Module 1 Objectives (Chapters 1-3) 1. Define Community Health Nursing (CHN) and Public Health Nursing (PHN) (p.

10) Community Health Nursing: the synthesis of nursing practice and public health practice applied to promoting and preserving the health of populations. Directs care to individuals, families, or groups; in turn contributes to the health of the total population CHN practice is collaborative and based in research and theory: applies nursing process to the care of individuals, families aggregates, and the community. Public Health Nursing: The practice of promoting and protecting the health of populations using knowledge from nursing, social, and public health sciences. Population focused, goals of promoting health and preventing disease and disability for all people through the creation of conditions in which people can be healthy. Core functions of PHN: assessment, policy development, and assurance 2. Differentiate upstream thinking from downstream intervention in CHN/PHN practice Upstream: Focus on modifying economic, political, and environmental practice for the prevention of illness prevent people from falling into the river macroscopic Downstream: episodic/short term and individual based care and interventions saving a drowning person from the river microscopic 3. Compare and contrast CHN with clinical nursing, community-based nursing, and public health nursing according to goals, clients, processes used, and settings for practice Clinical Nursing Goals: Improve the health of patients Clients: Patients of the health care system Processes Used: Nursing process: treatment and patient care procedures Setting: inpatient Community Based Nursing Goals: Application of the nursing process in caring for individuals, families, and groups where they live, work, and go to school; or as they move through the healthcare system Clients: Individuals and families Processes Used: Nursing process, diagnosis and treatment Setting: setting specific; emphasizes care to individuals: homes, outpatient, ambulatory clinics. o addresses acute and chronic health conditions. Public Health Nursing Goals: Protect and promote the health of the entire population, using knowledge from nursing, social & public health sciences o Promoting health and preventing disease and disability for all people through the creation of conditions in which people can be healthy Clients: Populations can be defined by geography, demographic, characteristic, or need Processes Used: assessment, policy development, assurance, public health intervention wheel (p. 14) Setting: in public? 4. Explain determinants of health and indicators of health for individuals and communities

The health status of a community is associated with a number of factors such as health care access, economic conditions, social and environmental issues, and cultural practices. Individual behaviors and environmental factors are responsible for 70% of all premature deaths in the US. Individual biology and behaviors influence health through their interaction with each other and with the individuals social and physical environments. In addition, policies and interventions can improve health by targeting detrimental or harmful factors related to individuals and their environment. At the population level, health can be largely attributed to higher standards of living, better nutrition, a healthier environment, and having fewer children. Community and public health nurses should understand these concepts and appreciate that health and illness are influenced by a web of factors, some which can be changed (e.g., individual behaviors, such as tobacco use, diet, activity), and some which cannot (e.g. biology, age, gender). When developing the national health objectives for Healthy People 2010, a total of 10 leading health indicators were identified that reflected the major public health concerns in the US. They include individual behaviors (e.g. physical activity, overweight and obesity), physical and social environmental factors (e.g., environmental quality, injury and violence), and health systems issues (e.g. access to health care). Each of these indicators can affect the health of individuals and communities, and they can be correlated with leading causes of morbidity and mortality. Leading health indicators: physical activity, overweight and obesity, tobacco use, substance abuse, responsible sexual behavior, mental health, injury and violence, environmental quality, immunization, access to health care. 5. Describe the historical development of community/ public health nursing Modern historians have shown that organized community health efforts to prevent disease, prolong life, and promote health have existed since prehistoric times. Public health efforts exist in various stages of development throughout the world. We are looking at the Western view of organized Public Health efforts. Prehistoric times o Nomadic humans became domesticated and tended to live in increasingly larger groups. o Based health care on superstition or sanitation, health practices evolved to ensure the survival of many aggregates. o Primitive societies used elements of medicine (voodoo), isolation (banishment), and fumigation (smoke) to manage disease and protect the community Classical times o 3000-4000 BC-Minoans devised ways to flush water and construct drainage systems. o Circa 1000 BC-Egyptians constructed elaborate drainage systems, developed pharmaceutical preparations, and embalmed the dead o Greece: communicable disease like diphtheria, mumps, and malaria. The Hippocratic book Airs, Waters and Places, was the only volume on this topic until the development of bacteriology in late 19 th century. Endemic disease: always present in a population, like colds and pneumonia. Epidemic: occasionally present, like diphtheria and measles. The Greeks emphasized the preservation of health, good living, which the goddess Hygeia personified, and curative medicine, which the goddess Panacea personified. Life had to be in balance with environmental demands; Greeks weighed the importance of exercise, rest, and nutrition according to age, sex, constitution, and climate. o Rome: constructed aqueducts, bathhouses, and sewer systems. They noted the pallor of the miners, the danger of suffocation, and the smell of caustic fumes. To protect them, miners devised safeguards by using bags, sacks, and masks made of membranes and bladder skins. In early years of Roman Republic, priests dispensed medicine. Public physicians worked and earned money. Hospitals, surgeries, infirmaries, and nursing homes appeared throughout Rome. A Christian woman, Fabiola, established a hospital for the sick poor. Middle Ages o The decline of Rome. The commonly occurring communicable diseases were measles, smallpox, diptheria, leprosy, and bubonic plague. The church took over by enforcing the hygienic codes from Leviticus and established isolation and leper houses, or leprosaria. The pandemic, the bubonic plague (the Black Death), claimed close to half the worlds population. Modern public health practices like isolation, disinfection, and ship quarantines emerged in response to bubonic plague. Clergymen acted as physicians and treated kings and noblemen. Monks and nuns provided nursing care in small houses designated as hospitals. Medieval writings contained info on hygiene and addressed such topics as housing, diet, personal cleanliness, and sleep. Renaissance o G. Fracastoro presented a theory that infection was a cause and epidemic was a consequence of the seeds of disease. A. van Leeuwehoek described microscopic organisms, but did not associate them with disease. The Elizabethan Poor law held the parishes responsible for providing relief for the poor. The law was governed health care for the poor for more than two centuries and became a prototype for later US laws. Eighteenth century o Great Britain: sanitary conditions were a great problem. The Elizabethan Poor Law made parishes establish workhouses to employ the poor. Orphans and poor children were wards of the parish, therefore children were forced into child labor. Vaccination was a major discovery of the times. E. Jenner observed that people who worked around cattle were less likely to have smallpox. The Sanitary Revolutions public health reforms were

beginning to take place throughout Europe and England. A health education movement provided books and pamphlets on health to the middle and upper classes, but neglected economic factors and was not concerned with the working classes. Nineteenth century o E. Chadwich called attention to the consequences of unsanitary conditions that shortened the life span of the laboring class in particular. He contended that death rates were high in large industrial cities. He published Report on an Inquiry Into the Sanitary Conditions of the Laboring Population of Great Britain. It established the General Board of Health for England in 1848. Social reform followed. Clean water, sewers, fireplugs, and sidewalks emerged as a result. o Rudolf Virchow argued for social action-bettering the lives of people through improving economic, social, and environmental conditions. To attack the root social causes of disease. Public Health nursing developed from providing nursing care to the sick poor and providing information and channels of community organization that enabled the poor to improve their own health status. District nursing, which stemmed from the first tradition, developed in England. Poor women were selected to provide nursing care to the communitys sick poor. The society theorized that nurses belonging to their patients social class would be more effective caregivers and that more nurses would be available in the community. Rathbone worked with Nightingale to develop a plan that divided the community into 18 districts and assigned a nurse and a social worker to each district. The model was successful. Health visiting: provided information for improved health is a parallel service based on the district nursing tradition. The model charged the district nurse with providing care for the sick in the home and the health visitor with providing health information in the home. Government agencies sponsored health visitors eventually, medical health officers supervised them, and the municipality paid them. A collaborative model developed between government and voluntary agencies and exists in the US today. Lillian Wald and Mary Brewster established a district nursing service on the Lower East Side of NY called the House on Henry Street. It played an important role in establishing public health nursing in the US. In 1902, NYC started a school nurse experiment. It was successful. 1910the demand for PHN increased so the Department of Nursing and Health formed at the Teachers College of Columbia University in NYC. 21st centurythe focus is on cost containment and the provision of health care services under managed care. The focus of care is increasing within the community, and new models that use nursing in the community to contain costs are appearing with variation among states and areas within a state. Some models focus on providing care to rural populations and disease management, where others focus on specialized areas like medically fragile children and clients with disabilities. 6. Identify theories applicable to CHN/PHN practice the individual is the locus of change (microscopic) o Orems self-care deficit theory of nursing o The health belief model (HBM) Thinking upstream: society is the locus of change (macroscopic) o Milios framework for prevention o Critical social theory Orem: theory is based on the assumption that self care needs and activities are the primary focus of nursing practice. She stated that this general theory is actually a composite of the following related constructs: the theory of self care deficits, which provides criteria for identifying those who need nursing; the theory of self care, which explains self care and why it is necessary; and the theory of nursing systems, which specifies nursings role in the delivery of care and how nursing helps people. Self deficit theory is based on the premise that nursing is a response to a sick persons inability to administer self care. Patient deficits are central to this theory; thus its ability to inform community level problems and health promotion strategies is limited. Health Belief Model evolved from the premise that the world of the perceiver determines action. Major concepts of the model include perceived susceptibility to disease x, perceived seriousness of disease x, modifying factors, cues to action, perceived benefits minus perceived barriers to preventative health action, perceived threat of disease x, and the likelihood of taking a recommended health action. Milios framework for prevention provides a thought provoking complement to the HBM and provides a mechanism for directing attention upstream and examining opportunities for nursing intervention at the population level. o Milio outlined six propositions that relate an individuals ability to improve healthful behavior to a societys ability to provide accessible and socially affirming options for healthy choices. o She stated that policy decisions in government and private organizations shape the range of choices available to individuals. o She proposed that health deficits often result from an imbalance between a populations health needs and its health sustaining resources. (diseases associated with excess-obesity and alcoholism-afflict fluent societies; disease resulting from inadequate or unsafe food, shelter, and water afflict the poor). o Personal and societal resources affect the range of health promoting or health damaging choices available to

individuals. Personal: awareness, knowledge, beliefs, and beliefs of the individuals family and friends. Money, time, and urgency are also personal resources. o She stated that health promoting choices must be more readily available and less costly than health damaging options for individuals to gain health and for society to improve health status. Critical Social Theory uses societal awareness to expose social inequalities that keep people from reaching their full potential. It is devised from the beliefe that social meaning structure life through social domination. Social exchanges that are not distorted from power imbalances will stimulate the evolution of a more just society. Uses inductive reasoning, it is an ongoing process of data collection and analysis. Example: the critical social theory was used to analyze the social, political, and economic conditions associated with the cost of prescription analgesics and the corresponding financial burden of clients who require these meds. The trends in pharmaceutical pricing were compared with inflation rates of other commodities. The study stated that pharm sales techniques, which market directly to physicians, distance the needs of ill clients from the pharm industry. Analysis specified nursing actions that a downstream analysis would not consider, such as challenging pricing policies on behalf of client groups. 7. Discuss the preventative approach to health care and give examples of the levels of prevention -so all I could really find that related to his was Milios framework for prevention on p.43 -it provides a thought provoking complement to the HBM and provides mechanism for directing attention upstream and examining opportunities for nursing intervention at he population level. -Nancy Milio outlined six propositions that related an individual's ability to improve healthful behavior to a societys ability to provide accessible and socially affirming options for healthy choices: 1. population health results from deprivation and/or excess of critical health resources 2. behaviors of populations result form selection from limited choices; these arise from actual and perceived options available as well as beliefs and expectations resulting form socialization, education, and experience 3. organizational decisions and policies (both governmental and non-governmental) dictate many of the options available to individuals and populations and influence choices 4. individual choices related to health promotion or health damaging behaviors is influenced by efforts to maximize valued resources 5. alteration in patterns of behavior resulting from decision making of a significant number of people in a population can result in social change 6. without concurrent availability of alternative health-promoting options for investment of personal resources, health education will be largely ineffective in changing behavior patterns -Refer to table 3-2 for population health examples p. 43 This is from the PPT: -Medical care (downstream or microscopic perspective) focuses on cure -Public health care (upstream or macroscopic perspective) focuses on prevention Levels of prevention: -Primary (prevents), Secondary (screens), Tertiary (treats) 8. Describe the purpose of Healthy People 2020 and give examples of focus areas that encompass the national health objectives -documents provide health professionals with a broad mandate to save lives by thinking and acting strategically; the Healthy People 2020 documents are classified into 38 topic areas that address specific diseases, care systems, and cross-cutting issues in public. -Each of the focal areas specified by the CDC and Prevention and in the Healthy People 2020 documents encompasses a complex and multifaceted problem one that can be addressed only by looking upstream.

Goal 1: Attain high quality, longer lives free of preventable disease, disability, injury and premature death Goal 2: Achieve health equity, eliminate disparities, and improve the health of all groups Goal 3: Create social and physical environments that promote good health for all Goal 4: Promote quality of life, healthy development and healthy behaviors across all life stages Focus areas include:
Access to health services, Adolescent health, Arthritis, Osteoporosis and chronic back conditions, Blood disorders and blood safety, Cancer, Chronic Kidney disease. Dementias (Alzheimers Disease), Diabetes, Disability and health, Early and middle childhood, Educational and community-based programs, Environmental health, Family planning, Food safety

Genomics, Global health, Healthcare-associated infections, Health communication and health information technology, Health-related quality of life and well-being, Heart disease and stroke, HIV, Immunization and infectious diseases, Injury and violence prevention, Lesbian, gay, bisexual and transgender health, Maternal, infant and child health, Medical Product Safety , Mental health and mental disorders, Hearing and other sensory or communication disorders Nutrition and weight status, Occupational Safety and health, Older adults, Oral health, Physical activity, Preparedness, Public health infrastructure, Respiratory disease, Sexually transmitted diseases, Sleep health, Social determinates of health, Substance abuse, Tobacco use, Vision 9. Identify potential public health nursing interventions for a variety of health issues This is referring to the Intervention wheel found on pg. 14 and Table. 1-5 on pg. 15- all of this is also found in the first powerpoint for module 1 10. Analyze opportunities to apply community health nursing standards in all areas of nursing practice - I mean this question is pretty self-explanatory: I mean from using all the levels of prevention (discussed before, ie. primary, secondary, tertiary...) throughout all types of nursing areas to taking into account holistic means in treating and providing patient care whether it be in the community or in a hospital institution. Even in looking at socioeconomic issues when incorporating patient history into their care- you would want to be aware of different cultural backgrounds, education and socioeconomic status and environment they live in that could affect the patient in the community or when treating them in other areas of nursing.....there are some pretty pictures on page 47 that also describes with captions how nurses help with the environment in different ways...You essentially just have to think about community health nursing as a whole and what community nurses do specifically and then how that would help in other areas of nursing Module 2 Objectives (Chapters 4, 13, 21-23) 1. Identify major indicators of the health status (morbidity, mortality, natality & life expectancy) of children, adolescents, men, women, and senior - Chart 4-1 page 53 - Social environment - Physical environment - Policies and Interventions -Access to quality healthcare - Cancer - Disability and secondary conditions - Health Communication - Indicators of health status: Morbidity-disease, Mortality-death, Natality-birth, and life expectancy 2. Relate the demographic characteristics of the population with the risk for disease, injury, disability or death - 90% of lung cancers in men and 80% of lung cancers in women are attributable to smoking. - More men smoke than women - The prevalence of smoking is highest among American Indians and AA. - Smoking is more common among less the less educated population and people below poverty level - Smokeless tobacco is more common among young white males with its heaviest use in the southern or north central states and among blue collar workers. - American Indians/ Alaska natives are the heaviest users of smokeless tobacco followed by whites - Men are more likely (68%) than women (55%) to be current drinkers and to binge drink - Men are more than 2X as likely to suffer death or injury related to drinking - Non-hispanic white people have the highest drinking prevalence, with non-hispanic white men being the heaviest drinkers - 17% of US children 2-19 years are overweight, and 32% are obese - Persons aged 45-64 years are more likely to be overweight in the US, with 73% of men and 63% of women being overweight. - between 2003 and 2006, 53% of non-Hispanic black women were overweight or obese compared with 32% of nonHispanic white women and 52% of women of Mexican origin. - More Hispanic males were overweight than white or non-Hispanic black men. - The highest consumption of fast food was associated with non-Hispanic black individuals, males, higher household income, older children, and living in the South - Men are a little more likely to engage in leisure physical activity and are more likely to engage in strength training than women. - Leisure physical activity is highest among adults aged 18-24 years - White adults and Asian adults are more likely to engage in leisure-time physical activity than are black and Hispanic adults. - As education increases so does leisure-time physical activity - The percentage of adults who engage in leisure time physical activity increases with income level

- Adults living in the Southern region of the US get the least amount of leisure time physical activity. - 17% of ihspanic adults and 16% of black adults report that they are in fair or poor health, compared with 10% of nonHispanic whites. - Cancer mortality rates are 35% higher in black Americans that whites - Black Americans who have DM are se en times more likely to have amputations and renal failure than are white with DM - 30% of Hispanics and 20% of black Americans lack a usual source of health care (compared than with fewer than 16% of whites) - Hispanic children are nearly 3 times as likely as non-Hispanic white children to have no usual source of health care - Black Americans (16%) and Hispanic Americans (13%) are more likely to rely on hospitals or clinics for health care than are whites (8%) - 24.5% of the black population is in poverty - 10.2% of the Asian population is in poverty -21.5% of the Hispanic population is in poverty - Children under 6 years of age are particularly vulnerable to poverty, with 20.8% of all US children in the age-group being poor. - blacks have the highest mortality rate and shortest survival rate for many cancers - blacks receive less information regarding cancer and heart disease that non-minority groups -blacks tend to underestimate the prevalence of cancer, give less credence to warning signs, obtain fewer screening tests, and receive a diagnosis at later stages of cancer than whites - heart disease is as common in black men as is in white men - black women die of coronary heart disease at a higher rate that white women - among Mexican Americans, cultural attitudes regarding obesity and diet are often barriers to achieving weight control. - Blacks (20.5%) had a higher rate of disability when compared with Asians (12.4%) and Hispanics (13.1%) Non-Hispanic whites (19.7%) - Females have a higher disability rate (20.1%) than males (17.3%) among all racial groups - among school aged children, almost 13% had a disability with 4% termed a severe disability - In 2005, half (51.8%) of people aged 65 and older had a disability, and (36.9%) was severe - the highest incidence of disability occurs in people aged 80 and older (71%) - People in nursing facilities have a disability rate of 97.3% and a median age of 83.2 years - for people aged 25-64 years of age in 2005, 12% with a non-sever disability and 27.1% with a severe disability lived in poverty - Among individuals from 21-64 years, only 45.6% of people with a disability and 30.7% with a severe disability were employed. 3. Describe the relationship between population size and density with the communitys risk for disease, injury, disability or death (I could not find this in the book, it might be there but I could not find it. This is from some older notes from a different edition of this book. But if you find it somewherePLEASE let me know where lol Sorry guys) - Environment can play a role in that low density areas have isolation problems and lack resources whereas hig density areas have increased crime, pollution, increased traffic related accidents and spread of infectious disease. - Rural areas may have limited economic opportunities - Many rural areas have limited primary car providers - Poverty rates for rural minorities are 2-3 times higher than for rural whites - Unintentional injuries are higher in rural areas - Smoking, smokeless tobacco, alcohol use, sedentary lifestyles, obesity, and higher infant mortality rates are higher in rural areas - Driving at high speeds, longer distances, and in worse weather conditions are higher in rural areas - Less likely to wear seatbelts - Rural males have higher unintentional injury rates - Access to mental health services limited - Youth substance abuse is the greatest problem of rural youth in America 4. Describe the relationship between population age and gender with the risk for disease, injury, disability or death This is combined in questions 2 answers. 5. Describe the relationship between race and ethnicity with the risk for disease, injury, disability or death Occurrence of many dzs/injuries/public health problems disproportionately higher in some groups o Access to health care may be more restricted o Overall healthcare may be deemed inferior Self-reports of fair/poor health: 17% of Hispanic adults, 16% of black, 10% non-Hispanic whites Cancer: mortality rates 35% higher in black Americans than whites Diabetes: Black Americans w/ diabetes are 7x more likely to have amputations or renal failure than diabetic whites

Having a usual source of health care increases the chance that one will receiving proper preventative care o Lack usual source of health care: 30% of Hispanics, 20% of blacks, 16% of whites o Hispanic children 3x more likely to have no usual source of health care than non-Hispanic whites o Rely on hospitals or clinics for health care: 16% black, 13% Hispanics, 8% whites

6. Describe the relationships among education levels, culture, economic status, and occupation with the risk for disease, injury, disability or death Where we live and work, our gender, age, and genetic makeup impact health Ones environment is significant health indicator (Ex: walkable cities inc. exercise) Education levels: o Educational attainment is perhaps the single most important factor in determining SES o There has been a recent increase in education in those that have traditionally not been educated (elders, women, minorities) o Women have higher rate of high school graduation than men o Dropout rates for both blacks and Hispanics are steadily declining Culture: o Cultural norms affect whether or not a symptoms is one of health or illness (the nurse may recognize it as indicative of illness, but if it is a similar to the norm in the culture, the pt may not think he/she needs treatment or to seek health care) o Pain is expressed differently in different cultures o Culture-bound syndromes are limited to a particular culture (Ex: anorexia nervosa & bulimia are primary found among members of the dominant US culture). o Family constellations affect childcare Hispanic teen mothers receive more child care help from grandmothers and peers than do white teen mothers Blacks & Puerto Ricans: presence of maternal grandmother ameliorates the negative consequences of adolescent childbirth Three-generation families provide more responsive social interactions with infants (due to experience of o Diet may be influenced by religious beliefs Economic status: o Measures such as median or average annual income, employment rate, poverty rate and net worth are often used to capture the facets of economic statusits better to use a combination for SES (socioeconomic status) o Most families w/ racially or ethnically diverse backgrounds have a lower SES (except Cuban and Asian Americans) o Poverty threshold affected by number of children (see Table 13-1, pg. 224 for graphic): number of children taken into account with determining poverty Poverty: 24.5% of blacks, 21.5% Hispanics, 10.2 % Asians Children < 6 years at high risk for poverty (20.8% of all US children poor) Occupation: o ??? Just says that its an indicator of health care (worse/lack of an occupation, less financial compensation, poorer health outcomes) Specific risks: o Smoking common in adults who have littler education and/or live below the poverty level o Prevalence of smoking is highest in African Americans (smoking cessation is an imp. step in achieving optimal health) o Men more likely to drink alcohol/binge drink & 2x more likely to suffer death/injury r/t alcohol; highest prevalence of drinking age 25-44 o Diet is one of the most modifiable risk factors o 66% of US adults are overweight and 32% are obese o Highest consumption of fast food in non-Hispanic black persons, males, higher household income, older children and those that live in the South 7. Analyze contributors to health disparities in the United States Disparities among racial & ethnic minorities, women, youth, older adults, people of low income & education, and people with disabilities Disability: o Disparities due to differences in access to care, provider biases, poor provider-patient communication, poor health literacy and other factors o Lower level of immunizations in the disabled elderly as compared to the non-disabled elderly o Those with disabilities are least likely to be employed (lower SES poorer health) o Those with intellectual disabilities are often undervalued May exhibit behavior differences that health care providers do not like to deal with (ouch!)

May resist care due to fear, discomfort, or unfamiliarity of health care system Disabled persons often stereotyped in contemporary literature Often cannot work (may be due to progressive disability), and may end up homeless Prevalence by race & sex: 20.5% black, 19,7% white, 13.1% Hispanic, 12.4% Asian 20.1% female, 17.3% male Higher female rate can be explained by higher number of elderly women o Prevalence in children 21.8% of households with children have @ least 1 special needs child May need: prescription meds, specialty medical care, vision care, mental health care, specialized therapies & medical equipment Preventative dental care is unmet need in 16% of these children o Disabling chronic health issues: chronic respiratory conditions, hearing/vision disabilities, stroke, fractures, dementia (risk increases with age) o Overweight & obese @ risk for type 2 diabetes disability o Those with disabilities more likely to lack employments, income, education, access to transportation Homelessness: o Those in shelters: domestic violence victims, veterans, persons with substance abuse problems, unaccompanied youth, persons with serious mental illness, and persons living with HIV/AIDS. 13% were victims of domestic violence 28% had serious mental illness 15% veterans 39% substance abusers o o o 70% of the homeless are individuals (men>women) 5% unaccompanied youth 55% adults aged 31-50 o Adults in homeless families (women>men) are younger than adults in poor families\ o 55% are African Americans o Factors that contribute to homelessness: 1) shortage of affordable housing 2) incomes insufficient to meet basic needs 3) inadequate and scarce support services (for more detail on these, see page 431) Living in rural areas: o Populations are older, poorer, and less-educated o Rural racial and ethnic minorities (Native Americans, Alaska Natives, Hispanic/Latinos & African Americans) in the South & West are more disadvantaged Not only in relation to the rural majority, but also to the urban minorities Disparities include: employment, income, education, health insurance, mortality, morbidity, and access to care o Health disparities in rural areas are either: 1) contextual; or 2) compositional 1) Contextual: based on the characteristics of the place Ex: limited economic opportunities, low wages available, agricultural accidents 2) Compositional: based on characteristics of the individual groups of people living in an area Ex: age, education, income, ethnicity, health behaviors Should use both to assess the rural area o Contextual issues in the rural area: Limited access to care (number one priority in need for change): Fewer primary care providers (inadequate access and gaps in US health care equality) Greater distribution of primary care providers in urban areas and growing shortage in the rural and underserved areas Availability of access to health care providers is imp. determinant of health in rural areas General health services: Many youth in rural areas move to urban areas rural area has higher concentration of older people As population dwindles, hospitals/pharmacies close must travel further or to urban areas to receive care Transportation may be an issue, or care in the urban area may be too expensive Health insurance: Economic decline & rising prices of insurance Those who have some form of health insurance are much more likely to receive care/benefit from

the education provided by health care workers for self-care regimens Rural industries often small & offer low wages lower rate of insurance Health insurance is a leading health indicator (in the absence of insurance, poverty become the leading indicator) Compositional issues in the rural area: Income/Poverty Higher rates of poverty in rural areas when compared with urban areas Poverty rates in rural & racial minorities 2-3x higher than poverty rates in rural whites Families w/ 2+ adults are less likely to be poor Female-headed families have highest poverty rate (when based on family composition) Highest rates of childhood poverty in South & West Health Risk, Injury & Death More smoking/obesity in South Unintentional injuries highest in males (age 15-24) & from urban counties with the lowest population densities Higher rates of death from accidents in rural areas Vulnerable Groups Retirees move to rural areas (higher numbers of elderly in rural areas w/out the health care facilities to meet their needs The elderly poor tend to be isolated Racial & ethnic diversity increasing in rural areas (esp. Hispanic) Nonmetropolitan children more likely to live in poverty/lack health insurance Education & Employment To sum it up, rural = less educated, less employed Occupational Health Risks More work-related injuries/deaths (esp. in South & West) Highest death rates: mining, agriculture, forestry, fishing, construction, transportation, public facilities (in that order) Injuries contribute to disability Those living in rural areas less likely to report themselves being in good/excellent health (higher prevalence of chronic dz)

8. Analyze the concept of vulnerability of selected populations Those with disabilities, those who are homeless, those who live in rural areas (see questions 7, these questions are kinda similar!) Disability: o Physical, sensory, intellectual disabilities, serious emotional disturbances, learning disabilities, significant chemical and environmental sensitivities and health problems such as AIDS/asthma may substantially limit major life activities The Homeless: o see various definitions of homelessness on pg. 428 o According to the federal government: a chronically homeless person is an unaccompanied homeless individual with a disabling condition who has either been continuously homeless for a year or has had at least four episodes of homelessness o May be chronic or temporary Rural: o Agricultural workers: Migrant & seasonal farm workers (MSFW) may have the poorest health & least access to health care 85% of MSFW are Hispanic, Latino, or African American (the rest are white) Work in highly variable environments, many work tasks, increased rates of injury/fatality Farmers often work alone, isolated, cant get help + increased risk for accidental injury = delayed access to emergency/trauma care Agricultural machinery (ex: tractors) are most common cause of farm injuries Higher rates of acute & chronic illness (Ex: long-term exposure to grain dusts resp. issues) Exposed to pesticides, herbicides & other chemicals s/s of pesticide poisoning on pg. 455 Often have musculoskeletal discomfort Suicide a major issue in rural areas Risk highest for non-Hispanic white males aged 65+ o Migrant & Seasonal Farm Workers: Low income & migrate

Culture, linguistic, economic, and mobility barriers Often considered the outsiders in the communities (isolated) Originate from Mexico, the Caribbean, and Central and South America (many do speak English)

9. Identify key legislation and policies related to caring for vulnerable individuals Individual w/disabilities education act= ensured free appropriate public education in the least restrictive setting to children w/disabilities based on their needs Cedar Rapids community school district Vs. Garret F. = ruled that the school must provide extensive health care services during the school day for Garret cognitively child paralyzed from the neck down as a result of a motorcycle accident The Americans with disabilities act of 1990 = provides a comprehensive civil rights legislation for people w/disabilities to help prevent discrimination toward the disabled Gives equal opportunity for people w/disabilities related to employment, transportation, public accommodations, public services, and telecommunication enforced by the employment opportunity commission --- landmark legislation! Ticket to work and to work incentives improvement actremoves the guidelines that typically result in the termination of Medicaid and Medicare benefits for people w/disabilities when they return to work Legislation for HPSAs Health professional shortage areas Create programs to provide acute care and services to help those in rural areas Module 3 Objectives (Chapter 5) 1. Define Epidemiology and Demography and discuss application of both to the community nursing process Epidemiology is the study of the distribution and determinants of health and disease in human populations and is the principal science of community health practice epidemiology helps identify risk factors and methods to reduce dz risk Epidemiology offers the community health nurse methods to quantify the extent of health problems in the community and provides a body of knowledge about risk factors and their association with dz Demography entails the who factors related to dz Compiling descriptive data from surveys or studies contributes to understanding the communitys health level 2. Define and describe major epidemiological concepts and their role in community nursing practice: a. Multiple causation many factors can be associated with the development of dz such as host and environmental interactions this concept is seen with the wheel model (fig 5-2, pg 70) b. Agent, host and environment interaction and web of causation models - The epidemiological triangle(fig 5-1) is a balance btwn the agent host and environment that can affect the rate of dz such interactions are: o Extent of the hosts exposure to an agent o Strength or virulence of the agent o Hosts genetic or immunologic susceptibility o Environmental conditions at the time of exposure including: biological, social, political, and physical environment A. The web of causation model identifies the relationship btwn causal factors that increase the rate of dz, this led to preventing many epidemics which caused the focus of public health to shift to chronic dz such as cancer & CAD(fig 5-3) B. Ecosocial epidemiology challenges the more individually focused risk to dz, looks at genes to determine risk c. Natural history of disease and levels of prevention associated with each disease stage natural history of dz stage of dz progression primary prevention o interventions occur BEFORE dz development o two types of activities health promotion actions to foster healthy lifestyles and safe environments ie regular exercise specific protection actions aimed at reducing the risk of specific dzs ie immunizations secondary prevention o interventions occur AFTER designed to detect dz at its earliest stage OR provide early tx and cure of dz o ie screening, physical exams, mammography, guiac testing of feces, tx of infections and dental carries tertiary prevention o interventions limiting disability and rehabilitating pts c irreversible dzs o ie diabetes , spinal cord injuries

d. Risk, risk factors and populations at risk risk o probability of an adverse event o ie likelihood that healthy ppl exposed to a specific factor will acquire a specific dz risk factor o specific exposure factor o ie cigarette smoke, excessive stress, high noise levels, environmental chemicals o frequently external to the individual but may include fixed characteristics, such as sex, age, or genetic makeup o certain lifestyle changes may reduce the effect of risk factors, ie ca and hormone supplements may reduce the risk of osteoporosis in susceptible women e. Morbidity, mortality and natality morbidity illness mortality deaths natality live births f. Incidence and prevalence rate counts an event relative to the size of a specific population (ie pop at risk, total pop) incidence o describes the occurrence of new cases (ie TB, teen preg) in a pop over a period of time relative to the size of the pop at risk (ie for TB, teen preg) during that same time period o ie (300 teen pregnancies in 1 year/1000 teens at risk in 1 year) x k o may be most sensitive indicator of changing health in a community bc it captures the fluctuations of dz in a pop o valuable for detected short-term acute dz changes ie infectious hepatitis of measles when duration of dz is typically short prevalence o number of all cases (ie deafness) in a pop at a given point in time relative to the pop at the same point in time o ie (300 deaf/1000 total pop) x k o cross-sectional studies frequently use prevalence rates o influenced by: # of ppl affected by a condition and duration of condition o prevalence pot figure 5.4 p 73 for further explanation my explanation below is lame-sauce relationship between incidence and prevalence those who survive a chronic dz (ie HIV) s a cure are in the pot, recovery from dz (ie cataract surgery) are out of the pot. incidence puts you in the pot, recovery and death take you out of the pot g. Distribution of disease according to person, place and time The Person-place-time model IDs characteristics of those w/ dz compared to characteristics of those remaining healthy. It is a descriptive way for epi to organize disease pattern in a community; IDable patterns frequently indicate possible cause of dz. - personal factors: age, gender, SES, and health status - place: determine whether diff in loc or living environment of ill ppl, compared w/ healthy ppl, influenced dz devt - time: are their common time factors (i.e., when ppl acquired dz) 3. Describe, recognize and be able to calculate biostatistical measures used in epidemiology: Rates: basic measures of dz or death occurrence in a defined pop over a specified period of time # of events occurring in a specified period of time --------------------------------------------------------------- x k pop in same area in same specified period a. Proportions (percentages) describes characteristics of a population. The percentage reps the numerator as the denominator. b. Ratios obtained by dividing one quantity by another, and the numerator is NOT necessarily part of the denominator (i.e., ratio contrasting the # of male births that of female births). c. Crude rates (mortality and birth rates) summarizes occurrence of births, deaths, or diseases in the general pop. # of events crude rate = ----------------------------------------- x k avg pop size or pop size at midyr rate = - crude rates are subject to certain biases in interpretation because the pop reps the TOTAL pop and not just the pop at risk for a given event.. age is one of the most common confounding factors that mask the true distribution of variables (i.e., older pop will prob produce higher crude death rate than a pop w/ a more evenly distributed age range).

d. Specific rates (age, cause, gender and race specific mortality rates, infant and maternal mortality) - Age-specific death rate= Number of deaths among people of a given age group in 1 yr/Average (midyear) population in specified age group, Usually per 100,000 population, 16.3 (5-14yr) 432 (45-54yr) 2137.1 (65-74yr) -Cause-specific death rate= Number of deaths from a stated cause in 1yr/Average (midyear) population, Usually per 100,000, 220 Heart diseases, 188.7 Malignant neoplasms - Infant mortality rate= Number of deaths in 1 yr of children younger than 1 yr/Number of live births in same yr, Usually per 1,000 births, 6.9 -Maternal mortality rate (puerperal)= Number of deaths from puerperal causes in 1 yr/Number of live births in same year, Usually per 100,000 live births, 15.1 *No gender or race specific rates covered in this chapter that I could find, table 5-10 to better understand e. Incidence and Prevalence morbidity rates -Incidence rate = (Number of new cases in given period of time/Population at risk in the same time period) X10,000 -Incidence rates describe the occurrence of new cases of a disease over a period of time, with the denominator consisting of only those at risk so old cases are subtracted . May be the most sensitive indicator of changing health of a community, useful in detecting short-term acute changes -Prevalence rate= (Number of existing cases/Total poplulation) X 1,000 -Prevalence rate is the number of all cases of a specific disease in a population at a given point in time relative to the population at the same point in time. Used in cross sectional studies frequently, P= I X D incidence x duration, *See Table 5-2 for clarification p 72 f. Case Fatality - Couldn't find it in the chapter but Dr. Wiki says: the Case Fatality rate measures the risk of a person dying from a disease in a certain period of time. -Case Fatality rate= (Number of deaths from a specific disease during a period of time/Number of cases of disease during same time period) x 100 4. Describe principles of screening tests and recognize examples of sensitivity and specificity of the tests -The purpose is to identify risk factors and diseases in their earliest stages, usually a secondary -Screening guidelines: 1. Screen for conditions in which early detection and treatment can improve outcome and quality of life 2. Screen populations that have risk factors or are more susceptible to the disease 3. Select a screening method that is simple, safe, inexpensive to administer, acceptable to clients, and has acceptable sensitivity and specificity 4. Plan for the timely referral and follow up of positive cases 5. Identify referral sources that are appropriate, cost effective, and convenient for Sensitivity is the probability that someone who has a disease will test positive Specificity is the probability that someone who does not have a disease will test negative DISEASE STATUS

prevention

activity

clients.

YES

NO

EXPOSURE

YES

A True Positives

B False Positives

A+B

STATUS

NO

C False Negatives

D True Negatives

C+D

A+C

B+D

Sensitivty %= (A/A+C) X 100 Specificty %= (D/B+D) X 100 5. Apply epidemiological concepts and measures to the description of the distribution of health problem in a community (wasnt quite sure what this one was asking for but did my best) Epidemiological triangle: interrelationships between host and environmental characteristics and uses an organized method of inquiry to derive explanation of disease; involves analysis of agent, host and environment o The development of disease is dependent on extent of hosts exposure to an agent, strength of virulence of agent, and hosts genetic or immunological susceptibility; disease is also dependent on environmental conditions existing at time of exposure, which include biological, social, political, and physical; model implies that the rate of disease will change when the balance among these three factors is altered Ecosocial epidemiology: emphasizes role of evolving macro-level socioenvironmental factors, including complex political and economic forces along with microbiological processes, in understanding health and illness Risk: refers to probability of an adverse event Risk factor: refers to specific exposure factor Surveillance: mechanism for ongoing collection of community health info; monitoring for changes in disease frequency is essential; identifying trends in disease incidence or indentifying risk factor status by location and population subgroup over time allows the community health nurse to evaluate the effectiveness of existing programs and implement interventions targeted to high risk groups Descriptive epidemiology: focuses on the amount of distribution of health and health problems within a population; its purpose is to describe the characteristics of both people who are protected from the disease and those who have a disease; factors of particular interest include age, sex, ethnicity, or race, socioecomonic status, occupation, and family status; epidemiologists use morbidity and mortality rates to describe the extent of disease and to determine the risk factors that make certain groups prone to acquiring the disease Analytic epidemiology: investigates the cause of disease by determining why a disease rate is lower in one population group than in another; tests hypotheses generated from descriptive data and either accepts or rejects them on the basis of analytic research; the epidemiologist seeks to establish a cause and effect relationship between a preexisting condition or event and the disease; to determine this relationship; they may undertake two major types of research studies (observational and experimental) 6. Discuss the levels of prevention and their application to intervention in the community. (77) Primary o Central goals of epidemiology: describing disease patterns, identifying etiological factors in disease development, and taking most effective preventative measures (dependent on natural history of disease aka stages of the disease progression) o Primary prevention: when interventions occur before disease development Health promotion: activities general in nature and designed to foster healthful lifestyles and a safe environment (exercise) Specific protection: actions aimed at reducing the risk of specific diseases (immunizations) Secondary o Occurs after pathogenesis o Screening and physical exams (measures designed to detect disease at its earliest stagemammography, guaiac testing of feces) o Interventions for early treatment and cure of disease are included here (treatment of infections and dental caries) Tertiary o Includes limitation of disability and the rehab of those with irreversible disease such as diabetes of spinal cord injury Module 4 Objectives (Chapter 14) 1. Define and describe the relevance of key environmental concepts and their impact on the health of a group, community or population Environmental health: those aspects of human health, disease, and injury that are determined or influenced by factors in the environment. This includes the study of both direct pathological effects of various chemical, physical, and biological agents, as well as the effects on health of the broad physical ad social environment, which includes housing, urban development, landuse and transportation, industry and agriculture o Vital in community nursing practice; evidence shows that environmental changes of past few decades profoundly influence the status of public health

Healthy people 2020: toxics. Waste, water quality, outdoor air quality, healthy homes and healthy communities, infrastructure/surveillance, and global environmental health Critical theory: an approach that raises questions about oppressive situations, involves community members in the definition and solution of problems, and facilitates interventions that reduce health damaging effects of environments Precautionary principle: when an activity raises threats of harm to human health of the environment, precautionary measures should be taken even if some cause-and-effect relationships are not fully established scientifically o Originated from concern that the use and release of hazardous substances into the environment have had negative consequences and that the public must become involved in calling attention to these activities Aggregate: a group that shares a common aspect, such as age, gender, race, economic status, cultural perspective, chronic illness, or area of residence o Ex: a community in which the members know and interact with each other (labor union); theoretically defined categories of individuals who may or may not interact regularly with others in the defined group such as crack cocaine users, women with physical disabilities or men over the age of 65 Environment: the accumulation of physical, social, cultural, economic, and political conditions that influence the lives of communities Community health: depends on integrity of physical environment, the humaneness of the social relations in the environment, the availability of resources necessary to sustain life and mange illness, the equitable distribution of health risks, attainable employment and education, cultural preservation and tolerance of diversity among subgroups, access to historical heritage, and a sense of empowerment and hope

2. Differentiate local, state and national governmental responsibility in the control of environmental risks (the only one I could find in the book was governmental responsibility) Local: State: National: o EPA: roles include health surveillance and monitoring, setting standards for air and water quality, evaluating environmental risks, acquiring info, screening new chemicals, performing basic research and training, and establishing, evaluating, and enforcing regulatory efforts o Occupational safety and health administration o Nuclear regulatory commission 3. Identify environmental factors affecting the health of a group, community, or population Environment is the accumulation of (1) physical, (2) social, (3) cultural, (4) economic, and (5) political conditions that influence the lives of communities. Community health depends on: o Integrity of physical environment o Humaneness of the social relations in the environment o Availability of resources necessary to sustain life and manage illness o Equitable distribution of health risks o Attainable employment and education o Cultural preservation and tolerance of diversity among subgroups o Access to historical heritage o Sense of empowerment and hope Public buildings, schools, workplaces, and mass transportation are environmental structures that are vital to peoples everyday functioning, but are typically taken for granted. Table 14-2: examples of environmental health problems o Living patterns Examples: drunk driving/ secondhand smoke/ noise exposure/ urban crowding/ technological hazards o Work risks Examples: occupational toxic poisoning/machine-operation hazards/ sexual harassment/ repetitive motion injuries/ carcinogenic worksites Agricultural workers and pesticide exposure o Those who apply pesticides accumulate the chemicals on their skin and clothing, taking it home with them and increasing their kids risk of exposure o Atmospheric quality Examples: gaseous pollutants/ greenhouse effect/ destruction of the ozone/ aerial spraying of herbicides / acid rain Air pollution o Contributes to 50,000 premature deaths annually o Water quality Contamination of drinking supply by human waste/oil spills in the worlds waterways/ pesticides or herbicide infiltration of groundwater/ aquifer contamination by industrial pollutants/ heavy metal poisoning

of fish Housing Homelessness/ rodent and insect infestation/ poisoning from lead based paint/ sick building syndrome/ unsafe neighborhoods o Food quality Malnutrition/bacterial food poisoning/ food adulteration/ disrupted food chains by ecosystem destruction/ carcinogenic chemical food additives o Waste control Use of non-biodegradable plastics/ poorly designated solid waste dumps/ inadequate sewage systems/ transport and storage of hazardous waste/ illegal industrial dumping o Radiation risk Nuclear facility emissions/ radioactive hazardous wastes/ radon gas seepage in homes and schools/ nuclear testing/ excessive exposure to XR 25% of preventable illnesses are due to poor environment quality o

4. Analyze the above factors according to the following framework: a. The environmental and ecologic concepts that apply o Globalization and industrialization have increased the number of health problems r/t the environment o Urbanization has made it difficult to maintain clean air, clean water, good sanitation practices b. Hazards and effect on health o Large scale hazards r/t global environmental conditions include climate change, stratospheric ozone depletion, loss of biodiversity, degradation, stresses on fluid-producing systems, changes in the hydrological systems and freshwater supplies (many corporations are going global and escaping US standards) o Urban areas are susceptible to emerging diseases because they permit rapid entrance of microbes and contaminants from other countries due to larger number of seaports and airports o Global climate change and international commerce/travel contributed to entry of west nile virus o SARS and H1N1: increased due to international travel o Meth home Cooking process: emits dangerous levels of toxic chemical and abandoned labs are a threat o Terrorist attacks o Natural Disasters c. Measures that lessen the hazards o Actions that accomplish positive environmental changes Coalition building Conscieousness-raising groups Educational forums in neighborhoods, workplaces, schools, churches and social clubs Seminars for healthcare providers, city officials, teachers, and employers Community needs assessment Dissemination of clinical research and policy analysis Use of mass media Canvassing litigation Legislative lobbying Testimony at public hearings Demonstrations Participatory research o Aggregate level interventions are most beneficial d.Governmental responsibility for control 1. Living patterns: Difficulties in altering state and federal officials about environmental health dangers and difficulties in obtaining compensation for environmental toxin-causing disease and death often result in resident revictimization. Urban sprawl is an emerging issue and an example of a living pattern that is of increasing concern. Urban sprawl has been defined as the conversion of land to nonagricultural or non-natural uses at a faster rate than the population growth. The sprawling development often occurs more rapidly than the expansion of the infrastructure (e.g., schools, sewer systems, water lines) needed for support. 2. Food Quality: The United States currently depends on the Food Borne Diseases Surveillance Network (FoodNet) of CDCs Emerging Infections Program to collect data on diseases caused by enteric pathogens transmitted through food. Although the U.S. Department of Agriculture and the U.S. Food and Drug Administration set policy for foods produced from new plant varieties and breeding, a number of groups and organizations have called for increased public awareness on the potential risks of genetically engineered foods and are working to require more stringent testing of them. 3. Water Quality: Advances in water treatment technologies in industrialized countries have controlled many water-related diseases such as cholera, typhoid, dysentery, and hepatitis A. Despite this, disease outbreaks resulting from contamination by untreated groundwater and inadequate chlorination are increasing in both urban and rural areas. In addition, more than 42 million Americans obtain their drinking water from private water supplies that have no treatment or monitoring guidelines.

e. Legislation that is in effect 1. Waste Control: Congress passed the Environmental Response Compensation and Liability Act, which established a revolving fund called the Superfund, to clean up several hundred of the worst abandoned chemical waste disposal sites. 2. Living Patterns: In the 1990s, the central issues of equity and justice emerged in environmental health policy. In 1994, President Clinton signed Executive Order 12898, which required all federal agencies to develop comprehensive strategies for achieving environmental justice. This legislation has served to increase public participation and access to information, as well as provision of education about multiple risks and cumulative exposures. f. Nurses role 1. Nurses must work with the public to promote more stringent and actively enforced environmental legislation and regulations. (ozone depletion, global warming, fossil fuel burning, marine dumping, etc.). 2. In an era of globalization, nurses must support actions for biodiversity, including pushing back the deserts, replanting the forests, stabilizing climate, and seeking alternative development pathways that do not destroy plant and animal species. In recognition of threats to the biosphere and exploitation of the worlds ecosystems, environmental integrity will require international assistance, ameliorative actions, and an environmentally educated global public. 3. Environmental concerns for clean air, clean water, and freedom from noxious chemicals must become global nursing concerns. Community health nurses can be catalysts to neighborhood efforts to produce safe living environments. Community health nursing must expand its theory and practice to incorporate the fact that individual and community health ultimately depends on global environmental integrity. 5. Apply principles from this module to the assessment and diagnosis of environmental risk factors in a group, community, or population A. Taking a Stand: Advocating for Change Nurses have the potential to increase or decrease inequalities seen in vulnerable groups who are more expose to health problems through the decisions they make about the positions they accept and the interventions they undertake. B. Asking Critical Questions Community health nurses must also consider the relationships between nonhealth policies and health policies. They should ask how policies concerning ecological preservation, energy, housing, immigration, civil rights, crime, nutrition, minimum wage, occupational safety, and defense might affect the well-being of people. C. Facilitating Community Involvement Approaching community health from a critical perspective requires working to improve health conditions and creating the context in which people can identify health-damaging problems in their environments. Nurses must help people learn from their own experiences and analyze the world with an intention to change it and to provide support information, and expertise to groups to assist them in the meeting the goals they set for environmental change. \ D. Forming Coalitions Nurses can approach existing community organizations, churches, and family and friendship networks to help mobilize aggregate members who have not previously socialized or acted together. Nurses can then expose hazards, assess needs, plan actions, report abuses, and secure appropriate resources, personnel, funding, and legislative changes. E. Using Collective Strategies Nurses can use a variety of strategies to intervene at the aggregate level and facilitate improvement in a communitys health. Nurses can organize people to change health-damaging environments through combinations of strategies including coalition building; consciousness-raising groups; educational forums in neighborhoods, workplaces, schools, churches, and social clubs; seminars for health care providers, city officials, teachers, and employers; community needs assessments; dissemination of clinical research and policy analyses, etc. a. One collective strategy that is an effective aggregate-level community health nursing intervention is participatory action research. Participatory action research calls for nurses, community members, and other resource people to work together in identifying environmental health problems, designing the studies, collecting, and alayzing the data, disseminating the results, and posing solutions to the problems.