Upstream, Midstream and Downstream Approaches to Health Promotion (Nursing)

by Heide Cygan, DNP, RN

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    00:01 Today, we're gonna talk about Upstream, Midstream, and Downstream Approaches to Health Promotion.

    00:07 Now imagine this, it's a beautiful sunny day.

    00:10 So you and your roommate decide you're going to take a study break.

    00:13 You walk across the street to the local park, and are taking a nice little stroll along the river front.

    00:19 A couple minutes into your walk, you see someone in the river.

    00:23 It's a woman calling for help, she needs you.

    00:25 So of course, you and your roommate help her out of the river.

    00:29 Well soon as you get her out of the river, you see an older gentleman in the same situation begging for help.

    00:35 You pull him out of the river, this happens over and over and over again.

    00:40 Finally, you look at your roommate and say, "We can't do this anymore, we have to figure out why people are falling into the river." So you go upstream.

    00:49 And you realize that the fence that's usually there preventing people from falling into the river is gone.

    00:55 The sign that says danger, it's gone.

    00:58 There's nothing there to prevent people from falling into the river.

    01:03 So you're probably wondering, what does this have to do with public health? Well, let me explain.

    01:08 In public health, we take three different approaches to health promotion.

    01:12 The first is upstream.

    01:14 And these are the approaches that address the social determinants of health.

    01:17 These are the approaches that prevent people from falling into the river.

    01:22 Next, we have midstream.

    01:23 These are approaches that strive to modify individuals behavior.

    01:27 So maybe we're teaching people how to swim just in case they fall into the river.

    01:32 And then finally, we have downstream approaches.

    01:35 These are approaches that focus on disease treatment.

    01:38 So this would be as pulling our friends out of the river.

    01:42 Now let's take a look at each of these individually a little bit more in detail, starting first with upstream.

    01:49 With upstream approaches, we really strive to improve community conditions.

    01:53 And we can do this in a variety of different ways.

    01:57 Mainly, we focus on laws, policies and regulations that create community conditions that support health for all people.

    02:05 So we're addressing those underlying conditions that put people at risk for becoming ill, or becoming injured in the first place.

    02:15 Moving on to midstream.

    02:17 Our midstream approaches really addressed those individual social needs.

    02:21 A few different strategies we could use here would be to include patients screening questions about social factors, such as housing, or access to food.

    02:30 And then we can use this data to inform our care or provide necessary referrals.

    02:36 It's also important to recognize that this type of work is done by other people other than nurses, social workers, community health workers.

    02:44 Community based organizations provide direct support services and assistance to meet the needs the social needs of our patients.

    02:54 And then finally, we have downstream.

    02:56 Downstream approaches are really focused on clinical care.

    02:59 So here our main strategy or medical interventions, taking care of people after they've already been injured or after they're already sick.

    03:08 Oftentimes, in health care, we focus on those downstream approaches.

    03:11 We spend so much time worried about clinical care that we don't look upstream to figure out what's actually causing people to be sick in the first place.

    03:20 It's important to understand that when we're working downstream, or even midstream, what we're doing is impacting the individual that we're working with.

    03:27 It's not until we move upstream that we have that impact on the entire community.

    03:33 Let's take a look at an example.

    03:35 Let's consider heart disease and come up with a plan to address this through health promotion at all three levels.

    03:42 Let's first start with downstream.

    03:43 And the reason we're going to do that is because it's likely that this is the type of approach that you're most familiar with.

    03:49 So take a second, pause the video.

    03:52 And consider what would you do at a downstream level to help an individual who has heart disease? A couple of strategies you may use are medication management, or it's possible that your patient needs surgical interventions to address their heart disease.

    04:15 Again, this is us pulling them out of the river.

    04:17 This is our downstream approach.

    04:20 Moving up then to midstream, what are some approaches that you could take to address heart disease through health promotion at that midstream level? Take a second think about it.

    04:39 Well, you could encourage individuals to start participating in physical activity programs, or maybe you're concerned about nutrition so you develop nutritional interventions.

    04:49 Again, these are all those midstream approaches.

    04:53 Let's move on now to upstream.

    04:55 What could you do at the upstream level to address heart disease? Here are some strategies that you can use at that upstream level.

    05:09 Now remember, a lot of this work is advocacy work, because we're what we're doing here is preventing people from falling into the river.

    05:16 We're addressing those underlying social conditions that put people at risk in this case of heart disease in the first place.

    05:24 So we can advocate for increased opportunities for physical activity, that could be increasing the number of bike lanes in a community.

    05:31 We could advocate for an increase in living wages.

    05:34 This would provide economic stability to those living in the community or we could focus on stress reduction.

    05:40 We know there's a relationship between stress and heart disease.

    05:44 But in order to do this at the community level, you'd have to understand what those community stressors are.

    05:49 And we do that through our community health assessment.

    05:52 We can then use that data to develop interventions that are specific to those community stressors.

    05:59 Now, all three levels of health promotion have a place.

    06:02 It's important that we continue to do downstream approaches and pull people out of the water once they're there.

    06:08 It's important that we continue our midstream approaches by teaching people to swim so if they do fall in the river, they have some skills.

    06:15 But it's also important to focus on these upstream approaches.

    06:18 And it's really those upstream approaches where we're going to have the most community impact.

    About the Lecture

    The lecture Upstream, Midstream and Downstream Approaches to Health Promotion (Nursing) by Heide Cygan, DNP, RN is from the course Basic Concepts in Public Health Nursing.

    Included Quiz Questions

    1. Upstream
    2. Downstream
    3. Midstream
    4. Overstream
    1. Upstream
    2. Downstream
    3. Midstream
    4. Overstream
    1. Downstream
    2. Midstream
    3. Upstream
    4. Overstream

    Author of lecture Upstream, Midstream and Downstream Approaches to Health Promotion (Nursing)

     Heide Cygan, DNP, RN

    Heide Cygan, DNP, RN

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