Chapter 9 Planning for Community Change

14. The nurse is reviewing the sources of funding for the local community health intervention program on smoking cessation. In the federal grant proposal, the nurse elaborates on all the various local organizations and private foundations that have pledged to support the program after initial funding from the grant ends. The nurse also explains the plan for ongoing fundraising efforts for the program for years to come. With these comments, the nurse is attempting to establish which essential component of funding? A) Sustainability B) Program replication C) Clinical expertise D) Accountability

Ans: A Feedback: Sustainability is an important consideration in program planning and a key factor in grant making. Most funding agencies expect programs to give a clear and convincing plan outlining how efforts started with grant funding will be continued after the grant ends. Accountability includes regular communication about how funds were used, details of program activities, and progress toward achieving program goals. The ability to replicate or reproduce a successful program within a different community or with a new population aggregate is a test of the strength of the design of an intervention. The explanation provided in the grant request does not mention the nurse's clinical expertise.

10. As an advocate for leukemia research, the nurse along with many others succeeded in urging the U.S. Congress to debate and vote on a bill that significantly increases federal funding for this research. Which system level would such an intervention address? A) Upstream B) Mainstream C) Sidestream D) Downstream

Ans: A Feedback: Upstream interventions effect change at the societal, environmental, or policy level; such is the case in this scenario. Mainstream interventions effect change at the population or community level. Downstream interventions effect change at the individual level. There is no "sidestream" system level.

17. The nurse reviews the logic model and formal evaluation plan of a grant proposal on a community rabies program. Which requirements should be included in the plan to support accountability? (Select all that apply.) A) Regular communication about funds that were not used B) Details of program activities C) Report of areas where there is no progress toward program goals D) Proof that the program can be reproduced effectively in other settings E)Explanation of how the program will be funded after grant funding expires

Ans: A, B, C Feedback: Accountability includes regular communication about how funds were used, details of program activities, and progress toward achieving program goals. Proof that the program can be reproduced effectively in other settings would establish program replication but would not be required for accountability. An explanation of how the program will be funded after grant funding expires would support the program's sustainability but would not be required for accountability.

12. The nurse decided to approach local organizations for financial and in-kind support for a new community health initiative. On which local resources can the nurse draw? (Select all that apply.) A) Catholic church B) Branch of Bank of America C) Car dealership D) Community Transformation Grant E) The Bill and Melinda Gates Foundation

Ans: A, B, C Feedback: Local banks and other businesses, faith communities, civic groups such as Rotary International or the Junior League, and other local resources may provide seed money, matching funds, or in-kind support for community health programs. The Client Protection and Affordable Care Act has created new opportunities for federal and state (not local) funding of health promotion and prevention programs. These opportunities include Community Transformation Grants that will fund programs to improve nutrition, physical activity, and wellness with priority given to strategies to reduce healthcare disparities. The Bill and Melinda Gates Foundation is a private foundation, not a local resource.

2. The nurse is in charge of a local community program that uses a logic model as a planning and communication tool. Which key components are included in this model? (Select all that apply.) A) Milestones for completing a community health clinic B) Plan to conduct cholesterol screenings C) Need for a nurse practitioner to manage the clinic D) Malaria prevention programs for developing nations E) Possible locations for the health clinic

Ans: A, B, C, E Feedback: A logic model for a community health program is a visual representation of the logic behind the operation of the program—who will receive services (target population), what will be done (activities), when it will happen (timeline), where, and why (program theory). The logic model is a tool for both planning and communication. It helps the community health nurse identify available and needed resources, plan the sequence and timeframe for program implementation, develop a budget, and identify how results will be measured. The logic model also functions to communicate to community leaders and program staff how the program will operate and to demonstrate to key stakeholders and decision makers who will approve or fund it how the program will achieve the desired results. Malaria prevention programs for developing nations would not be included in a local community program.

4. Which changes in the environment (second level from the bottom of the health impact pyramid) make the choice for a healthy behavior the default or easy choice? (Select all that apply.) A) Iodization of salt B) Restrictions on smoking in public places C) Community immunization programs D) Changing food manufacturing to eliminate trans fats E) Treatment of hypertension

Ans: A, B, D Feedback: At the second level from the bottom of the health impact pyramid are interventions that change the environment or options available so that making the choice for a healthy behavior is the "default" or easy choice whereas choosing a less healthy option would require a person to spend more time, effort, or money. Examples include food and drug safety, iodization of salt, elimination of trans fats in food, and restrictions on smoking in public places and work sites. Changing food manufacturing to eliminate trans fats, for example, will have a positive impact on the health of the entire population without people having to change their buying or eating habits and would be sustained over time. At the middle of the pyramid are community health interventions such as immunizations that have a long-term protective effect as well as periodic screenings such as colonoscopy. At the level just above the middle of the pyramid are clinical interventions such as treatment of hypertension, hyperlipidemia, and diabetes.

7. Which aspects of Lewin's change theory will help people visualize and create needed change? (Select all that apply.) A) Unfreezing the status quo B) Changing or moving to a new state C) Enforcing the status quo D) Refreezing to sustain the change or changes made E) Increasing restraining forces

Ans: A, B, D Feedback: In Lewin's model of change, the change process can be visualized as three steps: unfreezing the status quo, changing or moving to a new state, and refreezing to sustain the change or changes made. Force field analysis is a tool used to identify forces that enforce the status quo, not to actually enforce the status quo. The purpose of using levers of change is to increase driving forces and/or to decrease restraining forces—leverage points identified in the force field analysis.

16. The nurse reviews the job descriptions of the community health workers who work with community health nurses and other members of the program team. These workers are responsible for: (Select all that apply.) A) Serving as a cultural and language bridge to members of target population B) Performing minor surgical procedures C) Providing health education and outreach to community D) Offering assistance in accessing services E) Prescribing commonly used medications

Ans: A, C, D Feedback: Community health workers provide a cultural and language bridge to the members of the target population. They work with community health nurses and other members of the program team in both urban and rural areas to provide health education, outreach and assistance in accessing services, translation, and specific interventions. They do not perform minor surgical procedures or prescribe commonly used medications.

13. The nurse researches the role of nurse-managed health centers in the city. Which are common characteristics of these centers? (Select all that apply.) A) Led by advanced-practice nurses B) Serve upper-income mothers and children C) Emphasize health promotion, disease prevention, and health education D) Provide clinical practice for nursing students and faculty E) Offer specialized programs to meet the needs of specific population aggregates

Ans: A, C, D, E Feedback: Nurse-managed health centers (NMHCs) are a unique model of community health services led by advanced-practice nurses and providing a wide range of services and programs to vulnerable and underserved populations. The communities served by NMHCs are usually geographically defined and are most often vulnerable and underserved population aggregates such as the rural poor, migrant farm workers, low-income mothers and children, inner-city neighborhoods, and immigrant communities. The NMHCs emphasize health promotion, disease prevention, and health education. Many provide specialized programs to meet the needs of specific population aggregates such as pregnant and parenting women, teens, or homeless people. Many NMHCs are academic nursing centers established by colleges of nursing to provide service to the community as well as clinical practice and research opportunities for students and faculty and to prepare students with skills to work in medically underserved areas.

1. Which are recommendations made by the World Health Organization's Commission on Social Determinants of Health (CSDH)? (Select all that apply.) A) Improve conditions under which all people are born, grow, live, work, and age B) Provide increased funding for research of genetic disorders C) Ensure more equitable distribution of power, money, and resources D) Instill a sense of personal responsibility for one's health in each person E) Expand knowledge of the social determinants of health

Ans: A, C, E Feedback: The three overall recommendations of the CSDH are to: (1) improve the conditions under which all people are born, grow, live, work, and age to minimum standards; (2) ensure more equitable distribution of power, money, and resources; and (3) expand knowledge of the social determinants of health and establish a system to measure and monitor health inequity. Recommendations did not include providing increased funding for research of genetic disorders or instilling a sense of personal responsibility for one's health in each person.

5. Which exemplify clinical interventions (the level just above the middle of the health impact pyramid)? (Select all that apply.) A) Administration of insulin injections for diabetes B) Restrictions on smoking in public places C) Community immunization programs D) Instruction provided by a nurse regarding proper nutrition E) Treatment of hypertension

Ans: A, E Feedback: At the level just above the middle of the pyramid are clinical interventions such as treatment of hypertension, hyperlipidemia, and diabetes. At the second level from the bottom of the health impact pyramid are interventions that change the environment or options available so that making the choice for a healthy behavior is the "default" or easy choice whereas choosing a less healthy option would require a person to spend more time, effort, or money. Examples include food and drug safety, iodization of salt, elimination of trans fats in food, and restrictions on smoking in public places and work sites. Changing food manufacturing to eliminate trans fats, for example, will have a positive impact on the health of the entire population without people having to change their buying or eating habits and would be sustained over time. At the middle of the pyramid are community health interventions such as immunizations that have a long-term protective effect as well as periodic screenings such as colonoscopy. At the top of the pyramid are counseling and health education.

20. Which best illustrates systems theory? A) School systems in two different counties each setting up their own independent afterschool exercise programs B) Father being challenged to stop smoking because his daughter learned of the hazards of smoking from a smoke cessation program at her middle school C) Hospital requiring all of its nurses to wear an identification badge while on duty D) Physician in one state deciding to stop accepting Medicaid clients, while another physician in another state begins accepting Medicaid clients

Ans: B Feedback: A community is a complex system of human activity conducted within the context of the social and ecological environment. Every family, neighborhood, workplace, school, and recreational facility is itself a system with its own boundaries, rules, and purpose. These systems overlap to the extent that individual people in each family system participate in the activities or are affected by the decisions made within other systems. Social systems engage in reciprocal exchange or flows of information, energy, resources, and goods or services. Systems within the community are interdependent and interconnected. Change in one system leads to reciprocal changes in interconnected systems. The only example given above that reveals this reciprocal relationship between systems is the one in which the father, who is a member of a family system, is influenced by information learned by his daughter from an overlapping system, her middle school. The other answers reflect systems operating independently.

15. After successfully implementing and managing a smoking cessation program in an inner-city neighborhood for 5 years, the group expands the efforts to include a nearby rural community. After a challenging first year, the nurse finds that with a few modifications the program is proving successful in the rural setting, as well. Which essential component of program design has been established by success in the rural community? A) Sustainability B) Program replication C) Clinical expertise D) Accountability

Ans: B Feedback: The ability to replicate or reproduce a successful program within a different community or with a new population aggregate is a test of the strength of the design of an intervention. Sustainability is an important consideration in program planning and a key factor in grant making. Most funding agencies expect programs to give a clear and convincing plan outlining how efforts started with grant funding will be continued after the grant ends. Accountability includes regular communication about how funds were used, details of program activities, and progress toward achieving program goals. The explanation provided in the grant request does not mention the nurse's clinical expertise.

18. Which best defines program replication? A) Ability to replicate a successful program in the same community a second time B) Ability to reproduce a successful program within a different community C) Ability to replicate a successful program with a new sample aggregate D) Ability to implement a successful program with the same population aggregate

Ans: B Feedback: The ability to replicate or reproduce a successful program within a different community or with a new population aggregate is a test of the strength of the design of an intervention and is called program replication.

3. Which characterize health inequities? (Select all that apply.) A) Necessary B) Unfair C) Resulting from social injustices D) Avoidable E) Natural

Ans: B, C, D Feedback: According to Falk-Rafael and Betker (2012), "Health disparities become health inequities when they are unnecessary, unfair, and preventable resulting from social injustices that become engrained in the fabric of society through its social, economic, and political structures, laws, policies, and culture so as to become largely invisible." Health inequities are avoidable inequalities in health between groups of people within countries and between countries and are not in any sense a natural phenomenon.

11. Select the examples of social marketing. (Select all that apply.) A) Ad campaign for a new brand of toothpaste B) Brochure placed in obstetricians' offices promoting the benefits of breastfeeding C) Infomercial on television presenting the advantages of a piece of exercise equipment D) Billboard illustrating the dangers of texting while driving E) Posters placed in college dormitories encouraging condom use

Ans: B, D, E Feedback: Social marketing is the use of marketing principles and practices to change health behaviors or beliefs, social or cultural norms, or community standards to improve health or benefit society. Examples include the use of social marketing to promote health behavior change related to eating fruits and vegetables (5 a day), breastfeeding, active play by children, and following guidelines for cancer screenings. It has also been used to change social and cultural norms related to smoking, texting while driving, condom use, and consumption of trans fats. An ad campaign for a new brand of toothpaste and an infomercial on a piece of exercise equipment are examples of commercial marketing, as they are for profit and intended to help sell a particular product.

6. The nurse prepares community program objectives that are specific, measurable, achievable, relevant, and time bound (SMART) to help in planning interventions and establishing measurement systems to evaluate programs and outcomes. Which is a measurable objective? A) Program will reduce teenage obesity. B) Fewer teens will start smoking. C) Blood pressure for children aged 12 to 18 years in Marks School will be reduced by 5% after petting the dog for 1 day in March 2019. D) Number of older minority residents in Legacy Independent facility receiving a flu shot will triple.

Ans: C Feedback: Blood pressure for children aged 12 to 18 years in Marks School will be reduced by 5% after petting the dog for 1 day in March 2019 is an example of a measurable objective. The other objectives listed are not SMART objectives because the results are not measurable. The objective on teenage obesity should specify by what percentage or in how many teenagers obesity will be reduced and the minimum acceptable amount it will be reduced to, as well as from which population. The objective on teen smoking should specify how many fewer teens will start smoking and from which population. The objective on flu shots should define "older" and "minority" so that the exact population intended can be accurately identified and thus it can be determined at what point the number has "tripled."

8. Which most accurately describes the purpose of force field analysis? A) Unfreezing the status quo B) Changing or moving to a new state C) Identifying the forces driving the change and those resisting it D) Refreezing to sustain the change or changes made

Ans: C Feedback: Force field analysis involves identifying factors within a community or organization that are driving or reinforcing change in the desired direction, as well as those that are restraining or resisting change. The change process in Lewin's model of change can be visualized as three steps of unfreezing the status quo, changing or moving to a new state, and refreezing to sustain the change or changes made.

21. Which is the first step in developing a plan for evaluating a community-level intervention? A) Determine indicators or measures to answer evaluation questions B) Decide what method you will use to collect data C) Develop evaluation questions D) Decide how you will communicate your results

Ans: C Feedback: Steps in developing a plan for evaluating a community-level intervention include the following: (1) Develop evaluation questions "focused on what happened, how well it happened, why it happened the way it did, and what the results were"; (2) Determine indicators or measures you will use to answer your evaluation questions; (3) Identify where you will find the data you need to measure your indicators and answer your questions; (4) Decide what method you will use to collect data; (5) Specify the time frame for when you will collect data; (6) Plan how you will analyze your data on the basis of the type of data you are using; (7) Decide how you will communicate your results.

19. The nurse is in the process of forming a coalition to support a community flu shot program. Which step should the nurse take as part of this process? (Select all that apply.) A) Assign members of the coalition to tasks in a random manner. B) Seek out people with similar opinions and roles in the community. C) Consider how each member of the coalition and the organization or group represented will benefit from the work of the coalition. D) Understand group dynamics and members' motives for serving. E) Form a group that is heterogeneous but able to show mutual respect.

Ans: C, D, E Feedback: Organizers of a coalition should do the following: (1) Make use of the expertise of individual members by asking for their help and input on matters directly related to their field. (2) Seek out people with a range of opinions and roles in the community. Find out who has been a valuable member of previous community coalitions or teams. (3) Consider how each member of a coalition and the organization or group he or she represents will benefit from the work of the coalition. (4) Understand group dynamics and remember that people agree to serve on coalitions in exchange for more than feeling good about helping address a community issue. (5) Try to have a heterogeneous group but one in which members are able to show mutual respect and listen to each other's ideas without criticism of the person.

9. The nurse researches whether the community would benefit from monthly blood pressure clinics. Which system level would such an intervention address? A) Upstream B) Mainstream C) Sidestream D) Downstream

Ans: D Feedback: Mainstream interventions effect change at the population or community level, as in this scenario. Upstream interventions effect change at the societal, environmental, or policy level. Downstream interventions effect change at the individual level. There is no "sidestream" system level.