1 CHAPTER 16, 30, 31, 32 Rural Communities and Populations Fewer than 20,000 residents or < 99 persons per

r square mile **Higher than average residents between 6-17yrs *Aged population same or higher as urban Health Status and Health Risks of Rural populations *Rural Populations have: Higher death rates for working-age adults Highest death rates for children and young adults Unintentional injuries (Priority) MVC Farm-related occupational injuries Increased rates of infant and maternal morbidity and mortality **Higher rates of chronic illness **POORER HEALTH STATUS = Characteristics of rural/ small town life (SLIDE 4) High-risk occupations Agricultural (mechanical/machinery) related injuries Greater distances between residents and services Informal social and professional interactions Significant number of small, family-owned businesses Churches and schools = socialization centers Town center Extended kinship families High proportion of residents related or acquainted Anonymity & confidentiality challenges Preference for "insiders" verses outsiders Mistrust of newcomers Rural perspectives: Barriers to Health Care? *Rural reality: impoverished Indian reservation or migrant labor camp Barrier: distance, ability to reach health care sites, limited specialties **Common Barrier = inadequate provider attitudes and understanding of rural populations Lack of qualified health care providers Must be general practitioners *Utilization patterns of health care: **Less likely to seek medical care (Access is limited but available) **Poorer perception of their overall health and functional status than those in urban areas (will seek care on a NEEDS basis) leads to poorer overall health status Role of the Community Health Nurse in Rural Environments Characteristics of nursing practice: **Requires broad, diverse knowledge base

2 **Variety of clinical experiences Intergenerational scope of practice (Across the lifespan) *Greater independence and autonomy *Use community-oriented nursing skills Less resources requires creative interventions Two Effective Models in Rural Settings: Goal: Address and reduce rural health disparities **Case management **Client-Professional partnership Follow-up Continuity of care for individual and family *Rural Healthy People 2020 guides health care for rural communities **Focus = translation of national objectives to achievable community objectives Health promotion activities prioritized according to M & M for the population served Magnitude of the problem: 12.5% of U.S. population live in poverty *Children have the highest rate of poverty (WIC Program) *Children make up 39% of homeless Poverty defined: *Poverty will affect health and wellbeing **Leads to higher rates of chronic illness Poverty threshold guidelines, 2008: *Largest Federal support program for elderly & poor *created by Social Security Act PovertyVulnerable groups: **Vulnerable populations are MORE SENSITIVE TO RISK FACTORS + have WORSE HEALTH OUTCOMES Have multiple RISK FACTORS **Example: substance abuse + HIV + homelessness **Children (Highest rate of poverty) Young children (0 to 5 years of age) are at highest risk for the most harmful effects of poverty chronic diseases Injuries traumatic death developmental delays poor nutrition inadequate immunization levels iron deficiency anemia

3 elevated blood lead levels **Elderly **African American Elderly are at increased risk of chronic and nutritionally related diseases due to EFFECTS of POVERTY **Women are more likely to be affected by POVERTY Understanding Poverty & Homelessness **Nursing Role: **Understand POVERTY as a concept with historical, social, political, economic, biological, psychological, and spiritual dimensions The concepts of poverty and homelessness begins with an examination of one's own beliefs, values, and personal experience: **Make a home visit to a home which is unkempt!! Biophysical Factors *Homeless and poverty individuals are more likely to report: Poor health and have higher morbidity and mortality Have increased rates of chronic illness **Sero-prevalence of HIV is AT LEAST DOUBLE! Psychological Factors **Family dynamics Less support or smaller network to call upon for assistance **Non-supporting custodial parents should provide financial support to children BUT!! these are often low-income parents **Many parents never married **Have high intermittent work histories Health System Considerations **Barriers which prevent nurses from engaging in care of clients **Stigma: Fear & misconceptions by nurses related to POVERTY = Barrier that prevents nurses from engaging w/ people from different socioeconomic & cultural backgrounds **Waiting time and inadequate services **Solution: One-STOP service provides multiple services during 1 clinical visit **Costs and access to care **Solution: Mobile vans staffed by NPs serve: VULNERABLE, HOMELESS, POVERTY & RURAL populations **Lack of preventive services **Solution: OUTREACH is an approach to making health care more readily available **Wide variation in health services & health status between certain populations AKA: Health Disparity Solution: Assess, Evaluate: Determine the most common health concerns Compliance to medications may be difficult

4 Implementation of Primary Health Care Services *Initially: Create a trusting environment and establish a therapeutic relationship *Home visits: allows for the development of a therapeutic relationship with poor or homeless persons **Call clients by name! Many clients and families have been disappointed by interactions with health care and social systems, and are mistrustful and see little hope for change Primary Prevention *Outreach is an approach to make health care more readily available Secondary Prevention Strategies *Connecting poor or homeless with governmental aid (WELFARE) *WIC (Women, Infants & Children) *Federal Housing Assistance Programs *Food Stamps *Cash Assistance Programs *Medicaid **Soup kitchens *Connecting poor with local voluntary organizations (e.g., Shelters, Safe Havens) Tertiary Prevention Strategies **Abused women **Nurses can work with groups of abused women to enhance the levels of self-esteem! Migrant Farm-Workers & their Families: Vulnerable Population *Agricultural Work Study identified: CHRONIC DISEASE, INCREASE IN MENTAL HEALTH, & TUBERCULOSIS All impact the health status of migrant families and need to be understood by the nurse to direct further assessment The NSC ranks agricultural work in the top four most dangerous occupations in the United States leading to: (occupational and environmental health risks) **Work injuries + chemical exposures--MIGRANT WORKERS SPECIFICALLY Office of Migrant Health of the U.S. Public Health Service: Problems with health care services (Migrant farm-worker: agricultural work is seasonal) **Eastern Migratory stream = 1 of 3 migratory streams migrant workers follow **Fragmented services Prefer to seek care from folk healers

5 **Limited access to care and Health Services Lack of knowledge of services Lower educational level Fear deportation Common health concerns in farm worker children: ** FIREARMS or EXPLOSIVES = One of the 3 leading causes of death **Dental problems = 1 of top 5 health problems Health Promotion + Disease Prevention **Outreach Principle: need to recognize the diversity of this group and the need for flexibility in the provision of services Should improve utilization of health services Improve the effectiveness of health services Provide comprehensive health services Be accessible Alleviate fears of deportation Illness Prevention **Primary prevention **HIV prevention **Infectious disease prevention CHAPTER 33-36 Tertiary Prevention GOAL = *Note: Health Problems = Accidents, Homicides, Suicides Reduce or end substance abuse Modify the progression and negative consequences of dependence Nursing Role: **Therapeutic Relationship Patient Advocacy requires Self examination about attitudes Therapeutic relationship = Trust and no fear of being judged **Specialized assessment skills Understand the variables that influence ATOD use Family history *Setting: physical, social and cultural environment Readiness *Resource= SAMSHAs NREPP NATIONAL REGISTRY OF EVIDENCE-BASED PROGRAMS AND PRACTICES (NREPP) http://www.nrepp.samhsa.gov/index.asp **extra info below..only above **d Searchable database of independently-reviewed mental health and substance abuse interventions Descriptive information regarding interventions and target outcomes Reviews the quality and rigor of associated research Lists the body of materials submitted for review and researcher contact information.

6 April 2009the site reviewed two interventions with an explicit outcome of child maltreatment prevention: Triple P (Positive Parenting Program) and Nurse Family Partnership. TRENDS: National Survey on Drug Use & Health (SAMSHA, 2007) *Prescription drugs and over-the-counter drugs relieve or mask anxiety, tension, fatigue, physical + emotional pain myths including quick fix or good and bad drugs influence drug use! Nurses can help by: assisting patients to understand that meds mask the problem rather than solve them! SETTINGS FOR CHN Public Health Nursing (PHN): Areas of Practice Gap *Public Health *Primary Care Services Home Health Goals *Maximize health *Maximize level of independence *Improve quality of life Promoting self-care Health promotion & illness primary prevention Ex: tracking immunization status of patients Special Needs Require Different Types of Home Care Barriers: Plan of care for **Elderly home care patient should include: Expected patient outcomes for each identified problem *RISK FOR MED ERRORS (because elderly take high risk meds) Selection of ActivitiesFocus of strategies **Ensure comfortable and peaceful death *Knowledge, skill, compassion *Experience considers: *cultural values *expectations and preferences to address the unique needs of the patient + family at the end of life PHN in School Health: Roles, Process, Activities PHN as Direct Caregiver & Health Educator Coordinate educational program: MUST Involve school officials *Identify &/or care for other persons in the community

7 *Community Outreach Ex: *Health education program on: diet and nutrition for adults attending a GED program (general equivalency degree) held at the local high school in the evenings Health Fairs, lunch + learn, collaborative programs Diverse Roles at ALL levels of Prevention Secondary prevention: *Designing protocols for lead screening Barriers result from multiple areas of specialization Child abuse or neglect: *Children MUST know that if anything they reveal indicates that they are in danger *the parents and school officials must be told Outreach to ALL *Balance knowledge & skills + help the faith community become a caring place *Collaboration is Essential to the PURPOSE of Parish Nursing *Facilitator: develop support groups or coordinate Meals on Wheels