Community Exam 1

Healthy People 2030: Child and Adolescent Health

"Healthy People 2030" is a set of science-based, 10-year national objectives for improving the health of all Americans. It is developed by the U.S. Department of Health and Human Services (HHS) and is designed to provide a framework for public health initiatives and policies. The program sets specific, measurable goals and objectives to address various health issues. Regarding Child and Adolescent Health in the context of Healthy People 2030, the initiative aims to improve the physical, mental, and social well-being of children and adolescents. This includes addressing factors that contribute to healthy development, preventing health issues, and promoting overall well-being. Key areas of focus for Child and Adolescent Health in Healthy People 2030 may include: Physical Health: Ensuring that children and adolescents have access to preventive healthcare services, vaccinations, and nutrition, promoting healthy habits like regular exercise, and addressing issues such as obesity. Mental Health: Addressing mental health challenges, promoting positive mental well-being, and preventing conditions like anxiety and depression. This might involve improving access to mental health services and reducing stigma around seeking help. Substance Use: Preventing substance abuse among adolescents and promoting a substance-free lifestyle. This could involve educational programs, community initiatives, and policies to restrict access to harmful substances. Safety and Injury Prevention: Implementing strategies to reduce injuries and accidents among children and adolescents, whether at home, school, or in the community. This might involve promoting safety measures and educating parents, caregivers, and communities. Social Determinants of Health: Addressing social factors that influence health, such as access to education, economic stability,

Thinking Upstream

"Thinking upstream" is a concept often associated with a macroscopic or upstream approach to addressing public health issues. It involves looking beyond individual behaviors and immediate causes of health problems to focus on the underlying social, economic, and environmental determinants that contribute to those issues. The upstream approach recognizes that many health challenges are shaped by broader systemic factors and seeks to address these root causes to prevent or mitigate health problems. Here are key aspects of "thinking upstream" in the context of a macroscopic conceptualization of community health problems: Focus on Determinants: Macroscopic Perspective: "Thinking upstream" involves examining the social determinants of health, including factors such as income, education, employment, housing, and access to healthcare. Example: Instead of focusing solely on individual smoking behaviors, an upstream approach might explore the socio-economic factors that contribute to higher smoking rates in certain communities, such as limited access to education and job opportunities.

Nurses as Lobbyists

A lobbyist is a person who, voluntarily or for a fee, represents himself or herself, another individual, an organization, or an entity before the legislature. A lobbyist typically represents special-interest groups. The term derives from the fact that lobbyists usually stay in the areas (lobbies) next to the Senate and House chambers, seeking to speak with legislators and their aides as they walk to and from the chambers, or as lobbyists await legislative action that might affect their interests. To lobby is to try to influence legislators; it is an art of persuasion. Influencing lawmakers to pass effective health legislation requires the participation of individual nurses and nursing organizations.

Health Planning Model

A model based on Hogue's (1985) group intervention model was developed in response to this need for population focus. The Health Planning Model aims to improve aggregate health and applies the nursing process to the larger aggregate within a systems framework. Incorporated into a health planning project, the model can help students view larger client aggregates and gain knowledge and experience in the health planning process. Nurses must carefully consider each step in the process, using this model.

Morbidity: Prevalence

A prevalence rate is the number of all cases of a specific disease or condition (e.g., deafness) in a population at a given point in time relative to the population at the same point in time: When prevalence rates describe the number of people with the disease at a specific point in time, they are sometimes called point prevalences. For this reason, cross-sectional studies frequently use them. Period prevalences represent the number of existing cases during a specified period or interval of time and include old cases and new cases that appear within the same period.

Accreditation

Accreditation is one means to assess the quality of services and care of the organization. Specific minimum standards must be met by an organization to obtain accreditation. Indeed, accreditation serves the purpose of instilling public confidence in a program, institution, or organization (NAM, 2016). Purchasers of care, including insurers and MCOs, are concerned about the accreditation status of healthcare organizations when they negotiate reimbursement contracts. Other entities, such as nursing schools and medical schools, which use healthcare organizations for clinical sites, are also concerned with accreditation status.

Racial and Ethnic Disparities

Although children in the United States are healthier now than in any other time in our nation's history, overall improvements in health mask the poor health of some racial and ethnic subgroups (Fig. 16.4). For example, as mentioned previously, the infant mortality rate has plunged over the past century, yet infants born to non-Hispanic black women are 2.5 times more likely to die in the first year of life than babies born to non-Hispanic white mothers. Native Americans and African Americans account for a disproportionate share of disabilities and deaths due to fetal alcohol exposure. African American youth are at higher risk for gun violence than white youth and are more than four times as likely to die from asthma as non-Hispanic white children. Childhood obesity affects racial and ethnic minority children at much higher rates than non-Hispanic whites, driving up rates of associated diabetes.

Leininger's theory of culture care diversity and universality

Although many nurse-scholars have developed theories of nursing, Leininger's theory of culture care diversity and universality is the only one that gives precedence to understanding the cultural dimensions of human care and caring. Leininger's theory is concerned with describing, explaining, and projecting nursing similarities and differences focused primarily on human care and caring in human cultures. Leininger used worldview, social structure, language, ethnohistory, environmental context, and the generic or folk and professional systems to provide a comprehensive and holistic view of influences in cultural care and well-being. The following three models of nursing decisions and actions may be useful in providing culturally congruent and competent care

Analytic Epidemiology:

Analytic epidemiology investigates the causes of disease by determining why a disease rate is lower in one population group than in another. This method tests the 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 (see previous section on causality). To determine this relationship, the epidemiologist may undertake two major types of research studies: observational and experimental.

Experimental Studies

Another type of analytic study is the experimental design, called the randomized clinical trial (Fig. 5.8). Epidemiological investigations apply experimental methods to test treatment and prevention strategies. The investigator randomly assigns subjects at risk for a particular disease to an experimental or a control group. The investigator observes both groups for the occurrence of disease over time, but only the experimental group receives intervention, although often the control group receives a placebo. The primary statistical analysis is based on "intention to treat," that is, all subjects remain assigned to the original treatment group, regardless of whether subjects may have decided on their own to discontinue or change their therapy. For example, if a subject in a drug trial who is assigned to the active medication experiences side effects possibly from this medication and therefore discontinues the medication, this subject still is considered to be within the active drug group for the purpose of statistical testing. The change in category from treatment to no treatment, or vice versa, is called a crossover and may decrease the likelihood of finding a significant effect for the active treatment.

Naturalistic Perspective

Another way in which clients may explain the cause of illness is from the naturalistic (i.e., holistic) perspective. This viewpoint is found most frequently among Native Americans, Asians, and others who believe that human life is only one aspect of nature and a part of the general order of the cosmos. Individuals from these groups believe that the forces of nature must be kept in natural balance or harmony to maintain health and well-being. A combination of worldviews is possible, and many clients are likely to offer more than one explanation for the cause of their illness. As a profession, nursing largely embraces the biomedical-scientific worldview, but some aspects of holism have begun to gain popularity. These include a wide variety of techniques for management of chronic pain (e.g., hypnosis, therapeutic touch, and biofeedback). Many nurses hold a belief in spiritual power and readily credit supernatural forces with various unexplained phenomena related to clients' health and illness states.

Magicoreligious Perspective

Another way in which people explain the causation of illness is from a magicoreligious perspective. The basic premise of this explanatory model is that the world is seen as an arena in which supernatural forces dominate. The fate of the world and those in it depends on the action of supernatural forces for good or evil. Examples of magical causes of illness include the belief in voodoo or witchcraft among some African Americans and others from circum-Caribbean countries. Faith healing is based on religious beliefs and is most prevalent among selected Christian religions, including Christian Scientists. Various healing rituals (prayer, anointing, exorcism, laying of hands, etc.) may be found in many religions—Roman Catholicism, Mormonism (i.e., Church of Jesus Christ of Latter-day Saints), and others

Childhood Health Issues

At all ages, appropriate and timely medical care plays an important role in children's health status. However, other factors, including parental influences, nutrition, environment, community safety, and the overall quality of home life, exert even stronger influences over a child's well-being. Childhood is generally a healthy time of life, as evidenced by the improvement in many indicators of child health status over the past century. For example, the incidence of childhood disease has diminished because the majority of children receive a full complement of immunizations during infancy and toddlerhood.

Purpose of Case Management

Case management, care management, and care coordination are patient-centered and system-centered processes. Case management focuses on care coordination, financial management, and the utilization of resources for a patient-centered plan of care. Patient-centered case management improves self-management of chronic disease; helps the client or patient proceed through a complex, fragmented, and often confusing healthcare delivery system; and achieves specific client-centered goals. System-centered processes recognize that healthcare resources are finite. The upward spiral in healthcare costs leads third-party payers such as Medicare, managed care organizations, and commercial payers to demand cost-effective healthcare. Providers are reimbursed for care provided on the basis of value-based purchasing; this includes hospitals, skilled-nursing facilities, home health organizations, and practitioners. Client consumers insist on cost-effective, efficient, high-quality care. This demand forces healthcare providers to reevaluate the way they administer care, to emphasize quality improvement, and to focus on decreasing cost. Healthcare resources then become allocated to those populations with the greatest needs. Case management is used to promote and integrate the coordination of clinical services, linking patients to community services and agencies. Case managers monitor resources used by clients, support collaborative practice and continuity of care, and enhance patient satisfaction

Healthcare Use

Children grow and develop rapidly between infancy and adolescence; therefore, they are extremely vulnerable to the effects of illness and of environmental factors that influence physical and emotional health. Preventive health and dental care offer children and parents a chance to periodically meet with a healthcare provider to do the following: • Discuss the child's physical and emotional growth and development. • Learn about good nutrition. • Address safety issues, such as the use of car seats and seatbelts. • Receive immunizations and vision and hearing screening. • Learn about potential environmental threats to the child's health. • Begin prompt treatment for a condition discovered during the examination. • Ask other questions or obtain a referral if necessary. Access to a regular healthcare source can facilitate prompt attention to acute medical problems, which can help prevent chronic, disabling conditions. For example, untreated ear infections can cause hearing loss, which can lead to learning disabilities, school problems, and even school dropout. Resulting low self-esteem can increase the likelihood of depression, behavior problems, early sexual activity, STIs, and unplanned pregnancy. Comprehensive, regular health care helps all children achieve their potential.

Community Empowerment

Community empowerment is a central tenet of community organization, whereby community members take on greater power to create change. It is based on community cultural strengths and assets. An empowerment continuum acknowledges the value and interdependence of individual and political action strategies aimed at the collective while maintaining the community organization as central (Minkler et al., 2012). As such, community organization reinforces one of the field's underlying premises as outlined by Nyswander (1956): "Start where the people are." Furthermore, Labonte (1994) states that the community is an engine of health promotion and a vehicle for empowerment. He describes five spheres of an empowerment model, which focus on the following levels of social organization: interpersonal (personal empowerment), intragroup (small-group development), intergroup (community), interorganizational (coalition building), and political action.

community health nursing vs community-based nursing

Community health Nursing-the synthesis of nursing practice and public health practice applied to promoting and preserving the health of populations This viewpoint noted that a community health nurse directs care to individuals, families, or groups; this care, in turn, contributes to the health of the total population. Community-based nursing practice refers to "application of the nursing process in caring for individuals, families and groups where they live, work or go to school or as they move through the healthcare system"

Cultural Self-Assessment

Community health nurses can engage in a cultural self-assessment. Through identification of health-related attitudes, values, beliefs, and practices that are part of the personal cultural meaning brought to the nurse-client interaction, the nurse can better understand the cultural aspects of healthcare from the perspective of the client, family, group, or community. Everyone has ethnocentric tendencies that must be brought to a level of conscious awareness so that efforts can be made to temper ethnocentrism and view reality from the perspective of the client.

Epidemiological Triangle

Concept: The Epidemiological Triangle, also known as the Disease Triangle, is a classic model that depicts the interaction among three components: host, agent, and environment. Components: Host: The individual or population at risk of the disease. Agent: The infectious or non-infectious factor that causes the disease (e.g., a pathogen, chemical, or behavior). Environment: The external factors that influence the occurrence and distribution of the disease.

Web of Causation Model

Concept: The Web of Causation model illustrates the complex interplay of multiple factors contributing to a health outcome. It emphasizes the interconnectedness of various causes and how they interact in a web-like structure. Features: Factors may include biological, social, environmental, and behavioral elements. The model suggests that no single factor is solely responsible for a disease; instead, they interact in a multifactorial way.

Person, Place, and Time Model

Concept: This model is often used in outbreak investigations and focuses on three key dimensions: person, place, and time. Components: Person: Examines characteristics of individuals affected by the disease, including demographics, health status, and behaviors. Place: Analyzes the geographic distribution of cases to identify patterns and clusters. Time: Investigates when cases occur, looking for temporal trends and associations.

Modifiable Risk Factors

Modifiable risk factors are those aspects of a person's health risk over which he or she has control. Examples include smoking, leading a sedentary or active lifestyle, the type and amount of food eaten, and the type of activities in which he or she engages (skydiving is riskier than bowling).

Cross-Sectional Studies

Cross-sectional studies, sometimes called prevalence or correlational studies, examine relationships between potential causal factors and disease at a specific time (Fig. 5.5). Surveys that simultaneously collect information about risk factors and disease exemplify this design. For example, the National Health and Nutrition Examination Survey (NHANES) has collected cross-sectional data regarding current dietary practices, physical status, and health in adults and children in the United States since the early 1960s (CDC, 2021). Data from the NHANES studies have been analyzed and compared over the years by a number of researchers and have provided important health information.

Descriptive Epidemiology

Descriptive epidemiology focuses on the amount and distribution of health and health problems within a population. Its purpose is to describe the characteristics of both people who are protected from disease and those who have a disease. Factors of particular interest are age, sex, ethnicity or race, socioeconomic 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 more prone to acquiring disease. In addition to "person" characteristics, the place of occurrence describes disease frequency. For example, certain parasitic diseases, such as malaria and schistosomiasis, occur in tropical areas.

Pender's Health Promotion Model

Developed in the 1980s and revised in 1996, Pender's Health Promotion Model (HPM) explores the myriad biopsychosocial factors that influence individuals to pursue health promotion activities. The HPM depicts the complex multidimensional factors with which people interact as they work to achieve optimum health. This model contains seven variables related to health behaviors, as well as individual characteristics that may influence a behavioral outcome.

Discriminatory land use

Discriminatory land use ensures that many impoverished and marginalized groups, especially minorities, live in close proximity to industrial contamination (Collins, 2011; Nweke, 2011). People who live near such environmental hazards are in danger of becoming victims of illness and injury related to violence, poisonings and exposures, fires, and malignant and nonmalignant diseases. Clinical Example 14.1 provides an example. Though historically outdoor pollution and hazards have been considered the major contributors affecting environmental quality, one must also consider the influence of indoor residential environmental hazards, such as radon, asbestos, lead, insect and pet allergens, chemicals, and other consumer products, as well as secondhand smoke and fungi

Family and Medical Leave Act

Enacted in 1993, the Family and Medical Leave Act (FMLA) allows an employee a minimum provision of 12weeks unpaid leave each year for family and medical reasons such as personal illness; an ill child, parent, or spouse; and the birth or adoption of a child. In 2008, the FMLA was updated to include family providing care to members of the Armed Forces injured in the line of duty. This act guarantees the employee the same or an equivalent job with the same pay and benefits upon the employee's return to work. In addition, health benefits must continue throughout the leave. In 2018, 15% of employees utilized FMLA, the most common reason was for personal illness (51%) followed by care of a new child (25%) and care of a family member (19%). On average, women took longer leaves with an average of 35days (Brown et al., 2018).

Environmental health histories

Environmental health histories should be obtained for both adults and children, although the relationship between the environment and children's health is frequently overlooked. Fig. 14.2 demonstrates common assessment items of an environmental history. When looking at the community from a critical perspective, nurses have the opportunity to promote population health. In identifying environmental sources of health problems, nurses must be involved with the affected communities. Rather than impose their views of the problem, nurses should share their ideas and dialogue with community members. For example, nurses should listen to what the community believes is problematic, help raise consciousness about environmental dangers, and help bring about change. If nurses become involved in conducting community assessments and analyses, they can learn how the community members perceive themselves, their health, and their environmental influences.

Observational Studies

Epidemiologists frequently use observational studies for descriptive purposes, but they also use them to discover the etiology of disease. The investigator can begin to understand the factors that contribute to disease by observing disease rates in groups of people differentiated by experience or exposure. For example, differences in disease rates may occur in the obese compared with the nonobese, in smokers compared with nonsmokers, and in those with high stress levels compared with those with low stress levels. These characteristics (i.e., obesity, smoking, and stress) are called exposure variables. Unlike experimental studies, observational studies do not allow the investigator to manipulate the specific exposure or experience or to control or limit the effects of other extraneous factors that may influence disease development.

Monitoring and Tracking

Federal, state, and local governments and many national organizations collect and analyze data to track the well-being of children and adolescents. For example, the Maternal and Child Health Bureau of the Health Resources and Services Administration (HRSA/MCHB, 2020) generates a yearly report, Child Health USA, on child population characteristics, health status, and healthcare utilization. Such data are readily accessible online to citizens, health professionals, policy makers, and the media. A number of key indicators are tracked on a regular basis by the federal statistical system so that trends are revealed. State and local data also are used to track the well-being of children.

Food Safety

Food safety refers to availability, accessibility, and relative cost of healthy food free of contamination by harmful herbicides, pesticides, and bacteria. Food safety concerns include malnutrition, bacterial food poisoning (Clinical Example 14.6), carcinogenic chemical additives (e.g., nitrites, dyes, and cyclamate), improper or fraudulent meat inspection or food labeling, microbial epidemics among livestock (e.g., Escherichia coli), food products from diseased animal sources, and disruption of vital natural food chains by ecosystem destruction. Increased mobility and globalized trade also contribute to global contamination of the food supply. Finally, there are significant disparities in access to healthy and fresh food supplies, with poor minority families being more likely to live in a food desert—a neighborhood with little to no access to healthy foods (Institute of Medicine [IOM], 2009).

Disparity in Healthcare Delivery

Health disparities refer to observable or quantifiable differences in the presence of disease, health outcomes, or access to healthcare among different groups or populations. In the United States, health disparities have long been recognized as particularly problematic among ethnic minorities, including blacks, Native Americans, and Hispanics. Research indicates that often these groups have a higher prevalence of chronic conditions and higher rates of mortality and poorer health outcomes when compared with the white population. Furthermore, it is recognized that in addition to racial or ethnic group, health disparities adversely affect those based on such factors as socioeconomic status; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; or geographic location.

HMO

In HMO plans, preventive care is covered and encouraged, but specialty care is somewhat restricted, and HMOs are encouraged to reduce costs by providing only the most necessary services. This loss of choice led to a decrease in the popularity of HMOs. In the United States, the number of HMO plans peaked in the mid-1990s, when about 31% of the population was enrolled in them, and they continue to represent a small portion of the plans. In early years, HMOs were considerably less expensive than other insurance plans, but the difference is now relatively small. In 2010, about 19% of enrollees selected HMO plans, but their popularity has continued to decline, as in 2020 only 13% selected HMOs

Morbidity: Incidence

Incidence rates describe the occurrence of new cases of a disease (e.g., tuberculosis, influenza) or condition (e.g., teen pregnancy) in a community over a given period relative to the size of the population at risk for that disease or condition during that same period. The denominator consists of only those at risk for the disease or condition; therefore known cases or those not susceptible (e.g., those immunized against a disease) are subtracted from the total population

I PREPARE: Development and Clinical Utility of an Environmental Exposure History Mnemonic

I—Investigate Potential Exposures P—Present Work R—Residence E—Environmental Concerns P—Past Work A—Activities R—Referrals and Resources E—Educate

Local Health Department Subsystems

LHDs are generally responsible for the direct delivery of public health services and protection of the health of citizens, although not all communities/counties have LHDs. State and local (i.e., city and county) governments delegate the authority to conduct these activities. The organization of LHDs varies widely depending on community size, economics, partnerships with the private healthcare system, healthcare facilities, business support, healthcare needs, transportation, and the number of citizens requiring public healthcare. Some LHDs function as district offices of the state health department; others are responsible to local government and the state; and still others—particularly those in large cities—are autonomous. An LHD may be a separate agency or a division within an agency, such as the HHS.

Life expectancy

Life expectancy for Americans is at an all-time high, but the discrepancy between males and females remains. Males born in 2019 have a life expectancy of 76years, compared with 81years for females. This suggests a trend toward narrowing the gap between male and female life expectancies. Ethnic/racial disparities in life expectancy unfortunately continued into the twenty-first century, as there is considerable variation among races. For example, black females gained an additional 7.1 years, from 69.4years for those born in 1970 to 78years for those born beginning in 2005. Although that is a significant gain, it falls behind the 81years of life expectancy for white females born in 2018 and has not changed since 2005

Macroscopic conceptualizations of community health problems

Macroscopic Conceptualization: Focus: Macroscopic conceptualizations broaden the perspective to include larger social, economic, and environmental determinants of health problems. Level of Analysis: This approach considers factors at the community, societal, or systemic level that influence health outcomes. Examples: Analyzing social determinants of health like income inequality, access to education, healthcare policies, and community infrastructure that may contribute to health disparities. Interventions: Interventions based on a macroscopic conceptualization might involve policy changes, community development initiatives, or addressing structural factors that contribute to health inequalities.

Public Health Nursing, Managed Care, and Health Reform

Managed care refers to any method of healthcare delivery designed to reduce unnecessary use of services, improve cost containment or cost-effectiveness, and ensure high-quality care. Managed care is currently one of the predominant forces in healthcare delivery. It affects healthcare organizations, healthcare providers, and reimbursement and has a direct influence on what care is provided and by whom, where, when, and whether it is to be provided. Chapter 12 provides additional information on managed care and reimbursement.

Medicaid/ Children's Health Insurance Program (CHIP)

Medicaid (Title XIX of the Social Security Act) is a health insurance program for poor and low-income people. It is a federal/state entitlement program that plays an important role in providing health coverage for low-income women and children. The federal government sets the minimum guidelines for Medicaid eligibility, and states can chose to expand eligibility through the Children's Health Insurance Program (CHIP). Depending on the state, the average CHIP income eligibility level for children is 170% to 400% of the FPL. Together, Medicaid and CHIP serve about half of all low-income children

Medicare

Medicare is a federal entitlement program that is totally funded by a combination of payroll taxes, general federal taxes, and beneficiary premiums. This program is intended to help cover the costs of health care for people 65 years of age and older and people who are disabled, have end-stage renal disease, or have been diagnosed with amyotrophic lateral sclerosis. Medicare is divided into four parts. Medicare Part A is basically hospital insurance. Services covered by Medicare Part A include inpatient care in hospitals and skilled nursing facilities (not unskilled or long-term care). It also covers hospice care and some home health care. Most US residents are eligible for premium-free Medicare Part A benefits when they reach age 65, on the basis of their own or their spouse's employment. Although Medicare Part A is an entitlement program, the enrollee must pay a deductible for health services. The Part A deductible is the beneficiary's only cost for up to 60 days of Medicare-covered inpatient hospital care in a benefit period. Beneficiaries have to pay an additional copayment per day for days 61 through 90, and this copayment increases per day for hospital stays beyond the 90th day in a benefit period. The Centers for Medicare & Medicaid Services (CMS) Website (http://www.cms.gov) provides current information on costs for beneficiaries.

Microscopic conceptualizations of community health problems

Microscopic Conceptualization: Focus: Microscopic conceptualizations zoom in on individual-level factors and behaviors that contribute to health problems. Level of Analysis: This approach looks at specific individuals, their behaviors, lifestyles, and health-related choices. Examples: Examining factors such as individual smoking habits, dietary choices, exercise patterns, and healthcare-seeking behaviors at the level of the individual. Interventions: Interventions based on a microscopic conceptualization might include individual counseling, educational campaigns targeting specific behaviors, or clinical treatments.

Disability

More women than men have disabilities resulting from acute conditions, but women experience fewer disabilities resulting from chronic conditions because they report their symptoms earlier and receive necessary treatment. Women report proportionately more days of restricted activity than men.

Nonmodifiable Risk Factors

Nonmodifiable risk factors are those aspects of one's health risk over which one has no or little control. Examples include genetic makeup, gender, age, and environmental exposure.

Culturally competent community health nursing

Nurses' knowledge of culture and cultural concepts improves the health of the community by enhancing their ability to provide culturally competent care. Cultural competence is respecting and understanding the values and beliefs of a certain cultural group so that one can function effectively in caring for members of that cultural group. Culturally competent community health nursing requires that nurses understand the lifestyle, value system, and health and illness behaviors of diverse individuals, families, groups, and communities. Nurses should also understand the culture of institutions that influence the health and well-being of communities. Nurses who have knowledge of, and an ability to work with, diverse cultures are able to devise effective interventions to reduce risks in a manner that is culturally congruent with community, group, and individual values.

Ethnocentrism

One of the major challenges that community health nurses face in working with clients from culturally diverse backgrounds is overcoming individual ethnocentrism, which is a person's tendencies to view his or her own way of life as the most desirable, acceptable, or best and to act in a superior manner toward individuals from another culture. Nurses also must beware of cultural imposition, which is a person's tendency to impose his or her own beliefs, values, and patterns of behavior on individuals from another culture. When clients' cultural values and expressions of care differ from those of the nurse, the nurse must exercise caution to ensure that mutual goals have been established.

Time Orientation

People can perceive time in the following three ways: • The focus may be on the past, with traditions and ancestors playing an important role in the client's life. For example, many Asians, Native Americans, East Indians, and Africans hold particular beliefs about ancestors and tend to value long-standing traditions. In times of crisis, such as illness, individuals with a values orientation emphasizing the past may consult with ancestors or ask for their guidance or protection during the illness. • The focus may be on the present, with little attention paid to the past or the future. Individuals with this focus are concerned with the current situation, and they perceive the future as vague or unpredictable. Nurses may have difficulty encouraging such individuals to prepare for the future (e.g., to participate in primary prevention measures). • The focus may be on the future, with progress and change highly valued. Individuals with a future focus may express discontent with the past and present. In terms of healthcare, they may inquire about the "latest treatment" and the most advanced equipment available for a particular problem. The dominant U.S. cultural group is characterized by a belief in progress and a future orientation. This combination implies a strong task or goal focus. The group has an optimistic faith in what the future will bring. Change is often equated with improvement, and a rapid rate of change is usually normal.

A Major Paradigm Shift

Policy is based on values, and the first step in forming policy is identifying the issue. Therefore it would seem rational to define "health" as the starting point for any policy annexed to healthcare issues. Historically, health was defined in the context of infectious diseases. Current definitions encompass prevention and management of chronic conditions. The World Health Organization (WHO) considers health to be the state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. Despite this broad definition, it is only in the most recent decades that the WHO is refocusing on its initial definition as it attempts to deal with environmental issues such as nuclear contamination and industrial toxins in industrialized nations and the exploration of carcinogenic commercial products such as tobacco products. On a global level, the WHO is working to prevent, treat, and care for communicable diseases such as HIV/AIDS, tuberculosis, malaria, and, most recently, the Zika virus. In addition, WHO focuses on noncommunicable diseases such as heart disease, stroke, cancer, diabetes, and lung diseases, which are responsible for more than 70% of all deaths worldwide. WHO emphasizes promoting health through the life cycle, taking into account environmental risks and social determinants of health. Thus there is a realization that health is a basic human right and that health problems are linked to government actions and, hence, affect human rights.

Poverty

Poverty is the greatest threat to child health. Child poverty in the United States is higher than in most other industrialized countries, and the rate is rising. About 11 million (14.4%) of the nation's children live below the federal poverty level (FPL) (Haider, 2021). The official poverty level is calculated by using poverty thresholds that are issued each year by the U.S. Census Bureau. The thresholds represent the annual amount of cash income minimally required to support families of various sizes. The 2021 poverty guideline for a family of three in the 48 contiguous states and the District of Columbia was $21,960 (USDHHS, 2021a,b). Many more children (about 41%) live in low-income families that are close to the poverty level and unable to meet basic living expenses. Children are far more likely than adults to live in poverty. Poverty rates are highest for black, Hispanic, and American Indian children

PRECEDE-PROCEED framework

Predisposing factors: The knowledge, attitudes, behavior, beliefs, and values before intervention that affect willingness to change. Enabling factors: The environment or community of an individual that facilitates or presents obstacles to change. Reinforcing factors: The positive or negative effects of adopting new behavior (including social support).

Primary prevention

Primary prevention relates to activities directed at preventing a problem before it occurs by altering susceptibility or reducing exposure for susceptible individuals. Primary prevention consists of two elements: general health promotion and specific protection. Example: immunization

Prospective Studies

Prospective studies monitor a group of disease-free individuals to determine whether and when disease occurs (Fig. 5.7). These individuals, or the cohort, have a common experience within a defined period. For example, a birth cohort consists of all people born within a given period. The study assesses the cohort with respect to an exposure factor associated with the disease and thus classifies it at the beginning of the study. The study then monitors the cohort for disease development. The investigator compares the disease rates for those with a known exposure and the disease rates for those who remain unexposed. The study observes subjects prospectively; therefore, it summarizes data collected over time by the incidence rates of new cases (Box 5.8). Again, comparing two incidence rates produces a measure of relative risk:

Retrospective Studies

Retrospective studies compare individuals with a particular condition or disease and those who do not have the disease. These studies determine whether cases, or a diseased group, differ in their exposure to a specific factor or characteristic relative to controls, or a nondiseased group. To make unambiguous comparisons, investigators select the cases according to explicitly defined criteria regarding the type of case and the stage of disease. Investigators also select a control group from the general population that is characteristically similar to the cases (Fig. 5.6). Frequently, people hospitalized for diseases that are not under study become controls if they do not share the exposure or risk factor under study. For example, a researcher may select patients with heart disease to be controls in a study of patients with lung cancer.

Secondary prevention

Secondary prevention refers to early detection and prompt intervention during the period of early disease pathogenesis. Secondary prevention is implemented after a problem has begun, but before signs and symptoms appear, and targets those populations that have risk factors. Examples: Mammography, blood pressure screening, COVID-19 testing, and prostate-specific antigen (PSA) tests are examples of secondary prevention.

Tobacco and health risk

Smoking is a causal factor in cancers of the esophagus, bladder, stomach, oral cavity, pharynx, larynx, cervix, and lungs, with more than 90% of lung cancers in men and 80% of lung cancers among women attributable to smoking. Over 16 million Americans are currently living with a disease caused by smoking. Smoking harms nearly every organ in the body Smoking also has an economic impact, costing $170 billion annually in healthcare and lost productivity. Most smokers are between the ages of 18 and 44 years, and more men than women smoke. In 2019, 15.3% of adult men and 12.7% of adult women were smokers. The prevalence of smoking is highest among American Indians/Alaskan Natives and Caucasians. Smoking is most common among adults who are less educated and adults who live below the poverty level. Smoking rates are higher in the Midwest and lowest in the western US. Persons with a disability smoke at a higher rate than do persons without a disability. Gay, lesbian, and bisexual adults are more likely to smoke than straight Americans (CDC, 2020).

Sudden Unexplained Infant Death

Sudden unexplained infant death (SUID) is defined as death in an infant less than 1 year of age that occurs suddenly and unexpectedly, the cause of which is not immediately obvious before investigation. About 3500 infants die each year from SUID. Later investigation may reveal death in infants with SUID to be from poisoning, metabolic disorders, hyperthermia or hypothermia, neglect and homicide, and suffocation. About half of the infants who die from SUID die from SIDS, defined as the sudden death of an infant less than 1 year of age that cannot be explained after a thorough investigation is conducted, including a complete autopsy, examination of the death scene, and review of the clinical history.

Transitional Care Management

TCM patients are referred by practitioners or hospital staff for follow-up face-to-face visits with the outpatient practitioner and care coordination services for 30 days postdischarge. Patients are educated about new medications, condition-specific processes, and discharge instructions. As mentioned, care is coordinated for the patient, including a follow-up face-to-face visit with a practitioner. The goal of this program is to improve patient outcomes, increase understanding of condition-specific issues, and decrease hospital readmissions

Tertiary Prevention

Tertiary prevention targets populations that have experienced disease or injury and focuses on limitation of disability and rehabilitation. Aims of tertiary prevention are to keep health problems from getting worse, to reduce the effects of disease and injury, and to restore individuals to their optimal level of functioning. Examples: teaching how to perform insulin injections and disease management to a patient with diabetes, referral of a patient with spinal cord injury for occupational and physical therapy, and leading a support group for grieving parents.

Hospitalizations

The 2016 National Hospital Care Survey (NHCS) reported that more women than men are hospitalized each year in the United States (NHCS, 2016). Of the top 10 most common hospital diagnoses five are related to childbirth and pregnancy. Rounding out the top 10 are septicemia, osteoarthritis (OA), heart failure, chronic obstructive pulmonary disease, and urinary tract infections

Affordable Care Act (ACA) of 2010

The ACA law, also referred to as Obamacare, has three primary goals: 1. Make affordable health insurance available to more people. The law provides consumers with subsidies ("premium tax credits") that lower costs for households with incomes between 100% and 400% of the federal poverty level (FPL). Note: If your income is above 400% FPL, you may still qualify for the premium tax credit in 2021. 2. Expand the Medicaid program to cover all adults with income below 138% of the FPL. (Not all states have expanded their Medicaid programs.) 3. Support innovative medical care delivery methods designed to lower the costs of healthcare generally Healthcare.gov (2021). This act placed individuals, families, and small business owners in control of their healthcare. It reduced premium costs for millions of working families and small businesses by providing hundreds of billions of dollars in tax relief—the largest middle-class tax cut for healthcare in history. It also reduced what families paid for healthcare by capping out-of-pocket expenses and requiring preventive care to be fully covered without any out-of-pocket expense. It attempted to keep insurance companies honest by setting clear rules that rein in the worst insurance industry abuses. And it prohibited insurance companies from denying insurance coverage because of a person's preexisting medical conditions while giving consumers new power to appeal insurance company decisions that deny doctor-ordered treatments covered by insurance

Chronic Care Management

The CMS has recently developed criteria and reimbursement for chronic care management (CCM) and TCM in the primary care setting. Patients are referred to the CCM program by a practitioner who has identified the patient as having two or more chronic conditions that put the patient at a high risk of functional decline or death within the next 12 months (CMS.gov, 2021). Care coordinators work with patients and their caregivers to improve self-management of the disease process via support and education and coordinate care to empower patients to access care appropriately and efficiently.

Occupational Safety and Health Act

The Occupational Safety and Health Act, enacted in 1970, helps ensure safe and healthful working conditions for workers throughout the United States. Women experience work related musculoskeletal injuries, job stress, reproductive and cancer hazards, and workplace violence that impacts their overall health (National Institute for Occupational Safety and Health, 2001). For example, little is known about women who work in cottage industries, as domestic workers, as prostitutes, in agriculture, and in the garment industry. Investigations of factors that influence the health of these women workers are needed. Table 17.5 lists specific positions in which a large number of women are employed and the potential for health hazards within these positions. Community health nurses, occupational health nurses, and NPs need to be cognizant of environmental hazards wherever they find women at work. In taking a health history, the nurse should collect data regarding the client's occupational environment to assess the potential risk to emotional, general, and reproductive health. In addition, nurses must work individually and as an aggregate with their legislatures to maintain strong worker health and safety programs to protect the health of all women.

Patient-Centered Medical Home

The PCMH is a model of care developed to provide collaborative, quality-driven, safe primary care. The PCMH utilizes care coordination and case management processes to provide comprehensive, patient-centered, cost-effective, high-quality care (Henderson et al., 2012). In 2007, the report Joint Principles of the Patient-Centered Medical Home, sponsored by four medical professional organizations, described the seven principles or characteristics of the PCMH, which are listed in Box 9.3 (Patient-Centered Primary Care Collaborative, 2007). PCMHs are a care delivery model that utilizes the care coordination process as a foundational principle. The five key functions of the PCMH are care that is comprehensive, patient centered, coordinated, accessible, and safe (AHRQ, 2017).

Patient Protection and Affordable Care Act of 2010

The Patient Protection and Affordable Care Act of 2010, also called the Health Care Reform Act, is an extremely complex and comprehensive piece of legislation. One of the primary intents of the act is to reduce the number of uninsured Americans, and a number of provisions directly address this intent. For example, it requires all U.S. citizens and legal residents to have qualifying health coverage, whether provided through employers, individually purchased, or provided by federal plans (i.e., Medicare, Medicaid, CHIP). It also dramatically changes eligibility requirements for Medicaid, allowing coverage of childless adults with incomes up to 133% of the federal poverty line, and expands CHIP. Furthermore, it subsidizes premiums for lower- and middle-income families and requires coverage of dependent adult children up to age 26 for those with group policies

Social Security Act

The Social Security Act provides monthly retirement and disability benefits to workers and survivor benefits to families of workers covered by Social Security. Full retirement benefits are available after 10 years of covered employment, and workers can collect partial benefits beginning at age 62 and full benefits after age 67. The Social Security Act permits a divorced person to receive benefits based on a former spouse's earning record when that spouse retires, becomes disabled, or dies if the marriage lasted at least 10years. Since January 1985, a woman who has been divorced for at least 2years can receive spousal benefits at age 62, if her former husband is eligible for benefits, regardless of whether he is actually receiving them. Medicare and Medicaid also resulted from the Social Security Act. Medicare is the insurance plan that covers the majority of the healthcare expenses of older adults, including payments for hospital care, physicians, home healthcare, and other services and supplies after copayments and deductibles. Medicaid covers healthcare for indigent and eligible children and includes family planning, obstetrical care, and preventive cancer screening for women, such as mammography and Pap smears. Chapters 10 and 12 describe Medicare and Medicaid in detail, and they are further discussed later in this chapter.

The Transtheoretical Model

The Transtheoretical Model consists of six stages of change: Precontemplation: In this stage, individuals are not considering change and may be unaware or under-aware of the need for change. They may not see their behavior as a problem or may feel resistant to change. Contemplation: Individuals in this stage are aware of the need for change but are not yet committed to taking action. They may weigh the pros and cons of changing and may be ambivalent about making a decision. Preparation: In the preparation stage, individuals are getting ready to take action. They may have already taken some small steps toward change and are making plans to implement more substantial changes in the near future. Action: The action stage involves making specific, observable changes to behavior. This stage often requires significant effort and commitment, as individuals actively modify their behavior and environment to achieve their goals. Maintenance: After successfully making changes, individuals enter the maintenance stage, where the focus is on sustaining the new behavior over time. This stage aims to prevent relapse and consolidate the gains achieved during the action stage. Termination: In this stage, individuals have successfully maintained the new behavior, and the temptation to return to the old behavior is no longer a significant concern. Not everyone reaches this stage, especially for behaviors that may require ongoing effort and vigilance.

Biomedical Perspective

The biomedical (i.e., scientific) theory of illness causation is based on the following beliefs: 1. All events in life have a cause and effect. 2. The human body functions more or less mechanically (i.e., the functioning of the human body is analogous to the functioning of an automobile). 3. All life can be reduced or divided into smaller parts (e.g., the human person can be reduced into body, mind, and spirit). 4. All of reality can be observed and measured (e.g., with intelligence tests and psychometric measures of behavior). Among the biomedical explanations for disease is the germ theory, which posits that microscopic organisms such as bacteria and viruses are responsible for many specific disease conditions. Most educational programs for nurses and other healthcare providers embrace biomedical, or scientific, theories that explain the causes of physical and psychological illnesses.

The Built Environment

The built environment consists of the connections among people, communities, and their surrounding environments that affect health behaviors and habits, interpersonal relationships, cultural values, and customs. There is growing evidence that the built environment directly and indirectly affects health outcomes and disease rates (Table 14.3). One review of the literature found that neighborhoods that are more walkable are associated with increased physical activity, increased social capital, lower overweight, lower reports of depression, and less reported alcohol abuse (Renalds et al., 2009). Social capital refers to networks and the associated norms and expected collective benefits derived from cooperation between individuals and groups. Structural characteristics of the built environment, such as street condition, neighborhood deterioration, and the proportion of parks and playgrounds, affect levels of physical activity and obesity (Kerr et al., 2010; Schulz et al., 2013) found that women are more likely to increase physical activity if they live in a walkable community compared with men, indicating safety to be an attributing factor. Simply put, having a safe, intact place to walk may encourage exercise among adults.

Assessing the community: Sources of Data

The community health nurse becomes familiar with the community and begins to understand its nature by traveling through the area. The nurse begins to establish certain hunches or hypotheses about the community's health, strengths, and potential health problems through this down-to-earth approach, called shoe leather epidemiology. The community health nurse must substantiate these initial assessments and impressions with more concrete or defined data before he or she can formulate a community diagnosis and plan.

Components of the Healthcare System

The current healthcare system consists of private and public healthcare subsystems. The private healthcare subsystem includes personal care services from various sources, both nonprofit and profit, and numerous voluntary agencies. The major focus of the public health subsystem is prevention of disease and illness. These subsystems are not always mutually exclusive, and their functions sometimes overlap.

Person-Nature Orientation

The following three perspectives examine the ways in which the person-nature relationship is perceived: • Destiny, in which people are subjugated to nature in a fatalistic, inevitable manner • Harmony, in which people and nature exist together as a single entity • Mastery, in which people are intended to overcome natural forces and to put them to use for the benefit of humankind Most Americans consider humans and nature clearly separated; this is an incomprehensible perspective for many individuals of Asian heritage. The idea that a person can control his or her own destiny is unfamiliar to many individuals of culturally diverse backgrounds. Some cultures believe that people are driven and controlled by fate and can do very little, if anything, to influence it. The dominant U.S. cultural group, by contrast, has a mastery perspective. For example, the reader should consider three individuals in whom hypertension has been diagnosed, each of whom embraces one of the values orientations described. The person whose values orientation is destiny may say, "Why should I bother watching my diet, taking medication, and getting regular blood pressure checks? High blood pressure is part of my genetic destiny and there is nothing I can do to change the outcome.

The Health Belief Model

The model evolved from the premise that the world of the perceiver determines action. The model had its inception during the late 1950s when America was breathing a collective sigh of relief after the development of the polio vaccine. When some people chose not to bring themselves or their children into clinics for immunization, social psychologists and other public health workers recognized the need to develop a more complete understanding of factors that influence preventive health behaviors

sick building syndrome

The term sick building syndrome describes a phenomenon in which public structures and homes cause occupants to experience a variety of symptoms, such as headache, fatigue, and exacerbation of allergies. It typically results from poor ventilation and building operations, hazardous building materials, furniture and carpeting substances, and cleaning agents (EPA, 1991). Additionally, volatile organic compounds (VOCs) have been found in soil and soil vapor as a result of industrial spills that contaminate indoor air. One such spill in Endicott, New York, has been linked to congenital cardiac defects, low birth weight, and fetal growth restriction

Wheel Model of Human-Environment Interaction:

The wheel consists of a hub that represents the host and its human characteristics, such as genetic makeup, personality, and immunity. The surrounding wheel represents the environment and comprises biological, social, and physical dimensions. The relative size of each component in the wheel depends on the health problem. A relatively large genetic core represents health conditions associated with heredity. Origins of other health conditions may be more dependent on environmental factors. This model subscribes to multiple-causation rather than single-causation disease theory; therefore it is more useful for analyzing complex chronic conditions and identifying factors that are amenable to intervention. Concept: This model expands on the Epidemiological Triangle by incorporating the concept of time and highlighting the dynamic interaction between humans and their environment. Features: The wheel model includes the central components of the Epidemiological Triangle along with the dimension of time. It emphasizes that the relationship between humans and the environment is not static and may change over time.

Activity Orientation

There are different values orientations concerning activity. Philosophers have suggested the following three perspectives: Being, in which a spontaneous expression of impulses and desires is largely nondevelopmental in nature Growing, in which the person is self-contained and has inner control, including the ability to self-actualize Doing, in which the person actively strives to achieve and accomplish something that is regarded highly The person with a doing orientation often directs the doing toward achievement of an externally applied standard, such as a code of behavior from a religious or ethical perspective. The 10 Commandments, Pillars of Islam, Hippocratic Oath, and Nightingale Pledge are examples of externally applied standards. The dominant cultural value is action oriented, with an emphasis on productivity and being busy. As a result of this action orientation, Americans have become proficient at problem solving and decision making. Even during leisure time and vacations, many Americans value activity.

PPO

These types of insurance plans negotiated with healthcare providers for services at a reduced rate in exchange for a guaranteed increase in consumers. A negotiated reimbursement rate allows the cost of the plan to be somewhat controlled. Plan enrollees are offered cost incentives for choosing health care from within the plan's network of healthcare providers. Because they receive a specific amount of reimbursement, regardless of the rendered services, providers have an incentive to be conscious of the costs of the services provided (Young & Kroth, 2018). PPOs are more flexible than HMOs, but to receive full benefits, the covered individual must use network providers. PPOs are somewhat more expensive than HMO plans (about $90/month on average), but they are the most common type of insurance plan in the United States. Although down from 60% of all plans in 2009, in 2020, almost half (48%) of private insurance plans were PPOs.

Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

Through the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program, a child covered by Medicaid can receive a range of health and health-related services beginning in infancy. The program is designed to assure availability and accessibility of health care resources and to help Medicaid recipients and their parents effectively use them. The program's services far exceed those usually covered by private insurance and include the following: • Health, developmental, and nutritional screening • Physical examinations • Immunizations • Vision and hearing screening • Certain laboratory tests • Dental services

Language

To assess non-English-speaking clients, the nurse may need the help of an interpreter. Interviewing a non-English-speaking person requires a bilingual interpreter for full communication. Even the person from another culture or country who has a basic command of English may need an interpreter when faced with the anxiety-provoking situation of becoming ill; encountering a strange symptom; or discussing sensitive topics such as birth control, gynecological concerns, and urological problems. The nurse may be tempted to ask a relative or friend of another client to interpret because this person is readily available and is anxious to help. However, doing so is disadvantageous because it violates confidentiality for the client, who may not want personal information shared with another. Furthermore, the friend or relative, although fluent in ordinary language, is likely to be unfamiliar with medical terminology, clinical procedures, and medical ethics.

Social Orientation

Variations in cultural values orientation are also related to the relationships that exist with others. Relationships may be categorized in the following three ways: Lineal relationships: These exist by virtue of heredity and kinship ties. These relationships follow an ordered succession and have continuity through time. Collateral relationships: The focus is primarily on group goals, and family orientation is important. For example, many Asian clients describe family honor and the importance of working together toward an achievement of the group versus a personal goal. Individual relationships: These refer to personal autonomy and independence. Individual goals dominate, and group goals become secondary. The social orientation among the dominant U.S. cultural group is toward the importance of the individual and the equality of all people. Friendly, informal, outgoing, and extroverted members of the dominant cultural group may scorn rank and authority. For example, nursing students may call faculty members by their first names, clients may call nurses by their first names, and employees may fraternize with their employers.

Cross-Cultural Communication

Verbal communication and nonverbal communication are important in community health nursing and are influenced by the cultural background of the nurse and client. Cross-cultural, or intercultural, communication refers to the communication process between a nurse and a client with different cultural backgrounds as each attempts to understand the other's point of view from a cultural perspective.

Water Quality

Water quality refers to the water supply's availability, volume, mineral content levels, toxic chemical pollution, and pathogenic microorganism levels. Water quality consists of the balance between water contaminants and the existing capabilities to purify water for human use and plant and wildlife sustenance. Water quality problems include experiencing droughts, dousing reservoirs with chemicals to reduce algae, contaminating aquifers with pesticides and fertilizers (Clinical Example 14.5), leaching lead from water pipes, and oil spilling from transport tankers or leaking offshore wells. Other sources of water pollution are microbial contamination from poorly managed or maintained septic or sewage systems and animal feedlot wastes (EPA, 2013b). Water pollution can be from point sources (a well-defined source, e.g., factory wastewater discharge) or nonpoint sources (urban runoff, domestic lawn care, and air-to-water transfer).

Use of Epidemiology in Disease Prevention

When interventions occur before disease development, they are called primary prevention. Primary prevention relies on epidemiological information to indicate those behaviors that are protective, or those that will not contribute to an increase in disease, and those that are associated with increased risk. Secondary prevention occurs after pathogenesis. Those measures designed to detect disease at its earliest stage, namely screening and physical examinations that are aimed at early diagnosis, are secondary prevention. Tertiary prevention focuses on limitation of disability and the rehabilitation of those with irreversible diseases such as diabetes and spinal cord injury. Epidemiological studies examine risk factors affecting function and suggest optimal strategies in the care of patients with chronic advanced disease.

Chronic Conditions and Limitations

Women are more likely than men to be disabled by chronic conditions. Arthritis and rheumatism, hypertension, and impairment of the back or spine decrease women's activity level more often than they affect their male counterparts. The CDC (2019a) reports that prevalence in women is 23.5% as compared to 18.1% of men. Arthritis is often accompanied by comorbidities that contribute to the condition, including obesity, diabetes heart disease. Women are more likely than men to have difficulty performing activities such as walking, bathing or showering, preparing meals, and doing housework

Surgery

Women are more likely than men to have surgery. Hysterectomy is the second most frequently performed major surgical procedure among women of reproductive age after cesarean section (CDC, 2019f). Approximately 265,000 hysterectomies were performed in 2016 (Moore, 2016). The overall rate of hysterectomy decreased 12.3% between 2005 and 2013. For women over 50years old, 36.6% reported having a hysterectomy in 2008, while in 2018 that decreased to 31.7%. Overall, rates of hysterectomy decreased from 5.4 to 5.1 per 1000 in the years 2000 through 2004 (Whiteman et al., 2008). The most common reason for hysterectomy is uterine fibroids or leiomyoma, which contributes to more than one-third of all such surgeries, but considerably more in blacks (68%) than in whites (33%). White women are more often diagnosed with endometriosis and uterine prolapse, which are the second and third most common reasons for hysterectomy. Hysterectomy rates are the highest in women aged 35 to 54 years

Work-Related Exposures

Work-related exposures can happen as a result of poor working conditions and can lead to potential injury or illness. Environmental health problems posed by work-related exposures include such issues as occupational toxic poisoning, machine-operation hazards (e.g., falls, crushing injuries, burns), electrical hazards, repetitive motion injuries, carcinogenic particulate inhalation (e.g., of asbestos, coal dust), and heavy metal poisoning (Centers for Disease Control and Prevention [CDC], 2013; Krieger et al., 2008). Prevention of work-related health problems requires integrated action to improve job safety and the working environment. Occupational and environmental health nurses often collaborate on initiatives to reduce and eliminate work-related exposures, illnesses, and injuries. Nurses can be sure that workers are aware of and know where to access the safety data sheets relevant to their workplace. The U.S. Department of Labor's Occupational Safety and Health Administration (OSHA) (2013) requires chemical manufacturers, distributors, and importers to provide safety data sheets that communicate the hazards of chemical products.

sudden infant death syndrome (SIDS)

a condition that occurs when an infant stops breathing, usually during the night, and suddenly dies without an apparent cause Recommendations to reduce the risk of SIDS and sleep-related causes of infant death: Always place a baby on his or her back to sleep, both for naps and at night. • Use a firm sleep surface, covered by a fitted sheet. • Your baby should not sleep in an adult bed, on a couch, or on a chair alone, with you, or with anyone else. • Keep soft objects, toys, and loose bedding out of your baby's sleep area. • Do not smoke during pregnancy, and do not smoke or allow smoking around your baby. • Breast-feed your baby. • Do not let your baby get too hot during sleep. • Follow healthcare provider guidance on your baby's vaccines and regular health checkups. • Avoid products that claim to reduce the risk of SIDS and other sleep-related causes of infant death. • Get regular healthcare during pregnancy, and do not smoke, drink alcohol, or use illegal drugs during pregnancy or after the baby is born.

High-deductible health plans (HDHP)

began in the early 2000s as a method to involve the consumer in healthcare decisions. The intent was to encourage employees to select plans with lower premiums but more pronounced up-front cost sharing (i.e., higher deductibles). One incentive is to have the healthcare consumer become more involved in healthcare decisions from an economic standpoint and to "shop around" for lower-cost care. Many HDHPs included health savings accounts (HSAs), which are tax-free contributions that employees may make to a fund to cover their healthcare expenses (Young & Kroth, 2018). By 2020, HDHPs have become the second most prevalent insurance plan and represent about 31% of all plans in the United States

Point-of-service (POS)

combine elements of the HMO and the PPO. In POS plans, the covered individual designates an in-network physician as the primary healthcare provider (PCP). If the individual goes outside the network for care, he or she will be responsible for most of the costs unless referred by the PCP. POS plans were common during the early years of the 21st century (about 12% in 2008), but interest dropped off over time. In 2020, about 8% of all insurance plans were POS plans

Medicaid

healthcare coverage for the indigent. Eligibility for this program, a joint venture with state and federal funding, is determined by each state. Initially Medicaid was intended to focus benefits to children, pregnant women, the disabled, and impoverished elders. This changed dramatically, however, with implementation of the ACA, as funds were made available to provide health care for all adults below the poverty line—within states that elected to participate. The federal government sets baseline eligibility requirements for Medicaid. State governments that wish to provide care to more citizens through this program can alter the eligibility requirements. For example, the federal government may set 100% of poverty as an eligibility requirement, but an individual state may set the requirement as 110% of poverty. This means that a family living in that state can have an income slightly above the federal standard and still qualify for Medicaid.

The PRECEDE-PROCEED model

provides a structure for assessing health and quality-of-life needs. It also assists in designing, implementing, and evaluating health promotion and public health programs to meet those needs. PRECEDE (Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation) assesses the diagnostic and planning process to assist in the development of focused public health programs. PROCEED (Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development) guides the implementation and evaluation of the programs.

The Agency for Healthcare Research and Quality (AHRQ)

the main federal organization that works to improve the safety and quality of the healthcare system. Following the 1999 NAM report "To Err Is Human," AHRQ led the response to improving the safety of healthcare. This was largely through funding research to make care safer and to improve quality by publishing materials to educate healthcare systems and professionals to put research into practice and through generation of measures and data to be used by providers and policy-makers (AHRQ, 2021a).

Food Desert

there are significant disparities in access to healthy and fresh food supplies, with poor minority families being more likely to live in a food desert—a neighborhood with little to no access to healthy foods