4.2. Literature Review
Only nine articles were identified that contained the search terms and met the inclusion criteria of the literature review. Results of the literature review suggest that although there is a range of articles about various topics pertaining to public health nursing, systematized information about the current state of the field across the Americas is unavailable (see Table 4
). Reasons for the lack of organized information about public health nursing in the Americas include the use of varying names to refer to the field and the fact that few countries have established guidelines about or specific organizations dedicated to the field, among others. Also, the development of the field of public health nursing has varied across the Americas according to specific local, regional, and national health system demands, which are influenced by culture, history, politics, and economics; this increases the difficulty of finding systematized information about the profile of the public health nursing workforce in the Americas.
Public health nurses are referred to by a variety of titles in the Americas. Health professionals in the U.S. and Canada often use “public health nurse” or “community health practice.” Names used in Latin America and the Caribbean include the following: public health nurse (“enfermera de salud pública”) in Mexico, community health nurse (“enfermera de salud comunitaria) in Honduras; primary care health nurse (“enfermera de atención primaria de salud”) in Venezuela; visiting doctor (“visitador médico”) in Guyana; primary care psychiatric nurse (“enfermera de atención primaria psiquiátrica”) in Belize; rural nurse (“enfermera rural”) in Chile, family nurse (“enfermera familiar”) in Cuba; public health nurse (“enfermera sanitaria”); community nurse (“enfermera comunitaria”) [23
]. Regardless of the name, this type of nursing generally refers to the area of health practice that normally occurs outside of hospitals, where the majority of nurses work.
A 2001 PAHO report defines a public health nurse as a nurse who has at least completed high school and works with a program or activity targeting population health, a public health organization, or an entity contracted with the government [8
]. Despite this definition, the report states that many nurses unknowingly contribute to carrying out the essential public health functions and achieving health outcomes on a daily basis, even though they may not be familiar with terminology used in public health. For example, nurses often educate patients about healthy lifestyles and work with community groups to develop preventive health campaigns at the population level. Also, although nurses are often not recognized as responding to public health needs, in small communities and neighborhoods a public health nurse is often the only visible representative of the local public health system and acts as a first responder in cases of natural disasters and epidemics [8
]. Because nurses are regularly in close proximity to patients—often more than doctors or other health authorities—their socially-perceived primary function is close, confidential, face-to-face patient contact, but the tasks that nurses perform in public health are diverse, ranging from one-on-one consultation with individuals and families to participation in community health campaigns.
In her article about nursing in Colombia, Gaviria-Noreña argues nurses should participate in health promotion and disease prevention through community participation and communication with individuals and groups, gathering socio-demographic data to monitor population health, and making decisions to restructure health services according to context-specific social, cultural, political, and economic factors [24
]. While this explanation of nursing tasks does not use the term public health nursing, these responsibilities assigned to nurses are closely aligned with carrying out the essential functions of public health, demonstrating that the socially-perceived and practical roles of nursing and public health nursing intersect and overlap.
In addition, the PAHO report states that the classification of public health nursing as a separate field within the discipline of nursing is becoming less common, as health organizations tend to emphasize particular areas of health, such as vaccinations or maternal and child health, rather than public health more generally [8
]. Despite the tendency to not use terminology that links nurses to public health, it is clear that nurses frequently work at the community and population levels to fulfill the essential functions of public health according to context-specific needs. For instance, public health nurses in Brazil focus on children with disabilities and hypertension, while those in Cuba participate in health promotion projects in workplaces and neighborhoods [8
]. Although the report was published almost ten years ago, a consensus has yet to be achieved across the Americas regarding the definition, educational requirements, competencies, and workplace responsibilities of public health nurses and nurses who perform public health functions.
The Cuban nursing experience reported by Torres Esperón and Urbina Laza shows that changes in the National Health System in the 1980s resulted in the expansion of nursing job responsibilities to include community and population level actions [25
]. These responsibilities include improving population health through outreach projects that promote healthy lifestyles and hygiene practices, and developing research that targets population health needs. Interestingly, Cuban nurses have a high level of representation at the governmental level due to the creation of the National Nursing Administration, which allows nurses to have more influence in National Health System decision-making. Thus, nurses in Cuba carry out a wide range of important public health functions, including providing care for individuals, families, and communities, performing health administration duties, training other nursing and health personnel, researching population health problems, and shaping health policy. Academic programs for all levels of nursing education and training—from auxiliary to specialist nurses—have significant curricular content concerning public health.
In Canada, the field of public health nursing has experiences changes in recent decades. Public health nurses have historically provided postnatal care and services, child health assessments, health promotion education in schools, immunizations, and community development projects associated with health issues [5
]. Because the Canadian Health Act, established in 1984, defines essential health care mostly in terms of primary care services, provincial governments are largely responsible for disease prevention and promotion activities and campaigns, which are usually performed by community health organizations. Results of a 1999 survey of public health nurses in senior positions in Ontario and across Canada demonstrated that traditional public health nursing services offered to families and communities had diminished and significant regional disparities existed in regard to the availability of public health nurses [26
]. The authors argue that changes in health policy and reductions in resources and funding are some of the causes for these changes in public health nursing. In their 2005 report, Armstrong-Stassen and Cameron state that in Ontario, public health nurses “focus on health promotion and disease prevention in a wide range of settings, including workplaces, schools, community centers, and other community agencies” and made up about 30% of the province’s community nurses [27
]. Because these nurses work in such diverse environments, they must organize their work schedules to meet the demands of large caseloads, complex family and community related problems, while dealing with emotional stress and a lack of adequate resources and staffing.
The field of public health nursing is particularly well defined in the U.S. due to the sustained collaboration of academics and practitioners. The American Public Health Association defines public health nursing as “the practice of promoting and protecting the health of populations using knowledge from nursing, social and public health sciences” [28
]. Due to changes in health policy and financing, these nurses must possess a range of skills in order to meet U.S. demand for medical services and population health promotion and prevention. In 2000, Gebbie and Hwang collaborated with health professionals from academia and state and local health agencies, including state nursing directors, to confirm the need for public health nursing training, based on the concept that public health nurses’ “principle focus is on populations or groups rather than individuals, regardless of the type of agency or organization that employed them...” Agencies could be private, voluntary, or non-official organizations or managed care entities [29
]. While nurses employed in public health come from a range of educational backgrounds, the authors state that at the time of the research the only entry-level programs with curricula that address public health nursing theory and practice were baccalaureate programs. It is important to ensure that public health nurses possess a diverse set of skills, from epidemiological research to coalition building, but coordinating existing resources in order to guarantee that all nursing personnel acquire this knowledge is extremely difficult.
The Association of State and Territorial Directors of Nursing (ASTDN), which comprises a group of public health nursing leaders from across the U.S. and its territories, developed a set of public health nursing competencies in April 2003 [30
]. The competencies were developed in collaboration with the Quad Council of Public Health Nursing Organizations, a group of four national nursing organizations: the Association of Community Health Nurse Educators, the American Nurses Association’s Congress on Nursing Practice and Economics, the American Public Health Association-Public Health Nursing Section, and ASTDN. Using as a starting point the “Core Competencies for Public Health Professionals,” developed by the Council on Linkages between Academia and Public Health Practice, ASTDN developed competencies specific to public health nursing at the generalist/staff and the manager/executive levels that enable nurses to strengthen local, regional, and national health infrastructure. Other reports provide similar competencies and standards for public health nursing practice, including the American Nurses Association [31
] and nurses in the State of Georgia [32
Cross et al.
report that although many versions of public health competencies exist, including the aforementioned public health nursing competencies, is it difficult to measure changes in public health nursing competency levels [33
]. In order to determine changes in public health nursing competency before and after continuing education and training, and the competency level of the public health nursing workforce overall, the authors developed an instrument comprising more than 195 measurable activities that correspond to the framework of the nursing process. Although the instrument’s duration and detail may limit its usefulness in certain public health settings, this instrument serves to clarify and demarcate the field of public health nursing.
Despite these advances, it is difficult to define the field of public health nursing in the Americas, and systematized information about health human resources across the region is difficult to obtain. Information is not available regarding the number and profile of health personnel directly involved in public health settings in Latin America and the Caribbean, especially in regard to nurses. Moreover, the established indicators used to measure the performance of public health professionals does not adequately account for the contributions of nurses [8
]. PAHO provides information regarding the number of human resources from national sources in the Americas, but individual countries use different methods to gather health sector data. Moreover, local, regional, and national health systems across the Americas employ varying definitions of the role of nursing in public health systems. In contrast to those who define public health nursing by elaborating and refining established public health competencies, some experts argue that public health nursing should be examined from a perspective of nursing rather than public health, as these nurses provide a distinctive perspective gained from experiences in nursing education and the delivery of health services [7
All of the sources consulted suggest that with the proper training and support public health nurses can significantly contribute to strengthening public health services, increasing the quality of the essential functions of public health, and improving the health of populations across the Americas. The results of the literature review suggest that more research is needed to determine how public health nursing competency impacts public health outcomes in the short and long terms and more attention must be given to nursing professors, as they must achieve competency in the essential functions of public health and nursing in order to comprehensively prepare students for future careers in public health nursing. Additionally, in spite of the substantial and diverse contributions of nurses to public health, it is important to note that their potential role in shaping health policy is often unacknowledged and requires future development, as they can provide critical insight about health at the individual, community, and population levels. Despite the similarities amongst the reviewed articles, definitions of public health nursing continue to differ in theory and practice and current information about the profile of public health nurses is not available for many countries in the Americas.
4.3. Description of Three Cases
The purpose of the description of the three cases is to explore the recognition of public health nurses in the labor market and issues regarding nursing training in Mexico, Colombia, and Paraguay, as well as to provide examples of how nurses can assume leadership roles to execute public health programs. The information gathered through the interviews supports what was found in the literature review. The information in this section comes from the interviewees’ comments, as well as official documents and grey literature provided by the interviewees.
4.3.1. Mexico 
In Mexican nursing education, particularly at the high school level, programs of study include one semester of public health and three or more semesters of chemistry or math-related subjects. Some study plans include courses such as community nursing, and the majority address health education and teaching techniques. These topics are also common at the bachelor’s degree level. During high school level nursing training, practical experience gained through units about primary care is very limited, as programs of study prioritize units about hospital care.
A proposal to create a bachelor’s degree in public health nursing was developed by Mexican nursing societies and presented to the Inter-Institutional Commission for Human Resources for Health (ICHRH), a public agency coordinated by the Ministry of Health with the participation of universities, nursing schools, and health institutions. The Nursing Commission within ICHRH opposed this proposal with the argument that the labor market is not ready to demand nursing graduates from this type of program. However, the Commission recognizes the need to train more nurses with public health specialization at the graduate level.
According to information provided by the Secretary of Health, in 2007 there were 223,081 nurses in the public sector labor market, of which 209,907 had patient contact and 27,220 were specialists (see Table 5
]. Most of the nurses were general nurses who had completed high school and/or a bachelor’s degree.
The Nursing Commission of the Ministry of Health performed a survey in 2008 of 192,563 nurses and found that only 4,438 (or 2.3%) had studied public health in some way (see Table 6
Practically all nurses at the primary care level, who are predominantly auxiliary nurses, perform health promotion and prevention activities. A significant amount of their time is dedicated to developing national health programs, such as reproductive health, infant malnutrition, tuberculosis, vaccinations, and cancer. In the future, the participation of these nurses in monitoring individuals with chronic degenerative diseases and pregnant women should be strengthened. The prevention program of the Mexican Institute of Social Security (IMSS) offers training for its nursing personnel, which allows these professionals to develop their skills. The strength of the IMSS is based on the contributions of nursing personnel, as they provide information about health prevention and promotion for people insured by the IMSS. For example, nursing personnel give presentations and play videos about health prevention and promotion in waiting rooms at health centers and hospitals. They also offer individual consultation about health promotion and prevention in primary care settings. Furthermore, they provide periodic checkups for individuals with risk factors.
According to the professional job descriptions and work systems of the main employers in the public sector, specialist nurses who have completed graduate studies do not work in primary care. Nurses who have studied public health and have high school and bachelor’s degree level education are able to work in primary care.
Following this information about public health nursing in Mexico, it is possible to highlight the following:
In nursing education at the high school level, there are few courses related to public health.
Experience with primary care is very limited during training.
The majority of nurses who perform public health tasks in Mexico are auxiliary and general nurses who work in primary care.
Specialty nurses who have completed graduate education work exclusively in hospital units.
The percentage of nurses who have explicitly studied public health is very low.
4.3.2. Colombia 
According to the estimations of the University of Antioquia, Faculty of Public Health, in Colombia in 2005 there were 27,034 licensed nurses and 86,000 auxiliary nurses. Of these nurses, 23% had university training and 77% were auxiliary nurses [36
]. Nurses with university training frequently hold positions within health institutions that allow them to address questions related to management, supervision, and planning, while auxiliary nurses work in direct contact with patients.
With respect to nursing training, there is a tendency of students to enroll in programs for auxiliary nurses with relatively basic educational requirements. Universities have not been able to substantially improve the nursing programs they offer, or increase the completion rate of students. The University of Antioquia is the only institution which offers a bachelor’s degree in nursing.
According to information provided by the Ministry of Social Protection, in the area of public health 12% of nursing professionals work at the community level. Interestingly, the main actors responsible for public health interventions are local mayors, as they manage the budgets to finance these activities. With the recent health system reform which began in 1993, there has been a significant decrease of nursing personnel who work at the community level with special programs related to prevention, promotion, and control of chronic and infectious health problems. This area of nursing has practically disappeared, but recently there has been interest in reinitiating community level strategies through a new vision of primary care. The nursing department at the University of Antioquia has become a leader in this area by evaluating the resurgence of indicators concerning tuberculosis, acute respiratory infections, and acute diarrheal illnesses of children.
During the past five years, the Nursing Department of University of Antioquia revisited primary health care as a strategy to implement a departmental development plan. This was achieved by identifying primary health care as a priority for general policy. This pilot strategy is noteworthy because it situates nursing personnel—from hospital-based nurses to nursing professors—as leaders of projects focused on family care. The program has a methodology of epidemiological surveillance combined with a socially sensitive design that targets families and the community, so that the population can learn about health promotion and disease prevention. There is a wide range of actions that involve health personnel, including providing consultation, monitoring disease, and preventing chronic problems, such as hypertension and diabetes. Other nurses lead health promotion projects that target youth to prevent anorexia, bulimia, sexually transmitted diseases, and teen pregnancy, which is a significant problem at the national level. Nurses also participate in projects with an explicit gender focus, especially those concerning reproductive health and domestic violence prevention.
4.3.3. Paraguay 
Nursing education has a long history in Paraguay. In fact, the National University of Asunción began awarding bachelor’s degrees in nursing more than 45 years ago. Asunción, the capital of Paraguay, has the highest concentration of nurses with university training [38
In general, nursing students are required to take public health courses during the four years of the degree program, and the majority of schools strongly emphasize public health in nursing education. Some of the major problems related to nursing education include the lack of a unified curriculum across programs, the lack of an evaluation and monitoring system for schools, and the shortage of well-trained nursing educators, especially at the auxiliary and technical levels.
In Paraguay, there are more than 20,000 nurses, of which 16.7% have earned a bachelor’s degree in nursing (see Table 7
). In comparison with other countries in the region, Paraguay has one of the lowest ratios of nurses per 10,000 inhabitants (2.8), while Uruguay has 10.2, the Dominican Republic has 3.9, and Jamaica has 16.5 [39
The Ministry of Public Health and Social Welfare employs 9,106 nurses, which represents 44.5% of Paraguay’s total nursing personnel. Of the nurses employed by the Ministry, 65.3% are auxiliary nurses (see Table 8
All the nurses employed by the Ministry of Health perform public health tasks—from bachelor’s degree nurses to auxiliary and technical nurses. These nursing professionals focus on monitoring public health and managing health programs for immunizations, sexual and reproductive health, family planning, tuberculosis, diabetes, and epidemiological surveillance. Nursing personnel in the auxiliary and technical categories are able to assume responsibility of program execution, perform home visits, and give educational talks.
According to the Paraguayan Association of Nursing, recently nurses have received better working conditions and higher salaries. In fact, in some cases the salaries have doubled. Recently, the health sector renewed funding for 5,300 permanent positions, 2,900 of which are in the area of nursing. The creation of positions with fixed working schedules has increased the number of nurses. Also, the creation of a code of ethics and nursing law has strengthened the field of nursing.