Public & Community Health Nursing Practice: A Population-Based Approach

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Demetrius James Porche

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  • Part I: A Population-Based Framework for Public Health Practice

    Part II: Public Health—Community Health Assessment Framework

    Part III: Public Health: Community Health Interventions and Program Planning

    Part IV: Public Health Monitoring, Evaluation, Quality Improvement, Outcome Measures, and Evidence-Based Practice

    Part V: Public Health–Community Health Leadership and Administration

    Part VI: Public Health Policy, Law, and Ethics

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    Preface

    Public health practice focuses on the prevention of disease and disability as a means of promoting the health of communities and the individual constituent members who reside within those respective communities. Our goals for Healthy People 2010 are to increase the quality and quantity of years of healthy life and to eliminate health disparities. The achievement of these goals is dependent on public health nurses’ ability to implement the core functions of public health practice: assessment, assurance, and policy development through population-based practice.

    Population-based public health practice is the cornerstone to ensuring the health of our nation and the achievement of the Healthy People 2010 objectives. Population-based public health practice uses a defined population or community as the organizing principle for preventive action targeting the broad distribution of diseases and health determinants. Population-based public health practice is consistent with community-level interventions in that both have a widespread intervention scope. A key tenet of population-based public health practice is that a large number of people exposed to a small risk may generate more health alterations than a small number exposed to a high risk. Therefore, the proposition is to target interventions at the larger population group to maximize the public health benefits.

    Part I: A Population-Based Framework for Public Health Practice provides the public health underpinnings for population-based public health practice (Chapter 1). The public health system (Chapter 2) is described from an infrastructure perspective. Basic public health practice content in epidemiological investigations (Chapter 3) and behavioral science theories (Chapter 4) are presented as foundations to public health nursing practice.

    Part II: Public Health–Community Health Assessment Framework focuses on the core function of assessment. The public health nurse practicing at an advanced level is expected to have the skill set to conduct assessments at multiple levels. This section includes assessment strategies for behavioral assessments (Chapter 5), public health organizational assessments (Chapter 6), environmental health assessments (Chapter 7), and a comprehensive community assessment (Chapter 8). Assessment methods generating both primary and secondary data are expected to provide supporting data for program planning and the development of communitylevel interventions.

    The content on the assurance core function spans Parts III, IV, and V. Part III emphasizes public health and community health interventions and strategies for program planning. Cultural competence (Chapter 9), community development (Chapter 10), and community-level interventions (Chapter 11) are presented as essential skills needed to conduct public health and community health program planning for populations (Chapter 12).

    Public health nurses are increasingly held accountable for the effective implementation of population-based public health practice. Communities expect effective use of scarce public health resources. Part IV: Public Health Monitoring, Evaluation, Quality Improvement, Outcome Measures, and Evidence-Based Practice promotes the use of data for public health decision making. This section presents models and methods for program monitoring and evaluation (Chapter 13), performance measurement and improvement (Chapter 14), and public health research (Chapter 15) and concludes with evidence-based public health practice (Chapter 16).

    The public health infrastructure is dependent on a sufficient number and competency level of public health practitioners to deliver population-based public health services. Part V: Public Health–Community Health Leadership and Administration focuses on the administrative skills necessary for managing and leading public health organizations and professionals. This section covers information about leadership (Chapter 17); communication, collaboration, negotiation, and conflict resolution (Chapter 18); causal analysis (Chapter 19); fiscal and human resource management (Chapter 20); and informatics (Chapter 21) as public health nursing administrative functions.

    The text concludes with content on the core function of policy development, described in Part VI: Public Health Policy, Law, and Ethics. This section familiarizes the public health nurse with health policy and politics (Chapter 22); the process of public health policy development (Chapter 23); public health policy formulation, implementation, and modification (Chapter 24); public health policy analysis and evaluation (Chapter 25); review of public health law and the legal system (Chapter 26); and the scope of public health law (Chapter 27), concluding with an examination of ethical practice in public health (Chapter 28). Eight appendixes provide supplemental information that supports the text's chapters.

    Acknowledgments

    This book has been made possible through the support of my family, friends, and colleagues. First and foremost, I would like to thank my wonderful parents, Hayes and Diane Porche, for providing me with the love and support necessary to achieve an education and successful nursing career. Thanks go also to Anastasia Arceneaux and Chelsealea Lovell, my sisters, as well as their husbands, who always support my professional endeavors and provide me with continual enjoyment, and to Seth and Sebastian Porche, Janson Arceneaux, Jr., and Madeline Lovell, my nephews and niece, who are our family's future.

    I extend my appreciation to the Reverend Dr. James A. Ertl, my best friend, for providing me with daily encouragement, support, and guidance to achieve my professional and personal goals and aspirations, and to Lynette Little, who always knows the right encouraging words to keep me focused and motivated and who provides me with numerous laughs.

    My graduate community and public health nursing and public health students have encouraged the development and provided the direction for this text. I would also like to thank my mentors, Dr. Myrtis Snowden, Dr. Elizabeth Humphrey, Dr. Grace Guyden, Dr. Velma Sue Westbrook, and Dr. Richard Sowell, for having an impact on my professional career. In addition, I would like to thank my colleagues at Louisiana State University Health Sciences Center and Tulane School of Public Health for their professional affiliation.

    Sage Publications acquisitions editor Jim Brace-Thompson and editorial assistant Karen Ehrmann warrant special recognition for their guidance and assistance in bringing this manuscript to fulfillment. My copy editor, Catherine M. Chilton, and production editor, Sanford Robinson, for the hours of talented work and feedback and encouragement, are greatly appreciated.

    Thanks,

    Demetrius JamesPorche
  • Appendix A: Core Competencies for Public Health Professionals

    Staff Descriptions
    • Front-line staff: public health individuals who are involved in day-to-day public health activities
    • Senior-level staff: public health individuals with specialized functions (does not include managers)
    • Supervisory and management staff: public health individuals responsible for major programs or organizational functions with line authority for personnel
    Competency Levels
    • Aware: basic mastery level; can identify the skill or concept but has limited ability to perform
    • Knowledgeable: intermediate mastery level; can apply and describe the skill
    • Proficient: advanced mastery level; can synthesize, critique, or teach the skill

    Domain 1. Analytic Assessment Skills

    Domain 2. Policy Development and Program Planning Skills

    Domain 3. Communication Skills

    Domain 4. Cultural Competency Skills

    Domain 5. Community Dimensions of Practice Skills

    Domain 6. Basic Public Health Sciences Skills

    Domain 7. Financial Planning and Management Skills

    Domain 8. Leadership and Systems Thinking Skills

    Appendix B: Healthy People 2010: Healthy People 2010 Goals

    • Goal 1: Increase quality and years of healthy life
    • Goal 2: Eliminate health disparities
    Access to Quality Health Care
    • Goal: Improve access to comprehensive, high-quality health-care services.
    Clinical Preventive Care
    • Increase the proportion of persons with health insurance
    • (Developmental) Increase the proportion of insured persons with coverage for clinical preventive services
    • Increase the proportion of persons appropriately counseled about health behaviors
    Primary Care
    • Increase the proportion of persons that has a specific source of ongoing care
    • Increase the proportion of persons with a usual primary care provider
    • Reduce the proportion of families that experiences difficulties or delays in obtaining health care or does not receive needed care for one or more family members
    • (Developmental) Increase the proportion of schools of medicine, schools of nursing, and other health professional training schools whose basic curriculum for health-care providers includes the core competencies in health promotion and disease prevention
    • In the health professions, allied and associated health profession fields, and the field of nursing, increase the proportion of all degrees awarded to members of underrepresented racial and ethnic groups
    • Reduce hospitalization rates for three ambulatory-care–sensitive conditions: pediatric asthma, uncontrolled diabetes, and immunization-preventable pneumonia and influenza
    Emergency Services
    • (Developmental) Reduce the proportion of persons that delays or has difficulty in getting emergency medical care
    • (Developmental) Increase the proportion of persons that has access to rapid-response pre–hospital emergency medical services
    • Establish a single toll-free telephone number for access to poison control centers on a 24-hour basis throughout the United States
    • Increase the number of tribes and states (including the District of Columbia) with trauma care systems that maximize survival and functional outcomes of trauma patients and help prevent injuries from occurring
    • Increase the number of states (including the District of Columbia) that has implemented guidelines for prehospital and hospital pediatric care
    Long-Term Care and Rehabilitative Services
    • (Developmental) Increase the proportion of persons with long-term care needs who have access to the continuum of long-term care services
    • Reduce the proportion of nursing home residents with a current diagnosis of pressure ulcers
    Arthritis, Osteoporosis, and Chronic Back Conditions

    Goal: Prevent illness and disability related to arthritis and other rheumatic conditions, osteoporosis, and chronic back conditions.

    Arthritis and Other Rheumatic Conditions
    • (Developmental) Increase the mean number of days without severe pain among adults who have chronic joint symptoms
    • Reduce the proportion of adults with chronic joint symptoms who experience a limitation in activity due to arthritis
    • Preserve independence by reducing the proportion of all adults with chronic joint symptoms who have difficulty in performing two or more personal care activities
    • (Developmental) Increase the proportion of adults 18 years old and older with arthritis that seeks help in coping when experiencing personal and emotional problems
    • Increase the employment rate among adults with arthritis in the working-age population
    • (Developmental) Eliminate racial disparities in the rate of total knee replacements
    • (Developmental) Increase the proportion of adults that has seen a health-care provider for their chronic joint symptoms
    • (Developmental) Increase the proportion of persons with arthritis that has had effective, evidence-based arthritis education as an integral part of the management of the condition
    Osteoporosis
    • Reduce the proportion of adults with osteoporosis
    • Reduce the proportion of adults that is hospitalized for vertebral fractures associated with osteoporosis
    Chronic Back Conditions
    • Reduce activity limitation due to chronic back conditions.
    Cancer

    Goal: Reduce the number of new cancer cases, as well as the illness, disability, and death caused by cancer.

    • Reduce the overall cancer death rate
    • Reduce the lung cancer death rate
    • Reduce the breast cancer death rate
    • Reduce the death rate from cancer of the uterine cervix
    • Reduce the colorectal cancer death rate
    • Reduce the oropharyngeal cancer death rate
    • Reduce the prostate cancer death rate
    • Reduce the rate of deaths from melanoma
    • Increase the proportion of persons that uses at least one of the following protective measures that may reduce the risk of skin cancer: avoid the sun between 10 a.m. and 4 p.m., wear sun-protective clothing when exposed to sunlight, use sunscreen with a sun-protective factor of 15 or higher, and avoid artificial sources of ultraviolet light
    • Increase the proportion of physicians and dentists that counsels at-risk patients about tobacco use cessation, physical activity, and cancer screening
    • Increase the proportion of women that receives a Pap test
    • Increase the proportion of adults that receives a colorectal cancer screening examination
    • Increase the proportion of women 40 years old and older that has received a mammogram within the preceding 2 years
    • Increase the number of states that has a statewide population-based cancer registry that captures case information on at least 95% of the expected number of reportable cancers
    • Increase the proportion of cancer survivors that lives 5 years or longer after diagnosis
    Chronic Kidney Disease

    Goal: Reduce new cases of chronic kidney disease and its complications, disability, death, and economic costs.

    • Reduce the rate of new cases of end-stage renal disease
    • Reduce deaths from cardiovascular disease in persons with chronic kidney failure
    • Increase the proportion of treated chronic kidney failure patients that has received counseling on nutrition, treatment choices, and cardiovascular care 12 months before the start of kidney replacement therapy
    • Increase the proportion of new hemodialysis patients that uses arteriovenous fistulas as the primary mode of vascular access
    • Increase the proportion of dialysis patients registered on the waiting list for transplantation.
    • Increase the proportion of patients with treated chronic kidney failure who receive a transplant within 3 years of registration on the waiting list
    • Reduce kidney failure due to diabetes
    • (Developmental) Increase the proportion of persons with type 1 or type 2 diabetes and proteinuria that receives recommended medical therapy to reduce progression to chronic renal insufficiency
    Diabetes

    Goal: Through prevention programs, reduce the disease and economic burden of diabetes and improve the quality of life for all persons who have or are at risk for diabetes.

    • Increase the proportion of persons with diabetes that receives formal diabetes education
    • Prevent diabetes
    • Reduce the overall rate of diabetes that is clinically diagnosed
    • Increase the proportion of adults with diabetes whose condition has been diagnosed
    • Reduce the diabetes death rate
    • Reduce diabetes-related deaths among persons with diabetes
    • Reduce deaths from cardiovascular disease in persons with diabetes
    • (Developmental) Decrease the proportion of pregnant women with gestational diabetes
    • (Developmental) Reduce the frequency of foot ulcers in persons with diabetes
    • Reduce the rate of lower extremity amputations in persons with diabetes
    • (Developmental) Increase the proportion of persons with diabetes that obtains an annual urinary microalbumin measurement
    • Increase the proportion of adults with diabetes that has a glycosylated hemoglobin measurement at least once a year
    • Increase the proportion of adults with diabetes that has an annual dilated eye examination
    • Increase the proportion of adults with diabetes that has at least an annual foot examination
    • Increase the proportion of persons with diabetes that has at least an annual dental examination
    • Increase the proportion of adults with diabetes that takes aspirin at least 15 times per month
    • Increase the proportion of adults with diabetes that performs self-monitoring of blood glucose at least once daily
    Disability and Secondary Conditions

    Goal: Promote the health of people with disabilities, prevent secondary conditions, and eliminate disparities between people with and without disabilities in the U.S. population.

    • Include in the core of all relevant Healthy People 2010 surveillance instruments a standardized set of questions that identify “people with disabilities”
    • Reduce the proportion of children and adolescents with disabilities that is reported to be sad, unhappy, or depressed
    • Reduce the proportion of adults with disabilities that reports feelings such as sadness, unhappiness, or depression that prevent them from being active
    • Increase the proportion of adults with disabilities that participates in social activities
    • Increase the proportion of adults with disabilities reporting sufficient emotional support
    • Increase the proportion of adults with disabilities reporting satisfaction with life
    • Reduce the number of people with disabilities in congregate care facilities, consistent with permanency planning principles
    • Eliminate disparities in employment rates between working-age adults with and without disabilities
    • Increase the proportion of children and youth with disabilities that spends at least 80% of the time in regular education programs
    • (Developmental) Increase the proportion of health and wellness and treatment programs and facilities that provides full access for people with disabilities
    • (Developmental) Reduce the proportion of people with disabilities that reports not having the assistive devices and technology they need
    • (Developmental) Reduce the proportion of people with disabilities reporting environmental barriers to participation in home, school, work, or community activities
    • Increase the number of tribes and states (including the District of Columbia) that has public health surveillance and health promotion programs for people with disabilities and caregivers
    Educational and Community-Based Programs

    Goal: Increase the quality, availability, and effectiveness of educational and community-based programs designed to prevent disease and improve health and quality of life.

    School Setting
    • Increase high school completion
    • Increase the proportion of middle, junior high, and senior high schools that provides school health education to prevent health problems in the following areas: unintentional injury; violence; suicide; tobacco use and addiction; alcohol and other drug use; unintended pregnancy, HIV/AIDS, and STD infections; unhealthy dietary patterns; inadequate physical activity; and environmental health
    • Increase the proportion of college and university students that receives information from their institution on each of the six priority health-risk behavior areas
    • Increase the proportion of the nation's elementary, middle, junior high, and senior high schools that has a nurse-to-student ratio of at least 1:750
    Worksite Setting
    • Increase the proportion of worksites that offers a comprehensive employee health promotion program to their employees
    • Increase the proportion of employees that participates in employer-sponsored health promotion activities
    Health-Care Setting
    • (Developmental) Increase the proportion of health-care organizations that provides patient and family education
    • (Developmental) Increase the proportion of patients that reports satisfaction with the patient education received from the healthcare organization
    • (Developmental) Increase the proportion of hospitals and managed care organizations that provides community disease prevention and health promotion activities that address the priority health needs identified by the community
    Community Setting and Select Populations
    • (Developmental) Increase the proportion of tribal and local health service areas or jurisdictions that has established a community health promotion program that addresses multiple Healthy People 2010 focus areas
    • Increase the proportion of local health departments that has established culturally appropriate and linguistically competent community health promotion and disease prevention programs
    • Increase the proportion of older adults that has participated during the preceding year in at least one organized health promotion activity
    Environmental Health

    Goal: Promote health for all through a healthy environment.

    Outdoor Air Quality
    • Reduce the proportion of persons exposed to air that does not meet the U.S. Environmental Protection Agency's health-based standards for harmful air pollutants
    • Increase use of alternative modes of transportation to reduce motor vehicle emissions and improve the nation's air quality
    • Improve the nation's air quality by increasing the use of cleaner alternative fuels
    • Reduce air toxic emissions to decrease the risk of adverse health effects caused by airborne toxins
    Water Quality
    • Increase the proportion of persons served by community water systems that receives a supply of drinking water that meets the regulations of the Safe Drinking Water Act
    • Reduce waterborne disease outbreaks arising from water intended for drinking among persons served by community water systems
    • Reduce per capita domestic water withdrawals
    • (Developmental) Increase the proportion of assessed rivers, lakes, and estuaries that is safe for fishing and recreational purposes
    • (Developmental) Reduce the number of beach closings that results from the presence of harmful bacteria
    • (Developmental) Reduce the potential human exposure to persistent chemicals by decreasing fish contaminant levels
    Toxins and Waste
    • Eliminate elevated blood lead levels in children
    • Minimize the risks to human health and the environment posed by hazardous sites
    • Reduce pesticide exposures that result in visits to a health-care facility
    • (Developmental) Reduce the amount of toxic pollutants released, disposed of, treated, or used for energy recovery
    • Increase recycling of municipal solid waste
    Healthy Homes and Healthy Communities
    • Reduce indoor allergen levels
    • (Developmental) Increase the number of office buildings that is managed using good indoor air quality practices
    • Increase the proportion of persons that lives in homes tested for radon concentrations
    • Increase the number of new homes constructed to be radon resistant
    • (Developmental) Increase the proportion of the nation's primary and secondary schools that has official school policies ensuring the safety of students and staff in relation to environmental hazards, such as chemicals in special classrooms, poor indoor air quality, asbestos, and exposure to pesticides
    • (Developmental) Ensure that state health departments establish training, plans, and protocols and conduct annual multiinstitutional exercises to prepare for response to natural and technological disasters
    • Increase the proportion of persons living in pre-1950s housing that has been tested for the presence of lead-based paint
    • Reduce the proportion of occupied housing units that is substandard
    Infrastructure and Surveillance
    • Reduce exposure to pesticides as measured by urine concentration of metabolites
    • (Developmental) Reduce exposure of the population to pesticides, heavy metals, and other toxic chemicals, as measured by blood and urine concentrations of the substances or their metabolites
    • (Developmental) Improve the quality, utility, awareness, and use of existing information systems for environmental health
    • Increase or maintain the number of territories, tribes, and states (including the District of Columbia) that monitors diseases or conditions that can be caused by exposure to environmental hazards
    • (Developmental) Increase the number of local health departments or agencies that uses data from surveillance of environmental risk factors as part of their vector control programs
    Global Environmental Health
    • Reduce the global burden of disease due to poor water quality, sanitation, and personal and domestic hygiene
    • Increase the proportion of the population in the U.S.-Mexico border region that has adequate drinking water and sanitation facilities
    Family Planning

    Goal: Improve pregnancy planning and spacing and prevent unintended pregnancy.

    • Increase the proportion of pregnancies that is intended
    • Reduce the proportion of births occurring within 24 months of a previous birth
    • Increase the proportion of females at risk of unintended pregnancy (and their partners) who use contraception
    • Reduce the proportion of females experiencing pregnancy despite use of a reversible contraceptive method
    • (Developmental) Increase the proportion of health-care providers that provides emergency contraception
    • (Developmental) Increase male involvement in pregnancy prevention and family planning efforts
    • Reduce pregnancies among adolescent females
    • Increase the proportion of adolescents that has never engaged in sexual intercourse before they are 15 years old
    • Increase the proportion of adolescents that has never engaged in sexual intercourse
    • Increase the proportion of sexually active, unmarried adolescents 15 to 17 years old that uses contraception that both effectively prevents pregnancy and provides barrier protection against disease
    • Increase the proportion of young adults that has received formal instruction before turning 18 years old on reproductive health issues, including all of the following topics: birth control methods, safer sex to prevent HIV, prevention of sexually transmitted diseases, and abstinence
    • Reduce the proportion of married couples whose ability to conceive or maintain a pregnancy is impaired
    • (Developmental) Increase the proportion of health insurance policies that covers contraceptive supplies and services
    Food Safety

    Goal: Reduce food-borne illnesses.

    • Reduce infections caused by key food-borne pathogens
    • Reduce outbreaks of infections caused by key food-borne bacteria
    • Prevent an increase in the proportion of isolates of Salmonella species from humans and from animals at slaughter that are resistant to antimicrobial drugs
    • (Developmental) Reduce deaths from anaphylaxis caused by food allergies
    • Increase the proportion of consumers that follows key food safety practices
    • (Developmental) Improve food employee behaviors and food preparation practices that directly relate to food-borne illnesses in retail food establishments
    • (Developmental) Reduce human exposure to organophosphate pesticides from food
    Health Communication

    Goal: Use communication strategically to improve health.

    • Increase the proportion of households with access to the Internet at home
    • (Developmental) Improve the health literacy of persons with inadequate or marginal literacy skills
    • (Developmental) Increase the proportion of health communication activities that includes research and evaluation
    • (Developmental) Increase the proportion of health-related World Wide Web sites that discloses information that can be used to assess the quality of the site
    • (Developmental) Increase the number of centers for excellence that seeks to advance the research and practice of health communication
    • (Developmental) Increase the proportion of persons that reports that health-care providers have satisfactory communication skills
    Heart Disease and Stroke

    Goal: Improve cardiovascular health and quality of life through the prevention, detection, and treatment of risk factors; early identification and treatment of heart attacks and strokes; and prevention of recurrent cardiovascular events.

    Heart Disease
    • Reduce coronary heart disease deaths
    • (Developmental) Increase the proportion of adults 20 years old and older that is aware of the early warning symptoms and signs of a heart attack and the importance of accessing rapid emergency care by calling 911
    • (Developmental) Increase the proportion of eligible patients with heart attacks that receives artery-opening therapy within an hour of symptom onset
    • (Developmental) Increase the proportion of adults 20 years old and older that calls 911 and administer cardiopulmonary resuscitation when witnessing an out-of-hospital cardiac arrest
    • (Developmental) Increase the proportion of eligible persons with witnessed out-of-hospital cardiac arrest that receives the first therapeutic electrical shock within 6 minutes after collapse recognition
    • Reduce hospitalizations of older adults with congestive heart failure as the principal diagnosis
    Stroke
    • Reduce stroke deaths
    • (Developmental) Increase the proportion of adults that is aware of the early warning symptoms and signs of a stroke
    Blood Pressure
    • Reduce the proportion of adults with high blood pressure
    • Increase the proportion of adults with high blood pressure whose blood pressure is under control
    • Increase the proportion of adults with high blood pressure that is taking action (for example, losing weight, increasing physical activity, or reducing sodium intake) to help control blood pressure
    • Increase the proportion of adults that has had blood pressure measured within the preceding 2 years and can state whether blood pressure was normal or high
    Cholesterol
    • Reduce the mean total blood cholesterol levels among adults
    • Reduce the proportion of adults with high total blood cholesterol levels
    • Increase the proportion of adults that has had blood cholesterol checked within the preceding 5 years
    • (Developmental) Increase the proportion of persons with coronary heart disease that has LDL-cholesterol level treated, with the goal of reducing it to ≤100 mg/dL
    HIV

    Goal: Prevent human immunodeficiency virus (HIV) infection and its related illness and death.

    • Reduce AIDS among adolescents and adults
    • Reduce the number of new AIDS cases among adolescent and adult men who have sex with men
    • Reduce the number of new AIDS cases among females and males who inject drugs
    • Reduce the number of new AIDS cases among adolescent and adult men who have sex with men and inject drugs
    • (Developmental) Reduce the number of cases of HIV infection among adolescents and adults
    • Increase the proportion of sexually active persons that uses condoms
    • (Developmental) Increase the number of HIV-positive persons that knows serostatus
    • Increase the proportion of substance abuse treatment facilities that offers HIV/AIDS education, counseling, and support
    • (Developmental) Increase the number of state prison systems that provides comprehensive HIV/AIDS, sexually transmitted disease, and tuberculosis education.
    • (Developmental) Increase the proportion of inmates in state prison systems that receives voluntary HIV counseling and testing during incarceration
    • Increase the proportion of adults with tuberculosis that has been tested for HIV
    • (Developmental) Increase the proportion of adults in publicly funded HIV counseling and testing sites that is screened for common bacterial sexually transmitted diseases (chlamydia, gonorrhea, and syphilis) and immunized against hepatitis B virus
    • Increase the proportion of HIV-infected adolescents and adults that receives testing, treatment, and prophylaxis consistent with current Public Health Service treatment guidelines
    • Reduce deaths from HIV infection
    • (Developmental) Extend the interval of time between an initial diagnosis of HIV infection and AIDS diagnosis to increase years of life in individuals infected with HIV
    • (Developmental) Increase years of life of HIV-infected persons by extending the interval of time between AIDS diagnosis and death.
    • (Developmental) Reduce new cases of perinatally acquired HIV infection
    Immunization and Infectious Diseases

    Goal: Prevent disease, disability, and death from infectious diseases, including vaccine-preventable diseases.

    Diseases Preventable Through Universal Vaccination
    • Reduce or eliminate indigenous cases of vaccine-preventable diseases
    • Reduce chronic hepatitis B virus infections in infants and young children (perinatal infections)
    • Reduce hepatitis B
    • Reduce bacterial meningitis in young children
    • Reduce invasive pneumococcal infections
    Diseases Preventable Through Targeted Vaccination
    • Reduce hepatitis A
    • Reduce meningococcal disease
    • Reduce Lyme disease
    Infectious Diseases and Emerging Antimicrobial Resistance
    • Reduce hepatitis C
    • (Developmental) Increase the proportion of persons with chronic hepatitis C infection identified by state and local health departments
    • Reduce tuberculosis
    • Increase the proportion of all tuberculosis patients that completes curative therapy within 12 months
    • Increase the proportion of contacts and other high-risk persons with latent tuberculosis infection who complete a course of treatment
    • Reduce the average time for a laboratory to confirm and report tuberculosis cases
    • (Developmental) Increase the proportion of international travelers that receives recommended preventive services when traveling in areas of risk for select infectious diseases: hepatitis A, malaria, and typhoid
    • Reduce invasive early onset group B streptococcal disease
    • Reduce hospitalizations caused by peptic ulcer disease in the United States
    • Reduce the number of courses of antibiotics for ear infections for young children
    • Reduce the number of courses of antibiotics prescribed for the sole diagnosis of the common cold
    • Reduce hospital-acquired infections in intensive care unit patients
    • Reduce antimicrobial use among intensive care unit patients
    Vaccination Coverage and Strategies
    • Achieve and maintain effective vaccination coverage levels for universally recommended vaccines among young children
    • Maintain vaccination coverage levels for children in licensed day-care facilities and children in kindergarten through the first grade
    • Increase the proportion of young children and adolescents that receives all vaccines that have been recommended for universal administration for at least 5 years
    • Increase the proportion of providers that has measured the vaccination coverage levels among children in the practice population within the past 2 years
    • Increase the proportion of children that participates in fully operational population-based immunization registries
    • Increase routine vaccination coverage levels for adolescents
    • Increase hepatitis B vaccine coverage among high-risk groups
    • Increase the proportion of adults that is vaccinated annually against influenza and ever vaccinated against pneumococcal disease
    Vaccine Safety
    • Reduce vaccine-associated adverse events
    • Increase the number of persons under active surveillance for vaccine safety via large linked databases
    Injury and Violence Prevention

    Goal: Reduce injuries, disabilities, and deaths due to unintentional injuries and violence.

    Injury Prevention
    • Reduce hospitalization for nonfatal head injuries
    • Reduce hospitalization for nonfatal spinal cord injuries
    • Reduce firearm-related deaths
    • Reduce the proportion of persons living in homes with firearms that are loaded and unlocked
    • Reduce nonfatal firearm-related injuries
    • (Developmental) Extend state-level child fatality review of deaths due to external causes for children 14 years old or younger
    • Reduce nonfatal poisonings
    • Reduce deaths caused by poisonings
    • Reduce deaths caused by suffocation
    • Increase the number of states (including the District of Columbia) with statewide emergency department surveillance systems that collects data on external causes of injury
    • Increase the number of states (including the District of Columbia) that collects data on external causes of injury through hospital discharge data systems
    • Reduce hospital emergency department visits caused by injuries
    Unintentional Injury Prevention
    • Reduce deaths caused by unintentional injuries
    • (Developmental) Reduce nonfatal unintentional injuries
    • Reduce deaths caused by motor vehicle crashes
    • Reduce pedestrian deaths on public roads
    • Reduce nonfatal injuries caused by motor vehicle crashes
    • Reduce nonfatal pedestrian injuries on public roads
    • Increase use of safety belts
    • Increase use of child restraints
    • Increase the proportion of motorcyclists using helmets
    • Increase the number of states (including the District of Columbia) that has adopted a model graduated driver licensing law
    • (Developmental) Increase use of helmets by bicyclists
    • Increase the number of states (including the District of Columbia) with laws requiring bicycle helmets for bicycle riders
    • Reduce residential fire deaths
    • Increase functioning residential smoke alarms
    • Reduce deaths from falls
    • Reduce hip fractures among older adults
    • Reduce drownings
    • Reduce hospital emergency department visits for nonfatal dog bite injuries
    • (Developmental) Increase the proportion of public and private schools that requires use of appropriate head, face, eye, and mouth protection for students participating in school-sponsored physical activities
    Violence and Abuse Prevention
    • Reduce homicides
    • Reduce maltreatment and maltreatment fatalities of children
    • Reduce the rate of physical assault by current or former intimate partners
    • Reduce the annual rate of rape or attempted rape
    • Reduce sexual assault other than rape
    • Reduce physical assaults
    • Reduce physical fighting among adolescents
    • Reduce weapon carrying by adolescents on school property
    Maternal, Infant, and Child Health

    Goal: Improve the health and well-being of women, infants, children, and families.

    Fetal, Infant, Child, and Adolescent Deaths
    • Reduce fetal and infant deaths 16-2. Reduce the rate of child deaths
    • Reduce deaths of adolescents and young adults
    Maternal Deaths and Illnesses
    • Reduce maternal deaths
    • Reduce maternal illness and complications due to pregnancy
    Prenatal Care
    • Increase the proportion of pregnant women that receives early and adequate prenatal care
    • (Developmental) Increase the proportion of pregnant women that attends a series of prepared childbirth classes
    Obstetrical Care
    • Increase the proportion of very low birth weight infants born at level three hospitals or subspecialty perinatal centers
    • Reduce cesarean births among low-risk (full-term, singleton, vertex presentation) women
    Risk Factors
    • Reduce low birth weight and very low birth weight births
    • Reduce preterm births
    • (Developmental) Increase the proportion of mothers that achieves a recommended weight gain during their pregnancies
    • Increase the percentage of healthy, full-term infants that is put down to sleep on the back
    Developmental Disabilities and Neural Tube Defects
    • Reduce the occurrence of developmental disabilities
    • Reduce the occurrence of spina bifida and other neural tube defects
    • Increase the proportion of pregnancies begun with an optimum folic acid level
    Prenatal Substance Exposure
    • Increase abstinence from alcohol, cigarettes, and illicit drugs among pregnant women
    • (Developmental) Reduce the occurrence of fetal alcohol syndrome
    Breastfeeding, Newborn Screening, and Service Systems
    • Increase the proportion of mothers that breastfeeds the baby
    • (Developmental) Ensure appropriate newborn bloodspot screening, follow-up testing, and referral to services
    • (Developmental) Reduce hospitalization for life-threatening sepsis among children 4 years old and younger with sickling hemoglobinopathies
    • (Developmental) Increase the proportion of children with special health-care needs that has access to a medical home
    • Increase the proportion of territories and states that has service systems for children with special health-care needs
    Medical Product Safety

    Goal: Ensure the safe and effective use of medical products.

    • (Developmental) Increase the proportion of health-care organizations that is linked in an integrated system that monitors and reports adverse events
    • (Developmental) Increase the use of linked, automated systems to share information
    • (Developmental) Increase the proportion of primary care providers, pharmacists, and other health-care professionals that routinely reviews with patients 65 years old and older and patients with chronic illnesses or disabilities all new prescribed and over-the-counter medicines
    • (Developmental) Increase the proportion of patients receiving information that meets guidelines for usefulness when new prescriptions are dispensed
    • Increase the proportion of patients that receives verbal counseling from prescribers and pharmacists on the appropriate use and potential risks of medications
    • Increase the proportion of persons that donates blood and thus ensure an adequate supply of safe blood
    Mental Health and Mental Disorders

    Goal: Improve mental health and ensure access to appropriate, quality mental health services.

    Mental Health Status Improvement
    • Reduce the suicide rate
    • Reduce the rate of suicide attempts by adolescents
    • Reduce the proportion of homeless adults who have serious mental illness
    • Increase the proportion of persons with serious mental illness who are employed
    • (Developmental) Reduce the relapse rates for persons with eating disorders, including anorexia nervosa and bulimia nervosa
    Treatment Expansion
    • (Developmental) Increase the number of persons seen in primary health care that receives mental health screening and assessment
    • (Developmental) Increase the proportion of children with mental health problems that receives treatment
    • (Developmental) Increase the proportion of juvenile justice facilities that screens new admissions for mental health problems
    • Increase the proportion of adults with mental disorders that receives treatment.
    • (Developmental) Increase the proportion of persons with cooccurring substance abuse and mental disorders that receives treatment for both disorders
    • (Developmental) Increase the proportion of local governments with community-based jail diversion programs for adults with serious mental illness
    State Activities
    • Increase the number of states (including the District of Columbia) that tracks consumers’ satisfaction with mental health services received
    • (Developmental) Increase the number of territories and states (including the District of Columbia) with an operational mental health plan that addresses cultural competence
    • Increase the number of territories and states (including the District of Columbia) with an operational mental health plan that addresses mental health crisis interventions, ongoing screening, and treatment services for elderly persons
    Nutrition and Overweight

    Goal: Promote health and reduce chronic disease associated with diet and weight.

    Weight Status and Growth
    • Increase the proportion of adults who are at a healthy weight
    • Reduce the proportion of adults who are obese
    • Reduce the proportion of children and adolescents who are overweight or obese
    • Reduce growth retardation among low-income children under 5 years old
    Food and Nutrient Consumption
    • Increase the proportion of persons 2 years old and older who consume at least two daily servings of fruit
    • Increase the proportion of persons 2 years old and older who consume at least three daily servings of vegetables, with at least one third being dark green or orange vegetables
    • Increase the proportion of persons 2 years old and older who consume at least six daily servings of grain products, with at least three being whole grains
    • Increase the proportion of persons 2 years old and older who consume less than 10% of their total daily calories from saturated fat
    • Increase the proportion of persons 2 years old and older who consume no more than 30% of their total daily calories from total fat
    • Increase the proportion of persons 2 years old and older who consume 2400 mg or less of sodium daily
    • Increase the proportion of persons 2 years old and older who meet dietary recommendations for calcium
    Iron Deficiency and Anemia
    • Reduce iron deficiency among young children and females of childbearing age
    • Reduce anemia among low-income pregnant females in their third trimester
    • (Developmental) Reduce iron deficiency among pregnant females
    Schools, Worksites, and Nutrition Counseling
    • (Developmental) Increase the proportion of children and adolescents 6 to 19 years old whose intake of meals and snacks at school contributes to good overall dietary quality
    • Increase the proportion of worksites that offer nutrition or weight management classes or counseling
    • Increase the proportion of physician office visits made by patients with a diagnosis of cardiovascular disease, diabetes, or hyperlipidemia that includes counseling or education related to diet and nutrition
    Food Security
    • Increase food security among U.S. households and thus reduce hunger
    Occupational Safety and Health

    Goal: Promote the health and safety of people at work through prevention and early intervention.

    • Reduce deaths from work-related injuries
    • Reduce work-related injuries resulting in medical treatment, lost time from work, or restricted work activity
    • Reduce the rate of injury and illness cases involving days away from work due to overexertion or repetitive motion
    • Reduce pneumoconiosis deaths
    • Reduce deaths from work-related homicides
    • Reduce work-related assaults
    • Reduce the number of persons who have elevated blood lead concentrations from work exposures
    • Reduce occupational skin diseases or disorders among full-time workers
    • Increase the proportion of worksites employing 50 or more persons that provide programs to prevent or reduce employee stress
    • Reduce occupational needlestick injuries among health-care workers
    • (Developmental) Reduce new cases of work-related, noise-induced hearing loss
    Oral Health

    Goal: Prevent and control oral and craniofacial diseases, conditions, and injuries and improve access to related services.

    • Reduce the proportion of children and adolescents who have experience of dental caries in their primary or permanent teeth
    • Reduce the proportion of children, adolescents, and adults with untreated dental decay
    • Increase the proportion of adults who have never had a permanent tooth extracted because of dental caries or periodontal disease
    • Reduce the proportion of older adults who have had all their natural teeth extracted
    • Reduce periodontal disease
    • Increase the proportion of oral and pharyngeal cancers detected at the earliest stage
    • Increase the proportion of adults who, in the past 12 months, report having had an examination to detect oral and pharyngeal cancers
    • Increase the proportion of children who have received dental sealants on their molar teeth
    • Increase the proportion of the U.S. population served by community water systems with optimally fluoridated water
    • Increase the proportion of children and adults who use the oral health-care system each year
    • Increase the proportion of long-term care residents who use the oral health care system each year
    • Increase the proportion of low-income children and adolescents who received any preventive dental service during the past year
    • (Developmental) Increase the proportion of school-based health centers with an oral health component
    • Increase the proportion of local health departments and community-based health centers, including community, migrant, and homeless health centers, that has an oral health component
    • Increase the number of states (including the District of Columbia) that has a system for recording and referring infants and children with cleft lips, cleft palates, and other craniofacial anomalies to craniofacial anomaly rehabilitative teams
    • Increase the number of states (including the District of Columbia) that has an oral and craniofacial health surveillance system
    • (Developmental) Increase the number of tribal, state (including the District of Columbia), and local health agencies that serve jurisdictions of 250,000 or more persons that has in place an effective public dental health program directed by a dental professional with public health training
    Physical Activity and Fitness

    Goal: Improve health, fitness, and quality of life through daily physical activity.

    Physical Activity in Adults
    • Reduce the proportion of adults that engages in no leisure-time physical activity
    • Increase the proportion of adults that engages regularly, preferably daily, in moderate physical activity for at least 30 minutes per day
    • Increase the proportion of adults that engages in vigorous physical activity that promotes the development and maintenance of cardiorespiratory fitness 3 or more days per week for 20 or more minutes per occasion
    Muscular Strength/Endurance and Flexibility
    • Increase the proportion of adults that performs physical activities that enhance and maintain muscular strength and endurance
    • Increase the proportion of adults that performs physical activities that enhance and maintain flexibility
    Physical Activity in Children and Adolescents
    • Increase the proportion of adolescents that engages in moderate physical activity for at least 30 minutes on 5 or more days out of 7
    • Increase the proportion of adolescents that engages in vigorous physical activity that promotes cardiorespiratory fitness 3 or more days per week for 20 or more minutes per occasion
    • Increase the proportion of the nation's public and private schools that requires daily physical education for all students
    • Increase the proportion of adolescents that participates in daily school physical education
    • Increase the proportion of adolescents that spends at least 50% of school physical education class time being physically active
    • Increase the proportion of adolescents that views television 2 or fewer hours on a school day
    Access
    • (Developmental) Increase the proportion of the nation's public and private schools that provides access to physical activity spaces and facilities for all persons outside of normal school hours (that is, before and after the school day, on weekends, and during summer and other vacations)
    • Increase the proportion of worksites offering employer-sponsored physical activity and fitness programs
    • Increase the proportion of trips made by walking
    • Increase the proportion of trips made by bicycling.
    Public Health Infrastructure

    Goal: Ensure that federal, tribal, state, and local health agencies have the infrastructure to provide essential public health services effectively.

    Data and Information Systems
    • (Developmental) Increase the proportion of tribal, state, and local public health agencies that provide Internet and e-mail access for at least 75% of their employees and that teach employees to use the Internet and other electronic information systems to apply data and information to public health practice
    • (Developmental) Increase the proportion of federal, tribal, state, and local health agencies that have made information available to the public in the past year on the leading health indicators, health status indicators, and priority data needs
    • Increase the proportion of all major national, state, and local health data systems that use geocoding to promote nationwide use of geographic information systems at all levels
    • Increase the proportion of population-based Healthy People 2010 objectives for which national data are available for all population groups identified for the objective
    • (Developmental) Increase the proportion of leading health indicators, health status indicators, and priority data needs for which data—especially for select populations—are available at the tribal, state, and local levels
    • Increase the proportion of Healthy People 2010 objectives that is tracked regularly at the national level
    • Increase the proportion of Healthy People 2010 objectives for which national data are released within 1 year of the end of data collection
    • (Developmental) Increase the proportion of federal, tribal, state, and local agencies that incorporates specific competencies in the essential public health services into personnel systems
    • (Developmental) Increase the proportion of schools for public health workers that integrates into the curriculum specific content to develop competence in essential public health services
    • (Developmental) Increase the proportion of federal, tribal, state, and local public health agencies that provides continuing education to develop competence in essential public health services to employees
    • (Developmental) Increase the proportion of state and local public health agencies that meets national performance standards for essential public health services
    • Increase the proportion of tribes and states (including the District of Columbia) that has a health improvement plan and increase the proportion of local jurisdictions that has a health improvement plan linked with the state plan
    • (Developmental) Increase the proportion of tribal, state, and local health agencies that provides or ensures comprehensive laboratory services to support essential public health services
    • (Developmental) Increase the proportion of tribal, state, and local public health agencies that provides or ensures comprehensive epidemiology services to support essential public health services
    • (Developmental) Increase the proportion of federal, tribal, state, and local jurisdictions that reviews and evaluates the extent to which statutes, ordinances, and bylaws ensure the delivery of essential public health services
    Resources
    • (Developmental) Increase the proportion of federal, tribal, state, and local public health agencies that gathers accurate data on public health expenditures, categorized by essential public health service
    Prevention Research
    • (Developmental) Increase the proportion of federal, tribal, state, and local public health agencies that conducts or collaborates on population-based prevention research.
    Respiratory Diseases

    Goal: Promote respiratory health through better prevention, detection, treatment, and education efforts.

    Asthma
    • Reduce asthma deaths
    • Reduce hospitalizations for asthma
    • Reduce hospital emergency department visits for asthma
    • Reduce activity limitations among persons with asthma
    • (Developmental) Reduce the number of school or work days missed by persons with asthma due to asthma
    • Increase the proportion of persons with asthma that receives formal patient education, including information about community and self-help resources, as an essential part of the management of the condition
    • (Developmental) Increase the proportion of persons with asthma that receives appropriate asthma care according to the National Asthma Education and Prevention Program (NAEPP) guidelines
    • (Developmental) Establish in at least 25 states a surveillance system for tracking asthma death, illness, disability, impact of occupational and environmental factors on asthma, access to medical care, and asthma management
    Chronic Obstructive Pulmonary Disease
    • Reduce the proportion of adults whose activity is limited due to chronic lung and breathing problems
    • Reduce deaths from chronic obstructive pulmonary disease among adults
    Obstructive Sleep Apnea
    • (Developmental) Increase the proportion of persons with symptoms of obstructive sleep apnea whose condition is medically managed
    • (Developmental) Reduce the proportion of vehicular crashes caused by persons with excessive sleepiness
    Sexually Transmitted Diseases (STDs)

    Goal: Promote responsible sexual behaviors, strengthen community capacity, and increase access to quality services to prevent sexually transmitted diseases and their complications.

    Bacterial STD Illness and Disability
    • Reduce the proportion of adolescents and young adults with Chlamydia trachomatis infections
    • Reduce gonorrhea
    • Eliminate sustained domestic transmission of primary and secondary syphilis
    Viral STD Illness and Disability
    • Reduce the proportion of adults with genital herpes infection
    • (Developmental) Reduce the proportion of persons with human papillomavirus infection
    STD Complications Affecting Females
    • Reduce the proportion of females who have ever required treatment for pelvic inflammatory disease
    • Reduce the proportion of childless females with fertility problems who have had a sexually transmitted disease or who have required treatment for pelvic inflammatory disease
    • (Developmental) Reduce HIV infections in adolescent and young adult females 13 to 24 years old that are associated with heterosexual contact
    STD Complications Affecting the Fetus and Newborn
    • Reduce congenital syphilis
    • (Developmental) Reduce neonatal consequences from maternal sexually transmitted diseases, including chlamydial pneumonia, gonococcal and chlamydial ophthalmia neonatorum, laryngeal papillomatosis (from human papillomavirus infection), neonatal herpes, and preterm birth and low birth weight associated with bacterial vaginosis
    Personal Behaviors
    • Increase the proportion of adolescents that abstains from sexual intercourse or uses condoms if currently sexually active
    • (Developmental) Increase the number of positive messages related to responsible sexual behavior during weekday and nightly prime-time television programming
    Community Protection Infrastructure
    • Increase the proportion of tribal, state, and local sexually transmitted disease programs that routinely offers hepatitis B vaccines to all STD clients
    • (Developmental) Increase the proportion of youth detention facilities and adult city or county jails that screens for common bacterial sexually transmitted diseases within 24 hours of admission and treats STDs (when necessary) before persons are released
    • (Developmental) Increase the proportion of all local health departments that has contracts with managed care providers for the treatment of nonplan partners of patients with bacterial sexually transmitted diseases (gonorrhea, syphilis, and chlamy dia).
    Personal Health Services
    • (Developmental) Increase the proportion of sexually active females 25 years old and younger that is screened annually for genital chlamydia infections
    • (Developmental) Increase the proportion of pregnant females screened for sexually transmitted diseases (including HIV infection and bacterial vaginosis) during prenatal health care visits, according to recognized standards
    • Increase the proportion of primary care providers that treats patients with sexually transmitted diseases and that manages cases according to recognized standards
    • (Developmental) Increase the proportion of all sexually transmitted disease clinic patients that is being treated for bacterial STDs (chlamydia, gonorrhea, and syphilis) and that is offered provider referral services for sex partners
    Substance Abuse

    Goal: Reduce substance abuse to protect the health, safety, and quality of life for all, especially children.

    Adverse Consequences of Substance Use and Abuse
    • Reduce deaths and injuries caused by alcohol- and drug-related motor vehicle crashes
    • Reduce cirrhosis deaths
    • Reduce drug-induced deaths
    • Reduce drug-related hospital emergency department visits
    • (Developmental) Reduce alcohol-related hospital emergency department visits
    • Reduce the proportion of adolescents who report that they rode, during the previous 30 days, with a driver who had been drinking alcohol
    • (Developmental) Reduce intentional injuries resulting from alcohol- and illicit drug-related violence
    • (Developmental) Reduce the cost of lost productivity in the workplace due to alcohol and drug use
    Substance Use and Abuse
    • Increase the age and proportion of adolescents who remain alcohol and drug free
    • Reduce past-month use of illicit substances
    • Reduce the proportion of persons engaging in binge drinking of alcoholic beverages
    • Reduce average annual alcohol consumption
    • Reduce the proportion of adults who exceed guidelines for low-risk drinking
    • Reduce steroid use among adolescents
    • Reduce the proportion of adolescents who use inhalants
    Risk of Substance Use and Abuse
    • Increase the proportion of adolescents who disapprove of substance abuse
    • Increase the proportion of adolescents who perceive great risk associated with substance abuse
    Treatment for Substance Abuse
    • (Developmental) Reduce the treatment gap for illicit drugs in the general population
    • (Developmental) Increase the proportion of inmates receiving substance abuse treatment in correctional institutions
    • Increase the number of admissions to substance abuse treatment centers for injection drug use
    • (Developmental) Reduce the treatment gap for alcohol problems
    State and Local Efforts
    • (Developmental) Increase the proportion of persons who are referred for follow-up care for alcohol problems, drug problems, or suicide attempts after diagnosis or treatment for one of these conditions in a hospital emergency department
    • (Developmental) Increase the number of communities using partnerships or coalition models to conduct comprehensive substance abuse prevention efforts
    • Extend administrative license revocation laws, or programs of equal effectiveness, for persons who drive under the influence of intoxicants
    • Extend legal requirements for maximum blood alcohol concentration levels of 0.08% for motor vehicle drivers 21 years old and older
    Tobacco Use

    Goal: Reduce illness, disability, and death related to tobacco use and exposure to secondhand smoke.

    Tobacco Use in Population Groups
    • Reduce tobacco use by adults
    • Reduce tobacco use by adolescents
    • (Developmental) Reduce the initiation of tobacco use among children and adolescents
    • Increase the average age of first use of tobacco products by adolescents and young adults
    Cessation and Treatment
    • Increase smoking cessation attempts by adult smokers
    • Increase smoking cessation during pregnancy
    • Increase tobacco use cessation attempts by adolescent smokers
    • Increase insurance coverage of evidence-based treatment for nicotine dependency
    Exposure to Secondhand Smoke
    • Reduce the proportion of children that is regularly exposed to tobacco smoke at home
    • Reduce the proportion of nonsmokers exposed to environmental tobacco smoke
    • Increase smoke-free and tobacco-free environments in schools, including all school facilities, property, vehicles, and school events
    • Increase the proportion of worksites with formal smoking policies that prohibit smoking or limit it to separately ventilated areas
    • Establish laws regarding smoke-free indoor air that prohibit smoking or limit it to separately ventilated areas in public places and worksites
    Social and Environmental Changes
    • Reduce the rate of illegal sales to minors through enforcement of laws prohibiting the sale of tobacco products to minors
    • Increase the number of states (including the District of Columbia) that suspends or revokes state retail licenses for violations of laws prohibiting the sale of tobacco to minors
    • (Developmental) Eliminate tobacco advertising and promotions that influence adolescents and young adults
    • Increase adolescents’ disapproval of smoking
    • (Developmental) Increase the number of tribes, territories, and states (including the District of Columbia) with comprehensive, evidence-based tobacco control programs
    • Eliminate laws that preempt stronger tobacco control laws
    • (Developmental) Reduce the toxicity of tobacco products by establishing a regulatory structure to monitor toxicity
    • Increase the average federal and state taxes on tobacco products
    Vision and Hearing

    Goal: Improve the visual and hearing health of the nation through prevention, early detection, treatment, and rehabilitation.

    Vision
    • (Developmental) Increase the proportion of persons that has a dilated eye examination at appropriate intervals
    • (Developmental) Increase the proportion of preschool children 5 years old and younger that receives vision screening
    • (Developmental) Reduce uncorrected visual impairment due to refractive errors
    • Reduce blindness and visual impairment in children and adolescents 17 years old and younger
    • (Developmental) Reduce visual impairment due to diabetic retinopathy
    • (Developmental) Reduce visual impairment due to glaucoma
    • (Developmental) Reduce visual impairment due to cataract
    • (Developmental) Reduce occupational eye injuries
    • (Developmental) Increase the use of appropriate personal protective eyewear in recreational activities and hazardous situations around the home
    • (Developmental) Increase vision rehabilitation
    Hearing
    • (Developmental) Increase the proportion of newborns that is screened for hearing loss by 1 month, has audiologic evaluation by 3 months, and is enrolled in appropriate intervention services by 6 months
    • Reduce otitis media in children and adolescents
    • (Developmental) Increase access by persons who have hearing impairments to hearing rehabilitation services and adaptive devices, including hearing aids, cochlear implants, or tactile or other assistive or augmentive devices
    • (Developmental) Increase the proportion of persons that has had a hearing examination on schedule
    • (Developmental) Increase the number of persons that is referred by a primary care physician for hearing evaluation and treatment
    • (Developmental) Increase the use of appropriate ear protection devices, equipment, and practices
    • (Developmental) Reduce noise-induced hearing loss in children and adolescents 17 years old and younger
    • (Developmental) Reduce adult hearing loss in the noise-exposed public
    Reference
    Department of Health and Human Services. (2000). Healthy People 2010: Understanding and improving health (
    2nd ed.
    ). Washington, DC: U.S. Government Printing Office.

    Appendix C: Epidemiological Glossary

    AccuracyThe degree to which a measurement represents the true value of the attribute being measured.
    Active immunityThe resistance developed in response to a stimulus by an antigen (agent or vaccine).
    AgentA factor whose presence, excessive presence, or relative absence is essential for the occurrence of a disease.
    Analytic epidemiologyUse of epidemiological methods to test hypotheses about causality; the second phase of epidemiological investigations.
    Antifactual associationAlso known as a spurious association. A false association that occurs by chance or through bias due to confounding variables.
    AssociationA relationship between two factors or events, usually expressed as a degree of statistical dependence. Factors or events are said to be associated when they occur more frequently together than could be expected by chance alone.
    Attack rateA variant of an incidence rate in a narrowly defined population, usually expressed as a percent.
    Attributable riskThe rate of disease in those with the characteristic minus the rate of disease in those without the characteristic.
    Behavioral risk factorA characteristic or behavior that is associated with increased probability of a specified outcome.
    BiasThat which influences the outcome of a study, often to a degree sufficient to render questions regarding the validity of the results.
    Biological plausibilityA reasonable physiological mechanism that explains how a causal factor could operate to bring about a particular disease
    Biomodal epidemiologic curveThe distribution patterns have two peaks (which are part of the curve).
    BlindingAn attempt to limit bias in a study by preventing the participant and/or investigator from knowing to which group the participant belongs.
    CaseA person identified as having a particular disease, based on the presence of defined criteria
    Case definitionSet of standard criteria established for deciding whether a person has a specific disease or other health-related condition.
    Case fatality rateThe number of people dying during a specific period of time after disease onset or diagnosis, divided by the number of individuals with the specific disease, multiplied by 100.
    Case findingA concerted effort to search for previously unidentified cases of a disease.
    CausalityThe relating of causes to the effects they produce.
    CauseA stimulus that brings about an effect; usually defined operationally by determining that changing the amount or frequency of a suspected cause changes the amount or frequency of the related effect.
    Clinical epidemiologyThe application of epidemiological principles and methods to problems encountered in clinical medicine.
    ClusterAn aggregation of cases within a specified period of time in a specific place.
    CoherenceA biologically plausible phenomenon for an association between two factors.
    CohortA subsection of a population with a common feature, usually age. The component of the population born during a particular period and identified by period of birth so that its characteristics can be ascertained as it enters successive time and age periods. The term has been broadened to describe any designated group of persons who are followed or traced over a period of time.
    Cohort studyA study in which subsets of a defined population can be identified as exposed, not exposed, or exposed in varying degrees to a factor or factors hypothesized to cause a disease or other outcome.
    Common source epidemicAn epidemic caused by exposure of a group of persons to the same source of an agent (the “point source”).
    Communicable diseaseA disease in which the causative agent may be transmitted from one person to another person through direct or indirect contact.
    Confounding variableA factor that causes change in the frequency of a disease and also varies systematically with a third, potentially causal factor being studied.
    ConsistencyA criterion for inferring causality that requires similar findings from multiple studies of the relationships between two variables.
    Control groupA group of subjects that receives no treatment.
    Cross sectional studyA study that determines for each member of a study population or a representative sample of a population the presence or absence of hypothetical causal factors and disease at a single point in time.
    Crude birth rateThe number of total live births in a year divided by the population size for that year.
    Crude death rateThe number of total deaths in a year divided by the population size in that year.
    Cumulative incidenceThe proportion of persons who experience onset of a health-related event during a specified time interval.
    Dependent variableA variable which is dependent on the effect of other variables.
    Descriptive epidemiologyStudy of the occurrence of a disease or other health-related characteristics in human populations according to characteristics of person, place, and time. The first phase of epidemiological investigation.
    Direct transmissionThe transfer of an infectious agent from the reservoir to a receptive portal of entry through which human infection can take place.
    Dose effectAn increase in disease incidence related to the level or dose of exposure.
    Double-blind studyA study in which neither the participant nor the investigator knows which group any subject belongs to.
    Ecological fallacyTwo populations differ in many factors other than the observed relationship, and one or more of those factors may be the underlying reason for the differences in the observed experience. An error in inference caused by failure to distinguish between different levels of organization, assuming that relationships between factors and diseases observed for groups can be equally applied to individuals.
    Ecological studyA study that looks for relationships between factors or events and disease frequency or level, based on aggregate data for entire populations. The joint presence or absence of disease and the etiological factor for individuals is not established.
    EndemicA situation in which the occurrence of a disease is at a persistent level (usually low to moderate) for a defined area.
    Environmental factorsExtrinsic factors that affect the host's potential for exposure to an agent. Physical, biological, and socioeconomic factors, such as crowding and sanitation.
    EpidemicA situation in which the occurrence of a disease within a defined area is clearly in excess of the expected level in that area for a defined period of time.
    Epidemic curveThe distribution of the times of onset of a disease. A graphic plotting of the distribution of causes by time of onset.
    Epidemiological triadThe interaction of agent, host, and environment.
    EpidemiologyThe study of the distribution and determinants of diseases or conditions in populations.
    Etiologic agentAn agent that causes a specific disease state.
    EtiologyPostulated causes that initiate the pathogenic process.
    Experimental epidemiologyThe use of experimental studies to establish disease causality.
    Experimental groupA group that receives the treatment under investigation.
    False negativeA negative test result in an individual who actually possesses the attribute for which the test was conducted.
    False positiveA positive test result in an individual who actually does not possess the attribute for which the test was conducted.
    Health risk appraisalA method of estimating an individual's risk of developing a disease or other outcome.
    Herd immunityThe immunity of a group or community. Resistance of a group to invasion and spread of an infectious agent, based on the resistance to infection of a high proportion of individual members of the group.
    Horizontal transmissionA term used to describe transmission that generally occurs within a population.
    Host factorsIntrinsic factors that influence a person's exposure, susceptibility, or response to an agent.
    HyperendemicA persistently high level of occurrence. A persistently high endemic.
    IncidenceThe number of new cases of a disease in a population during a defined period of time. Also, the number of new cases of a disease occurring in a population during a specific time period divided by the number of persons at risk of developing the disease during the period of time multiplied by 1000 and expressed as a rate per 1000 persons.
    Incubation periodThe period of time from the development of an illness or infection to the onset of the illness (presentation of symptoms). The period of time from the causal event to the initiation of disease.
    Independent variableThe exposure of a characteristic being observed or measured that is hypothesized to influence the outcome of interest.
    Index caseThe first case in a defined population unit to come to the attention of the investigator.
    Indirect transmissionTransport of an organism by means of air, vehicles, or vectors from a reservoir to a receptive portal of entry through which human infection can take place.
    Interrater reliabilityTest consistency of value obtained by two individuals rating the same phenomenon using the same method.
    Intrarater reliabilityTest consistency of values produced by an individual rater.
    Life expectancyThe average number of years an individual is expected to live.
    Life-time incidenceA cumulative incidence rate in which the time interval is a person's lifespan.
    Mass screeningApplication of screening test unselectively to entire populations or selectively to high-risk groups.
    Multiphasic screeningSimultaneous application of screening tests for a variety of diseases or conditions. Multiple tests on single sample of blood.
    Natural historyStages in the process of development and progression of a disease without intervention by man.
    Natural immunitySpecies-determined inherent resistance to a disease or agent.
    Necessary causeA factor that must be present before an event occurs.
    OddsRatio of occurrence of an event to that of a nonoccurrence.
    Odds ratioA comparison of the presence of a risk factor for a disease in a sample of diseased subjects and nondiseased controls.
    OutbreakAn epidemic in the defined area.
    PandemicAn epidemic that spreads over several countries or continents, affecting a large number of people.
    Parallel testingThe simultaneous application of multiple diagnostic tests.
    PathogenAn organism capable of causing disease.
    Period prevalenceThe prevalence of a disease at any time during a specified time interval.
    Person-yearStatistical measure representing the risk over one year of one person developing a disease.
    Point prevalenceThe prevalence of the disease at a specific point in time.
    Population at riskAll the people who are identified as vulnerable to a condition.
    Potential years of life lostA measure of the loss to society due to youthful or early deaths, calculated as the sum, over all persons dying from that cause, of the years these individuals would have lived had they fulfilled a normal life expectancy.
    Predictive value negativeThe probability that an individual with a negative test is a true negative; that is, that the individual with the negative test actually does not have the disease for which the test was conducted.
    Predictive value positiveThe probability that an individual with a positive test is a true positive; that is, that the individual with the positive test actually does have the disease for which the test was conducted.
    PrepathogenesisFirst period in the natural history of disease, before initiation of any changes at the cellular level in the host.
    Presymptomatic diseaseEarly stage in the natural history of disease, before initiation of any changes at the cellular level in the host and before the development of symptoms.
    PrevalenceThe number of existing cases in a population during a defined period of time. This includes the number of new and old cases. Also, the number of cases of a disease present in a population during a specific time divided by the number of persons in the population at that specific time, multiplied by 1000, and expressed as a rate per 1000 persons.
    Primary preventionActions taken to prevent the development of a disease in a person who is well and does not have the disease. It occurs at the prepathological level.
    Propagated epidemicAn epidemic caused by person-to-person transmission of a disease agent.
    ProportionSpecific type of ratio in which the numerator is included in the denominator and the resultant value is expressed as a percentage.
    RatesFractions derived from a numerator and a denominator. The numerator counts the number of times that a particular event occurs. The denominator counts the population at risk during the time interval in question.
    RatioThe relationship between two numbers expressed as a fraction; the value obtained by dividing the numerator of the fraction by the denominator.
    Relative riskThe ratio of the risk of disease or death among those exposed to the risk as compared to those not exposed.
    ReliabilityThe extent to which repeated measurements of a relatively stable phenomenon provide consistent results.
    Reportable diseaseAlso known as a notifiable disease. A disease, usually infectious in nature, that is required by law to be reported to the appropriate health officer or authority.
    ReservoirThe habitat in which an agent lives, grows, or multiplies.
    RiskProbability that an unfavorable event will occur.
    Risk appraisalAn estimation of an individual's risk for developing an outcome.
    Risk factorAn attribute or exposure associated with increased probability of a specified outcome (a risk marker). An attribute or exposure that increases the probability of occurrence of disease (a determinant).A determinant that can be modified by intervention, thus reducing the risk (a modifiable risk factor).
    Secondary attack rateThe number of new cases of a disease among the contacts of the index case. Expressed as a percentage.
    Secondary preventionThe screening, testing, and treatment of a disease that is at the pathological level.
    SensitivityThe ability of a screening test to identify correctly those cases that truly have the disease.
    Serial testingApplication of diagnostic test consecutively to one subject at a time.
    Single-blind studyA study in which only participants do not know to which group they belong.
    SpecificityThe ability of a screening test to identify correctly those cases that do not have the disease.
    Standard metropolitan statistical areaA county or group of counties containing at least one city with a population of 50,000 people or more.
    StandardizationTechnique used to remove the effects of differences in age, sex, race, or other confounding variables when comparing two rates for two or more populations.
    Standardized mortality ratioThe observed number of deaths per year divided by the expected number of deaths per year multiplied by 100.
    Statistical powerThe relative frequency with which a true difference of specified size between populations would be detected by the proposed experiment or test.
    Substantive epidemiologyThe collection of epidemiological knowledge about disease.
    Surveillance of diseaseSystem of monitoring all aspects of occurrence and spread of a disease that are relevant to disease control.
    TemporalityEvidence that exposure to a causal factor occurred before initiation of the disease process.
    Tertiary preventionActions taken to limit the disability of a disease state.
    Test-retest reliabilityTest consistency of values across time with repeated testing.
    Triple-blind studyA study in which the subject and investigator are ignorant of the group to which the subject belongs and the data analysis is done without information about which group individual subjects belong to.
    Type I errorThe error of rejecting a true null hypothesis. Alpha error.
    Type II errorThe error of failing to reject a false null hypothesis. Beta error.
    Unimodal epidemiologic curveThe distribution pattern has only one peak.
    ValidityThe degree to which the results of a measurement correspond to the true state of the phenomenon being measured. The degree to which the instrument measures what it is expected to measure.
    VectorThe insect or other living thing that transports an infectious agent from an infected individual or its wastes to a susceptible individual or its food or immediate surroundings.
    VehicleAn inanimate substance that transports an infectious agent to a susceptible host.
    Vertical transmissionTransmission that occurs when a mother conveys an infection to her unborn offspring.
    Vital statisticsData relating to births (natality), deaths (mortality), marriage, divorce, and illness (morbidity).
    References
    Gordis, L. (2000). Epidemiology (
    2nd ed.
    ). Philadelphia, PA: W. B. Saunders.
    Last, J. (1988). Dictionary of epidemiology (
    2nd ed.
    ). New York: Oxford University Press.
    Valanis, B. (1999). Epidemiology in health care (
    3rd ed.
    ). Stamford, CT: Appleton & Lange.

    Appendix D: Community-Based Organization Assessment

    This assessment tool provides a sample of the areas questioned but is not intended to be comprehensive.

    Organizational Infrastructure
    • The organization has established a recruitment and relationship-building committee charged with developing, evaluating, and monitoring resource development policies, practices, and goals.
    • The organization has the resources it needs to accomplish its strategic objectives on its own.
    • Staff employed include
      • Full-time staff
      • Part-time staff
      • Volunteers
      • Interns
      • Board
      • Other
    • Chapters and offices
      • Members
      • Staff
    • Committees have
      • a clear statement of purpose
      • clear written goals and objectives
      • function
      • specific roles and responsibilities
    • The committee structure and membership are reviewed annually for relevance.
    • The organization's by-laws are up to date.
    • The roles of the board and the executive director are defined and respected. The executive director is the manager of the organization's operations. The board is focused on policy and planning.
    • The executive director is recruited, selected, and employed by the board of directors. The board provides clearly written expectations and qualifications for the position, as well as reasonable compensation.
    • Board organization is documented, with a description of the board and board committee responsibilities.
    • The bylaws include
      • how and when notices for board meetings are made
      • how members are elected or appointed by the board
      • what the terms of office are for officers and members
      • how board members are rotated
      • how ineffective board members are removed from the board
      • how many board members makes up the quorum required for all policy decisions
    • The organization has a written personnel handbook or policy that is regularly reviewed and updated.
    • The organization has job descriptions, including qualifications, duties, reporting relationships, and key indicators.
    Strategic Development
    • The organization has a written, updated, strategic plan.
    • The written strategic plan has been developed by researching the internal and external environment.
    • The strategic plan identifies changing community needs, including the agency's strengths, weaknesses, opportunities, and threats.
    • The organization has a clear, meaningful, written mission statement that reflects its fundamental purpose, values, and people served.
    • The organization has developed a vision statement that communicates the organization's future direction and desired results.
    • The mission statement is widely understood, agreed on, and communicated by the board, staff, volunteers, constituents, and community.
    • The strategic plan sets goals and measurable objectives that address identified critical issues for the next 3 to 5 years.
    • The plan establishes an evaluation process and performance indicators to measure progress toward the achievement of goals and objectives.
    • Through work plans, human and financial resources are allocated to ensure the accomplishment of the goals in a timely fashion.
    Board Functions
    • The organization has completed a formal review of its current board profile and has identified deficiencies.
    • Board members serve without payment unless the agency has a policy identifying reimbursable out-of-pocket expenses.
    • Board members are accessible to stakeholders and to staff (volunteer and paid).
    • The board members receive orientation, regular training, and information about their responsibilities. Orientation includes information on the organization's mission, bylaws, policies, practices, and programs, as well as board members’ governance roles and responsibilities as board members.
    • Each board has a board operations manual that summarizes responsibilities (including job descriptions for officers) and operation procedures. This manual includes a copy of the organization's bylaws.
    • The number of current board members is consistent with what is required in the bylaws or state statutes.
    • The board reviews the bylaws on at least an annual basis. Bylaws should clearly state the organization's purpose, service area, defined members, defined board of directors, specific meeting guidelines, defined officers, defined committees, guidelines for amending bylaws, guidelines for dissolution of the organization, and guidelines for financial and legal procedures.
    • The board has developed an annual meeting calendar with tasks that routinely need to be done at specific board meetings.
    • All board meetings have written agendas and materials that are given to the board in advance of the meetings. Board reports and minutes are recorded and action taken on the minutes of all meetings.
    • The board takes the leadership role in fundraising and financial management.
    • The board oversees the annual audit and uses it to strengthen the organization's financial policies.
    • The board prepares a budget (based on a recommendation from the executive director, if one exists) that allocates funds to the major priorities identified in the strategic plan of the organization.
    • The board reviews monthly reports of expenditures and revenues.
    Financial Management
    • A financial plan has been developed to ensure financial stability for 3 to 4 years and is consistent with the organization's strategic plan.
    • The current budget information is used as a base for future budgeting and board meetings.
    • The organization has a cash operating reserve of at least 90 days.
    • The organization follows accounting practices that conform to accepted standards and fulfill Internal Revenue Service requirements.
    • The organization has an ongoing training program for staff and board members that addresses how to read, interpret, and use the organization's financial statements.
    • The organization has documented a set of internal controls, including the handling of cash and deposits and approval of spending and disbursements.
    • The organization develops an annual comprehensive operating budget that includes all expenses and revenue sources for all programs. The budget is reviewed and approved by the board of directors.
    • The board of directors reviews assets and liabilities every 12 months to determine if the organization has enough liquidity.
    • There is a 5-year capital expenditures plan that is updated annually.
    • There are written policies stating who can authorize debt.
    • The organization monitors unit costs of programs and services through the documentation of staff time and direct expenses and use of a process for allocation of management and general fund-raising expenses.
    • The organization reconciles all cash accounts monthly.
    Human Resources
    • The board has a nominating process that ensures that the board remains appropriately diverse with respect to ethnicity, gender, economic status, culture, disabilities, age, skills and expertise.
    • Volunteers are viewed as nonsalaried personnel.
    • Job descriptions have been developed for volunteer positions.
    • There are written policies for and about volunteers.
    • Written job descriptions have been developed for each volunteer work assignment.
    • The organization follows nondiscriminatory hiring practices.
    • The organization has a timely process for filling vacant positions to prevent an interruption of program services or disruption to organization operations.
    Leadership and Management Effectiveness
    • The executive director regularly meets with staff to discuss both financial and nonfinancial information.
    • The organization is guided by sound business principles.
    • Leadership has the courage to embrace change.
    • The organization uses its resources efficiently.
    • Key management possess leadership and management skills.
    • Patterns of organizational communication promote effectiveness.
    Physical and Technological Resources
    • List physical assets.
    • Describe office space.
    • Describe computer and telecommunication capabilities.
    Outcome Measurement and Evaluation
    • Stakeholders are involved in the evaluation process.
    • The evaluation includes a review of the organizational programs and systems to ensure that they comply with the organization's mission, values, and goals.
    • Periodically the organization conducts a comprehensive evaluation of its programs.
    • A plan has been developed to clearly communicate the importance of outcome measurement to all important members of the public, including staff (volunteers and paid staff).
    • The organization has selected the outcomes that are important to measure.
    • Data sources for the outcome indicators have been identified.
    • Data collection methods have been designed.
    • Data collection instruments and procedures have been pretested and are valid and reliable.
    • The outcome measurement process has been monitored.
    • The data have been analyzed.
    • Findings are used to guide budgets and resource allocations.
    • Findings are presented regularly to the board to help board members focus on programmatic issues.
    • Findings are used to communicate program results to stakeholders.
    Program Planning, Development, and Implementation
    • The organization has a program planning process in place that includes stakeholders.
    • Each program has a program plan written that includes program goals, objectives, specific activities, timeline for each activity, responsible individuals, and outcome and evaluation measures.
    • The organization has developed programs that inform, educate, and involve the public.
    • The organization has developed a formal process to identify and expand its most effective and needed programs.
    • A timeline for major implementation steps has been completed.
    • The planning process identifies the critical issues facing the organization.
    Reference
    Lewis, A. (2000). Nonprofit organizational assessment tool. Retrieved July 2, 2003, from http://www.uwex.edu/li/learner/assessment.htm

    Appendix E: Hazardous Environmental Agents, Routes of Entry, and Symptoms

    Metals
    Arsenic

    Routes of entry: Ingestion, inhalation, and permeation of skin or mucous membranes.

    Symptoms: Burning lips, throat constriction, and dysphagia, followed by excruciating abdominal pain, hemorrhagic gastritis, gastroenteritis, severe nausea, projectile vomiting, profuse “rice-water–like” diarrhea, with hypovolemia, resulting in hypotension and an irregular pulse. Muscle cramps, facial edema, bronchitis, dyspnea, chest pain, dehydration, intense thirst, and fluid-electrolyte disturbances are also common. A garlic-like odor of the breath and feces may occur. Hypotension and tachycardia are common early signs. Fever and tachypnea may occur.

    Arsine

    Routes of entry: Inhalation or through cuts and breaks in the skin.

    Symptoms: Acute poisoning causes severe vomiting and diarrhea, muscular cramps, facial edema, and cardiac abnormalities. Shock is also possible. Chronic arsine exposure can affect the skin, respiratory tract, heart, liver, kidneys, blood and blood-producing organs, and the nervous system. Death may occur quickly following a massive or concentrated exposure.

    Beryllium

    Routes of entry: Inhalation, ingestion, or skin contact.

    Symptoms: Pulmonary and systemic granulomatous disease. Nodular skin lesions in patients with chronic beryllium disease. Acute chemical pneumonitis, tracheobronchitis, conjunctivitis, dermatitis, and chronic granulomatous pulmonary disease with systemic manifestations. Acute beryllium disease consists of respiratory tract irritation and dermatitis, sometimes with conjunctivitis. Respiratory tract symptoms range from mild nasopharyngitis to a severe chemical pulmonitis that may be fatal.

    Cadmium

    Routes of entry: Ingestion or inhalation of dust or fumes.

    Symptoms: Acute poisoning after inhalation results in chest pain, cough (with bloody sputum), difficulty breathing, sore throat, “metal fume fever” (shivering, sweating, body pains, headache), dizziness, irritability, weakness, nausea, vomiting, diarrhea, tracheobronchitis, pneumonitis, and pulmonary edema. After acute ingestion, symptoms include abdominal pain, burning sensation, nausea, vomiting, salivation, muscle cramps, vertigo, shock, unconsciousness and convulsions. Chronic exposure (by inhalation or ingestion) results in kidney damage, gastrointestinal symptoms, loss of sense of smell, nasal discharge, nose and throat irritation, lack of appetite, weight loss, nausea, tooth discoloration, bone defects, liver damage, anemia, pulmonary emphysema, chronic bronchitis, bronchopneumonia, and death.

    Chromium

    Routes of entry: Inhalation, ingestion, or skin absorption.

    Symptoms: Irritation to the upper respiratory tract, severe nasal irritation. Ingestion of hexavalent chromium may cause intense gastrointestinal irritation or ulceration and corrosion, epigastric pain, nausea, vomiting, diarrhea, vertigo, fever, muscle cramps, hemorrhagic diathesis, toxic nephritis, renal failure, intravascular hemolysis, circulatory collapse, peripheral vascular collapse, liver damage, acute multisystem shock, coma, and even death, depending on the dose.

    Lead

    Routes of entry: Inhalation or ingestion of dust.

    Symptoms: Acute exposure produces symptoms in the nervous, hematologic, renal, gastrointestinal, and cardiovascular systems. Symptoms include anorexia, vomiting, malaise, and convulsions; may cause permanent brain damage and reversible renal injury.

    Mercury

    Routes of entry: Vapor inhalation or skin absorption.

    Symptoms: Weakness, chills, metallic taste, nausea, vomiting, abdominal pain, diarrhea, headache, visual disturbances, dyspnea, cough, and chest tightness. Chronic mercury exposure may cause rashes and corneal and lens changes with visual impairment.

    Nickel

    Route of entry: Inhalation of dust or fumes.

    Symptoms: Asthma, urticaria, erythema multiforme, contact dermatitis, and hand eczema. Acute toxicity from nickel inhalation includes sore throat and hoarseness.

    Zinc Oxide

    Route of entry: Inhalation of dust or fumes.

    Symptoms: Metal fume fever (zinc chills, brass founder's ague, etc.) from the inhalation of zinc oxide fumes. Fever, chills, muscular pain, nausea, and vomiting. Tachycardia and/or dyspnea may be present.

    Hydrocarbons
    Benzene

    Routes of entry: Vapor inhalation or skin absorption.

    Symptoms: The major toxic effect is on the CNS. Symptoms include dizziness, weakness, euphoria, headache, nausea, vomiting, tightness in chest, and staggering. With severe exposure, symptoms include blurred vision, tremors, shallow and rapid respiration, ventricular dyrhythmia, paralysis, and unconsciousness. Toxicities from inhalation of benzene include irritation of conjunctiva and visual blurring, irritation of mucous membranes, dizziness, headache, unconsciousness, convulsions, tremors, ataxia, delirium, tightness in chest, irreversible brain damage with cerebral atrophy, fatigue, vertigo, dyspnea, respiratory arrest, cardiac failure and ventricular arrhythmias, leukopenia, anemia, thrombocytopenia, petechiae, blood dyscrasia, leukemia, bone marrow aplasia, death, and fatty degeneration and necrosis of heart, liver, and adrenal glands.

    Toluene

    Routes of entry: Vapor inhalation or skin absorption.

    Symptoms: Irritation of eyes and upper respiratory tract, dizziness, headache, anesthesia, and respiratory arrest. Liquid also irritates eyes; if aspirated, causes coughing, gagging, distress, and rapidly developing pulmonary edema. If ingested, causes vomiting, griping, diarrhea, and depressed respiration. Kidney and liver damage may follow ingestion. Toluene embryopathy is characterized by microcephaly, central nervous system dysfunction, attention deficits and hyperactivity, developmental delay with greater language deficits, minor craniofacial and limb anomalies, and variable growth deficiency.

    Xylene

    Routes of entry: Vapor inhalation or skin absorption.

    Symptoms: Vapor irritates eyes and mucous membranes and may cause dizziness, headache, nausea, and mental confusion. Liquid irritates eyes and mucous membranes. Swallowing or absorption through skin causes poisoning. Prolonged exposure to skin contact may result in dermatitis. Repeated, prolonged exposure to fumes may produce conjunctivitis of the eye and dryness of the nose, throat, and skin. Direct liquid contact may result in flaky or moderate dermatitis. Inhalation of vapors may cause CNS excitation, then depression, characterized by paresthesia, tremors, apprehension, impaired memory, weakness, nervous irritation, vertigo, headache, anorexia, nausea, and flatulence, and can lead to anemia and mucosal hemorrhage.

    Formaldehyde

    Route of entry: Inhalation.

    Symptoms: Conjunctivitis, corneal burns, brownish discoloration of skin, dermatitis, urticaria (hives), pustulovesicular eruption. Inhalation results in rhinitis and anosmia (loss of sense of smell), pharyngitis, laryngospasm; tracheitis and bronchitis, pulmonary edema, cough, chest tightness, dypsnea (difficult breathing), headache, weakness, palpitation (rapid heart beat), gastroenteritis (inflammation of the stomach and intestines), burning in mouth and esophagus, nausea and vomiting, abdominal pain, diarrhea, vertigo (dizziness), unconsciousness, jaundice, albuminuria, hematuria, anuria, acidosis, convulsions.

    Trichloroethylene

    Routes of entry: Ingestion, inhalation, or skin exposure.

    Symptoms: Acute inhalation produces rapid coma and may result in death.

    Carbon Disulfide

    Routes of entry: Vapor inhalation or skin absorption.

    Symptoms: Conjunctivitis, epithelial hyperplasia of cornea, and eczematous inflammation of eyelids.

    Ethylene Oxide

    Route of entry: Inhalation.

    Symptoms: Nausea, vomiting, neurological disorders, and death.

    Polychlorinated Diphenyls

    Routes of entry: Inhalation, ingestion, or skin absorption.

    Symptoms: Abdominal pain, anorexia, nausea, vomiting, jaundice, rare cases of coma and death. Neurological symptoms, such as headache, dizziness, depression, nervousness. Other symptoms, such as fatigue, loss of weight, loss of libido, and muscle and joint pains.

    Gases
    Ammonia

    Route of entry: Inhalation.

    Symptoms: Vapors cause irritation of eyes and respiratory tract. Contact with skin can cause burns and vesication. If systemic absorption becomes extensive, coma may occur, preceded by hypertonic contractions and convulsions.

    Hydrochloric Acid

    Routes of entry: Inhalation or skin absorption.

    Symptoms: Inhalation of hydrochloric acid fumes produces nose, throat, and laryngeal burning and irritation; pain and inflammation; coughing; sneezing; choking; hoarseness; dyspnea; bronchitis; chest pain; laryngeal spasms and upper respiratory tract edema; headache; and palpitations. Contact with fumes or liquid can produce corrosive burns. Dermal exposure also results in irritation, pain, dermatitis, and ulceration. Contact with refrigerated liquid can produce frostbite. Eye contact with fumes is extremely irritating. Contact with liquid produces pain, swelling, conjunctivitis, corneal erosion, and necrosis of conjunctiva and corneal epithelium, with perforation or scarring.

    Hydrofluoric Acid

    Routes of entry: Inhalation, ingestion, or contact (skin, eyes) with vapors or dusts.

    Symptoms: Irritation of eyes, nose, and throat; pulmonary edema; skin and eye burns; nasal congestion; and bronchitis.

    Sulfur Dioxide

    Routes of entry: Inhalation or direct contact with skin or mucous membrane.

    Symptoms: Acute symptoms include respiratory tract irritation, cough, burning, lacrimation, conjunctival injection, difficulty in swallowing, and oropharyngeal erythema after substantial exposure. Vomiting, diarrhea, abdominal pain, fever, headache, vertigo, agitation, tremor, convulsions, and peripheral neuritis may also be experienced.

    Chlorine

    Route of entry: Inhalation.

    Symptoms: Burning of eyes, nose, and mouth; lacrimation; rhinorrhea; coughing; choking and substernal pain; nausea; vomiting; headache; dizziness; syncope; pulmonary edema; pneumonia; hypoxemia; dermatitis; eye and skin burns.

    Ozone

    Route of entry: Inhalation.

    Symptoms: Irritation of eye, nose, throat, and skin.

    Nitrogen Oxides

    Route of entry: Inhalation.

    Symptoms: Usually no symptoms occur at the time of exposure, with the exception of a slight cough, fatigue, and nausea. Fatigue, uneasiness, restlessness, cough, hyperpnea, and dyspnea appear insidiously, with adult respiratory distress syndrome developing gradually.

    Asphyxiants
    Carbon Monoxide

    Route of entry: Inhalation.

    Symptoms: Rapidly fatal cases of carbon monoxide poisoning are characterized by congestion and hemorrhages in all organs. Headache, dizziness, and blurred vision.

    Hydrogen Sulfide

    Route of entry: Inhalation.

    Symptoms: Eye irritation, painful conjunctivitis, photophobia, tearing, and corneal opacity. Respiratory symptoms include rhinitis with anosmia, tracheobronchitis, pulmonary edema. Death from rapid respiratory paralysis.

    Cyanide

    Routes of entry: Inhalation of vapor or aerosol, skin absorption.

    Symptoms: Massive doses can produce a sudden loss of consciousness and prompt death from respiratory arrest without warning. Ingestion can produce a bitter, acrid, burning taste, followed by a feeling of constriction or numbness in the throat. Salivation, nausea, and vomiting are common. Anxiety, confusion, vertigo, giddiness, and often a sensation of stiffness in the lower jaw. Hyperpnea and dyspnea. Odor of bitter almonds may be noted on the breath or vomitus. A bright pink coloration of the skin due to high concentrations of oxyhemoglobin in the venous return may be confused with that of carbon monoxide poisoning. The skin color appears red. Death from respiratory arrest.

    Pesticides
    Organophosphates (e.g., Parathion)

    Routes of entry: Inhalation, ingestion, or skin absorption.

    Symptoms: Headache, giddiness, nervousness, blurred vision, weakness, nausea, cramps, diarrhea, and discomfort in the chest. Sweating, miosis, tearing, salivation, and other excessive respiratory tract secretion, vomiting, cyanosis, papilledema, uncontrollable muscle twitches followed by muscular weakness, convulsions, coma, loss of reflexes, and loss of sphincter control. Cardiac arrhythmias, various degrees of heart block, and cardiac arrest may occur. Acute emphysema, pulmonary edema, pink froth in the trachea and bronchi, and considerable congestion of the organs are found at autopsy.

    Reference
    Environmental Defense. (2003). Scorecard: About the chemicals. Retrieved July 2, 2003, from http://www.scorecard.org/chemical-profiles/
    Environmental Protection Agency. (2003). Green book: Nonattainment areas for critical pollutants. Retrieved July 2, 2003, at http://www.epa.gov/air/oaqps/greenbk/
    Helvie, C. (1998). Advanced practice nursing in the community. Thousand Oaks, CA: Sage.

    Appendix F: Integrated Community Assessment Process and Tool

    The Integrated Community Assessment Process

    Phase I: Data Collection. Primary and secondary data collection are used to identify community assets and needs. Data are collected for each component's area of inquiry. Behavioral assessment, public health agency, and environmental assessment data sources are tapped.

    Phase II: Data Analysis. A comprehensive review, critique, and analysis of all data are completed to develop a list of assets, deficits, or needs.

    Phase III: Community Diagnosis. Health-care assets, deficits, and needs, as identified through data collection and analysis, are listed.

    Phase IV: Proposed Multilevel Community Interventions. Recommendations based on community assets and deficits are made for identified concerns.

    Phase V: Report. An oral and written report on the community assessment is disseminated to key community stakeholders.

    Phase VI: Evaluation. The community assessment process is evaluated.

    The Integrated Community Assessment Tool
    Phase I: Data Collection
    Part I. Community Description

    Instructions: Provide a general, broad-based description of the community that includes what you know about the geographical area, population demographics, political factors, community resources and institutions, and environment. From this information, describe what population group constitutes the defining characteristics of the community. This description should provide clear, defining boundaries of the population and the community being assessed.

    Part II. Windshield Survey (Primary Data Collection)

    Conduct the windshield survey at various times of the day and night. List community assets and deficits noted during the windshield survey. Secondary data can cover areas of inquiry unanswered during the windshield survey.

    Part III. Community Data Collection (Primary and Secondary Data Collection)

    Collect existing data for each of the areas of inquiry. Potential data sources are identified.

    Phase II: Data Analysis
    Analysis of Windshield Surve
    AssetsDeficitsPotential Interventions
    1.1.1.
    2.2.2.
    3.3.3.
    Focus Group Thematic Analysis (Community Constituents, Community Leaders)
    AssetsDeficitsPotential Interventions
    1.1.1.
    2.2.2.
    3.3.3.
    Interview Thematic Analysis (Community Constituents, Community Leaders)
    AssetsDeficitsPossible Interventions
    1.1.1.
    2.2.2.
    3.3.3.
    Analysis of Community Assessment Data Components (Data from Phase I, Part II)
    AssetsDeficitsPossible Interventions
    1.1.1.
    2.2.2.
    3.3.3.
    Phase III: Community Diagnosis

    List community asset and diagnosis statements. These statements provide direction for the evaluation of community interventions.

    Community Diagnosis Statement

    [Community deficit or problem] related to [potential causes or associated factors] as evidenced by [community assessment data].

    Community Assets Statement

    [Community asset] promotes a healthy community, as evidenced by [outcomes of community asset].

    Phase IV: Proposed Multilevel Community-Level Interventions

    Interventions should be proposed that relate to community diagnosis and community asset statements.

    AssetsInterventions for Expansion of Assets
    1.1.
    2.2.
    3.3.
    AssetsInterventions for Expansion of Assets
    1.1.
    2.2.
    3.3.
    Phase V: Report

    Narrative community action plan is developed with appropriate objectives, interventions, and methods of evaluation identified and a timeline provided.

    Phase VI: Evaluation

    Evaluate each community assessment process.

    Reference
    Krieger, N., & Harton, M. (1992). Community health assessment tool: A pattern approach to data collection and diagnosis. Journal of Community Health Nursing, 9, 229–234. http://dx.doi.org/10.1207/s15327655jchn0904_4

    Appendix G: Chronological List of Public Health Laws

    1902:P.L. 57-244, Biologics Control Act
    1906:P.L. 59-384, Pure Food and Drug Act (also known as Wiley Act)
    1920:P.L. 66-141, Snyder Act
    1921:P.L. 67-97, Maternity and Infancy Act (also known as Sheppard-Towner Act)
    1935:P.L. 74-271, Social Security Act
    1936:P.L. 74-846, Walsh-Healy Act
    1937:P.L. 75-244, National Cancer Institute Act
    1938:P.L. 75-540, LaFollette-Bulwinkle Act; P.L. 75-717, Food, Drug and Cosmetic Act
    1939:P.L. 76-19, Reorganization Act
    1941:P.L. 77-146, Nurse Training Act
    1944:P.L. 78-410, Public Health Service Act
    1945:P.L. 79-15, McCarran-Ferguson Act
    1946:P.L. 79-487, National Mental Health Act; P.L. 79-725, Hospital Survey and Construction Act (also known as Hill-Burton Act)
    1948:P.L. 80-655, National Health Act; P.L. 80-845, Water Pollution Control Act
    1952:P.L. 82-414, Immigration and Nationality Act (also known as McCarran-Walter Act)
    1954:P.L. 83-482, Medical Facilities Survey and Construction Act; P.L. 83-703, Atomic Energy Act
    1955:P.L. 84-159, Air Pollution Control Act; P.L. 84-377, Polio Vaccination Assistance Act
    1956:P.L. 84-569, Dependents Medical Care Act; P.L. 84-652, National Health Survey Act; P.L. 84-660, Water Pollution Control Act Amendments of 1956; P.L. 84-911, Health Amendments Act
    1958:P.L. 85-544, Grants-in-aid to Schools of Public Health; P.L. 85-929, Food Additive Amendment
    1959:P.L. 86-121, Indian Sanitation Facilities Act; P.L. 86-352, Federal Employees Health Benefits Act
    1960:P.L. 86-778, Social Security Amendments (also known as Kerr-Mills Act)
    1962:P.L. 87-692, Health Services for Agricultural Migratory Workers Act; P.L. 87-781, Drug Amendments (also known as Kefauver-Harris amendments)
    1963:P.L. 88-129, Health Professions Educational Assistance Act; P.L. 88-156, Maternal and Child Health and Mental Retardation Planning Amendments; P.L. 88-164, Mental Retardation Facilities and Community Mental Health Centers Construction Act; P.L. 88-206, Clean Air Act
    1964:P.L. 88-443, Hospital and Medical Facilities Amendments (amended the Hill-Burton Act); P.L. 88-452, Economic Opportunity Act; P.L. 88-581, Nurse Training Act
    1965:P.L. 89-4, Appalachian Redevelopment Act; P.L. 89-73, Older Americans Act; P.L. 89-92, Federal Cigarette Labeling and Advertising Act; P.L. 89-97, Social Security Amendments; P.L. 89-239, Heart Disease, Cancer and Stroke Amendments; P.L. 89-272, Clean Air Act Amendments; P.L. 89-290, Health Professions Educational Assistance Amendments
    1966:P.L. 89-564, Highway Safety Act; P.L. 89-642, Child Nutrition Act; P.L. 89-749, Comprehensive Health Planning Act (also known as Partnership for Health Act); P.L. 89-751, Allied Health Professions Personnel Training Act; P.L. 89-794, Economic Opportunity Act Amendments
    1967:P.L. 90-31, Mental Health Amendments; P.L. 90-148, Air Quality Act; P.L. 90-170, Mental Retardation Amendments; P.L. 90-174, Clinical Laboratory Improvement Act; P.L. 90-189, Flammable Fabrics Act; P.L. 90-248, Social Security Amendments
    1968:P.L. 90-490, Health Manpower Act
    1969:P.L. 91-173, Federal Coal Mine Health and Safety Act; P.L. 91-190, National Environmental Policy Act
    1970:P.L. 91-222, Public Health Cigarette Smoking Act; P.L. 91-224, Water Quality Improvement Act; P.L. 91-296, Medical Facilities Construction and Modernization Amendments (amended Hill-Burton Act); P.L. 91-464, Communicable Disease Control Amendments; P.L. 91-513, Comprehensive Drug Abuse Prevention and Control Act; P.L. 91-572, Family Planning Services and Population Research Act; P.L. 91-596, Occupational Safety and Health Act; P.L. 91-601, Poison Prevention Packaging Act; P.L. 91-604, Clean Air Amendments; P.L. 91-616, Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act; P.L. 91-623, Emergency Health Personnel Act; P.L. 91-695, Lead-Based Paint Poisoning Prevention Act
    1971:P.L. 92-157, Comprehensive Health Manpower Training Act
    1972:P.L. 92-294, National Sickle Cell Anemia Control Act; P.L. 92-303, Federal Coal Mine Health and Safety Amendments; P.L. 92-426, Uniformed Services Health Professions Revitalization Act; P.L. 92-433, National School Lunch and Child Nutrition Amendments (amended Child Nutrition Act); P.L. 92-573, Consumer Product Safety Act; P.L. 92-574, Noise Control Act; P.L. 92-603, Social Security Amendments; P.L. 92-714, National Cooley's Anemia Control Act
    1973:P.L. 93-29, Older Americans Act; P.L. 93-154, Emergency Medical Services Systems Act; P.L. 93-222, Health Maintenance Organization Act
    1974:P.L. 93-247, Child Abuse Prevention and Treatment Act; P.L. 93-270, Sudden Infant Death Syndrome Act; P.L. 93-296, Research in Aging Act; P.L. 93-344, Congressional Budget and Impoundment Control Act; P.L. 93-360, Nonprofit Hospital Amendments; P.L. 93-406, Employee Retirement Income Security Act (also known as ERISA); P.L. 93-523, Safe Drinking Water Act; P.L. 93-641, National Health Planning and Resources Development Act; P.L. 93-647, Social Security Amendments (also known as Social Services Amendments)
    1976:P.L. 94-295, Medical Devices Amendments; P.L. 94-317, National Consumer Health Information and Health Promotion Act; P.L. 94-437, Indian Health Care Improvement Act; P.L. 94-460, Health Maintenance Organization Amendments; P.L. 94-469, Toxic Substances Control Act (TSCA); P.L. 94-484, Health Professions Educational Assistance Act
    1977:P.L. 95-142, Medicare-Medicaid Antifraud and Abuse Amendments; P.L. 95-210, Rural Health Clinic Services Amendments
    1978:P.L. 95-292, Medicare End-Stage Renal Disease Amendments; P.L. 95-559, Health Maintenance Organization Amendments
    1979:P.L. 96-79, Health Planning and Resources Development Amendments
    1980:P.L. 96-398, Mental Health Systems Act; P.L. 96-499, Omnibus Budget Reconciliation Act (OBRA ‘80); P.L. 96-510, Comprehensive Environmental Response, Compensation and Liability Act (CERCLA)
    1981:P.L. 97-35, Omnibus Budget Reconciliation Act (OBRA ‘81)
    1982:P.L. 97-248, Tax Equity and Fiscal Responsibility Act (TEFRA); P.L. 97-414, Orphan Drug Act (ODA)
    1983:P.L. 98-21, Social Security Amendments
    1984:P.L. 98-369, Deficit Reduction Act (DEFRA); P.L. 98-417, Drug Price Competition and Patent Term Restoration Act; P.L. 98-457, Child Abuse Amendments; P.L. 98-507, National Organ Transplant Act
    1985:P.L. 99-177, Emergency Deficit Reduction and Balanced Budget Act (also known as Gramm-Rudman-Hollins Act); P.L. 99-272, Consolidated Omnibus Budget Reconciliation Act (COBRA ‘85)
    1986:P.L. 99-509, Omnibus Budget Reconciliation Act (OBRA ‘86); P.L. 99-660, Omnibus Health Act
    1987:P.L. 100-177, National Health Service Corps Amendments; P.L. 100-203, Omnibus Budget Reconciliation Act (OBRA ‘87)
    1988:P.L. 100-360, Medicare Catastrophic Coverage Act; P.L. 100-578, Clinical Laboratory Improvement Amendments; P.L. 100-582, Medical Waste Tracking Act; P.L. 100-607, National Organ Transplant Amendments; P.L. 100-647, Technical and Miscellaneous Revenue Act
    1989:P.L. 101-239, Omnibus Budget Reconciliation Act (OBRA ‘89)
    1990:P.L. 101-336, Americans with Disabilities Act (ADA); P.L. 101-381, Ryan White Comprehensive AIDS Resources Emergency Act (CARE); P.L. 101-508, Omnibus Budget Reconciliation Act (OBRA ‘90); P.L. 101-629, Safe Medical Devices Act; P.L. 101-649, Immigration and Nationality Act of 1990
    1992:P.L. 102-585, Veterans Health Care Act
    1993:P.L. 103-43, National Institutes of Health Revitalization Act; P.L. 103-66, Omnibus Budget Reconciliation Act (OBRA ‘93)
    1995:P.L. 104-65, Lobbying Disclosure Act
    1996:P.L. 104-134, Departments of Veterans Affairs, Housing and Urban Development, and Independent Agencies Appropriations Act; P.L. 104-191, Health Insurance Portability and Accountability Act (also known as Kassebaum-Kennedy Act); P.L. 104-193, Personal Responsibility and Work Opportunity Reconciliation Act (also known as Welfare Reform Act)
    1997:P.L. 105-33, Balanced Budget Act of 1997; P.L. 105-115, Food and Drug Administration Modernization and Accountability Act
    1998:P.L. 105-357, Controlled Substances Trafficking Prohibition Act; P.L. 105-369, Ricky Ray Hemophilia Relief Fund Act
    1999:P.L. 106-113, Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 (BBRA); P.L. 106-117, Veterans Millennium Health Care and Benefits Act
    2000:P.L. 106-354, Breast and Cervical Cancer Prevention and Treatment Act; P.L. 106-430, Needlestick and Safety Prevention Act; P.L. 106-525, Minority Health and Health Disparities Research and Education Act; P.L. 106-554, Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA); P.L. 106-580, National Institute of Biomedical Imaging and Bioengineering Establishment Act
    2001:P.L. 107-9, Animal Disease Risk Assessment, Prevention and Control Act; P.L. 107-38, Emergency Supplemental Appropriations Act for Recovery from and Response to Terrorist Attacks on the United States

    Note: Public health laws can be accessed at http://www.firstgov.gov or http://www.access.gpo.gov. P.L. = public law. The first number before the hyphen refers to the Congress that enacted the legislation. The number after the hyphen refers to the sequence in which the law was enacted. For example, P.L. 107-38 is the 38th public law enacted by the 107th Congress.

    Reference
    Longest, B. (2002). Health policymaking in the United States (
    3rd ed.
    ). Washington, DC: Association of University Programs in Health Administration.

    Appendix H: Institutions Concerned with Public Health

    Agency for Health Care Research and Quality

    2101 E. Jefferson St., Suite 501

    Rockville, MD 20852

    Phone: 301-594-1364

    http://www.ahcpr.gov

    American Medical Association

    1101 Vermont Ave. NW, 12th Floor

    Washington, DC 20005

    Phone: 202-789-7400

    http://www.ama-assn.org

    American Nurses Association

    600 Maryland Ave. SW, #100W

    Washington, DC 20024-2571

    Phone: 202-651-7000

    http://www.nursingworld.org

    American Public Health Association

    800 I St., NW

    Washington, DC 20001-3710

    Phone: 202-777-2742

    http://www.apha.org

    Association of State and Territorial Health Officials

    1275 K St., N.W., Suite 800

    Washington, DC 20005

    Phone: 202-371-9090

    http://www.astho.org

    Association of Clinicians for the Underserved

    501 Darby Creek Rd., Suite 20

    Lexington, KY 40509-1606

    Phone: 606-263-0046

    http://www.clinicians.org

    Brookings Institution

    1775 Massachusetts Ave. NW

    Washington, DC 20036

    Phone: 202-797-6302

    http://www.brook.edu/

    Center for the Advancement of Health

    2000 Florida Ave., NW, Suite 210

    Washington, DC 20009

    Phone: 202-387-2829

    http://www.cfah.org

    Centers for Medicare and Medicaid Services (CMS)

    7500 Security Boulevard

    Baltimore, MD 21244

    Phone: 410-786-3000

    http://www.cms.hhs.gov

    Center for Patient Advocacy

    1350 Beverly Rd., #108

    McLean, VA 22101

    Phone: 800-846-7444

    http://www.patientadvocacy.org

    Environmental Protection Agency

    Headquarters Information

    Resources Center

    401 M St., SW

    Mailcode 3404

    Washington, DC 20460

    Phone: 202-260-5922

    http://www.epa.gov

    Food and Drug Administration

    5600 Fishers Lane

    Rockville, MD 20857

    Phone: 888-463-6332

    http://www.fda.gov/

    Health Resources and Services Administration (HRSA)

    Information Center

    P.O. Box 2910

    Merrifield, VA 22116

    Phone: 888-275-4772

    http://www.ask.hrsa.gov

    Immunization Action Coalition

    1573 Selby Ave.

    Suite 234

    St. Paul, MN 55104

    Phone: 651-647-9009

    http://www.immunize.org

    Institute of Medicine

    2101 Constitution Ave., NW

    Washington, DC 20418

    Phone: 202-334-2169

    http://www.iom.edu

    Migrant Clinicians Network

    P. O. Box 164285

    Austin, TX 78716

    Phone: 512-327-2017

    http://www.migrantclinician.org

    National Alliance for Hispanic Health

    1501 16th St., NW

    Washington, DC 20036

    Phone: 202-387-5000

    http://www.hispanichealth.org

    National Association for the Advancement of Colored People (NAACP)

    4805 Mount Hope Dr.

    Baltimore, MD 21215

    Phone: 410-358-8900

    http://www.naacp.org

    National Association of Community Health Centers

    1330 New Hampshire Ave., NW

    Suite 122

    Washington, DC 20036

    Phone: 202-659-8008

    http://www.nachc.com

    National Association of County and City Health Officials

    1100 17th St., N.W., Second Floor

    Washington, DC 20036

    Phone: 202-783-5550

    http://www.naccho.org

    National Association of Home Care

    228 7th St. SE

    Washington, DC 20003

    Phone: 202-547-6586

    National Association of Local Boards of Health

    1840 East Gypsy Lane Rd.

    Bowling Green, OH 43402

    Phone: 419-353-7714

    http://www.nalboh.org

    National Black Nurses’ Association, Inc.

    8630 Fenton St., Suite 330

    Silver Spring, MD 20910

    Phone: 301-589-3200

    http://www.nbna.org/

    National Black Women's Health Project (NBWHP)

    Public Education/Policy Office

    1211 Connecticut Ave., NW, Suite 310

    Washington, DC 20036

    Phone: 202-835-0117

    http://www.blackwomenshealth.org/site/PageServer

    National Center for Health Statistics

    3311 Toledo Rd.

    Hyattsville, MD 20782

    Phone: 301-458-4636

    http://www.cdc.gov/nchs/

    National Center for Injury Prevention and Control (NCIPC)

    Mailstop K65

    4770 Buford Highway, NE

    Atlanta, GA 30341-3724

    Phone: 770-488-1506

    http://www.cdc.gov/ncipc

    National Coalition Building Institute (NCBI)

    1835 K St. N.W., Suite 715

    Washington, DC 20006

    Phone: 202-785-9400

    http://www.ncbi.org

    National Health Resource Center on Domestic Violence

    6400 Flank Dr.

    Suite 1300

    Harrisburg, PA 17112

    Phone: 800-537-2238

    http://endabuse.org/programs/display.php3?DocID=41

    National Hospice and Palliative Care Organization

    1901 North Moore St., #901

    Arlington, VA 22209

    Phone: 800-658-8898

    http://www.nho.org/templates/1/home-page.cfm

    National Immunization Program (NIP)

    Centers for Disease Control and

    Prevention

    1600 Clifton Road, NE

    Mailstop E52

    Atlanta, GA 30333

    Phone: 800-232-2522

    http://www.cdc.gov/nip

    National Indian Health Board

    1385 South Colorado Blvd.,

    Suite A-707

    Denver, CO 80222

    Phone: 303-759-3075

    http://www.nihb.org

    National Institute for Occupational Safety and Health (NIOSH)

    4676 Columbia Parkway

    Cincinnati, OH 45226

    Phone: 800-356-4674

    http://www.cdc.gov/niosh

    National Lead Information Center

    8601 Georgia Ave.

    Suite 503

    Silver Spring, MD 20910

    Phone: 800-424-5323

    http://www.epa.gov/lead/nlic.htm

    National Medical Association

    1012 10th St., NW

    Washington, DC 20001

    Phone: 202-347-1895

    http://nmanet.org

    Office of Minority Health Resource Center, Public Health Service, US Department of Health and Human Services

    P.O. Box 37337

    Washington, DC 20013-7337

    Phone: 301-230-7199

    http://www.omhrc.gov/omhrc/index.htm

    Office of Population Affairs

    1101 Wootton Parkway, Suite 700

    Rockville, MD 20852

    Phone: 301-654-6190

    http://opa.osophs.dhhs.gov/

    Public Health Foundation

    1220 L St., N.W., Suite 350

    Washington, DC 20005

    Phone: 202-898-5600

    http://www.phf.org

    Resources for Cross Cultural Health Care

    27 Aspen Circle

    Albany, NY 12208

    Phone: 518-435-1972

    http://www.diversityrx.org/HTML/WERCCH.htm

    Robert Wood Johnson Foundation

    Route One and College Road East

    P.O. Box 2316

    Princeton, NJ 08543-2316

    http://www.rwjf.org

    Sexuality Information and Education Council of the U.S. (SIECUS)

    130 W. 42nd Street, Suite 350

    New York, NY 10036-7802

    Phone: 212-819-9770

    http://www.siecus.org

    The Center for Mental Health Services

    P.O. Box 42490

    Washington, DC 20015

    Phone: 800-789-2647

    http://www.mentalhealth.org

    Office on Violence Against Women Office

    U.S. Department of Justice

    810 7th St., NW

    Washington, DC 20531

    Phone: 202-307-6026

    http://www.ojp.usdoj.gov/vawo/welcome.html

    Author Index

    About the Author

    Demetrius James Porche, Ph.D., is Professor of Nursing and Associate Dean for Nursing Research and Evaluation at the Louisiana State University Health Sciences Center in New Orleans, Louisiana, and Adjunct, Associate Professor at Tulane University School of Public Health and Tropical Medicine in the Community Health Sciences Department. He received his Bachelor of Science in Nursing degree from Nicholls State University and his Master of Nursing and Doctor of Nursing Science degrees from Louisiana State University Medical Center. A certified clinical specialist in community health nursing and family nurse practitioner, his clinical experience includes critical care nursing, home health nursing, hospice nursing, infection control and epidemiological surveillance, and clinical specialization in HIV and other blood-borne illnesses. His community health experience is concentrated in comprehensive school health program management, the homeless population, HIV prevention, community capacity building, and program planning. His research interests include health promotion and disease prevention, men's health, behavior change and modification, and community-level evaluation. He is currently a research and evaluation consultant to several community-based organizations. His professional leadership roles include Vice President of the New Orleans District Nurses Association, Louisiana State Nurses Association Consultant to the Louisiana Association of Student Nurses, President of Xi Zeta Sigma (Theta Tau Chapter), and HIV/AIDS Expert Panel Member for the International Council for Nurses. He currently serves as associate editor of the Journal of the Association of Nurses in AIDS Care and associate editor of the Journal of Multicultural Nursing and Health Care.


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