For those with existing disabilities, assuring ease of
access to all manner of recreation and exercise options is of
paramount importance. For those who may develop disabili-
ties or chronic illnesses, having the opportunities for healthy
participation in physical activity may forestall or prevent the
development of illness. For the community, having an envi-
ronment that promotes rather than restricts a healthy lifestyle
can be economically advantageous. Even schools have a role
to play (CDC, 2008a). Building new schools away from res-
idential areas decreases opportunities for exercise and after-
school activities. As parents are increasingly forced to drive
their children to school, the children remain sedentary, the
pollution from cars is increased, and the risk of automobile
accidents increases. Community design is a complicated and
evolving issue, but the point remains: a healthier population
may be achieved with attention to the environmental barriers
that impede healthy lifestyles for all persons.
This chapter has discussed a number of areas in which the
community health nurse plays a key role. It is important to
review those roles in the context of the individual, the fam-
ily, and the community as prime areas for nursing interven-
that the professional nurse takes on within the community. It
is helpful to review those roles and think about their appli-
cation to disabled and chronically ill clients, their families,
and the communities in which they live.
examples of the roles that community health nurses assume
in relation to disabilities and chronic illnesses. Take note of
each role that you participate in or observe while complet-
the various roles at each level, perhaps you can interview a
community health nurse during your clinical experience and
find examples of how she performs activities in each of
single issue with a client, the community health nurse serves
in a variety of roles and at different levels.
Consider as an example of the variety of roles and mul-
tilevel practice that the community health nurse assumes
with respect to a 55-year-old female client who uses a
examination because of the lack of accessible examination
tables at the local clinic; as a result, she has not had an
examination for more than 20 years. Recognizing the need
for a complete examination, the community health nurse
will aid the client in receiving the needed examination, pos-
sibly by ensuring that additional personnel are provided
Because this solution is temporary and less than optimal,
the nurse contacts a number of clinics in neighboring com-
nation table. Unfortunately, this clinic is 1 hour away. The
nurse then contacts a number of other community health
of women clients with this problem who have not received a
Community Level).
Through a coordinated effort with a local transporta-
tion company and the clinic, the nurse is able to arrange a
twice-yearly gynecologic screening program for the women
in the community who require special accommodations
Information sheets that discuss the need for annual gyneco-
logic examinations and advertise the program are distributed
to area public health nurses, employers, and health clinics
examinations provided over the next few years shows a 65%
increase in the number of women with special needs who
have received a gynecologic examination within the past
 This is not an uncommon scenario in the practice of
community health nursing. Often, the needs of an individual
open the door to areas of concern for many in a community
population.
Like nursing practice in general, the role of the com-
munity health nurse with respect to disabilities and chronic
illness requires broad and holistic practice. The complexity
of issues surrounding these conditions requires creativity,
tenacity, honesty, and, most of all, knowledge. Community
health nurses who are informed about the issues that affect
the disabled and chronically ill at local, state, and national
levels are prepared to offer assistance to their clients and to
their communities. Knowledge of civil rights for these indi-
viduals is crucial in serving as advocates.
The issues facing individuals and families with disabil-
ities require strong and sustained efforts to achieve results.
Although successes at the individual level are laudable, the
extent to which the health and well-being of those affected
is improved must be the ultimate goal. Community health
nursing is in a prime position to initiate and support efforts
to improve the health status of those populations. We can
either leave the issues to other professionals or use our
expertise and long history of caring for those less fortunate
to make major and lasting changes. It is up to us.
The issue of disability and chronic illness is of growing
importance in community health, both nationally and inter-
nationally. Through the efforts of the WHO, the interna-
tional community has been challenged to provide increased
attention to health promotion and disease prevention. Even
in less developed countries, behavioral patterns linked to
excesses in consumption (overweight and tobacco/alcohol
use) have an impact on the quality and quantity of healthy
years of life. The ICF provides a universal classification
system that standardizes language and takes into account
the biopsychosocial realms in health assessment and well-
being of disabled persons. Along with the World Health
Report 2002, this document now places the emphasis
squarely on prevention of disease and disability. This
means, of course, that the health promotion and disease pre-
vention needs of the disabled and chronically ill must be
given the same emphasis as the needs of those who are not
disabled or ill.
The aging of the U.S. population and the rise in
lifestyle-related illnesses such as diabetes and obesity are
often linked with increasing rates of disability. Prevention of
disability and disease is emphasized in Healthy People
2010, which serves as a wake-up call to Americans about the
need to give serious attention to health promoting and dis-
ease prevention activities. In this current edition of Healthy
People, unique emphasis is placed on health promotion and
disease prevention needs of those with disabilities and
chronic illness. It is no longer acceptable that these individ-
uals be treated solely for tertiary health needs. Research has
shown that when health promoting (lifestyle) issues are
addressed with these clients, the rates of secondary condi-
tions are reduced, including medical, social, emotional,
mental, family, and community problems. Like the ICF,
Healthy People 2010 takes the position that disability and
chronic conditions are not universally debilitating and that
the overall well-being and health of these individuals must
be a priority.
Legislation is but one step toward equality for those
affected by disabilities and chronic illnesses. The ADA has
legal protections for the disabled, but it is only the beginning.
Discrimination can occur at many levels; some is hurtful and
intentional, but most results from misunderstanding of the
needs and desires of disabled persons and their families. This
may even occur in relation to the provision of health care
because of lack of education. Improvement can be found only
with increased community education programs for profes-
sionals and the public that target the myths and misunder-
standings about those with disabilities and chronic illnesses.
Community health nurses are in a prime position to
advocate for the health needs of the disabled and chronically
ill. With a long history of serving those who are most vulner-
able, community health nurses can help make needed changes
at the individual, family, and community levels. Although it is
often easier to focus on the needs of the individual, those
needs are most often shared by many others. Nurses have long
recognized the need to collaborate with other professionals in
reaching the goal of improved health care for their clients; this
continues to be an important aspect of successful efforts on
behalf of the disabled and the chronically ill. It will take the
concerted efforts of many to implement the changes neces-
sary to improve the lives of those most affected, their families,
and the communities in which they live.
unusually heavy or struggle to open the lid of a jar or feel
that you were treated differently than someone else in the
receipt of services, take a moment to think. Think about the
challenges, struggles, and pain that face so many citizens.
Consider the impact of universal design at improving your
life or the life of a family member or friend. Although many
argue against improving accessibility of city streets and
sidewalks because of the expense, those same people may
curb that is just a bit too high.
1. Arrange to interview an individual with a disability
(e.g., hearing, vision, mobility) about the challenges
that he has faced in interactions with nondisabled
persons.
2. Visit some of the nongovernmental sites listed
under Internet Resources and read some of the per-
sonal stories that are included.
3. Take an inventory of your house or apartment and
chair. Would you even be able to stay in your cur-
rent residence?
4. As part of your regular clinical assignment in com-
munity health nursing, look at those clients and
families who are dealing with either a disability or

chronic illness and assess how often you or other
community health nurses have addressed health
promotion activities (e.g., healthy eating, physical
activity, leisure-time activities) with those clients.
5. Review your family history for chronic health con-
ditions. Are you at risk? If so, what have you done
to reduce your risk over the past 12 months?
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 chapter describes the role behavioral health plays in
the overall health of a community and provides an overview
of behavioral health prevention and treatment from the per-
spective of community health nursing practice with a focus
on community level interventions. The following questions
should be kept in mind while reading about the issues sur-
rounding behavioral health: in what sense does behavioral
health relate to the health of communities? What are the
global implications related to an increase in mental health-
related diagnoses and risky-to-dependent substance use?
What is the role of a community health nurse in helping
individuals, families, and communities to promote optimal
mental health and responsible substance use and thereby
decrease the prevalence and incidence of mental and sub-
stance use disorders (SUDs)?
Several terms that are useful for community health nurses
working in the behavioral and mental health fields are
An individual
whose practice is centered on the mental health
needs of the populations served.
that seeks to promote the mental health of the com-
munity by preventing mental illness and addressing
the needs of the mentally ill.
Facilities that provide comprehensive, publicly
funded services to the mentally ill population.
The collective
programs designed for anyone with a mental illness.
These programs may include treatments, services, or
other types of supports, such as housing,
Healthy People 2010,
relationships, and the ability to adapt to change and
and Human Services [USDHHS], 2000, p. 37).
able mental disorders [which] are health conditions
that are characterized by alterations in thinking,
mood, or behavior (or some combination thereof)
associated with distress and/or impaired function-
or pattern that occurs in a person and that is associ-
ated with present distress (e.g., a painful symptom)
or disability (i.e., impairment in one or more
important areas of functioning), or with a
pain, disability, or an important loss of
freedom . . . and is not merely an expectable and
culturally sanctioned response to a particular event
Mental illness that
and his or her quality of life is known as SMI.
is
the preferred term for serious mental illness of a
chronic nature. For example, schizophrenia is usu-
A complex neuro biobehavioral disor-
der characterized by impaired control, compulsive
use, dependency, and craving for the activity, sub-
stance, or food. Relapses are possible even after
long periods of abstinence (Armstrong,
Feigenbaum, Savage, & Vourakis, 2006; National
Institute on Drug Abuse [NIDA], 2004a).
The spectrum of disor-
ders that include substance abuse and dependence
and are attributed to problematic consumption or
illicit use of alcohol, tobacco, illicit, and legal
drugs (Armstrong et al., 2006).
(National Institute on Alco-
hol Abuse and Alcoholism [NIAAA], 2007):
Abstinence: Consumption of fewer than four stan-
dard drinks per year.
Low-risk drinking: Low-level alcohol use that is
not problematic (see below).
Risky/hazardous use: Pattern of alcohol consump-
tion that increases the risk of harmful
consequences for the user or others.
Harmful use: Alcohol consumption that results in
consequences to physical and mental health.
Alcoholism:
disease that includes four symptoms: craving, loss
of control, physical dependence, and tolerance.
An adaptive physiological state that
includes craving, loss of control, physical depend-
ence, and usually tolerance (NIAAA, 2007; NIDA,
2004a).
A mechanism used to evaluate the pres-
ence of substance use problems and to estimate the
tools, such as questionnaires (NIAAA, 2007).
amounts of alcohol or drug to achieve intoxication
or the desired effect or a markedly diminished
effect with the continued use of the same amount
of alcohol or drug (Armstrong et al., 2006).
Return to heavy alcohol, tobacco, or drug
use after a period of abstinence or moderate use
(NIAAA, 2007).
The advances in research today and evolving best evidence-
based practice models of mental health care are gaining
ground across the world in various mental health centers of
excellence. At the same time, numerous centers provide care
with declining resources such that services are compromised.
The science on brain structure functions and how learning
occurs over time has impacted mental health services by
expanding the possibilities of available therapies. Today,