Running head: POPULATION AND COMMUNITY HEALTH 1

Population and Community Health Promotion Project: Promoting Health in the High School

Setting

Ashley Selby

Delaware Technical Community College

NUR 330
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Introduction

Adolescence is a critical time in a person’s development. According to Salam et al.

(2016), a quarter of the world’s population is comprised of young adults. Between the ages of 12

-18 a person experiences rapid growth and changes in both physiological and mental

characteristics. With the changes that are occurring during the adolescent stage of life, multiple

needs are required for an individual both physically and mentally. Along with their physical and

mental needs, adolescents must be well educated and prepared for their next step in life as they

slowly start to move to adulthood and become more in control of their health and their needs.

Practicum Site/Population of Study

The community group that was studied during this project was the student population at

Caesar Rodney High School located in the small town of Camden, Delaware. Currently, there are

1,996 students enrolled at Caesar Rodney, and it is the only high school for the Caesar Rodney

School District (U.S. New & World Report, .n.d.) The school is located in Kent County, the

smallest county in Delaware with a reported population of 180,786 (United States Census

Bureau, 2019). Caesar Rodney’s student demographic has a variety of ethnic backgrounds.

According to U.S. News & World Report (n.d.), 53% of the school’s population is Caucasian,

31% African American, 8% Hispanic, 5% Asian, 2% mixed ethnicity, 1% Native American

Indian, and 0.2% Hawaiian. The ages of the student population range from 14-18 year-old.

County and School Statistics

Little geographic information is reported regarding Camden as the city’s population is

under 5,000. Kent County, however, has reported numerous statistics and information based on

its residents. According to the United States Census Bureau (2019), 22.9% of Kent County’s

population is under the age of 18. Of its population, 87.1% are high school graduates over the
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age of 25 (United States Census Bureau, 2019). The median income for Kent County is $58,775

with 11,888 residents receiving healthcare assistance (United States Census Bureau, 2019).

The data and statistical information regarding Cesar Rodney’s student testing varies

across different topics of interest. In a report published by the Delaware Department of

Education (2019), the average of students graduating from Caesar Rodney High School has

greatly improved over the last several years. In 2016 it was reported that 84.82% of its student

population graduated, however, 2018 indicated a large increase as the percent of students

graduating rose to 94.4%. Information about the strategies used by school administration and

faculty to increase graduation rates could not be found.

Delaware School Health Regulations

Delaware State health regulations for public school students are overseen by the

Delaware Department of Health and the Delaware Department of Education. According to the

Delaware Department of Education (2020), it is required by law that all students entering a

school system provide proof of immunizations. The following required immunizations are as

follows: 5 or more doses of DTAP or DTP td vaccine, 4 doses of IPV or OPV, 3 doses of

Hepatitis B vaccines, 2 doses of Measles, Mumps, and Rubella vaccine, 2 doses of Varicella or a

written disease history by a licensed healthcare provider, and in addition, any 9th grader entering

into a public school must have an additional 1 dose Tdap adult booster and 1 dose of

meningococcal vaccine (Delaware Department of Education, 2020). Delaware law allows two

exemptions to these immunizations: a medical exemption requested in writing by the student’s

healthcare provider or a religious exemption that must be notarized and submitted to the

Delaware Affidavit of Religious Belief (Delaware Department of Education, 2020).

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Along with immunization records, it is also required by state law that all students have

periodic health screenings provided by the school and two health examinations; one when the

student is entering a public school for the first time and a second examination when they are

entering the 9th grade (Delaware Department of Education, 2020).

The School Nurse in the High School Setting

The role of a school nurse is vital in the school setting and requires many different skills

and a plethora of knowledge. They must be compliant with multiple regulatory activities

including state laws, public health laws, and school regulations and policies. Currently, ninety

eight percent of children in the United States attends school. Within that population, health

concerns such as chronic illness, communicable diseases, violence/bullying, and mental illness

continue to grow. The school nurse’s role requires multiple duties and functions that include

medication administration, immunizations, record keeping, health promotion, and responding to

any medical crisis within the school setting.

Currently, there are three nurses employed at Caesar Rodney High School and all are

required to perform a multitude of duties. Health records, immunizations, medication orders,

doctor’s notes, and a care plan on each student, must be filed and maintained by the school

nurses (Wearden, A. 2020 February 27, Personal Interview). Along with providing medical care

to the students and staff, nurses at Caesar Rodney are also required to keep track of all

emergency equipment as well as create and develop an action plan for school emergencies

(Wearden, A. 2020 February 27, Personal Interview).

Communication, education, and leadership skills are some of the core competencies for a

public health nurse (Savage, 2020). The nurses at Caesar Rodney High School exemplify their

knowledge and skills of these competencies by sharing student information with staff that is
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within the Federal Education Rights and Privacy Act’s (FERPA) guidelines and educate the

student population on current health problems.

Reviewing Data and Identifying Priorities of Care

Due to the Covid-19 pandemic, direct observation of Caesar Rodney’s student population

could not be performed for this project. To assess the priority of care needed for this population,

data was gathered from published articles, staff members at Caesar Rodney, and statistical

information of the surrounding area.

In a personal interview conducted on February 27th, 2020 with Mrs. Anne Wearden one

of the school nurses at Caesar Rodney, health concerns regarding the student population and the

use of electronic cigarettes were discussed. Advertising for e-cigarettes often use a light and

youthful undertone targeting a young audience. In 2018 it was reported that 3.5 million

adolescents were using e-cigarettes (Beal, 2019). According to Wearden (2020), the use of e-

cigarettes among students has been an ongoing problem. Students who use e-cigarettes have

complained of high heart rate, feelings of anxiousness, and have exhibited high blood pressure

when examined in the nurse’s office (Wearden, 2020). Many e-cigarettes contain higher

concentrations of nicotine than regular cigarettes (Jones & Salzman, 2020). The effects of

nicotine on blood pressure, heart rate, and respiratory rate are well documented and known to the

public. It has also been well documented about the addictive properties nicotine has on the body

and its effects on the brain’s reward system. According to Jones and Salzman (2020), adolescents

who use e-cigarettes are 3.6 times more likely to use combustible cigarettes later in life. It has

also been reported that teens who use e-cigarettes on a regular basis are 3 to 4 times more likely
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to start using marijuana as many vaping devices has the ability to inhale cannabinoids through

liquid pods (Jones & Salzman, 2020).

Education posters and health lectures regarding the health risks associated with electronic

cigarette use have all been used and demonstrated in an effort to help protect the students’ health

at Caesar Rodney (Wearden, A. 2020 February 27, Personal Interview). One of the priorities of

care for this population identified for the school students was prevention education on the use of

e-cigarettes and the risks associated. Since it is an ongoing problem, further education and

awareness needs to be presented to the student population.

Another health priority identified for the adolescent population at Caesar Rodney High

School is mental health and depression. During their years of development adolescents will

experience a wide variety of emotions. It is very common for adolescents at one point to feel

anxious or experience a period of depression. Depression affects nearly one in eight adolescents

and is the most common mental health disorder (U.S. Department of Health and Human

Services, n.d.). When left untreated, mental health disorders can lead to multiple health problems

and can become a major risk factor for the development of suicidal ideation. According to the

U.S. Department of Health and Human Services (n.d.) suicide is the second leading cause of

death for young adults ages 15-24. Identifying common and early warning signs of mental illness

is detrimental in providing adolescents with proper care and support. Health care workers should

have a strong knowledge of identifiers as well as provide counseling or information for

counseling for adolescents suffering from depression or other mental illnesses.

The third health priority identified for Caesar Rodney’s student population is proper

health literacy and education. According to Hughes and Maiden (2018), there are currently no

interventions in Delaware public schools regarding the transitioning of health care

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responsibilities from parents to teens. Currently, the Patient Protection and Affordable Care Act

mandates that all health insurance carriers in every state offers coverage to both adults and their

dependents until the dependents are 26 years old (National Conference of State Legislators,

2016). However, when a child turns 18 they are considered an adult and under the Health

Insurance Portability and Accountability Act (HIPAA), a parent does not need to be present for

medical visits unless granted by the child/patient. Up until they turn 18 most children and

adolescents have had their parents or guardians present during doctors exams and visits. The

parents in the room ask the doctors the appropriate questions and are given discharge instructions

leaving the child to be dependent on what the parent has learned from the visit. After they turn

18 however, they have the freedom to make their own decision and judgement on their health

and health needs. This can be a confusing time for an adolescent as the child who has been

dependent on their parents for medical decisions now must be responsible for themselves. Over

36% of adults in the United States have limited health literacy (Hughes & Maiden, 2018). With

limited health literacy skills an individual is more at risk to develop poor health habits and make

poor health-related decisions. There is limited studies and statistics on adolescent health literacy,

however, it is reported that 46% of adolescents in the United States read below their grade level

(Hughes & Maiden, 2018). According to U.S. News and World Report (n.d.), 46% of Caesar

Rodney High School’s students are proficient in reading while 22% are partially proficient and

19% are inadequate. It can be assumed that those adolescents that read at a low proficiency are

going to have a more difficult time interpreting common health literature and tasks. Therefore, it

is important that the adolescent population is educated on common health literacy concepts so

that they have a better understanding when they transition into adult roles.

Action Plan for Vaping

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While the nursing staff at Caesar Rodney has already taken action in educating and

informing the student population about the risks associated with vaping and e-cigarettes, it is still

reported that students are regularly using e-cigarettes. While it could not be confirmed how often

students are using e-cigarettes on school grounds, it can be assumed that there is undetected use

during the school period due to many vaping cartridges having the option of odorless vapor. To

help further decrease the use of e-cigarettes there are several plans that can be added to the

already established ones at Caesar Rodney.

To ensure students are being held responsible for their actions of breaking school policy

of vaping on campus, any student that is caught with a vaping device will receive an automatic

one day suspension. This policy would have to be approved by school faculty and principles,

however, in an article by Vestel (2019) it was reported that a Portland high school who switched

from a traditional 3-4-day suspension to a mandatory one-day, saw a decrease of students

carrying and using e-cigarettes in school. While there is no factual information on why there was

a decrease in using e-cigarettes on campus after suspension, it can be assumed that the

inconvenience a one-day suspension might influence students to stop vaping. Usually with 3-4

day suspensions students are able to make up their work in an appropriate length of time. With a

one day suspension, there is less time needed to make up missed work. This could be a positive

influence on students to not bring the e-cigarettes to school and the constant short suspensions

become more of a nuisance than a “little break”.

Along with stronger disciplinary precautions, peer education committees can be

developed in the school to help further educate students of the risks associated with using e-

cigarettes. During adolescence, peer relationships are an important and vital part of daily life.

During the adolescent phase of life an individual is trying to come into their own self-identity
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and make their own independent decisions. Often, adolescents will relate to their peers who view

the same opinions as them and are experiencing similar life situations (Brown & Larson, 2009).

By developing a peer education committee on the health risks associated with vaping, students

are more likely to listen and retain knowledge as it is coming from a group that they can relate to.

Along with information regarding the risks associated with vaping, the peer committee groups

would provide information for support sites and numbers such as the Delaware Quit Line and the

Healthy Delaware website which provides tools and resources on how to approach the adolescent

population with information through different technologies they currently utilize such as social

media and texting (Healthy Delaware, n.d.).

To help measure the effectiveness of the new approach to the student vaping concern,

staff and peer committees would gather information from students currently vaping using

questionnaires and interviews during health examinations and during peer discussions. Records

would be kept in place of those who identify with using e-cigarettes. After a four month time

frame with the new peer committee and disciplinary action in place, students previously recorded

to have used e-cigarettes would be re-evaluated by physical exam and by peer committee

interviews and discussion. With a new disciplinary approach and a peer committee to help with

education and support against e-cigarettes, the goal would be to see a 10% decrease from the

initial reported students that vaped.

Action Plan for Depression

Due to the Covid-19 pandemic and the inability to observe the student population

at Caesar Rodney High School it is unknown how many students currently report feelings of

depression and what resources are available to them in the school. Since literature has shown that

peer relationships play a critical role in adolescent development, a support team of students and
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staff educated on the signs and effects of depression would be created and implemented for

student use. These support teams would be well trained and educated on supporting and listening

to students who approach them with concerns and thoughts of depression.

Since withdraw from school and other activities may occur with depression, it is

important that faculty staff understands that the student with depression may be experiencing a

lack in personal resources to do their best work. Non-criticized approaches such as assisting the

student with breaking assignments into smaller pieces and assisting them with setting up

schedules or study habits suitable to their schedules will help make the student feel that they are

in control. Planning pleasant activities with other students, such as those in the peer support

team, can also help the student that is feeling depressed.

By using these techniques, the goal would be a reported improvement by the student after

a month of involvement with the peer support group and support faculty. To measure how the

student is doing during this month-long interaction, weekly check-ins with either a school nurse

or counselor would be arranged to ensure the resources provided at the school are having a

positive impact. Additional resources outside the school such as information to the Delaware

Mental Health Association would be provided to the student and their family as well.

Action Plan for Health Literacy

Since there is no current curriculum for health literacy this would be a new topic that the

school would have to investigate funding of teacher training and staying within the guidelines of

the National Health Education standards. In an experimental research study conducted by

Hughes and Maiden during the 2014-2015 school year, a unit called “Navigating the Health Care

System” was created for high school students to provide them with appropriate information to

enhance their knowledge and skills on making appropriate informed health care decisions
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(Hughes & Maiden, 2018). Hughes and Maiden (2018) designated 13 health and career technical

education teachers in 11 Delaware high school to teach two 90-minute classes regarding

information on proper health techniques regarding nutrition, preventative care, appropriate

questions for healthcare providers during examinations, as well as when to receive yearly

physicals and how to set up and make appointments with health care providers. Hughes and

Maiden’s study showed positive feedback from both staff and students who participated in unit.

A similar unit would be created at Caesar Rodney following similar guidelines that

Hughes and Maiden used, however, this unit would be more focused on the student transition

from a minor to an adult and the process of taking control of their care. To make the unit more

appropriate to the population at Caesar Rodney, a questionnaire would be first filled by students

asking them about their current knowledge on any health conditions they may have, their current

health insurance plans, and who their primary care doctors are. Currently, 92.4% of the

population of Kent County has health coverage; 42.6% are on employee plans, 19.2% on

Medicaid, 10.6% on Medicare, 15.5% on non-group plans, and 4.56% on military or Veterans

Affairs plans (Data USA, n.d.). Information on the students’ current health insurances at Caesar

Rodney is unknown. However, based on the information provided by the students and the current

statistics of Kent County, the unit would focus primarily on teaching students of both insured and

Medicaid assisted insurances and the terms and literature associated with each and the resources

that are available. Along with insurance information, discussions on interactions with doctors

and other healthcare providers would also be addressed in the unity. Teachers would provide

scenarios to students regarding health problems they may have and what type of questions and

concerns would be appropriate to discuss with the doctor. Workbooks with definitions and terms,
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interactive games, and presentations would all be part of the unit’s curriculum in an effort to help

the students develop strong health literacies in both insurance information and with primary care.

The unit would be taught for 45 minutes for one week straight. The goal at the end of the

week would be that the students would have a better understanding on how to take control of

their healthcare. The students would be able to recite terms and definitions regarding common

insurance literature as well as demonstrate the ability to find information on local health care

providers and how to set up appointments and ask appropriate questions.

Conclusion

It is unfortunate that direct observation was not able to be performed with this population

to have a strong first person understanding of their health needs. Based on previous studies,

research, and statistics, the adolescent population in the high school setting has a multitude of

needs physically, socially, and mentally. It is a very important time in a person’s life as the

transition from childhood to adulthood occurs. It is important that healthcare providers such as

school nurses, understand the needs of this population and provides adequate support and

education to them so that they may be successful in both their health and life.
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Delaware Department of Education (2020, March 10). School health services.

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United States Census Bureau. (2019, July 1). Quick facts: kent county, delaware.

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