Public Health Practice

Professional work in community health is dynamic because the environment changes continuously. Community health is affected by social, demographic, political, economic, and technologic changes. In this milieu, public health practitioners perform a broad array of duties focused on entire populations, with the overarching goal that people are healthy and live in healthy communities.1,2 The mission of public health is to “fulfill society’s interest in assuring the conditions in which people can be healthy.”^3,4 Public health carries out this mission through organized, interdisciplinary efforts that address health problems in communities. Its mission is achieved through the application of health promotion and disease prevention and control efforts designed to improve health and enhance quality of life.^1–4

Public health services incorporate the roles of a myriad of public health professionals in various sectors and from diverse disciplines that form the public health workforce in the United States.4,5 Public health professionals can belong to many professional disciplines, including oral health, nursing, nutrition, social work, health promotion, laboratory science, environmental health, administration, and epidemiology. Public health professionals have expertise in diverse public health practices.⁵ Several organizations and agencies have called for an increase in the visibility of public health and the core workforce that forms its foundation.^1,2

As a result, collaborative efforts have been undertaken to enhance the recognition of the public health professions by measuring and improving the competency and consistency of public health workers nationwide. In 2005, the National Board of Public Health Examiners (NBPHE) was established to ensure that graduates from schools and programs of public health accredited by the Council on Education for Public Health (CEPH) have mastered the knowledge and skills relevant to contemporary public health.¹ The NBPHE has developed and now administers an examination for the credential, Certified in Public Health (CPH).¹ The national examination covers the five core areas of knowledge offered in CEPH–accredited schools and programs, as well as interdisciplinary cross-cutting areas relevant to contemporary public health. The core areas include biostatistics, environmental health sciences, epidemiology, health policy and management, and social and behavioral sciences.^1,2 The cross-cutting areas are communication and informatics, diversity and culture, leadership, public health biology, professionalism, programs planning, and systems thinking.^1,24646

In addition, the Council on Linkages Between Academia and Public Health Practice has developed a set of core competencies for public health professionals to help strengthen public health workforce development.1,2 The competencies guide academic institutions and training providers to develop curricula and course content and to evaluate public health education and training programs. The competencies are used in practice settings as a framework for hiring and evaluating staff and assessing organization-wide gaps in skills and knowledge. The competencies are divided into the eight domains outlined in Box 3-1. Skills and knowledge are outlined within each domain, linked with important attitudes relevant to the practice of public health. This effort of the Council focuses on core competencies as they apply to three different categories of professional positions: front line staff, senior level staff, and supervisory and management staff.

The core competencies were crafted to transcend the boundaries of specific disciplines and to help unify the public health profession. The list has been cross-walked with the Essential Public Health Services to ensure that the competencies help build the skills necessary for assuring the provision of these services. Academic institutions and health departments nationwide, as well as the Centers for Disease Control and Prevention (CDC), the Centers for Public Health Preparedness (CPHP), and the Health Resources and Services Administration (HRSA)-funded Public Health Training Centers, have used the core competencies to extend capacity and to ensure that public health professionals have expertise in key public health services.

Successful provision of public health services requires collaboration among public, nonprofit, and private partners within a given community and across various levels of government.⁴ To fulfill these goals, partnerships must have broad-based representation of constituency and stakeholder groups, including private, voluntary, nonprofit, and public agencies or organizations involved in health, mental health, substance abuse, environmental health protection, and public health.⁶ Examples of organizations and agencies that can be engaged in coalitions and collaborative partnerships to improve health in communities are presented in Appendix C.

Assessment: A Core Public Health Function

The contemporary principles of public health practice and science have been highlighted in several national reports.3–5 These consensus reports, published by the Institute of Medicine (IOM), detail past contributions and identify challenges to public health. They outline recommendations to improve the nation’s public health system and to ensure universal access to necessary public health services.

The Future of Public Health report specified three core public health functions that shape the basic practice of public health at the federal, state, and local levels.³ Health agencies and health departments must perform these functions to protect and promote health, wellness, and quality of life and to prevent disease, injury, disability, and death. These functions (as noted in Chapter 1) are (1) assessment, (2) policy development, and (3) assurance.³ This chapter emphasizes the core public health function of assessment in the community.

The IOM report called for public health agencies to promote, to facilitate, and—when necessary and appropriate—to perform community health assessments and to monitor change in key measures to evaluate performance. Assessment is defined as the regular and systematic collection, assemblage, analysis, and communication on the health of the community.³ The IOM report stated that assessment includes statistics on health status, community health needs, and epidemiologic and other studies of health problems.³

Roles of Public Health Professionals in Assessment

The effective use of information in the twenty-first century is crucial to ensure that healthy children and adults are living in healthy communities. Technologies available to public health professionals influence the capacity and ability to generate and collect a vast amount of information.1,2 In addition, evidence-based decision making is shaping the development of public health policies, programs, and practices.⁴ Therefore it is essential for public health practitioners to have skills in collecting, analyzing, disseminating, and effectively using data and information.⁵ Public health professionals must have the knowledge, skills, and values to do the following^5,7:

Public health dental hygienists are expected to play a leadership role in community oral health assessments.9,10 As agencies and organizations take on greater responsibility in conducting periodic assessments, public health dental hygienists will be involved in evaluating assets, needs, problems, and resources of the populations they serve in the community. Dental public health professionals working at the national, state, and local levels will be responsible for community oral health assessment.⁹ Essential public health services for oral health were developed to describe community oral health assessment (see Chapter 6 and Guiding Principles box).

Dental hygienists working within the public, private, or nonprofit sectors must have skills to assess community oral health problems, as well as evaluate outcomes of oral health population-based and personal oral health services. Dental hygienists working in community settings generally participate in a variety of assessment and evaluation activities. Examples of some of these roles and potential activities are shown in Box 3-2.

Overview of Epidemiology: Population-Based Study of Health

Public health dental hygienists involved in assessment and evaluation should become well versed in the basic concepts of epidemiology, which is a core science of community health. This section provides a broad overview of epidemiology. Table 3-1 provides the definitions of terms used in epidemiology and community health assessments.

Epidemiology is the study of the distribution and determinants of health-related states and events in specified populations and the application of this study to the prevention and control of health problems.¹¹ Epidemiologists consider the interactions and relationships among the multiple factors that influence health status and health problems.¹² Methods used in epidemiology and research are combined to focus on comparisons between groups or defined populations. Epidemiologists make comparisons by examining the occurrences of the health events, locations, times, and variations to assess the distribution and determinants of health events.¹³ The principal factors analyzed in epidemiology are as follows:

Epidemiology is based on a multifactorial perspective, with consideration given to the interacting relationships among host factors, agent factors, and environmental factors.12,14

Environmental Factors

Environmental factors include physical, sociocultural, sociopolitical, and economic components. The media, beliefs, occupation, food sources, geography, climate, housing, social roles, technology, and other factors can influence environmental conditions.

The “epidemiologic triangle” depicts disease as the outcome of the interactions among host, agent, and environmental factors.¹² For example, the development and progression of dental caries is attributed to multiple factors.^15,16 Figure 3-1 portrays the epidemiologic triangle, with dental caries shown as a multifactorial disease influenced by host, agent, and environmental factors.

Changing Perspectives of Health

During the twentieth century, major transformations took place in the concepts of health and the understanding of the determinants of diseases, disabilities, and injuries. Many historic developments contributed to these expanded visions and had a profound effect on the health of individuals and populations.1,2,18 These developments contributed to changes in clinical health care and public health practice. Box 3-4 outlines broad trends that influenced the conceptions of health in the twentieth century.

Reports from studies have identified many factors that influence the health of individuals and populations.4,19–23,25–31 Several of these factors are generally recognized as broader determinants of health (e.g., employment; education; environment; income; shelter; food; social justice and equity; family, friends, and social supports; peace and safety; culture and race relations).^{14,22–24,31–33} Other factors (e.g., language, learning, meaningful work, recreation, self-esteem, personal control) are considered contributors to well-being. These factors may also be classified as follows¹⁴:

There has been a broadening of the concepts of health promotion and disease prevention from an individual focus toward a human ecologic perspective.¹⁷ Health became much more than just the absence of disability and disease. In 1948, The World Health Organization (WHO) Constitution defined health as “a state of complete physical, social and mental well-being, and not merely the absence of disease or infirmity.” The fundamental conditions and resources for health were described in 1986 by the Ottawa Charter for Health Promotion (Box 3-5). Improvement in health requires a secure foundation in these basic prerequisites.

Health promotion was discussed as the process of enabling people to increase control over and to improve their health. To reach a state of complete physical, mental, and social well-being, an individual or group must be able to identify and realize aspirations, satisfy needs, and change or cope with the environment. Health was therefore seen as a resource for everyday life not the objective of living. Health was a positive concept emphasizing social and personal resources, as well as physical capacities. Therefore health promotion is not just the responsibility of the health sector but goes beyond healthy lifestyles to well-being.

Conceptual Models of the Determinants of Health

Many models describing the multiple factors that influence the broader dimensions of health in individuals and populations were developed in the second half of the twentieth century.⁴ Multicausal perspectives of health and disease began to take precedence over monocausal models.¹² The epidemiologic triangle model waned as the emphasis on infectious diseases diminished in the later part of the centu/>