1. Nelson, Roxanne


A plan to improve community health in five years.


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The Centers for Disease Control and Prevention (CDC) has rolled out an ambitious initiative to improve public health, known as Health Impact in 5 Years or HI-5 ( The aim of the HI-5 initiative is to have a "lasting impact on health outcomes" by focusing on the social determinants of health (rather than only on patient care) and on making it easier to make healthy choices. HI-5 highlights 14 well-known, already proven community-wide interventions (see HI-5 Interventions). Each intervention has had a positive impact on health, has seen results within five years or less, and has been cost-effective or has cut costs over the lifetime of the population or earlier.

Figure. Sandra Cote,... - Click to enlarge in new window Sandra Cote, principal of Greylock Elementary School in North Adams, Massachusetts, leads a "walking school bus" of her students on International Walk to School Day. School-based programs to increase physical activity are one of the interventions in the CDC's HI-5 initiative. Photo (C) Associated Press.
Box. HI-5 Interventi... - Click to enlarge in new window HI-5 Interventions


"HI-5 initiatives are evidence-based programs that have demonstrated the ability to find solutions to identifiable problems," says Lauren Valk Lawson, DNP, RN, assistant professor in the College of Nursing at Seattle University. She notes that a successful outcome within five years means that the return on efforts is something legislators can support. "Not all the challenges to creating healthy communities are so easily addressed, although these initiatives can be a starting point to building community collaboration," Lawson adds. "The resulting social capital has the potential to develop skills to address other issues."


In a recent webinar, Elizabeth L. Skillen, PhD, MS, senior advisor in the CDC's Office of the Associate Director for Policy in Atlanta, discussed the importance of the HI-5 initiative in terms of changing trends in health care. An increasing focus on prevention and wellness has opened the door to strategies that promote health-and lower costs. State and local health departments have been adversely affected by economic shifts, she explained. "Local health departments have eliminated 51,700 jobs between 2008 and 2015, and budget cuts affect almost one in four local health departments."


There has also been a shift in health care models, from focusing only on the health of individuals to that of populations. HI-5's community-wide approaches have the greatest potential to impact health because they can reach entire populations at once and require less individual effort than clinical interventions. HI-5 also complements the CDC's 6|18 Initiative (, which focuses on 18 clinical interventions for six common and costly health conditions (asthma, unintended pregnancy, tobacco use, health care-associated infections, diabetes, and hypertension).


HI-5's interventions are divided into two broad categories. Those that focus on "changing the context"-like implementing motorcycle helmet laws and tobacco control interventions, for example-are intended to make it easier to make healthier choices. Those that zero in on the social determinants of health-such as providing home improvement loans and earned income tax credits to low-income families-aim to improve a population's social, economic, and physical conditions, thus positively influencing the overall health of the community. Both have the potential to make a significant health impact. One example of an ongoing HI-5 action is "Power Up for 30," a statewide program in Georgia that integrates 30 minutes of physical activity into each school day as part of the state's childhood obesity prevention initiative.



The scope of the HI-5 initiative is wide ranging, giving nurses significant opportunities to promote population health. According to Lawson, doing so requires a shift in the current understanding of nursing's role. "Nurses will need to transition from a 'diagnose and treat' mentality and look at the bigger picture of what is causing poor health in our communities and populations," she says.


"Nurses are involved in interventions that impact health and health outcomes, and that address the social determinants of health for individuals and specific populations," says Teri A. Murray, PhD, RN, APHN-BC, FAAN, dean and professor at the Saint Louis University School of Nursing. "For example, nurses can promote child health through health education and wellness programs-such as teaching about healthy diets, how to read food labels, exercise and health, stress management techniques, violence prevention, and anger management," she says. "Nurses can empower individuals through teaching the public about matters related to health promotion and risk reduction so that individuals or specific groups can maximize their health."


Nurses can work with adolescents, for instance, teaching them about reducing risky behaviors such as the use of tobacco, alcohol, and nonprescribed or street drugs, as well as unprotected sex. "They can also conduct screenings for lead at local schools and health departments; many older homes have lead-based paint, which can be disastrous for a child's normal growth and development," says Murray.


She also points out that there are a host of services that nurses can provide to address the social determinants of health. One example is advocacy: "Nurses work with neighborhood constituent groups, community organizations, local politicians, and state legislatures to advocate for policies to improve the community-level conditions that foster poor health outcomes, such as poor lighting in impoverished neighborhoods, unenforced housing codes, inadequate public transportation, and food deserts-areas with no fresh fruits or vegetables-and to raise awareness about urban decay and the lack of green space for neighborhood children to play," she says.


Finally, nursing education programs can help achieve community health goals. For example, Murray thinks nursing faculty can ensure that nursing students have a depth and breadth of clinical experiences that include not only primary care, but public health and population health as well.


It's also important for nurses to be politically active, as key elements in U.S. health care policy are in flux. "It's extremely important to urge Congress to [continue to] fund CHIP [the Children's Health Insurance Program], a proven strategy that provides health insurance and care to many millions of children," says Carol Brewer, PhD, RN, FAAN, distinguished professor emerita of nursing at the University at Buffalo School of Nursing in Buffalo, New York. "Health outcomes for these children are at high risk of decline." She also points out that the 2017 tax bill signed into law in December by President Trump undermines the Affordable Care Act by repealing the individual mandate.


"Placing more than 11 million people at risk for loss of health insurance will prevent the use of primary care, which prevents crises and extremely costly ED visits and uncompensated care," Brewer adds. "These costs are not included in the balance sheet presented in the tax bill."-Roxanne Nelson