Chapter 21 Vulnerability

trauma and violence

-A lifetime history of sexual abuse among women in childhood or adulthood ranges from 15% to 25%. -The prevalence of domestic violence among women in the United States ranges from 9% to 44%, depending on definitions. -The cost of intimate partner violence, which disproportionately affects women and girls, was estimated to be $8.3 billion in 2003. This total includes the costs of medical care, mental health services, and lost productivity. -In a 2008 study by RAND, 18.5% of returning veterans reported symptoms consistent with post-traumatic stress disorder (PTSD) or depression. -In the United States, 18.9% of men and 15.2% of women reported a lifetime experience of a natural disaster. (SAMHSA, 2014)

disabilities

-About 1/5 of the U.S population reports having a disability -Exact definitions of disabilities are determined by specific disciplines of care i.e. children with special health care needs, alcoholism, developmental disabilities/autism, physical disability due to injury or chronic disease -Refers to physical or psychological factor that impacts the way an individual interacts with the environment -Genetics, aging, environment, injury, alcoholism or substance abuse can lead to disabilities -Other terms used to describe disabled are challenged, compromised Individuals with Disabilities Education Act (IDEA) ensures free public education and accommodations to prepare child for independent living, assists with education funding, and evaluates education effectiveness (Children with Special Health Care Needs)

appropriate response and support services

-Assess for safety/provide emergency care as needed -Referrals to community agencies for advocacy, support services -Annual staff training and policies and procedures

universal screening

-Assume all clients have past trauma -Asking what happened to you? Instead of what's wrong with you?

adverse childhood experinces

-Effects of traumatic events place a heavy burden on individuals, families, and communities (SAMHSA, 2014). -Many people who experience a traumatic event will go on with their lives without lasting negative effects, others will have difficulties and experience traumatic stress reactions (SAMHSA, 2014). -These behavioral health concerns can present challenges in relationships, careers, and other aspects of life - it's important for health care professionals to understand the nature and impact of trauma, and to explore healing (SAMHSA, 2014). -Evolving body of research purports Trauma Informed Care as approach to care to address trauma from ACE and/or lifetime exposure to violence

safe environment

-Environment and staff that foster trust, empowerment, inclusion of client in decision-making for all treatments and procedures

organizational structure

-Leadership supports transparency - consumer participation in organizational structure and processes

tertiary prevention

-Mandated reporting of abuse/injury to appropriate agency/authorities -Forensic examinations to provide medical care and collect evidence for criminal prosecution of perpetrators -Referrals for long term health care needs - emotional, psychological, physical -Referrals to community domestic violence groups, support groups -Grief counseling

other vulnerable populations

-Older Adults -Immigrants -Refugees -Corrections -Foster Care -LGBTQ

community risk factors for violence

-Stressful work environment -Unemployment -Crowded living conditions -Poverty -Media exposure: music, film, sports, video games -lack of community resources -Feelings of isolation, hopelessness

health status of rural residents

-in rural areas people have poorer perception of their overall health and functional status than their urban counterparts -rural adults are less likely to engage in preventive behavior which increases their exposure to risk -more likely to smoke and have higher rates of alcohol and obesity, less likely to engage in physical activity during leisure time, wear seat belts, have regular blood pressure checks, pap smears and do breast exams -more likely to have one or more chronic conditions like heart disease, COPD, hypertension, arthritis, diabetes, cancer, cvd -tend to have to have an overall poorer health status and are less likely to seek medical care than urban adults -want to remain in homes as long as possible -fewer physicians from which care can be sought -less likely to have employer sponsored health insurance or prescription drug coverage -traveling time or distance to ambulatory care services affects access to care for both rural and urban residents

barriers to health care in rural areas

-lack of HCP and services and great distances to obtain services -lack of personal transportation -lack of telephone services -unavailable outreach services -inequitable reimbursement policies for providers -unpredictable weather or travel conditions -inability to pay for care or lack of health care insurance -lack of know how to procure publicly funded entitlements and services -inadequate provider attitudes and understanding about rural populations -language barriers (caregivers are not linguistically competent) -care and services not culturally and linguistically appropriate

characteristics of rural life

-more space, greater distances between residents and services -cyclical more seasonal work and leisure activities -informal social and professional interactions -residents who are related or acquainted -lack of anonymity -challenges in maintaining confidentiality stemming from familiarly among residents -small family enterprises, fewer large industries -economic orientation to land and nature, agriculture, mining, lumbering, fishing, marine related -more high risk occupations -town as the center of trade -churches and schools are socialization centers -preference for interacting with locals -mistrust of newcomers to the community

levels of prevention

-one way to improve health of vulnerable populations is to have a primary care provider who both coordinates health services for them and provides their preventative services -another approach is for nurse to serve as a case manager for vulnerable clients coordinating services and provide illness prevention and health promotion services primary- giving influenza vaccines to vulnerable populations who are immunocompromised secondary- screening for vulnerable populations tertiary- conducting group therapy for those for the severely mental ill

issues in migrant health

-poor unsanitary working and housing conditions make them more susceptible to health problems -agriculture industry is one of the most dangerous occupations in US -they are exposed to hazards of pesticide exposure, heat and sun exposure, skin disorders, infectious diseases, lung problems, hearing and vision disorders, strained muscles and bones -have identified diabetes, poor dental health, obesity, depression factors that limit provision to health services -lack of knowledge of services (isolation and lack of fluency in english) -inability to afford care (medicaid does not cover migrant workers and do not stay long enough to be considered for benefits, salaries fluctuate) -affordable care act or health insurance subsidies (do not receive employee mandated health insurance especially if undocumented) -availability of services -transportation (can be located far from home and may not have access to vehicles) -hours of service (many only during work hours and would cost them lost earnings to go during that time) -mobility and tracking (move job to job and health records dont usually follow with them) -language barriers -discrimination (perceived as poor, uneducated, transient, ethically different) -documentation (fear of being known as undocumented can lead to deportation) -cultural aspects of health care

homelessness

-poverty is the leading cause of _____ -correlated with poor health outcomes -increasing numbers of ____ are families and children -defined as lack of regular night rime residence -numbers are often inaccurate due to transient nature of ________ counts assessing numbers during specific time frame -are exposed to elements of crowded, unsanitary living conditions, malnutrition, lack of sleep and stress -healthcare is crisis oriented and sought in ED and those with prescribed regimen are have a hard time following -health problems are directly related to poor access to preventative health services -in addition to affects on physical health it also affects psychological, social, spiritual well being since it means losing a home or a regular place to sleep and eat, losing friends, personal possessions and familiar surroundings -live in fear, chaos, confusion -addressing needs is complex but priority must include securing long term safe adequate sheltering

poverty

-primary cause of vulnerability and it is a growing problem in the US -insufficient means and resources to meet the basic living expenses, food, shelter, clothing, transportation, healthcare -family of 4 has to make less than $24,300 -chronic stress factors of ___, unemployment, poor education can lead to maladaptive physical responses and disease -causes are complex -people who do not have the financial resources to pay for medical care are considered medically indigent\ -people who are poor are more likely to live in hazardous areas that are overcrowded, have inadequate sanitation, working in high risk jobs, have less nutritious diets and have multiple stressors because they do not have extra resources to manage unexpected crises or manage daily life -access to care is an issue -directly related to poor health outcomes -high rates of infant mortality and chronic disease -higher hospitalization rates

characteristics of migrant farmworkers

-rural homeless may be ____ -often have unpredictable and difficult lifestyles as many leave their home each year to travel to distant locations for work -they may feel isolated in new communities and lack adequate resources to meet their needs which can lead to stress -they rarely receive benefits such as workers comp, disability comp or health retirement benefits -traditionally have followed one of three migratory streams: eastern florida, or midwestern texas, and western originating in california -cyclic nature of agricultural work and its dependence on weather and economic conditions results in considerable uncertainty for migrant farmworkers results in considerable uncertainty for migrant farmworker -word of mouth from friends, family, newspapers or employers help determine destination -however when arrive they can be late where other workers arrived first, crops are late leaving unemployment

characteristics of nursing practice in rural areas

-variety and diversity in clincial experiences -broader and expanding scope of practice -generalist skills with speciality knowledge of crises assessment and other management across disciplines and specialities -flexibility and creativity in delivering care -sparse resources -professional or personal isolation -greater independence and autonomy -role overlap with other disciplines -lack of anonymity -slower pace -increased opportunity for informal interactions with clients and coworkers -opportunity for client follow up on discharge in informal community settings -discharge planning allowing for integration of formal and informal resources -care for clients across lifespan -exposure to clients with full range of conditions and diagnoses -status in community -viewed as professional role model -opportunity for community involvement and informal health education

secondary prevention

Assessment in every clinical interaction Screening is important to identify s/s that may indicate victimization, abuse/neglect -unexplained bruises, injuries -behavior changes -changes in sleep patterns -changes in appetite -inappropriate dress -financial problems - bills not paid on time -Referrals to community resources for at risk clients/families -Mandated reporting of suspected child abuse/neglect and/or criminal activities -Adults being neglected/abused is less clear - work with agencies to establish clear policies and procedures for assistance and services

rural areas

access is a problem in ____ including farms that rely on migrant workers to harvest their crops -scarcity of health care professionals, poverty, limited access to services, lack of knowledge and social isolation have plagued many ___ communities for generations -major is often the distance people must go to find health care providers -for migrant workers, language barrier and cultural differences often exist between them

human capital

all the strengths, knowledge and skills that enable a person to live a happy, productive life -people with less education have less __ because their choices are more limited that those of people with higher levels of education

families with children

are the fastest growing segment of the homeless population with the numbers higher in rural areas

vulnerable populations

are those groups who have an increased risk for developing adverse health outcomes -subgroup of a population that is more likely to develop health problems as a result of exposure to risk or have worse outcomes from these health problems -more than general population to experience health disparities -more sensitive to risk factors often experience cumulative risk factors

poverty guidelines

are used to determine whether a family or person is financially eligible for services under a particular federal program -TANF -WIC -SNAP -headstart -medical assistance they are issued each year in the federal register by the department of health and human services

education

best defense against poverty is

correlation of ACES

between ACES______ in adults and chronic disease and premature mortality Study: Adult clients in HMO with lifetime exposure to 8 categories of abuse and family dysfunction (Felitti et al., 1998) •Verbal , physical, or sexual abuse •Household mental illness •Household substance abuse •Domestic violence •Parental separation/divorce •Incarcerated family members Results: •4+ ACE compared to those who experienced none had 4-12 fold increase in smoking, poor self-rated health, multiple sexual partners and Hx STI •1.4-1.6 fold increase in physical inactivity and severe obesity •Impact of ACES is cumulative - more ACESs = worse health outcomes

other specific health problems of migrant workers

dental disease tuberculosis HIV/AIDS -risk factors of poverty, low income, substandard housing, limited access to healthcare, limited english, unprotected sex, injectional drug use, tattoos depression -related to isolation, economic hardship, weather conditions that interrupt work -stress of new culture, low self esteem, discrimination, frequent mobility, long work hours, no benefits -harassment or sexual abuse in women migrant workers type 2 diabetes -due to poverty, stress, cultural dietary practices, long term exposure to certain pesticides, genetic predispositions

homeless people health issues

hypothermia and health related illnesses infestations and poor skin integrity peripheral vascular disease and hypertension diabetes and nutritional deficits respiratory infections and chronic obstructive pulmonary diseases TB HIV/AIDS trauma mental illness use of tobacco, alcohol, and illicit drugs

risk

means some people have a higher probability than others of illness -however not everyone at ____ will develop health problems -these people are just more vulnerable than others -can be from environmental (lead exposure from pain) social hazards (crime or violence) personal behavior (diet and exercise, smoking) or genetic makeup

stewart b mckinney homeless assistance act

people are considered homeless in cases of 1) lacks a fixed, regular night time residency 2) has a primary night time residency that is -supervised publicly or privately operated shelter designed to provide temporary living accommodations -institution that provides a temporary residence for individuals intended to be institutionalized -public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings

primary ways to determine homeless

point in time counts period prevalence counts which examine the number of people who are homeless over a given period of time -both methods undercount because they fail to visit may locations where homeless people stay -hard to know how many exactly are homeless

vulnerable population groups of special concern

poor and homeless veterans pregnant adolescents rural populations: migrant workers and immigrants severely mental ill disabilities-physical and developmental young or advanced age violence and trauma/toxic stress substance abusers persons with communicable disease or those at risk person with HIV, hepatitis B, STD

level of preventions related vulnerable populations

primary prevention -provide culturally and economically sensitive health teaching about balanced diet and exercise -develop a portable immunization chart such as a wallet card that mobile population groups such as homeless and migrant workers can carry with them secondary prevention -conduct screening clinics to assess for things such as obesity, diabetes, heart disease, TB -develop a way for homeless individuals to read their TB skin test if necessary and to transfer the results back to the facility at which the skin test was administered tertiary prevention -develop a community based exercise program for people identified as obese or have increased blood pressure or increased blood sugar -provide directly observed medication therapy for people with active TB

levels of prevention related to rural health

primary prevention -teach workers how to reduce exposure to pesticides secondary prevention -conduct screening such as urine for pesticide exposure tertiary prevention -initiate treatment for the symptoms of pesticide exposure such as nausea, vomit, skin irriataiton

health disparities

refer to the wide variations in health services and health stats among certain population groups -occur in cause of death by gender, age, race, socioeconomic status, and other factors

neighborhood poverty

refers to geographically defined areas of high poverty characterized by dilapidated housing and high levels of unemployment

persistent poverty

refers to individuals and families who remain poor for long periods and who pass poverty onto their descendants (long term and or intergenerational) -typically affects those that are chronically homeless and many have mental or physical disabilities -has been homeless for more than a year or has 4 episodes for the last 3 years

disenfranchisement

refers to the feeling of separation from mainstream society -person does not seem to have an emotional connection with any group in particular or with large society ex: the poor, migrant or homeless people are invisible to society as a whole and tend to be forgotten in health and social planning -vulnerable populations are at risk for ___ because their social supports are are often weak as their linkages to formal community

trauma informed care

safe environment universal screening Appropriate response with adequate support services organizational structure

social determinants of health

social and economic factors contribute heavy to ___ they are factors such as economic status, education, environmental factors, nutrition, stress, prejudice that lead to resource constraints, poor health or health risk

vulnerability

susceptibility to actual or potential stressors that may lead to an adverse effect -results from interacting effects of many internal and external factors which over people have little to no control over -usually effected by limited resources of physical, enviromental, personal, and biopsychosocial

crisis poverty

the lives of those involved are marked by hardship and struggle -for them homelessness is often transient of episodic and they may have brief stays in shelters or other temporary accommodations

healthcare of veterans

vulnerable: members of the military and their families -members in military service have been found to be more susceptive to domestic violence and child maltreatment -physical and psychological impact of both current and past wartime and military experiences has created a large population of veterans needing health care -stress from being deployed affected both the person serving and their families -for person serving stress comes from killing, watching friends die, personal danger, danger to others, danger to accidents and need for constant vigilance related to difficulty determining enemy -family members suffer from being left behind and having to cope with jobs, money and missing their service member -important for public health nurses to know about the health care issues and needs of veterans -many veterans suffer from PTSD and major depression which symptoms can arise soon after or appear months and years later

physical health consequences of violence

•Abdominal injuries •Thoracic injuries •TBI •Burns •Fractures •Lacerations Disability

psychological/behavioral health consequences of violence

•Alcohol/SA •Anxiety/Depression •Behavior Disorders •PTSD •Sleep disorders •Eating disorders •Smoking

chronic disease consequences of violence

•Arthritis •Asthma •Cancer •Cardiac •Diabetes •Renal disease •Liver disease •Complex pain •syndromes

veterans

•Dept of Veterans Affairs estimates 21.6 million veterans in the U.S. •Veterans Health Administration responsible for providing health care coverage to veterans and dependents •Networks provide acute and long term care, home care, hospice, residential rehabilitative treatment, and counseling centers •High risk for trauma related PTSD symptoms and sequelae including alcohol and substance abuse, and suicide •Long term disabilities from combat injuries i.e. TBI, spinal cord injuries, amputations •Continuity of care between acute and outpatient settings essential •Coordinate referrals to available resources/services for mental health, alcohol and substance abuse

primary prevention

•Parenting classes - home visiting, anticipatory guidance for childhood G & D and age appropriate behaviors, parenting education and support groups •Schools - Antibullying campaigns, suicide prevention, healthy relationships •Communities - education about conflict resolution and coping strategies, community support groups, after school youth programs •Older Adults - services to relieve caregivers, financial safeguards for assets i.e. durable POA

seasonal agricultural workers

•Temporary residence in communities; sometimes supporting families that live in permanent residences elsewhere •Often not covered under general labor laws i.e. minor children can work along side parents, even in unsafe conditions •Federally funded Migrant Health Centers designed to address health care needs but there are still gaps •Include undocumented immigrants not eligible for federally funded health care and other programs/services •Discrimination, not speaking English negatively impact ability to access and quality health care •Health care issues similar to homeless population; increased risks of acute and long term work related injuries from use of farm equipment and poisoning from use of pesticides

rural health issues

•Typically defined as less than 20,000 residents •Generally lack specialty services and often no community hospital •Shortage of HCP - more likely to see a nurse practitioner who cares for patients across the lifespan - this includes shortage of ST, HHA which also impact rural populations for availability of services •Lack of transportation and inaccessible terrain issues reduce access to health care •Socioeconomic and cultural factors act as barriers- i.e. lack of engagement/belief in healthy behaviors, non-belief in preventive health care •Emphasis should be on preventative health services •Federally qualified health centers designed to address health care needs of rural residents but there are still gaps in services

reproductive health consequences of violence

•Unintended pregnancy •Preterm labor •HIV/STI •Chronic pelvic pain/PID