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  • This presentation conveys how a community health nurse, could work with a small Northern Alberta community facing some significant rural poverty issues. Clear examples health service integrationalong with concepts of population health, primary health care and health promotion are presented.Namwayut (we are all one) is the name chosen for the title. In the spirit of diversity it is about coming together as one. The tenants of health promotion must incorporate shared beliefs common with this community of First Nations people as well as others. The nurse must identify both strengths as well as weaknesses already present in the community. Every effort must be made to build on strengths. Some argue that to make positive changes in the health and wellbeing of others one must go to where the problems are (community) not the institutions (hospitals) if you want to be a catalyst for change (Dr. Bang-ShodhGram, 2009) in a community. A health professionals best resource is the people, the knowledge share is the tool. This opens the doors for individuals, families and communities to feel empowered. For instance Black Elk (1992) stated, “ primary health care makes it possible to consider the different cultures under one tree”. So primary health care is a holistic philosophical approach that is complementary with aboriginal spiritual beliefs.
  • Health promotion described in the Ottawa Charter is not a new concept, it has been around for thousands of years. For example the Old Testament Bible gave dietary advice regarding foods that are considered unclean which may seem rigid now, however in times when there were challenges with storing, preparing and preserving food along poor sanitation the advice may have been sound to protect health. Both Jewish and Egyptian people were warned regarding the negative effects of too much alcohol. The bible offers mental health advice like avoiding angry people along suggesting activities to maintain peace of mind. Judaism teaches that God gave the earth to the people with expectations they care of it as well as each other (widows, orphans and the less fortunate). The Muslim faith contains pretty much the same guidance as Christianity. Care of self and others as well as the interconnection of all living things can be found in Buddhist philosophy, Sikh and Hindu faiths. Florence Nightingale improved the health of others by altering environmental conditions such as clean air, sanitation, warmth, building design, hand hygiene, nutrition, hydration as well as using scientific methods (accurate statistical documentation) to determine which methods impact positively on health and wellbeing others as a means to provide compelling arguments to the political leaders of the time. The Klondike nurses in Canada had few medicines at their disposal however they altered environments, used creatively improvised for instance providing warmth for a man ceased up with rheumatism was able to regain his mobility, they would splint fractures with what they could find in the environment are just a few examples of creative solutions they used to have a positive impact on health in environments which were harsh lacking even basic resources including physicians in the northern most parts of Canada. In relation to primary health care we can build on work that is evidence based and successful such as the 1930’s response to respond the health inequities in northern rural China a famous primary health care program the ‘ Barefoot Doctors’ program trained chosen rice paddy farmers in the basics of health care which in turn they took the knowledge back to their communities with very simple methods they were able to make a positive difference which later became the catalyst for rural transformation in China. Health experts Carl Taylor and his son wrote a book called, “ Just and Lasting Change” which outlines how this work in China was accomplished. John Gordon expanded on this work developing routine home visits and surveillance in response to epidemics i.e. rheumatic fever which had enormous positive implications for public health. Data was collected from the beginning of the epidemic to the end. In 1978 the Alma Ata World Health Conference in Kazakhstan used the phrase ‘primary health care’ which is the endorsed approach to health care that uses the best available scientific evidence combined with social influence which ( not primary care – one person at a time, which relates more to the medical model of care with physicians specialists, assistants, and nurse practioners who are called primary health providers, they were considered the first point of contact for health care). The conference recommendations that more consideration of factors that influence the health of a community for instance environment, economic conditions, housing, education, food security and protection from infectious disease must be included due to the influence they have on health. So basically this declaration is calling for essential health care, that is comprehensive, based on the best scientific evidence available that is affordable as well as sustainable for the community. One may ask what is included with this? The main focus areas are health education, disease prevention, proper nutrition, safe environments including water, immunization, treatment of disease/injury and provision of essential live saving medications ( antibiotics and antivirals ). Canadians have the privilege of leadership which strongly influenced the development of the charters. There have been differing opinions about primary health care especially with Americans in particular from the John Hopkins school of public health which argued the Ottawa Charter(1974) and the Lalonde Report with Health for all 2000 including the Alma Ata declaration were considered too lofty not being economically viable. The sociopolitical context of both arguments likely stems from two differing health care systems (Canadian publically funded universal health care and the American private for profit). In the to United States there was alack of political will to push for universal accessible health care because some did not have the vision to see how a community or nation profited as methods believed to be socialist were avoided. Multinational corporations including pharmaceutical , insurance and government policy wielded the balance of power and control in relation to health policy in the country. In summary the Bangkok Charter of 2007 expanded on the earlier guidelines of the earlier Ottawa Charter, making health promotion a central global agenda, a core responsibility of all governments. The direction is for health friendly globalization, partnerships, alliance building, building capacity, policy development that is regulated, cost effective and sustainable. Health professionals are to be advocates with values promoting social justice, human rights and solidarity, very much like a global organizing model for better health, better world.
  • As a nurse the community information about the district is;There is greater than 20% unemploymentThe majority of families are severely in debtFamilies state the welfare money is insufficient to meet the basic needs.The only grocery store is unwilling to extend more credit. The cost of food three to four times greater than what it is in the nearest city.Crime with increase in theft at the grocery store over the last year.Increased smoking of tobaccoObjective evidence of malnutrition (anemia & fatigue) among community members across the life span; fatigue with increase susceptibility to respiratory infections. Families are sharing concerns that they cannot even provide basic necessities of life to their children (hopelessness, fear, depression). Increasing the risk for mental illness.In spite of this the community health nurse must listen to the people to make sure she has clarity on the health needs of the people from their perspective. It is important to build relationships based on mutual Respect and trust. Some of the ways are to meet with aboriginal liaisons, respected elders community groups, pastors, business leaders, teachers conduct community visits, walk or drive a bout tips making observations.
  • The aggregate is community as partner. Any community development will focus on strengths and assets as determined by the whole community. The approach to collection of assessment information from psycho/social/ environmental view that does not view people as broken needing to be fixed.A review of the current literature (refer to references) will be completed including any available community reports. Statistics Canada has excellent online information available. Other methods to assist with the process may include a drive about with intent to observe the community noting services, neighbourhoods or other aspects that may impact of health. Research if other communities with similar problems have projects or interventions that demonstrate improvements in health outcomes.Talk to the people, get their opinions. Interviews can be done by phone, e-mail, notices placed in community bulletins inviting contact, visiting groups of people i.e. friendship centre, schools, community forums and focus groups. Contact a community/band liaison to speak to tribe council members, chief and elders. Though it is important to interview leaders it is necessary to interview the individual community as well members to learn what their issues and concerns are. Listen to the solutions they have to offer.Document by keeping accurate records of the project as well as planning, set community health goals which are measurable , implementation of community action followed by evaluation and identification of the health outcomes.
  • So far in this presentation the community health registered nurse has become aware of the detrimental affects of health inequities in this community following assessments made during the course of her traditional duties this presentation is to help provide compelling evidence that our health unit has a role to assess, plan, intervene and evaluate. When there is evident social injustice we are duty bound to advocate for change in traditional service delivery which can best be supported by dedicated nursing time full time equivalent hours to assist with the assessment, planning, intervening and evaluating health services so safe, compassionate, competent ethical care is maintained.Promotion of health and wellbeing of individuals, families and communities ensuring informed decision making. The work must preserve dignity with in the community.Promote justice.Be professionally accountable as community health nurse as well as our health unit.Collaboration/ partnering and negotiating ( or identifying a third party mediator ) with stakeholders, individuals, families and communities to establish short term and long term goals with cost effective sustainable solutions.
  • Inequality takes life on a grand scale.The inequities can be seen in rich as well as poor countries (Commission on Social Development 2007).“Think local go Global” ( Dr. Bang-ShodhGram, 2009)The Alma Ata declaration (1978) calls for global health care that is sustainable, integrated, comprehensive at a price the countries can afford. Little change in health improvements have been achieved by individually focused methods over the last twenty years. There is evidence to support that hospitals only account for about 10% of health out- comes (Hacker 2013). This position is supported by recent examples of successful primary health careprojects that started local but went global. The Jamkhed Comprehensive Rural Project in India ( 2010) has been in operation since 1970. It is a grass roots work which mobilized through community groups. It is an example of primary health care that has a positive transformational impact through simple interventions that occur at three levels; community, mobile health teams, hospital and training centre. The project has been replicated in other areas of India. Another work is Nagpur, founded by D. Abhay Bang-ShodhGram where individual female community health workers were chosen for training in antenatal maternal and infant care including infant resuscitation on par with pediatricians. The results of the project supported by record keeping with statistical data show the effort is sustainable with a significant reduction in the infant mortality rate. The project gained acceptance of the Indian Government. The work is replicated in other rural areas of India extending to other countries in similar areas where the people are poor and marginalized. Dr. Raj Panjabi is a cofounder of Tiyatien Health developed to address serious threats to health in post war/ conflict countries where community infrastructure has been destroyed. The method used is community based with chosen women that are trained as community health workers. This method is replicated outside of Liberia with success in reducing health inequities. All projects provided records of documentation with statistical data. As well the are consistent with the Alma Ata declaration and the Bangkok Charter guidelines.
  • It is estimated 50 to 60 % of health outcomes are because of health behaviors ( Hacker, 2013). Rubric of health care has three goals; improving the experience of care, improving the health of populations and reducing costs per capita costs of health care (Hacker 2013). Health Canada’s established twelve determinates; Income and Social StatusSocial Support NetworksEducation and LiteracyEmployment/Working ConditionsSocial EnvironmentsPhysical EnvironmentsPersonal Health Practices and Coping SkillsHealthy Child DevelopmentBiology and Genetic EndowmentHealth ServicesGenderCulturehttp://www.phac-aspc.gc.ca/ph-sp/determinants/index-eng.php
  • With the unemployment rate in the community being greater then 20% combined with significant numbers of community members relying on social assistance which many have stated is insufficient for even basic nutritional needs for their children. This kind of powerlessness leads to hopelessness which creates risks of mental illness. Negative coping behaviors in the community have been described as increased smoking which is a behavior is linked with negative health incomes which is evident in the increase in respiratory infections. Smoking cessation is probably the single most important thing one can do to improve health and well being. It is also reported that there is an increase in thefts from the one and only grocery store over the last year. The business owner’ s food is highly priced, he has extended credit to families however now families are burdened with large debt so credit will no longer be available. It is at least a four hour drive to the nearest city where discount foods are more available.
  • All Local citizens including 80% First Nations that live on band and off band ( status or non status).A few local farmers have been identified have expressed interest in a food bank.A local business man has expressed interest as well the chief,elders and health leaders of the local band.Other businesses, financial institutions.Nongovernmental organizations (NGO’s)The provincial dietician has offered her services.Telephone health services.Mennonite, Catholic and Anglican Local Churches.Schools and community centres.The local religious congregations are small and have exceeded their ability to provide food hamper except at Christmas. The local farmers and a businessmen have no experience setting up or operating a food bank, they are asking for help the only stipulation they have is no one gets a free hand out.
  • Start with the common values and beliefs that we share.Since 1978 primary health care as defined by the WHO is an important part of any strategic planning relating to improvements, ‘Health care by the people for the people’. WHO defines primary health care as “ essential health care based on practical, scientifically sound and acceptable methods and technology, made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every state of their development in the spirit of self reliance and determination…”
  • It has been said by First Nation’s people in relation to art that ‘ what is in your heart comes out of your hands. Please take some time to reflect on Aboriginal artist Leah Fontaine's compelling visual representation of one of seven regional discussions held tocompile the Health Council of Canada’s report on improving cultural sensitivity in aboriginal health care. Following the release of the report, an Alberta MLA is calling for improved health services for aboriginals in the province. (Courtesy Health Council of Canada 2012)
  • The local tribal council has decided to have a healing ceremony, the elders support this and have invited First Nations spiritual leaders to assist with the ceremony all community members are welcome to attend.Spiritual Clearing of negative past.Action: Invitation extended to all community members welcome to attend.2. Improved Food security over the next six months.Action:The band invited the provincial dietician met with the tribal council, the local ministerial association, service groups, agricultural council and local business leaders to come together determinesolutions preferred dietary preferences. She will meet with community chosen cooperative bulk purchase shoppers in the nearest city 4 hour away. To educate regarding shopping method, best deal identification. 3. Community selected women will receive education regarding options regarding food banks, community kitchens, soup suppers etc. within the next thirty days.Connections with interchange of ideas can be shared with other northern communities that have programs in place so sharing and support is developed.4. Goal : Immediately address community nutrition by using community designated workers that are provided with basic nutrition education and food safe practices which they share at home visits with focus of prenatal and nursing mothers, young children and the elderly. Action:As a short term measure there is agreement to purchase bulk vitamins and micronutrients to immediately address concerns of anemia. Those deemed to need B12 injections can receive them at the local community health centre or in the home by the designated, trained community health worker.There are other possible actions the community could choose to support the established goals.Action: Addiction community health workers will meet with those known to suffer from alcoholism to offer support with community Alcoholic Anonymous meetings and assess for readiness for treatment programs or home detoxification. Priority will be given to prenatal mothers with addiction.Action: The local community friendship center will offer food safe courses, the band will have designated leaders of community health improvement workers attending, in turn they are to share what they learn and encourage as many people to attend. A food safe trained individuals will be involved with food preparation for ceremonies such as Pow Wows.
  • Action: dietician will make a shopping visit with band purchasing leaders to educate regarding food purchases in bulk to achieve quality, quantity that is cost effective as well as takes into consideration what is available in the community that includes the ingredients for dietary preferences of the band.Action: The friendship centre will offer drop in lunches as well volunteers will make up the school lunch boxes. The food preparations will be done by volunteers that have a food safe certificate. The farmers will provide produce to the friendship centre and one of the local churches that has agreed to provide a supper on Saturday and the band will provide a meal on Sunday.Action: Citizens will volunteer to help the farmers with harvesting and or farm work in lieu of food donated to the food bank.Action: A steering committee of community members with determine the structure of the food bank.Action: The band will support young graduates that have expressed interest in studying agriculture with the aim for creating ways to extend the growing cycle time or other methods of developing food security.
  • The friendship centre will offer counselling services as well will liaise with families needing credit counselling. A credit counsellor will be available at the friendship center twice a month. The friendship center will serve as a referral and resource centre for those needing assistance with mental health or addiction issues. There are designated band members that can provide support. Band members with interest will be supported to attend nearest college to train as community mental health and eldercare workers. A barter service and job board will be on site. Vocational counsellors will be at the friendship centre once a week.The business person will liaise with other businesses including the financial institutions and United Way to develop a “ Best Beginnings” program to support young mothers and their children.Band leaders with expertise in grant proposal preparation will begin to make requests for a family enhancement program with preschool programs and afterschool care with recreational opportunities. Other example of solutions could experienced hunters mentoring others in this to make share wild game meat. Food preserve sessions where groups of women prepare fruit, vegetables, at church kitchens.Smoking cessation support by ministry of health both federal and provincial allowing free tobacco cessation products which pharmacist can dispense. Smoking cessation support via telephone volunteers from the provincial cancer agency or telehealth line.Education with community support for exercise, Nordic walking programs, Tai Chi These are some of the possible goals and strategy the community could choose the people will have the solutions.Interdisciplinary health team members with continue to provide health education, immunizations, physician visits, internet based psychiatric consultations with psychiatrists and mental health team, Elder health, disease monitoring, as well of non health professionals such as conservation and environmental officers are just some of the examples. Through out this presentation there is emphasis about the people taking charge of their health, where they develop goals with a strategic plan. Provided is an example of population health. Canada must get serious about working with the First Nations People as they have the fastest growing youth population in our country. In the northern most areas they will be the majority population so we need for them to grow up with healthy minds and bodies so the can be leaders for our nation. We must be respectful and listen to their needs so we are invited to be part of their community. It is important to understand history, intergenerational trauma, spiritual beliefs, of this traditional hunter gathering population. That we reconcile the past not to forget but to build a better future.
  • Aboriginal Population- Indicators of Well-being in Canada www4.hrsdc.gc.ca A Snapshot of Canada’s Booming Aboriginal Population. www. cbc.ca/…/canada/a-snapshot-of-canada-s-booming-aboriginal-poulation .../story.html Beaglehole, R. B. (2004). Public Health in the new era: Improving health through collective action. The Lancet, 2084-2086.Bernstein, J. (2012). Beyond Public Health Emergency Legal Preparedness: Rethinking Best Practices. Journal of Law, Medicine and Ethics, 13-16.Canada, P. H. (2013, 08 16). Determinants of Health. Retrieved from What Determines Health? Population Health: http://www.phac-aspc.gc.ca/ph-sp/determinants/index-eng.phpComprehensive Rural Rural Health Project in Jamkhed, India www.youtube.com/watch?v=k3cXVNCg04sDr. Abhay Bang-ShodhGram Society, Education, Action and Research in Community Health. Nagpur (2012) TEDxNagpurwww.youtube.com/watch?v=5FO0fgn7nLc Dr. Raj Panjabi: Post Conflict Health YouTube www.youtube.com/watch?v=C9fWGocHNwsGrant, R. G. (2012). The Health Care Home Model: Primary Health Care Meeting Public Goals. American Journal of Public Health, 1096-1103.Habersac, M. L. (2009). WHO-definition of health must be enforced by national law: a debate. Lancet, Abstract.Hacker, K. W. (2013). Achieving Population Health in Accountable Care Organizations. American Journal of Public Health, e1-e5.Health Care System. (2012, 11 02). Retrieved from Health Canada: www.hc-sc.gc.ca/hcs-sss/index/- eng.phpHealth Equity Matters- IPPH Strategic Plan- Executive Summary (2012) www.cihr-irc.gc.caHealth inequity a ‘stain on our societies,’ doctors www.canada.com/health/Health+Inequality+stain+societiesLucy, P. (2007). Social Concern: A Continuing Tradition for Nursing. Nursing Economics, 40-46.Population and Development and Review. (2007). The World Health Organization on Health Equity, Inequity, and Social Determinates of Health. New York: Blackwell Publishing Limited.Primary Health Care. (1996-2013). Retrieved from Canadian Health Institute for Health Information: www.cihi.ca/phcReichel, J. (2012). Mainstream Health Care not Meeting Aboriginal's Needs. Vancouver: Epoch Times.Report on the State of Public Health in Canada 2008 www.phac-aspc.gc.caThirteen Public Interventions in Canada that have Contributed to a Reduction in Health Inequalities (National Collaborating Centre for Healthy Public Policy 2010) www.ncchpp.caYiu, L. (2012). Community Health Nursing A Canadian Perspective. Toronto: Pearson Canada Inc.World Health Organization (WHO) 10 facts on health inequities and their causes. (2011) www.who.int/features/facilities/health_inequities/en/WHO e-Library of Evidence for Nutrition Actions (eLENA) www.who.int/elenaWynn, A. M. (2012). Integration of Primary Health Care and Public Health During a Public Health Emergency. American Journal of Public Health, e9-e12.

Transcript

  • 1. Assignment 3: Application Exercise 1 From Theory to Practice Kathrine Churchill RN Athabasca University Nursing 434 Instructor: Lisa Barrett September 4, 2013 Namwayut
  • 2. Ottawa Charter 1986 “ The process of enabling people to increase control over, and to improve their health” (Ottawa Charter 1986). Bangkok Charter 2007 Expanded on the Ottawa Charter of twenty years earlier with stronger recommendations.
  • 3. CHN identified problems- What does the community think?
  • 4. The Assessment Process Progress
  • 5. Ethical Considerations Code of Ethics for Registered Nurses (2008) Canadian Nurses Association
  • 6. “ Collective action for sustained population-wide health improvement” (Beaglehole et al 2007).
  • 7. Key Determinants of Health Health Canada has created a list of 12 determinants of health.
  • 8. Community Chosen Priority Determinates of Health Nutrition Food Security Employment Income Education
  • 9. Building Resilient Sustainable Communities
  • 10. Partnering with First Nations People First Nations is a rapidly growing population to the extent they will become the dominant cultural group in many cities in Canada with in the next decade.
  • 11. Goals
  • 12. Goals
  • 13. Community Determined Strategy  .
  • 14. References These provide some of the best evidence available to address the health inequities in this community.