1. Gerrity, Patricia RN, PhD, FAAN

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According to the 1990 census, more than one in every five people in the United States lives in the 100 largest cities. With respect to health care, these cities are a study in contrasts. They contain some of the best facilities and brightest health care workers, yet many residents have limited access to needed care and services. The dichotomy between the often highly coordinated services offered within the large health care institutions and the fragmented services available in the community is vast.


Inner-city communities may be facing the greatest health care challenges of all areas of the country. The circumstances of poverty are exacerbated by racial and ethnic segregation and discrimination. The health status of inner-city residents is significantly lower than the rest of the country; and lack of access to health care because of poverty, lack of insurance, transportation, and overwhelming family issues is a longstanding problem. The urban environment contributes to the complexity of physical and mental illness. Poverty, poor nutrition, and unemployment combine with deteriorating housing, loss of services, and violence, to create a deepening health crisis in the inner city. Factors related to burden of urban health problems are complex and interrelated and require community partnerships with health care providers to address them effectively.


Although social changes and their related health problems are often first experienced in cities, these changes quickly spread to the surrounding suburban areas and eventually to rural communities as well. Health problems such as the concentration of violence, AIDS, drug abuse, and related conditions commonly associated with urban areas are diffusing out to suburban areas and smaller communities because of migration out of inner cities and transportation links with outlying areas. Therefore, lessons learned from the urban experience have implications for other areas of the country.


This issue of Holistic Nursing Practice highlights some of the major health issues facing cities today; cancer, violence, lead poisoning, asthma, and infection with HIV. These conditions are all linked to the physical and social environment and are either preventable or able to be detected early. Although each article describes a unique program, several common themes emerge. First, the authors all note that the root causes of the health problems are complex and interrelated requiring a systems approach for effective problem solving. They recognize that multiple factors impact a person's behavior and that effective programs need to move beyond institutionally based health care services to extend throughout a participant's social network.


An additional common element includes the notion of building on a community's strengths and actively engaging residents in community-health care provider and community-researcher partnerships. Representatives of the target community need to be involved in both program planning and implementation. The goal of effective programs is to develop community leadership that empowers the community by building skills and resources of the residents to address complex problems.


The use of peer volunteers in health promotion activities such as screening and education is highlighted in three of the articles. The use of opinion leaders and influential people in the community to carry a health promoting message is effective in all age groups, from violence prevention in youth to cancer screening in the elderly. The use of community members as change agents helps to facilitate trust and credibility for the providers of the health promoting activities and communicates community norms for engagement in health behavior.


Nurses play an important role in community-based urban health initiatives. They provide leadership throughout the community organizing process and help to conduct assessment and plan and implement programs in partnership with the residents themselves. As health services continue to move from institutionally based to community based programs, nurses need to be problem solvers, collaborators, and systems thinkers and it is imperative that nursing students receive the necessary preparation to fulfill these functions as well. Students can benefit from community based learning where they directly experience the complexity of community interactions. They need to understand the interplay between culture, economics, housing, and education and the severity of an illness and the disparities between the care a person needs and what is actually received. We must not make the mistake of trying to move institutional systems and care to communities but learn additional skills and competencies for problem solving with and not for communities in need.