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

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.