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Social Determinants of Health, the Physical Environment and Public Health Nursing
Gay Edgecombe
Associate Professor/Clinical Chair, Community Child Health Nursing, RMIT University, VIC
Article Text
Since late in the 19th century, public health nursing has played a major role in providing services to people living in poverty and to populations disadvantaged by race, geography, age and political systems. As we approach the beginning of the 21st century, issues associated with nurses providing public health services to these vulnerable populations are much the same.
Social Determinants of Health and the Physical Environment
During the late 19th century, two issues stood out as requiring the urgent attention of governments: the impact of:
- the social determinants of health, such as poverty and lack of social support; and
- the physical environment, particularly contaminated water, overcrowding and pollution on heath of citizens.
Both issues were viewed as being strongly linked. Therefore, public health as we know it today was based on an understanding of the impact of these issues on the health of populations (Eyler, 1997; Holland & Stewart, 1997; Nightingale, 1874).
Brief History of Public Health Nursing
Public health nursing was established as an advanced nursing specialty by Florence Nightingale and her colleagues during the latter stages of the 19th century. These early public health nurses were originally called 'district nurses' and later, health visitors. Health visitors still play a major public health role in the United Kingdom today. The intended role of the 'district nurse' (as envisaged by Nightingale) was unequivocal. Baly (1989) writes that in 1874, with the support of the Duke of Westminister, a national appeal, and Miss Nightingale (who wrote letters to The Times), the Metropolitan and National Nursing association was founded. In one of her letters to The Times Nightingale stated:
A district nurse must first nurse. She must be of a yet higher class and yet of a fuller training than that of a hospital nurse because she has no hospital appliances at hand at all...
The first district nurses undertook 12 months training at St Thomas's Hospital and six months training in district nursing. According to Baly they had:
Lectures on subjects that general training omitted, such as the care of mothers and their infants after childbirth, sanitary reforms, drainage, water supply, infectious diseases, and the teaching of health care.
It was the intention of the pioneers of public health nursing that these new nurses would become leaders in public health. During the early 20th century, public health nursing services wee established in many other countries, including Australia, New Zealand, Canada United States, the Republic of Ireland, Finland and Norway. The titles of these new nursing roles reflected wither a generalist approach (hence the title health visitor or generalist public health nurse) or a specialist focus (for example, maternal and child health nurses, school health nurses, and occupational health nurses).
Definition of the Generalist Public Health Nurse
The role of the generalist public health nurse was first described by WHO in the late 1950s and 1960s (WHO, 1959, p.31; WHO, 1961, p.7). WHO descriptions encompass the following statements:
General public health nurses were introduced to provide services for populations recognised by health departments as being at-risk or more susceptible than the general community to communicable and noncommunicable disease and/or to develop ill health. Such at-risk groups often have limited or no access to basic health services. Public health nurses, therefore provide whatever public health programmes are required to meet the public health needs of disadvantaged and at risk-groups living anywhere in the community across the lifespan. Such programmes differ from country to country and community to community. (WHO, 1978; Mahler, 1998) and health promotion (WHO, 1986).
The Current Situation
What is different at the end of the 20th century? All countries are still experiencing the impact of the social determinants and physical environment on the health of their citizens. Many public health nursing services are under threat because governments have failed to consistently make the connection between the social determinants of health and the physical environment of health. Despite such setbacks there are large numbers of public health nurses providing valuable front-line public health services around the world. It is critical that these nursing services provide evidence of their effectiveness and demonstrate leadership through working with all nurses and midwives and other related groups and individuals on the two key public health issues identified at the beginning of this discussion.
A Starting Place
A crucial question to be raised here is: Where should public health nursing activism focus at the end of this century? An important starting point lies in reading the following two works: The Ecological Self in Australian Nursing (Lacroix, 1996) and The Solid Facts: Social Determinants of Health (WHO, 1998). The latter work is particularly helpful, since it discusses (with supporting evidence) the following 'ten different but interrelated aspects of the social determinants of health' (an understanding of which is critical to advancing the new public health movement):
- The social gradient. People's social and economic circumstances strongly effect their health throughout life, so health policy must be linked to the social and economic determinants of health.
- Stress. Stress harms health. Social and psychological circumstances can cause long-term stress.
- Early Life. The effects of early development last a lifetime; a good start in life means supporting mothers and young children.
- Social exclusion. Social exclusion creates misery and costs lives.
- Work. Stress in the workplace increases the risk of disease.
- Unemployment. Job security increases health, wellbeing and job satisfaction.
- Social support. Friendship, good social relations and strong supportive networks improve health at home, at work and in the community.
- Addiction. Individuals turn to alcohol, drugs and tobacco and suffer from their use, but use is influenced by the wider social setting.
- Food. Health food is a political issue. There is a need to ensure access to supplies of healthy food for everyone.
- Transport. Healthy transport means reducing driving and encouraging more walking and cycling, backed up by better public transport (WHO, 1998, p.1-10).
This document is available from the following Internet address: http://www.who.dk/tech/hcp/index.htm
Secondment to the WHO
During December 1998 and January 1999, I was seconded to the Nursing and Midwifery program, World Health Organisation (WHO), Regional Office for Europe Copenhagen, Denmark to prepare a discussion paper on public health nursing. I found that nurses and midwifery associations are examining their public health roles, particularly in respect to the impact of the social determinants of health and the physical environment on the health of the people of Europe.
Australian nurses, midwives and public health nurses need to do the same. This process has begun in Australia through the Public Health Partnership which has as its main aim 'to improve the health of Australian through consistent, coordination and collaborated action between the Commonwealth, states and territories' (Baum, 1998, p.54).
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