Community-based health care is an increasingly important concept in contemporary society. As the American population ages and diversifies, connotations of health are becoming broader and more specific at the same time. Individuals' lives are extended, society is more complex, and health includes the prevention of illness and a mosaic of beliefs and practices. 

Responding to these changing times, health care professionals are increasingly reaching out to communities to support long-term health and well-being for individuals, families, and populations of varying cultural backgrounds. These professionals are challenged to provide a range of services and to meet a variety of health care needs. The extent to which they are successful often depends on their appreciation of a community's values. 

Health care is not solely the domain of a local hospital. Social movements and changes in practice and in payment mechanisms have altered the landscape of health care in America forever. Today, health care providers attend to their clients' needs in clinics, nursing homes, retirement centers, rehabilitation facilities, managed care organizations, churches, schools, the workplace, and other settings. Providers also interact with informal health care networks in the community, including extended families, support groups, and lay caregivers. 

Changes in the American population and in the structure of health care generate a renewed interest in communities their diversity, complexity, and boundaries. The role of communities in health care is being explored and offers many opportunities for research. 

To consider these opportunities, the National Institute of Nursing Research convened a Priority Expert Panel on Community-Based Health Care: Nursing Strategies. This panel met in December 1993 and developed its report and recommendations over the next one and a half years. The panel reviewed the state of the science, identified research needs and opportunities, and delineated recommendations for research. 

This summary of the panel's report describes the panel's perspective, the organization of the report, research progress, broad research goals, research needs and opportunities, and implementation of the Institute's priorities. The summary concludes with a list of the recommendations presented in the full report. 

The Panel's Perspective 

Community-based health care is a complex subject. As defined by the panel, it includes several key concepts. These concepts served to organize the panel's deliberations and to provide a framework for the panel's recommendations. 

First, the panel emphasizes the concept of community as multifaceted. That is, communities can be schools, churches, worksites, prisons, villages, towns, counties, or urban centers. Within these communities, both individuals and family networks are important. Community may be alternately the focal unit of health care as well as the location of services. 

Second, special attention is given to the health care needs of community groups that are vulnerable and underserved. Major populations with vulnerable and underserved groups include low-income individuals and families, ethnic and racial minorities, workers, frail elderly, and middle-aged or elderly caregivers. In its report, the panel focuses on two major population segments: all rural populations and underserved, urban populations. 

Third, the panel views community-based health care as embracing the concept of primary health care an integrated approach to providing primary, secondary, and tertiary prevention services across a continuum of care. This approach incorporates health promotion and disease prevention, screening and early detection, and supportive and restorative care (Leavell & Clark, 1965). It involves coordination between formal and informal care providers and provision of chronic illness care as well as transition care. This conceptualization of primary health care builds on the public health care model of prevention and is consistent with other current and proposed definitions (Abramson & Kark, 1983; Institute of Medicine, 1978, 1994; Starf ield, 1992). 

Fourth, community-based care, as defined by the panel, requires active involvement of clients and communities in assessing the need for care, designing service programs, implementing interventions, and evaluating outcomes. Community-based care is thus founded on partnerships between consumers and providers of care. Every attempt is made through these partnerships to develop and promote services that are both sensitive and relevant to the cultures and mores of the individuals, families, populations, and communities to which care is directed. 

This notion of community-based care represents a paradigm shift from traditional health care approaches which focus on one-on-one interactions between a health care provider and a client or patient. These interactions are expanded not only in each direction to include other providers as well as a client's family and community, but also across the spectrum of care to include a full continuum of services from primary through tertiary care. One-on-one interactions occur within this framework, but are enclosed by an integrated system of care. 

Fifth, the panel was asked to address specifically nursing strategies and multidisciplinary interventions that include nursing. To achieve effective community-based health care, interdisciplinary approaches are needed that combine the skills, talents, and experiences of a wide range of health care providers. Nurses are in positions where they can play a critical role in managing, coordinating, training persons for, and guiding these cooperative efforts. They already provide liaison between formal and informal systems of care and facilitate transition care. They are well placed to serve as brokers between community members and multidisciplinary health care teams. Advanced practice nurses, herein defined as all registered nurses with a master's degree in nursing, are particularly well prepared to fulfill these functions (American Nurses Association, 1993). 

Finally, it should be noted that this report addresses research opportunities. While it is expected that research outcomes will yield useful guidance and tools for practice, the goal of all NINR Priority Expert Panels is to develop recommendations for research. These research recommendations are directed to the broad biomedical and behavioral research community, and it is hoped that nurse researchers and other scientists will respond to the opportunities presented. 

Organization of Report 

This Priority Expert Panel Report on Community-Based Health Care: Nursing Strategies comprises three chapters: 

• Chapter 1. Community-Based Care: Concepts and Definitions 
• Chapter 2. Rural America: Challenges and Opportunities 
• Chapter 3. Urban Populations: Needs and Directions. 

In the introductory chapter, the panel defines the concepts of primary health care and community-based health care. Describing a rural/urban continuum, the panel also defines the concepts of rural and urban adopted for this report. 

In the next two chapters, the panel focuses separately on rural and on underserved, urban populations. These chapters are organized into four parts: an overview of health status and health care needs, a review of the state of the science, identification of research needs and opportunities, and research recommendations. A reference list concludes each chapter. 

Although organized in similar fashion, the chapters diverge importantly in their orientation. In chapter 2 on rural America, the focus is on broad, community-based health care strategies for all populations within rural settings. Accordingly, the text addresses challenges that are faced in delivering care to all populations and the different dimensions of primary, secondary, and tertiary prevention. In chapter 3 on urban populations, the focus is on community-based strategies for specific vulnerable and underserved populations: low-income individuals and families, ethnic and racial minorities, urban elderly, and urban workers. The state of the science is addressed with respect to each of these populations, and research needs and opportunities are presented for all under- served, urban populations. 

Two populations that are clearly vulnerable but not addressed specifically in this report are homeless persons and the mentally ill. The research literature on homeless persons is sparse, not allowing for a detailed review of community-based health care needs, and major research programs are already under way for mentally ill persons. 

The difference in chapters 2 and 3 reflects the orientation of research studies and programs directed to the health of rural and of underserved, urban populations. Rural programs are generally organized and funded according to level of care, whereas urban programs are generally targeted to categorically defined population groups. In order to best assess the state of the science, the panel elected to organize and present its review accordingly. 

This review is not intended to be exhaustive, but rather to illustrate the state of the science pertaining to community-based health care for rural and underserved, urban populations. Similarly, the panel relates a number of existing models or strategies of care. These are not all the models or strategies available; they are cited only as examples of community-based interventions that have been completed or are under way. 

Research Progress 

Progress has been made in understanding the challenges of community-based health care, the similarities and differences among rural and urban settings, and the health status and needs of rural and urban populations. In response to the health needs of specific populations, various community-based intervention models are being developed, tested, or implemented. 

Challenges for Community-Based Health Care

Community-based health care strategies must respond to at least six challenges. These strategies must assure that a broad range of services are available, accessible, affordable, appropriate, adequate, and acceptable for the many diverse client groups present in a community (Krout, 1986, 1994). These six challenges relate to both the provision and receipt of care in that they must be addressed from two different perspectives those of providers and recipients of care. These perspectives may differ substantially. 

Also, in order for care to be truly available, accessible, affordable, appropriate, adequate, and acceptable, it must be culturally sensitive and culturally relevant to those receiving care. The sensitivity and relevance of care are critical aspects of the challenges to community-based care, all of which influence the utilization of services and health care outcomes. 

The six major challenges have been defined and described in the research literature, and they have been examined in various studies. They form the basis for the panel's review and recommendations in this report. 

Rural and Urban Settings: Similarities and Differences 

Although some understanding has been gained of the differences and similarities between rural and urban areas, the panel notes that no concise and universally held definitions of urban and rural exist and that the definitions commonly used do not adequately reflect the differences between these areas and the groups residing in them (Coward, McLaughlin, Duncan, & Bull, 1994). Standard, appropriate, and consistently used definitions are sorely needed. 

For this report, the panel considers urban and rural to be anchors on two ends of a continuum regarding place of residence. Urban and rural points along this continuum are differentiated according to total number of persons living in a geographic area, distance of a place from a larger metropolitan service area, and density of the population dispersion (Coward et al., 1994). In this report, "rural" includes towns and open country with small or widely dispersed populations remote from large, metropolitan cities; it does not include suburbs or small cities close to large urban areas. 

Both rural and urban areas are characterized by diversity heterogeneous populations and wide-ranging health care needs. This diversity is found not only across rural or urban areas, but also within rural and urban communities. In both areas, certain populations have an increased need for community-based services: low-income individuals and families, especially women and children; ethnic and racial minorities; workers; and elderly persons. The social conditions that often affect health (e.g., poverty, low income, low education level, violence, crime, drug abuse) are also similar and increasingly common to both areas. They may, however, be expressed in different ways within different communities. 

Distinctions between rural and urban populations arise in their perception of health and illness, specific health needs, health beliefs, and health practices. For example, rural populations tend to associate health with the ability to work and thus may not seek care for illnesses or diseases as long as a person can work (Lee, 1989; Ross, 1982; Weinert & Long, 1987). Urban populations may not make similar associations. Certain populations or communities may be placed at risk when such perceptions and beliefs are combined with obvious health needs. 

In rural settings, these distinctions are compounded by reduced availability of and accessibility to health care services. Rural health care services are generally less available than in urban environments because of the dearth of providers located in rural areas, and the services that exist may be less accessible than in urban areas because of greater distances, geography, and climate. 

Health care strategies are needed which respond to the similarities of rural and urban communities while accommodating all the differences between and within these communities. A "top-down" approach that lacks the flexibility to meet the diverse health needs of different populations is neither suitable nor effective. 

Rural and Urban Populations: Health Status and Needs 

The overall health status and needs of rural and urban populations have been well described in the research literature and documented in descriptive epidemiological studies and policy reports. It is known, for example, that rural populations, in comparison with urban populations, experience greater morbidity and have higher crude rates of mortality and higher rates of chronic illness (Office of Technology Assessment [OTA], 1990; Schneider & Greenberg, 1992; Yawn, Bushy, & Yawn, 1994). Farming has one of the highest work-related injuries and death rates among all occupations in the United States (Pratt, 1990), and rural populations have significantly greater rates of death from accidents. 

Rural populations also have poorer health among elders (Coward et al., 1994) and higher rates of infant mortality among some populations (Shotland, Loonin, & Haas, 1988). These and other health problems are exacerbated by rural populations' higher rates of poverty and low education levels (Coward et al., 1994; Rural Sociological Society Task Force on Persistent Rural Poverty, 1993) and their consumption of (i.e., access to) fewer health care services and resources (National Center for Health Statistics, 1989; OTA, 1990). 

Certain populations are particularly at risk of illness and disease. In rural areas, for example, these populations include persons who reside in persistently low-income or frontier counties and persons who are at greater risk of poor health (e.g., those who have high levels of need, low levels of service, are poor or impaired) (Beaulieu, 1988; Rowland & Lyons, 1989). In both rural and urban areas, two groups that require special attention are older and middle-aged adults who have chronic illness and/or disability, are poor, and lack sufficient insurance coverage. Also, the incidence of leading causes of death chronic disease, cancer, cerebrovascular disease, chronic pulmonary disease, and accidents is considered greater among populations at special risk than among those who are not at risk and are better served by the health care system. 

In addition, both rural and urban populations subscribe to behavior patterns that contribute to more than 50 percent of U.S. deaths each year (McGinnis & Foege, 1993). These risky behaviors include tobacco use, unhealthy diet, physical inactivity, alcohol use, exposure to microbial and toxic agents, firearm use, unprotected sexual intercourse, motor vehicle accidents, and illicit drug use. The devastating combination of poverty, behavior, and insufficient access to health care is well evident in the AIDS crisis affecting major metropolitan areas in the United States and elsewhere. 

Intervention Models 

In both rural and urban settings, investigators have examined multiple variables and have applied multiple health care strategies in response to identified needs. However, few comprehensive, community-based interventions have been described in the research literature. Most community-based strategies that have been implemented are not comprehensive and have not been tested rigorously or replicated in other populations or communities. Many do not involve the full participation of and partnership with community residents. Neither do they offer integrated, coordinat- ed health care across the prevention spectrum. 

In rural settings, health care delivery has been focused on entire communities, with little regard for population differences within these communities. Because of categorical funding streams, interventions have been targeted largely to specific health problems in a community. Little attempt has been made to design or implement broad-based interventions or to compare variables and test strategies across populations and/or communities. In general, the research base is scarce and replicated studies are few, given that rural health is studied less often than urban health. 

In urban settings, community-based strategies that incorporate some of the features identified by the panel have been implemented through public health departments, categorical programs targeted at specific populations or health problems, community health centers, community nursing centers, and case management services. Some of the benefits of these strategies are being documented, and a broad-scale evaluation is being conducted by Federal agencies. Existing outcome studies, however, are severely limited with respect to conceptual design, analytical features, and generalizability. Rigorous longitudinal and comparative studies have not been reported. In addition, community-based programs are categorical and tend to focus on specific problems and/or populations. These programs are not comprehensive and do not address the multiple health care needs of diverse populations within or across communities. 

Notwithstanding these limitations, some intervention strategies have been implemented and are available for further testing and adaptation. The state of the science regarding these rural and urban strategies is summarized below. 

Rural Strategies 

Health care practices and research in rural areas generally subdivide into two main parts of the prevention spectrum: primary and secondary prevention, and tertiary prevention. Program goals, types of interventions, outcomes, and funding with respect to these two parts are different. Although long-term care and tertiary prevention have been emphasized in public programs and resources (e.g., Medicare, Medicaid), relatively little attention has been given to primary and secondary prevention. 

Primary and Secondary Prevention. In rural areas, three health care problems dominate this part of the prevention spectrum: maternal and child health, including infant mortality; unintentional injuries; and behavioral contributors to mortality (National Association of Community Health Centers & National Rural Health Association, 1988, 1989; McGinnis & Foege, 1993). These three areas also serve as key areas of research. Interventions are available in each area for study and application. Primary and secondary prevention strategies also cut across these key areas. 

Studies include NINR support of several community-based strategies emphasizing community involvement and cultural sensitivity and relevance. Nurse researchers are the principal or primary investigators in these studies. Several assessment models also have been used successfully by nurses and nurse researchers as a basis for community interventions in primary and secondary prevention. 

Additional primary and secondary prevention strategies have been used to intervene in specific health problems. These applications have been shown to be effective in the sites studied and could be adapted for community-based interventions in other problems and/or populations in both rural and urban settings. 

Tertiary Prevention. Supportive and restorative care is a necessary component of community-based health care in rural settings. These services are provided increasingly in community-based settings such as homes, rehabilitation centers, community health clinics, and primary care centers. Integration of services is a growing trend, and formal care providers are working together to meet identified needs. 

Research on and models of tertiary prevention for rural populations, however, are limited. Little systematic research has been conducted on supportive and restorative care, and much of the literature is not specific to rural communities. In addition, although supportive and restorative care can be expected to have a significant impact on the health of rural communities, few rigorous studies document the outcomes of this care. Nursing research is particularly lacking. 

Among health care needs and key areas of research, two topics dominate: chronic illness, and formal and informal support. Researchers focusing on chronic illness largely attend to two age groups: older adults and middlescent, or middle-aged, adults. Rural nursing research on tertiary prevention for older adults is very limited and does not serve to guide nursing practice (Weinert & Burman, 1994). However, the health care needs of frail or chronically ill rural elders have been described by other researchers and reported in a previous NINR report, Long-Term Care for Older Adults: A Report of the NINR Priority Expert Panel on Long-Term Care (National Institutes of Health, 1994). The panel encourages testing and application of the community-based strategies and interventions presented in this report. 

Chronic illness among rural middlescent adults has received less attention and findings are conflicting. Community-based health care strategies can help resolve the problems that have been identified and should be combined with more comprehensive solutions that also address the poverty, harsh economic conditions, and lack of health insurance found in rural areas. 

The need for transition care presents an even greater problem for rural residents with chronic illness and/or disability. Yet, research on the effectiveness of discharge planning protocols and other aspects of transition care is lacking. Appropriate, cost-effective, and coordinated transition care services also have not been documented in the literature. Interdisciplinary intervention strategies to ensure smooth health care transitions need to be developed and tested. 

Several nurse researchers have addressed the coordination of formal and informal support in community-based research studies, and family caregiving as an informal source of care has been emphasized in the literature. Although nurses involved in community-based strategies play an important role in delivering services and support to family caregivers, few nursing intervention models involving family or community caregivers have been described or assessed in terms of their effectiveness. Specific factors affecting family caregiving in rural settings also have not been studied. 

Existing community-based strategies in tertiary prevention which involve nurse researchers are a first step toward developing and testing comprehensive interventions that include community participation, coordinated services, integration of formal and informal sources of support, and response to multiple health needs. Other interventions, designed for primary and secondary prevention, also may be applicable to tertiary prevention. 

Nursing case management, sometimes referred to as care management or care coordination, also could serve as an effective strategy for linking fragmented health services for individuals with chronic illness in rural settings. Empirical studies of the use of this strategy in rural communities are few, and its effectiveness as a model for tertiary prevention is not evident. 

Urban Strategies

In practice and research, intervention programs for vulnerable, under- served urban populations are largely defined by diagnostic categories (e.g., asthma prevention, prenatal care, hypertension control), reflecting the funding of these programs. Community-based health care strategies are often initiated in response to a single problem or the health needs of a particular age group or population. Similarly, outcomes are generally measured in terms of one dimension only (e.g., birth outcome). The status of intervention models for four population categories is exemplified below. 

Low-Income Individuals and Families. Community-based strategies designed to address the multiple health care needs of low-income families, including men, women, and children, are lacking. Low-income women are often served by a number of categorical programs or programs pieced together from different funding sources. Comprehensive, integrated programs that address the overall health of these women across a continuum of care are lacking. The research that has been conducted is broad, unfocused, and largely descriptive. Nursing interventions are few. 

Areas in which some practice and research have been conducted and which deserve increased attention are: development across the life cycle; health promotion and maintenance; health care delivery; reproductive health; physical diseases and health problems; mental health and illness; and economics, ethics, policy, and legislation (McElmurry & Parker, 1993). With regard to the health problems of children and youth, policy makers and child health researchers continue to argue strongly for effective interventions. Yet, as with other groups, these programs continue to be targeted to single problems or age groups. 

Some exciting research has been conducted recently which has applicability to community-based interventions. These studies are focused on defining target communities, encouraging collaboration between health care providers and lay workers, and incorporating cultural attitudes and practices of ethnic populations. Contributing to these efforts, the NINR is supporting a community-based program to improve pregnancy outcomes and infant development among urban minority women, as well as several promising interventions to promote health and prevent disease among urban youth. 

Ethnic and Racial Minorities. Ethnicity and race are added risk factors that, in association with low income, complicate the health problems and health care needs of underserved, vulnerable populations. Three minority groups are specifically addressed by the panel: African Americans, Asian and Pacific Islander Americans, and Latinos. Research conducted with these groups has contributed to an understanding of the difficulties faced in defining minority populations and an appreciation of the health status of minority populations and their use of health care services. This research also has demonstrated the importance of recognizing that, within the major minority groups, are multiple ethnic communities, each of which has its own social and cultural patterns that influence the health behaviors and practices in these communities. 

Among African Americans, community-based health care strategies have proven to be successful in bridging gaps in the health care system. Numerous reports by nurses and other professionals have described effective interventions focused on specific problems, such as infant mortality and low birthweight, cancer prevention and early detection, AIDS education, substance abuse, and coronary heart disease. Also highlighted in the literature are strategies that have engaged institutions within and peripheral to the community and interventions that have involved persons indigenous to the community. Comprehensive community-based strategies addressing multiple health care problems and the continuum of care are needed, as are comparative studies and measures of effectiveness. 

Among Asian and Pacific Islander Americans (APIAs), few studies have assessed or tested health-related intervention programs or community-based health care strategies. A major difficulty is the dearth of information on potential or real health problems of these populations and the inadequacy of programs for meeting the health care needs of APIAs (Guillermo, 1993). The NINR is supporting several community-based interventions for tuberculosis, a major problem among APIAs. 

For Latinos, data on the impact, efficacy, and cost effectiveness of established or innovative health services are limited. However, community-based interventions have been shown to be successful and may decrease the cost of care when they include members of the community and culturally sensitive health professionals (Mahon, McFarlane, & Golden, 1991; Milburn, 1993). 

In summary, the limited data on comprehensive, community-based strategies for ethnic and racial minority groups suggest that broad-based, community approaches can be effective, as measured by different variables, including cost and patient outcome. Care must be culturally relevant and sensitive, and community involvement is essential. 

Urban Elderly. A variety of intervention strategies have been directed toward elderly persons residing in urban areas. These include primary and secondary prevention strategies aimed at improving exercise levels, reducing functional dependence, promoting smoking cessation, and screening for and preventing disease. Knowledge of the benefits of these strategies has been accumulated and needs to be incorporated into more comprehensive, community-based health care interventions. Many of these strategies may be applicable to rural areas and other populations. 

With regard to tertiary prevention, several comprehensive strategies for older adults have been implemented and evaluated, many in urban settings. Specific attention has been paid to the accessibility, appropriateness, and adequacy of services, but less attention has been given to the acceptability of these services to urban elderly. Differences in implementation and outcomes between urban and rural settings also have received little attention. Although the completed studies have yielded mixed results in terms of outcomes, they suggest that there is both a demand and unmet need for comprehensive, integrated strategies of supportive and restorative care. 

In addition to the more comprehensive strategies, some community programs have addressed specific needs for tertiary care among vulnerable older adults (e.g., transitional care, long-term monitoring of chronic illness, assistance with activities of daily living, respite care, and support for caregivers). In an NINR-supported study and other nursing-centered models, nurses play a pivotal role. Many of the interventions include supportive and restorative care and most have been implemented in urban settings. Additional research, however, is needed to clarify and compare outcomes among the studies. 

Urban Workers. Workplaces offer convenience and accessibility for primary health care delivery as well as opportunities for monitoring outcomes of care (Burgel, 1992). Within these settings, occupational health nurses provide an array of comprehensive health and safety services for workers and their families (American Association of Occupational Health Nurses, 1993). The nature of primary, secondary, and tertiary prevention interventions in the workplace has been described; surveys of these programs have been conducted; and efforts have been made to determine the health and cost out- comes of these services. 

Most of the research on prevention strategies in the workplace, however, has been descriptive and documents individual programs rather than comprehensive, integrated strategies across the continuum of care. A few examples linking primary, secondary, and tertiary services have been described, but most programs are fragmented and uncoordinated. 

Nurse-managed primary health care delivery models at or near worksites have been proposed as a strategy for meeting the needs of a changing American workforce (Burgel, 1992). Such strategies could deliver accessible, quality care to employees and their dependents at a reasonable cost. 

Broad Research Goals

Based on a review of research progress and the state of the science in community-based health care, the panel sets forth five broad research goals for the next decade. These goals are as follows: 

• Develop and test comprehensive, innovative, community-based health care strategies designed to meet the health needs of individuals, families, and groups in rural and underserved, urban communities. 
• Assure that these strategies involve full community participation and are culturally sensitive and culturally relevant to the populations and communities served. 
• Assess the usefulness of existing data on the health status and needs of diverse populations, obtaining additional data as needed, including relevant socioeconomic factors that affect health and wellness. 
• Define the applicability of new and existing intervention models and strategies for different populations, problems, and settings. 
• Establish and apply meaningful measures for assessing the clinical and cost effectiveness of new and existing interventions. 

These goals and other research needs and opportunities are discussed below. 

Research Needs and Opportunities 

As noted above, researchers have made considerable progress in elucidating the variables involved in designing and implementing effective health care strategies. Separate studies have shown that active community involvement is a critical part of assessing health care needs and designing and implementing intervention programs. The health status and problems that have been documented for diverse populations, varying in ethnicity and age, demonstrate the need for coordinated care across the spectrum of primary, secondary, and tertiary prevention. The multiplicity and complexity of these problems have been compounded by socioeconomic conditions and emphasize the need for comprehensive, integrated approaches to health care in which all providers cooperate and share information with each other and with individual clients and families. 

Additional studies have shown that health care must be culturally relevant and sensitive in order to be appropriate, adequate, and acceptable to those receiving care. Models of intervention that incorporate some or all of these variables have been proposed and tested among rural and urban populations, and the effectiveness of certain models and strategies has been assessed in terms of selected outcome measures. 

The challenge ahead is to confront broader issues of applicability and effectiveness. Interventions that have been applied need to be tested in different settings and with different populations to establish replicability and generalizability. For example, interventions shown to be effective for rural populations could be adapted for urban residents and those shown to be effective for one minority group could be adapted for another group. Interventions that have been applied also need to be tested across all levels of intervention (primary, secondary, and tertiary) and among all clients (individuals, families, communities). For example, a culturally sensitive health promotion strategy found to be effective for a minority group also may be applicable to tertiary care, and an immunization strategy targeted to individuals could be expanded to entire families and communities. 

In addition, model components that have been tested need to be combined into comprehensive, community-based strategies for application in and across rural and urban communities. These strategies should be broadly applicable to community residents and specifically applicable to targeted vulnerable and underserved groups. Building on the knowledge gained thus far, it is also appropriate to undertake new comprehensive, community-based strategies. These would begin with well-designed community assessments that involve representative community members and incorporate outcome measures to be included in the intervention design. 

Specific intervention strategies need to be tested and/or developed to combat the major health problems suggested in this report. These key areas of research are maternal and child health, including infant mortality; unintentional injuries, including agricultural injuries, exposures to microbial and toxic agents, accidents resulting from motor vehicle use, and firearm injuries; behavioral contributors to mortality, including use of tobacco and alcohol, poor diet, physical inactivity, failure to take preventive action (e.g., immunization) against infectious agents, unprotected sexual intercourse, and illicit drug use; and chronic illness. 

The socioeconomic factors that affect health status (e.g., poverty, class, race, ethnicity, geographical location, insurance status, literacy, education, occupation, unemployment) should be addressed in the design, implementation, and assessment of these targeted intervention strategies. Other variables that influence availability, accessibility, and affordability of care for individuals, families, and communities also need to be considered (e.g., dearth of available health care providers; number, range, type, and frequency of health and social services offered; distance from and cost of services; available resources). Related contextual factors (e.g., family structure and function, community environment) are also important. 

New intervention strategies also must be appropriate, adequate, and acceptable. In this regard, attention to cultural factors and cultural diversity is paramount. Factors that may promote or impede utilization of health care services need to be considered (e.g., the language, health beliefs, and health practices of the population served; the cultural knowledge and experience of health care providers). These cultural factors need to be incorporated at all stages of an intervention, from the initial community assessment to planning and design, implementation, analysis, and outcome assessment. Specific intervention strategies also need to be tested and/or developed to combat the health care needs of individuals and families who are at particular risk of illness and disease. 

An area of health research that is particularly underdeveloped is assessment of the effectiveness of community-based interventions. In this regard, meaningful measures of the outcomes of health care services need to be identified, described, and documented. Examination of outcomes only in terms of utilization or cost is neither sufficient nor informative. Other measures both qualitative and quantitative need to be explored and tested (e.g., improved health status, quality of life, client satisfaction). After their validity, sensitivity, and reliability have been established, these measures need to be standardized and used consistently in order to enhance comparison and further assessment of study results. 

Although the research literature strongly supports the promise of comprehensive, community-based strategies, the extent of involvement and impact of a community's participation have not been rigorously addressed. Research is particularly needed on the factors that foster and maintain a community's "ownership" of the health care services offered. The influence of community participation on the outcome of community-based interventions also needs to be assessed and documented in multiple studies across communities, interventions, and clients. 

Innovative nursing-based strategies have much to offer in preventing disease and delivering care to multirisk, vulnerable populations. In many instances, nurses already are well placed in communities, serving individuals and families in a variety and range of settings (e.g., schools, medical offices, clinics, nursing homes, intermediate care facilities, retirement/extended care centers, public health departments, homes). Already acting as liaison between community members and other health care providers and institutions, advanced practice nurses have an opportunity to extend this role further into formal leadership and coordinating positions in community-based strategies. 

Nurse researchers, in association with community nurses, can foster assessment and evaluation of comprehensive, community-based health care strategies targeted to both individuals and communities. Nurse researchers can play an especially important role in primary prevention by assessing health education efforts to reduce risk factors. They can also contribute their unique perspective to the design and assessment of secondary prevention strategies such as health surveillance and screening. Tertiary prevention programs to which they can offer special insights include transition care management, rehabilitation, and case management. With respect to outcomes, there is a particular need for assessments of the effectiveness of different nursing interventions that address barriers to utilization across sites. 

Important to any study is the use of well-defined, accepted terminology. As noted in this report, the concepts of urban and rural need to be defined more precisely and these definitions need to be applied consistently by researchers and public and private organizations sponsoring or funding programs. In community-based health care interventions, the urban or rural nature of the population served must be defined consistently across studies. 

Similarly, a clear definition of low income and of vulnerability with respect to income and/or health is not available or used consistently. The ability to obtain research funds, compare study results, assess interventions, and make policy may be greatly jeopardized by this lack of definition. 

The complexity of racial and ethnic minority groups is consistently distorted in epidemiological and statistical surveys by the use of generic population terms (e.g., African American, Asian and Pacific Islander American, Latino) that do not take into account important social and cultural differences among subgroups. In order to design health care strategies aimed at improving health and preventing disease in and with the participation of communities, these differences are critical. The effectiveness of these strategies will depend largely on a complete understanding of the health status and needs and the health beliefs, practices, and behaviors of all groups within a community. Population data on minority subgroups will underpin this understanding. 

New measures of ethnic identity are available to allow researchers to discriminate individuals who identify with a particular subgroup or with multiple groups. These measures need to be applied more extensively and consistently. New, more refined measures of socioeconomic status and assimilation also are available and need to be applied consistently. 

For many populations, additional descriptive data are needed to clarify their health status, problems, and needs before appropriate and effective health care interventions can be designed. These data include information on potential and known risk factors, disease markers, and illness and treatment outcomes. Also needed are culturally sensitive categories for gathering detailed information on the health status of individuals and on changes in group membership (e.g., through birth, death, marriage, adoption, divorce, emigration, immigration, health insurance). From these basic descriptive data, researchers can determine the identifying characteristics for individuals and families within a community. 

Summary of Recommendations

In response to these research needs and opportunities, the panel has delineated specific recommendations for research. These recommendations, which appear at the end of chapters 2 and 3, reflect the panel's review of the state of the science and its projection of research needs and opportunities for nursing strategies in community-based health care. The recommendations are not listed in order of priority and may pertain equally to both rural and urban populations. Designed to serve as a guide for researchers, they capture some, but not all, of the promising avenues of nursing research in community-based health care. 

Rural America: Challenges and Opportunities

• Develop and test innovative community strategies, including public-private partnerships between existing health care organizations, nurses and other health professionals, and community residents, focused on primary, secondary, and tertiary prevention in rural communities. Rural strategies may be targeted at the individual, family, and community level or at larger population groups, rather than using categorical programs often designed for urban settings. 
• Assess the process and effects of various care management strategies (e.g., case management, parish nursing, telecommunications) designed to integrate supportive and restorative care and to coordinate transitions among health services. Identify and develop measures of outcomes that result from transitions and long-term care. 
• Develop new community-based nursing strategies in collaboration with individuals from the relevant communities and areas of expertise to ensure that the research process, research designs, and interventions are culturally appropriate and culturally relevant. 
• Determine the impact, effectiveness, and efficiency of culturally sensitive, community-based health care strategies targeted to vulnerable and underserved rural populations and groups. 
• Replicate, refine, and extend successful community-based health care strategies aimed at increasing accessibility, availability, appropriateness, acceptability, affordability, and adequacy of rural health services. 
• Describe, explore, and evaluate the interrelation among use of health promotion and prevention strategies, stress and coping capacity, and development and/or exacerbation of chronic illness and disability in rural residents who provide and coordinate care for older family members. 
• Explore the process and outcomes of living with chronic illness and disability, especially among middle-aged rural residents and their families. 
• Promote research that determines the influence of formal and informal health care systems on long-term outcomes of elders. Promote caregiving intervention studies that target interventions to both clients and caregivers, and assess the outcomes of these interventions for both clients and caregivers, particularly outcomes related to physical and mental health. 
• Determine the effectiveness of various advanced practice nursing roles with rural populations in health and illness. Test care management strategies that use advanced practice interventions to determine their effectiveness with respect to client outcomes and overall cost. 
• Examine ways in which tertiary prevention (supportive and restorative care) can be made more accessible to chronically ill rural persons living in isolated settings. 
• Develop and test the effects of home care strategies, discharge planning and case management strategies, use of technologies, and housing and supportive services on the maintenance of independence and functional ability. 
• Design innovative approaches using technology for nursing interventions, information systems, and assisting families in rural settings, especially frontier settings, in receiving and participating in health care services. 

Urban Populations: Needs and Directions

• Develop and test innovative community-based strategies for health care, including public-private partnerships among managed care organizations, state and local health departments, and public and private health programs that focus on disease prevention and health promotion and management of chronic illness in vulnerable and underserved urban populations. 
• Develop and test screening tools for identifying urban populations that are vulnerable to health problems requiring intervention and health status monitoring. 
• Determine the impact of various care management strategies, including managed care, on outcomes and costs for at-risk individuals, families, and defined populations across various types of urban community settings. 
• Develop culturally relevant measures of individual, family, and community functioning which are appropriate for community-based studies. 
• Develop and test culturally relevant measures of clinical and cost outcomes of community-based interventions. Examine the impact of cultural factors on use and outcomes of community-based programs. 
• Develop and test community-based strategies that actively seek and have consumer participation in the design, conduct, and evaluation of health services. Develop and test measures of the extent and effect of community representation on meeting the goals and objectives of community models being evaluated. 
• Design studies of community-based health care strategies, including managed care, that are of sufficiently large enough scale to enable analy- sis of the relative contribution of individual, family, and community characteristics and of intervention(s) to clinical and cost outcomes. 
• Describe factors associated with successful outcomes of community-based care strategies targeted to vulnerable and underserved urban populations. 
• Develop and test classification systems for health problems and interventions that are sensitive to cultural differences. 
• Develop and test strategies, such as disease registries, within communities as a basis for implementing and testing "safety net" programs in secondary and tertiary prevention. 
• Develop and test alternative primary care strategies that integrate delivery of acute, ambulatory, and long-term care for vulnerable populations such as frail elderly. 

Implementation of Priorities

The National Nursing Research Agenda (NNRA) represents a major effort of the NINR to specify priorities for nursing research funding. The purposes of the NNRA are to provide structure for selecting scientific opportunities and initiatives; promote depth in developing a knowledge base for nursing practice; and provide direction for nursing research within the discipline. 

Successful implementation of the recommendations of the Priority Expert Panel on Community-Based Health Care: Nursing Strategies depends on research initiatives proposed by investigators consistent with their own research programs and expertise. Publication of this report and its distribution to multiple audiences, foremost of which is the potential applicant pool, will constitute the major dissemination effort for informing the scientific community about the panel's deliberations. 

Applicants are encouraged to contact NINR program staff in the early stages of application development to discuss their preliminary plans for applications. Virtually all funding mechanisms available through the NINR can be used. All applications are subject to the dual review system normally used at the National Institutes of Health (NIH), where an application is reviewed for scientific merit by a scientific review group and, for programmatic considerations, by the National Advisory Council for Nursing Research (or another specially constituted group). 

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