Evolving Public Health Nursing Roles

Focus on Community Participatory Health Promotion and Prevention

Pamela A. Kulbok, DNSc, RN, PHCNS-BC, FAAN; Esther Thatcher, MSN, RN; Eunhee Park, BSN, RN; Peggy S. Meszaros, PhD.


Online J Issues Nurs. 2012;17(2) 

In This Article

Youth Substance Use Prevention in a Rural County: An Exemplar

The Problem

Adults and youths in rural southern states have some of the highest rates of cigarette and smokeless tobacco (ST) use in the US (Centers for Disease Control and Prevention [CDC], 2010). Adolescent tobacco use is highly correlated with use of alcohol and other drugs (Hair, Park, Ling, & Moore, 2009; Kulbok & Cox, 2002). Tobacco, alcohol, and other drug use remain pervasive problems worldwide and are responsible for a large proportion of morbidity and mortality in the US (CDC, 2010). Healthy People (HP) 2020 (U.S. Department of Health and Human Services [DHHS], 2010) pointed to the long-term health threat of adolescent substance use and the need to increase the proportion of adolescents who remain substance free. Many rural counties, however, have little knowledge of effective intervention strategies to prevent adolescent substance use. Healthy People 2020 (DHHS, 2010) recommended increasing population-oriented, primary prevention programs provided by community-based organizations to prevent youth tobacco, alcohol, and drug use.

The Project

A project involving the community participation and ethnographic model provides an exemplar of evolving PHN roles in community participatory health promotion. An inter-professional team, led by an advanced practice public health nurse and a human development specialist, is currently using these innovative, community participatory strategies, including GIS mapping and Photovoice, to design a substance use prevention program in a rural tobacco-growing county in the south. Public health nurses and interdisciplinary researchers created a team with youths, parents, and community leaders, to complete a comprehensive community and environmental assessment of the county, its rural ecological context and culture; and, to review evidence-based prevention programs, as the foundation for a youth substance use prevention program that will be acceptable, effective, relevant, and sustainable by the rural county.

The inter-professional research team previously worked with youths, parents, and community leaders in a rural tobacco-growing county of Virginia on two collaborative research projects focused on youth tobacco prevention (Kulbok et al., 2010; Kulbok, Meszaros, Hinton, Botchwey, & Noonan, 2009). With first-hand knowledge of the challenges faced by this rural county when attempting to prevent youth substance use, the team proposed and received funding for a project (Kulbok, Meszaros, Bond et al., 2009) based on Healthy People 2020 (DHHS, 2010) recommendations for community-based, population-oriented primary prevention. The project aims were to:

  1. Establish a community participatory research team (CPRT) in a rural county composed of youth, parents, and trusted community leaders;

  2. Conduct a community and environmental assessment with the CPRT to identify ecological, cultural, and contextual factors influencing substance-free and substance-using adolescent lifestyles;

  3. Evaluate the effectiveness of prevention programs with the CPRT in light of the community's ecological, cultural, and contextual dimensions, health attitudes and behaviors, and on that basis develop a tobacco, alcohol, and drug use preventive intervention for this rural tobacco-producing community; and,

  4. Pilot test the intervention to determine feasibility, acceptability, obtain preliminary effectiveness data, and refine the intervention for formal testing in other rural communities.

This youth substance use prevention project is currently in year three, the final stages of designing and testing a preventive intervention with the CPRT. The project, which is being implemented in stages that correspond to the aims, was reviewed and approved by the Institutional Review Boards of the University of Virginia and Virginia Tech. The inter-professional project team currently includes an advanced practice public health nurse and specialists from anthropology, architecture and urban planning, epidemiology, human development, and psychology. The team also includes public health nursing and psychology doctoral students. The community members of the CPRT, during the course of the three year project, included four community leaders, twelve youths, and eight parents. All of the adult CPRT members successfully completed research ethics education required by the Instuitional Review Boards.

The CPRT completed a comprehensive community and environmental assessment of the rural county to identify assets and needs related to five assessment domains: the community's people and history, and its physical environment, idea systems, social systems, and belief systems. In order to gather qualitative data about substance use in this county, the team completed 14 individual interviews of community leaders and five youth group interviews, with a total of 34 youths, 14 to 18 years of age. The team also completed one group interview with seven parents. Analysis of the data from these multiple sources was integrated into a comprehensive community assessment by the CPRT. Guided by the community participatory and ethnographic model, and using innovative strategies (i.e., GIS and Photovoice) described in the previous section, the team used the GIS method to visualize and analyze the assessed data related to substance use.

Innovative Strategies for Community Assessment

A series of community assessment maps displayed socio-demographic information about teens in the community, as well as important "teen places" that were associated with substance nonuse and use (refer to Figure 2 for one hypothetical map of "teen places" with comments from CPRT members). The data used to create these maps was collected during monthly CPRT meetings held in the county and semi-structured interviews conducted by teams of CPRT members with community leaders, youths, and parents. Interview questions were developed by the CPRT to obtain community assessment data, and identify assets and needs. Public health nurses can use GIS mapping to visualize and analyze assessment data more effectively.

Figure 2.

Map of "Teen Places" and Factors Related to Youth Substance Nonuse and Use

Photovoice is another method public health nurses can use in the community assessment process. The CPRT utilized the Photovoice method as part of their community assessment and in response to semi-structured interview questions about their rural county. Five youths received instructions to take pictures as a visual means of answering the community assessment questions. Subsequently, their pictures were displayed on "picture boards" according to the five community assessment domains, i.e., people and history, physical environment, idea systems, social systems, and belief systems, and used to facilitate discussion during group interviews with youths and parents. These "picture boards" were displayed at the end of the youth and parent group interviews to enhance each group's description of youth substance nonuse- and use-related factors in their community.

Analysis to Date

During the timeframe that the community assessment was conducted, the CPRT used nominal group process to analyze and select six relevant effectiveness criteria for a youth substance use prevention program in their rural county. These criteria were selected from ten established criteria on substance use prevention (Winters, Fawkes, Fahnhorse, Botzet, & August, 2007). The CPRT then examined three existing substance use prevention programs with effectiveness data to assess whether they met these criteria. Selection of a prevention program that meets the chosen effectiveness criteria and fits with the ecological context and culture of their rural community is a challenging process. It is ongoing at this time and involves consideration of multi-level factors identified in the community assessment process including culture, economics, politics, and psychosocial concerns related to youth substance nonuse and use.

Although the CBPR process is challenging, the resulting local knowledge and understanding of the unique characteristics of this rural county are providing direction in the selection of a program. For example, preliminary decisions made by the CPRT include: (1) the target population for the prevention program will be middle school-aged adolescents; (2) the most feasible and desirable setting for a prevention program is the summer 4-H youth camp held in the county; and, (3) high school students, 4-H camp counselors, may be the best "instructors" for the prevention program.

This exemplar demonstrates the need for specialized knowledge, competencies, and skills utilized by public health nurses to successfully carry out complex assessments and interventions in communities. Emphasis on essential knowledge and skills in core PHN competencies and education helps to ensure that public health nurses are prepared to move their nursing practice into the future as leaders in community participatory health promotion and prevention.