undertaken resulting in identification
of Predisposing, Reinforcing and Enabling factors. Predisposing factors include knowledge,
attitudes, values and perceptions of community members, making it essential to assess health
literacy at this stage. Reinforcing factors include the attitudes and behaviours of others that
can affect behaviour and environments for change (Green & Kreuter 2005). Enabling factors
are those skills, resources, assets or barriers that may either support or obstruct wanted change.
Finally, an administrative and policy diagnosis is undertaken to clarify what strengths and
resources are present in the community to enable it to respond to needs. Once complete, such
a detailed assessment allows implementation of changes to begin (Green & Kreuter 1991,
2005). The PRECEDE-PROCEED model has been used for many years to make a community
diagnosis, but like some of the other models, it is limited by the top-down perspective of the
health practitioner on what a community needs or prefers. In this respect, it is limited in
providing a comprehensive assessment that includes input from community members who
feel empowered to participate in charting the course of community health.
SOCIAL EPIDEMIOLOGY, CBPR, PRIMARY HEALTH

CARE AND THE SDH
In a comprehensive primary health care context, assessment information should reveal where
inequities exist in the community, what levels of disadvantage exist for which groups in the
community, what links there are between community attitudes, local and centralised decisions
and health outcomes, and a myriad other relationships relevant to the SDH. One approach to
collecting this information is to adopt a ‘social epidemiological’ approach. Social epidemiology
is a subset of epidemiology that focuses on the social factors that contribute to the distribution
of disease (Tuazon 2016). The goal of social epidemiology is to test associations between the
socio-ecological aspects of community life and population health outcomes (Tuazon 2016).
This approach is closer to the goals of both primary health care and the SDH than the types
of assessment outlined above, in that it is aimed at resolving issues of inequity. Used in conjunc-
tion with CBPR, social epidemiology yields a depth and breadth of information that can be
helpful for planning.
KEY POINT
Social epidemiology is an approach to assessing associations between the socio-ecological

aspects of community life and population health outcomes.
A social epidemiological assessment begins with demographic and epidemiological data,

mapping the main indicators of community life. Concurrently, a CBPR study can provide
information on what people believe community life is like, what could be done to improve
the community, what would improve health, how the health department could help, and how
the community nurse and other health practitioners can effectively participate in enabling
health and wellbeing (Shaha et al. 2015). Next the social epidemiological data will show the
balance between resources and demand, strengths and needs. Among the information collected
would be indicators of social capital such as indicators of cohesiveness and bonding, health
behaviours, illness indicators and community perceptions. Integral to the process is evaluation
of the power structures and how they affect certain groups, to provide policy planners with
the information to challenge these conditions, including issues of racism, discrimination or
other forms of social exclusion (Couzos et al. 2015). Identifying community assets or strengths
can help community members develop empowering strategies to gain mastery and control
over health decision making—particularly in communities that have experienced social exclusion
such as LGBTI and other diverse groups. In this way, information can be inspiring, helping
people participate fully in their community and expand their ability to negotiate, influence,
control and hold accountable the institutions and decision makers that control their lives
(South et al. 2017).
STREAMLINING COMMUNITY ASSESSMENT—THE

MCMURRAY COMMUNITY ASSESSMENT FRAMEWORK
It should be evident from the assessment models described above that most community
assessment tools combine epidemiological data with psychological, socio-cultural and envi-
ronmental indicators, including information about the health system and its use. The most
useful tools are those that combine the multidimensional and dynamic nature of community
life as well as capturing individual and family strengths and constraints (McMurray 2014).
Community assessment does not need to be a complex process, although the more information
that is included in the assessment, the more likely it will be that the interventions will be
appropriate and acceptable to the community. Fig. 5.4 shows the McMurray Community
MAP community
EMPOWER the
strengths, resources
Approach key community members community
and risks Analyse the information in
to identify how you can work with
their community to undertake a collaboration with community
Map community strengths, resources members using a
community assessment. Gain their Share the findings with community
and risks by a) talking with everyday SWOT analysis:
consent to work in and with the members and work with them to
community members about their • Strengths
community and work with them to develop interventions strategies for
perceptions, priorities, and relationships • Weaknesses
identify how they appraise and improvement or measures that
within and external to the community • Opportunities
assess their health strengths and sustain positive community life.
and b) collecting information using the • Threats
needs along with their perceptions, SDH Assessment Circle as a
priorities and understanding of framework for organising the data.
community assessment.
ENGAGE with the

community ANALYSE
Biology,
genetic Cultural
Health characteristics strengths,
practices, values, beliefs,
coping skills needs,
gender
Health
Physical
services,
environments
resources
Social
determinants
of health
circle
Social
Social
support
environments
networks
Employment Indicators of
and working child health and
conditions Education development
and
literacy
Figure 5.4 McMurray Community Assessment Framework

Assessment Framework. The framework describes a step-by-step process for undertaking a

community assessment. Each step ensures community members are engaged in the process,
which ultimately results in community empowerment.
1. ENGAGE with the community

Approach key community members to identify how you can work with their community to
undertake a community assessment. Gain their consent to work in and with the community
and work with them to identify how they appraise and assess their health strengths and needs
along with their perceptions, priorities and understanding of community assessment. Key
community members are those who hold positions of respect and/or authority in the community,
either through formal or informal leadership. These people may be community elders, local
health care providers, teachers, social workers, town council or community board members,
and/or others who may provide services in the community. While speaking with some of these
people may simply be a formality, speaking with community elders and gaining their consent
to work with you in the community is an essential first step to community assessment. Talk
to them about what you want to find out, what they want to find out, and let them tell you
where to find the information. They will know who to talk to, where to look for information,
and what not to do as you undertake your community assessment. This process will also help
establish trust between you and the community and keeps everyone ‘in the loop’ as you go
about your assessment.
2. MAP community strengths, resources and risks

Mapping is a two-step process (although both steps can occur concurrently). Firstly, talking
with community members yields a wide range of information that shows the demographic
‘mix’ in the community—how many people in which population groups may require certain
specific services (e.g. older persons, young children); the mix of cultures in the community;
what people think about their lives; opinions about environmental strengths that may support
healthy lifestyles, or barriers to health. Find out about people’s perceptions, priorities and
relationships—these are the relationships that exist between people, and between people and
their environment. Once this information is gleaned, the second part of this step involves
mapping resources—trying to understand the capacity for supporting health, and the assets
and support systems that may be mobilised for certain interventions. The SDH Assessment
Circle outlined in Fig. 5.5 comprises part of the McMurray Community Assessment Framework
and enables the mapping of these resources. The SDH Assessment Circle gathers informa-
tion within the 10 categories of the social determinants of health. The circle incorporates
all the elements of community assessment, epidemiological data and social epidemiological
information in one cohesive place. Appendix A shows the SDH Assessment Circle broken
down into separate sections with accompanying questions. These questions will guide you
as you undertake your review and many can only be answered by speaking with community
members. Further information on sources of assessment information can be found later in
the chapter.
Healthy
child
Biology, development Social
genetic support
Cultural
strengths,
values, beliefs, Education,
needs; literacy
Gender Social
determinants
of health
Health Employment
services, and working
resources conditions
Health
Social
practices,
environments
coping skills
Physical
environments
Figure 5.5 The SDH Community Assessment Circle
1 Indicators of child health and development

2 Biological or genetic population indicators
3 Cultural strengths, values, beliefs, history and needs; gender
4 Health services and resources and patterns of accessing these by various population groups
5 Health practices, coping skills in the context of recreation and leisure, which may support or compromise health,
such as drop-in centres, places that encourage health literacy and capacity, or drug and alcohol misuse
6 Physical environments, including geographical factors such as climate change or transportation barriers to care,
or activity-friendly neighbourhoods
7 Social environments, indicators of social inclusion or exclusion
8 Employment and financial status of the population, including unemployment rates, working conditions, types of
employers, availability of workplace support
9 Education and literacy indicators
10 Social support networks, access for vulnerable groups, volunteer networks
3. ANALYSE the information in collaboration with community members

using a strengths, weaknesses, opportunities and threats (SWOT) analysis
The third step is to analyse the information gathered using a SWOT analysis to identify
strengths, weaknesses, opportunities and threats to community health. Included in the SWOT
analysis will be a deeper level of analysis of the community that provides information on the
SDH. This analysis should be done in collaboration with community members to ensure the
way you interpret and make sense of the information is aligned with community members’
understanding of the data. This action will help build trust with the community and serve to
facilitate the development of the community-led interventions that make up the final step in
the process.
KEY POINTS
A SWOT analysis identifies:

Strengths
Weaknesses
Opportunities and
Threats … to health
4. EMPOWER the community by sharing the findings with community

members and working with them to develop intervention strategies for
improvement or measures that sustain positive community life
The final step is where you work with the community to identify, develop and implement
interventions to support the needs of the community. Interventions may be as simple as
lobbying local government for a new pedestrian crossing or as complex as a multifaceted
diabetes prevention program. Engaging with communities throughout the assessment process
is key to empowering community members to identify, seek and implement solutions to their
own issues and concerns. An example of the importance of community engagement can be
found in a study comparing the effectiveness of a community engagement model for disseminating
depression care for low-income women with traditional technical assistance. Ngo et al. (2016)
found activating community networks to develop community-specific solutions to improve
depression services directly resulted in improved mental health quality of life, fewer missed
work days, reduced barriers to care and fewer financial difficulties.
SOURCES OF ASSESSMENT INFORMATION

For health practitioners who are new to a community, comprehensive assessments can be
daunting, and the sources of information a bit confusing. Some information will be available
online in government documents. For example, Australian data on morbidity, mortality and
age-related conditions are included in the document ‘Australia’s Health’, which is updated
every two to four years. This can be found at http://www.aihw.gov.au/. Australian Government
Census reports and health department reports on a variety of topics are also available online.
The New Zealand Ministry of Health has a range of publications that provide background data
on the health status of New Zealanders. The New Zealand Health Survey is now a continuous
study and provides the most up-to-date information on population health in New Zealand.
Findings are published on the Ministry of Health website: www.health.govt.nz. Statistics
New Zealand (www.stats.govt.nz) is also a useful portal for accessing any statistical data on
communities and publishes many existing community profiles developed from census data.
For the more enthusiastic practitioner, it is also possible to manipulate Excel data tables
to find the specific statistics required for a geographic area. The Yellow Pages are another
source of community information, as are community business directories. Some of the most
useful information for community assessment comes from local surveys that may have been
conducted in recent years, or from observations of community life. A search of websites
like Google or PubMed, or any of the research databases (see Chapter 10) may also reveal
whether there have been any research studies in the community, which may provide additional
information.
Most community nurses and other health practitioners have their own strategies for collecting
various types of information, depending on whether they are responsible for the whole community,
or practising in specific areas, such as general practice, child, school or occupational health, or
in a visiting nurse service. In the first instance health practitioners can become familiar with a
community by conducting a ‘windscreen survey’, driving around to gain a sense of the community—a
big picture of life in that context. Such a survey can yield information about spaces for recreation,
transportation and access, child care services, the location of schools, clinics, hospitals and other
health services, places of employment, the state of available housing such as whether there are
affordable homes, or whether certain sections of the community seem to be in decline. This type
of information can also be confirmed by speaking to various community groups or by analysing
records of community activities such as immunisation rates, public health indicators and data
from other policy documents that indicate activities of the local council or other authorities
(fitness programs, elder day care facilities). Community assets, strengths and risks can also be
identified by being attentive to people’s visible health behaviours such as observing people out
walking, older persons engaging in Tai Chi, and/or parent get-togethers.
KEY POINT
A windscreen survey is an effective way of gaining an understanding of the ‘lay of the land’ in a
community.
On completion of an SDH assessment, presentation of your work to the community and/

or to your colleagues and peers is a useful way of disseminating the information you have
gathered. These groups may have useful ideas on where further information can be obtained,
how the information can be used, and what the next steps in the process may be. In the context
of community placements, discussion of assessment information with community nurses or
the teaching staff supervising your placement can also provide locally relevant information
for health promotion.
Conclusion
Assessment of the community enables a deeper understanding of strengths, weaknesses, opportunities
and threats to community health. The McMurray Community Assessment Framework provides us
with a structure to grow our understanding of a community and work alongside community members
to identify and develop interventions to empower communities to address their own health and
social needs. Chapter 6 builds on our assessment knowledge to help us plan interventions with
individuals, families and communities. Before we move on, take some time to consider how the
McMurray Community Assessment Framework may help the Mason and Smith families.
CASE Assessing community needs for the Mason and

STUDY
: Smith families
We now return to the Smith and Mason families to provide an example of some of the information you
may collect as part of assessing their communities’ strengths, weaknesses, opportunities and threats to
health. There are distinctive differences in the three communities that influence health and wellness for
both families. The mining camp where Colin works is sparse and functional, approximately 1000 km from
Perth, the capital of Western Australia and the epicentre of the ‘resources boom’. In the area surrounding
the mining camp are several small towns, where each community is composed of a mix of long-term
residents and newcomers. Many of the townspeople live in caravan parks because of the shortage and
high cost of housing. Some are service workers who service the mine and the local population. The
physical environment is challenging, with extreme dry, dusty heat during the day and little rainfall.
Maddington is known as a family-friendly but diverse community with many young families, some of
them migrants, and older residents. The Smith family has ready access to the train station and the
shopping centre, which they can reach by bus from the stop on their street. There is moderate
unemployment in the suburb because there are so many opportunities across a range of jobs to work in
the mines, and access to the airport is ideal, within 10 km of Maddington. The Smiths’ neighbourhood
has a large number of FIFO families, and an informal mining wives’ club that meets regularly at the
community centre. There is a shortage of GPs in the area, but several child health clinics, and a school
health nurse attends the public school. The day care is staffed by accredited early childhood educators.
Papakura is a low socio-economic community with moderate levels of unemployment and a high
multicultural population. The area has a large number of young families, single-parent households and
older retired people. There are also a large number of state houses, private rental properties and
some home ownership. The community has a local integrated family health centre which offers
general practice, pharmacy and physiotherapy services. There is a local Plunket room and a
playground near the shops.
■ Community assessment includes mapping strengths, resources, risks and needs with input from
members of the community.
■ Epidemiological data provide information on the determinants and distribution of risks and diseases
in the population, usually defined as incidence and prevalence rates.
■ Quantifying rates of health risks and diseases is useful in some ways, but is not inclusive of
community perspectives and preferences or the particular needs of subgroups in the population.
■ Socio-ecological assessment tools have evolved over the years to reflect an increasing emphasis
on the SDH.
■ Asset mapping is a tool for assessment that outlines primary, secondary and potential features and
resources that can be mobilised for community health.
■ Community-based participatory research (CBPR) can be combined with asset mapping to provide a
realistic assessment of community health needs.
■ Social epidemiological assessment integrates demographic and epidemiological assessment data
with information from the community, often in the context of CBPR.
■ The McMurray Community Assessment Framework is an ideal way to ensure data are collected on
all the social determinants of health in a community.
1 Using the McMurray Community Assessment Framework, identify the most important priorities for promoting
health in the mining community.
2 What information will you use to assess the Maddington community in relation to its strengths, weaknesses,
threats and opportunities for socio-ecological support for the Smith family?
3 What strengths, weaknesses, threats and opportunities are readily identifiable in Papakura?
4 What information do you need to glean from Rebecca and Huia on their family and community needs?
Compile a list of questions to prompt your assessment interview with both of the women.
5 What gaps in assessment data did you find from your assessment interviews?
6 What extra sources of information did you use to complete the assessments in both communities?
7 From the assessment data of all three communities, what provisional plans would you put in place for health
promotion?
8 Group Exercise: Community assessment
9 Working in small groups, brainstorm the various ways you think information about a community can be
collected. Save your ideas and as you work through the chapter, see if the ways you have identified are
discussed in the text. Use your discussion forum or pinboard if working online.
10 Group exercise: SDH assessment

11 Working in groups of two to three, undertake a windscreen survey in your local community. Make notes on
what you observe. Consider how the notes you have made (the data you collected) fit into the McMurray
Community Assessment Framework and where. Make some notes on how useful you found this exercise
and what you learned. Share your findings with the wider group.
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CHAPTER 6
Planning for intervention
INTRODUCTION
Chapter 6 provides the framework for our work with individuals, families and communities.
We have explored community assessment tools and introduced the McMurray Community
Assessment Framework as a tool for working with communities in the previous chapter. In
this chapter we will extend our understanding of assessment to consider individuals and
families more closely and the steps needed to work at the individual and family level. We
explore care planning for individuals and families, and then project planning for communities,
both informed by the principles of primary health care. We describe how strengths-based
approaches to the development of care and project planning can result in flexible delivery of
interventions across local, national and global communities. The importance of evaluating
our interventions and the varying ways in which this can be done within the context of primary
health care practice is also reviewed.
OBJECTIVES
1 outline current and potential nurse-led 4 describe the contribution of the socio-
primary health care models of practice for ecological approach to health improvement
health and wellness 5 outline the role of primary health care
2 identify strategies for working in partner- practitioners in managing chronic disease in
ship with individuals and families to the community
develop sustainable people-centred care 6 develop a comprehensive evaluation
plans and interventions strategy for a primary health care program.
3 describe an approach to project planning
with communities
OVERVIEW
In order to provide a high standard of care, community health nurses and other health
practitioners use several tools to assist them in developing relevant and appropriate
intervention strategies. One of these foundational tools is planning for intervention, which
guides practice by identifying and developing community, family and person-centred
diagnoses, objectives and strategies for care, followed by evaluation criteria. The aim is to
develop a systematic approach to evidence-based customised care relevant to need and
involves four steps: assessment, development of objectives, implementation and evaluation
(Ballantyne 2016).
Community health nurses and other health practitioners need to plan for interventions in
environments that are less structured or controlled than those in hospitals. Practitioners must
be able to understand the implications of the social determinants of health (SDH) and incorporate
these with the immediate presenting issues in order to design meaningful objectives and
implementation strategies (Ricci 2016). Planning is an integral part of clinical reasoning,
enhancing critical thinking for effective practice (Kuiper et al. 2017).
As discussed in previous chapters, planning for intervention should be undertaken within a
social model of health, in collaboration with individuals, families and communities, and have an
interdisciplinary approach with other health and non-health practitioners. Community, family
and person-centred approaches facilitate self-identified goals and objectives in addition to
appropriate, meaningful, achievable, equitable and sustainable strategies, which take into account
primary health care principles and the SDH influencing their lives (Keleher & MacDougall 2016,
Rylance & Graham 2014). However, several factors may disrupt these approaches, including
clinical conventions and restrictions, organisational culture and ineffective interprofessional
relationships. There may also be a lack of support for the inclusion of up-to-date evidence to
support intervention planning and implementation (Rylance & Graham 2014). It is essential
to include legally designated strategies that promote people’s health and wellbeing, such as
mandatory reporting for child and senior abuse (Department of Health 2016, Royal Commis-
sion into Institutional Responses to Child Sexual Abuse 2017). The Australian guidelines for
mandatory reporting differ between states and territories and there is no national legislation
in New Zealand, although there is some regulation by district health boards (CFCA 2016,
NZMOH 2017).

Mandatory reporting guidelines
• Australia: www.aifs.gov.au/cfca/publications/mandatory-reporting-child-abuse-and-neglect
• New Zealand: www.health.govt.nz/our-work/preventative-health-wellness/family-violence/
family-violence-questions-and-answers
GUIDING APPROACHES FOR EFFECTIVE PLANNING

Two approaches underpin effective planning: strength-based approaches and the principles
of primary health care.
Strengths-based approaches
Remembering our previous discussions on empowerment, self-efficacy and self-determination,
it is important for strengths-based approaches to be used when formulating intervention plans.
This enables issues for individuals, families and communities to be considered within broader,
holistic contexts that impact on both strengths and challenges. Strengths-based practice identifies
people’s abilities, interests and skills that may be nurtured to help them develop their own
health and wellbeing goals and strategies (Gottlieb 2014).
Primary health care principles

Integration of primary health care principles into planning is essential for effective and sustainable
outcomes. Comprehensive primary health care encourages partnerships between people and
their communities and health practitioners for the planning and delivery of equitable, accessible,
culturally respectful and socially acceptable services. Appreciation of the influence of the SDH
is vital along with the ability of these determinants to enhance or diminish health and wellbeing
strategies (Keleher & MacDougall 2016). Contemporary care is shifting from disease models
to a focus on health and wellbeing, particularly in relation to prevention, health promotion
and quality outcomes for tertiary levels of disease progression. Community health nurses and
other practitioners are well positioned within interdisciplinary teams to contribute their primary
health care expertise to facilitate quality community, family and person-centred intervention
planning (Salmond & Echevarria 2017).
PLANNING FOR INTERVENTION: STEPS
Assessment with individuals and families

A comprehensive assessment of the individual or family using appropriate evidence-based or
evidence-informed tools and effective communication and observation will allow you to identify
and validate health and wellbeing issues. It is important to remember that these can be potential
or actual issues where you can recognise both deficit and strengths-based areas affecting people
and communities. Assessment tools also provide a baseline from which health and wellbeing
can be monitored (Ballantyne 2016).
POINT TO PONDER
Review the primary health care principles in Chapter 1. Consider how you could use these in care
planning for individuals, families and communities. Remember that communities may be
geographical or virtual.
The previous chapter has given an extensive overview of assessment tools for use with
communities and we now extend this to family and individual assessments. Examples include
the Calgary Family Assessment Model (Wright & Leahey 2013), Friedman’s Family Assessment
Tool (Friedman et al. 2003), Bristol Breastfeeding Assessment Tool (Ingram et al. 2015), the
HEEADSSS Adolescent Assessment Tool (Klein et al. 2014, see Appendix C) and the Edinburgh
Postnatal Depression Scale (Cox et al. 1987). Complementing these tools is the use of genograms
and ecomaps. Assessments of families is integral to community health practice as their function-
ing, parenting capacity and access to social and family supports influence child and family
health, wellbeing and resilience. Exploring family functioning can be challenging, as issues
are complex and multidimensional, with the SDH impacting on family members’ abilities to
cope in times of physical and psychosocial stress (AIHW 2015a). Of note is recent research
highlighting the self-identified need for health care providers to have improved communication
skills in relation to discussing psychosocial concerns with families. This directly affects their
ability to focus on prevention and management of challenges arising from the SDH (Tallon
et al. 2017).
A comprehensive framework for family assessment is the Calgary Family Assessment Model,
comprising three major classifications: the structural, developmental and functions aspects of
families (Wright & Leahey 2013). The model is found in Appendix B. You will note there are
several subcategories within each of the classifications. However, professional expertise can
be used in deciding which of these are relevant for discussion. It is important to be aware of
how families cope with the process of exploring their lives. If they are feeling overwhelmed
or challenged, it may be beneficial to collect the data over a period of time. Community health
nurses need to be cognisant of families’ individual situations and their own personal belief
systems and biases. Reflexive practice is important in order to develop trust and accurately
appreciate family circumstances, particularly in cross-cultural contexts (Munns et al. 2017a,
2017b, Wright & Leahy 2013).
Additional strategies to assist with family assessment are the use of the Family Partnership
model of interaction along with genograms and ecomaps (see box below). The Family Partnership
approach facilitates non-expert, partnership communications between nurse and families, with
genograms and ecomaps being visual representations of family structures and their social
support interactions (Patane & Forster 2017). They are important as assessment tools as well
as enhancing therapeutic questions and client engagement (Leahey & Wright 2016).

Genograms
• https://www.communities.qld.gov.au/resources/childsafety/foster-care/fcagenogram.pdf
Ecomaps
• https://www.communities.qld.gov.au/resources/childsafety/foster-care/familymapinstruct.pdf
Consider how these tools can be used across a range of family environments. Try drawing a
genogram and ecomap for your own family.
Individual members of families require assessments for a range of issues. The HEEADSSS
Adolescent Assessment Tool (Klein et al. 2014) and the Edinburgh Postnatal Depression
Scale (EPDS) (Cox et al. 1987) are two tools frequently applied in community midwifery,
child and school health settings. We discuss the HEEADSSS assessment in detail in Chapter
8. The EPDS can be used to assess the risk of anxiety and depression for women in the
antenatal and postnatal periods. It can also be used with male partners. In partnership, this
tool has the potential to enhance safe communication about sensitive topics with parents
(CAHS 2017).
Effective communication is vital to the assessment process, with community health nurses
and other health practitioners needing to be aware of any issues, such as the effects of culture
on language expression, how questions are best communicated, whether people are being
interviewed in their primary language and what effects people’s views on health and wellbeing
have on the assessment information. It is important to note any subjective information which
illustrates people’s perceptions of topics under discussion, along with objective evidence which
the nurse or other health practitioner identifies from observations of individuals and families
and how they are functioning within their community (Potter et al. 2017).
Following comprehensive data collection, presenting issues can be identified. Within nursing,
these are referred to as nursing diagnoses but will be referred to here as issues as they encompass
a wide range of psychosocial strengths and challenges.
KEY POINTS
Presenting issues can relate to:

• individuals
• families
• communities.
When documenting issues, it is important they are community, family or person-centred

and include all the information that allows the factors affecting the issue to be understood.
They can have four parts:
■ A label. What is the issue affecting the community, family or person? For example,
‘ineffective breastfeeding’ (individual); ‘Dysfunctional family processes’ (family) and
‘Ineffective activity planning’ (community) (NANDA International 2012). This describes
the actual issue.
■ The related factors. These contribute to or are associated with the issue and can include a
wide range of physical, psychosocial and developmental factors. For example, ‘ineffective
breastfeeding related to lack of maternal self-confidence’ (individual); ‘Dysfunctional
family processes related to maternal anxiety’ (family); ‘Ineffective activity

planning related to lack of recreational space’ (community) (NANDA International
2012).
■ Signs supporting the issue. This part is supported by the subjective and/or objective
evidence. For example, ‘ineffective breastfeeding related to lack of maternal
self-confidence as evidenced by the mother’s anxiety and stating she is not sure about
how to breastfeed’ (Lippincott Williams & Wilkins 2013, p. 59, NANDA International
2012); ‘Dysfunctional family processes related to maternal anxiety as evidenced by the
father stating that his wife is too nervous to take the children to school’ (family);
‘Ineffective activity planning related to lack of recreational space as evidenced by 100%
of resident responses in community assessment’ (community) (NANDA International
2012).
■ Evidence supporting the issue. This may not be a well-understood component of your
documentation, but it is important to demonstrate evidence-based practice by
supporting your clinical reasoning and judgement with research evidence.
Where possible, it is important to identify and document the issues in partnership with
the community, family or person and an interdisciplinary team. Additionally, discussion to
identify which issues are a priority is necessary as there will be reduced acceptance of any
interventions unless strategies are meaningful and co-designed with the community. Short-,
medium- and long-term priorities may need to be set.
Development of objectives
Setting objectives provides a focus for direction in care and project planning and benchmarks
for evaluation (Ballantyne 2016). When addressing the needs of communities, there may also
be overall goals or aims that indicate planned, long-term changes. A common problem is for
objectives to be written outlining what the health practitioner will do. In partnership with
individuals, families and communities, it is important to co-design objectives, setting key steps
towards targets they want to achieve (Talbot & Verrinder 2014). To be effective, objectives
need to be SMART:
■ specific, with one idea per objective
■ measurable, with each objective having an action verb that can be measured
■ achievable, ensuring that the activities associated with the objective will be realistic for
the individual, family or community and health practitioner
■ relevant, ensuring that the objectives are clearly linked to the identified issue and any
overall goals or aims;
■ include a timeframe, stating a realistic time for each objective to be achieved (Talbot &
Verrinder 2014:203)
■ fiscally and ethically responsible.
The evaluation measures the objectives, so it is crucial that they address all the areas above
to ensure effective measurement.

Developing measurable objectives
Guidelines for Writing Learning Objectives (n.d.). Available from
http://www.nhnurses.org/Especially-for-You/CE-Resources/Writing-Objectives-Guidelines.pdf
Implementation
Implementation strategies are the activities planned to enable the objectives to be achieved
(Talbot & Verrinder 2014). They will have credibility if they are supported by evidence-based
research and address a holistic range of activities such as physical, psychosocial, spiritual
and financial strategies. Incorporation of primary health care principles enhances their
effectiveness and acceptability, thereby facilitating sustainability of outcomes. Additionally,
with the aim of developing self-efficacy, health literacy and empowerment for individuals,
families and communities, embedding health education and health promotion within care
plan implementation strategies is a crucial step. Theoretical models help guide the planning
of implementation strategies and influence the way in which we implement them. Modes of
intervention provide tools for how we may work in partnership with individuals, families and
whole communities. Below we give some examples of some different types of theoretical models,
models of care and modes of intervention to help build our understanding of planning for
interventions.
Theoretical models underpinning care planning implementation strategies

The ecological model which was discussed in Chapter 1 recognises that health and well-
ness are influenced by both biological and environmental factors. Use of the term ‘socio-
ecological’ identifies that social influences are also included in the environmental domain.
The interactions between individual, family, organisational, community and public policy
factors highlight the range of factors influencing the ability of people and communities
to maintain health and wellbeing. Fig. 6.1 demonstrates the influences each factor has on
the other.
Individual factors relate to biological and personal histories that enhance and present
challenges to maintaining health and wellness. SDH involving age, gender, socio-economic
status and genetics influence people’s abilities for self-efficacy, health literacy and self-management
of health. Interpersonal factors recognise that a person’s peers such as family members shape
their health-seeking behaviours, influencing their physical and psychosocial environments to
enable or inhibit health and wellbeing activities. Organisational and community factors investigate
the quality of settings in which people work, learn and live, examining the characteristics that
enable or counter healthy lifestyles. SDH such as housing, transport and economic considerations
influence these opportunities. Public policy factors relating to health, economic and social
policies can influence social inequalities by supporting accessible, affordable and culturally
Public Policy
ial/territorial, local law
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a po
ion m m u n lic
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Figure 6.1 Socio-ecological model of health
Source: Adapted from Centers for Disease Control and Prevention, Social Ecological Model,
https://www.cdc.gov/cancer/crccp/sem.htm
appropriate ways of assisting individuals or groups in the community (CDC 2015). When
planning strategies, community health nurses and others working in the community need to
understand the characteristics of each factor within the model and how they interrelate and
influence each other.
As you can see, the impacts of the SDH need to be recognised when developing implementation
strategies within care and project plans. Each level in the socio-ecological model of health can
be positively influenced by primary health care approaches, particularly in relation to health
education and health-promoting activities.
The Ottawa Charter for Health Promotion outlined in Chapter 1 is a further model or
framework for guiding planning of strategies for care and project planning. The five core
strategies of the Charter (build public health policy, create supportive environments, strengthen
community action, develop personal skills, re-orient health services) are underpinned by the
principles of primary health care to enhance health promotion approaches within community
health, thereby assisting individuals, families and communities to be empowered and sup-
ported to make changes to their health and wellbeing (Guzys et al. 2014, WHO 2017). The
Ottawa Charter identifies the fundamental conditions and resources for community health
and using the Charter to guide care planning, ensures a comprehensive approach to improving
health.
KEY POINT
Inequalities and inequities

The implementation strategies encouraged by the Ottawa Charter are aimed at overcoming
inequalities (bias and disadvantage) and inequities (unfair distribution of health care and other
resources) through action on the social determinants of health at all levels of society.
The ultimate goal is social justice.
Models of care and project planning

A model of care is simply the way in which services are designed and delivered (Clendon
2014). The best models use a multidimensional approach to suit different contexts of holistic
care. Models are underpinned by theory and practice and are designed utilising critical thinking
skills to ensure evidence-based implementation and evaluation strategies are incorporated
(Ballantyne 2016). Within nursing and midwifery practice, there are several examples of models
of care including nurse/midwife-led clinics, family/women-centred care, transitional care and
case management. A primary health care approach can be used to develop a range of models
within health care settings, such as general practice, hospital and community care and specialist
health services in tertiary centres. The following common elements have been identified in a
range of literature as having the best potential for success (Clendon 2014).
• be co-designed and individual, family and community-centred;

• be interdisciplinary (where each team member recognises and respects the knowledge and skills other
health practitioners are able to bring to the care of a patient);
• involve collaborative teamwork (with the right person providing the right care at the right time at the
right place to the right person);
• consult and engage end users, clinicians, managers, and key stakeholders throughout the development
and application of any model;
• be robustly evaluated; and
• have strong organisational commitment
(as cited in Clendon 2014:4).
Evidence-based models of care are able to provide guiding frameworks for community
health practitioners and interprofessional teams. Different models highlight distinct aspects
of care delivery, with those that are primary health care based reflecting a holistic and viable
approach (Ballantyne 2016).
Flexible models of care acknowledge that people, whether individuals, families or whole
communities, may need different strategic approaches to optimally provide for their needs.
Comprehensive primary health care approaches recognise that flexible models and strategies
are needed to address cultural obligations and relationships within Aboriginal communities
(Bullinah Aboriginal Health Service 2017) and with Māori. Home visiting is an approach to
engage people in their own settings, which enables community practitioners to develop plans
with them to suit their unique needs. Peer support has been an important part of community
mental health for many years (Beales & Wilson 2015). Of note, is the emerging collaboration
between peer support workers and community health nurses to develop culturally acceptable
support strategies for Aboriginal parents through home visiting or in a range of community
venues. The peer support workers’ abilities to understand local SDH through the lived experience
is a source of strength-based strategies, helping parents to cope with health and social inequalities
(Munns et al. 2016, Munns & Walker 2015).
New models of care will be required to meet the challenges currently facing health systems.
A growing population, growing diversity, increasing prevalence of long-term conditions and
an ageing population will continue to challenge the ways we provide care, and nurses and
other health practitioners will need to develop new models to address these needs. Changing
technology will enable more flexible delivery of care and disruptive innovation such as that
seen by the advent of new technology-based providers like AirBnB, Uber and Babylon, which
challenge traditional approaches. Babylon, for example, provides internet-based access to general
practitioner services with no requirement for the bricks and mortar models we currently use.
It is important we think carefully about the value of current models and the changes we will
need to make to improve health outcomes among the most vulnerable families and communities
we work with. Others are already considering new approaches and we need to be ready to
join them or, at the minimum, understand them, as the people we currently work with will
want to know more about them whether we like it or not.
Modes of intervention
In the same way health services will change as we move into the future, the types of interventions
we use will also change. Traditional approaches will still have a place and we will consider
these first. The use of groups as a flexible model of care delivery has been discussed in Chapter
4. This model can be used for a wide range of people and settings, such as seniors’ groups,
men’s groups, health fairs and primary and adolescent health groups in urban, rural and remote
areas. Planning care for men in the community can be challenging, but connecting and developing
strategies through innovations such as Men’s Sheds have the potential to offer health and
wellbeing support, reduce loneliness and improve social connectedness (Johnston et al. 2014).
Health and wellbeing expos or fairs are able to use novel methods of presenting health education
and health promotion across a wide range of topics. Strategies such as demonstrations, personal
use of health products and the availability of health promotion material can be made available
to large numbers of people (Australian Institute of Male Health and Studies n.d., Northern
NSW Health Promotion 2017). As previously highlighted, adapting group work to virtual
online engagement is an emerging strategy that is being used by community health nurses for
people preferring this type of approach and for isolated population groups (Coggio & Deveneau
2016, Johansson et al. 2017).
Primary health care practitioners, including community health nurses, have an integral
role in the prevention and management of chronic diseases using a primary health care
approach within the socio-ecological model of care. Chronic diseases are long lasting with
continuing effects and include cardiovascular conditions, cancers, mental illness, diabetes,
respiratory diseases, musculoskeletal conditions, chronic kidney disease and oral diseases
(AIHW 2015b). Most morbidity and mortality is caused by chronic diseases. In Australia, if
people understood and modified their risk factors such as tobacco and alcohol consumption,
obesity, sedentary behaviour and hypertension, approximately 31% of the burden of disease
could potentially be prevented (AIHW 2016). These risk factors are of urgent concern for
Australian and New Zealand children and adults. Community health nurses are taking a lead
role in health education, health promotion, advocacy and case management of these clients
(Johnston et al. 2014). They are also able to work in partnership with entire communities
to help facilitate population level changes to help individuals and families maintain health
and wellbeing.
Nurses and other health practitioners need to be cognisant of how the SDH are influencing
clients’ behaviours and responses to prevention and management strategies. Interdisciplinary
practice is a strong feature of chronic disease management, with a range of strategies such as
group work, general practice management plans and motivational interviewing being utilised
to support ongoing client health management and behaviour change (Johnston et al. 2014).
Motivational interviewing is a credible strategy to encourage behaviour change. It engages
people in purposefully directive discussions to collaboratively recognise and appreciate associa-
tions between their lifestyle behaviours and health status or conditions. By using a range of
communication techniques over 10 to 15 minutes, health practitioners are able to empathetically
pinpoint inconsistencies in people’s health beliefs and behaviours and focus on adoption of
realistic, accessible and acceptable lifestyle changes (Guzys 2014:145). A recent systematic
review highlighted that motivational interviewing appears to be an enabling strategy for health
care practitioners and people across a range of single diseases, recommending further research
for use in multimorbidity interventions (McKenzie et al. 2015). Motivational interviewing is
frequently used in chronic disease models of care and for behaviours not conducive to health
and wellbeing, such as smoking and unhealthy alcohol intake. It is also shown to be beneficial
when working with families with complex needs who may be resistant to engaging with support
programs. Health practitioners are encouraged to view these families as people dealing with
motivational conflict, ranging between wanting to maintain their current situation and aspirations
for change (Iannos & Antcliff 2017).

Strategies for motivational interviewing
https://aifs.gov.au/cfca/publications/application-motivational-interviewing-techniques-engaging-
resistant (Iannos & Antcliff 2017)
New and innovative modes of intervention are also starting to become more prevalent.
Examples include computer gaming for the management of dementia and improving muscular-
skeletal balance and coordination, and telehealth for long-term condition management where
nurses might manage over 100 patients through digital technology (Gerling et al. 2016). Personal
health trackers already enable constant measurement of heart rate, oxygen saturation, stress
levels and blood sugar. This data will soon upload automatically to an individual’s personal
health record enabling a nurse or other health practitioner to immediately access data for
monitoring health and wellness. Automatic monitoring of blood concentrations of certain
medicines is likely to follow soon. Planning for care will need to take into account the growing
demands of individuals and families for flexible, innovative but still person-centred approaches
to care.
In summary, care plans are optimally implemented when they are developed in collaboration
with people and other agencies and practitioners. Research evidence is crucial for substantiating
strategies that are used for individual planning, establishing evidence-based models of care
and government-funded models with a flexible range of implementation. It is also crucial to
ensure a primary health care approach underpins these strategies to ensure they are culturally
appropriate for all population groups, realistic, achievable and affordable. Just a reminder for
your documentation: it is important to list all resources needed for your strategies in a single
document, particularly for community group activities. This enables you to consider costs
more effectively and remember requirements such as booking venues and guest speakers. It
also allows other health practitioners to quickly understand all that is needed if they are
undertaking the strategies in your absence. Examples of care plans and project planning
approaches are available online at http://evolve.elsevier.com/AU/Clendon/community/.
Evaluation
A care plan allows objectives to be measured, thereby assessing whether the care has met the
outcome criteria (Ballantyne 2016). It is a continual, cyclic process where strengths and chal-
lenges of objectives and intervention strategies can be highlighted (Talbot & Verrinder 2014).
It is important to take a strengths-based approach, reviewing what went well, what contributed
to the success and how these factors may be incorporated into future care planning. Giving
praise to people for achievements is integral to feelings of self-efficacy and self-determination.
Even when outcomes have not met anticipated objectives, commending them for their efforts,
‘giving it a go’, is fundamental for ongoing confidence.
The processes of evaluation have similarities and differences for individuals, families and
communities. Individuals and families have a more personalised approach than whole com-
munities with the following steps being carried out:
■ comparing evaluation findings with the care plan objectives
■ assessing if the objectives have been met, partially met or not met
■ revising the care plan (Lippincott Williams & Wilkins 2013:137).
Using critical reflection and judgement, evaluation findings can be reviewed to con-
sider if the original care plan remains relevant to the presenting issues and whether there
have been unanticipated deterioration or problems. This reassessment allows for more
specific, tailored objectives and intervention strategies to be developed. Evaluation can
also determine whether established professional standards have been met as well as the
criteria for government-funded priority strategies. An interdisciplinary approach also
requires outcomes of care from all contributing team members (Lippincott Williams &
Wilkins 2013:137–138).
Evaluation of planning for community projects is required for identifying strengths and
challenges in addition to informing reports for funding agencies and stakeholders. To inform
a comprehensive approach, both quantitative and qualitative data are collected, enabling both
statistical results and the lived, contextual experiences of program participants. The primary
health care and health promotion aspects are difficult to evaluate as issues such as the impact
of the SDH and behavioural change are developmental and complex. It is recognised that the
achievement of overall program aims can be long term with direct association of strategies to
outcomes being problematic (Talbot & Verrinder 2014).
Three basic types of evaluation underpin the assessment of community programs: process,
impact and outcome evaluation (RHIHub 2017).
■ Process evaluation assesses the type, quantity and quality of program strategies
implemented.
■ Impact evaluation assesses the immediate program effects on participants. A crucial
factor is whether the program’s objectives have been met.
■ Outcome evaluation considers if the long-term program aims or goals have been
achieved. Measures may reveal changes in health behaviours and indicators (RHIHub
2017, Talbot & Verrinder 2014).
There are a range of tools that can be used to collect data for each of these types of evalua-
tion. Process evaluation assesses the degree to which the community group has been engaged
with the program and participant satisfaction. Feedback on the organisation of activities and
strategies such as suitability and accessibility of venues, length of session times, availability
of child activities, availability of refreshments, suitability of program content and facilitator
presentation and interpersonal skills are important for ongoing participant engagement. Paper-
based or online questionnaires are the most commonly used data-collection tools (Guzys &
Grieve 2014).
Impact evaluation reviews if the program objectives were met. Critical analysis of the
evaluation also reveals the reasons for successful objectives and strategies within care and
project planning along with details on why they may not have been achieved. Unexpected
program outcomes may be learned, all of which help improve the design of programs and their
supporting policies (World Bank 2016). Quasi-experimental and non-experimental evaluation
designs are generally used for data collection. Quasi-experimental designs can use comparison
groups, while both are frequently used for pre-test/post-test assessment (Talbot & Verrinder
2014). Paper-based and online questionnaires, individual and group interviews, observation
and the use of journals recording participant behaviour following a community program are
all strategies that may be used as evaluation tools (Guzys & Grieve 2014).
Outcome evaluation frequently utilises statistical indicators such as quality of life, health
status and morbidity and mortality indices to assess if aims or goals have been achieved.
Measurements of behavioural changes are difficult as successful outcomes may be attributed
to a number of integrated strategies. The same tools as detailed above for impact evaluation
can also be used for outcome evaluation (Guzys & Grieve 2014, Talbot & Verrinder 2014).
Once the evaluation of community programs has been completed, development of
an information dissemination strategy is an important step. This is seen as a community
development process, supporting community members in their empowerment, health
literacy and health and wellness capacity building (Talbot & Verrinder 2014). It is also
recognition of the partnership approach within care and project planning and community
health practice. Reports on program outcomes potentially benefit ongoing program funding,
contribute to the evidence base for care and project planning and demonstrate quality practice
approaches.
DISABILITY
Internationally, governments have developed and funded key strategies to improve care planning
in identified chronic disease and disability priority areas. These include Disability Support
Services (DSS) in New Zealand (NZMOH 2016), the National Disability Insurance Scheme
(NDIS) in Australia and the National Service Frameworks in the United Kingdom (Doncaster
and Bassetlaw Hospitals NHS Foundation Trust n.d.). A defining feature of NDIS in Australia
is the ability of individuals and their families to have greater choice over their own planning
and resources than in previous programs (Department of Social Services 2017). Although the
strategies are legislated, community health practitioners are encouraged to personalise the
approaches as much as possible according to clinical need and preferences of individuals and
families. In New Zealand, individualised funding is helping people with disabilities make their
own decisions regarding their care and who provides it. These new funding mechanisms will
enable nurses to work with families more effectively to meet their needs.
ADVOCACY GROUPS
Advocacy groups also research and develop policy advice for governments and health practitioners
for improved health and wellbeing strategies, thereby influencing funding and evidence for
care planning. The Australian National Rural Health Alliance is an example of a national
alliance of consumer and professional groups developing well-targeted, cost-effective, evidence-
based strategies aimed at improving the health and wellbeing of people in rural and remote
Australia (NRHA 2017). Similarly, the Rural Health Alliance Aotearoa New Zealand is an
association of multiple rural sector consumer and professional organisations, identifying priority
needs in rural health and providing government advocacy for equitable health and wellbeing
care strategies (RHAANZ 2015). Community health nurses and other practitioners are encour-
aged to access these advocacy services to keep current with policy development and to integrate
contemporary strategies into practice.

Rural and remote health strategies
• The National Rural Health Alliance Fact Sheets: www.ruralhealth.org.au/factsheets/thumbs
• The Rural Health Alliance Aotearoa New Zealand information, resources and podcasts: www.
rhaanz.org.nz/
Conclusion
Planning for care and projects is an essential element of working with individuals, families and
communities. The key elements of care and project planning have been identified across individual,
family and community contexts, highlighting the need to work in partnership with clients and
interdisciplinary groups. Evidence-based planning is essential for quality assurance, safety and credibility
of strategies and outcomes. We have developed a set of care plans for the Smith and Mason families
that are available online. These examples show how care plans can be used within the context of
complex family lives. We also present two examples of project planning that can be implemented
following community assessments.
CASE Care and project planning with the Smith and

STUDY
: Mason families
Care plans for the Smith and Mason families http://evolve.elsevier.com/AU/Clendon/community/

Community project plans http://evolve.elsevier.com/AU/Clendon/community/
■ Nurses and other health practitioners use a range of tools to develop relevant and appropriate
intervention strategies including care and project planning.
■ Care and project planning is optimally undertaken in partnership with individuals, families, com-
munities and interdisciplinary teams.
■ Care and project planning is developed within a primary health care and strengths-based
framework.
■ The SDH have a significant role in determining aims/goals, objectives and strategies within care and
project plans that work towards social justice for all.
■ Care and project planning comprises assessment, development of objectives, implementation and
evaluation.
■ Ecomaps, genograms and family assessment are useful tools in the assessment process.
■ Theoretical models such as the ecological model and the Ottawa Charter underpin implementation
approaches.
■ Models of care describes the way in which services are designed and implemented.
■ Modes of intervention, such as motivational interviewing and group work, are the types of
approaches we use in our work with families.
■ New approaches to disability support, such as individualised funding, enable individuals and
families to work more closely with health practitioners to have their needs met.
■ Nurses and other health practitioners can work with advocacy groups to help develop care and
project plans.
1 Explain the importance of evidence-based care planning in community health nursing practice.
2 What conditions might affect culturally acceptable care plans?
3 Explain how to develop care and project plan objectives that are measurable and relevant.
4 Create a mind map with an overview of the differing implementation strategies that can be used across a
range of individual, family and community situations. Consider their relevance to each situation.
4 Develop ecomaps for the Smith and Mason families.
5 What tools could you use to work with Colin to proactively encourage him to reflect on his drinking?
6 Reflecting on the project plans found online, what other approaches may be appropriate for developing
breastfeeding support in a community?
7 Write a project plan designed to increase exercise among a group of teenage girls.
8 Develop a care plan designed to address Jake’s asthma.
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Section 3
Health and wellness

throughout the lifespan
CHAPTER 7 The early years

CHAPTER 8 Transitions to adulthood and beyond
This section reflects the importance of promoting health and wellness at each stage along the
life course from birth to death. Chapter 7 focuses on the contemporary family and healthy
children. Because the family is so important to both individual and community health, we
provide a detailed section to guide your learning, covering the rapid social, technological and
workplace changes that are influencing general family life, couple relationships and family life
across the transitions of partnering, marriage and, in some cases, marital separation. We also
discuss the unique circumstances of some families living in our communities, including migrant
and refugee families, families coping with illness or disability and rural families. The second part
of Chapter 7 focuses on child health. Child health is commonly understood as the most
significant indicator of how families, neighbourhoods, communities and nations are able to
provide health-enhancing conditions for daily living. We consider the burgeoning body of
research into biological embeddedness, the role of environmental stimuli and the social
determinants of child health and how these contribute to raising healthy children.
Chapter 8 traverses life from adolescence through to older age, focusing on three stages along
life’s journey: adolescence, adulthood and older adulthood. The health status of adolescents in
any community provides a barometer of a community’s progress in creating and supporting a
healthy start to life, and creating a template for the future. At this crucial stage, a large segment
of the population is launched from childhood to adulthood, from dependence to independence.
How adolescents deal with the various challenges and negotiate the many transitions of a few
delicate years often heralds how well they will cope with the transitions of adult life.
Healthy adulthood reflects the culmination of socially and environmentally supported choices
for health and wellness made by individuals at earlier stages of their development. Adulthood is
also the time when many chronic diseases emerge and when the risks of ill health or injury are
acute. For younger adults, particularly parents, social and occupational pressures loom large and
our discussion extends to issues related to formal and informal work and family life.
The final section of the chapter examines the features of healthy ageing. Managing chronic
conditions is of major concern in this part of life’s pathway, and we revisit some of the main
strategies for helping people shape their lifestyles and their communities to promote healthy
ageing. A social perspective of ageing is outlined, including the need to attend to older people’s
numerous transitions; those related to family members joining or leaving the family home,
retirement, loss and the adjustments of widowhood.
Our two families, the Smiths and the Masons, also feature in both chapters, as the case study
unfolds with a different focus for each, ranging from the family to the children, adolescents,
adults and older family members. As you read through the chapters, we encourage you again to
think about the big issues, some of which we mention at the end of each chapter, and reflect on
practice and its evidence base.
CHAPTER 7
The early years
INTRODUCTION
Few people would challenge the notion that the family is the most important influence on the
health of a society. The family is where individuals are nurtured and guided to adopt and
adapt beliefs, behaviours, values and attitudes that will help their members become healthy
and competent citizens of wider worlds. There are many influences on health and development
that arise from the interactions between families and communities. Some of the most important
of these are habits of mind and action that emerge from a child’s early experience in the family.
Daily interactions between family members create opportunities for inherent traits and
predispositions to be shaped into positive or negative behaviours in relation to health and
wellbeing. These become habitual and refined as they are reinforced and nurtured, and as
family members interact with others external to the family. Families play an important role
in nurturing their children along their developmental pathways. This has a reciprocal effect
on parents or caregivers as each interaction provides not only an opportunity for parental
dialogue, but also renewed consideration of the way adult family members are relating to one
another. In this era of increasing cross-border migration, there are also many lessons to be
learned about the distinctiveness of these family interactions in families with different cultural
traditions.
Adult family members make lifestyle choices, and this can be crucial to a child’s decision
making in relation to healthy lifestyles. Children’s choices are cultivated by what is observed
and modelled within the family, and how family health is entrenched in the social conditions
and relationships beyond the family. In this respect, families play a significant gatekeeping
role as the main link between individuals and their environments. Because families themselves
are dynamic, their roles change in various ways and this has implications for family health
and wellbeing. As individual family members change and develop in their encounters of daily
life, the family as an entity also changes to adapt to the outside world, which affects its ability
to provide a supportive environment for the adults and children. Each opportunity to adapt
and change can be used to share strengths and challenges, and to teach children the skills to
be self-regulating and competent, to create and sustain health and wellbeing as they negotiate
the critical stages along the pathways to adulthood.
In a contemporary world where change is both rapid and constant, the way family members
interact with their environments determines the extent to which the family can provide support,
protection, encouragement and direction to each of its members. Families that are able to
162 Section 3 Health and wellness throughout the lifespan
provide a firm grounding for all their members to deal with outside stressors can foster
understanding, tolerance and social cohesion within the family and community. Alternatively,
a lack of strong family bonds to shelter or safeguard family members from adverse influences
can have harmful effects on family members and the wider community.
One of the greatest indicators of health and wellness in a community is the extent to which
it invests in and nurtures its children. As we outline in this chapter, our knowledge of the
factors that contribute to child health is growing at a rapid rate, and there is widespread
understanding that the most important avenue to good health in any community is supporting
a healthy start to life. This includes support for parents from the time they begin to plan a
family, through conception, childbirth and parenting. Community life is crucial to good parenting
and it requires commitment at all levels of society to develop community structures and
processes that will be helpful to parents and others who interact with children.
This chapter examines the importance of primary health care practice for families and
children in the early years. Our SDH perspective addresses the multiple, reciprocal, positive
and negative influences on family life and how these may change over time. Towards that end,
the chapter examines families and children in the context of today’s societies, how they are
changed by contemporary life, and the role of nurses and other health practitioners in helping
them achieve and sustain health and wellbeing.
OBJECTIVES
1 discuss local, national and global influences 4 use a primary health care and social
on families and children in a range of determinants framework to develop
settings community goals and strategies for
2 describe the major risk and protective sustaining child and family health and
factors influencing families and children in wellbeing within a range of family
contemporary society structures.
3 describe the impact of pre-conceptual and
antenatal care on children’s health and
developmental pathways
PART 1: HEALTHY FAMILIES
What are families?

When we think of family, some of us think of the protective envelope that provides a refuge
from the stresses and strains of contemporary society. Others see family as a combat zone, a
kind of repository for the collective problems of both the inside and outside world. Most
people hold a view of family that lies somewhere between these two extremes.
KEY POINT
What is … the family?

A protective gatekeeper between individual family members and their culture, and wider
society.
Family is the most important influence on the health of a society.
Defining the family is important for several reasons. These include some of the most important
social and structural determinants of health, such as the socio-legal family environment.
Socio-legal arrangements dictate which members have access to children’s school records, who
is eligible for reproductive assistance and who is legally responsible for children’s health decisions.
The concept of family is difficult to define as the meaning varies considerably within community
and population groups. For statistical and reporting purposes, the ABS (2014) describes family
as being:
Two or more persons, one of whom is at least 15 years of age, who are related by blood, marriage
(registered or de facto), adoption, step or fostering, and who are usually resident in the same household.
The basis of a family is formed by identifying the presence of a couple relationship, lone parent–child
relationship or other blood relationship.
Similarly, Statistics New Zealand (2014) defines a family as ‘two or more people living in
the same household, who are either a couple with or without children, or one parent and their
children’. Both countries have comparable family types, with the most common form being a
couple with children (opposite-sex and same-sex couples), followed by couples without children
and one parent with children. Grandparents in a parental role is an increasingly common
category with extended family type being classified as a group of related people usually residing
in the same household (ABS 2014, Statistics New Zealand 2014).
However, these scientific, quantifiable descriptions do not take into account social and
cultural structures that influence how people relate to each other (Taylor & Guerin 2014). For
example, the kinship system within Aboriginal communities involves both biological parents
and other family members having defined social structure roles within families, influencing
issues such as communication and decision making. Extended family members assume diverse
roles, particularly in relation to children (Smith 2016, Taylor & Guerin 2014).
In Australian and New Zealand Indigenous groups, ‘family’ is pre-eminent. Australian
Indigenous groups have variable languages with which to describe their families and the notion
of family connectedness, however, government agencies describe all Australian Aboriginal
and non-Aboriginal families as ‘family’ using common terminology. In Australia, working

with Aboriginal family groups is inclusive of Aboriginal people, such as child and family health
workers, who are from the same group as the group they work with, or those who are known
to be accepted by the families. These Aboriginal health workers may be part of mainstream
government services, community controlled Aboriginal health services or non-government
organisations and are educated in family therapy, research and policy development as well as
having local cultural knowledge. Examples of services employing such health workers include
the Bouverie Centre in Victoria (Elliott et al. 2015) and the Yorgum Aboriginal Family Counselling
Service in Western Australia (Yorgum Aboriginal Corporation 2015). The Bouverie Centre
works in conjunction with participating Aboriginal Community Cooperatives, Child and Family
Services and Latrobe University. The Yorgum Aboriginal Family Counselling Service is an
Aboriginal community controlled family counselling service that provides specialist assessment
and counselling and links family members, including Aboriginal grandmother groups, to those
who require their services.
In New Zealand, Māori families are known as whānau. Whānau is an extended family group
comprising three to four generations. Traditionally whānau were made up of 20 to 30 people
and were generally self-sufficient in everything except for matters of defence where they called
on hapū (sub-tribe) and iwi (tribe) for support. Whānau cared for their older members (kaumatua
and kuia) and their tamariki (children) collectively; where a child lost a parent or the family
was too large to support a child, the child became known as whangāi and was cared for by the
larger whānau – this is still common practice today (New Zealand Government 2017). For
Māori, whānau is what they say it is. The collective nature of whānau is important to understand
in relation to family policy in New Zealand and will be discussed later in the chapter.
These descriptions highlight a focus of family function rather than structure, where family
can be seen as a continuing system of interrelationships. Choices are made about who people
want to be with and where shared roles, rules and rituals determine who is family, rather than
being a biological group (Boss et al. 2017).
KEY POINT
‘Relational’ view of family

• Families connect and shape one another’s lives and the situations, contexts and processes of
their external environments.
• The family is … ‘whoever the family says it is’ (Wright & Leahey 1987).
Family developmental pathways

Developmental theorists suggest that families and their members go through various stages
with some degree of consistency, each of which is quantitatively and qualitatively different
from adjacent stages. The stages work through a set of transitions from beginning a partnership
or marriage, to parenthood, to having children, seeing them off to school and ultimately to
leaving home, to when a couple enters retirement. These stages may reflect the pathway of a
traditional nuclear family, but they do not capture the multiple transitions and role changes
of contemporary families in today’s society. In many cases, children attend child care from
very early after birth, and both partners are in some form of employment outside the home
(AIFS 2017). Older children leave and return home which has the potential to reduce parental
assets and savings (Maroto 2017). Same-sex couples may take turns enacting caregiver roles,
and older, even retired, people re-enter the workforce several times and often re-partner in
old age. In addition, the beginning of family life may vary according to the couple’s lifestyle
choices; for example, at the stage of cohabitating. Cohabitation either prior to or instead of
marriage, frequently out-of-wedlock childbearing, is one of the most predominant contemporary
trends for couples (Gassman-Pines et al. 2017). Step-parenting before biological parenting is
another feature of today’s families (Sanner & Coleman 2017).

Contemporary family structures:
https://aifs.gov.au/sites/default/files/families-week2016-final-20160517.pdf
Family functions
Although there is considerable diversity among families, in most cases, communities situate
the family at the centre of social life, thereby being a conduit through which society transmits
to individuals its social and cultural norms, roles and responsibilities. It also acts as a com-
municative structure from within, providing a scaffold for interactions, with the goal of bonding
individuals into a cohesive whole with shared attitudes, values and opinions. When this goal
is achieved, the family is able to give voice to needs and preferences, which has the potential
to inform societal policies and processes that can strengthen the community.
According to their developmental stage, members make decisions affecting access to health
care and social services, prevention of illness, preservation of the natural and built environment,
the cultivation of knowledge and strategies to manage the social determinants of their health
and wellbeing. These are the essential elements of a healthy society. However, family life can
also exert a negative influence on these decisions, constraining individuals and circumstances,
precipitating illness, failing to protect its members from harm, or endangering their physical,
psychosocial or cultural environments. Families are therefore the pivot point around which
societies revolve.
Family roles tend to be focused around children’s learning and wellbeing (Elliot 2014). The
ability of children to develop responsive relationships within the family helps to promote
secure attachments, emotional security and trust. These personal attributes contribute to
confidence with relationships external to the family, with appropriate social skills and peer
interactions having associations with positive mental health and ongoing learning outcomes
(Beamish & Saggers 2014).
The family functions listed above represent an ideal. When families are able to provide
these caring functions and encourage protective functions such as family and community
values and linkages, there is a greater likelihood of positive health and wellbeing. This promotes
the development of social cohesion and social capital (Talbot & Verrinder 2014). Thinking of
the family in terms of social capital ultimately means that family members are part of a
community’s sense of community empowerment and competence. Societal norms and standards
are not imposed from outside the family, but take shape through the way families interact
with a range of institutions and processes. This is a ‘relational’ view, where the family context
is seen as integrally influencing family members’ lives, particularly the children (Mullan &
Higgins 2014). Families have changed dramatically in the 21st century in form, function and
relationships. In this era of globalisation and mass migration, most societies, especially in
wealthier countries, are composed of more culturally and linguistically diverse (CALD) families
than in the past. Interactions within and between different cultural groups are influenced by
this diversity, highlighting the concept of connectedness where the perspectives of others are
able to be acknowledged and respected (Elliot 2014).
Nationally and internationally, the world of work has also transformed family roles and
function considerably, as have changing attitudes and policies affecting areas such as parental
leave, care of children and schooling (Beamish & Saggers 2014, Goldscheider et al. 2015, Oláh
et al. 2017). As an example, in both Australia and New Zealand, grandparents are called upon
to provide informal, short- and long-term child care. This is often at great personal cost given
that many are themselves engaged in part-time employment and some have carer responsibilities
for a spouse or older family member. Assuming custody of grandchildren, either formalised
or unofficially, can give way to feelings of grief or loss, disappearance of parenting abilities of
their own children, as well as financial difficulties for child-rearing costs (RCN 2016). Most
grandparents readily accept the responsibility and reciprocity of their grandchildren, recognising
the importance and value of the role, but they may also have few opportunities for social
support for themselves. Despite the pressures, the pleasures and rewards of maintaining con-
nections with grandchildren are appreciated by the grandparents (Horsfall & Dempsey 2016,
Wilkins 2016). Child care and the many ways it affects contemporary family life and work
choices remains a major issue for social policy planners and health care practitioners supporting
parents and their wider families.
Common changes in the formation and stability of families are relationship dissolution and
re-partnering. Changing SDH, such as societal values, the economy and new legislation, create
opportunities and challenges for families and parents, influencing their relationships and
structures (Weston & Qu 2014). However, these have considerable financial and family functioning
ramifications requiring support from a range of health practitioners. Box 7.1 outlines con-
temporary trends affecting family life, health and wellbeing.
In the context of these changes, the challenge for health practitioners is to explore ways of
promoting and supporting family choices, enabling and enhancing health for all family members.
Promoting family health is, at times, a daunting challenge given that it occurs in the face of
BOX 7.1
TRENDS AFFECTING FAMILY LIFE, HEALTH AND WELLBEING
• Most parents are both employed, often working long hours.

• Maternal employment is at an all-time high.
• Fathers take 1–4 weeks’ leave after birth.
• Many jobs have been casualised, leaving parents with job insecurity.
• Casual pay rates are being reduced for weekend work.
• Many parents are underemployed.
• Some parents work from home.
• Many parents are expected to be electronically contactable for work seven days a
week.
• Women tend to work part-time, increasing hours as their children grow.
• Single mothers have low employment rates.
• Many children are in child care by the first year of life.
• Grandparents are undertaking considerable child care.
• Parents may have long absences from home with fly-in-fly-out/drive-in-drive-out
employment or deployment with armed services.
constant change, but it is also fascinating, providing us with constantly evolving understandings
of how families define themselves and how they manage their lives and health across a variety
of situations.
Family nursing scholars have tended to define family and family function according to
three basic theoretical perspectives. The first is Structural Functional Theory, where families
are identified by how they are organised and what practices they undertake to address family
needs and promote family health (Kitchen 2016). Another approach to defining the family is
within Developmental Theory, which views families in terms of a sequence of life cycle stages,
each with developmental tasks such as establishing a marriage, child rearing, children leaving
home and retirement (Rago 2016). The third and most influential theoretical tradition is seen
within the rubric of Family Systems Theory, where the family is seen as an entity in itself,
consisting of subsystems (of siblings, for example). Current and multigenerational reciprocity
in functioning between subsystems (family members) and interactions between members and
the family’s environment affect the family as a whole (Center for Family Systems Theory of
Western New York, Inc. 2015).
The above theoretical approaches can all be used to define the family as a basis for assessing
and categorising family needs; however, each carries a presumption of understanding that
may not be congruent with the primary health care philosophy and socio-ecological framework
for health. The various theories and assessment tools may not consider the relational experiences
of families, of how families see themselves, which will limit a holistic understanding of their
needs (Hartrick Doane & Varcoe 2015). As we have seen, families are a microcosm of adaptive
interactions that are determined by historical events, cultural mores, preferences for spiritual
or lifestyle activities, continuity or discontinuity of relationships, and connections to their
neighbourhood and community. Family forms such as single-parent or blended households,
same-sex couples or intergenerational families often have unique structures, roles and challenges
(AIFS 2017). Because of this variability, the relational view of families is more appropriate in
a primary health care context. The family as a relational entity is inclusive of the family’s perspec-
tives, choices, internal interactions and interactions with the external world in the face of
changes and challenges.
Assessing a family on the basis of a set of guidelines or behavioural norms also sends a
message that there are normative criteria and expectations for interactions and behaviours.
This can be disempowering for families who experience historical or situational disadvantage.
A more authentic approach to working with families is first to discover how the family sees
itself, and then encourage their participation in identifying any changes they seek to make or
reinforce their strategies for maintaining health and preventing illness or injury (Hartrick
Doane & Varcoe 2015, Stanhope et al. 2017). We have discussed family assessment frameworks
and care planning in Chapter 6, which emphasised the partnership approach to working with
families. This is underpinned by the way health practitioners define family and family function,
and work with them to facilitate their self-perceived health and wellness.

• Diverse family structures and child outcomes: https://aifs.gov.au/publications/family-
structure-child-outcomes-and-environmental-mediators/export
• Parental leave support to help parents to take time off to parent a newborn or recently
adopted child: www.humanservices.gov.au/customer/services/centrelink/parental-leave-pay
• Being a grandparent carer: http://raisingchildren.net.au/articles/grownups_grandparent_
carer_nutshell.html
Contemporary issues within distinctive families

As discussed in Chapter 3, within global, national and local communities there are distinctive
and special populations. In this next section of the chapter, we will explore family function
and approaches to health and wellbeing for families within these communities.
Rural and remote families
Families living in rural and remote areas experience greater life satisfaction, including peace,
freedom and sense of community, than those living in urban areas (National Rural Health
Alliance Inc. 2017, Wilkins 2016). However, they are also impacted by a range of adverse SDH.
Poverty through lower incomes or deprivation due to inflated costs of accessing essential goods
and services is highest for families in Australian rural and remote areas with greater un- and
under-employment and higher costs of living being the main contributing factors. Families
who are especially vulnerable include those headed by sole parents and households dependent
on social security incomes. Aboriginal and Torres Strait Islander families have fewer employment
opportunities (National Rural Health Alliance Inc. 2015a).
There is a disproportionate number of people living with chronic illnesses and disabilities,
including cardiovascular disease, diabetes, renal disease and mental health. Management of
these conditions is complex due to geographical distances affecting health service access and
utilisation, reduced health infrastructure and family disruption when members are sent to
distant tertiary centres for specialist treatment (Kay-Lambkin et al. 2014, National Rural Health
Alliance Inc. 2015b).
Community health practitioners working with families in rural and remote areas have
practice challenges related to distances from services and collegial support. An understanding
of families’ needs, priorities, assets and values will guide partnership and interdisciplinary
approaches to relevant plans of care that take into account impacting SDH (University of
Wisconsin, Population Health Institute 2015).
Refugee and migrant families
Planned and humanitarian (refugee) migrant families have created indelible changes to the
evolving national character of Australian and New Zealand community life (Jenkinson et al.
2016). In both countries, the last few decades have seen a steady growth of migrants from
Asian countries and the subcontinent, the UK and other European countries, as well as cross-
migration between the two countries. Refugee families also contribute to the multicultural
vibrancy of the family and society in both countries in spite of the difficulties many of these
groups experience in the resettlement processes. At a societal level, migration from poor to
wealthy countries can create tensions, particularly if public opinion debates focus on the strain
on the host country’s resources from waves of migration. At the same time, there is widespread
discussion over how to meet work skill shortages. Obviously, the two issues need to be resolved
in the same arena, but the challenge remains for health and social service planners to identify
how migrant people can be educated and employed in the areas of greatest need without
disempowering them, or denigrating their lifestyles.
KEY POINT
Migration to a new country can create new opportunities for families but can also be one of
the most stressful periods in a family’s life course.
The transition to a new country is complex for all family members and affects family
functioning in both subtle and overt ways. Pre-migration trauma and current physical and
psychosocial health are significant issues, with many migrant families suffering separation
anxiety from having left behind family members (Baxter 2016, Jenkinson et al. 2016). A
considerable number do not have relatives in their country of relocation so are unable to draw
upon family for support (Baxter 2016). Some families experience a conflict of competing
cultures and new family structures, as young family members straddle traditional family values
and new ways of thinking. Their challenges include being accepted into the mainstream culture
and difficulties with language that affect education and employment (Hugo et al. 2014).
Unemployment and casual work contracts can place further stress on family functioning.
Support from community health practitioners is a major influence on ongoing patterns of
family development and the family’s ability to connect with networks in the wider community.
Working with refugee and migrant families can be challenging. Working from a primary health
care perspective can ensure that the care provided for these families is non-judgemental, culturally
relevant and appropriate for the various needs and preferences of family members. Engaging
with migrant and refugee families in a community context needs to be focused on promoting
inclusiveness, family cohesion and the transmission of strengths, needs and preferences along
their variable developmental pathways and transitions. We explore issues of refugee and migrant
health further in Chapter 9.

• Barriers to formal and informal supports for refugee families: https://aifs.gov.au/
cfca/2017/04/06/barriers-formal-and-informal-supports-refugee-families-australia
• Supporting young people from refugee and migrant backgrounds: Good practice and
ensuring settlement outcomes (Webinar) https://aifs.gov.au/cfca/events/
supporting-young-people-refugee-and-migrant-backgrounds-good-practice-and-measuring
Fly-in Fly-out families

Although each style of employment poses challenges to family life, the increase in the fly-in
fly-out (FIFO) (or drive-in-drive-out) employment pattern has had a major impact on families.
FIFO families are likely to be functioning well, but there are potential negative impacts of this
lifestyle on parents and children (Meredith et al. 2014). For parents, the FIFO arrangement
presents constraints to family life that are similar to those of separated or military families.
Their experiences are often similar to those of non-residential, separated parents in terms of
having to make constant adjustments to the multiple entries and exits into family life. Being
away from family and the return/departure work cycle stages are emotionally and functionally
stressful for the FIFO parent; however, the extended periods of time at home with family can
be a positive aspect of these work arrangements. There can also be difficulties for the parent
left behind, as they need to assume the role of managing the family and renegotiate roles when
the other partner returns (Meredith et al. 2014). A recent Australian study has suggested there
is the possibility of at-home parents punitively disciplining their children, which is a predictor
of ongoing child behavioural and emotional issues (Dittman et al. 2016). Additionally, increased
adolescent stress has been highlighted within FIFO families with less parent connectedness,
which has been shown to lead to greater emotional and behavioural problems and depressive
symptoms. Regular contact through modalities such as mobile phone, email, social media and
SKYPE between families and the non-residential parent have been identified as enabling
strategies for maintaining connectedness with adolescents (Lester et al. 2016). Primary health
care support strategies to assist FIFO families to deal with parenting issues and child and
adolescent behaviours need to be flexible and non-stigmatising as these have been identified
as barriers to sustainable participation. A range of options have been acknowledged by parents
as being acceptable for their needs, including tip sheets, online and face-to-face programs
(Dittman et al. 2016), which enables child and adolescent health nurses and other health
practitioners to work in partnership with this unique population to design and implement
appropriate flexible approaches.

• The effects of fly-in fly-out (FIFO) workforce practices on families (Webinar): https://aifs.gov.au/
cfca/events/effects-fly-fly-out-fifo-workforce-practices-families-australia
• The FIFO families team, which works to connect FIFO families across Australia and New
Zealand. Review their website to see how they assist families and companies engaged in FIFO
activities: http://www.fifofamilies.com.au/
Violence in the family

One of the greatest risks to the health and wellbeing of families is violence among family
members, the infliction of abuse by one family member against another. There are various forms
of family violence, including child-to-parent violence, elder abuse, intrafamilial abuse or intimate
partner violence, the latter of which is the most frequent form of violence in the family. Intimate
partner violence is perpetrated by partners or ex-partners who engage in intimidation, manipulation
and exertion of power that may consist of physical, sexual and psychosocial violence and financial
exploitation (NZMFW 2016). Women and children are disproportionately impacted by family
violence as perpetrators are more likely to be men than women. Periods of increased risk are
during pregnancy and family separation, with children being affected directly or through witnessing
maternal violence (State of Victoria 2016). For many women, the cycle of daily disempowering
conditions becomes the norm for their lives in the ordinary interactions of marriage or partnership.
Family violence can also be perpetrated against men and same-sex partners and can involve a
range of physical and psychosocial impacts.
Across a wide scope of socio-cultural and -economic environments, witnessing family
violence, particularly intimate partner violence, has a profound effect on children’s emotional,
social, behavioural and cognitive developmental health. There are adverse implications prenatally
through to adolescence, which impact on lifelong health and wellbeing trajectories (Howell
et al. 2016). In some families, there is a co-occurrence of family violence and child abuse
(Coulter & Mercado-Crespo 2015), which have both been associated with an increased likelihood
of becoming a perpetrator (CDC 2016a). Box 7.2 describes some of the many forms of family
violence.
BOX 7.2
FORMS OF FAMILY VIOLENCE
• physical injury
• sexual abuse
• emotional or psychological abuse
• verbal abuse
• spiritual abuse
• stalking and intimidation
• social and geographic isolation
• financial abuse
• cruelty to pets
• damage to property (AMA 2016:3)
Aboriginal peoples experience more family violence than non-Aboriginal Australians, with
women and children having the greatest possibility of harm. Aboriginal and migrant/refugee
families are also confronted by unique barriers when seeking culturally relevant support (State
of Victoria 2016). Similarly, Māori women are at greater risk of family violence than non-Māori
women in New Zealand (NZMFW 2016). Within the discussion of family violence, it needs
to be highlighted that the experiences of Indigenous women are complex and include a combina-
tion of factors related to colonisation history, racism and marginalisation as well as their social
and economic vulnerability (AIHW 2017a).
The special issues of migrant and refugee families are also a consideration, where the women
in particular are at risk of family violence due to social isolation and insecurity of their
immigration status. Relocation issues and difficulties with the language of their adopted country
are further considerations needing to be taken into account by community health practitioners
(State of Victoria 2016).

• Rates of violence against women and men in Australia: https://www.anrows.org.au/resources/
media/for-the-media/key-statistics-violence-against-women
• Data summaries family violence in New Zealand: https://library.nzfvc.org.nz/cgi-bin/koha/
opac-detail.pl?biblionumber=5079
Family and domestic violence is more prevalent in rural and remote areas, underpinned
by geographically related family, social and cultural issues which, in turn, are difficult to address
due to the impact of distance on health and social service availability. Unfortunately, partners
tend to remain or repartner with abusive perpetrators as there are financial implications and
less opportunities for housing relocation and local acceptance of the situation for partners
and their children (Campo & Tayton 2015). We explore intimate partner violence in more
detail in Chapter 9.

• Domestic and family violence in rural and remote areas:
• https://aifs.gov.au/cfca/publications/
domestic-and-family-violence-regional-rural-and-remote-communities
There are several practice points for community health nurses and other practitioners
engaged with families experiencing family violence. Effective, non-judgemental and confidential
communication is essential, with interactions often having to be outside the family home.
How to undertake an assessment of family violence is challenging as is accessing evidence-based
pathways to guide practitioners in helping families. Early detection and intervention by com-
munity health practitioners has strong potential for preventing and reducing the current and
intergenerational effects of family violence (Howell et al. 2016). Identifying factors that could
mediate the relationship between family structure and family violence need to be explored
sensitively and integrated into strategy planning in partnership with family members. It is
important that a primary health care approach is used, with a range of interdisciplinary agencies,
to facilitate appropriate, realistic, culturally relevant and sustainable outcomes.
POINT TO PONDER
What visible behaviours might you see in a child health clinic in encountering a mother and child
who are victims of intimate partner abuse?
Goals for healthy families

A comprehensive primary health care approach is able to meet the needs of families at multiple
contact points throughout life. Universal and targeted health and wellbeing support can be
undertaken by a range of interdisciplinary practitioners such as child, adolescent and family
health nurses, nurse practitioners, midwives, social services’ support practitioners and general
GLOBAL
International influence on
government and community, financial,
global employment, migration and health
PUBLIC POLICIES
Commonwealth, state, local
government policies and funding
COMMUNITY
A secure base, social
capital, positive activities, safe
FAMILY
Positive values, close
relationships, community
connectedness
CHILD
Persistent, self-
regulating
temperament,
talents, interests
Figure 7.1 Child, family, community, societal and global assets and protective factors
practitioners (COAG Health Council 2015). Bronfenbrenner (1986) highlighted the interactions,
linkages and impacts between families and other settings such as the community, social networks
and work environments, in addition to public policies which provide a secure base for families
and communities. In turn, the intrafamilial processes such as love and acceptance offer dependable
settings for children for their developmental health and wellbeing (Fig. 7.1). From our earlier
chapters, you can also recall global factors impacting on governments and communities, such
as the influence of conflict and migration.
As primary health care practitioners, it is imperative that we develop strategies for assisting
families that are linked to the wider social and cultural context of their lives. In working with
families, contemporary skills and services need to be developed from a base of research evidence
to inform accessible, adequate and appropriate care. We need to orient our research strategies
to strength-based approaches, considering what works and to provide exemplars of good and
best practice in family care. To this body of evidence we should add our practice-based argu-
ments for preventive care, which is visionary, culturally appropriate and relevant to each
family’s environment. Caring, as the fundamental essence of practitioner practice, mandates
our involvement in social and political processes. This guides us towards working intersectorally
as facilitating partners with families to secure accessible, equitable and empowering health
and wellbeing.
PART 2: HEALTHY CHILDREN
Biological embedding and genetics

Healthy children can be defined on the basis of a wide variety of indicators, some of which
change throughout childhood. Being born healthy to a family with adequate resources and
supports gives a child a head start, whereas coming into an environment of social disadvantage
or experiencing ill health or disability compromises a child’s chance of achieving health and
wellbeing over the life course (AIHW 2015a). The traditional debate on the influences of
nature (genetics) and nurture (environment) on an individual’s growth and development has
been advanced and understood in more depth through the study of epigenetics (Crews et al.
2014). A child’s health depends on a combination of biology, family and environments that
provide opportunities to lead a healthy, nurtured and well-nourished lifestyle with a minimum
of stress. Biological and social processes that change the way genes are expressed with subsequent
variations in cellular-level functioning are termed epigenetic changes. These are associated
with long-term health consequences for children, with early harmful psychosocial environments
and adverse childhood experiences such as low socio-economic status and adverse parenting
having the potential to cause epigenetic change (Box 7.3) (Beach et al. 2016). Epigenetics also
relates to normal antenatal and postnatal development, especially during sensitive developmental
periods and is crucial in sustaining healthy embryonic gene expression along with normal
and abnormal growth and maturation following birth (Lester et al. 2016).
KEY POINTS
• Epigenetic mechanisms change gene expression and the action or activity of the gene,
thereby altering cell function (Lester et al. 2016:31).
• Epigenetics is the mechanism for biological embedding (Demetriou et al. 2015).
BOX 7.3
POTENTIAL OUTCOMES OF ADVERSE CHILDHOOD EXPERIENCES
• unsafe health activities and practices

• chronic diseases
• fewer opportunities to develop capacities to participate in life activities
• premature death
Source: Centers for Disease Control and Prevention (CDC), 2016b. About adverse childhood experiences.
Atlanta, GA, U.S. Department of Health & Human Services.
Epigenetics is the mechanism through which the changes to genetic expression are biologically
embedded in altered physiology across body systems, thereby influencing long-term physical and
psychosocial health outcomes (Berens et al. 2017, Demetriou et al. 2015). Biological embedding
usually refers to experiences with negative influences on long-term and intergenerational health
trajectories, which needs to be taken into account by community health practitioners when
planning interventions and strategies. Working in partnership with families and communities
to reduce the risk of biologically embedding stress in the early years is crucial for enabling
positive lifelong health and wellbeing outcomes (Nist 2016). Additionally, parents who have
experienced this type of stress are at risk of reduced capacity to care for their children which,
in turn, induces compromised family environments (Tallon et al. 2015).
Preconceptual and antenatal care

As identified, epigenetic influences on gene expression can occur with associated biological
embedding during the antenatal period. This highlights the need for healthy and nurturing
physical and psychosocial environments during the preconceptual period in order to optimally
enhance growth and development during pregnancy. Community-based preconception care
facilitates biomedical, behavioural and social health interventions for women and families prior
to conception (Ayalew et al. 2017). In partnership, women, men, and health practitioners can
develop strategies to reduce the risk of an unhealthy pregnancy. Enhancing opportunities for
healthy lifestyles encourages sound fetal growth, especially during the sensitive periods of
development. This is of particular importance as pregnancies may not be diagnosed until well
into the vulnerable period of development between 17 and 56 days after conception (CDC 2015).
Research has shown that in both developing and developed countries, there is a lack of
maternal and family knowledge about preconception care (Ayalew et al. 2017, Stephensen
et al. 2014). As such, there is an important education and advocacy role for community health
practitioners. Working collaboratively with families and communities, three goals of preconception
care can be supported:
■ Screening for individual women and men, family and environmental risks.
■ Developing evidence-based strategies to address the identified risks.
■ Promoting health and providing educational opportunities for women and men, families
and communities (CDC 2015).
Women, men and families have been shown to be amenable to behaviour and lifestyle
change in the preconceptual period, with health practitioners having an important role in
helping to address health inequities relating to SDH such as housing and risk behaviours
including smoking and alcohol consumption (Ayalew et al. 2017).

• Preconception care: Maximising the gains for maternal and child health: www.who.int/
maternal_child_adolescent/documents/preconception_care_policy_brief.pdf?ua=1
Antenatal care by a community health practitioner from the earliest stages of pregnancy
can help pregnant women and their partners identify the need for lifestyle changes and ways
of sustaining those changes throughout the pregnancy and beyond the birth of the child. It
also provides an opportunity to help parents create the emotional foundations for the child’s
life; one of the most important elements of early parenting. High levels of stress and anxiety
in the mother can effect epigenetic influences on the function of the fetal-placental unit,
compromising fetal growth and causing a risk of preterm birth or low birth weight. Further
potential developmental difficulties in the antenatal period include fetal arousal and physiological
changes which are suspected to delay maturation of fetal neurological development, in addition
to structural brain changes with associated adverse effects on the development of the brain.
These issues further affect postnatal growth and development of children through infant
temperament difficulties and compromised physical, emotional and behavioural development
(Newman et al. 2017). There are also adverse impacts on the quality of parenting as antenatal
stress is a strong predictor of postnatal anxiety and depression and reduced maternal attachment
to their children. Knowledge of this early neurological development of the fetus, along with
our understanding of the effects of stress on neural development during the critical periods,
underlines the importance of community health practitioners engaging with women and their
partners to develop culturally appropriate and accessible early and ongoing antenatal care
(Milgrom 2017).
KEY POINT
Antenatal care
Provides an opportunity for parents to create the emotional foundations for a child’s life and to
initiate lifestyle changes.
Maternal attendance at regular antenatal care in the first trimester of pregnancy is associated
with improved maternal health and less medical interventions later in the pregnancy which
support good child health and wellbeing outcomes. It is important for community health
practitioners such as nurses and midwives to identify and engage with vulnerable women and
their partners as they are less likely to present to antenatal services. Women living in low
socio-economic areas, Indigenous women and adolescents have particular issues with attendance
(AIHW 2016a). We need to consider the SDH impacting on their abilities to obtain antenatal
care and apply a primary health care approach when facilitating care, such as provision of
culturally appropriate services which are accessible and affordable with gender-specific health
care practitioners.

The Australian Nurse-Family Partnership Program utilises the skills of home-visiting nurses and
Family Partnership Worker/Aboriginal Community Workers to work with Aboriginal families
during pregnancy to two years of age. This is an adapted program from the evidence-based
Nurse Family Partnership model developed by David Olds in the USA: www.anfpp.com.au/
about-anfpp/origins
Antenatal visits can act as a platform for planning and empowerment for parents through
trusting relationships with health practitioners that will help women develop the skills for
decision making on birthing. Preparation includes gathering information about preferred
place of birth, and the choice of birth attendant or birth companion. A contemporary model
of birthing care is midwife-led continuity of care, where a known and trusted midwife or small
group of known midwives provide stable antenatal, intrapartum and postnatal services. This
is the most common type of maternity care in New Zealand. Health promotion activities such
as promotion of breastfeeding and safe sleeping for babies can also be undertaken (Red Nose
Saving Little Lives 2017, Starship Foundation 2017, WHO 2016). The challenge for community
health nurses, midwives and social support practitioners is to support parents, their families
and communities in the antenatal period in order to establish safe physical and psychosocial
environments for a healthy start to life and lifelong health trajectories.
Resilience and critical pathways to child health

From all the research into early parenting and development, we know that the health of children
reflects the social determinants that impact on their world; the national policy environment
that encourages or discourages the expression of their culture; their genetic make-up, and that
of their parents; their ability to access early, high-quality education; the family’s socio-economic
status, including their place of residence; their access to and preferences for health services;
family harmony, the extent to which healthy behaviours are modelled in the family and com-
munity; and features of the physical environment. There are three critical pathways that
summarise steps towards achieving health for children.
KEY POINT
Critical step one towards healthy children: the health and wellbeing of women.
The first critical step on the pathway to healthy children is to focus on the health and
wellbeing of women and this begins with educating women throughout the world. Women’s
education and empowerment have significant effects on their socio-economic capability, and
that of their children (Robinson-Pant 2016). The pathway to health and wellbeing extends
from women’s preconception health literacy about diet, smoking, exercise and self-esteem, to
political decisions aimed at enhancing structural support for families at all stages from birth
through maturation to death (CDC 2015, Schofield 2015).
KEY POINT
Critical step two towards healthy children: linking child, family and community to build
resilience.
A second critical pathway overlaps the first, in that health promotion activities should
address the links between individual development and competence, and the aspects of society
and the environment that either provide social buffering or social enhancement (Schofield
2015). A socio-ecological view of child health includes attention to the characteristics of the
child, family and community, ensuring that a socially just, inclusive society supports the
development of resilience along the pathway to maturity (Carswell et al. 2017). Children also
need to be seen from very early in life as learners, right from play in the family and earliest
child care to high school and beyond (Britto 2017). Supporting early, high-quality child care
and education are therefore important policy initiatives.
KEY POINT
Critical step three towards healthy children: early childhood education, high-quality child care.
Early childhood education is one of the most important policy government initiatives in
relation to child development, education and productivity. It has universal positive impacts
on all children, developing their capacity and resilience and is a key strategy for addressing
adverse SDH and enhancing educational, health and wellbeing outcomes. Developmentally
appropriate early education in early childhood education and child care in the two years prior
to school is associated with positive lifelong trajectories (O’Connell et al. 2016).
Overall, the goals for child health are to address the major health issues for their wellbeing
in today’s society, including adequate societal investment in the early years, supportive com-
munities that protect and enable child and family health, health literacy for parents and their
children, and continuing evolution of the evidence base for child and family health. The most
optimal circumstance for a healthy child is to be born into a child-friendly, healthy and safe
family and community. To support parents in this endeavour, community health nurses need
to assist families in key developmental areas with activities such as:
■ maintaining culturally appropriate support for parents, children and their communities
(AIHW 2015a), with particular reference to Australian Aboriginal and New Zealand
Māori families
■ encouraging exclusive breastfeeding for six months within their circumstances and
environment (WHO 2017a,b)
■ promoting physical and psychosocial development (CDC 2016b)
■ promoting developmentally appropriate strategies for infant sleeping (NZMOH 2015)
■ prevention of injuries and accidents (Safekids Aotearoa 2015)
■ promotion of up-to-date immunisation for children, parents and caregivers (CDC 2016c)
■ promoting food security, particularly for vulnerable population groups (South
Metropolitan Population Health Unit 2014).
BOX 7.4
PRACTICE PROFILE: SCHOOL NURSE
Hi. My name is Alison and I am a community health nurse working in the high school
setting.
What the role entails:
The role is based on a comprehensive social model of care. This role includes traditional
aspects of general nursing care including: basic emergency care to ill and injured students,
direct hands-on care to students and staff for subacute minor conditions, immunisation,
health screening for vision, hearing and weight, and the management of chronic health
conditions. High school nurses spend a large amount of time with students, teachers and
parents to address student mental health problems. Seventy five per cent of the day usually
involves assessment and care for adolescents who seek help for physiological and
psychosocial reasons. The students may present with a somatic complaint related to
mental health problems that include anxiety and depression. During a typical day, I will
provide information and support to students in the classroom and on a one-on-one basis
on topics such as: sexual health, healthy eating, smoking prevention and cessation and the
prevention of sexually transmitted diseases. I will also provide information to the parents and
teachers on topics including: adolescent development, asthma, medication and anaphylaxis
management, infectious diseases, immunisations and asthma. I work within the health-
promoting school framework and this involves working with internal and external allied health
providers.
How I came to be in the role:
I have a genuine interest in adolescent development and wanted to work in a challenging
position where I could make a difference. I completed a Graduate Diploma in Community
Health and following this I undertook further qualifications in school health. In the beginning I
worked in District schools assessing primary school children. Following this, I accepted the
challenge to develop further skills and knowledge about adolescent development.
BOX 7.4
PRACTICE PROFILE: SCHOOL NURSE—cont’d
What I find most interesting about the role:

The role is complex and interesting because each student and family’s needs are different. I
find it most rewarding to support adolescents who seek help and to promote adolescent
mental health care.
Advice for anyone wanting to become a high school nurse:
Enhance your skills and knowledge about adolescent development by undertaking tertiary
studies in this specialty area. A good starting point is to undertake a Graduate Certificate in
Community Health, specialising in Child and Adolescent Health. Be prepared to critically
analyse situations and have well-developed communication skills that are required to assist
with students, parents and teachers who present with sensitive problems. As this is a highly
sought after position and the process is fiercely competitive, undertake sound research on
the application process and seek help through a mentor to achieve your goal to work in this
area of specialty.
To achieve positive child health in any community, all known risk factors and factors that
develop children’s resilience and capacity to cope with their environments must be acknowledged
and incorporated into a community’s goals and targets for prevention, protection and health
promotion. Resilience is centred on complex interrelationships between risk (adversity) and
protective factors. Adverse physical and psychosocial environments can lead to harmful outcomes
such as substance abuse. However, supportive relationships for children from family, schools,
relatives, friends and community have been shown to reduce the impact of negative influences.
Recent research in New Zealand with children and families has identified common key factors
integral in the development of resilience:
■ Individual factors—positive attitudes, beliefs and aspirations
■ Interpersonal factors—supportive relationships and networks
■ Community/societal factors—responsive government and community services (Carswell
et al. 2017).
Developmentally appropriate literature for children and youth is available to help them
address concerns and worries that may be so concerning they lead to poor resilience. Publications
may have information for anxiety while others interactively guide children and their parents
in cognitive-behavioural approaches which enhance sustainable change (Huebner 2005). Online
technologies are gaining more acceptance by service providers and users. There is a strong
evidence base supporting the use of technology-based strategies for engaging with children
and youth either as primary health care prevention or secondary early intervention support
(Burns 2017).

‘Technology use by, and to support, children and young people—a snapshot of the research
evidence’ (Burns 2017): www.ccyp.wa.gov.au/media/2522/report-technology-use-by-and-to-
suppo-ementary-document-to-the-report-of-the-2016-17-thinker-in-residence-june-2017.pdf
Partnerships between community health practitioners such as nurses and midwives enable
a comprehensive primary health care approach to health and wellbeing strategies for families
and children. The periods of preconception, antenatal, postnatal and the early years are considered
crucial times for engagement with families with significant opportunities available to develop
relevant, empowering and sustainable support strategies with potential for current and lifelong
affirmative outcomes.
Obesity
As children grow, the compound effects of the SDH become more evident, and this is particularly
concerning in relation to the global ‘obesity epidemic’ (Box 7.5). Social and cultural issues,
environment, food industry practices, personal, family and community viewpoints and behaviours,
and government policies demonstrate complex interacting impacts and predisposing foundations
for child obesity (NHMRC 2014). There is evidence of a social gradient effect, which means
that children who are disadvantaged socially, economically and geographically are at increased
risk of becoming overweight (AIHW 2015b). There is an association between SDH such as
food security, the built environment and residence in outer regional and rural areas (AIHW
2017b, Glanz et al. 2016, VicHealth 2016).
Obesity is as much a problem for Australian and New Zealand children as it is throughout
the world, which is a concern, given that obesity is a risk factor for heart disease, type 2
diabetes and some types of cancer (AIHW 2015b). In New Zealand, child obesity increased
by 4% between 2006/7 and 2014/5, with 21% of children aged two to 14 years overweight and
11% in the obese range. Māori and Pacific children are also more likely to be obese than other
New Zealanders, with Pacific children being twice as likely to be obese as Māori (NZMOH
2016, 2017). In 2014/15, around 27% of Australian children aged five to 17 years were overweight
or obese, compared to approximately 26% in 2011/12 (ABS 2017).
Researchers and community health practitioners are collaborating to examine evidence-based
management for overweight and obesity in children. Family-, child- and community-centred
strategies include taxation on high sugar food and beverages, regulation of food marketing
campaigns and health promotion in relation to healthy activities and diets (WHO 2017c). The
role of the community child and school health nurse is paramount in health education, health
promotion, growth monitoring, family assessment and referrals for children and their families.
Working in partnership with parents enables them to understand their child’s growth and
development and has the potential to improve their parental efficacy (CAHS 2014). Undertaking
BOX 7.5
WHY AN OBESITY EPIDEMIC?
• Genetic predisposition
• Excess maternal weight gain
• Social disadvantage, poverty
• Poor nutrition (high salt, sugar diets)
• Poor oral health
• Fast food outlets in neighbourhoods
• Trend towards ‘eating out’
• Unscheduled meal times
• Inadequate physical activity
• No parks, walkable/safe/playable spaces
• Poor parental role-modelling
• Education, knowledge, skills
• Too much ‘screen time’
• Lack of school support
BMI assessment in school settings allows the school health nurse to identify children with
growth that is not within healthy parameters. Once assessments have been made to exclude
growth faltering, supportive positive lifestyle changes for the children and their families can
be undertaken (CAHS 2017).

• Australia’s physical activity and sedentary behaviour guidelines: www.health.gov.au/internet/
main/publishing.nsf/content/health-pubhlth-strateg-phys-act-guidelines
• New Zealand’s physical activity guidelines: http://www.health.govt.nz/our-work/preventative-
health-wellness/physical-activity
It is tempting to blame parents for child overweight and obesity problems, but there is a
web of social and environmental factors that have created obesogenic environments, many of
which affect parents, children and communities. Solutions, therefore, have to be aimed at the
broader circumstances that create unhealthy lifestyles for the entire family.
Child poverty
The health of the world’s children is of concern to everyone who claims global citizenship.
Most children in the world are cared for and loved, but many other children and their families
suffer from poverty. Those living in impoverished circumstances with few resources to mitigate
risks are most vulnerable to ill health (AIHW 2016b). Poverty is an adverse SDH affecting
health inequities and impacting as a stressor on brain development both antenatally and in
the early years. As we have discussed, these epigenetic influences have long-term consequences
to health and wellbeing (AAP Council on Community Pediatrics 2016). Child poverty is also
associated with poor educational achievement and social exclusion, with immediate and long-
term psychosocial outcomes such as unemployment, homelessness and a wide range of negative
physical and psychological outcomes that restrict lifelong potential and capacity building
(Wickham et al. 2016).
In New Zealand and Australia, many children and their families are impoverished, living
in poverty, with Māori, Pacific peoples and Aboriginal and Torres Strait Islander people being
overrepresented. In 2015, 13% of New Zealand children between 0 and 17 years were classified
as living in poverty, with approximately 33% of Māori children and 28% of Pacific children
affected (Simpson et al. 2016). Of note is the increased inequality in New Zealand with child
poverty being viewed as a persistent critical social issue. With increasing cultural and ethnic
diversity, the development of socio-economic disparities are becoming increasingly established,
particularly in relation to minority population groups (Boston 2014).
Australian statistics reflect a 2% increase in child poverty between 2004 and 2014 with
17.4% children currently in poverty. This has not significantly changed since 2012. However,
the poverty rate for children in single-parent families had a large increase from 36.8% to 40.6%
in the same period. More Aboriginal children were in receipt of social support payments and
their families were more likely to retain this form of income than non-Aboriginal families
(Dorsch et al. 2016).
The discourse on poverty and associated social and health issues can frequently highlight
lifestyle and choice as assumptions causing this deprivation. Reflections on the importance of
predetermining SDH by communities, health practitioners and policy planners are necessary
in order that relevant and meaningful primary health care support can be established, along
with development of trust and feelings of mutuality across the life course (Taylor & Guerin
2014). (See Fig. 7.2.)
Goals for healthy children

A partnership approach between community health practitioners and children, their families
and communities is needed to achieve optimal and sustainable child health and wellbeing. A
particular focus is on parental support to enhance their role in providing healthy physical,
social and emotional environments for their children. Fetal development and the early years
are windows of opportunity for cognitive, physical and social-emotional growth along with
primary health care interventions that offer opportunities for positive development with lifelong
benefits (NHMRC 2017).
CRITICAL PATHWAY TO CHILD HEALTH
Family resources, Safe, cohesive, culturally sensitive,

cohesion equitable, supportive,
caring community
Biological Access to Healthy

embedding education adulthood
Figure 7.2 Critical pathway to child health and wellbeing
Conclusion
Reflecting back to Fig. 7.1, we can see how children are nested within and influenced by protective
factors from families, communities, public policies and global factors. A child’s health depends on
the combination of biology, family and the extended environments that provide opportunities to
lead healthy, nurtured and well-nourished lifestyles with a minimum of stress. Community health
practitioners, particularly child and school health nurses and midwives are able to provide a base of
expertise using primary health care principles to advocate against social and structural inequalities
affecting the health and wellbeing of children, families and their communities. Understanding the
impacts and interactions between families, communities, public policies and global factors allows
nurses and midwives to guide opportunities for accessible and culturally appropriate support. Taking
into account both enhancing and adverse SDH, they are able to undertake interdisciplinary approaches
within their practice and work collaboratively with children, parents and communities to encourage
health literacy and their participation in health decisions that will sustain lifelong wellbeing.
CASE
STUDY Family life for the Smiths and Masons
7a:
Returning to our families, we see that Rebecca and Huia attended child health clinics in their
respective communities for their children’s annual check-ups. As Rebecca outlined relatively minor
child health issues, the nurse conducted an in-depth assessment of some of the special family issues
facing the family—in particular those related to FIFO work, the father–child relationships, father role
identity, the marital relationship, couples’ counselling, the need for extended family support or
appropriate substitute support systems. These are sensitive issues, so communication strategies were
foremost in the nurse’s approach when working with Rebecca.
Huia and Jason have both been able to attend their clinic appointment due to extended clinic hours
for working parents. The Well child/Tamariki Ora nurse performing Jake’s four-year-old before-school
check had some helpful suggestions for parenting strategies and the couple plans to implement some
of these strategies, work together as a team and be consistent in their parenting.
In the mining community the occupational health nurse conducted a company-endorsed interactive
family training session for all workers, where issues were addressed relating to housing,
transportation, community support for transient families and mining management support for families.
■ Family life is multidimensional and consists of the family system, sibling subsystems and extended
kinship networks.
■ Family health and wellbeing is a product of individual and family interactions and the way family
members interact with the external world, including the immediate community and society.
■ The primary goal for empowering family members is to work in partnership with them to undertake
collaborative planning to help them develop individual, family and community capacity and choices
for family health and wellbeing.
■ It is important for nurses and other health practitioners to be aware of family issues such as marital
separation, family violence, family caregiving, work–life issues and the intersection of gender,
culture and family histories in affecting family change.
■ The environments within which families interact influence their health and wellbeing, with urban and
rural families experiencing differential levels of vulnerability.
■ Nursing interventions should be based on research evidence as well as careful assessment of the
family and the circumstances and events surrounding them.
1 Prepare a genogram and ecomap of the Smith and Mason families.

2 What family goals would you establish for each family to ensure health and wellbeing for all family members?
3 How would you approach family assessment if you were conducting a home visit?
4 Would you alert the school nurse of any problems with the family? Why or Why not?
5 What actions would you take if family violence was disclosed during the family interview with either of the
mothers?
6 During the interactive sessions with the miners how would you address family relationship issues and conflict
resolution?
7 What resources would you use to ensure you had access to current research evidence for your actions?
CASE
STUDY Child health for the Smith and Mason families
7b:
With Colin absent from the home so much, Rebecca is left to cope with the children’s issues,
especially Gemma’s eczema, which she thinks may be linked to stress as well as an unknown allergy.
She is also concerned about Emily’s difficulties at school and hesitates to involve Colin too much in
her approach to seeking help for her. The school nurse has been to see Rebecca about Emily to try
to help her work out some behavioural strategies to help her.
In Pakakura Jake has been admitted to hospital again for an acute asthma attack, which has meant
that Huia has had to take time off work and arrange for someone else to care for the other children as
Jason is away. Huia’s job is under threat because of her frequent absences due to Jake’s asthma.
■ The most important investment governments can make is in supporting child and family health.
■ The SDH have a profound impact on the health of children and families.
■ One of the most significant threats to child health is poverty.
■ Healthy pregnancy and antenatal care establish a platform for good health in childhood.
■ Exclusive breastfeeding for six months is the ideal for nourishing infants.
■ Family lifestyle and parenting practices have a profound impact on child health.
■ Community health care practice should be evidence based and connected to child and family
outcomes.
1 What are the main priorities you would identify in a first home visit with Rebecca or Huia?
2 How would you assess the Smith and Mason household environments for risks and protective factors for their
children?
3 How would your knowledge of Jason and Colin’s employment and Huia’s role as a teacher change your
approach to assessing their needs and that of their children?
4 Which support services in Huia and Rebecca’s home communities would be most likely to provide support
for their needs and that of their family?
5 What are the most visible effects of the SDH on both families?
6 Explain how you would ensure that both families had sufficient health literacy for their parenting
responsibilities.
7 Describe three aspects of their school or recreational setting that would be crucial to providing family support.
For each, explain the importance of the setting in promoting child health and its link to primary health care
principles.
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CHAPTER 8
Transitions to adulthood
and beyond
INTRODUCTION
Life is composed of a series of transitions from before birth through to death. Many people
manage these transitions with ease, using each phase of life as a building block to the next.
But for some people, each phase presents challenges that at times may seem insurmountable.
Supporting people to manage these transitions through life in a way that promotes health and
wellbeing, and builds and sustains resilience is an important role for the health professional.
In Chapter 7 we examined the importance of primary health care practice with children and
families in the early years and in Chapter 8 we expand this to explore the experiences of
adolescents, adults and older adults as they transition through life. During adolescence, social
determinants outside the family home become a greater influence on health and wellbeing
than in childhood. Peers, media, education and early workplace experiences become prominent.
As the individual transitions from adolescence to adulthood and on to older adulthood, com-
munity and structural determinants continue to remain influential, employment becomes a
major influence in adulthood, with family growing in importance as one ages (Patton et al.
2017). Fig. 8.1 captures the changing proximal social determinants of health across the life
OBJECTIVES
1 identify the main factors contributing to 5 using a primary health care and social
healthy adolescence determinants framework, develop com-
2 explain the primary influences on health munity goals and strategies for sustaining
and wellness in adulthood adolescent, adult and older adult health
and wellbeing within a range of family
3 discuss the critical pathways to healthy
structures.
ageing
4 explore the role of technology in support-
ing transitions across the life course
course and provides the basis for exploring these life transitions throughout the chapter. This
developmental approach enables us to consider the importance of promoting health and wellness
at each stage along the life course from before birth to death. It is important to be mindful
that although development is generally linear, biological, social and cultural factors such as
intergenerational relationships will influence individual and family pathways through life. We
have avoided a focus on the specifics surrounding health status of each group but provide
pointers for where you can access the most up-to-date information on this for each population
group. Throughout the chapter we outline some of the fundamental principles of working
across the life course.
Media
Peers
Employment
Education
Family of origin
Family of one’s own
Childhood Adolescence Adulthood Old age

(10–24 years)
Figure 8.1 Changing proximal social determinants of health across the life course
Source: Patton, G.C. et al., 2017. Our future: A Lancet commission on adolescent health and wellbeing.
The Lancet, 387(10036).
PART ONE: HEALTHY ADOLESCENCE
Context
Adolescents—that is, young people in their teenage years—play a vital role in community life,
contributing energy and vibrancy to the population through the spirit of youth and a promise
for the future. In most cases, adolescents are in good health and their health and wellbeing is
focused on school and the developmental tasks and transitions of adolescence. It is also during
adolescence that we physically start to age (Kloep et al. 2016), however it is the social sphere
within which adolescents interact that is predominant. It is the pivot around which their lives
and their identity revolves. Although the adolescent journey is sometimes described as fraught
with confusion, conflict and risk, an alternative view sees adolescents ‘at promise’ instead of
‘at risk’, and we address the pathway from risk to promise and, ultimately, to resilience. Adolescence
is the most dramatic, the most interesting and the most tortuous stage on the journey to
adulthood as significant habits of mind and action are formed. A strengths-based approach
to supporting adolescents in all of the contexts in which they stretch towards the future and
across all of the social determinants of their lives is essential. Our definition of adolescence
stretches from those on the cusp of adolescence, aged 10–13, to those beyond the teenage
years, aged 19–24. From a professional perspective, understanding which risks and assets are
modifiable in the world that these adolescents inhabit can be used to plan interventions that
will promote and sustain health in this age group. Evaluating the health practitioner’s role in
the journey towards empowerment and good citizenship is fundamental to community health
promotion.
Social determinants of adolescent health, risk-taking, resilience,

and decision making
The social ecology of adolescent development can be seen as a matrix of interrelated factors
that influence adolescents’ health and wellbeing. As with other population groups, the social
determinants of their lives present strengths, weaknesses, threats and opportunities. The main
strength of adolescents is that most tend to be physically well. The weaknesses or risks inherent
in adolescent life generally revolve around the fact that, because they are in the formative
stages of development, most adolescents are not yet able to take control of their lives or
health-related decisions. But the strongest determinants of adolescent health are not these
individual factors, but the structural determinants that provide them with education, employment
and the equitable living conditions that will allow them to develop their full potential in adult
life (Cockerham et al. 2017, Hassan et al. 2015). To provide a capacity-building transition to
adulthood, opportunities to participate in education and the workforce must also be accompanied
by safe and supportive families, schools, peers and communities. These are the structural
conditions within which young people are exposed to strengths or compromises to health
during transitions through school, from education to work, from family dependence to
independence, autonomy, partnering and parenthood, and ultimately to responsible citizenship
(Kloep et al. 2016).
KEY POINT
Adolescent transitions include:

• primary to secondary school to higher education
• education to workforce
• family to self-responsibility for health
• family living to autonomy, partnering, parenthood
• growing towards responsible citizenship.
According to life course theorists, there are three ways the SDH affect young people (Viner
et al. 2012). First, the ‘latent effects’ that determine early development occur when a child’s
biological mechanisms are preset in utero. Second, there are experiences that determine
health and wellbeing over the life trajectory, called the ‘pathway effects’. Third, there are
‘cumulative effects’ from the advantages or disadvantages that a person experiences from
exposure to unfavourable environments over time (Viner et al. 2012). Years ago the prevail-
ing view was that the young brain was fully developed in childhood, yet research evidence
now shows that the brain architecture of both children and adolescents is malleable, and
social, emotional and neural development takes place until the early twenties (Kvalsvig
et al. 2015). Understanding the second ‘sensitive period’ in a young person’s development
has important implications for health promotion, in that some of the negative effects of
structural factors in the early years, such as poverty, unemployment, racism, poor housing,
cultural or gender-based inequities, or anti-social behaviours at school, can be modified in
adolescence, predominantly by strong family and community support (DeMichelis 2016, Viner
et al. 2012). As health professionals, this leads us to renewed optimism for the success of
family- and school-based interventions that will help young people navigate their transitions
successfully.
Contemporary health promotion strategies are also informed by understanding the distinctions
between early, middle and late adolescence. Early adolescence involves entering puberty,
beginning the process of sexual maturation and shifting focus from family to friends. Early
adolescents (age 13–14) ask ‘Am I normal?’ Middle adolescence sees physical development
continue, with increasing reliance on friends and peer groups. This stage is accompanied by
the risk of adopting peer-influenced behaviours such as experimenting with drugs and alcohol.
Middle adolescents (15–16) ask ‘Who am I?’ In late adolescence, physical changes have levelled
off and cognitive development continues, with adult thinking becoming closer to maturity
(Patton et al. 2017). Late adolescents (age 17–18) ask ‘What is my place in the world?’ Under-
standing the subtle differences between the various stages helps frame adult interactions with
adolescents in slightly different ways.
KEY POINT
Stages of adolescence
• Early—puberty, sexual maturation, friendships
• Middle—physical development, reliance on friends, peer groups
• Late—cognitive development, adult thinking
Adolescence has traditionally been a period characterised by risk-taking behaviours (including

alcohol and drug use, unprotected sex, smoking and taking part in extreme activities), as
young people explore and push their boundaries and seek to understand their place in society.
Box 8.1 lists some of the risks and challenges facing young people in Australia and New
Zealand. But these activities are subscribed to by adults at least as frequently and in some
cases more frequently than adolescents (Kloep 2016). By characterising adolescents as ‘at risk’
and spending substantial resources on finding out why adolescents may engage in risky
behaviours, we paint a highly negative picture of adolescents and potentially lose the opportunity
to investigate why people of any age take risks, and understand the potential of young people
(Kloep et al. 2016). By understanding the potential of young people and what makes them
BOX 8.1
RISKS AND CHALLENGES FACING YOUNG PEOPLE
• Alcohol use
• Substance use
• Mental health issues
• Suicide
• Smoking
• Unprotected sex
• Bullying including cyber-bullying
• Overweight and obesity
• Lack of exercise
• Poor nutrition
• Eating disorders
• Injuries
resilient, we can then develop strategies that will help support young people as they transition
to adulthood.
In this book, we draw on DeMichelis (2016) and Kvalsvig et al. (2015) and describe resilience
as a process of complex interpersonal, institutional and political interactions enabling positive
adaptation within the context of adversity. Young people are able to achieve and maintain
wellbeing when they are supported by their families and friends, are able to maintain constructive
partnerships with their schools and workplaces, and experience equitable political and social
systems (DeMichelis 2016). The contexts within which young people live, work and play,
alongside the behaviours that establish health and wellbeing, are the same as the context and
behaviours that support the development of resilience (Kvalsvig et al. 2015). This definition
of resilience fits with our socio-ecological approach to community health that draws on the
interactions between individuals, families, communities, society and the global environment
to achieve wellness. We can support the development of young people’s resilience, and strengthen
their coping mechanisms, by helping them to build strong interpersonal, cultural, institutional,
social and political relationships (DeMichelis 2016). Strong, positive relationships and role
models will help guide young people to find their place in society and assist them in identifying
and managing risks and challenges to their health and wellbeing (Patton et al. 2017).

• Adolescent health status in New Zealand: www.fmhs.auckland.ac.nz/en/faculty/adolescent-
health-research-group/publications-and-reports.html
• The latest statistics on youth health in Australia: https://www.aihw.gov.au/reports-statistics/
population-groups/children-youth/about
• Global information on youth health: www.who.int/topics/adolescent_health/en/
• The Global Strategy for Women’s, Children’s and Adolescent’s Health 2016–2030: http://www.
who.int/life-course/partners/global-strategy/globalstrategyreport2016-2030-lowres.
pdf?ua=1&ua=1
• Training courses for health professionals working with young people (including free online
courses): www.werryworkforce.org/
• Resources for health professionals and young people: www.rch.org.au/cah/ Supporting young
people to achieve their potential – Goals for adolescent health
The major health goals for adolescents include mental and emotional health and maturity,
good physical health and safety, academic engagement, minimisation of conditions that create
risks to health and wellbeing, sustainable lifestyle habits in healthy environments, adolescent-
appropriate nursing and health services, and empowering structures and processes for successive
generations. Addressing these goals can help adolescents move from risk to promise and all
are embedded in the ecological framework outlined in Fig. 8.2 (Blum et al. 2012).
More recent work by Patton et al. (2017) shows a simplified version of the ecological model
to capture more clearly how development across the lifespan from preconception to adulthood
impacts on adolescent health needs, risks and problems, how actions are required to address
Macro-level factors
Neighbourhood
Family
School
Goals for
healthy adolescence
• Academically engaged
• Emotionally and physically safe
• Positive sense of self or self-efficacy
• Life and decision-making skills
• Physically and mentally
healthy
Safety Supports
Connections Expectations
Opportunities
Expectations Monitoring
Community and supports Economic
assets resources
Connectedness Behavioural
Gender regulation Community
norms risks
Natural Norms or
events Safety Cultural beliefs values
or attitudes
Collective
Political socialisation National
events priorities
Economic Historical
forces events
Life course
Preconception Perinatal Infant Child Early adolescent Adolescent Adult Old age
Figure 8.2 The ecological framework for adolescent health
Source: Blum, R. et al., 2012. Adolescent health in the 21st century. The Lancet, 379(9826).
these at the structural, community and health service levels and how these factors lead into
adulthood and onto the next generation – see Fig. 8.3.
One of the most important things the health practitioner can do when working with
adolescents is to develop the attitudes, knowledge and skills that foster engagement with young
people while maintaining engagement and interaction with the family (Patton et al. 2017).
The single most important predictor of resilience in children and young people is access to at
least one stable, caring and supportive relationship with an adult in their life (National Scientific
Council on the Developing Child 2015). Health practitioners need to consider the ways they
can work intersectorally to support and enable young people to engage: with their parents or
caregivers; with their communities through partnership with adults; in training and mentorship,
and in creating new structures and processes that facilitate young people’s involvement in
decision making (Patton et al. 2017). Digital media and technology provide exponential
opportunities for engagement and service delivery that matches young people’s needs and
Needs
Health Health
determinants risks
Health
problems
Preconception Fetal Early child Adolescence

health development development Adulthood
Health
services
Next generation
Structural Community
actions actions
Actions
Figure 8.3 Conceptual framework for defining health needs and actions in adolescents and
young adults
Source: Patton, G.C. et al., 2017. Our future: A Lancet commission on adolescent health and wellbeing.
The Lancet, 387 (10036), 2431.
BOX 8.2
Suicide—Jessica’s story
www.youtube.com/watch?v=WdC3nhxA66U
digital savvy. Young people not only use technology, they are dependent on it. It is up to us
as health practitioners to identify and use these opportunities to develop new models of care
based around these technologies. Talking and working with young people in a way that enables
us to co-design these new models will ensure we draw on their expertise of what they need
as well as facilitate young people’s need to build social capital through engagement with their
communities, peers and health providers. Examples such as SPARX (www.sparx.org.nz/) that
uses online gaming and cognitive behavioural therapy to help adolescents experiencing mild
to moderate depression show how effective this approach can be (Malatest International 2016a).
Helping adolescents realise their right to sustainable health and wellbeing will deliver enormous
social, economic, demographic and health benefits globally (United Nations 2016).
Good assessment is the key to understanding young people and provides an opportunity
to intervene where needed—particularly with young people who are engaged in risky behaviour
or who may be experiencing mental health issues. For example, the risk of suicide among
young people experiencing depression is high and it is important to recognise the warning
signs of an impending suicide attempt. Box 8.2 has a link to a video featuring a young Australian
Contextual factors
1. Cultural factors Suicidal behaviour
2. Institutional settings Suicide, suicide attempts, deliberate
3. Media climate self-harm, suicidal ideation
4. Physical environment
Mental health problems

(e.g. mood disorders, substance use disorders,
antisocial behaviour/disorders, anxiety disorders,
psychotic disorders, eating disorders)
Y
Individual Exposure to Family factors Life events Social supports Socio-economic Cultural factors Macrosocial/
factors trauma e.g. parental e.g. marital/legal/ e.g. social factors e.g. extent of economic factors
e.g. personality, e.g. family separation, financial problems, isolation, living e.g. income, acculturation, e.g. economic
genes violence, mental illness unemployment, alone education, integration, restructuring,
child abuse, discrimination housing, autonomy, birth, divorce,
bullying mobility language, unemployment
identity rates
Y Y Y Y Y Y Y Y
Biological Æ Social continuum
Y Denotes New Zealand evidence is available
Figure 8.4 Pathways to self-harm
Source: Ministry of Health, 2015. Suicide Prevention Toolkit for District Health Boards. Wellington:
Ministry of Health, p. 18.
named ‘Jessica’, aged 19, and follows her non-fatal attempt to take her own life and the factors
leading up to this. Pathways to self-harm are outlined below in Fig. 8.4. Lesbian, gay, bisexual
and transgender/transsexual/intersex/takatapu/fa’afine (LGBTI) young people are at particular
risk of bullying, verbal and physical abuse, and challenges to their self-esteem due to their
sexual orientation (Mueller et al. 2015) and particular attention must be paid to supporting
young people who may identify as LGBTI or be questioning.

Information and support for LGBTI and questioning young people.
• Australia: https://minus18.org.au/
• New Zealand (Rainbow Youth): www.ry.org.nz/
Undertaking a HEEADSSS (Home, Education/Employment, Eating, Activities, Drugs and

Alcohol, Sexuality, Suicide and Depression, Safety) assessment is one of the first steps in
working with young people (Klein et al. 2014, see Appendix C). The assessment gathers
information on the most common influences on an adolescent’s life at home, school and in
other social environments. The tool can help nurses and other health practitioners gain a
multidimensional, yet individual, perspective of adolescent life. The assessment data can be
used to foster closer engagement with their world, identify strengths, and ultimately, strategies
to help protect and nurture them through uncharted pathways. Assessment can also be col-
laborative, aimed at helping inform a whole-of-community approach. Teachers, administrators,
parents, community members and others can encourage constructive opportunities and validate
the adolescent’s ability for decision making.
Two of the most important environments influencing adolescent health are the school and
social environment. Schools play a privileged and strategic role in the development of adolescent
identity and competence and in helping young people make positive choices for healthy
behaviours (McCluskey 2015). School-based health services provide interventions designed
specifically for young people, providing a safe, supportive and accessible environment for
young people to seek help. McCluskey’s (2015) practice framework for school nurses shows
that with the right time, professional development, clinic access and support, school nurses
can have substantial input into improving mental and physical health care for young people.
In New Zealand, Malatest International (2016b) has demonstrated that enhanced primary
mental health services for young people have contributed to improvements in the quality,
safety and experience of young people seeking help. Unfortunately, the variable distribution
and role of school nurses in both countries means some young people continue to miss out.
Advocating for enhanced school and locality-based youth health services—particularly in
rural, remote and socio-economically deprived areas—is an important role for all health
practitioners.

• Information on school based health services (New Zealand): www.health.govt.nz/our-work/
mental-health-and-addictions/youth-mental-health-project/youth-mental-health-project-
initiatives/expanded-school-based-health-services-making-difference/
school-based-health-services-case-studies
• School based health services (Western Australia): http://healthywa.wa.gov.au/Articles/S_T/
School-health-services
• New Zealand School Nurses: https://www.nzschoolnurses.org.nz/
• National School Nursing Professional Practice Standards (Australia): http://anmf.org.au/pages/
school-nursing-standards
Nurses and other health practitioners can support parents and caregivers by providing a
bridge between home, school and the community. Although the primary community for most
adolescents is the school, the family environment and family support behaviours are critical
in helping adolescents through behaviour changes and identity formation, especially in relation
to alcohol and substance use, sexual identity and coping with bullying (Patton et al. 2017).
Because many parents and caregivers do not have time to be closely engaged with the school
or social environment, it is important that teachers, nurses and other health and support
practitioners take advantage of every encounter, to assess how they are coping with parenting,
to keep the channels of communication open and to maintain non-judgemental support and
a positive attitude. This can be approached by communicating understanding of the complexity
of adolescent issues, and of the importance of building family resilience and a strong sense of
place. Resilient children and young people surrounded by resilient families have a greater
chance of escaping social and economic disadvantage, lower risks of psychological problems
as an adult, and smoother transitions along the life course (Patton et al. 2017, United
Nations 2016).
PART TWO: HEALTHY ADULTHOOD
Context
Adulthood is the time of a person’s life when the intersecting influences of biology, the environ-
ment and lifestyle are most apparent. The years between age 20 to around 50 are concerned
with finding one’s place in the family, work environment and society, and reconciling the needs
of various roles and expectations. By the time people have become adults, their innate pre-
dispositions combine with their past and current lifestyles and a variety of life circumstances
to establish relatively stable patterns for the future. For most, the prospect for a long life free
of the burden of illness and disability is good. However, other people achieve less than optimal
health because of genetic predisposition, the social determinants of their childhood, or current
circumstances. Fortunately for most adults in Australia and New Zealand, the environment
provides considerable potential for overcoming vulnerability to ill health and achieving high
levels of health and wellbeing. Unlike some other parts of the world, most people in this part
of the world have access to nutritious food, clean air and water, good housing, education and
employment possibilities, scientific and technological expertise, relatively low levels of com-
munity violence, and accessible and appropriate health care and social support services.
Adult health and wellbeing also reflect the culmination of the policy environments that
have circumscribed people’s lives and constrained or facilitated their choices for health and
lifestyles. These include a wide range of policies; for example, those governing taxes on alcohol
or tobacco, or workplace policies permitting sick leave when workers are ill, or family leave
when children need to be cared for. Besides these influences, health in adult life is also a
product of family structure, ethnicity, education, employment and place of residence. How an
individual has learned to cope with any of these influences, as well as historical illness, injury,
disabling conditions or various stressors may be indicative of whether they are able to cope
with unexpected events in adult life. Stress and coping are therefore central elements in sustaining
health in adult life. Coping strategies also indicate how well an adult is able to continue on
the pathway to older age.
The environments surrounding adult life are critical factors in determining their health.
This is particularly evident in the effects of the social environment on health and quality of
life. A growing body of research linking health to socio-economic disparities, cultural and
economic factors sets the stage for greater knowledge of adult health than was available in the
past. Some aspects of the environment are a cause for urgent concern, with the health effects
of climate change and other global changes having a major effect on the way we live our lives
in the 21st century. Contemporary lifestyles are also influenced by new developments in
research and technology. Unique programs of research are forging ahead in informing health
promotion and disease treatments, particularly since the mapping of the human genome and
the development of stem cell therapies to respond to errant genes and their expression in the
human body. This ‘translational’ body of research knowledge is an important part of the toolkit
for guiding adults towards better health.
KEY POINT
• The most common causes of adult mortality are cancer, heart disease and cerebrovascular
disease (stroke).
• The most common causes of morbidity are cancer, cardiovascular disease and mental illness.

Information on causes of death and disability in adulthood:
• Australia: The Australian Institute of Health and Welfare
www.aihw.gov.au/home/
www.aihw.gov.au/australias-health-publications/
• New Zealand: The Ministry of Health
www.health.govt.nz/
www.health.govt.nz/nz-health-statistics/national-collections-and-surveys/surveys/current-
recent-surveys/new-zealand-health-survey?mega=Health%20statistics&title=NZ%20
Health%20Survey
Priorities for health interventions are based on data indicating the major causes of morbidity
and mortality. Long-term or chronic conditions such as type 2 diabetes or cardiovascular
disease are the most urgent concern for Australian and New Zealand adults. The global picture
of health is similar and shows that chronic diseases are now the most significant cause of
mortality worldwide, causing 68% of deaths (WHO 2016a). Many of these are linked to modifiable
lifestyle factors such as exercise and nutrition. Addressing risk factors for chronic disease such
as smoking, inactivity, obesity and overweight, and poor diet are an important focus for health
practitioners.
For people who are obese or who have been diagnosed with chronic illnesses, nutrition
counselling is often a first step in making lifestyle improvements. Advice needs to be tailored
to individual needs, as a one-size-fits-all prescription for healthy eating may present barriers
for certain individuals. Many people live in circumstances that prevent them from adopting
healthy lifestyle practices that may be appropriate for someone else. Some of these circumstances
that act as barriers to change include pregnancy, living in a situation where they have little
personal support or are subjected to ridicule from family members or close friends, or having
co-morbidities. Any of the chronic conditions may change a person’s appetite and attitude to
food as well as their access to preferred products. Some diabetics, for example, have difficulty
with the constant food vigilance that can be involved in managing their condition. They
may feel uncomfortable eating with others, or have variable treatment regimes. Many people
live alone and those with chronic disease, limited finances, functional difficulties or who
suffer from loneliness, anxiety or depression may simply fail to take the time to prepare
appropriate meals. Ensuring healthy foods are readily available in the neighbourhood is also
essential for enabling those needing to make dietary changes to do so. Healthy foods need
to be affordable and accessible and it may be necessary to lobby locally and nationally to
make this happen. Encouraging schools and hospitals to sell only healthy foods in vending
machines, and supporting supermarkets to replace sugar-laden foods at the checkout with
fruits and healthy snacks are simple steps that can be easily taken. Sugar has now been identi-
fied as one of the most dangerous food items for health and the World Health Organization
is encouraging governments to take steps to encourage manufacturers to reduce the sugar
content of their food and improve labelling for consumers (WHO 2014). Health practition-
ers can check to ensure their government is following this advice and support efforts to
improve nutrition labelling and decreases in sugar content. These interventions help address
the obesogenic environment—that is, those environments that are more likely to promote
weight gain and obesity (Mackenbach et al. 2014). Interventions that focus on the whole
family can also be particularly effective in supporting people to make changes to their diet
(Funaki-Tahifote et al. 2016).
KEY POINT
Nutrition counselling needs to be tailored to meet individual needs. Cultural imperatives, the
social context of eating and motivation influence the ability of individuals to make the dietary
changes they need to maintain good health.
Social, cultural and environmental factors are important in promoting lifestyle changes,
especially those intended to increase exercise and other activities. Organised physical activities
at the neighbourhood level can provide opportunities to develop supportive social networks
as well as helping manage chronic conditions, or preventing further deterioration once a
person has experienced an acute episode such as a cardiac event. The environmental determinants
for healthy lifestyles include safe walkways, cycleways and well-lit streets to allow working
people to exercise and socialise after working hours. Intersectoral planning by engineering,
transportation, recreation, health and education professionals can help make neighbourhoods
conducive to activities. Structured group exercise programs tend to create a feeling of wellbeing
that can enhance value, belongingness and attachment to others, which builds social capital.
At a personal level, exercise improves muscular and cardiorespiratory fitness, improves bone
and functional health, reduces the risk of hypertension, cardiovascular disease, stroke, diabetes,
cancer and depression, and reduces the risk of falls (WHO 2017). For this reason, ‘sweat’ has
been called the natural antidepressant.
The relationship between health and place is an important element of the social context
that creates lifestyle risks. Urban living has risks from crime, neighbourhood violence, various
air, water and food pollutants, motor vehicles and a proliferation of fast-food outlets. However,
compared to urban dwellers, people living in regional or rural areas, many of whom are
Indigenous, are at significantly higher risk of chronic illness and mental health issues (particularly
depression) due to geographical isolation, lack of support, poor access to primary care services,
low levels of health literacy, and high rates of smoking and alcohol consumption (Hickman
2015, Sav et al. 2015).

Rural health
• Australia: www.aihw.gov.au/reports/rural-health/rural-remote-health/contents/rural-health
• New Zealand: www.health.govt.nz/our-work/populations/rural-health
Health promotion strategies that revolve around health literacy and empowering people to
take control over their lifestyles are important, but these are often hampered by a lack of access
to resources. Unlike urban dwellers many rural people do not have opportunities for group
sports or other activities, and many regional towns and rural areas do not have access to green
parks, exercise playgrounds for children or safe walking trails close to schools. When they
need assistance, there are few specialists available to treat chronic illnesses or to offer them
preventative programs. In addition to supportive services and programs, the ‘digital divide’
between those with and without access to internet information can worsen inequities by prevent-
ing the level of education enjoyed by people in the city.
Work
Work is one of the main activities of adults and, where working conditions and culture are
conducive, is generally good for health and wellbeing (Australasian Faculty of Occupational
and Environmental Medicine 2011, Hagler et al. 2016). Work contributes to individual autonomy,
personal development, empowerment, and feelings of satisfaction in the ability to support
one’s family and to help others (Hagler et al. 2016). Work also contributes to mental wellbeing
and improved quality of life (Jakobsen 2016). Conversely, long-term work absence, work
disability, unemployment, unsafe working environments and workplace incivility can have a
negative impact on health and wellbeing, contributing to stress, inequalities and poor outcomes
(Australasian Faculty of Occupational and Environmental Medicine 2011).
Workplace stressors affect members of cultural and socio-economic groups differently,

but in general, workplace stress is becoming more prevalent across all categories of workers.
This is linked to changing social conditions. Life in the twenty-first century has become
fast-paced for many adults, with resounding effects on the family, the workplace and society.
For example, labour market policies in some places have resulted in growing numbers of
people in ‘precarious’ work. Precarious work is characterised by a fundamental uncertainty
in conditions, duration and pay, and may include work described as seasonal, casual, sea-
sonal contracting or zero hours contracts (Wilson 2014). One of the major consequences
of precarious work is the lack of involvement of the precarious worker in the lives of their
children (Wilson 2014) raising concerns about the ability of these families to grow resil-
ient children and families. Some also believe precarious work can disturb the transition
to adulthood due to the longer dependence of the adolescent on the family for support
(Chan & Tweedie 2015).
The ‘busyness’ of lifestyles and changes in workplace demands, such as precarious work,
fly-in fly-out (FIFO) jobs, high workloads and employer expectations regarding digital media
and the ability to be able to access work ‘anywhere, anytime’ are major sources of stress (de
Vente et al. 2015, Langdon et al. 2016). There are clear links between stress and physical and
psychosocial outcomes with those experiencing stress in the workplace at greater risk of
depression, cardiovascular disease, diabetes and musculoskeletal issues (Beck et al. 2015).
Workplace policies themselves can add to or alleviate stress. Some, but not all, countries have
flexible workplace policies, where employees can negotiate work hours that are more suitable
to their lifestyle. Whether this is working around children and family or for personal satisfaction,
flexibility can help improve work–life balance. However, when flexibility in the workplace
results in precarious work or a lack of income security, workers hesitate to take sick leave,
even in the face of severe illness or injury. This creates additional stress, especially with the
threat that the worker may be dismissed without explanation or financial compensation, which
affects the entire family (Wilson 2014). Many large resource sector companies now also employ
nurses and other health practitioners to work on improving and managing health and safety
on site which includes providing support for workers who may be experiencing depression,
stress and anxiety as a result of their working circumstances. Despite the implementation of
new and extensive health and safety laws in both Australia and New Zealand, health and safety
at work remains problematic in both countries.
Health and safety at work

Health and safety at work are essential for ensuring all workers come home safely. Between
60% and 70% of the population in both Australia (http://www.abs.gov.au/ausstats/[email protected]/
mf/6202.0) and New Zealand (www.stats.govt.nz/browse_for_stats/snapshots-of-nz/nz-social-
indicators/Home/Labour%20market/lab-force-particip.aspx) are employed, meaning health
and safety in the workplace can be considered a major risk to most adult’s health and wellbeing.
Illness and injury at work has the potential for long-term disability, which can affect not only
the worker, but his/her family and community. Workplace events also cause losses in worker
productivity which, in cases where a worker does not have job security, can exacerbate
socio-economic disadvantage. Accidents and injuries also incur costs to businesses and the
health care system. Workplace accidents are highly variable, depending on the type of work
and the workplace culture, particularly in terms of safety and support. Musculoskeletal injuries
are the most common work-related injuries. Another prevalent work-related injury is hearing
loss, caused by excessive noise in the workplace. In some cases, workplace injuries are linked
to individual worker characteristics as well as the work environment, including the worker’s
commitment to health and safety. For example, the consumption of alcohol or substances,
either during or before work, can interfere with jobs that require the operation of machinery
or intense concentration. Other factors affecting health and safety in the workplace include
the type of work undertaken, the pressures placed on workers to meet productivity targets,
and exposure to hazardous substances or safety risks. Productivity pressures can cause biologic,
physical or psychosocial risks or a combination of these.

Workplace health and safety
• In Australia: www.safeworkaustralia.gov.au
• In New Zealand: www.worksafe.govt.nz
For this reason, primary prevention activities include a hazard or risk assessment in the
workplace. This begins with an ergonomic assessment of the workplace and the working conditions.
Ergonomic assessment involves examining the engineering aspects of the relationship between
the worker and her/his work environment. Ergonomic hazards are those that induce fatigue,
boredom or glare, or tasks that must be conducted in an abnormal position. Examples include
work that causes vibration, repetitive motion, poor workstation–worker fit and lifting heavy
loads. Biologic hazards can include exposure to bacteria, moulds, insects, viruses or infectious
co-workers. Chemical hazards can include exposure to dangerous liquids, gases, dust, vapour
or fumes. Physical hazards include extremes of temperature, noise, radiation, poor lighting,
lifting or exposure to unprotected machinery. Nurses, for example, are at risk of musculoskeletal
injuries, obesity and overweight and cardiovascular disease due to the physical nature of their
work and the shift work required (Kyle et al. 2016, Long et al. 2013, Vetter et al. 2016).
The sandwich generation

Through the middle stages of adulthood, a combination of unique stressors can prove challenging.
Juggling work, caring for children and, increasingly, caring for older parents can test the resilience
of many, particularly women, who are more likely to take on these multiple roles. Called the
‘sandwich generation’, these women (and some men) contribute more than 1500 hours per year
each of unpaid family care (Deloitte Access Economics 2015, Grimmond 2014). Informal caregiving
is recognised as a chronic stressor, creating physical and psychological strain over extended
periods of time (Boumans & Dorant 2014, Schulz & Sherwood 2008). Family caregivers can
earn up to 10% less than non-caregivers despite similar occupational backgrounds, largely
attributable to working part-time (Grimmond 2014). Ultimately, many give up work to care
full-time, further affecting their finances (Horrell et al. 2014). Despite negative outcomes for
caregivers, there are benefits. These include the emotional and relational rewards associated
with caring for loved family members (Cicchelli & Mcleod 2012, Horrell et al. 2014). Being
aware of these multiple stressors on the adult enables nurses and other health professionals to
put in place appropriate strategies and interventions to support healthy adulthood.
Goals for healthy adulthood

The best approach for adult health is community participation in all matters concerning health
and wellbeing, irrespective of whether the objective is to overcome risks or enhance the quality
of people’s lives. The most pertinent issues in planning for healthy adulthood are social: to
overcome inequity and inequality. The focus of today’s health promotion agenda for adults
should be to address the SDH, to reduce risk, to improve the quality of work and family life, to
prevent and better manage chronic diseases, including mental health, and to respond capably to
current and future threats including both infectious diseases and threats to the environment. To
address these issues requires public awareness of the seriousness of each, and dissemination of
accurate information that will be both instructive and supportive. The focus should remain on
communities in creating and maintaining health to decrease the incidence of chronic diseases,
develop safer workplaces, living spaces and societies, and provide greater opportunities for
people to achieve better physical, mental, spiritual, environmental and culturally sensitive
health. Box 8.3 outlines a set of specific recommendations that help guide nurses and other
health practitioners in their work with adults. It is important to take an ecological approach
and consider the needs of each individual in the context of their community and society as
well as the impact of global issues on their circumstances. Achieving a healthy adulthood
enables the individual to manage the transition to healthy ageing with ease.
BOX 8.3
GOALS FOR ADULT HEALTH
The major goals for adult health include:

• ensuring an appropriate balance between comprehensive and selective primary health
care (PHC), particularly in addressing chronic conditions for disadvantaged
populations
• providing political support for health in all policies
• integrating primary, secondary and tertiary intervention for adult health in the
workplace and community
Continued
BOX 8.3
GOALS FOR ADULT HEALTH—cont’d
• adopting a life course approach for the prevention of chronic conditions

• promoting an ecological risk-reduction approach by focusing on the environments for
good health
• using intersectoral collaboration to address physical and mental health issues
comprehensively
• ensuring cultural sensitivity in all interactions
• designing health promotion strategies that are empowering, with people and families
as partners at the centre of care
• using health resources efficiently and effectively, eliminating boundaries between
professionals
• using the World Health Organization’s Ottawa Charter as a guideline for health
promotion
• considering the career needs of adults as they plan for retirement.
PART THREE: HEALTHY AGEING
Context
The central challenge for healthy ageing lies in creating the conditions for people to age with
optimal health and wellbeing and a good quality of life. But what is ageing? In the twenty-first
century, social commentators quip that 40 is the new 20, and 60 the new 40. Does this make
80 the new 60, and, if so, what does that mean for the way we nurture health and wellbeing
along the latter stages of life’s pathway? We know that the quality of ageing depends on the
cumulative effects of social determinants in the earlier years. But there are also developmental
changes that occur in the years from 65 to 90 and beyond, and these have not often attracted
the attention of health care planners. Instead, planning has tended to revolve around population
trends towards disease states, and how to prevent, treat and palliate these. This ‘illness’ rather
than ‘wellness’ focus, is disempowering for older people, especially for those trying to cope
with the cumulative effects of lifelong disadvantage. Community-based actions to support and
enhance healthy ageing should revolve around health promotion; improving the social, physical,
economic and policy environments within which older people can enjoy good health into
their latter years and engage in healthy lifestyles.
Communities for healthy ageing need to acknowledge the extent to which older persons
contribute to the social, cultural and geographical life of the community. People over the age
of 65 are vital to child care and other aspects of family life, particularly for their grown children
who may be living in busy, dual-earner families. Many older persons are also carers for family
members with disabling conditions. Importantly, older citizens are also a viable economic
force. Some continue in the workplace longer than their forebears, bringing wisdom to a wide
range of industries, including health care. As people remain in the workforce longer, employers
will need to accommodate any declines in older workers’ capacity, including work content or
physical loading, stressful work environments and the psychosocial elements of good work
practices. They will also need to ensure there is a culture that supports worker interaction and
social engagement. Vulnerable groups among older generations in need of supportive environ-
ments include the migrant population, the rural population, the economically disadvantaged
and those attempting to fulfil casual employment positions. Strategies for mentoring young
workers can have maximum value for both the mentors and the mentees, as older people are
encouraged to pass on their experience to those who need to develop knowledge and skills.
Older adults also have the potential to dominate shifts in the economy through their spending,
investments and service requirements. They are a political force through the sheer weight
of numbers, capable of swaying the policy climate for health, the environment and their
grandchildren’s educational future. In some communities, older people help calm the social
climate through their understanding, and by having a more emotionally balanced perspective that
comes with the patience of ageing. Others’ lives may be destitute and lonely. The combination
is unique for every person and experienced differently, depending on social and environmental
supports. First and foremost among the goals for healthy ageing is empowerment, to nurture
older citizens’ participation in community life and in their health care decisions.
Health in older age

Many people over the age of 65 in Australia and New Zealand lead healthy and productive
lives, some thriving in ways they could not during their middle years, when their life circumstances
prevented them from achieving a balance between work, recreation and family responsibilities.
A large number of older people are also unwell, suffering from chronic diseases or long-term
conditions that limit their mobility or sense of wellbeing. But these two groups are not polar
opposites. There are numerous older people whose health lies between the extremes of high-level
wellness and immobility. The challenge for nurses and other health practitioners working with
older persons is to see each person in terms of individual strengths and needs, and in the
context of the environments that support or constrain their health and wellbeing. This includes
understanding their individual journey, and what it has meant for the way they experience
health. Although the lives of many have been affected by conflict, including the First and Second
World Wars (1914–1918 and 1939–1945), and the Korean and Vietnam wars of the 1950s to
1970s, the current generation of older people born in Australia and New Zealand now live in
relative peace and harmony. But some have also been beleaguered by the global financial crisis
of 2008–2009 that eroded their retirement income, causing uncertainty about the future. Conflicts
and disrupted living circumstances have also affected the earlier years of many immigrants
and refugees who are ageing in both countries. Ageing is also proving difficult for lesbian, gay,
bisexual and transgender/transsexual/intersex (LGBTI) elders, some of whom have suffered
the cumulative strains of lifelong discrimination which continues into aged and residential
care facilities (Neville et al. 2015). The older years are also challenging for Indigenous people
who may live in remote areas with few services or supports.

The health of older people
• Australia: www.aihw.gov.au/ageing/
• New Zealand: www.health.govt.nz/our-work/life-stages/health-older-people www.health.govt.
nz/our-work/life-stages/health-older-people/lilacs-nz-research-programme
Those in rural and remote areas need special attention. For those ageing at home in rural
and remote areas, community services are often absent, leaving them at a disadvantage. The
shrinking of the rural sector is an issue that has caused many older rural people consider-
able stress. Age-friendly community networks, especially for the large proportion of women
caring for family members and their caregivers, can help rural people remain connected and
feeling valued until the end of life. Older people in rural areas believe maintaining social
connections and remaining optimistic are key to helping them age in place (Bacsu et al.
2014). Often though, it is their chronic and long-term conditions that contribute to older
people making the move from their rural homes to cities, to be closer to health services.
Away from their familiar space and sense of independence, many experience the crowding
and financial stress of cities for the first time, during and after retirement. Many of these
people have led self-reliant and independent lives, yet find their preferences subsumed
within lifestyles unfamiliar to them. Nurses and other health practitioners working with
older people in the community need to be vigilant to ensure that rural voices are heard,
and that policies include strategies for implementation with a focus on the specific needs
of elders.
Today, society is gradually becoming aware of the need to value older people as instru-
mental to sustaining community capacity. Older people themselves are also more inclined
to consider the potential of modifying their environments and engaging in robust personal
behaviours for healthier lives. These include healthy nutrition, physical exercise, low-risk
personal habits and coping styles and a general refocusing on what can enrich, rather than
compromise, their health and happiness in the later years. Healthy lifestyles among older
people are visible in communities that provide environmental supports, such as the beach
communities on Queensland’s Gold Coast, which attract a large number of retirees. The local
Gold Coast Council has established walking trails alongside the beaches, with exercise sta-
tions approximately every 10 metres. The stations are equipped with weather-resistant gym
equipment that is shared by young and old people alike on a daily basis. The equipment
represents a small investment in the health and fitness of citizens that might otherwise be
precluded from exercising because of a lack of transportation or finances. Twice weekly free
Tai Chi sessions on Burleigh Beach, courtesy of Gold Coast Council’s ‘Active and Healthy Gold
Coast’ strategy are another way in which the Council demonstrates its commitment to health
and wellbeing.
Ageist attitudes
Despite today’s older adults having grown up in an era of experimentation, dramatic social
change and relative prosperity, they are still subject to ageist attitudes, behaviours and stereotypes
from those younger than themselves. Ageism is a type of discrimination against older adults
on the basis of misconceptions about their characteristics, attitudes, abilities and capacity. The
most obvious example of ageism is the global state of alarm at population ageing with some
describing older persons as a ‘demographic time bomb’ or as universally and exclusively needy,
dependent and frail (Dowsett et al. 2014, Malta 2016). Ageism can result in older adults being
over- or under-treated in our healthcare systems, can limit their ability to find work, contributes
to the provision of poor health care, and can shorten life (Kagan & Melendez-Torres 2015,
Robbins 2015). In many cases, where ageism is present, there is little consideration of personality
characteristics, or personal responses to provocation, pain, disability or recent life events.
Instead, the older adult’s concerns are often stereotyped as if they were typical of the entire
demographic group. Making assumptions about the experiences of older people is risky. The
video and website found in Box 8.4 show the results of research with women over 60 and their
diverse experiences of intimacy. The work shows that preconceived ideas surrounding intimacy
and older women are often not true. Other initiatives such as the co-location of kindergartens
with aged care facilities build inter-generational connections and help remove the stigma of
ageing.
BOX 8.4
STILL DOING IT
• Video: www.youtube.com/watch?v=NVgcdULvtX0
• Website: www.stilldoingit.com/
Retirement
Some policy experts have argued that retirement is a risk factor for illness or frailty, while
others have mounted a counter-argument—that leaving the stress of the workplace and assuming
a healthier lifestyle during retirement has major health benefits. Some older workers prefer
to remain in the workforce (although often cut down on hours), as a way of remaining connected
with their colleagues and their self-identity. Older nurses, for example, may struggle with some
of the physical challenges of nursing, but have developed substantial resilience in order to
manage these challenges and continue to work often into their 70s (Clendon & Walker 2016).
Others stay for financial reasons. During the retirement or semi-retirement phase of life,
increased leisure time provides opportunities for closer social engagement than during a
person’s working life. Social engagement helps maintain emotional closeness, or social intimacy,
as well as instrumental assistance, which is usually seen in having greater social support for
times when it is needed. Social engagement in older age is considered a key component of
healthy ageing with substantial health benefits for the individual and the wider community
(Sabbath et al. 2015). Participating in social activities tends to help people feel they have
maintained mastery over their life; that they continue to accomplish things despite any constraints
associated with ageing such as functional impairments, widowhood or lack of family support.
Encouraging social engagement is an important goal for nurses and other health practitioners
who work with older adults.
One of the greatest community assets in many cities and communities today is the vast
array of volunteer networks that often provide a critical link to social life and social services.
These networks often comprise numerous people having reached older age themselves. Their
guidance is often invaluable in helping others make the transitions from rural to urban,
home to community or residential care, or to services and facilities they need. Volunteering
is one of the most rewarding activities for older adults, as it helps build a strong sense of
control. Often volunteers have a deep understanding of older adults’ problems from first-hand
experience, and they often recognise the type of information or assistance that is needed. They
may also have the time and patience to listen when it is most needed, especially for people
who may be suffering from depression or other mental illness. Volunteers also develop a
sense of self-esteem through their actions, especially knowing the extent to which their input
is valued.
One of the most vital movements of current times is the response to widespread recognition
of the need for lifelong learning, through courses such as those in the University of the Third
Age (U3A). Older students are often willing to share life experiences, integrating their insights
into course material. Older people also approach learning in unique ways, using new knowledge
to forestall deterioration of their cognitive abilities, eager to build linkages between old and
new knowledge. Studying and learning helps build cultural bridges, linking personal and
public perspectives, blending emotional insights with enhanced awareness of the world. The
advent of the internet has also provided some older persons with a thirst for even more
knowledge, and different ways of exploring the world. Organisations such as SeniorNet
(www.seniornet.co.nz) provide opportunities for older people to learn internet skills at a pace
that is appropriate to their needs. Evaluation data show that SeniorNet not only enhances
older people’s use of the internet to find information and to engage with organisations and
agencies online, but has also decreased the sense of isolation older people can feel as they age,
increased mental stimulation and improved contact with family and friends (Litmus & The
Federation of New Zealand SeniorNet Societies 2009).
One way to promote connectedness within the ageing community is to reinforce the value
of religious institutions, where this is appropriate to community members. Relocation to a
different environment may cause older adults enormous stress if they are unable to retrieve
the familiarity of the church, temple or synagogue, or those who provide religious support.
Our role as health advocates should include assessing older community members’ needs for
communication and spiritual worship. This may involve arranging transportation, social networks
of lay people with similar religious affiliations or visits by members of the church, especially
for older adults who are incapacitated and cannot meet the obligations of their faith.
Challenges in older age

Although many people age well, as noted earlier, many will also face challenges that warrant
further attention here. In addition to the cumulative effects of long-term conditions such as
cardiac disease and diabetes, dementia is one of the major causes of disability and dependency
among older adults worldwide (WHO 2016b). The numbers of people with dementia in Australia
and New Zealand are expected to rise by over 50% in the next 10 years (Associate Minister
of Health 2016, Digby 2016). Dementia is considered an umbrella term that includes a number
of conditions that affect the function of the brain. Approximately two-thirds of people with
dementia have Alzheimer’s disease (WHO 2016b). People with dementia and their carers often
adopt strategies to help manage the disease, minimise losses and reduce isolation (Bunn et al.
2015). These strategies may include facilitating participation of the person with dementia in
activities and helping them to maintain their sense of identity (Bunn et al. 2015). Carers
themselves may be under tremendous stress as they experience changes in their own role as
they care for their family member (Bunn et al. 2015, Dening & Hibberd 2016). Nurses and
other health practitioners have an important role in supporting people with dementia and
their families by providing information and advice, non-judgemental support and referral for
further assessment and intervention where needed (Associate Minister of Health 2016, Dening
& Hibberd 2016).

Dementia and alzheimers disease
• Australia: www.fightdementia.org.au/
• New Zealand: www.alzheimers.org.nz/
Older people with dementia may also be at particular risk of elder abuse (Dong 2015a).
The United Nations and World Health Organization define elder abuse as ‘…a single, or
repeated act, or lack of appropriate action, occurring within any relationship where there is
an expectation of trust which causes harm or distress to an older person’ (WHO 2016c). Elder
abuse includes physical, psychological and sexual abuse, financial exploitation and neglect
(Dong 2015b). It is estimated that between 2% and 10% of older Australians and New Zealanders
experience abuse every year (Kaspiew et al. 2016, Office for Senior Citizens 2015). Elder abuse
has significant ramifications for the individual and for communities. People experiencing elder
abuse suffer significant psychological distress, may die earlier, are more likely to use health
services and be hospitalised, and have poorer mental health and depression (Dong 2015b,
Office for Senior Citizens 2015). Nurses and other health practitioners have an important role
to play in identifying and preventing elder abuse and supporting those who have experienced
it. Holistic assessment of the older person should include screening for elder abuse. The Vulner-
ability to Abuse Screening Scale (VASS) is used around the world to measure vulnerability,
dependence, dejection and coercion (Dong 2015a) – see Box 8.5. Nurses and other health
practitioners need to be knowledgeable of community support services for older people and
BOX 8.5
VASS SCREENING QUESTIONS (DONG 2015a)
1 Are you afraid of anyone in your family?

2 Has anyone close to you tried to hurt or harm you recently?
3 Has anyone close to you called you names or put you down or made you feel bad
recently?
4 Does someone in your family make you stay in bed or tell you you’re sick when you
know you aren’t?
5 Has anyone forced you to do things you didn’t want to do?
6 Has anyone taken things that belong to you without your OK?
Source: Dong, X.Q., 2015b. Screening for Elder Abuse in Healthcare Settings: Why Should We Care, and Is
It a Missed Quality Indicator? Journal of the American Geriatrics Society, 63(8).
what actions to take if abuse is identified. The McMurray Community Assessment Framework
will help nurses and other health practitioners identify key community resources.
Prevention approaches to elder abuse can be classified into two broad themes: changing
values and attitudes among the broader community and among professionals and individuals
who have contact with older people; and addressing the risk factors for elder abuse (Kaspiew
et al. 2016). The World Health Organization (2015) has identified four effective approaches
to preventing elder abuse:
1 Pooling the expertise of professionals within multidisciplinary teams to resolve cases
of elder abuse;
2 Providing helplines and websites that provide information to potential victims;
3 Encouraging financial institutions to monitor for suspicious patterns to identify older
adults at risk of financial abuse; and
4 Undertaking public campaigns to raise awareness of elder abuse and heighten respect
for older adults.
A multifaceted approach to addressing elder abuse will be the most effective with nurses
having a role at each level from individual identification to supporting families where abuse
is a risk, and to community-wide interventions to encourage greater knowledge and understanding
of the strengths and value of older people in the community.
Frailty is also gaining recognition as contributing to morbidity and early mortality among
older adults. Frailty is described as a multidimensional syndrome characterised by unintentional
weight loss, weakness, poor endurance, exhaustion, decreased muscle mass and decreased
resistance to stressors (Buigues et al. 2015, Phillips-Burkhart 2016, Widagdo et al. 2015). Prevalence
of frailty among Australian and New Zealand older people is largely unknown due to variable
screening tools (Widagdo et al. 2015). However, given the contribution of frailty to depression,
falls, fractures and lengthy hospitalisations, recognition and early intervention can make a
substantial difference in the older adult’s life (Buigues et al. 2015, Phillips-Burkhart 2016).
Dementia and frailty combined with other common long-term conditions present among
older people means many are taking multiple medications in order to manage their health.
As a result, polypharmacy is a significant issue among older people in Australia and New
Zealand. Older people on multiple medications are more prone to drug-related complications
due to the complex medicine regimes they may be required to adhere to and the physiological
changes associated with ageing. Adverse events and interactions associated with this polypharmacy
can lead to a greater risk of falls, fractures, confusion, incontinence, constipation and other
issues that can cause distress. These events can also lead to admission to hospital or residential
care facilities (Fried et al. 2014). Nurses and other health practitioners, such as pharmacists,
have an important role in ensuring older people are managing their medicines well, providing
education and support in the home or clinic. Identifying where polypharmacy may put an
older person at risk and putting in place appropriate strategies to manage this, including
regular medicine reviews, referral and reconciliation, is important. Often older people may
also be taking over-the-counter medicines or complementary and alternative medicines and
may be reluctant to share this with their health practitioner. Careful assessment can help
identify where this may be occurring and allow preventative strategies to be put in place early.

Information on medication safety
• www.hqsc.govt.nz/our-programmes/medication-safety/
• www.safetyandquality.gov.au/our-work/medication-safety/
Supporting transitions to and within older adulthood

Building personal health capacity in the later years should be multidimensional, addressing
psychosocial health issues and health literacy, as well as any risks related to disability or poor
general health. Effective pain management strategies can support older people to overcome
the impact of pain on their lives and develop the resiliency needed to age well. One of the
most useful resources is a website developed in Western Australia to help people understand
and manage pain: Pain Health (http://painhealth.csse.uwa.edu.au). The website explains dif-
ferent types of pain, provides various personal stories of pain and outlines ways of coping
with pain through techniques such as mindfulness and goal setting as well as medication
management.
It is difficult to understand the challenges and obstacles involved in trying to unlearn, then
relearn ways of behaving. Patience is crucial, and this helps older adults feel that they are being
taken seriously. For some, massage, therapeutic touch and alternative therapies provide a
remedy to counter unhealthy lifestyles or loneliness. Others respond to a more cognitive,
rational approach and can be convinced to reframe a negative lifestyle practice as a threat to
their longevity or to the quality of their life. The most successful techniques to help build
personal strengths capitalise on both the unique and shared characteristics of people attempting
to change. They also place at least equal emphasis on community infrastructure that would
support the change. The most important determinant of change is a sense of control: believing
you can change, and that the community is there to support you. Supportive communities are
empowering, and aimed at nurturing health literacy. Understanding an older person’s need
for knowledge to maintain personal capacity begins with a comprehensive assessment of personal
strengths and barriers to change. This information can then be used to validate their existing
knowledge and direct them to access any further information that will help support choices
for health and wellbeing.
Mental health services for older people continue to be sporadic, especially in regional and
rural areas, and community nurses with specific training in mental health remain one of the
best sources of assistance for families trying to manage dementia-related behaviours. These
nurses are also an ideal support for family members trying to manage their own anxieties
related to caregiving (McInally 2015, Mendes 2015). Using tools to gather accurate data can
provide the best foundation for a personalised, solution-focused approach to care. Including
the perspectives of the individual and family members to ensure that their preferences and
needs are acknowledged is also essential (McCann et al. 2015). This information can then
provide a foundation for creative and imaginative solutions. Another important role for nurses
working in home and community care is to help older people manage chronic conditions and
prevent deteriorating health (Walker et al. 2015, Wilkes et al. 2014). Ideally, this is achieved
in collaboration with practice nurses who adopt a primary health care approach to encouraging
client self-management.
An interdisciplinary, collaborative team approach with personal involvement from nurses,
pharmacists and dietitians may be better able to focus comprehensively on risk reduction,
educating people about diet and exercise, monitoring and adjusting drug therapy, and helping
motivate them to adhere with prescribed medications (Morgan et al. 2015, Robinson 2015,
Wilkes et al. 2014). The interdisciplinary approach should also extend across the continuum
of care, to include acute care episodes and palliative care, involving the older person and family
members as partners in care with specialist support as required from palliative care professionals
(Raphael et al. 2014).
Nurses and/or nurse practitioners are also among the most frequent visitors to long-term
care homes, and in this capacity they can help promote continuity between services and
caregivers and decrease hospital admissions (King et al. 2011, Peri et al. 2013). These nurses
play an important dual role in helping create awareness of the range of issues that may be
challenging in care, as well as encouraging evidence-based practice and the translation of new
information into practice changes such as person-centred care. The video found in Box 8.6
showcases how nurses, clinical nurse specialists and nurse practitioners are working together
to improve their care for older people. Research into the types of skills required of nurses
working with older people in residential care settings shows that they need advanced assessment
skills, the ability to manage complex care, and a focus on primary health care and keeping
people well (Clendon 2011, Davis 2016, Phelan 2016). Nursing plans should also be mindful
of people’s sense of place. Older adults living in residential care settings are, in essence, at
‘home’. Nurses can help others in the aged-care setting work within a primary health care
approach that includes social inclusion, connectedness, cultural safety, person-centred care,
health literacy, and appropriate use of technology to tailor plans to people’s multidimensional
needs.
Another aspect of service provision demanding attention is the need to tailor services to
the needs of different community groups of older citizens. Older adults are not a homogeneous
BOX 8.6
NURSES IN LONG-TERM CARE HOMES
https://youtu.be/NFzAGoQJ8Ys
group, nor do they represent a common culture, or common experiences of illness or disability.
It is therefore important to assess people’s individual needs before assigning them to one type
of care. Care facilities are already being redesigned to accommodate various subgroups within
residential and semi-residential care, and this is a step in the right direction. Home to residential
care will probably be the most problematic transition for the oldest old, and current initiatives
for ‘ageing in place’ need to be customised to individual preferences and needs, particularly
for older people from a culturally and linguistically disadvantaged (CALD) background (Li
et al. 2014). Understandings of ageing generally are important. Older people value physical
comfort, but place equal, if not greater, importance on social integration, their ongoing contribu-
tion to society, security, autonomy and enjoyment (Stephens et al. 2015). However, it is important
to remember that ageing in place in the community will work for some, but not all people,
and services should accommodate a range of preferences and choices where possible.
In an era of protracted economic restraint, increasing emphasis on community and home
care inadvertently increases the burden on family caregivers. These people need ongoing support
and education—in particular greater information on the rehabilitation strategies and intervention
technologies intended for their family member. There is also a significant need for respite care
to prevent situations where they are overcome by the stress of caregiving. Caring for our ageing
population requires careful deliberation of the mix that constitutes optimal conditions for health
enhancement. Included is access and equity in service provision, empowerment for older adults
and their families and a physical and social environment within which health can be achieved
until the end of life within a milieu of encouragement and caring.
The future
The most significant societal level challenge for the next decades will be how to best care for
the over-85 age group, which is the fastest growing group globally (Greenleaf Brown 2016).
Population ageing will require adjustments in pension and income security schemes, to support
the ageing population. Health care systems will also have to accommodate changing needs.
Acute care hospitals will be populated by a large proportion of the oldest old, many of whom
will experience multiple health problems. With shortened hospital stays, nurses practising in
the community have already begun to provide the bulk of care across extended periods of
time for a wide range of acuity. In the near future, evolving technologies and therapeutic
techniques will transform home care. Nurses will be part of the rapidly developing models of
care that will see treatments customised to individual needs. Their roles will be central to
caring for the communities where ageing takes place, supporting health-promoting behaviours,
advocating for environmental supports for lifestyle modifications and helping people navigate
the myriad services available. Many older people are embracing technologies, and these can
be used to optimise care. Computer training, memory tapes and video games are proving
promising strategies for helping older people retain cognitive function (Miller et al. 2014).
Many older people are internet savvy, some using social networking to stay in touch with
family members, and others using it to search for services or supports. Developing internet
literacy can help people remain in their homes safely, access groceries and other services, and
prevent deterioration in their health. For example, there are electronic devices now with motion
and vibration sensors that can detect falls. Other mobile devices connect health practitioners
with older people living alone to collect information about their medical condition or alert
authorities when they have a problem. Technological devices can also monitor sleep, toileting
and urinary tract infections. Some general practices are now adopting a Health Risk Appraisal
(HRA) system for older people that can help identify risk factors for disability, ill health and
social isolation (Iliffe et al. 2010). This systematic approach has been trialled on the basis that
older people themselves could complete interactive computer-based HRAs, yet, because of
some difficulties in using the technology, support from health practitioners remains the key
to successful implementation (Iliffe et al. 2010, Lafata et al. 2016).
Goals for healthy ageing
Involving older persons as partners in health is crucial to developing age-appropriate health
care systems and healthy ageing. Older persons consume more health care than any other
demographic group. They carry the major burden of chronic diseases and primary care services.
But they also contribute to the overall care of the population, especially for those with disabilities.
This unpaid work should warrant a greater voice in health care planning, and some older
persons do participate in this type of planning. But, far too often, older people are excluded
from participating in meaningful ways for service improvements. As a numerically dominant
group they should be given greater opportunities to influence models of health care, based
on their experiences and needs. This will become even more important in future, with the
development of personalised therapies from genomics and molecular biology on the horizon.
Box 8.7 outlines our goals for healthy ageing.
BOX 8.7
GOALS FOR HEALTHY AGEING
• Access, equity, empowerment and cultural safety

• Physical, emotional and spiritual health
• Intersectoral collaboration for services and resources based on individual needs and
strengths
• A balance between independent living and adequate service provision based on
appropriate technologies
• Acknowledgement of the relationship between health and place
• A place to feel safe and comfortable in living a dignified life
• Adequate financial and health care resources to sustain the latter stages of life
irrespective of geographic location
• Policies to promote social inclusion and social engagement
Conclusion
Taking a life course approach to this and the previous chapter has enabled us to consider the key
influences on health from pre-pregnancy through childhood, adolescence, adulthood and on to older
adulthood. Supporting people to manage transitions through life is an important goal for nurses and
other health practitioners working in primary health care settings. Understanding the challenges to
health as well as those factors that strengthen people’s response to challenges enable us to develop
appropriate interventions. Below we return to the Smith and Mason families to consider the challenges
of dealing with current and future adolescent issues to maintain family health and harmony, issues
related to the health of the adults in the Smith and Mason families and issues related to ageing.
CASE
STUDY From pre-adolescence to adolescence in the Mason and
8a: Smith families
Jason and Huia’s son John is 12 and on the cusp of adolescence. As parents, they were surprised,
alarmed, then sad to learn from his teacher that he has just been diagnosed with a learning disability. They
are also concerned to know that he has begun hanging out with a group of older boys who are drinking
and sniffing glue. John claims that he is not taking part in any of these behaviours but Huia has her
doubts. Jason takes a heavy-handed approach to dealing with John but this only serves to alienate John
further. After consulting with Huia, John’s teacher at the Kura Kaupapa has initiated a referral to the child
and adolescent mental health service to manage John’s behaviour and provide parenting skills for Huia.
CASE
STUDY Healthy adults in the Mason and Smith families
8b:
The occupational health nurse has been developing health promotion materials for the miners at
Colin’s work on a variety of health issues, including heart disease, depression, stress and diabetes.
She is finding that the materials provoke some discussion but continues to offer personal assistance
to those who don’t seem to find the materials helpful.
Rebecca has been developing her health knowledge about her pre-metabolic syndrome and has
become quite health literate in the process. Working with the practice nurse to manage her diet and
lifestyle, she has brought her blood sugar and weight into a healthy range.
Jason has been finding the health promotion material provided by the occupational health nurse who
visits his workplace helpful in managing his blood pressure, but he still struggles with his diet and
exercise—particularly with his long commute into the city for work each day.
Huia is worried about losing her job because of Jake’s asthma and although the family doesn’t need
the extra income, she finds the work rewarding and stimulating. She has not shared her concerns with
Jason.
CASE
STUDY Older workers, older Mason and Smith family members
8c:
Some of the occupational health nurses are working with older mining managers, many of whom had
not expected to continue working after age 65. They are addressing the special needs of the older
worker in the context of not only chronic illness management but preventative care and the effect of
shiftwork on older workers.
Rebecca’s mum has developed breast cancer and is having to travel to the city for chemotherapy.
During those weeks of treatment she is staying in Rebecca’s home, and this is causing some
problems with the young children disturbing her mother’s rehabilitation and adding to the pressure on
Rebecca of maintaining family harmony.
Huia’s mother has recently had a heart attack and moved into the family home for Huia to look after
her, which is normal practice for Māori families. This has created additional pressures on her and now
she has become one of the sandwich carers, dealing with both children and parents. Although her
mum has tried hard to help around the house, her recent illness hampers her ability to contribute
much. Huia has spoken with the Māori nurse practitioner who works in Papakura and she has
promised to make a home visit.
■ Through each transition from adolescence to adulthood to older adulthood, every person’s
experience will be individual and each will have differing health and wellness needs.
■ Adolescents are generally healthy but often have psychosocial issues that create risks to their
health.
■ Adolescents can be seen as ‘at promise’ as well as ‘at risk’.
■ From a socio-ecological perspective, home, school and the social environment are closely con-
nected in adolescents’ lives.
■ Adult health is socially determined and needs to be seen in the context of a person’s life course
development.
■ Adult health can be compromised by unhealthy behaviours.
■ The physical environment has a major influence on health behaviours, suggesting an important
relationship between health and place.
■ Equity is a major factor in adult health, with chronic illnesses experienced more intensely by those
who are disadvantaged.
■ As most adults spend the majority of their time in the workplace, the health of both worker and
workplace is a major focus for intervention.
■ The work–home life nexus can create major stress, especially for women trying to lead a balanced
life.
■ Workplace relationships can be a source of psychological ill health.
■ Older people are often the subject of stereotypical age discrimination in the workplace, in social life
and in health care.
■ Older people need to be valued for their wisdom, calmness and ability to see life in perspective.
■ An older person’s health and wellbeing is the product of cumulative experiences, indicating the
need for a life course approach in evaluating health and wellness.
■ Older people undertake a disproportionate amount of family caregiving and community volunteer
work.
■ The principles of primary health care can be used to ensure that adolescents, adults and older
adults have access to health and other services, that their needs are met sensitively and that they
develop in equitable life conditions.
1 Explain the main risks of adolescence and how these can be addressed by nurses in a range of settings
using a variety of strategies.
2 Using the HEEADSSS assessment (Appendix C), identify some of the needs that you believe would be revealed
by an adolescent. Explain how you would promote a sense of community and school connectedness for this
person.
3 Explain the health literacy needs of an adolescent, an adult and an older adult. What age-appropriate strategies
would you use to build health literacy in each group?
4 What social, physical and psychological influences have the most important effects on healthy ageing?
5 How does the environment affect older people’s risk and potential in relation to falls prevention?
6 How can primary health care principles be used to guide a holistic assessment of the health needs of adolescents,
adults and older adults?
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Section 4
Evidence to support
primary health care
CHAPTER 9 Inclusive communities

CHAPTER 10 Inclusive research
This section begins with an explanation of what is meant by an inclusive community and society,
and how these concepts are integral to primary health care. Social inclusion and social exclusion
lie at two ends of the same continuum. Along this continuum, people have varying
opportunities to achieve health. As mentioned in Chapter 1, social exclusion leaves many
members of society without the support and resources they need for health and wellbeing.
Social inclusion creates social capital, trust, norms of reciprocity and cohesion—the essence of a
healthy community. These vital elements of community life are important to any discussion of
the power relations that exist in society and are our primary focus in Chapter 9. The first part of
the chapter focuses on gender before moving onto cultural inclusiveness. Gender is identified as
a separate social determinant of health, yet the gender relationships in a family and community
may be intensified by the intersection of racial or ethnic issues, family conflict, societal norms of
behaviour, migration experiences and gender identity. The chapter unravels the issues inherent
in gender, culture and power relationships that impinge on the health and wellbeing of
communities and those who live in them before moving on to explore the need for communities
to provide the foundations for cultural safety, especially in relation to Indigenous people’s
health, risk and potential. International reports indicate that there has been some progress in
redressing the culturally constructed inequities in societies that have left a legacy of illness,
injury and disability among Indigenous people. New initiatives have been developed within the
auspices of the World Health Organization’s Commission on the Social Determinants of Health,
and at a national level, Closing the Gap initiatives in Australia and New Zealand. Yet cultural
disadvantage is socially embedded, and the barriers to equality of opportunity are well known.
Redressing the social conditions that create disadvantage is a matter of urgency. We therefore
focus on Indigenous people’s health as a critical element of cultural inclusiveness. Our discussion
revolves around the need to share both the risks and wisdom of each of our nations with one
another for mutual benefit and capacity enhancement. The end-point of the chapter is a
renewed call to create an ethos of community and social life built on equitable foundations.
Perhaps with cross-fertilisation of good ideas, and the cautionary tales of barriers to equity, we
can draw into clearer focus strategies for achieving inclusive communities and social justice.
Chapter 10 provides an exploration of research, its major elements and strategies and where we
need to fill gaps in our knowledge base for translating evidence into practice. Evidence-based
practice is outlined as important to informing community health strategies, but evidence is
generated and used in many forms. Everyone working with communities has some level of
obligation to be research-minded, and to embrace the trend towards knowledge translation
(KT), ensuring research findings are adopted in practice. We have undertaken a major scan of the
nursing and midwifery publications over the past several years, to develop a sense of what gaps
remain in the growing knowledge base for community practice. Reporting on this body of
knowledge in Chapter 10 is intended to inspire further participation in research by practitioners
as well as students. When research is integral to planning, implementing and evaluating the
merits of community-level interventions, we will all be speaking in a language that helps create
enthusiasm for change, and incremental development of rational, justified and defensible
community health and wellbeing policies and strategies.
CHAPTER 9
Inclusive communities
INTRODUCTION
This chapter focuses on gender, culture and power. Our attention is directed to how gender
and culture influence the ways in which people approach and receive health care and on how
we as health practitioners can work to ensure equity and inclusion for all people. The first
part of the chapter focuses on gender and the second on culture.
Attention to gender issues is important for several reasons. Gender is a pivotal social
determinant of health (SDH) and instrumental to socio-economic position (SEP). A person’s
gender can determine the extent to which they have opportunities to achieve health and
wellbeing. People are also assigned relatively different positions in society depending on their
gender, particularly in being granted differential education, work opportunities or social support.
Gender influences can be cumulative along the life course. As individuals develop along the
critical pathways from birth to older age, gender, like other SDH, shapes not only biology, but
experiences and opportunities that become reinforced over time. Because men and women
occupy different social positions in the household, the workplace and in the community, they
are exposed to different risks and potential. Along the pathways of women’s and men’s life
course, gender differences are apparent at every stage, and this is the case in different countries
and contexts. These gender differences interact with other life circumstances to create complex
webs of factors affecting health and wellbeing.
KEY POINT
The most compelling mark of an inclusive society is the respect conferred on its Indigenous
people.
Culture provides a different marker for inclusiveness with the most compelling indicator of
an inclusive society the respect conferred on its Indigenous people. Yet, in many countries of
the world Indigenous people are treated as outsiders, the ‘other’ in relation to the dominant
culture. This lack of cultural inclusiveness has an enormous impact on their health and wellbeing,
and, in some cases, determines whether an Indigenous person is able to live a long life in harmony
with the natural and spiritual environment, or suffer premature mortality. In many places,
cultural exclusiveness divides citizens by race, ethnicity or affiliation, igniting oppressive actions
232 Section 4 Evidence to support primary health care
that, at worst, include violent exchanges and civil wars. In other places, cultural exclusion is
more subtle and expressed in racist attitudes, thinly veiled arrogance, and dominant forms of
exclusive language. Over time, those who are disadvantaged by ethnicity, race or affiliation, lose
not only opportunities to live vibrant, healthy lives, but their sense of place in the world, and
in the community. As time goes by, dispossession and hopelessness pervade all aspects of life,
and create a self-fulfilling prophecy of vulnerability to ill health and incapacity to change.
The community is an ideal place to address inequities that arise from social and cultural
exclusion, particularly in the process of unravelling constraints and facilitating factors involved
in developing capacity. Gender and cultural equity, and differential access to childhood education,
health literacy, prevention, care and economic opportunities are pivotal to community develop-
ment, community competence and building social capital. Support for equity must therefore
begin in the community; otherwise, in this rapidly changing global world, civilisations will
grow stagnant. To flourish, societies need to address the way power and social inclusion interact
with the social determinants of health, and to seek ways of creating more harmonious, socially
just communities.
OBJECTIVES
1 discuss the importance of social inclusion 4 define cultural safety as a concept and
and its relevance to primary health care explain its relevance and importance in the
2 describe the role of equity in the health of provision of health care
individuals, communities and societies 5 prioritise a set of goals for primary health
3 explain the influence of culture on health care practice when working with diverse
and social justice communities.
PART ONE: INEQUALITY, SOCIAL EXCLUSION, GENDER,

CULTURE AND POWER
Social exclusion plays an important role in the relationship between many of the social
determinants of health (SDH) and poor health. Socially excluded people are unable to access
opportunities to become educated, earn a living, receive social support for their personal
needs, live in safe houses and neighbourhoods with a secure food supply and a viable physical
environment, raise their children in a non-violent home, cultivate friendships or participate
in social and political life. The Australian Government defines four domains of social inclusion.
These are the opportunity to:
1 participate in society through employment and access to services
2 connect with family, friends and the local community
3 deal with personal crises such as ill health

4 be heard (McDonald 2011).
Social exclusion is not the equivalent of poverty or deprivation, which can result from other
circumstances. Instead, it is about connectedness and participation (McDonald 2011). When
people are excluded from full participation in social life, the effects prevent societal development
by inhibiting them from reaching their full potential. For example, children living in a jobless
household grow up with the risk of becoming socially excluded through a lack of education
and other opportunities to change the course of their lives, which can lead to intergenerational
poverty. Women confined to physical work from an early age, such as occurs in many developing
countries, are socially excluded by virtue of having no opportunities to become educated or
to change their status or that of their children. Men working in isolated circumstances may
be socially excluded because they have few opportunities to find a partner, raise a family or
gain employment in a geographic area with social amenities. Members of sexually diverse
minorities such as lesbian, gay, bisexual, transgender/transsexual or intersex (LGBTI) groups
are at particular risk of social exclusion, and, because of the dominance of our Western health
and education systems, cultural minorities are often socially excluded from some of the most
significant aspects of social life, with profound negative impacts on their health and wellbeing.
People with impairments can also be excluded from social participation on the basis of a
perceived lack of capabilities. Although social exclusion can arise from a lack of capabilities,
it is often the result of a denial of resources, rights, goods and services that are available to
the majority of people in society. Clearly, there is a mandate for health and social service
practitioners to work towards overcoming social exclusion to promote equity and cohesion
in community life.
KEY POINT
Gender, culture, disability or any point of social ‘difference’ can lead to social exclusion, which is
detrimental to health and wellbeing.
Cultural norms can play a major role in social exclusion, particularly in ascribing roles on
the basis of gender. Gender differences are grounded in biology, but they are enacted within
different social and cultural constructions of roles, norms, behaviours, activities and attributes
that are considered appropriate for men and women (Malmusi et al. 2014). Gender equality
refers to equal opportunities for men and women to enjoy socially valued goods, opportunities,
resources and rewards (Usher-Patel 2013). Equitable societies provide these opportunities to
both. Inequitable societies place many women at risk through law, religion, or cultural norms
that treat women as productive chattels to care for the household but with little decision-making
over their life, health, sexuality and fertility (Usher-Patel 2013). Even in relatively equitable
societies there are differences in the social expectations of masculine and feminine roles, which
typically privilege men in the home and workplace (Malmusi et al. 2014). The differential
expectations and inequalities are manifest in power imbalances created from social pressures
to conform to gender roles.
KEY POINT
Gender comprises a set of socio-culturally constructed roles and norms of behaviour for men
and women.
KEY POINT
Inequality—measurable outcomes in terms of opportunity

Inequity—value-based concept of unfairness
Life experiences demonstrate patterns of gendered expectations that have changed little in
terms of marriage and family life. Trends in marriage and childrearing have seen dual-earner
families become the norm, with many women choosing to work. However, many women are
socially excluded from this mix of work–home lifestyle because of economic circumstances
or lack of access to opportunities. Others have greater freedom to choose lifestyles but social
norms create pressure on women to nurture, and on men to be breadwinners. Employers also
shape understandings of gender by providing greater opportunities to men in the workplace,
because of their role as a family provider or on the assumption that men have better management
skills. This situation creates job insecurity and lower promotional opportunities for many
women, who tend to work flexible schedules to meet home and workplace needs. These factors
contribute to a large pay gap between men and women (Workplace Gender Equality Agency
2016). The gap in workplace pay and participation between men and women is a significant
global problem and achieving gender equality is one of the World Health Organization’s sustain-
able development goals. The Australian Government has established the Workplace Gender
Equality Agency in an attempt to support organisations and businesses in addressing the
gender pay gap and achieve equality. The gap in pay has substantial long-term impacts on
women. As women in the workplace approach retirement, they also discover a gender gap
between income and retirement savings, affecting their ability to enjoy retirement to the same
degree as their male counterparts. Divorce, widowhood and single parenthood can compound
the impact of the gender pay gap (Workplace Gender Equality Agency 2016). Lower levels of
income across the life course can also have profound long-term effects on a woman’s health
and housing situation as they age (DiGiacomo, Lewis et al. 2015).

Gender pay gap
• Australia: www.wgea.gov.au/
• New Zealand: http://women.govt.nz/work-skills/income/gender-pay-gap
Women’s health issues

Women’s health issues are influenced by many factors: childbirth, gender-linked health conditions
including unique reproductive health risks, women’s health behaviours and their longevity
and social position relative to men. Women’s innate constitution gives them an advantage over
men in terms of life expectancy, but living longer is a double-edged sword, with older women
suffering from chronic diseases for more years of their lives compared with men (DiGiacomo,
Green et al. 2015). Data from the World Health Survey of 57 countries showed that worldwide,
women’s health is significantly lower than men’s, with most of the inequality attributed to the
social determinants of women’s lives (Hosseinpoor et al. 2012). Although these inequalities
span all age groups, the social conditions associated with contraception, pregnancy, childbirth
and a lack of autonomy in seeking health care are major factors in women’s health, as are
changes in marital status. In Hosseinpoor et al.’s (2012) analysis, socio-economic position
(SEP), which is the culmination of education, income and occupation, was found to have a
powerful influence on the type, magnitude and distribution of health across all countries. This
is also the case in other societies where women are disadvantaged by their social position.
KEY POINT
Socio-economic position (SEP) = education, income and occupation.
In Australia and New Zealand, two leading mortality risks for women are cardiovascular
disease and dementia (Australian Institute of Health and Welfare 2016, New Zealand Ministry
of Health 2015). Gender differences lie in the fact that women’s symptoms may be different
from those of men’s, they tend to develop later in life, and, in some cases, suffer more post-
treatment complications (Malmusi et al. 2014). Indigenous women in particular suffer a
disproportionate burden of diseases, including those related to pregnancy and childbirth
(de-Vitry Smith 2016). In their later years, women also experience a higher burden of dementia
and other cognitive disorders, primarily because of their longevity (Usher-Patel 2013).
Another disadvantage arises from the fact that women’s medical treatments often show
marked differences from the way men’s health is managed. Women’s screening for illnesses is
also different to men’s (Hyun 2016). Women are less likely to be treated according to guideline-
indicated therapies, such as cardiac rehabilitation programs, despite evidence indicating the
advantages of such programs (Lavie & Milani 2009). When women are referred to rehabilitation
programs, it is often for shorter periods of time than their male counterparts (Lavie & Milani
2009). These disparities have been linked to physicians’ differential interpretation of guidelines,
gender and attentiveness to the gender of the patient (Delpech et al. 2016). Women in rural
areas can also be disadvantaged by the lack of specialist practitioners to help in dealing with
family planning or pregnancy issues, particularly those that require confidential discussions
of treatment or interventions (de-Vitry Smith 2016).
Some practitioners have little understanding of the cross-cultural differences in women’s
experience of health. For example, a study in Western Australia found that Aboriginal women
did not experience the premenopausal protective effect from cardiovascular disease that was
present in non-Indigenous women (Katzenellenbogen et al. 2010). Because many Indigenous
cultures tend to see ‘women’s business’ as private, they do not seek medical help for symptoms
of menopause, which could place them at risk of under-diagnosis of other conditions (Jones
et al. 2012). Women’s mental health also suffers from the combination of lack of understanding
and inability to access a range of treatments. In some cases, Indigenous women are under-
diagnosed with mental ill health due to the high acuity and prevalence of conditions such as
postnatal depression (PND) being considered as normal in their population.
KEY POINT
Women’s global disadvantage

• Unequal power relationships
• Social norms impinging on their opportunities
• Focus on reproductive roles
• Physical, sexual, emotional violence
Globally, human trafficking, lack of education, poverty, war, refugee status and cultural
norms such as female genital mutilation (FGM) have a profound impact on the health of
women. Women are also more vulnerable to the effects of climate change due to loss of crops,
poor nutrition and inability to relocate when their community is imperilled by weather events
or disasters (Levy & Patz 2015). The irony is that women have been identified as important
participants and leaders in addressing climate change but the narrative around women and
climate change continues to portray them as victims (Lewis 2016). As health practitioners, we
can advocate for women to be involved at all levels of climate change mitigation and support
work towards achieving the sustainable development goals (see Chapters 2 and 3). We can
also be aware of the particular experiences of refugee and migrant women who may be
experiencing severe trauma from their lives previous to arriving in Australia or New Zealand
including FGM and post-traumatic stress disorder. Such women may be more prone to family
violence due to the challenges of settling into a new country with a new culture and away
from traditional family support systems. As nurses, our obligation to these women is to work
with other members of the health care team to help them through the multiple transitions,
supporting the women and their families in achieving health and wellbeing at as high a standard
as possible. Community nurses encounter these women in the context of home visiting, child
and school health centres, neighbourhood or community groups, or in specialised community
centres for victims of torture and trauma, including women who have been trafficked. Nurses
must be wary of imposing Western ideals of health care, parenting and maternity on migrant
mothers. Ways in which nurses traditionally provide care to the individual may paradoxically
disempower migrant women whose collective ideals may differ from those of their care providers
(DeSouza 2013).

Refugee and migrant women
Australia
• The Forced Migration Network: www.arts.unsw.edu.au/research/
forced-migration-research-network/
• Refugee Health Australia: www.refugeehealthaustralia.org/
• http://www.refugeecouncil.org.au/getfacts/settlement/livinghere/health/
New Zealand
• www.refugeehealth.govt.nz/
A lack of education is a major risk to women’s health. In every region of the world, educat-
ing girls is the single most powerful way to promote equitable personal opportunities, and
pathways to health and wellbeing. It is also good for the economy, with a flow-on effect for
building social cohesion. Women with access to education tend to marry later than uneducated
women. They have smaller families, make better use of antenatal and delivery care, and
understand how to use family planning methods. They seek medical care sooner in the event
of illness, maintain higher nutritional standards, and raise their daughters to receive sufficient
education to keep the cycle of health improvements moving in a positive direction (Borkotoky
& Sayeed 2015). Educated women typically have the level of health literacy to retain control
over their reproductive function. They understand the issues involved, the presence of risk
and the steps that need to be taken to ensure health and safety for them and their babies. It
is also widely accepted that education prepares mothers in developing early, enhanced child-
rearing practices, which affects their children’s lifelong potential. However, education alone
cannot completely prevent a gender gap in terms of women’s professional lives and levels of
pay (see earlier).
KEY POINT
Educating girls is the single most powerful way to promote equitable personal opportunities
and pathways to health and wellbeing in any country.
Men’s health issues

Like women’s health, men’s health is created in the context of the SDH. Sometimes these
determinants go unrecognised, especially when it comes to the socially determined differences
between men and women. It is far easier for most people to relate to men’s and women’s health
in terms of biological factors, categorising health and health needs in terms of their respective
reproductive systems or body parts, instead of socially constructed patterns of behaviours.
Images of health and wellbeing are also socially engineered by the media. These images disguise
reality, by portraying biologically perfect specimens doing exciting things or, in complete
contrast, images of young people engaged in a wide range of antisocial acts. Little wonder that
those on the verge of developing their gender identity are uncertain of where to find role
models.
KEY POINT
Men’s behaviours are due to a combination of social and cultural expectations regarding
expectations of the ‘male ideal’.
Will Courtenay (2000), a leading men’s health researcher, argues that social and institutional
structures help to sustain and reproduce men’s health risks and the social construction of men
as the stronger sex. These structures reproduce a hegemonic view of gender. Hegemony refers
to the fact that men are more culturally valued in Western society, and therefore the dominant
sex. Gender, as an SDH, is one of the most significant influences on health-related behaviour
for men, as well as for women, yet common perceptions of gender as a social determinant
revolve around women’s health. The way men negotiate gender roles actually creates higher
health risks for many men as compared to women. Their elevated risk of some of the most
prevalent conditions, such as cardiovascular disease, type 2 diabetes and mental illness, is
linked to a cluster of unhealthy lifestyle behaviours that many men see as synonymous with
masculinity. These are the deadly risks of smoking, drinking and driving, unhealthy diets,
avoiding exercise and emotional help, or screening for various conditions.
Besides notions of the ‘male ideal’, men’s lifestyles are also determined by their socio-economic
position (SEP) on the social gradient. Rurality or remoteness, limited help-seeking behaviours
and poor health literacy contribute further to the premature mortality, injury and disease
incidence and prevalence among men (Cordier & Wilson 2014a). Men at the lower end of the
social gradient may see their bodies as a work instrument, and large body size as an indication
of strength and dominance. This perspective can lead to a lack of concern for the combination
of diet and exercise that would reduce their risk of cardiovascular or metabolic diseases.
Although somewhat stereotypical, men’s employment often drives their motivation for taking
care of themselves, particularly in terms of exercise. For many men, strenuous manual work
limits their motivation for recreational exercise. Large body size can also be culturally mediated.
Addressing culturally embedded notions of gender, food and body size is challenging. Efforts
among Pacific communities living in New Zealand frequently revolve around church- and
community-based activities that focus on nutrition and exercise. Working with local communities
in spaces and places that are relevant to them and guided by their needs are proving to be the
most effective approaches to addressing the health and lifestyle needs of Pacific people (Funaki-
Tahifote et al. 2016).
To some extent, men’s unhealthy behaviours are due to the greater social pressure to conform,
relative to women. Conforming to the male ideal means a man sees himself as not only strong,
but independent, in control, self-reliant, robust and tough (Griffith 2015). Although some
behaviours are shaped by ethnicity, social class and sexuality, most men also take unnecessary
risks to assert their masculine side. They brag about resisting the need for sick leave from
work, boast that drinking does not impair their driving and dismiss the need for preventative
health care, all aimed at maintaining their ranking among other men (Courtenay 2000, Griffith
2015). Illness is not masculine, so they tend to ignore anything that does not seem to be
life-threatening.
The social construction of masculinity does not negate biological differences, but there are
several other important social and cultural determinants of men’s health. Men have more
intentional and non-intentional injuries than women, particularly Indigenous men. They die
younger than women, with three times as many young men (four times as many young Indigenous
men) dying from suicide than women (Australian Institute of Health and Welfare 2016). Like
women, the main cause of death among Australian and New Zealand men is cardiovascular
disease (Australian Institute of Health and Welfare 2016, New Zealand Ministry of Health
2015). The cluster of major risk factors for men’s ill health includes obesity, physical inactivity,
alcohol and substance abuse, tobacco smoking, injuries and violence. These risk factors, combined
with hereditary predisposition and social disadvantage, lead to high rates of type 2 diabetes
(especially in the over 55s), cardiovascular disease, cancers and depression (Australian Institute
of Health and Welfare 2016, New Zealand Ministry of Health 2015). Men are also dispropor-
tionately represented in workplace injury statistics, especially in construction, mining and, in
New Zealand, forestry.
Psychological health is also a different experience for men and women. Depression is a
problem for many young people, but girls tend to seek help more readily than young males
do. Men are more likely to use illicit drugs than women are—in particular methamphetamine
(Australian Institute of Health and Welfare 2016). For indicators of psychological health, such
as self-esteem, men tend to be favoured, but in the web of factors comprising mental health,
men’s risks are greater.
The Male Room is a drop-in centre for men, providing counselling and other mental health
services (photo: Jill Clendon).
The social pressures of masculinity, especially in socially dictated norms and roles, create
conditions that see many men disadvantaged in relationships. Men hesitate to talk about
sensitive issues which are often seen as damaging to their identity (Cordier & Wilson 2014b,
Tyler & Williams 2014). Their hesitancy to disclose stress or other psychological problems is
a major problem for rural men, who have few sources of community support. Men in rural
and remote areas are at significant risk of suicide (Australian Institute of Health and Welfare
2016, Culph et al. 2015).
Depression is the major risk factor for suicide and, in men, it is often less likely to be diagnosed
(Scholz et al. 2016). Depression can manifest in aggressive behaviour, obsession about work,
substance abuse, destructive thoughts and refusal to seek help. Behind these behaviours may
be vulnerabilities that are not well understood, including a predisposition to PND (Cameron
et al. 2016). This context of mental ill health has thus far been virtually ignored in the health
care system. Similarly, attention to the psychological and physical health of single fathers has
been overlooked, yet the same factors of low income, unemployment, social isolation and child
care affect both men and women as single heads of the household. Men’s psychological health
is further jeopardised by a lack of appropriate counselling services, especially those that could
address the constellation of determinants that shape men’s lives. Whereas women-only services
have been developed to help women feel comfortable in treatment and screening, equivalent
services for men have yet to emerge and, where they do exist, they are often provided to
address deficiencies, such as sexual dysfunction clinics. The exception is ‘Men’s Sheds’, which
have evolved in tandem with the men’s health movement to encourage safe spaces for men to
interact and share emotional as well as physical issues, with demonstrable improvements in
mental health among men who attend (Culph et al. 2015).
KEY POINT
Depression may manifest itself among men in different ways to women. Health practitioners
need to be able to recognise male-specific symptoms and risk situations in order to be able to
provide appropriate care.
Men’s and women’s health policies

Australia has developed both men’s and women’s health policies to ensure the health needs of
both groups are addressed. Both have a core focus on the SDH and addressing immediate and
future health challenges. Addressing health inequities is also key. New Zealand does not have
policies specific to men’s or women’s health. The country does, however, have a Ministry for
Women. The Ministry for Women, Te Minitatanga mō ngā Wāhine, has a key role in providing
policy advice on improving outcomes for women in New Zealand. There is no men’s equivalent.
One of the most important elements of any health policy is to ensure it is making a difference
for the people it is intended to help. Health policy evaluation is discussed in detail in Chapter 2.

• Australian Men’s health policy: www.health.gov.au/internet/main/publishing.nsf/Content/
national%20mens%20health-1
• Australian Men’s health research: www.tentomen.org.au/
• Australian Women’s health policy: www.health.gov.au/internet/main/publishing.nsf/Content/
national-womens-health-policy
• Australian Women’s health research: www.health.gov.au/internet/main/publishing.nsf/Content/
phd-women-longitudinal.htm-alt
• New Zealand women: http://women.govt.nz/
Gender issues among sexually diverse populations

Lesbian, gay, bisexual, transgender/transsexual and intersex (LGBTI) populations face a variety
of health care disparities, frequently because they are marginalised in many Western societies
such as our own, by discrimination and social exclusion. Although women and men within
these groups have distinctive needs, as a group, they have an additional illness burden related
to their sexual identities and expressions. The socially patterned discrimination that exists
in many aspects of their lives leads to heightened risks of violence, social invisibility and
marginalisation, isolation, self-denial, guilt and internalised homo/bi/transphobias (Richards
& Barker 2015). Population studies in the UK, the US, Australia and New Zealand indicate
that LGBTI people have higher rates of certain chronic illnesses, cancers, mental health issues,
alcohol, tobacco and other drug abuse, body dysmorphia, disordered eating practices and
sexually transmitted infections (STIs) such as human immunodeficiency virus (HIV) (Donald
& Ehrenfeld 2015). These conditions are exacerbated by lower levels of access to appropriate,
culturally and gender sensitive health services (Donald & Ehrenfeld 2015). Lesbian women
and gay men often fail to disclose their gender identity to avoid being stereotyped, stigmatised
or treated in a prejudicial or discriminatory manner (Sirota 2013). Lack of recognition of
the fluidity of relationships can also create barriers to comprehensive, individualised care
(Rounds et al. 2013). Worse still, in some cases, members of sexual minorities are refused
care, or have their needs dismissed by health practitioners, which creates a lack of trust in the
health system and perpetuates the disparities that they have experienced throughout their lives
(Rounds et al. 2013).
Few heterosexual health practitioners have a deep understanding of how difficult life can
be for LGBTI groups. Prior to 1973, being gay was pathologised as a mental disorder. Since
that time, the research agenda has advanced public understanding of identity development in
‘coming out models’ (Dunlap 2014). Like all young people, identity formation begins during
adolescence, when they become sensitised to feelings, including being attracted to another
person. When these feelings are towards a person of the same sex, there is a challenge for the
young person to deal with the feelings in a way that will help them ‘come out’ and reach a
degree of comfort in and enjoyment with their sexual identity and satisfaction with membership
in the LGBTI community. With social support and a sense of community, young people can
maintain psychological wellbeing through the ‘coming out’ process.
KEY POINT
Trending now in homosexual families:

• Lower risk of HIV/AIDS because of reduced promiscuity
• Equality in housework
• More opportunities to socialise
• Young men have difficulty coming out
• Some children face discrimination, bullying
• Ageist attitudes
• Overlooked in mainstream health services
The past few years have seen growing acceptance of gender difference within many com-
munities. Social media has played an important role in this process. For example, media coverage
of Caitlyn Jenner brought transgender issues into the public arena in a way that had not
occurred previously with mainstream media adopting her preferred name and female pronouns
in a predominantly positive manner (Telfer et al. 2015). Resultant discussions in areas such
as gender and sexual identity, usage of pronouns (for example he, she, they) and adoption of
language to describe gender and sexual identity such as asexual, pansexual and cisgender are
becoming increasingly common. These conversations encourage acceptance and inclusion of
LGBTI individuals and families within communities. Victoria, for example, has invested $6
million to increase gender reassignment services at the Royal Children’s Hospital multidisciplinary
gender service in Melbourne to meet growing demand. It is estimated 1.2% of adolescents
identify as transgender (Clark et al. 2014) and that early intervention can improve quality of
life and educational and vocational outcomes (de Vries et al. 2014).

• Gender definitions: www.transstudent.org/definitions
School nurses are an important source of support and empowerment for children and
young people who identify as LGBTI or whose parents identify as such. The children of sexually
diverse parents can also experience discrimination regardless of their own sexual and gender
identity. Many do not identify as gay, but spend their lives concealing the sexual orientation
of their parents as a way of preventing bullying or overt discrimination. School nurses can
help children and young people maintain perspective and mental health. They also play an
important role in encouraging inclusiveness in the wider school environment and helping
non-diverse peers recognise the value of diversity within a school.

• The health and wellbeing of gender diverse people: http://lgbtihealth.org.au/
• Supporting LGBTI young people in New Zealand: www.msd.govt.nz/documents/about-msd-
and-our-work/newsroom/lgbti-release-ministry-of-youth-development.pdf
Mental health issues have a major impact on the lives of sexually diverse people. Institu-
tionalised and interpersonal discrimination increases vulnerability to mental illness and distress
and the LGBTI populations in Australia and New Zealand experience some of the poorest
mental health outcomes of any group (Jenkins 2016). Those who are attracted to the same sex
are twice as likely to experience anxiety disorders compared with the general population and
14 times more likely to attempt suicide (Jenkins 2016). People with intersex variation experience
psychological distress at levels comparable with people who have suffered severe abuse (Jenkins
2016) and older LGBTI people experience higher levels of depression than heterosexual older
people (Tinney et al. 2015). Both males and females suffer from the identity confusion and
turmoil of adolescence, and adding discrimination to the mix can be a heavy burden, particularly
for gay Indigenous people.
Because sexually diverse people have not been recognised as an identifiable population
group for health care, their health needs are virtually ignored in mainstream service planning.
Intersex people are visibly marginalised as soon as a person is asked to identify their gender.
For those who identify as intersex, which box do they tick—male or female? Some researchers
are adding ‘prefer not to say’ to surveys but this approach is also problematic—it still does
not identify those who identify as intersex and may skew gender analyses. As a group, sexually
diverse people under-utilise health services, often because of a lack of confidence and systemic
discrimination, which leaves some with sub-standard care. Because of typical patterns of
medical history taking, their gender identity, sexual orientation and health-related behaviour
or circumstances are often overlooked. This leaves health problems undiagnosed, misdiagnosed
or untreated, especially where risky sexual practices have not been identified. Because health
services are generally based on the expectation that most clients are heterosexual, it is important
that nurses and others ensure they use inclusive language, and that questions regarding sexuality
and sexual orientation are included in assessment processes.
Intimate partner violence

Although we have addressed family violence in the context of family relations in Chapter 7,
it is addressed here as one of the most gender-specific causes of women’s disempowerment.
Intimate partner violence (IPV) is usually about one partner in a relationship controlling
another. Violence against women is a pervasive global problem with the most damaging violence
caused by male intimate partners (Sawyer et al. 2015). In Australia and New Zealand, between
17 and 35% of women have experienced some form of violence against them (Fanslow et al.
2016, Gulliver & Fanslow 2015, Sawyer et al. 2015).
Besides physical injuries the outcomes of violence against women can include stress, poor
mental health, self-harm, substance abuse, difficulty accessing services and poor sexual and
reproductive outcomes (Sawyer et al. 2015). The threat of having children removed from a
violent home can act as a deterrent to disclosure and lead women to escape the domestic situation
for the sake of their children. Some then become homeless, which starts a vicious cycle of
disempowerment for them and their children. The social context of homelessness can leave
them enmeshed in a network of alcohol and substance abusers as well as ongoing vulnerability
to further violence on the streets. Young homeless women in particular are vulnerable to sexual
coercion simply to survive. In some cases, women who have fallen into this type of cycle become
further victimised by health and social services, especially where personnel have been ill prepared
to understand the depth or breadth of their distress or the physical effects of sex work, which
can include sexually transmissible diseases and other illnesses (Benoit et al. 2016).
The effects of IPV also have profound harmful effects on the children witnessing abuse in
any context. Young children in detention centres are often exposed to gender norms of violence
that may be culturally acceptable but not appropriate in terms of the gendered behaviours
they will observe in their host country post-migration, which are usually more gender balanced.
Their time in detention can therefore leave them at risk of a distorted view of gender relations.
In other living environments children may be caught between violent parents or partners role
modelling violence on a regular basis, or intermittently at the time of transitions between
staying with one or another parent. Their exposure is a serious problem in both the immediate
and long term and has widespread repercussions as children who witness abuse are more
likely to be abused themselves, to have behaviour problems and increased exposure to other
adversities such as alcohol and drug abuse, crime and other antisocial coping strategies (Fanslow
et al. 2016). The risk factors for violence against women and their children vary across cultures
and, to date, there remains no definitive pattern for predicting which factors will lead a man
to abuse a woman. Those factors that have been identified comprise a multifaceted web of
causation, where violence is a result of the interaction between aspects of the individual, the
relationship, the community and society, as illustrated in Fig. 9.1.
The frequency of violence against women has inspired the WHO Global Campaign for
Violence Prevention to implement the recommendations of the world report on violence and
health and global status report on violence prevention (WHO 2014). The campaign is aimed
at raising awareness of what has become a major source of injury among women, highlighting
the role of public health in addressing its causes and consequences and in fostering prevention.
The campaign also provides an online platform for dissemination and exchange of evidence-
based knowledge about violence prevention as well as policies, plans and experiences (see
www.who.int/violence_injury_prevention/violence/global_campaign/en/). Addressing all four
risk factors associated with family violence (individual, relationship, community and society
factors) is the ideal approach to preventing violence. Nurses, midwives, paramedics and other
AL FACT
IVIDU O
IND RS
• Low income/education
• Young age
• Separated/divorced
• Exposure to child maltreatment
• Intra-parental violence
• Mental health issues
• Substance abuse
RS
including alcohol
RS
IONSHIP FACTO
misuse
• Acceptance
AL FACTO
• Marital conflict
of violence
• Marital instability
• Male family dominance • Traditional gender norms
• Poor family functioning • Societal norms supportive
• Multiple partners/infidelity of violence
• Low resistance to •Economic stress
CIET
peer pressure
LAT
SO
• Poverty
RE
• Low social capital

• Weak community sanctions
against domestic violence
CO S
MMU OR
NIT Y FACT
Figure 9.1 Web of causation: Factors associated with a man’s risk of abusing his partner
Source: World Health Organization and London School of Hygiene and Tropical Medicine, 2010. Preventing
intimate partner and sexual violence against women: Taking action and generating evidence, Geneva, World
Health Organization.
health practitioners who work in communities and frequently see people in their own homes
are often best positioned to respond with assistance and support (Prosman et al. 2015, Sawyer
et al. 2015, Usher-Patel 2013). Many are leading advocates for championing the rights of
women and addressing IPV and its effects on health and wellbeing. Screening for violence in
health settings and home visits by maternal, child and family nurses is also gaining momentum,
particularly with research studies indicating that women appreciate being asked about abuse
(Fanslow et al. 2016). New Zealand and Australian screening protocols are based on empower-
ment and safety, and ensuring there are adequately prepared health practitioners to be of
primary, secondary and tertiary assistance to women. Once a woman’s immediate needs are
met, longer-term empowerment can be based on providing them with the opportunity to
explore the issues of power and control embedded in their relationships (Usher-Patel 2013).
Support groups, advocacy, shelter, education, legal aid and collaboration between service
providers are also important components of service provision (Usher-Patel 2013). Equally as
important is the need for mutual support friendship networks, which women often find the
most accessible means of support, and the need to keep social inclusion on the research agenda.
KEY POINT
Screening for interpersonal violence is an effective means of reaching women who may be at
risk of violence. It also offers the opportunity to provide support, safety and validation of the
woman’s experience.
Goals for gender-inclusive communities

■ Eliminating all forms of gender bias
■ Public awareness of the need for gender-sensitivity in health
■ Health literacy, targeting the fundamental issues related to gender equality, such as
poverty and social exclusion
■ Equal access to fair conditions and fair remuneration in the workplace
■ Gender equality in power and decision making in the family
■ Eliminating all forms of discrimination and violation of human rights
■ Heightening awareness of the gender bias inherent in globalisation
■ Gendering the social and political debates on child care, gun control, crime prevention,
transportation, education and other forums for intersectoral collaboration
■ Heightening awareness of linkages between health, health care, cultural norms and
human rights
■ Promoting the health and safety of all family members, free from violence in the home
■ National child care strategies accommodating the needs of different family types
■ Healthy, just and equitable public policies
We now turn our attention towards culture and inclusiveness. While our predominant
focus is on Indigenous culture, refugee and migrant communities and, in particular,
Pacific communities, also warrant further attention. As noted earlier, the most compelling
mark of an inclusive society is the respect conferred on its Indigenous people. The gross
social and health inequities experienced by Indigenous people in Australia and New
Zealand are a result of colonisation, disempowerment, individual and institutional racism,
alienation from land and culture and social exclusion that extends back generations.
How these are addressed moving forward is an area all health practitioners should be
concerned with.
PART TWO: CULTURE AND HEALTH

Indigenous people in Australia and New Zealand have different histories and experiences. As
population groups, what they have in common is a history of colonisation and dispossession
that has not yet been fully redressed by non-Indigenous people in either country. New Zealand
has made greater progress than Australia in valuing its Indigenous people, particularly since
the Treaty of Waitangi and its mandate for recognition of all New Zealanders as equal before
the law. Although Australia has yet to develop a treaty with Indigenous people, there is a
renewal of political attention to the need for reconciliation between Australia’s Indigenous
and non-Indigenous people. This was enshrined in the national public apology to Indigenous
people by Australia’s Prime Minister in 2008, but much remains to be done in re-shaping
Australia as an inclusive society. State, Territory and Commonwealth government initiatives
to ‘control’ Indigenous affairs, and therefore Indigenous people’s health, have polarised public
opinion. Some condone heavy-handed measures to intervene in the way some Indigenous
communities live their lives, while others are outraged that non-Indigenous norms and expecta-
tions would be placed on Indigenous communities. Australian public opinion is also divided
on the plight of refugees from other countries, with some citizens advocating a greater human
rights orientation, and others arguing for ‘fairness’ in the way migrants are processed and/or
allowed into the country. This is one area where New Zealand political will is decidedly clear,
supporting a compassionate basis for decision making.
The relevance of political decisions governing migrants and Indigenous people is of major
importance to nurses and other health practitioners working towards community health and
wellness. As a basis for any type of intervention, the professions need to be fully informed
of how both historical factors and current realities interact to keep Indigenous or other
cultural groups socially disadvantaged. Understanding Indigenous ways of knowing, and the
worldviews of other cultures, should lead to change, but it does not always achieve this.
The challenge is to advance this knowledge as a basis for informing community awareness,
then provide a rationale for policy and practice with the ultimate goal of social justice and
inclusion.
We are both members of the non-Indigenous cultures of our respective countries, and we
write this section drawing on a wide range of Indigenous and non-Indigenous literature, in
consultation with members of Indigenous cultures, and on our respective experiences of the
health and political environments in which we live and work. From this base of knowledge,
we can work together, seeking common solutions that redress past and current barriers to
health and wellness. We can then work towards helping Indigenous people negotiate retention
of their culture, and promote equitable, inclusive environments for health and wellbeing.
Culture
Cultural groups are bound together by a tapestry of historically inherited ideas, beliefs, values,
knowledge and traditions, art, customs, habits, language, roles, rules and shared meanings
about the world. Culture is therefore multidimensional. Cultural influences are often tacit in
people’s behaviours, as unconscious, shared predispositions, rather than deliberate attempts
to be distinctive. Although there are commonalities that bind members of a particular cultural
group, individual expressions of culture vary according to a person’s characteristics and
experiences.
Diversity in expressions of culture is also a product of how people relate to their environments.
Culture is integral to a person’s social life, part of his or her ecological relationship with the
world, which is dynamic and adaptive. In ecological terms, as people in any cultural group
interact with their environments, there is a reciprocal effect on the environments and the
people themselves (Eckermann et al. 2010). Culture is also experienced differently at different
ages and stages of life, as people self-reflect, develop their own identities and respond to
circumstances and self-reflection. Their cultural behaviours are therefore shaped by a range
of experiences besides the cultural norms of language, lifestyle habits and family expectations.
Although cultural traditions can bind people together, it is inappropriate to consider members
of one or another culture as homogeneous, as within cultural groups there is often wide
variability.
A critical view of culture seeks to overcome the monolithic view that all members are relatively
similar. Instead, understanding individuals comes from exploring their history, behaviour and
particular view of the world as it is embedded in their culture, but distinctive in their patterns
of attitude and behaviour. Conducting an assessment of a person’s needs therefore has to
include both unique and common strengths and needs. Like other cultural groups, Indigenous
‘culture’ is not something that can be made explicit, and health services need to be designed
using localised evidence obtained through culturally appropriate methods, guidelines and
culturally competent care (Kendall & Barnett 2015). Trying to define a certain culture as a
cultural outsider is difficult and can lead to stereotyping. To be authentically inclusive, health
practitioners have to understand the history and structural factors that have been part of a
person’s experience, in the context of diversity within and external to the group (Kendall &
Barnett 2015). This non-stereotypical approach provides insight into people’s worldview and
their history, their declaration of what they value and the barriers and strengths that can lead
to empowerment and self-determined decision making. These choices are embedded in family
and community and the human right to achieve social and cultural capital (see Fig. 9.2). We
have previously defined social capital in terms of trust, civic engagement, participation and
belonging. Cultural capital refers to the source of power and resources that can help people
maintain social capital in a way that will be beneficial and validate their ways of knowing and
understanding.
KEY POINTS
Social capital
The values of trust, reciprocity, participation and belonging.
Cultural capital
The power and resources that help people maintain social capital in a way that values cultural
understandings.
Culture conflict
In some cases, the ecological interactions between people, their culture and other cultural
groups is mutually beneficial. People of different cultures settling together in a new land often
Nature
History Spirit world

Language
Kinship group
Political/economic Interactions with
factors others
Land rights Knowledge

Education
l/Cul tur al capita l
Soc i a
Decolonisation Experience
experiences reciprocity, collec with health
rust,
of t tive
ac care system
rms tio
o
N
Family
Traditi
Lo
ss, ons/World v i e w
sep ces
arati rien
on, traumatic expe
Figure 9.2 Family, culture and social capital

learn from one another. Over time, their long-term contact with one another can result in the
type of acculturation where two cultural groups become integrated; or relatively similar
(Agbemenu 2016). However, attempts at acculturating two groups can also be fraught with
conflict. Berry (1995) describes four different reactions to acculturation. The first is assimilation,
where one culture group abandons their culture in favour of the new or host culture. Integration
is the creative blending of the two cultures. Rejection is a reaction in which the new culture
replaces the heritage culture, and marginalisation occurs where neither the new nor the old
culture are accepted. Clearly, the most desirable option is integration, with marginalisation
the least desirable.
■ Assimilation—abandoning culture
■ Integration—blending cultures
■ Rejection—replacing culture
■ Marginalisation—non-acceptance of culture
Culture conflict typically occurs where people are not committed to similar goals or ambitions
and where societal decision making is based on dissimilar principles and philosophies. In its
extreme form, culture conflict can be enacted within racialised social structures, such as occurs
when all groups are defined and their behaviours measured according to white Western beliefs.
Racialised social structures often pervade Indigenous cultures in countries like Australia,
Canada, New Zealand and the US, where discriminatory and often racist attitudes promulgated
by media stereotypes portray Indigenous people as a ‘problem’ rather than showing balanced,
positive images of successful Indigenous people and families. Problematising their lives can
subjugate Indigenous knowledge, beliefs and values in a way that disempowers members of
Indigenous cultures by establishing standards and expectations against which differences, or
deviations from the norm, are measured, valued and often demeaned (Durey & Thompson
2012). For example, the high rate of smoking among pregnant Māori women in New Zealand
is frequently seen as an individual choice and women are blamed and condemned for this
behaviour (Houkamau et al. 2016). What this fails to account for is the reasons Māori women
smoke in the first place, such as institutional racism that results in fewer occupational, social
and educational opportunities, poverty, chronic stress and a lack of psychological resources
to support efforts to quit (Houkamau et al. 2016).
At the community level, culture conflict erodes social and cultural capital by causing dis-
harmony. When this occurs, members of the conflicting groups close ranks and withdraw
from each other, rather than cooperating to build a system of mutual community support. On
the other hand, when people from different cultures live with realistic possibilities for the
future, they are more likely to work within a type of cultural relativism; acceptance of one
another’s culture as the legitimate adaptation of different peoples to various historical, natural,
socio-economic and political environments (Eckermann et al. 2010). Cultural relativism lies
at the centre of tolerance and social inclusiveness. For two cultures to work together, no one
culture needs to abandon its traditions or philosophies, but each suspends judgement of the
other’s beliefs and practices. In this process, each makes a conscious decision to proceed on
the basis of their willingness to recognise and respect the beliefs and practices of others, and
to continually question their own views and presumptions (Eckermann et al. 2010). This is
also the first step in maintaining cultural safety.
Cultural safety
A culturally safe environment safeguards the authenticity and acceptability of diversity in
people’s beliefs, behaviours and social constructs. Appreciation of this concept has become
an integral area of community health practice. It requires all health practitioners to reflect
on their own cultural identity in order to understand and acknowledge how their mores
influence their interactions and health care practice with clients (Smith 2016). This helps
to ensure that the cultural needs of individuals and families across Australia and New
Zealand are addressed through inclusive health environments (ANZCA 2016). Aware-
ness of this quality of practice will facilitate acceptable and relevant interpersonal and
therapeutic relationships between health practitioners and their clients, thus avoiding
stereotyping.
KEY POINT
Culturally safe practice

1 Acknowledge that the health care relationship is power-laden, with the health care
professional holding the majority of power.
2 Develop cultural sensitivity by reflecting on your impact on the ‘other’.
3 Make a commitment to preserve and protect all cultures.
Cultural safety is a term that grew out of the colonial history of Aotearoa (New Zealand).
It was first described in 1988 by Māori nursing students expressing their concern about
safeguarding their culture as they were socialised into the world of nursing education and
ensuring the safety of Māori culture among those they would be helping in practice (Eckermann
et al. 2010). Their concerns were recorded by Irahapeti Ramsden, a Māori nurse who spearheaded
the cultural safety movement in Aotearoa, ensuring that cultural safety found its way into
curricula and nursing practice (Eckermann et al. 2010). As we mentioned in Chapter 1, cultural
safety means being aware of your own and others’ cultural beliefs, values and knowledge and
how these shape health and health decisions. Ultimately, culturally safe behaviour promotes
partnership, participation and cultural protection. By the 1990s cultural safety had been refined
beyond Māori culture to be inclusive of all cultures and all health care recipients whose culture
differs from their health care provider in any way (Gerlach 2012). Cultural safety is a form of
cultural relativism, which is concerned with how culture shapes power relations within the
social world of the community. It is designed to enable safe spaces for the interaction of all
BOX 9.1
CULTURALLY COMPETENT HEALTH SYSTEMS AND ORGANISATIONS
• Acknowledge diversity.
• Provide culturally appropriate care.
• Enable self-determination and reciprocity.
• Hold governments and health planners accountable for meeting needs of all cultures.
• Manage from a culturally competent evidence base.
• Recognise need for culturally competent training.
cultural groups, and their understanding of cultural identity. It is absent in the face of actions
that assault, diminish, demean or disempower the cultural identity and wellbeing of any
individual (Nursing Council of New Zealand 2012).
The first step in achieving cultural safety is cultural awareness. This includes recognis-
ing the fact that any health care relationship is unique, power-laden and culturally dyadic.
In other words, there is always the potential for one person (the health provider) to hold
power over the other person (someone seeking to access services). When the health care
relationship is built on a foundation of cultural sensitivity, there is a greater recognition of,
and respect for, cultural differences. People develop cultural sensitivity when they begin to
engage in self-exploration of their own life experience and realities, and the impact this may
have on others. The final stage in developing cultural safety is a conscious commitment to
ensuring preservation and protection of others’ cultures. Cultural safety is therefore a type
of advocacy informed by a recognition of self, the rights of others and the legitimacy of
difference (Nursing Council of New Zealand 2011). It is aimed at unveiling the unconscious
and unspoken assumptions of power of health practitioners with a view towards transferring
some of this power to those seeking care by using an inclusive approach, receptive to new
ways of knowing and understanding (Gerlach 2012). Nurses in New Zealand are required
to demonstrate how they practise in a culturally safe manner as part of maintaining their
nursing registration (Nursing Council of New Zealand 2012). In the process of being inclusive
of others’ voices, they gain an authentic understanding of health issues as a basis for planning
care, or cultural competence (Doutrich et al. 2014, Gerlach 2012). Equally as important is
the need for culturally competent health care systems and organisations to value diversity
and demonstrate reciprocity between and among cultures (Farmer et al. 2012, Perry et al.
2015). Box 9.1 outlines the requirements for culturally competent organisations and health
care systems.
POINT TO PONDER
New Zealand is a leading nation in the development of cultural safety and competency,
embedded within a primary health care framework. Ramsden’s (1992) seminal work identified
opportunities for teaching nurses about culturally safe clinical practice with Māori clients.
Ramsden further contributed to the development of the Guidelines for Cultural Safety, the Treaty
of Waitangi and Maori Health in Nursing Education and Practice (Nursing Council of New Zealand
2011). Review the following document: ‘Towards a shared understanding of terms and concepts:
Strengthening nursing and midwifery care of Aboriginal and Torres Strait Islander peoples’
(CATSINaM 2014) which discusses the relationship between New Zealand and Australian concepts
of culturally safe practice. In particular, take note of the section on cultural safety, cultural respect,
cultural security, cultural responsiveness and cultural competence.
Multiculturalism
The intent of multiculturalism is that ethnic group differences should be appreciated and
celebrated and that different groups make unique and valued contributions to society (Vorauer
& Quesnel 2017). However, multiculturalism is a value-laden term that has sometimes been
used as a panacea for intolerance. The term has been used to camouflage feelings of superiority
of one culture over another. It has also been used to salve the consciences of many people,
believing that because they live in a community containing many cultures, the community
must be inclusive, when this may be disputed by the realities of daily life.
Although small steps have been made towards heightening public awareness of the role of
culture in health, these have been only marginally effective in improving health outcomes. To
advance multiculturalism, societies need to institutionalise understanding and tolerance of one
another’s cultural beliefs and practices in the context of daily living as well as in the health care
system, and in planning for a future in which all cultures will be sustained. Not many societies
achieve this level of equity, but it is seen to be an aspiration worthy of just and civil societies.
Ethnocentrism, racism and differential health care

Ethnocentrism is the tendency to view the world through one’s own cultural filters, perceiving
and interpreting others’ behaviours according to a personal belief system and set of behaviours
(Durey & Thompson 2012). Each of us views the world through the cultural lens with which
we have been socialised, and this is why it takes a conscious effort to really ‘see’ other cultures.
When people develop an aversion to the very notion of tolerating other cultures, they are
described as xenophobic: fearing and despising those who differ. Xenophobia is often used
synonymously with racism, which is a belief in the distinctiveness of human races, usually
involving the idea that one’s birth-ascribed race or skin colour is superior to another (Durey
& Thompson 2012). Maintaining feelings of superiority about another race, or another group,
is called stereotyping. These feelings can lead to prejudicial attitudes, which, when acted upon,
result in discrimination. Discrimination is shown by speaking against the other person or
group, excluding or segregating them, committing acts of violence against them, or, at its
extreme, exterminating them as has occurred in World War II and other wars and conflicts.
Institutional racism operates at the level of legal, political and economic organisation in a
society, and it creates the impression that, because power dominance is exerted by essential
and respected forces in society, it is somehow tacitly acceptable (Eckermann et al. 2010).
Systemic bias allows one group to dominate another through the predominant social order,
where organisational and communication skills, financial resources and commitment of those
involved in running a system are able to exclude others, making them dependent on the
powerful group rather than allowing them full participation (Eckermann et al. 2010). In some
cases, this type of power imbalance occurs because of a lack of knowledge and awareness
rather than an intention to dominate. For example, culture blindness, where, inadvertently,
someone who believes they are working within an ethos of social justice develops universalism,
or an approach to health and social care where an individual proclaims to ‘treat everyone the
same’ (Durey & Thompson 2012:160). The issue here is that some people have greater needs
than others, so a universal approach will not help achieve equal opportunities and therefore
may perpetuate disparities for disadvantaged cultural groups (Marmot 2016).
KEY POINTS
Systemic bias is:

• benchmarking Indigenous health against non-Indigenous population norms
• using a universal or ‘one-size-fits-all’ approach to health care
• attributing needs to culture instead of structural and social determinants of health.
The other manifestations of systemic bias are evident when the health of Indigenous people
is analysed according to benchmarks established for non-Indigenous populations, or when
the blame for social and health problems is attributed to cultural characteristics instead of
inequities in the health care system (Durey & Thompson 2012). There is now a body of evidence
showing that Indigenous people in Australia and New Zealand have inadequate access to
health services and lower rates of medical interventions when they are hospitalised (de-Vitry
Smith 2016, Durey & Thompson 2012, Harris et al. 2012, Zambas & Wright 2016). Stereotyping
anyone’s health needs can be detrimental to health. For example, there are cases where a
person’s refusal of treatment is described as a lack of adherence, when it could be due to
communication difficulties. We frequently focus on the disparities in health and the state of
inequity that exists as a result of these inequities. And rightly so as this identifies the issues
and enables us to focus on interventions that may help address these. However, by focusing
solely on the disparities and poor state of health of Indigenous people in both Australia and
New Zealand, we fail to recognise the strength and resiliency that individuals, families and
communities bring to addressing their own health needs. To understand this strength and
resiliency, we need to understand more about each of these groups.
Aboriginality, culture and health

The term Aboriginal refers to the initial, or earliest, inhabitants of a place. They are also
described as First Nations, or Indigenous, people. Nelson et al. (2010) explain that the definition
of an Australian Aboriginal person is social rather than racial: a person who has descended
from an original inhabitant, who identifies as an Aboriginal person and is recognised as
Aboriginal by his or her community. Despite this commonality, Indigenous people have diverse
subcultures and worldviews. Members of different groups also have different influences on
their lives, many as a result of their environment. The influences on their health are shaped
by different determinants beyond biology, age, gender, education, socio-economic status, family
membership or neighbourhood. In some groups, cultural knowledge may prescribe everything
from diet and eating habits to child-rearing practices, and from reactions to pain, stress and
death to which behaviours may violate cultural norms. Cultural knowledge may also dictate
a palpable sense of past, present and future, the impact of community and economic structures
and the different ways people respond to health care services and practitioners.
Tshepiso Mojapelo (Daisy), child health nurse in Wurrimiyanga (Bathurst Island), Tiwi Islands,
Northern Territory (photo courtesy of Tshepiso Mojapelo)
KEY POINT
Indigenous understandings of health and wellbeing are manifest within holistic, symbolic,
spiritual and ecological perspectives.
The most distinctive feature of Indigenous cultures is a holistic, ecological, spiritual view
of health and wellbeing. This perspective encompasses physical, mental, cultural and spiritual
dimensions of health, and the harmonised inter-relationships between these and environmental,
ideological, political, social and economic conditions (Eckermann et al. 2010). At the centre
of Indigenous people’s relationship with each dimension of health is a fundamental spiritual
connection with land, symbolising their responsibility as inhabitants of the land, to take care
of it and preserve it for the next generations (Kingsley et al. 2013). This is integral to their
ecological connection between health and place.
Indigenous people’s relationships between health and place

The spiritual relationship with land is a metaphysical connection, governing all other inter-
relationships. The land is typically described by Indigenous Australians as ‘Country’, which is
the place that gives and receives life and is part of the support cycle of life-death-life (Kingsley
et al. 2013). Indigenous Australians talk about Country in the same way that they would talk
about a person. Country refers to everything including land, air and water and Indigenous
Australians have a spiritual connection to the land built over thousands of generations (Kingsley
et al. 2013). This is a different concept of land from the non-Indigenous understanding, where
land is considered an empty space to be ‘tamed’ or worked (Kingsley et al. 2013). New Zealand
Māori articulate a similar connection with the land to the Aboriginal understanding. The land
historically provided the sustenance necessary for life, but it is also the spiritual, cultural and
ancestral home for Māori. This relationship is based on the worldview that Ranginui (Sky
Father), and Papatuanuku (Earth Mother), are the primal parents from whom all Māori descend.
Māori refer to themselves as Tangata Whenua (people of the land), which captures the spirit
of this kin relationship making the people and the land inseparable. Platforms for Māori health
are considered to be ‘… constructed from land, language, and whānau; from marae and hapu;
from Rangi and Papa; from the ashes of colonisation; from adequate opportunity for cultural
expression; and from being able to participate fully within society’ (Durie 2004:35–36).
The close connection with land is what distinguishes the Indigenous ‘holistic’ view from
other common perceptions of holism (Anderson et al. 2011). The uncritical way non-Indigenous
policymakers and health planners understand Indigenous ‘holism’ is problematic when it is
seen as a biomedical concept and translated into strategies for health and health services
without deeper understandings of this holistic worldview (Durey & Thompson 2012). Locally
relevant interventions need to reflect local knowledge from place-based communities whose
members have developed the skills to articulate their needs from the holistic interpretations
that resonate with the community (Anderson et al. 2011).
The health of Indigenous Australian people

and New Zealand Māori
It is well known that there are gross inequities in health outcomes for both the Indigenous
people of Australia and New Zealand Māori. Life expectancy for both groups is substantially
less than that of the non-Indigenous populations in either country. Health outcomes across
most measures are also worse. Further information on where to find more on the specific
BOX 9.2
THE HEALTH OF AUSTRALIAN INDIGENOUS PEOPLE

AND NEW ZEALAND MĀORI
Indigenous health in Australia

• http://www.healthinfonet.ecu.edu.au/about
• http://closingthegap.pmc.gov.au/
Māori health in New Zealand
• http://www.health.govt.nz/our-work/populations/maori-health
• http://hauora.co.nz/maori-health-promotion/
• http://www.health.govt.nz/publication/dhb-maori-health-profiles
statistics and health issues that face both groups can be found through the links in Box 9.2.
Because work is under way in both countries to address these inequities, we choose here to
focus on the strengths and efforts that are being made to address inequities rather than on
the deficits. We focus closely on mental health and healing.
Health and healing

Therapeutic approaches to healing must be based on understanding the cultural meanings of
kinship, the land, spirituality and heritage of Indigenous people (NiaNia et al. 2016). Working
with Indigenous people to improve health is a circular process of holistic, spiritual and cultural
understandings of the contextual realities of a person’s life, family context and past experiences
(NiaNia et al. 2016).
Young Māori thriving (photo courtesy of the Powell whānau)

Assessing an Indigenous person’s wellbeing must be done in a way that is sensitive to the way
mental health is conceptualised. For example, some Indigenous Australian groups may believe
they are being ‘sung’ by an aggrieved party, married the ‘wrong way’, ‘caught out’ by the law
or ‘crying for Country’. The latter example illustrates the interrelatedness of health and place,
acknowledging Indigenous people’s close connection to Country.
The Whare Tapa Wha Māori Model of Health developed by Mason Durie in New Zealand
articulates a concept of holism that has been adopted by many Māori and non-Māori, as a
means of understanding the way in which Māori conceptualise health. The four cornerstones
of the Whare Tapa Wha model are Hinengaro (mental wellbeing), Tinana (physical wellbeing),
Whānau (family wellbeing) and Wairua (spiritual wellbeing). Each cornerstone is interlinked,
and health may not be achieved without a balance between all four cornerstones (Durie 2004).
As a spiritual journey, healing requires time and a culturally safe, capacity-strengthening
approach to assist in the recovery from past traumas, addictions or other problems. The ‘by
Māori for Māori’ health services in New Zealand are one approach to addressing many of the
cultural needs of Māori as they seek to address their health needs. These services are based
in both traditional settings, such as hospitals, and in non-traditional settings, such as on Marae
(Māori meeting ground).
Importantly, past traumas, such as those experienced by the Stolen Generations, cannot be
resolved until there is government and societal acknowledgement of the source of these problems.
Long-term grief and trauma can become transgenerational, and can lead to dysfunctional
family life, including violence, self-harm and suicide. In Australia, Indigenous suicide rates
are estimated to be twice that of non-Indigenous people (Department of the Prime Minister
and Cabinet 2017).

Health promotion programs developed to address young indigenous people’s
mental health which include cultural healing and counselling
• Indigenous hip hop projects: https://indigenoushiphop.com/
• Resourceful Adolescent Program: http://www.rap.qut.edu.au/
• The Healing Foundation: https://healingfoundation.org.au/
The oppression of Indigenous people is indisputable, and it creates enormous challenges

for medical practitioners, nurses, midwives, paramedics, health workers, teachers, police and
other practitioners working in Indigenous communities. For all of these health advocates the
objective is to work out ways of helping people retrieve their sense of self, family, culture,
community and society (see Fig. 9.2). This can begin through delving into the root causes of
a set of behaviours such as alcohol or substance misuse that create cycles of risk, then working
with individuals and families to see what can be done to reset the pattern for a more optimistic
future.
Goals for Indigenous health

■ Eliminate racism and all forms of discrimination against Indigenous people.
■ Address the social determinants of disadvantage and inequity for Indigenous people.
■ Improve child and youth health and wellbeing through perinatal and early childhood
intervention and prevention strategies.
■ Recognise the uniqueness and importance of Indigenous family and extended family
networks.
■ Promote public acceptance of the unique needs and sensitivities of Indigenous people.
■ Improve the cultural responsiveness of mainstream services through better transparency
and accountability, and develop specific services tailored to cultural needs.
■ Develop a well-resourced evidence base for best practice in Indigenous health.
■ Recognise the impact of environmental degradation on Indigenous people, and create
genuine opportunities for affected communities to participate in decision making for
environmental restoration.
■ Acknowledge the uniqueness of Indigenous systems of knowledge in caring for Country.
■ Maintain the health of Indigenous people as the highest priority for health planning.
■ Support the development of economic, social and cultural capital to foster
self-determinism, and strategies for culturally appropriate, sufficiently resourced
education and skill development.
■ Adopt strategies for intersectoral collaboration in all policies and planning strategies at
all levels.
■ Ensure cultural safety in all service provision for all people.
■ Enshrine diversity and culture in the laws and social processes of the country.
Inclusive migrant communities—the Pacific experience

in New Zealand
Pacific people comprise close to 7% of the New Zealand population and come from over 22
different Pacific nations. Each Pacific community has its own distinctive culture, language,
history and health status. The largest Pacific groups are the Samoan, Cook Island, Tongan and
Niuean communities. Over 65% of the Pacific people living in New Zealand live in the Auckland
area (New Zealand Ministry of Health 2014a). Auckland (along with Sydney, Australia) is now
recognised as one of the most culturally diverse cities in the world, but Pacific people in New
Zealand experience poorer health outcomes than other New Zealanders across a range of
health and disability indicators (New Zealand Ministry of Health 2016).
New Zealand has made a significant and long-term commitment to addressing the inequi-
ties experienced by Pacific people, working closely with the Pacific community to develop
a range of policies designed to improve health. The current strategic plan for addressing
Pacific health, ‘ ’Ala Mo’ui: Pathways to Pacific Health and Wellbeing 2014–2018’ (New Zealand
Ministry of Health 2014b) identifies a range of outcomes to be achieved for Pacific people.
These include ensuring that: systems and services meet the needs of Pacific people, there
are more locally delivered services in the community and in primary care, Pacific people
experience improved broader determinants of health, Pacific people are better supported
to be healthy, the Pacific workforce supply meets service demand, every dollar is spent in
the best way possible to improve health outcomes, and Pacific culture is respected (New
Zealand Ministry of Health 2014b). ’Ala Mo’ui was developed in collaboration with a range
of clinical and community leaders in an effort to ensure the policy goals and actions are
in line with the expectations of the community. Such inclusive approaches to policy devel-
opment are essential to achieving health equity for Indigenous people, and migrant and
refugee groups.
Conclusion
We discuss the various experiences of refugee, migrant, Indigenous and other minority and gender
groups throughout this book with the ultimate goal of health, equity, social justice and inclusiveness
for all. Social inclusion is a social determinant of health equity. Achieving equity and, therefore, social
justice begins with acknowledging the inter-relatedness of health, place and economic viability.
Creating a strong sense of identity among Indigenous people, addressing Māori health through
approaches such as whānau ora, fostering community, place-based initiatives, empowering com-
munities through engagement and co-design, and building human capital through education, parenting
skills and work experience skills will all engender inclusiveness. Health practitioners must get involved
in communities’ self-defined priorities for health and wellbeing. Advocacy, maintaining current
knowledge of the decisions that are being taken at the political level, maintaining cultural safety
and seeking the views of local Indigenous people on how actions may affect their capacity for
self-determination are all essential in achieving these goals. Equally as important is developing the
Indigenous and minority health workforce to ensure Indigenous and minority groups have access
to health practitioners of their choice. Inclusive communities emerge from conditions where everyone
has an equal opportunity in their daily lives. Our case study now examines issues of inclusiveness
for the Smith and Mason families.

Whānau ora
Whānau Ora is an approach designed to reduce health and social wellbeing disparities among
vulnerable families by supporting families to achieve their maximum health and wellbeing:
https://www.tpk.govt.nz/en/whakamahia/whanau-ora/
CASE
STUDY Inclusiveness and the Smith and Mason families
:
The mining site where Colin works has encouraged the employment of Indigenous men through the
Australia One initiative. The Indigenous mining training program has proven successful in creating
employment for local Indigenous people. The management group and health and safety group have
done some public awareness work on the company’s social inclusion agenda in all aspects of the
mining operations.
Rebecca has been supporting a group of young mothers in her community to advocate for safe
breastfeeding spaces in public places. A number of the young women had been made to feel
uncomfortable about breastfeeding in public and, with the support of some of the older mothers in
the community, were working with local businesses to make breastfeeding accepted.
Huia is very connected to her Māori culture and is determined that her children remain engaged in Māori
culture, so she makes the effort to send them to the nearest Māori immersion school (Te Kura Kaupapa
Māori) and preschool (Kohanga Reo). While having her mum come to live in the family home is
challenging, Huia finds the relationship and connections between her mother and her children rewarding.
Jason is working with his company to develop an inclusive workplace policy aimed at creating a safe
workplace for LGBTI workers. This has included creating gender-neutral bathrooms and signage. The
new policy has been challenging for some in the workplace but has been welcomed by others.
■ Social inclusion and social exclusion are two points on a continuum of social equity.
■ Our society remains unequal, with pockets of systematic discrimination and oppression on the
basis of gender, race, ethnicity and sexual diversity.
■ Women and men have different health issues and some common issues related to a combination of
biological, behavioural and social factors.
■ Intimate partner violence is caused by one person’s need to exert power and control over another.
■ Migrant, refugee and LGBTI groups have multiple layers of disadvantage through discrimination and
stereotyped societal responses to their needs.
■ The reasons for the lower health status and shorter lifespan of Indigenous people compared with
non-Indigenous people include socio-economic disparities, deprivation, unequal treatment, racism
and discrimination and unhealthy environments.
■ Societies cannot be inclusive until historical traumas against Indigenous people are dealt with by
the wider society.
■ Community engagement must be undertaken from a perspective of cultural safety and respect for
Indigenous culture.
1 What indicators of social exclusion exist in your community?

2 What are the most prevalent issues confronting women in today’s workplace?
3 Identify the chain of factors related to colonisation that predispose Indigenous people to ill health.
4 Outline a strategy for promoting health literacy among middle-aged Indigenous residents of a rural or remote
community with a view towards managing chronic illness.
5. Explain how you would develop a plan for a domestic violence prevention session to include Indigenous and
non-Indigenous workers at the mining site.
6 What primary health care initiatives would you include in a program to develop a socially inclusive Health Promoting
School in either Maddington or Papakura?
7 Construct a set of guidelines or prompts that you might use to ensure your interactions are culturally safe,
irrespective of your client group.
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CHAPTER 10
Inclusive research
INTRODUCTION
Planning to support the health of individuals, families and communities relies on quality
information regarding what is effective, efficient in terms of resource use and appropriate to
the people whose lives will be affected. Effectiveness, efficiency and appropriateness are important
variables to study in relation to health care systems and how health services and programs
are implemented in communities. What is effective, efficient or appropriate can vary for particular
individuals and groups across different settings and circumstances. Because of this variability,
and the fact that people’s lives are constantly changing, the research agenda is constantly
evolving. It will always be necessary to gather information on community needs, strengths
and resources to identify what is transferable across settings and what is unique to a particular
community. For example, we know that a multidimensional health promotion strategy that is
inclusive of environmental as well as behavioural factors will be more effective in helping
people quit smoking than a single-factor intervention. However, the way a quit-smoking
intervention is introduced, planned and received by various members of the community can
vary widely.
KEY POINT
Why we research
• To advance knowledge
• To practise effectively, from an understanding of what works, for whom, in what context, why,
with what costs and outcomes
• To compare or ‘benchmark’ knowledge with others to develop guidelines for best practice
Planning an effective intervention for smoking cessation, or any other initiative, depends
not only on aggregated, population-level information from programs that have worked, but
on the strengths of the community and characteristics of the group for whom the intervention
is intended. These characteristics can be demographic features such as age, stage or gender,
or clinical factors, such as whether or not the impetus for smoking cessation has come from
an illness, impairment or, in some cases, the influence of a significant other. Other important
issues lie in situational factors such as people’s preferences, their receptiveness or readiness to
make a change, how they view the constraints and/or facilitating factors that affect their health
choices, and what supports are available to them to sustain the change. So although the findings
from a body of research can sometimes be translated into practice across settings, there remains
a need for contextual information, to study effectiveness and acceptability at the local level.
This is the essence of most community health research. It is often evaluative; focusing on
gathering and analysing data from within and outside the community, to identify what works,
for whom, where, why, with what costs and outcomes, including acceptability by local
residents.
Primary studies that collect evidence on the effect of certain interventions can be useful in
studying population-level outcomes as a basis for benchmarking. This is a process of comparing
outcomes across populations to forecast the likelihood of success in other populations. However,
research is also needed on the differential needs and effects for various groups, and how certain
interventions were experienced by people whose lives were changed. Although scientific evidence
is important to indicate what works from a statistical point of view, community health research
also requires explanations of why it did or did not. This type of contextual information can
help health planners understand what structural features of the community contributed to
the health outcomes, and whether certain initiatives or processes could be tried in other
contexts and with other people.
KEY POINT
Community health research needs both scientific evidence to support outcomes and
explanations of why an intervention may or may not have worked.
Besides identifying needs, structures, processes and outcomes, the research agenda also
needs to include the type of studies that are aimed at developing conceptual frameworks for
community health. These studies advance the field of community health by building a scaffold
for knowledge development that can attract scholars and researchers to investigate the broader
dimensions of community health. There is a need to study examples of good and best practice
by nurses and others who promote the health of a community through health education,
advocacy or specific interventions. The research agenda should also include studies that link
community health practice outcomes with the level or type of practitioners’ educational
preparation, experience, expertise and scope of practice. Attention to these issues is fundamental
to informing our professional knowledge development and mapping our progress in developing
and adapting new understandings.
Undertaking research should be a partnership, where information is seen to be the
property of those providing it, often in the spirit of generating mutual understanding and
benefits. Despite different methods, designs and philosophical approaches, the common
goal of research is to inform improvements to the health of the population or the com-
munity itself, either through small incremental contributions to knowledge, or studies of
such magnitude as to create system change. This chapter provides an overview of issues
and progress related to community health research, and suggests a number of research
challenges and strategies that could be used to inform the creation and maintenance of
community health.
OBJECTIVES
1 describe the importance of translating 4 develop a research question grounded in

research evidence into better community the conceptual foundations of primary
health and wellbeing health care to respond to a specific
2 identify a range of research approaches that community health issue
may be useful in a primary health care 5 outline the most important ethical issues
setting associated with primary health care
3 explain the major issues in undertaking research and practice.
culturally safe research
RESEARCHING THE SOCIAL DETERMINANTS OF

HEALTH—GLOBALLY, NATIONALLY AND LOCALLY
Research is a core competency of nursing practice around the world (International Council
of Nurses 2016, Nursing and Midwifery Board of Australia 2016, Nursing Council of New
Zealand 2016). Communities are part of a global network working towards the common
goal of social justice. Ideally, research studies that underpin the social justice agenda would
build a body of knowledge to inform health promotion strategies, policies and practices
to respond to global problems that also have implications at the local level. These prob-
lems include poverty, inequity in resource allocation, disparities in health and education,
discrimination and disadvantage on the basis of gender, culture, race, age or geography,
infectious diseases among those without access to treatment and environmental issues such
as climate change and its impact on communities. However, the global research agenda
continues to be disadvantaged by the lack of large, interlinked databases, inadequate funding
and, in some cases, the lack of political will to secure effective mechanisms for research
collaborations.
KEY POINTS
The global research agenda includes:

• poverty
• resource inequities
• disparities in health, education
• discrimination, social exclusion
• lack of access to treatments
• environmental issues.
Research studies are expensive. They require funding for researchers, investment in support
structures (including the type of databases that could help integrate findings), personnel and,
in many cases, specialised equipment. Clinicians, academics, policy makers and technical staff
with research skills often have work demands other than research, which means that without
financial support, their research becomes relegated to a low priority. Funding can help ensure
that data are gathered and analysed appropriately, and that researchers have time and resources
to promote collegial deliberation and dissemination of findings. Like other activities that have
resource implications, research is inherently political. This means that at the national, regional
and institutional levels, there are competing agendas for budget allocations. Decisions about
funding research can be made on the basis of local issues, researcher interests, or the needs
of policy makers and politicians to demonstrate a short-term impact. When short-term, local
goals are the focus, the broader global social justice agenda is likely to be given little attention.
As health practitioners, it is important to advance local agendas and be responsive to the need
for local research, but at the same time, maintain a commitment to the wider agenda of collecting
data and translating findings into better health care for the global population.
KEY POINT
Think global in translating local findings into better health care for the global population,
especially those investigating the SDH.
The most salient community issues at all levels are generally those related to the social
determinants of health (SDH). Research into the SDH is increasing. In 2006, 523 papers were
indexed in Pubmed using the term ‘social determinants’. In 2016 this had increased to 2398.
Despite these increases, under-researched issues remain. These include questions that investigate
equity of access to health services, models of empowerment for various groups differentiated
by gender, culture and ethnicity, mechanisms for education and health literacy, and environmental
supports for healthy childhoods and lifelong wellbeing, including healthy ageing. These are
complex issues, and research addressing these social determinants involves long-term, multi
disciplinary studies of multiple factors across various settings and groups. There are limited
opportunities for large-scale, comprehensive, longitudinal studies that would gather data from
diverse groups in different countries over sufficient time to provide definitive answers to
research questions. These studies are costly and rely on ongoing funding—often over decades.
However, the findings from such studies provide much of the evidence for how the SDH
impact on people’s lives and will provide the future evidence for how interventions we develop
now will work. For these reasons, it is imperative such studies continue. Box 10.1 describes
the Nurses’ Health Study as an example of the findings of longitudinal studies and their contribu-
tion to the SDH.
The theoretical basis of studies examining the SDH has also increased as researchers attempt
to explain the dynamics of the relationship between the SDH and disease (Cockerham et al.
2017). The life course theory proposes that socio-economic disadvantage originating in childhood
accumulates over the life course to disadvantage health in older age and vice versa (Cockerham
et al. 2017). This theory underpins much of the discourse in Australian and New Zealand
policy around the SDH. The fundamental cause theory suggests for a social variable to cause
disease and mortality, it must firstly influence multiple diseases, secondly affect those diseases
BOX 10.1
THE NURSES’ HEALTH STUDY
The Nurses’ Health Study (NHS) started in 1976 and is now into its third generation of
nurses. It is one of the largest prospective investigations into the risk factors for chronic
disease among women. Over 275,000 participants have taken part since its inception.
Regular follow-up of study participants and repeated assessments of health and lifestyle
factors have played a key role in shaping public health recommendations over many
decades. Examples include:
• uncovering early links between smoking and cardiovascular disease
• determining links between postmenopausal obesity and breast cancer
• identifying a range of links between physical activity and health including how
moderate physical activity reduces the risk of cognitive impairment
• identifying links between anxiety, posttraumatic stress disorder, childhood violence,
caregiver burden and job insecurity and increased risk of coronary heart disease and
diabetes (Trudel-Fitzgerald et al. 2016)
Further information on the Nurses’ Health Study can be found at: http://www.
nurseshealthstudy.org/.
through multiple pathways of risk, thirdly be reproduced over time, and fourthly involve access
to resources that can minimise or avoid the risks and consequences of the disease (Cockerham
et al. 2017, Link & Phelan 1995). An example would be socio-economic status and the impact
of income (or lack of) on various pathways to health and ill health. A third explanatory theory
of the SDH is the health lifestyle theory that suggests structural variables such as class cir-
cumstances (age, gender, ethnicity), social networks and living conditions provide the social
context for socialisation and the types of experiences that influence life choices (Cockerham
et al. 2017). Particularly important to understand in this theory is that health lifestyles are not
the individualised decisions of a single person but are personal routines that merge into an
aggregated characteristic of specific groups and classes (Cockerham et al. 2017). These growing
theories underpin the development of the SDH research agenda and our growing knowledge
of the increasing number of factors that interact to create health and how we can strengthen
these. However, challenges remain.
Another constraint on the evidence-based agenda is the lack of coherence in the topics
studied in different countries and between different cultures. To drive major change, research
studies need to be collaborative, right from the stage of establishing the research agenda, to
identifying and evaluating solutions. The logistics of international or cross-institutional col-
laboration is sometimes prohibitive in terms of time or commitment of individual researchers,
or when collaborators have different organisational pressures. Some of these pressures revolve
around the lack of understanding by policy makers and research-granting agencies of the need
for different perspectives in investigating a problem. Funding bodies often favour studies that
are highly scientific, such as systematic reviews of existing research, especially clinical trials,
rather than evaluative studies based on community perspectives. Community-based research
studies must be collaborative—locally with community members, and nationally and internation-
ally with those committed to generating the evidence to address equity.
The current trend towards translational research involves generating evidence, combining
findings from multiple studies in a systematic review, and translating the collective findings
into clinical guidelines and change management strategies. An example of how research can
lead to changes in policy, development of guidelines and ultimately improved health outcomes
is the work undertaken to address Sudden Infant Death Syndrome (SIDS) or, as it is known
in New Zealand, Sudden Unexplained Death of an Infant (SUDI).
EVIDENCE, TO EDUCATION, TO CHILD-HEALTH

PRACTICE IN PREVENTING SIDS/SUDI—CASE STUDY
Australian and New Zealand child health professionals have spent the past decade researching
sudden unexpected infant deaths. In partnership with public health policy makers, clinicians
and community members, their work is directed towards ensuring translation of research into
policy and then into the best possible practice. Significant work is being done to address the
high rate of SIDS/SUDI among Indigenous groups in both Australia and New Zealand and
recent falls in rates in New Zealand is demonstrating the partnership approach between
researchers, policy makers and practitioners is working (Mitchell et al. 2016). A ‘blitz’ approach
to SUDI education, the targeted provision of portable infant safe sleeping devices (such as the
Pepi-Pod® and wahakura), and the development of safe sleeping policy across district health
boards are seen as combining to create the reduction in incidence of SUDI (Mitchell et al.
2016). The Pepi-Pod® program comprises the provision of a portable infant sleeping device,
safe sleeping parent education and safety briefing; and a family commitment to share safe
sleeping messages within social networks (Young et al. 2017).
Professor Jeanine Young demonstrating safe sleeping pod (photo courtesy of

Professor Jeanine Young).
The program has been successful in New Zealand and is currently being trialled in Queensland
with the Aboriginal and Torres Strait Islander population (Young et al. 2017). Māori researchers
are also currently examining the efficacy of the wahakura. A wahakura is a hand-woven flax
basket rather than the plastic Pepi-Pod® that the baby is put to sleep in. The wahakura with
baby in it then stays in the bed so that baby is close to mum but has its own sleeping space.
Researchers have found the wahakura is culturally acceptable, just as safe as a bassinet and
has other benefits including improved breastfeeding rates among women who use it for their
infants (Baddock et al. 2017).
Contributing work by Professor Jeanine Young’s research team from Queensland saw the
development of an effective, accessible health promotion program for both parents and health
practitioners to promote safe sleeping. Based on epidemiological data showing that Queensland
has one of the highest rates of SIDS/SUDI in Australia, the research team devised a set of
studies to examine the extent to which Queensland nurses, midwives and parents were aware
KEY POINTS
The evidence for safe sleeping is:

• baby on back
• head and face uncovered
• smoke-free environment
• safe sleeping night and day
• baby’s own sleeping place in adult caregivers’ room for 6–12 months
• breastfeed baby
• keep immunisation up to date.
of the relevant policies and public health recommendations for safe sleeping. With her colleagues
from Queensland Health and SIDS and Kids Australia, Young designed an eLearning program
that is accessible to nurses and other child-health practitioners irrespective of their location.
The program is available at https://rednose.com.au/page/e-learning-education-package. Evaluation
of knowledge and knowledge application in those who completed the program, including
nurses, midwives, allied health, medical practitioners, students, parents, Indigenous health
workers and SIDS and Kids employees found that the program increased knowledge, and
self-reported and actual advice to parents (Young et al. 2013).
KEY POINT
Evidence for practice is the best available research evidence, the clinician’s knowledge and
expertise, and the individual patient’s views and preferences.
EVIDENCE-BASED PRACTICE
Since the 1970s the evidence-based practice (EBP) movement has worked towards involving
health professionals throughout the world in evidence-based health planning and evidence-
informed practice. The objective of EBP at the global level is to help societies achieve efficiency,
effectiveness, equity and improved global health (Lockwood & Pearson 2016). At the local
level many EBP initiatives are intended to achieve similar goals and, in the process, to advance
knowledge that can be used to develop capacity for ongoing developments. The SIDS/SUDI
case study is an excellent example of EBP.
EBP is often described in relation to evidence-based medicine (EBM), which was originally
devised to inform a medical practitioner’s intention to treat or intervene in a person’s care.
EBP is the integration of three things: the best available research evidence, the clinician’s
knowledge and expertise and the individual patients’ preferences, needs and values. All of
these inform decision making regarding care and treatment (Cummins et al. 2016). Establishing
a research culture of EBP in any health service or community promotes an attitude of inquiry
among health practitioners. A further benefit is that evidence can play a role in maintaining
accountability for health resources by guiding decision makers to plan appropriately (Schneider
& Whitehead 2016). The process of EBP involves five steps. Firstly, convert the need for
information into an answerable research question. Some of the most important research questions
for community health pose questions about how to promote health literacy or participation
among certain groups, how outcomes may be moderated by various approaches to health
promotion or the context of care, or the effectiveness of interventions across cultural groups
or across the life course. The second step is to search for the best existing evidence to answer
the research question, which involves searching databases or scholarly journals, or other sources
of research such as local reports or reviews. The third step is to critically appraise existing
evidence for its validity, impact and applicability. This step is made easier by the fact that in
recent years helpful guidelines have been developed to help researchers appraise different types
of studies. The EQUATOR network (Enhancing the Quality and Transparency of Health
Research) is one of the most useful of these guidelines (www.equator-network.org). The fourth
step in EBP is integration of the evidence with the researcher’s existing knowledge, contextual
information about the group or community circumstances and preferences, and any other
situational information that may help inform the research. The fifth step is concerned with
quality in that it involves self-reflection on the thoroughness and accuracy of steps 1–4 (Lockwood
& Pearson 2016).
KEY POINTS
The steps in EBP are:

1 researchable question
2 literature review
3 critical appraisal of studies
4 integrate knowledge with contextual information
5 re-check accuracy of steps above.
In most cases, researchers begin by posing their question, then refining it to reduce ambiguity,
to clarify what data they will collect, and to guide the literature search. It is helpful to collect
and review the literature around the PICO mnemonic. That is, search for studies of the Population
(children, adults, etc.), the Intervention (e.g. smoking cessation), Comparisons (group versus
individual health education and supports), and Outcomes (e.g. smoke-free days). In the process
of searching the literature, researchers usually use synonyms and variant words and expressions,
often in databases like CINAHL, MEDLINE, PUBMed or PROQUEST with which they are
familiar, or in journals where similar studies have been published in the area of interest. In
some cases, the research project is the literature review, either as a systematic review, integrative
review or meta-analysis.
KEY POINTS
Systematic reviews have several limitations. These include:

• synthesising studies with different methods
• disparate theoretical foundations
• variable population groups
• insufficient studies on a particular topic.
Systematic reviews, literature reviews, integrative reviews

and meta-analyses
A systematic review establishes the parameters for adequate or best available research evidence
using preset criteria, derived primarily from randomised controlled clinical trials (RCTs) and
other high-quality primary research studies. The original intention of systematic reviews for
EBM was to provide the basis for treatment recommendations (Bero & Rennie 1995). In
community health the ‘best treatment’ often means the best strategies for health promotion.
The advantage of a systematic review is that it uses an explicit and auditable protocol. Common
protocols are available from the resources of the Cochrane Collaboration (www.cochrane.org)
or the Joanna Briggs Institute (www.joannabriggs.org). Using a protocol ensures breadth and
consistency in terms of appraising the participants, interventions and outcomes. The systematic
review involves a clear definition of eligibility criteria for a study, a comprehensive search of
all relevant studies available at the time of the review, explicit, reproducible and uniformly
applied criteria in selecting studies for the review, rigorous appraisal of potential bias in the
studies reviewed and a synthesis of study results (Lockwood & Pearson 2016). A meta-analysis
takes the review to another level by combining and statistically analysing the evidence from
a number of studies on a similar topic to enhance the validity of findings in relation to the
outcomes of the study or the effect size. This statistical computation can provide a better
estimate of a clinical effect than simply analysing the results from individual studies (Da Costa
& Schneider 2016). In cases where the studies selected cannot be combined statistically, the
review can consist of a narrative analysis.
KEY POINT
Systematic review is the method of choice for EBP but it is important to evaluate the
effectiveness and appropriateness of health care in differing contexts for different groups of
people, which may require less structured reviews.
BOX 10.2
THE PARACHUTE STUDY: A CAUTIONARY TALE
Because of the myriad factors influencing community health, formulaic research strategies
are not always appropriate. Community problems and issues require different paradigms
that encourage researchers to articulate the range of problems and solutions in the context
of the community or group. A persuasive argument for a multidimensional approach to
research is cleverly presented in a study of parachute use to prevent death and major
trauma related to gravitational challenge (Smith & Pell 2003). The authors’ objective was to
determine whether parachutes are effective in preventing major trauma. Predictably, they
found no randomised controlled trials in their systematic review, and concluded that the
effectiveness of parachutes has not been subjected to rigorous evaluation. They suggested
that the most radical proponents of evidence-based practice, those who criticise
observational studies, might want to conduct a double blind, randomised, placebo-
controlled, crossover trial of jumping out of a plane without a parachute!
Diabetes is one area of community health that has attracted a proliferation of systematic
reviews in recent times, which reflects its importance to clinicians and policy makers. Systematic
reviews have been conducted on the links between exercise and glucose control (Heiss &
Petosa 2014) and a diabetic person’s ability to work (Lobato et al. 2014). Other systematic
reviews have been conducted on different populations in relation to the uptake of programs
and benefits of physical activity and/or good nutrition. Others still on the systemic changes
that might be required to improve diabetes care. For example, Gibson and Segal (2015) conducted
a systematic review of health system, clinical system or service level initiatives designed to
improve the management of diabetes in Indigenous populations in Australia, New Zealand,
Canada and the United States. They found that although six of the 13 studies included in the
review showed improved health outcomes, the evidence base was not sufficient for making
policy and practice decisions due to the small number of studies, reliance on intermediate
health outcomes and predominance of observational studies (Gibson & Segal 2015). Each of
these reviews conclude with statements about the limitations of the analysis in terms of disparate
methods, the failure of some researchers to identify the theoretical foundations of their research,
the difficulties in comparing different population groups and the need for more studies on a
particular topic. These criticisms are typical of most systematic reviews, particularly where
the reviewers try to draw definitive conclusions on appropriate intervention strategies or
clinical guidelines from different research approaches.
Some researchers argue that all research should be preceded by a systematic review; however,
there are many aspects of community health for which systematic reviews are not available,
so researchers setting out to conduct a study often review the literature available using alternative
strategies such as integrative reviews. Integrative reviews also review the literature pertaining
to a certain topic, but they are broader reviews than systematic reviews in that they include
experimental and non-experimental studies (Whitehead & Maude 2016). An integrative review
can also be designed to define concepts, review theories, review evidence and analyse meth-
odological issues (Whittemore & Knafl 2005). As care provision shifts from hospitals into
primary health care settings, a number of useful integrative reviews have helped identify issues
for nurses transitioning to work in primary health care. For example, Ashley et al. (2016)
examined the transition experiences of nurses shifting from acute care settings into primary
health care. They identified three themes in their review: a conceptual understanding of
transition; role losses and gains; and barriers and enablers. Ashley et al. concluded that there
is a need for further research in this area to support recruitment and retention of nurses in
The main advantage of an integrative review is that combining and summarising several
types of literature, including theoretical literature, can provide a more complete picture of a
phenomenon or health care problem (Whittemore & Knafl 2005). Others have used a scoping
review, which is broader than a review of a single problem or issue in that it is intended to
scope a broad topic. Valaitis et al.’s (2017) scoping review of the implementation of patient
navigator programs designed to link primary care with community-based health and social
services, found a range of factors influenced implementation of the programs and these factors
either support or inhibit implementation processes.
Another useful type of review is the concept analysis, which can help build a common theoreti-
cal foundation for future studies from a consistent set of understandings. Literature retrieval
and appraisal can be time-consuming and requires a high level of skill. Because not all community
practitioners have the time or support from management to develop and use these skills in
practice, access to quality systematic reviews can be achieved through journals whose sole
pupose is to collate and share systematic reviews. These include the Journal of Evidence-based
Health Care, and Evidence Based Nursing.
Randomised controlled trials

Randomised controlled trials (RCTs) are described as the ‘gold standard’ in research, because
they use an experimental study design, which allows the researcher the greatest control over
the research (Harrington 2017). Some studies are ‘quasi-experimental’ in that the researcher
may not have the degree of control expected of a scientific experiment, such as when they
are unable to randomise subjects. Over the past two decades researchers have refined the
techniques involved in conducting RCTs with a set of guidelines, the Consolidated Standards
of Reporting Trials (CONSORT), which are widely used throughout the world to ensure
consistency in reporting findings (see www.bmj.com/content/328/7441/702). At a basic level,
the RCT uses a population sample and randomly allocates approximately half to an experimental
group and the other half to a control group. The experimental group receives an intervention,
while the control group typically has ‘usual care’ or no intervention. The outcome of interest
is measured in both groups before (pre-test) and after (post-test) the intervention. Changes
that occur in the experimental group between the pre-test and the post-test are reasonably
attributed to the intervention (Shields & Smyth 2016). This attribution relies on the condition
that all other influences are controlled, which can be difficult for educational interventions.
So, for example, if a researcher was introducing a program to teach parents about nutrition
it would be necessary that the intervention group had no outside influences other than the
education provided as part of the program. This would be a challenge as some parents may
have pre-existing knowledge, others may have little access to the recommended foods and
others may have a child who was a fussy eater. In these cases, the challenge would be to
eliminate extraneous influences by selecting participants with exactly the same knowledge
level, similar access to the nutritious foods and infants with similar temperaments. Some
researchers would find this level of control impossible and they may revert to a more qualitative
evaluation of their educational program.
Clearly, RCTs are important for developing well-verified, objective research studies, but in
reducing the factors studied within tightly defined criteria they often fail to reveal the complexity
within which people maintain health (de Jong et al. 2015). Another criticism of RCTs is that
the controlled conditions of a clinical trial are rarely available in communities. It would be
unethical and not useful to allocate people to an RCT, giving one group the intervention and
withholding it from the other. On the other hand, a meta-analysis that combines the findings
from a group of studies can be useful, especially if the findings and conclusions of the studies
are synthesised into new ways of looking at the community or planning for community
change.
EVIDENCE FOR PRACTICE: HOME VISITING

We have noted throughout this book that home visiting is an important practice strategy for
nurses and others working in primary health care settings. It is used as an intervention across
the spectrum from prior to birth through to old age and palliative care. David Olds and
colleagues have examined the positive outcomes among children and their mothers where the
mothers had received intensive nurse home visiting in the first two years of the child’s life
(Kitzman et al. 2010). Other research into home visiting programs in the early childhood
period has, however, had more mixed results. In a local example, a nine-year follow-up study
of children and families who had received intensive home visiting as part of the Early Start
program in New Zealand, found that while some outcomes were encouraging, others were
less so. The positive outcomes included significantly reduced risk of hospital attendance for
unintentional injury, lower risk of parent-reported harsh punishment, lower levels of physical
punishment, higher parenting competence scores and more positive child behavioural adjustment
scores. However, there were no significant differences in a range of measures of parental
behaviour and family outcomes such as maternal depression, parental substance use, intimate
partner violence, adverse economic outcomes and life stress (Fergusson et al. 2013). Fergusson
et al. (2013) conclude that while there were small to moderate benefits for children, these
benefits did not extend to parents or the family overall.
So how does the evidence guide our practice when there are such variable outcomes? While
a systematic review gives us a useful overview of outcomes, it is also important to consider the
context within which interventions are designed and implemented, and the research question
that guides the review. The evidence suggests that home visitation programs are most effective
when they focus on children through providing parents with new skills, knowledge and approaches
to parenting, but less successful when targeted at changing long-standing parent or family issues
and challenges. It is important that home visitation programs have clear goals and that nurses
and others engaged in them are realistic about the outcomes that can be achieved.
BIG DATA
Big data is the term used to refer to the massive data sets that are being generated from a
range of sources, including electronic medical records, mobile devices, laboratory studies and
administrative claims data (Barton 2016). Researchers are starting to explore how this data
can be analysed on a mass basis to identify patterns, causes and outcomes of disease, improve
the understanding of health behaviour and provide the basis for more personalized medicine
(Barton 2016). Very little nursing data is collected in these data sets currently and some are
arguing for nursing education to discourage free text documentation of care in order for these
large data sets to capture the work of nursing (Barton 2016). The challenge of this approach
is the risk the contextual information about individuals and communities will be lost. If we
do not understand the experience of people and communities, our efforts to support them
may be futile. So although big data provides new and exciting opportunities for understanding
the world, it is only one source of information about people and communities.
PARADIGMS
From the early days of EBP, ‘evidence’ was considered as quantifiable data situated within the
paradigm of logical positivism. A paradigm is a set of beliefs or perspectives that creates a
pattern for scholarly inquiry. Paradigms therefore encompass the philosophical assumptions
that underpin the way we view natural phenomena (Francis et al. 2016). The positivist paradigm
is used in quantitative studies, where the research is based on rigid rules of logic and measure-
ment, truth, absolute principles and prediction (Francis et al. 2016). Randomised controlled
trials and systematic reviews are part of the positivist paradigm. In contrast, the interpretive
paradigm focuses on the meanings people ascribe to their actions and interactions and is one
of the approaches used in qualitative studies. Interpretive research is undertaken on the
assumption that reality is socially constructed through the use of language and shared meanings,
so researchers seek to understand phenomena by listening to people or observing their actions

(Francis et al. 2016). Another paradigm or philosophical perspective is the critical perspective,
sometimes called the critical social theory paradigm, which addresses social institutions, and
issues of power and alienation as well as new opportunities (Francis et al. 2016). Critical perspec-
tives are based on the assumption that knowledge is value-laden, and shaped by historical,
social, political, gender and economic conditions that, for some people, can be oppressive.
Critical approaches endeavour to encourage empowerment and equality for participants, as
well as generate knowledge that can be used as a basis for change (Francis et al. 2016).
These existing approaches provide the basis for what may become the next paradigm of
thought that will come to bear on nursing. New technologies, including artificial intelligence,
cyborgs, biotechnologies and other information technologies, such as big data, blur the boundaries
between what is human and what is artificial. Nurses traditionally span the borders between
technology and the person, but these borders are narrowing. Our research endeavours will be
challenged as we seek to balance person-centred care approaches with new technologies and
what they mean for the way people live their lives and respond to health care. Teixeira de
Almeida Vieira Monteiro (2016) proposes that nursing research must now be built on these
previous paradigms but will take a different shape and meaning as we begin to grasp the
impact of technology on human life as we know it today.
KEY POINT
A paradigm is an understanding or viewpoint of the world. Three common paradigms are

positivist, interpretive and critical. The impact of artificial intelligence, cyborg technology,
genomics and big data on human life will see the advent of a new paradigm of thought we
have yet to fully conceptualise.
The multidimensional nature of communities requires us to include the cultural, spiritual

and environmental dimensions of community life when we undertake research within this
domain. The type of knowing we gain from this approach is multifaceted and likely to provide
richer knowledge than that obtained from systematic assessments of prior research findings.
It is often described as naturalistic inquiry, as information is gleaned from the natural setting
and interpreted using various interpretive, rather than statistical, techniques. Naturalistic data
can include informant interviews, focus groups (sometimes called ‘yarning’ groups), observational
data and document analysis (Walker et al. 2014). The knowledge gained from this type of
research is an important element in informing policy and practice changes, especially when
more than one type of inquiry is used in combination. Interpretive methods can be a useful
approach to gathering and analysing data on the realities of community life for different groups
of people. Three of the most common interpretive methods that are based on naturalistic
inquiry are Phenomenology, Ethnography and Grounded Theory. Case study research is also
becoming increasingly common in community settings. The EQUATOR Network outlined
earlier in the chapter also provides criteria for reporting qualitative research known as COREQ.
These criteria help us appraise the quality of qualitative research.

• Qualitative research approaches: http://www.qualres.org/index.html
TRANSLATIONAL RESEARCH: KNOWLEDGE

TRANSLATION AND KNOWLEDGE TRANSFER (KT)
Translating research into policy and/or practice is a complex social process involving multiple
interactions and linkages between producers and users of research. Knowledge transfer or
knowledge translation as this process is known, includes not only disseminating or distributing
knowledge but using carefully planned strategies to identify target audiences and delivering
messages in ways that are understandable, actionable, accommodating and cost effective
(Lockwood & Pearson 2016). In translating program knowledge to practice, partnerships with
community members are integral to success, ensuring the acceptability of implementation
strategies. Fig. 10.1 shows the interactions required to translate evidence into practice.
One of the trends guiding research in nursing and other health disciplines is the move
towards community-based research partnerships. Community-based research provides an
ideal opportunity to inform policies from the ground up as well as supporting communities
to implement the findings of the research back into their communities. It is also a way of
providing feedback to policy makers of the applicability of policies on the ground, where
Individual Patient’s
clinical values and
expertise expectations
IMPROVED
PATIENT
OUTCOMES
Best
available
clinical
evidence
Figure 10.1 Translating evidence to practice

people live, work, study or play. Funding bodies often support community partners such as
government departments, hospitals or health districts, as collaborators in research studies,
knowing that the information that will emerge will be more authentic than it would be if the
researcher was working alone to investigate a community problem. Local partnerships are
also considered to have ecological validity; that is, real-world relevance.
Partnering with communities in planning and implementing research creates many kinds
of knowledge. These include propositional knowledge gained from identifying the research
question(s), practical knowledge, from developing the skills and competencies of research,
experiential knowledge from participating in the research and presentational knowledge from
sharing information that will address the research question. Nykiforuk et al. (2013) explain
that generating these types of knowledge through ongoing interaction between researchers
and the many levels of stakeholders is crucial to translating evidence to practice for evidence-
informed decision making. The process also builds capacity, not only in knowledge development
but in fostering skills and confidence among community members for empowerment and
long-term commitment (Nykiforuk et al. 2013). Some other types of research that involve
community members closely in the research process include community-based participatory
research (CBPR) and action research.
Researchers have also come to realise that clinical guidelines are a crucial aspect of promoting
knowledge transfer (KT). Techniques for developing clinical guidelines are rapidly evolving with
the development of protocols for grading evidence and rating the strength of recommendations
from research studies. The Cochrane Collaboration and other organisations maintain a repository
of protocols or ‘guidelines for developing guidelines’ (www.cochrane.org).
Community-based participatory research (CBPR)

CBPR is a collaborative research approach that specifically focuses on the equitable involvement
of community partners in the research process (Israel et al. 2001). CBPR should always begin
with a research topic of importance to the community and be based on the principles of co-
learning and community partnerships in investigating inequities, which is intended to address
health from both positive and ecological processes and promote sharing of findings (Israel
et al. 2001). CBPR is a culturally sensitive approach to community health research in that the
researcher adopts an attitude of ‘cultural humility’, which is intended to redress power imbalances
and maintain mutually respectful, dynamic community partnerships (Foronda et al. 2016).
The key principles of CBPR are listed in Box 10.3, and Box 10.4 describes an example of CBPR
in action. We also discuss CBPR in Chapter 5.
KEY POINT
Community-based participatory research is research undertaken with the participation of

community members affected by an issue with a view to education, action or social change.
BOX 10.3
KEY PRINCIPLES OF CBPR
1 Acknowledges community as the unit of identity

2 Builds on community strengths and resources
3 Facilitates collaborative, equitable involvement of all partners in all research phases
4 Integrates knowledge and action for mutual benefit
5 Promotes co-learning and empowerment to address social inequalities
6 Involves a cyclical and iterative process
7 Addresses health from both positive and ecological perspectives
8 Disseminates findings and knowledge to all partners
9 Involves a long-term commitment by all partners
Source: Israel, B. et al., 2001. Community-based participatory research: policy recommendations for
promoting a partnership approach in health research. Education for Health: Change in Learning & Practice,
14(2), pp.182–197. With permission of Wolters Kluwer.
BOX 10.4
‘TALKING ABOUT THE SMOKES’
The ‘Talking about the smokes project’ was a large-scale community-based participatory
research project in Australia that was initiated in 2010 as part of the International Tobacco
Control Policy Evaluation Project. This national project was designed to examine pathways
to quitting smoking for Aboriginal and Torres Strait islanders. The project built on community
strengths and priorities by establishing community partnerships from project inception
through all the phases of the study (Couzos et al. 2015). The CBPR approach used in the
study combined multiple approaches to data collection and is ongoing. Further information
can be found at http://www.itcproject.org/countries/australia/tats and www.menzies.edu.au/
page/Research/Projects/Smoking/Talking_About_the_Smokes/.
Action research
Action research revolves around flexible planning through iterative (repetitive) cycles, wherein
the researchers and their partners in the community consider a research problem, then together
engage in cycles of planning, proposed action, evaluation and further cycles of planning and
action (Carr & Kemmis 1986). Action research studies are conducted within the critical paradigm
with the aim of decreasing the gap between research and implementation (Whitehead & Day
2016). Action research actively engages those who would normally be considered subjects of
research and is a particularly useful method for changing clinical practice (Hockley & Stacpoole
2014, Whitehead & Day 2016). Action research adopts a partnership approach similar to
CBPR, in which all partners are considered co-researchers in exploring solutions to an issue
of concern. As in CBPR, the researcher’s role is to create a trusting environment, and to help
keep the analysis on track with careful documentation, while helping others develop analytic
skills and capacity. One of the most salient issues relevant to community health research is
the capacity of action research studies to help people clarify their meanings, behaviours and
interactions in the cultural contexts of their lives. Action research is an umbrella term that
captures a range of different research processes including appreciative inquiry, participatory
action research (PAR), community action research, co-operative inquiry and emancipatory
action research (Hockley & Stacpoole 2014, Whitehead & Day 2016).
MIXED METHODS RESEARCH

While this chapter cannot report on all the differing types of research that exist, the types
mentioned are particularly appropriate for use when working with communities. The final
type we cover here is mixed methods research. Mixed methods research is an approach that
combines qualitative and quantitative data, different qualitative approaches to explore a single
phenomena or different quantitative approaches to examine a single factor (Whitehead & Day
2016). Incorporating contextual and cultural elements to the traditional designs of RCTs or
quasi-experimental studies can help improve both theoretical and practical understandings
that lie at the heart of community interventions. Similarly, discovering people’s perspectives
on health and wellbeing by listening to their stories or interview responses can lead to hypotheses
that can be tested in the controlled conditions of quantitative research (Whitehead &
Day 2016).
Questions that require a mixed-method design are those that cannot be explained by only
one type of data; issues that require considerable breadth and depth; problems where there is
a need to confirm or enhance findings with a second type of data; or studies where a research
instrument is being developed from comprehensive information about the topic (Whitehead
& Day 2016). Using mixed methods is not a new technique, but it is growing in popularity
for a number of reasons. These include increased reflexivity among nurses and other health
practitioners about the relationship between the researcher and the researched; heightened
political awareness about the issues surrounding research, increased procedural knowledge
about research governance and ethics and a trend towards international collaboration (Brannen
in Andrew & Halcomb 2009).
RESEARCHING CULTURE
Over the past decades, research into cultural issues has grown steadily. This agenda should be
extended to provide insights into the features of inclusive societies, intergenerational interactions
in different cultures and how expressions of culture affect health and wellbeing. Investigating
cultural issues as a basis for practice is essential to successfully confront the needs of migrant
groups during transitions to their new life, to anticipate influences on differing cultural groups’
health and health service preferences throughout ageing, and to explore how families negotiate,
change and work within the context of their cultural and social lives.
Naturalistic research, on its own, or in combination with other methods, is an ideal approach
to begin a program of culturally oriented research, especially if the nascent ideas for the study
arise from the cultural community itself. This often occurs in a round table or discussion
forum, where ideas can evolve into CBPR. One approach that has gained popularity with
different cultural groups is appreciative inquiry, which is conducted within the interpretive or
naturalistic paradigm. An appreciative inquiry is similar to PAR and participatory evaluation
in that the objective is to ensure inclusive, empowering research processes that build hope,
trust, respect and, ultimately, capacity for change. The researcher attempts to bring people
together to ‘discover, dream, design and deliver’ solutions to existing problems and innovations
for change (Murphy et al. 2004:12). This can begin from a story-telling group, as is often the
case in understanding cultural aspects of social life from individuals’ oral histories. Research
approaches such as photovoice could be considered as a form of appreciative inquiry, or an
adjunct to ethnographic studies.
Photos capture many stories and perspectives that may differ from the written word
(photo: Jill Clendon).
Ethnography focuses on the descriptive study of cultures and the different ways cultural
groups view relationships and the world around them (Whitehead et al. 2016). This means
that all data must be culturally contextualised with special attention to cultural relevance of
language and meaning at the individual, group and community level (Dove & Muir-Cochrane
2014). Research studies that do not attend to these cultural aspects may be well intentioned,
but they can potentially negate the socio-cultural reality of a vulnerable population (Wilson
& Neville 2009). Ethnographers explore the artifacts, structures and dimensions of a culture
that create people’s life worlds, including their knowledge.
RESEARCHING WITH INDIGENOUS PEOPLE

Indigenous people have been the focus of many studies in Australia and New Zealand, and
some of this research has not advanced the type of knowledge that contributes to their empower-
ment or self-determination. In some cases, researchers have forged relationships that have
unearthed important features of Indigenous people’s health, but in other cases, research reports
have shown stereotypical perspectives of the researchers, rather than the researched. Some
studies have actually damaged relationships and violated the principles of cultural safety (Wilson
& Neville 2009). This oversight has not been an intended goal of the research, but rather a
lack of understanding of the cultural and structural constraints on gathering meaningful data.
As Bandler (2015:187) asserts:
The progression of research, particularly health research, and research ethics in work with Aboriginal
Australians, parallels the progression of Australian history, from protection and biological assimilation
through cultural assimilation to political activism and self-determination.
Culturally safe research

Researchers involved in research with Indigenous people must approach any project from a
position of humility and cultural safety. Research is never done on people but with people,
acknowledging their rights, recognising their sovereignty and respecting their perspective. A
framework and guidelines for addressing ethical issues in research with Māori has been developed
in New Zealand and researchers are required to demonstrate their use of the guidelines in
order to obtain ethical approval to undertake a study (Hudson et al. 2010). The guidelines are
useful for any research with Indigenous people and offer three standards: the minimum standard
is to consult with the Indigenous group throughout the research process, good practice is to
engage with the group (particularly important where the research seeks to answer questions
of particular relevance to the Indigenous group), and best practice is to empower the group
to take a guardianship role over the research to ensure tangible outcomes for their communities
(Hudson et al. 2010).
Importantly, there is a need for external researchers to eliminate their propensity to draw
comparisons between Indigenous and non-Indigenous populations, and instead study phe-
nomena or events in Indigenous groups over time using Indigenous methodologies (Kite &
Davy 2015). In any context, researching people’s experiences of health and wellbeing can be
strengthened with a trajectory perspective, particularly over the life course. Trajectory research
is a succinct and useful way to describe changes over time to identify assets and risks as a basis
for planning how, when and for whom nursing and other interventions and self-care are most
effective. For example, a study of the developmental trajectories of suicidal ideation among
a sample of 521 early to middle adolescents found suicidal ideation varies according to age
with the best time for intervention in early adolescence, particularly around school transitions
(Adrian et al. 2016).
Canadian researchers have also drawn attention to the need for Aboriginal health research
that encompasses the relationships between health and place (Anderson et al. 2011). They
describe place-based communities as dialogue-based supportive networks that not only produce
locally relevant knowledge, but that develop residents’ research capacity. Such networks offer
the opportunity to focus on strengths with the premise of creating social change through
empowerment, especially in reinforcing Aboriginal identity (Gray & Oprescu 2016). Academics
can be part of these networks, framing cultural communities as learning communities where
all members are co-producers of knowledge. According to Wilson and Neville (2009:72),
studies with Indigenous groups should conform to the principles of the Treaty of Waitangi:
‘partnership, participation, protection and power’. When these principles guide the research
there is a greater likelihood of maintaining cultural safety. A major task for the researcher is
to create safe spaces for dialogue and negotiation, so the group can determine the extent and
nature of their involvement. Dimer et al.’s (2013) cardiac rehabilitation program for a group
of Aboriginal people in Western Australia demonstrated the importance of engaging Aboriginal
health practitioners in program implementation and research. They adopted a partnership
approach at each step of the way, using yarning groups to develop, implement and evaluate
the program (Dimer et al. 2013). This approach is empowering, enabling mutual understanding
and the type of cultural humility that characterises CBPR. Yarning is a culturally appropriate
way of encouraging dialogue with Aboriginal and Torres Strait Islander people and involves
the sharing of stories and development of knowledge (Walker et al. 2014). Yarning enables
Indigenous people to talk freely and as a research approach can help eliminate the structural
disadvantage that often occurs with externally imposed research contributing to the process
of decolonisation (Walker et al. 2014).
In New Zealand, concern and distrust over the way in which research on Māori has been
practised and by whom has led to a growth in research using an approach called Kaupapa
Māori research (Rolleston et al. 2016). Kaupapa Māori is a term used by Māori to describe
the practice and philosophy of living a life that is informed by Māori culture (Pihama et al.
2002, Rolleston et al. 2016). Kaupapa Māori research describes research that is collectivist,
acknowledges Māori aspirations for research and is largely conceived, developed and frequently
carried out by Māori with the end outcome of benefit to Māori (Rolleston et al. 2016). Although
the approach developed firstly in education research, it has become commonly used in health.
Lawton et al. (2017) describe how a Kaupapa Māori approach to their research with young
Māori mothers-to-be embeds the consultation process within the research from the outset.
Three advisory groups have oversight of the research including one comprising Māori elders,
one of young Māori mothers and a third of academic researchers. Ongoing consultation
throughout the project ensures development, implementation and translation of findings into
practice is done appropriately and in a manner that is acceptable to the community. This
approach has many similarities to other participatory approaches in that it enables engagement
and empowerment of participants and co-researchers. It is the embedding of cultural mores

and values specific to Māori within Kaupapa Māori research that makes this approach unique.
In addition, the approach contributes to tino rangatiratanga (self-determination) and mana
motuhake (autonomy), specific rights that are guaranteed for Māori under the Treaty of
Waitangi.
One of the most important elements of planning Indigenous research is for the researcher
to assume a reflexive attitude as a first step in ensuring cultural safety. For a non-Indigenous
researcher, this involves reflecting on how her/his worldview might influence the research,
and the processes of analysis and dissemination of findings (Wilson & Neville 2009). Another
important element is to actively pursue ethical approval for the research from Indigenous-
controlled ethics committees, to ensure that Indigenous interests are represented in all processes.
These include committees such as the Māori Health Committee of the Health Research Council
of New Zealand, the Queensland Aboriginal and Islander Health Forum, and the Western
Australian Aboriginal Health Information and Ethics Committee. In other states of Australia
besides Western Australia and Queensland, separate arrangements are made for ethical review
through Aboriginal peak bodies at state and territory level. What all have in common is
adherence to the values and principles mandated by the National Health and Medical Research
Councils of Australia and New Zealand, to ensure culturally appropriate research. These
principles include reciprocity (including the community’s perspectives), respect (transparent
acknowledgement of Indigenous beliefs and practices), equality (through authentic research
partnership strategies), responsibility (developing cultural protocols for all stages of the research),
survival and protection (promoting the crucial role of culture in the research), and spirit and
integrity (demonstrating respect for the richness, diversity and integrity of the Indigenous
community) (National Health and Medical Research Council Australian Research Council
2007/2015).
RESEARCHING THE FUTURE

Although the research agenda for community health is growing, many areas remain inadequately
researched for a number of reasons. In most cases, the length of time required to investigate
a web of factors or situations is prohibitive. Research may also be hampered by a lack of
funding, due to the rigidity of many granting agencies to support broadly based studies.
Dilution of interventions in large sites sometimes leads to a lack of clarity in the findings,
which can be complicated by time trend effects. This occurs when the circumstances of the
community change over time, or where the true costs of engaging with a community at each
step of the process are underestimated.
Another difficulty is that there are varying cultural norms and expectations evident in
community health research, which makes sharing the experience between different groups
somewhat of a challenge. In action research studies, changes in health outcomes as a result of
interventions are often not detectable for many years, which may create tensions on those
waiting for results, including funding agencies. This is a particular problem if the effect of an
intervention falls outside the political planning time frame. A further issue is related to the
challenges of measuring place-based improvements at the neighbourhood or community level,

especially if the research team has not enlisted team members who have cultural and statistical
expertise. So, although the optimal approach is to investigate multidimensional studies of
community health and wellness, the cautionary tale is that current funding agencies tend to
seek out and fund research with short, sharp, measurable outcomes, within the parameters of
their reporting requirements and political needs.
What remains for the future is to develop incremental, expanded programs of community
health research that will highlight the aspects of community culture and social life, in a way
that can be readily used for policy makers, health service managers and practitioners, and the
community itself. This agenda includes the trajectory research mentioned earlier in the chapter,
to assess change over time, including the effectiveness of interventions with individuals, families,
groups or populations as they experience health and illness across settings and across the life
span. The research to policy agenda will always have gaps to be filled with research into ways
of shaping health care systems to provide appropriate, accessible, acceptable, effective, efficient
and equitable care. It will also reflect trends and vested interests, particularly with budget
constraints on health and research funding bodies. For those who are not working within
large networks of researchers or organised programs of research, numerous research topics
arise out of everyday practice with communities. Many practitioners at the cutting edge of
practice have an ideal opportunity through research to make significant inroads into health
care improvements or to manage care and interactions with greater efficiency and
effectiveness.
Demographic changes are occurring in the community in tandem with the evolution of
sophisticated research strategies that will enable greater clarity in investigating issues such as
chronic conditions within a primary health care, social justice ethos. It is crucial that Australian
and New Zealand nurses add our voices to those of primary health care nurses internationally
to connect care, prevention and attention to the SDH at the grassroots level to global health
policy (Betony & Yarwood 2013). Population ageing, exponential increase in chronic illness
and lifestyle-related problems such as obesity and mental health problems have heightened
the need to research strategies for health literacy, empowerment and various versions of client-
centred care. Research studies need to include the rapidly growing cohort of baby boomers,
who, as we have mentioned previously, may want personalised accessible services with well-
informed choices. Their needs and preferences may see the nursing role transformed into that
of knowledge broker, culture broker and collaborative problem-solver partner.
Although there are few audits of nursing research in Australia and New Zealand, a review
of published studies in professional journals globally reveals some interesting trends. The
Journal of Community Health Nursing publishes a wide range of community research, some
of which is focused on behaviour change and chronic illness management, but research reports
also include studies that advance knowledge, for example, by framing various interventions
within a socio-ecological perspective of community life. Family and Community Health is
another journal which reports studies on health promotion interventions for community
residents, as well as social and environmental issues. These include studies of community
environments that support injury prevention strategies, healthy adolescence and ageing, and
reports of various specific nursing interventions. The journal Health and Social Care in the
Community reports numerous studies of home care and other contexts for care giving. In the
past few years, this journal has published widely on service organisation and the needs of
carers. Studies also include those addressing the SDH: housing and homelessness, poverty,
health inequalities and social inclusion. The Australian Journal of Rural Health contains reports
of nursing research, but its major focus is on the rural community, so the reports are more
interdisciplinary than some of the other nursing and midwifery journals. With workforce
shortages, a large proportion of the research concerns recruitment and retention of health
professionals, and professional issues related to attracting staff. The Journal of Advanced Nursing
and the Journal of Clinical Nursing publish more frequently than some of the other nursing
journals, and these have a strong mix of examples of evidence-based practice and topics
addressing community health issues. Some of the more recent studies reported in these journals
include research into psychosocial issues in health care, models of service delivery, and approaches
for working with vulnerable groups.
KEY POINT
Databases such as Proquest, Cinahl, Medline, PubMed, PsychInfo and Scopus provide
extraordinary resources to support research.
Australian journals such as Contemporary Nurse, Collegian and the Australian Journal of
Advanced Practice also address a balanced mix of nursing and midwifery research that focuses
on interventions, professional development and the needs of communities. All publish
international nursing studies. In some cases, the journals develop special issues dedicated to
a certain topic, which can be particularly helpful to nurses and midwives working in the
community. Contemporary Nurse publishes many special issues, with a strong emphasis on
community and family topics, as well as culture and Indigenous health. Nursing Praxis in New
Zealand publishes a range of nursing research specific to New Zealand and is an excellent
source of New Zealand-specific studies. Kai Tiaki Nursing Research is a recently established
New Zealand peer-reviewed nursing journal that publishes research on a range of topics
specific to nursing and is another useful source of research specific to New Zealand. The
Journal of Primary Healthcare, likewise is a New Zealand-specific journal that takes a multi-
disciplinary approach to research, publishing peer-reviewed, scientific research targeting general
practice.
There are many aspects of community life in Australia and New Zealand that have yet to
be sufficiently researched. Our review of journals in which Australian and New Zealand nurses
publish their research reveals a dearth of studies that respond to the SDH, although much of
this work is published in a range of interdisciplinary journals, especially public health and
health promotion journals. However, with the trend towards researching chronic conditions
and ageing, numerous other journals publish studies relevant to all aspects of community
practice. We have tried throughout this book to outline a wide range of resources from the
most community-relevant journals. The best way to extend this work is by accessing further
information through the large, comprehensive databases that are available to most scholars
and practitioners who have access to the internet. When all else fails, there is always Google!
Some of the burning questions that remain are listed in Box 10.5
The research questions found in Box 10.5 could be used to guide an entire program of
research. However, the most important element in any investigation is the need to pose a
manageable question; one that can be addressed in the timeframe allowed, using a defined
pool of resources. Although other aspects of the research process are important, the method
is ultimately driven by the research question. Information on writing a study proposal and
tips for arguing for the study to a granting body are available online at the Elsevier site associated
with this book. These tips are offered in the hope that we have persuaded all readers of this
text to participate in generating and/or using the evidence base that will help communities
become healthy, happy, vibrant and sustainable.
BOX 10.5
COMMUNITY HEALTH RESEARCH QUESTIONS
• What community support mechanisms will create the best opportunities for
empowerment and self-determinism among disadvantaged people? How can these
be tailored to groups differentiated by race, ethnicity, gender, health status, age or
geography?
• What policies and practices will create the best opportunities for enriched parenting?
What are the barriers to good parenting for different age, stage and socio-economic
groups? How can communities support parenting?
• What are the most helpful strategies in reducing alcohol and tobacco use/overuse for
particular groups? How are these embedded in social and environmental factors?
• Which interventions have shown the most promise in fostering the combination of
healthy nutrition and physical activity across the lifespan? What environmental
influences facilitate healthy lifestyles for which groups?
• What are the moderators of workplace stress in promoting family health and
happiness? Which occupational supports can help alleviate workplace stress for
different types of workers?
• How can nurses enhance access to effective neighbourhood or community-based
strategies for supporting families experiencing disruptions and transitions? Where and
how are they most effective?
• What is good and best practice, or good and best process in maintaining mental
health for different age groups? How are these practices implemented in rural and
remote areas?
BOX 10.5
COMMUNITY HEALTH RESEARCH QUESTIONS—cont’d
• How can schools support urban and rural adolescents through the crucial time of
emerging identities?
• Which technologies are most helpful to develop health assets and meeting health
needs for different age groups?
• How can health practitioners participate in creating sustainable neighbourhoods to
support healthy ageing?
• To what extent do emerging technologies, particularly telecommunications, provide
health benefits for older rural residents?
• What are the barriers and facilitators involved in nurses becoming active advocates
for social policies to protect human rights?
• In what ways can collaborative practice enhance health outcomes for communities?
• How do nurses understand the SDH and how do they integrate this understanding
into their practice?
• What are the most effective models of nursing care for chronic condition
management, for health promotion, for community capacity building?
Conclusion
Nurses and other health practitioners at the cutting edge of practice often identify problems or
issues that need to be researched. In this chapter we have covered a wide range of approaches to
research and how these can be used in the community context. While it may not always be practicable
for frontline practitioners to do the research themselves, knowledge of the research process, where
to find good quality research and how to contribute to research within communities are essential
skills. We encourage you to use research wisely, identify and recommend research to be undertaken
in the communities you work with and read widely. These skills will help develop your community
practice and strengthen your work with individuals, families and communities. Community health
and wellness can be achieved through a combination of knowledge generation, practical application
of that knowledge in communities, and an approach to working with people and the communities
within which they live that recognises their strengths and capabilities. Thinking globally and acting
locally has never been more important. We finish this book by turning to the last of our case studies
with the Mason and Smith families. We hope you have enjoyed their company while you have journeyed
through this book.
CASE
STUDY EBP to assist the Mason and Smith families
:
Nurses working in the mine site and in the home communities of both families are conscious of the
need for evidence-based practice. A number of research findings have already affected the families,
including global studies on sustainable environments and studies on family life and child health. For
example, Huia has enrolled Jake in a research study to examine the effectiveness of nurse-led asthma
clinics in managing childhood asthma. School health nurses in Perth are evaluating healthy school
initiatives in relation to children’s coping strategies and public health researchers are working with
nurses to identify the range of issues associated with FIFO family life to develop support programs.
■ Research is an important part of practice.

■ Researching community health issues requires a broader approach than the traditional evidence-
based practice methods.
■ Mixed-method research can help provide the community perspective as well as specific investiga-
tion of designated variables.
■ Research is time and resource intensive.
■ Multidisciplinary studies can give a greater breadth to studies of community health.
■ Special considerations must be given to researching with Indigenous people, to ensure their cultural
safety.
■ Community-based participatory research, especially participatory action research, is well suited to
studies of the community.
■ The research questions should dictate the research method, which then follows appropriate
conventions for data collection, analysis and dissemination of findings.
■ Translational studies are designed to transfer or translate knowledge into practice.
■ The community research agenda has many gaps that indicate the need for ongoing research,
particularly addressing the SDH.
■ Research is something that all nurses working in communities can and should be involved in.
1 Identify one research question for each family unit involved in the case study throughout the previous
chapters.
2 Explain how you would investigate each of these questions.
3 How would the results of each study inform primary health care in your practice?
4 There are innumerable topics that nurses can and do research. Working in pairs, identify a topic area that
interests you. Why is it important that nurses undertake research in this area? Argue your case for undertaking
nursing research in this area to the wider group.
I hope you have enjoyed this book as much as we have enjoyed writing it for you. A book is a labour of
love in many ways and we hope you will find within it the tools you need to work successfully with
communities and contribute in some small way to improving the lives of those you work with. Ngā mihi
mahana kia koutou.
Jill Clendon
As an author, academic and community child and adolescent health nurse at Curtin University in Western
Australia, I am privileged to be working in Noongar (or Nyungar) Country. Out of respect to the traditional
custodians, the Nyungar people and their Elders past, present and future, I would like to say farewell and
thank you using ‘Boordah’ which is a Noongar/Nyungar word that refers to ‘later on’ or ‘in the future’.
Ailsa Munns
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APPENDIX A
The McMurray Community

Assessment Framework
MAP community
EMPOWER the
strengths, resources
Approach key community members community
and risks Analyse the information in
to identify how you can work with
their community to undertake a collaboration with community
Map community strengths, resources members using a SWOT analysis:
community assessment. Gain their Share the findings with community
and risks by a) talking with everyday • Strengths
consent to work in and with the members and work with them to
community members about their • Weaknesses
community and work with them to develop interventions strategies for
perceptions, priorities, and relationships • Opportunities
identify how they appraise and improvement or measures that
within and external to the community • Threats
assess their health strengths and sustain positive community life.
and b) collecting information using the
needs along with their perceptions, SDH Assessment Circle as a
priorities and understanding of framework for organising the data.
community assessment.
ENGAGE with the

community ANALYSE
Biology,
genetic Cultural
Health characteristics strengths,
practices, values, beliefs,
coping skills needs,
gender
Health
Physical
services,
environments
resources
Social
determinants
of health
circle
Social
Social
support
environments
networks
Employment Indicators of
and working child health and
conditions Education development
and
literacy
Figure A.1 McMurray Community Assessment Framework

Healthy
child
development Social
Biology, genetic support
Cultural
strengths,
values, beliefs, Education,
needs; literacy
Gender Social
determinants
of health
Health
Employment
services,
and working
resources
conditions
Health
Social
practices,
environments
coping skills
Physical
environments
Figure A.2 The SDH Community Assessment Circle
1 Indicators of child health and development

2 Biological or genetic population indicators
3 Cultural strengths, values, beliefs, history and needs; gender
4 Health services and resources and patterns of accessing these by various population groups
5 Health practices, coping skills in the context of recreation and leisure, which may support or compromise health,
such as drop-in centres, places that encourage health literacy and capacity, or drug and alcohol misuse
6 Physical environments, including geographical factors such as climate change or transportation barriers to care,
or activity-friendly neighbourhoods
7 Social environments, indicators of social inclusion or exclusion
8 Employment and financial status of the population, including unemployment rates, working conditions, types of
employers, availability of workplace support
9 Education and literacy indicators
10 Social support networks, access for vulnerable groups, volunteer networks
300 APPENDIX A The McMurray Community Assessment Framework
Physical
environments
Health
Social
services,
environments
resources
What is the demographic mix of population by age, Health

Employment
gender, ethnicity? practices,
and working
coping skills
What is the birth rate among the various groups? conditions
Social
What is the death rate and the
determinants
leading causes of death? of health
What patterns of health and disease Biology, Education,
exist in the community? genetic literacy
What is the prevalence and incidence characteristics
of the most common conditions in the
Social
community? support
Which groups in the community are more prone to Healthy networks
child
certain genetic or biological conditions? development
What is the mix of dual and single parent households?
What proportion are single dweller households?
Cultural
strengths,
values,
What are the indicators of gender beliefs, needs;
inequality in the community? Gender
What languages are spoken?
What cultural or special needs groups are visible in the community?
What are the cultural strengths, values, beliefs and needs in the community?
To what extent are gender relations protected through a women’s health
and men’s health policy?
Is there equal support for fathers and mothers in the education, health, childcare
and social support systems?
How are the rights of LGBTI people supported in the community?
Are there groups in the community with particular spiritual needs? How are these addressed?
Figure A.3 The SDH Community Assessment Circle—biology/genetic factors and gender/culture
What supportive programs are available to promote healthy lifestyles? For which groups of people?
To what extent is housing adequate, safe, warm or cool enough, and protective from crowding?
Which areas in the community have substandard housing? Is emergency housing available
when needed? Are any community groups excluded from this type of help?
What policies and programs are available to support those with difficulties in finding housing?
What are the indicators that the social environment is inclusive? How are different groups
encouraged to participate in community life?
What special programs are available to support cultural diversity?
What types of social support are available for different age groups?
What local council initiatives support families?
To what extent do citizens of all ages have access to the internet? Social
environments
To what extent is the community disadvantaged by

remoteness or distance from health and social supports?
What steps are taken to ensure the community
has clean air, water, and sufficient
environmental supports for health? Physical Healthy
How is the link between climate and health environments child

Social
development
support
outcomes measured and disseminated to the networks
population?
What health literacy initiatives help develop knowledge
of environmental risks? For which groups of people? Education,
literacy
What green spaces are available for people to engage
in recreation, and for children to play? Social
To what extent do all population groups have determinants
of health
access to safe, efficient and affordable public Health Employment
transportation? services, and working
resources conditions
What types of systems are in place to ensure
healthy food and safe water is available?
Health Biology,
To what extent are food bank and budgeting services genetic
practices, Cultural
available where needed in the community? coping skills characteristics
strengths,
How are pollution and waste managed? values, beliefs
needs;
Gender
Figure A.4 The SDH Community Assessment Circle—physical and social environments
What is the distribution of publicly subsidised schools in the community? To what extent do these serve
all neighbourhoods?
What initiatives exist to encourage adolescents to complete high school?
How do schools support the health and wellbeing of children and their families?
How are schools involved in community life?
What literacy programs are available for new migrants, non-English-speaking groups?
What supports are in place for vulnerable and disadvantaged people to undertake education
and/or skills retraining?
How is health literacy addressed in the community? To what extent are health literacy programs inclusive?
Education, What is the rate of employment/unemployment

literacy for various groups (young people, adults)?
What are the more predominant occupations in
the community?
What are the rates and types of occupational
Employment
Healthy injuries, diseases and exposures to hazards?
child
and working
conditions What policies exist to support those who are
development
Cultural unable to find work?
strengths,
values, beliefs To what extent do workplaces support parental
needs; leave arrangements?
Gender
How does the workplace support workers’ rights
Biology, at work, especially for migrants, casual
genetic
Social employees, and those disadvantaged by illness
characteristics
determinants Social or distance?
support
of health networks
What physical and psychosocial supports exist
for workers to minimise the risk of illness, injury
Physical and work-related stress?
environments What are the indicators of gender and cultural
Health
services, equality in the workplace?
resources
Social
Health
environments
practices,
coping skills
Figure A.5 The SDH Community Assessment Circle—education/literacy and employment/

working conditions
What are the indicators that health and other services are governed by a ‘health in all policies’ program?
What is the distribution of acute and community services?
To what extent are these appropriate for all population groups?
To what extent does the community provide equal access to affordable care?
What evidence is there that health services are well governed?
What evidence-based clinical and management practices are used?
What is the distribution of culturally appropriate services for indigenous people, and those who have language
or communication difficulties?
What limitations exist on access for older or disabled residents?
What indicators are there that community services are client-centred, promoting self-care and choice?
What health promotion initiatives exist to reduce alcohol, tobacco, fat consumption and other hazardous
lifestyle factors? What is the prevalence of these lifestyle factors in the community?
Health
services, What are the indicators of community advocacy
resources initiatives to promote health literacy?
What is the distribution of health professionals?
To what extent is this adequate for the population?
To what extent are all health practices, including
Healthy Health alternative practices, and access to alternative
child
practices, practitioners available?
development
Cultural coping skills To what extent are working people able to access
strengths,
values, beliefs appropriate health and social services outside
needs; working hours?
Gender
How are people made aware of local resources?
Biology, Which mental and emotional health services are
genetic
Social available to all?
characteristics
determinants Social How are the needs of the mentally ill
support
of health networks accommodated?
How are family support centres made available
Physical for those in crisis?
environments
Education,
literacy
Social
environments Employment
and working
conditions
Figure A.6 The SDH Community Assessment Circle—health services/resources and health
practices/coping skills
Physical
environments
Social Education,
environments literacy What reproductive choices are available to women
in the community?
What is the distribution of antenatal services and
Health
services, Employment other forms of pregnancy support? To what extent
resources and working
conditions are these available to all parents?
Social
What is the rate of child and maternal mortality?
determinants
of health Very low birthweight? stillbirths? What is the variability
Health of these rates for various groups in the community?
practices, Healthy
coping skills What supports exist for postnatal depression and
child
other postpartum issues?
development
Cultural To what extent do all families have access to
strengths,
values, beliefs,
neonatal and ongoing child care? What programs
needs; Biology, are available to support parenting?
Gender genetic
characteristics Is there access to early childhood education (ECE)
and child care for everyone who wants these
services?
To what extent do ECE and child care services
Social accommodate cultural diversity? Are they inclusive
support of the needs of disadvantaged children?
networks
To what extent are there sufficient voluntary agencies and volunteers to help those in need?
How does the community support those who are impoverished?
What disability supports are provided for the disabled and their families?
How are community members encouraged to engage in partnerships for health and wellbeing?
How do community organisations reduce social exclusion?
Figure A.7 The SDH Community Assessment Circle—healthy child development and social
support networks
APPENDIX B
Calgary Family
Assessment Model
Pulliam, L.W., Plowfield, L.A., Fuess, S., 1996. Developmental Care: The key to the emergence of the vital older
woman. J Obstet Gynecol Neonatal Nurs. 25 (7), 623–628. With permission from Elsevier.
APPENDIX C
HEEADSSS Assessment Tool for

use with Adolescents
A psychosocial assessment of young people is equally as important as a physical assessment.

The following tool is based on Goldenring & Cohen’s (1988), Goldenring & Rosen’s (2004) and
Klein et al.’s (2014) HEEADSSS method of interviewing. HEEADSSS stands for Home, Education/
Employment, Eating, peer group Activities, Drugs and Alcohol, Sexuality, Suicide and Depression,
and Safety. We suggest that you also consider exploring the adolescent’s level of community
involvement as this may be an area of strength for the individual or an area where support can
be found.
We recommend you undertake formal training in the use of the HEEADSSS assessment
tool prior to use.
THE TOOL
HOME
In the home setting, we cover family, culture and connections, looking for both resiliency and
risk issues.
■ Where do you live? Who do you live with?
■ Ask about extended family links and culture—iwi, hapu, whānau, tribe.
■ Where were you born? How long have you been here?
■ Do you belong to a church? What activities and length of time have you been involved
with the church?
■ Tell me about the jobs or responsibilities at your place?
■ Who makes the rules? What happens if rules are broken?
■ What happens when you fight at your house?
■ Is there any violence occurring at your house?
■ Who in your family do you get along well with? Not so well?
■ Who is the person you talk to most?
EDUCATION
■ Tell me about school/training course/work?
■ If none—how long have you been out of school/work? Why? Plans? What do you do
with your time now?
■ If yes—which school? What is good about school? Not so good?

■ Do you have friends at school? Is there a teacher you get along well with?
■ How do you do in your school work and classes?
■ Do you have ideas about what you might like to do when you leave school?
■ Do you miss much school? Why?
■ Are you bullied at school?
EATING
■ What do you like and not like about your body?
■ Have there been any recent changes in your diet?
■ Have you dieted in the last year? How? How often?
■ Have you done anything else to try to manage your weight?
■ How much exercise do you get in an average day? Week?
■ What do you think would be a healthy diet? How does that compare to your current
eating patterns?
■ Does your weight or body shape cause you any stress? If so, tell me about it?
ACTIVITIES
Here we cover what you do. for example, with your friends, with your family and in your
community.
■ What do you and your friends do for fun? (With whom, where and when?)
■ What do you and your family do for fun? (With whom, where and when?)
■ Do you participate in any sports or other activities?
■ Do you regularly attend a church group, club or other organised activity?
■ Are you involved in any community activities?
■ How do you get money?
■ How do you get around? Do you drive sometimes?
■ What about sleeping? Do you sleep well?
■ Some teenagers tell me they spend much of their time online. What types of things do
you use the internet for?
■ How many hours do you spend on any given day in front of a screen such as a computer,
TV or phone? Do you wish you spent less time on these things?
DRUGS/ALCOHOL
Introduce, for example, ‘We know that many young people try alcohol and drugs; is it all right
if I ask you some questions about that now?’
■ Do young people at your school smoke? Do your friends smoke? Do you smoke?
■ Do your friends/parents ever drink alcohol? Do you?
308 APPENDIX C HEEADSSS Assessment Tool for use with Adolescents
■ Have you ever used marijuana? What other drugs/solvents are young people using these
days?
■ What do you think about that? What have you tried?
■ If the young person is using:
• How much are you using? In what circumstances? What do you like and not like
about using?
• What risks do you take when using? Have you ever considered using less?
SEXUALITY
Introduce, for example, ‘We ask everyone about sexuality because that is a very important
aspect of young people’s lives and can affect their health so much. Is that OK with you? You
can “pass” on questions if you want to.’
■ Have you had any sexuality education at school? What was that like?
■ Do your friends have sexual relationships? Do you?
■ Are you attracted to anyone now?
■ Are you interested in boys? Girls? Both? Not sure yet?
■ What do you know about safe sex?
■ What do you do (in terms of keeping sexually safe)? Do you use condoms? How much
of the time? (Every time? Just when you can get them? Sometimes?)
■ What could you do if you thought you might be pregnant?
■ Has anybody ever touched you in a way that you don’t like?
■ If you ever felt uncomfortable or something unpleasant happened to you, is there anyone
that you could tell?
■ Are there adults you can go to for advice/help about sex and relationships?
■ Do you want to talk about anything else about relationships or sex?
SUICIDE AND DEPRESSION

In this area, we cover issues of mental health and self-harm.
■ How would you describe your mood/feelings most of the time? (Scale 1–10)
■ Do you have really good/bad times?
If low mood is an issue, review sleeping, eating, energy, concentration, feelings of guilt/
worthlessness and safety.
■ Do you ever have worries or hassles that bother you?
If yes:
■ Do they keep you awake at night?
■ Do you have to do anything to keep them under control?
■ Do you sometimes feel that life is not worth it?
■ Have you ever harmed yourself deliberately?
If no, you may not need to continue this line of questioning.

■ Have you ever thought of ending your pain once and for all?
■ Do you know anyone who has died from suicide? Who? When?
■ How often do you think about doing it? How did you think you would do it?
■ How strong are these feelings for you at the moment?
■ Do you think you might try?
■ What if something went wrong for you? (Relationship break-up, etc.)
■ Who could you tell about feeling suicidal?
Regarding previous suicidal behaviour:
■ What did they do? How many times? How long ago? What happened?
■ How do they feel about the fact that they did not die?
■ Do they wish they had died?
■ Have things changed since then? What?
■ Do they think that they might try again?
SAFETY
■ Have you ever been seriously injured? How? How about anyone else you know?
■ Do you always wear a seatbelt in the car?
■ Have you ever ridden with a driver who was drunk or high? When? How often?
■ Do you use safety equipment for sports and/or other physical activities (e.g. helmets for
biking or skateboarding)?
■ Is there any violence in your home?
■ Does the violence ever get physical?
■ Is there a lot of violence at your school? In your neighbourhood? Among your friends?
■ Have you ever been physically or sexually abused? Have you ever been raped on a date
or at any other time?
■ Have you ever been in a car or motorbike accident? (What happened?)
■ Have you ever been picked on or bullied? Is that still a problem?
■ Have you gotten into any physical fights in school or in your neighbourhood? Do you
still feel that way?
■ Have you ever felt like you needed to carry a knife, gun or other weapon to protect
yourself? Do you still feel that way?
310 APPENDIX C HEEADSSS Assessment Tool for use with Adolescents

HEEADSSS assessment tool
• http://contemporarypediatrics.modernmedicine.com/contemporary-pediatrics/content/tags/
adolescent-medicine/heeadsss-30-psychosocial-interview-adolesce?page=full
• Free, online learning: https://www.goodfellowunit.org/courses/
introduction-heeadsss-assessment
References
Goldenring, J.M., Cohen, E., 1988. Getting into adolescent heads. Contemp. Pediatr. 5 (7), 75–90.
Goldenring, J.M., Rosen, D.S., 2004. Getting into adolescent heads: An essential update. Contemp. Pediatr. 21 (1),
64–90.
Klein, D., Goldenring, J., Adelman, W., 2014. HEEADSSS 3.0: The psychosocial interview for adolescents updated
for a new century fuelled by media. Contemp. Pediatr. 31, 16–28.
Index
Page numbers followed by ‘f ’ indicate figures, ‘t’ indicate tables, and ‘b’ indicate boxes.
resilience of, 195–203

A risk-taking and, 195–203, 197b
Aboriginal Australians, 255 social capital and, 199–200
cultural safety, 255 transitions, 196b
family of, 163–164 adolescent health
research on, 287 conceptual framework for, 200b, 200f
violence in, 172, 172b ecological framework for, 198–199,
Aboriginality, 255–256, 255b, 255f 199f
absolute poverty, 64 environments influencing, 202
abuse goals for, 198
elder, 216–217 nurses for, 202–203
of women, 244–245, 245f school and, 202
see also intimate partner violence; substance SDHs of, 194f, 195–203
abuse self-harm and, 201f
accessible health care, 14, 14b social environment and, 202
cultural safety and, 15–16, 17b stages of, 197b
cultural sensitivity and, 15–16, 17b suicide and, 200–201
equity and, 14 supportive environment for, 161
health promotion and, 14 adults, 203
intersectoral collaboration and, 15 cardiovascular disease in, 204
social justice and, 14 causes of death and disability in, 204b
technology and, 14–15 chronic conditions in, 204
Accident Compensation Corporation (ACC), context, 203–206
42–43 definition of, 222
acculturation, 249–250 diabetes in, 204
action research, 283–284 frailty in, 217
adolescents, 195–203, 222b health literacy and, 218
context, 195 lifestyle changes in, 205–206
decision making by, 195–203 middle stages of, 208–209
depression in, 117 morbidity, 204b
early adolescence, 196 mortality, 204b
HEEADSSS assessment for, 201–202 nutrition counselling, 205b
late adolescence, 196 obesity in, 204
LGBTI, 200–201, 201b stress in, 207
mental health services for, 202 transitions to adulthood, 218–220
middle adolescence, 196 work and, 206–208
312 Index
adult health, 203–209 assimilation, 249–250

goals for, 209, 209b–210b, 222b–223b Australia
nutrition counselling for, 205b adolescent people in, 197–198, 198b
advanced practice nurses, 90–92 adults in, 203
advocacy, 23 advanced practice nurses in, 90–91
advocacy groups, 152–153, 153b assessment information sources in, 133–134,
affiliation, 73–74 134b
Aged Care Assessment Team (ACAT), 37–38 child health nurses in, 92–93
Age-Friendly City, 68 child poverty in, 184
ageing, 210–221 Commonwealth government of, 37
ageist attitudes, 213, 214b community mental health nurses in, 96–97
future for, 220–221 community nursing services in, 37–38
goals for, 221, 221b FIFO in, 72–73
LGBTI and, 211–212 general practice nurses in, 92
religious institutions and, 215 gross domestic product (GDP) of, 35
retirement and, 214–215 health care system of, 35–39, 35b, 37b
in rural and remote areas, 212 health impact assessment (HIA) of, 50b
transitions and, 218–220 hospital performance of, 37b
see also older people HPH in, 76
ageism, 213, 214b HPS in, 77–78
Alzheimer’s disease, older people with, 215, 216b Indigenous people in, health of, 256–257,
analysis, 132–133 257b
Anderson and McFarlane’s community integrated care in, 39, 39b
assessment tool, 121–122, 123b medical practitioners of, 38–39
antenatal care, 176–178, 177b Medicare in, 35, 35b
antenatal visits, 178 midwives in, 98–99
appreciative inquiry, 285 migrants in, 169
assessment National Disability Insurance Scheme (NDIS)
asset mapping in, 125–126, 125b–126b of, 38
community, 114–138, 115b, 135b–136b National Health Performance Framework
cultural, 124, 124b (NHPF) of, 36
deficit model of, 125 nurses in, 38b
epidemiological, 115–117, 116b obesity in, 182
ergonomic, 208 older people in, 211–212
of families, 141–144, 141b, 143b, 168 paramedic practitioners in, 99
health education planning, 127–129 paramedicine practice in, 99
of individuals, 141–144, 141b, 143b primary care performance of, 37b
information sources for, 133–134, 134b Private Health Insurance Rebate of, 35
in intervention planning, 141b refugees in, 169
asset rural communities in, 70–71, 71b
cultural information and, 124 SDH of, 51
health promotion and, 20–21 statutory agencies of, 36b
identifying, 129–130 see also Aboriginal Australians
mapping, 125–126, 125b–126b Australian Health Practitioners Registration
model, 125f Authority (AHPRA), 38b
Index 313
Australian Institute of Health and Welfare preconceptual, 176–178, 176b

(AIHW), 37 see also accessible health care; health care;
Australian Journal of Rural Health, 289–290 primary health care
Australian National Rural Health Alliance, 77, caregivers
152–153 family, 208–209
Australian Nurse-Family Partnership Program, same-sex couples as, 164–165
178b school health and, 70
Australian Red Cross Blood service, 36–37 causation, 244–245
‘Australia’s Health’, 133–134 CBPR see community-based participatory
research
C-FERST see community-focused exposure and
B risk screening tool
behaviour change, motivational interviewing chemical hazards, 208
and, 149 child health
behaviour-change model, 24 critical pathways of, 178–182, 178b–179b, 185f
behaviours, of men, 238b goals for, 184
belongingness, 205–206 nursing practice and, 92–94, 94b
‘best treatment’, 275 poverty and, 184
bias, systemic, 254, 254b for SIDS/SUDI prevention, 271–273
Bierce, Ambrose, 47 children
big data, 279 healthy, 175–184, 175b
biologic hazards, 208 IPV and, 171
biological embedding, 7, 175–176 obesity in, 182–183, 183b
biology resilience of, 178–182, 180b–182b
community assessment and, 115–116 Children’s Action Plan, 93
in individual health, 4 chronic conditions, in adults, 204
‘Blitz’ approach, to SIDS/SUDI prevention, cities
271–272 age-friendly, 68
Blue Care, 38 built environment of, 68
bonding social capital, 18 health in, 76
Bouverie Centre, 163–164 health promotion in, 76
bridging social capital, 18 inequity in, 67–68
Bristol Breastfeeding Assessment Tool, 141–142 older persons in, 68
‘butterfly effect’, 46–47 see also urban communities
Clark’s model of assessment, 121, 122b–123b
client-centred care, 89
C client-centred model, 24
Calgary Family Assessment Model, 142 clinical input, in policy, 49b
cardiovascular disease collaboration, intersectoral, 15, 17b
in adults, 204 communication, assessment and, 143
in women, 235 communicative health literacy, 19, 19t
care community, 232
antenatal, 176–178, 177b of affiliation, 73–74
client-centred, 89 biological factors, 4–5
institutional, 3 contemporary issues within, 72–75
314 Index
community (Continued) community mental health nursing, 96–98, 97b

definition of, 5 community midwifery practice, 98–99, 99b
families in, 67 community participation, 16–17, 17b
FIFO, 72–73 community-based participatory research
fundamentals of, 3–33, 4b (CBPR), 126–127, 127b, 129–130, 282,
global, 64–71 282b–283b
inclusive, 231–265 community-based preconception care, 176
Indigenous populations, 75 community-based research, 271
migrant, 74–75 community-based research partnerships,
multilayered perspective of, 4–6 281–282
as partner, 121–122 community-focused exposure and risk screening
of place, 63–83, 63b, 79b tool (C-FERST), 118–119
practice, 3 comprehensive assessment, 124
refugee, 74–75, 74b comprehensive data collection, 143
relational, 72 comprehensive PHC, 15, 127b
research and, 268, 269b concept analysis, 277
rural, 69b–70b, 70–71 connectedness, 5
social media, 72 Consolidated Standards of Reporting Trials
urban, 67–68, 68b (CONSORT), 277–278
virtual, 72 CONSORT see Consolidated Standards of
community assessment, 114–138, 115b, Reporting Trials
135b–136b contemporary issues
Anderson and McFarlane’s, 121–122, 123b in communities, 72–75
epidemiological approach, 119–120 within family, 168–173
epidemiological assessment, 115–117 in refugee and migrant families, 169–170,
evolution of, 120–124, 121b–122b 170b
in nursing, 120–124, 121b–122b in rural and remote families, 168–169
physical environment in, 67 contemporary methods, epidemiology, 118–119
streamlining, 130–133 Contemporary Nurse, 290b
tools for, 115–120 content, of groups, 104
community health, 9–11, 9b Convention Relating to Status of Refugees,
case study on, 28b–29b 74b
definition of, 10, 10b Country, 256
diabetes in, 276–277 critical health literacy, 19t, 20
empowerment in, 10 critical pathways, 178–182, 178b–179b, 185f
factors in, 4 critical perspective paradigm, 279–280
inequities and, 9 critical social theory paradigm, 279–280
perspective of, 4–6 cultural assessment, 124, 124b
poverty and, 182–183 cultural awareness, 252
research, 267b cultural blindness, 254
wellness and, 13 cultural capital, 249b, 249f
community health nurse, in intervention cultural competence, 252
planning, 140, 149 cultural information, 124
community health practice, 92–94 cultural relativism, 250–251
child health nursing practice in, 92–94, 94b cultural safety, 15–16, 17b, 251–252, 251b
general practice nursing in, 92 cultural sensitivity, 15–16, 17b, 252
Index 315
culture, 15–16, 232–249, 233b diabetes

Aboriginality and, 255–256, 255f in adults, 204
acculturation of, 249–250 in community health, 276–277
assimilation, 249–250 DIDO, 72–73
conflict, 249–251, 249f differential health care, 253–255
discrimination of, 253–254 digital media, 199–200
diversity in, 248 disability, in intervention planning, 152
ethnocentrism, 253–255 Disability Support Services (DSS), 152
family, 249f discrimination, 253–254
health and, 247–260 disempowerment, 8–9
Indigenous, 248–249 distributional equity, 14–15
integration of, 249–250 District Health Boards (DHBs), in New Zealand,
marginalisation of, 249–250 40–41, 41b
monolithic view of, 248–249 diversity, 248
multiculturalism, 253 domestic violence, 173
racism, 253–255 drive-in drive-out, 72–73
rejection of, 249–250 drugs, 239–240
stereotyping, 253–254
systemic bias in, 254
‘cumulative effects’, 196 E
early adolescence, 196, 197b
early years, health care during, 161–192, 162b,
D 164b, 186b–187b
data collection, comprehensive, 143 ecological fallacy, 118–119, 119b
decision making, 195–203 ecological framework, for adolescent health,
Declaration of Alma-Ata, 22 198–199, 199f
declarations, 22 ecology, 3
deficit model, of assessment, 125 ecomaps, 142b
dementia Edinburgh Postnatal Depression Scale (EPDS), 143
abuse and, 216–217 education
frailty and, 217–218 for SIDS/SUDI prevention, 271–273
in older people, 215, 216b for women, 237–238, 238b
in women, 235 effect size, 275
demographic time bomb, 213 effective communication, 143
Department of Health (DoH), 35–36 elder abuse, 216–217
Department of Veterans’ Affairs (DVA), embedding, biological, 175–176
37–38 empowerment, 10b, 133
depression in community health, 10
in adolescents, 117 empowerment model, 24
in men, 239–241, 241b enabling factors, 128–129
postnatal, 240–241 engagement, community, 131
design, quasi-experimental, 151 environments
determinism, reciprocal, 63 influencing adolescent health, 202
developing countries, 65–67 obesogenic, 183
developmental pathways, 164–165, 165b epidemiologic prevention process model, 121
Developmental Theory, 167 epidemiological approach, 119–120
316 Index
epidemiological assessment, 115–117, 116b

epidemiology
F
family, 162–164
classic model of, 115–116
assessment, 141–144, 141b, 143b
definition of, 115–116, 116b
in community, 67
limitations of, 120, 120b
contemporary issues within, 168–173
methods supporting, 118–119
definition of, 162–164, 163b
social, 129–130, 129b
developmental pathways of, 164–165, 165b
epigenetics, 175, 175b
FIFO, 170–171, 171b
equality, accessible health care and, 14
functions, 165–168, 167b–168b
EQUATOR (Enhancing the Quality and
healthy, 162–174, 174f
Transparency of Health Research) network,
interactions, 161
273–274
migrant, 169–170, 169b–170b
equity
refugee, 169–170, 170b
accessible health care and, 13–14
relational view of, 164b, 166
in cities, 68
remote, 168–169
community health and, 11
roles, 165–166
distributional, 14–15
rural, 168–169
in health care systems, 51, 51b
stability of, changes in, 166
SDH and, 15
violence in, 171–173, 172b–173b
ergonomic assessment, 208
Family and Community Health, 289–290
ergonomic hazards, 208
family health, 166–167, 167b
ethnocentrism, 253–255
goals for, 173–174
ethnography, 285–286
policies on, 173–174
evaluation
practice, 174
advocacy groups, 152–153, 153b
Family Partnership model, 142
disability, 152
Family Start, 93
in intervention planning, 150–152
Family Systems Theory, 167
process of, 150
female genital mutilation (FGM), 236–237
types of, 151
fetal development, 184
evidence
FIFO see fly-in fly-out
in SIDS/SUDI prevention, 271–273
fly-in fly-out (FIFO), 29, 73b
supporting issue, 144
in Australia, 72–73
evidence-based medicine (EBM), 273–274
communities, 72–73
evidence-based practice, 273–278, 273b–274b
families, 170–171, 171b, 174
evidence-based medicine (EBM) in, 273–274
in New Zealand, 72–73
home visiting, 278–279
sustainability and, 73
integrative reviews in, 275–277
frailty, in older adults, 217
literature reviews in, 275–277
Friedman’s Family Assessment Tool, 141–142
meta-analyses in, 275–277
functional health literacy, 19, 19t
paradigms in, 280b
process of, 273–274
randomised controlled trials in, 277–278 G
steps in, 274b gender, 232–247, 233b
systematic reviews in, 275–277, 275b–276b cultural norms in, 234b
explanatory theory, of SDH, 270–271 definitions, 243b
Index 317
issues among sexually diverse populations, at work, 207–208

241–244 see also adolescent health; adult health;
gender equality, 233–234 community health; family health; global
gender pay gap, 234, 235b health; Indigenous health; mental health;
gender-inclusive communities, goals for, public health; social determinants of health;
246–247 individual health
general practice nursing, 92 Health and Social Care in the Community,
genetics, 175–176 289–290
genograms, 142b Health Belief Model, 24
geographic information systems (GIS), health care
118–119 differential, 253–255
Global Campaign for Violence Prevention, policy making and, 52f, 53–55
245–246 see also accessible health care; primary health
global community, 64–71 care
global health promotion, 22–23 health care institution, 3
global poverty, 47, 47b health care practitioners
Global Strategy for Women’s, Children’s and advanced practice nurses as, 90–92
Adolescent’s Health, 198b in community health practice, 92–94
globalisation, 64, 65b in community mental health nursing practice,
Gold Coast Integrated Care Model (GCIC), 39 96–98, 97b
grandparents, 163, 166 in community midwifery practice, 98–99, 99b
Green and Kreuter’s model, 127–128 in intervention planning, 140
group leadership and, 106–107
advocacy, 152–153, 153b in paramedicine practice, 99–100, 100b
work, 103–105, 104b practice strategies of, 103–107
group facilitators, 104–105 in reflective practice, 105
in rural and remote area practice, 101–103,
101f, 102b
H in school health nursing practice, 94–96, 95b
health, 3, 4b types and categories of, 90–103
of adolescents, 195–203 in working with groups, 103–105, 104b
in cities, 76 health care system, 51b, 57
in communities of place, 75–78 of Australia, 35–39, 35b, 37b
concepts of, 5 building a better, 55–57
culture and, 247–260 culturally competent, 252b
definition of, 4–5 equity in, 51b
education, 23–26, 24b features of, 55b–56b
healing and, 257–258, 257f, 258b fiscal savings in, 44b
in older people, 211–213, 212b goals for, 56b–57b
of Pacific people, 40 of New Zealand, 39–44
promotion, 15, 16t policies on, 44–48
social capital and, 18 policy making and, 44–48, 46b
social determinants of, 3, 7–11, 8f, 131, politics and, 44–48
132f resources and good management in, 55–57
social gradient in, 7 SDHs and, 51–52
318 Index
health care system (Continued) Home and Community Care (HACC), 37–38
state and territory governments in, 36 home visiting, 278–279
stewardship in, 55–57 homelessness, 244
health education planning homosexual families, 242b
assessment tools, 127–129 hospital, health promotion in, 76
PRECEDE-PROCEED model, 128–129 HPH see Health Promoting Hospitals
health impact assessment (HIA), 50, 50b HPS see Health Promoting Schools
health in all policies (HiAP), 46, 46b human rights
health lifestyle theory, 270–271 health as, 46
health literacy, 18–20, 19b, 19t policies, 48–49
communicative, 19
critical, 19
functional, 19 I
wellbeing, 20–21 impact evaluation, 151
health policy making, 46, 58b implementation
evaluation of, 52b in intervention planning, 145–150, 147b
primary health care, 52f, 53–55 models of care and project planning, 147–148
Health Practitioners Competence Assurance Act modes of intervention, 148–150, 149b
(HPCA Act), 43–44 theoretical models underpinning care
Health Promoting Hospitals (HPH), 76 planning, 145–146
Health Promoting Schools (HPS), 77–78, 96 incidence, 115–116, 116b
health promotion inclusion see social inclusion
accessible health care and, 14 inclusive communities, 231–265
case study on, 29b migrant, 259–260
in cities, 76 inclusive research, 266–297, 268b
in communities of place, 75–78, 78b inclusive society, 231, 231b, 261b
emphasis on, 15, 17b Indigenous health, goals of, 259
evaluation of, 26–27, 27b Indigenous people, 231b, 247
in families, 166–167 culture of, 248–249, 255b
global, 22–23 health and place of, 256
in hospitals, 76 Indigenous populations, 75
in PHC, 20–22, 21b individual health
rural, 76–77 assessment, 141–144, 141b, 143b
in schools, 77–78 biology in, 4
through virtual technologies, 78, 78b nutritional status in, 4
Health Risk Appraisal (HRA), 220–221 personal history in, 4
health trackers, personal, 150 stress in, 4
Healthy Ageing Strategy, in New Zealand, 49–50 inequality, 232–247, 234b
Healthy Cities initiative, 68, 76 implementation strategies and, 147b
HEEADSSS Adolescent Assessment Tool, 143, inequity, 234b
201–202 implementation strategies and, 147b
HEEADSSS (Home, Education/Employment, infants, 177
Eating, Activities, Drugs and Alcohol, inquiry
Sexuality, Suicide and Depression, Safety) appreciative, 285
assessment, 201–202 naturalistic, 280–281
hegemony, 238 institutional care, 3
Index 319
institutional racism, 254 leadership, 106–107

integrated care, 39, 39b lesbian, gay, bisexual and transgender/
integration, of culture, 249–250 transsexual/intersex/takatapui/fa’afine
integrative reviews, 275–277 (LGBTI), 241–242
interactive health literacy, 19, 19t adolescence, 200–201, 201b
interdisciplinary practice, 88–89, 88t, 89b mental health issues of, 243
in intervention planning, 149 older people and, 211–212
international contemporary models, 89 school nurses for, 243
internet see social media supporting, 243b
interpersonal violence, 246b LGBTI see lesbian, gay, bisexual and
interpretive methods, 280–281 transgender/transsexual/intersex/takatapui/
interpretive paradigm, 279–280 fa’afine (LGBTI)
interprofessional practice, 88t life course theory, of SDH, 270–271
intersectoral collaboration, 15, 17b literature reviews, 275–277
intervention, planning for, 139–157, 139b, 153b
assessment in, 141–144, 141b–143b
development of objectives in, 144, 145b M
evaluation in, 150–152 Male Room, 240f
guiding approaches for, 140 mandatory reporting guidelines, 140b
implementation in, 145–146, 147b Māori
steps in, 141–152 comprehensive PHC in, 147–148
intimate partner violence (IPV), 171, 244–246 cultural safety and, 251–252
see also violence culture conflict in, 250
IPV see intimate partner violence disparities in health within, 40–41
families, 75, 164
family violence and, 172
J health of, 256–257, 257b
Journal of Advanced Nursing and the Journal of obesity and, 182
Clinical Nursing, 289–290 Pacific providers and, 40
Journal of Community Health Nursing, 289–290 poverty and, 184
Journal of Primary Healthcare, 290b research on, 287–288
rural and remote practice in, 103
mapping, 131
K marginalisation, of culture, 249–250
Kai Tiaki Nursing Research, 290b McMurray Community Assessment Framework,
Kaupapa Māori research, 287–288 130–133, 130f, 216–217
knowledge transfer, 281–284 Medicare (Australia), 35, 35b
knowledge translation, 281–284 Medicare Locals, 54
Kura kaupapa, 28b–29b men
behaviours of, 238b
depression in, 239–241, 241b
L employment of, 239
label, in documenting issues, 143 health issues in, 238–241
late adolescence, 196, 197b health policy of, 241, 241b
‘latent effects’, 196 illicit drug use of, 239–240
Lead Maternity Carers (LMCs), 43, 99 masculinity of, 239
320 Index
men (Continued) National Service Frameworks, 152

prevalent conditions of, 238 naturalistic inquiry, 280–281
psychological health of, 239–240 New Zealand
mental health, community, 96–98, 97b adolescent people in, 197–198, 198b
Mental Health Nurse Incentive Program adults in, 203
(MHNIP), 97 advanced practice nurses in, 91
mental health services, for older people, 218–219 aged and residential care in, 42
meta-analyses, 275–277 child health nurses in, 92–93
middle adolescence, 196, 197b child poverty in, 184
midwifery practice, community, 98–99, 99b community mental health nurses in, 96–97
migrant, 64, 74b cultural safety in, 251–252, 253b
in Australia, 169 family in, 163–164
community, 74–75 FIFO in, 72–73
family, 169–170, 169b–170b general practice nurses in, 92
in New Zealand, 169 health care system of, 35b, 39–44
stress on, 169–170 health impact assessment (HIA) of, 50b
women, 237b health policy of, 44
Millenium Development Goals (MDGs), 65 Health Practitioners Competence Act, 43–44
Ministry for Women, 241 Healthy Ageing Strategy in, 49–50
mixed methods research, 284 HPH in, 76
model HPS in, 77–78
of care and project planning, 147–148 inclusive migrant communities in, 259–260
of intervention, 148–150 Indigenous people in, health of, 256–257,
practice, 88–89, 88t 257b
morbidity, 204b integrated care in, 39, 39b
mortality, 204b maternity care in, 43
motivational interviewing, 149, 149b midwives in, 98–99
multiculturalism, 253 migrant in, 169
multidisciplinary practice, 88t minister of health of, 39–40
multiprofessional practice, 88t obesity in, 182
MyAgedCare, 37–38 older people in, 211–212
Pacific people’s health in, 40
paramedic practitioners in, 99
N paramedicine practice in, 99
National Digital Health Strategy, 37 PHARMAC in, 43
National Disability Insurance Scheme (NDIS), primary health care, 54
38, 152 refugees in, 169
National Health Performance Framework rural communities in, 70–71, 71b
(NHPF), 36 school based health services in, 202b
national health policies, 45 school nurses in, 94–95
National Health Reform Agreement of 2011, 54 SDH of, 51
National Primary Health Care Strategic strategy of, 40
Framework of 2013, 54 New Zealand Health Strategy, 39–40, 40b
National Registration and Accreditation Scheme, New Zealand Health Survey, 133–134
38 New Zealand Ministry of Health, 133–134
Index 321
New Zealand Well Child Schedule, 93 nurses in long-term care homes for, 219b
nurse polypharmacy in, 217–218, 218b
advanced practice, 90–92 retirement of, 214–215
in long-term care homes, 219b in rural areas, 212
see also school nurse social engagement in, 214
Nurses’ Health Study, 270b transitions of, 218–220
nursing volunteering in, 214
child health and, 92–94, 94b Ottawa Charter for Health Promotion, 21b, 22,
community assessment tools in, 120–124, 146
121b–122b outcome evaluation, 152
general practice, 92
school health, 94–96, 95b
nursing practice P
child health, 92–94, 94b Pacific community, 259
community mental health, 96–98, 97b Pacific people, 40
school health, 94–96, 95b Pain Health, 218
Nursing Praxis in New Zealand, 290b parachute study, 276b
nutrition paradigms, 279–281, 280b
for adult health, 205b critical perspective, 279–280
in individual health, 4 critical social theory, 279–280
interpretive, 279–280
positivist, 279–280
O paramedicine practice, 99–100, 100b
obesity ‘pathway effects’, 196
in Australia, 182 Pepi-Pod® program, 271–272
in children, 182–183, 183b perinatal period, 98–99
in New Zealand, 182 personal health trackers, 150
objectives, development of, 144, 145b personal history, 4
occupational health, 108b personal skills development, 19, 19b
older people PHARMAC see Pharmaceutical Management
abuse of, 216–217 Agency
ageism in, 213 Pharmaceutical Benefits Scheme, 35–36
Alzheimer’s disease in, 215, 216b Pharmaceutical Management Agency
attitudes of, 213, 214b (PHARMAC), 43
challenges in, 215–218 PHC see primary health care
in cities, 68 Phenomenology, Ethnography and Grounded
dementia in, 215, 216b Theory, 280–281
drug-related complications in, 217–218, physical environment, in community assessment,
218b 67
frailty in, 217 physical hazards, 208
future for, 220–221 place
health in, 211–213, 212b, 223b community of, 63–83, 63b, 79b
healthy lifestyles in, 212–213, 213f conventional view of, 72
interdisciplinary approach for, 219 health and, 75–78
mental health services for, 218–219 relational view of, 72
322 Index
planning, 139–157, 139b, 153b, 266–267 in community mental health nursing practice,
assessment in, 141–144, 141b–143b 96–98, 97b
evaluation in, 150–152 in community midwifery practice, 98–99, 99b
guiding approaches for, 140 in intervention planning, 149
implementation in, 145–146, 147b leadership and, 106–107
objectives development in, 144, 145b in paramedicine practice, 99–100, 100b
primary health care principles, 141 practice strategies of, 103–107
steps in, 141–152 in reflective practice, 105
strengths-based approaches, 141 in rural and remote area practice, 101–103,
PND see postnatal depression 101f, 102b
policy in school health nursing practice, 94–96, 95b
advocacy and involvement in, 50b types and categories of, 90–103
clinical input of, 49b in working with groups, 103–105, 104b
on family health, 173–174 precarious work, 207
on health care system, 44–48, 45b, 49b PRECEDE-PROCEED model, 24b, 127–129,
makers, issues for, 54b 128f
of nurse practitioners, 50b preconceptual care, 176–178, 176b
with social determinants of health, 51–52 community-based, 176
politics, on health care system, 44–48, 49b predisposing factors, 128–129
polypharmacy, in older people, 217–218, 218b prejudicial attitudes, 253–254
population health, 9, 9b prevalence, 115–116, 116b
populations, Indigenous, 75 prevention, primary, secondary and tertiary,
positivist paradigm, 279–280 25–26, 26f
postnatal depression (PND), 240–241 primary care, 11, 36
poverty, 51 primary health care (PHC), 3, 11, 12b
absolute, 64 access to, 14
in Australia, 184 barrier to, 51–52
child, 184 community participation in, 16–17
global, 47, 47b comprehensive, 15, 16t
in New Zealand, 184 cultural safety and, 15–16
power, 232–247 cultural sensitivity in, 15–16
practice FIFO and, 170–171
community, 3 health promotion in, 15, 20–22
community mental health nursing, 96–98, 97b interdisciplinary approach to, 88–89, 88t, 89b
community midwifery, 98–99, 99b intersectoral collaboration in, 15
on family health, 174 planning and, 141
interdisciplinary, in intervention planning, 149 policy making and, 52f, 53–55
paramedicine, 99–100, 100b in practice, 87–113, 87b
in primary health care, 87–113, 87b, 108b principles of, 13–17, 13f, 17b
reflective, 105 in SDH, 129–130
school health nursing, 94–96, 95b selective, 15, 16t
practice nurse, 12b technology in, 14–15
practitioners, health care primary health care practitioners, 149
advanced practice nurses as, 90–92 Primary Health Care Strategy, 54
in community health practice, 92–94 Primary Health Organisations (PHOs), 41
Index 323
primary prevention, 25–26, 26f culture, 284–286, 285f

Private Health Insurance Rebate, of Australia, 35 evidence-based agenda, 271
process evaluation, 151 evidence-based practice, 273–278
processes, of groups, 104–105 future, 288–291, 290b, 293b
professional development goal of, 267–268
ongoing, team-based, 89 in health promotion, 95
videoconferencing and, 102 home visiting and, 278–279
project planning, 147–148 inclusive, 266–297, 267b–268b
psychological health, of men, 239–240 with Indigenous people, 286–288
public health, 9, 9b mixed method, 284
paradigms in, 279–281
questions, 291b–292b
Q social determinants of health, 268–271,
qualitative research, 281b 269b
quasi-experimental designs, 151 translational, 281–284, 281f
see also community-based participatory
research
R researchers, poverty and, 182–183
racism, 253–255 resilience, 195–203
institutional, 254 child health and, 178–182, 178b–179b,
randomised controlled trials (RCTs), 277–278 185f
rate, 116b predictor of, 199–200
reciprocal determinism, 63 retirement, of older people, 214–215
reflective practice, 105 Rights of Indigenous Peoples, 48–49
refugee, 64, 74b risk-taking, adolescent and, 195–203, 197b
in Australia, 169 Royal District Nursing Services, 38
community, 74–75 Royal Flying Doctor Service, 36–37
family, 169–170, 170b rural communities, 69b–70b, 70–71
in New Zealand, 169 adults in, 206b
women, 237b families in, 168–169
Regional Health Services, 37–38 health practice in, 101–103, 101f, 102b
reinforcing factors, 128–129 older people in, 212
rejection, of culture, 249–250 screening in, 70–71
related factors, in documenting issues, 143–144 rural health, 71b
relative risk, 117, 117b Rural Health Alliance Aotearoa New Zealand,
remote area practice, 101–103, 101f, 102b 152–153, 153b
Remoteness Areas framework, 100 rural health promotion, 76–77
research, 266b
action, 283–284
big data in, 279 S
case study, 271–273 safety
community-based, 271 cultural, 15–16, 17b, 251–252, 251b
community-based participatory, 282, at work, 207–208, 208b
282b–283b same-sex couples, 164–165
culturally safe, 286–288 sandwich generation, 208–209
324 Index
school socio-ecological model of health, 146, 146f

adolescent health and, 202 socio-economic position (SEP)
health promotion in, 77–78 of men, 239
health services in, 202, 202b of women, 235, 235b
school health nursing practice, 94–96, 95b socio-legal arrangements, of family, 163
school nurse, 94–95 SPARX, 199–200
scoping review, 277 St John Ambulance service, 38–39
screening, 70–71 state governments, 36
SDH Assessment Circle, 131, 132f state trauma centres, 36–37
SDHs see social determinants of health Statistics New Zealand, 133–134
secondary prevention, 25–26, 26f stereotyping, 253–254
selective PHC, 15, 127b stratified information, 126
self-harm, pathways to, 201f streamlining community assessment, 130–133
SeniorNet, 215 strengths, weaknesses, opportunities and threats
signs, supporting issue, 144 (SWOT) analysis, 132–133, 133b
Silver Chain Nursing, 38 strengths-based approaches, 141
sleep, safe, 271–272, 273b stress
social capital, 18, 18b, 249b, 249f in individual health, 4
bonding, 18 on migrants, 169–170
bridging, 18 in workplace, 207
research on, 18 Structural Functional Theory, 167
social determinants of health (SDHs), 3, 7–11, 8f substance abuse, 244
of adolescents, 194f, 195–203 Sudden Infant Death Syndrome/Sudden
of communities, 18, 18b, 232 Unexplained Death of Infant (SIDS/SUDI),
of families, 166 prevention, child-health practice in,
health care systems and, 51–52 271–273
health lifestyle theory of, 270–271 suicide, risk of, 200–201, 200b
research in, 268–271, 269b sustainability, FIFO and, 73
theoretical basis of, 270–271 sustainable development goals (SDGs), 65,
WHO and, 22 66b
social ecology, 3 SWOT ( strengths, weaknesses, opportunities
social engagement, 214 and threats) analysis, 132–133
social epidemiology, 129–130, 129b systematic reviews, 275–277, 275b–276b
social exclusion, 10, 232–247, 232b systemic bias, 254, 254b
cultural norms in, 233–234
social gradient, 8–9
social inclusion, 10 T
four domains of, 232–233 ‘Talking about the smoke project’, 283b
social justice, accessible health care and, 14 Tangata Whenua, 256
social media technology, 14–15, 17b, 199–200
community, 72 territory governments, 36
gender differences and, 242–243 tertiary prevention, 25–26, 26f
society theoretical models, for planning implementation
goals for, 56b–57b strategies, 145–146, 147b
inclusive, 231, 231b Therapeutic Goods Administration, 35–36
Index 325
traditional epidemiological measurements, 117, Whare Tapa Wha Māori Model of Health, 258
118f Whānau, 164
traditional medical model, 24 Whānau Ora, 260b
Transformational Leadership theory, 106 WHO see World Health Organization
translational research, 281–284, 281f windscreen survey, 134, 134b
Treaty of Waitangi, principles of, 287 women
cardiovascular disease in, 235
cross-cultural differences in, 236
U dementia in, 235
UN Convention on the Rights of the Child, global disadvantage of, 236–237, 236b
48–49 health issues in, 235–238
uniprofessional practice, 88t health policy of, 241, 241b
United Nations Department of Economic and lack of education in, 237–238, 238b
Social Affairs 2016, 47–48 mental health of, 236
United Nations High Commissioner for mortality risks for, 235
Refugees, 74–75 refugee and migrant, 237b
urban communities, 67–68, 68b violence against, 244, 245f, 246b
work
adulthood and, 206–208
V group, 103–105, 104b
violence health and safety at, 207–208, 208b
domestic, 173 precarious, 207
in family, 171–173, 172b–173b Workplace Gender Equality Agency, 234
see also intimate partner violence workplace stressors, 207
virtual communities, 72 World Health Organization (WHO), 4, 48–49
virtual technologies, health promotion, 78, 78b
visits, antenatal, 178
volunteering, 214 X
Vulnerability to Abuse Screening Scale (VASS), xenophobia, 253–254
216–217, 216b
Y
W Yellow pages, 133–134
Wahakura, 271–272 Yorgum Aboriginal Family Counselling Service,
wealth, 65–67 163–164
web of causation, 117, 118f Young, Jeanine, 272–273
Wellness, 6, 6b

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eBook ACCESS CODE

National Library of Australia Cataloguing-in-Publication Data

Content Strategist: Natalie Hunt

Jill Clendon, Ailsa Munns

CHAPTER 1 Fundamentals of creating and maintaining a healthy community 3

CHAPTER 2 Healthy policies for healthy communities 34

Policy action at the national level: think global, act local 48

CHAPTER 3 Communities of place 63

CHAPTER 4 Primary health care in practice 87

CHAPTER 5 Assessing the community 114

The evolution of community assessment tools in nursing 120

CHAPTER 6 Planning for intervention 139

CHAPTER 7 The early years 161

CHAPTER 8 Transitions to adulthood and beyond 193

CHAPTER 9 Inclusive communities 231

CHAPTER 10 Inclusive research 266

Evidence-based practice 273

APPENDIX A The McMurray Community Assessment Framework 298

APPENDIX B Calgary Family Assessment Model 305

APPENDIX C HEEADSSS Assessment Tool for use with Adolescents 306

Emeritus Professor Anne McMurray AM

About the Authors

Sandra Bayliss RN, BN, MN

CHAPTER 1 Fundamentals of creating and maintaining a healthy community

Fundamentals of creating and

By the end of this chapter you will be able to:

THE ECOLOGICAL MULTILAYERED PERSPECTIVE OF

What do we mean by community?

Health and wellness are ecological.

THE SOCIAL DETERMINANTS OF HEALTH (SDH)

Figure 1.1 The social determinants of health

The social gradient

Public health focuses on promoting and sustaining the health of populations.

Our definition of community health is as follows:

The characteristics of an enabling community health practitioner include:

PRIMARY HEALTH CARE

Reprinted from World Health Organization (1978) Declaration of the Alma-Ata,

Where to find out more on…

PRACTICE PROFILE: PRACTICE NURSE

Hi. My name is Carter and I’m a Practice Nurse.

PRIMARY HEALTH CARE PRINCIPLES

Figure 1.2 Primary health care principles

Accessible health care

Increased emphasis on health promotion

Cultural sensitivity, cultural safety

Table 1.1 Selective and comprehensive PHC

Characteristic Selective primary health care Comprehensive primary health care

Primary health care in practice

Primary health care is focused on redressing social disadvantage by promoting healthy

Research to practice: social capital and health

Table 1.2 Health literacy: A continuum of knowledge and skill development

Functional Communicative/interactive Critical

Health promotion is essentially a political, ecological and capacity-building process, aimed

Where to find out more on…

What’s the point?

PROMOTING GLOBAL HEALTH

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