Public Health Program Development to Complement Occupational Therapy Practice
SDH Presentation San Antonio
1. Changing Nursing Graduate
Students’ Understanding of
Social Determinants of Health
Costa Rica
Nicaragua
Panama
Honduras
El Salvador
Dr. April Folgert
Concordia University Wisconsin
Colombia
2. Objectives
Identify trends and approaches to reduce health
disparities across populations.
• Identify two curricular strategies to enhance
students’ knowledge of social injustice.
• Explain two lessons students learned about the
social determinants of health.
• Explain one or more challenges and strategies
for organizing a short-term study abroad course
designed to teach students about the social
determinants of health.
4. Within the Context of Culture
Image adapted from https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health
Neighborhood
and Built
Environment
Health and
Health Care
Social and
Community
Context
Education
Economic
Stability
SDOH
19. • Analyze the health care system
• Analyze levels of health care access
implications for health
• Develop plan to promote health
Written Assignment
20. • Health Care
• Culture
• Social Inequality
• Role for Nurse Practitioners
Image adapted from https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health
21. % rated perceptions mostly or
significantly increased
50
55
60
65
70
75
80
85
90
95
100
Arrival Hospital and
Caja
EBAIS and
Indg Cult
EBAIS &
Indig Culture
Free Time
Cult Comp
Soc Injustice
Healthcare
22. “I found it surprising
to take 8 hours to
receive care…”
“Immersing ourselves in another
culture is an important aspect of
learning to deliver culturally
congruent care to the patients
we serve.”
“As an NP, I need to
advocate for a better
system.”
“It was nice to hear the
perspectives of those
who use the system.”
24. References
Davis, S. L., & Chapa, D. W. (2015). Social determinants of health: Knowledge to effective action for
change. Journal for Nurse Practitioners, 11(4), 424-429. Retrieved from www.npjournal.org
Carryer, J., Halcomb, E., & Davidson, P. M. (2015). Nursing: The answer to the primary health care
dilemma. Collegian, 22(2), 151-152. doi: 10.1016/j.colegn.2015.05.001
Carryer, J., & Yarwood, J. (2015). The nurse practitioner role: Solution or servant in improving primary
health care service delivery. Collegian, 22(2), 169-174. doi: 10.1016/j.colegn.2015.02.004
Kidder, R. M. (2009). Overview: The ethics of right versus might. In R. M. Kidder (Ed.), How good people
make touch choices: Resolving the dilemmas of ethical living (pp. 12-29). Camden, MA: Institute for
Global Ethics.
Lanthrop, B. (2013). Nursing leadership in addressing the social determinants of health. Policy, Politics,
and Nursing Practice, 14(1), 41-47. doi: 10.1177/1527154413489887
Riner, M. E., Bai, J., & Larimer, S. (2015). Intercultural global health assessment and reflection framework
for teaching study abroad courses. Journal of Nursing Education and Practice, 5(5), 65-72.
doi:10.5430/jnep.v5n5p65
U. S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion.
(2011). Social determinants of health. Healthy People 2020. Washington, DC. Retrieved from World
Health Organization. (2012a). Social determinants of health. Retrieved from http://www.who.int/
social_determinants/thecommission/finalreport/key_concepts/ en/index.html
Editor's Notes
Introduction
Studying abroad is one of the most unforgettable ways to learn about culture and the social determinants of health.
During the next 20 minutes I’m going to share with you a course I developed for nurse practitioner students that includes a short-term study abroad experience in Costa Rica.
The Objectives
The objectives for this session are listed in your handout and on the screen and relate to the conference objective of identifying trends and approaches to reduce health disparities across populations.
Nurse Practitioners
You may be surprised to learn that nurses and nurse practitioners are challenged by the complexity of health care issues related to community health, access, and social injustice.
My concern in teaching nurse practitioner students is the possibility that their primary care focus would take them further away from the broad yet very real issues related to the social determinants of health.
Social Determinants of Health in Cultural Context
So I began looking at the learning objectives and considering the strategies I could use for this course.
But I began to think about what I wanted students to gain from this experience. What would be so impactful that it would change how they practice currently as nurses and how they would advocate for patients locally and globally.
Challenges
From a personal perspective, I had some challenges. I wasn’t certain what types of experiences were available because I had never set foot there. I had never been to Costa Rica but this is where the students were expecting to go.
Where were my resources? Did they have hospitals? And when we get there, how do we behave? I had a lot to learn about Costa Rica before I could truly lead a group of 24 students there.
Lastly, yo hablo mui pochito Espanol. That means, I speak very little Spanish. Now don’t let the fool you. I learned that just to give those whom I was communicating with a “heads up.”
Strategies
Google was truly my friend. I learned a lot about Costa Rica, the culture, health care system, economic stability of the country, common health concerns.
I took a scouting trip so I could see, first-hand, what the resources were and where I wanted students to study. I was able to determine that it is possible to study the urban and rural areas of Costa Rica in a week’s time since the country is only about the size of West Virginia.
I hired a tour guide. These folks know the area and with medical tourism being a major component of income for the country, they had very good ideas and access to healthcare facilities.
I took time to learn the basics of the language, cultural norms, and ensured I had Google Translate on my phone. Trust me, it came in handy.
Curricular Strategies
Once I learned what was possible, I went to the drawing board to develop strategies that would prepare students for the experience, allow them to engage in meaningful experiences in Costa Rica, reflect upon the experiences, and transform their understanding of culture and the social determinants of health.
Pre-Travel Assignments
List of assigned readings
Online discussion questions
Cultural Self-Assessment
Experiences
CIMA –
Private
Technology
Customer Service
Hospital Nacional de Ninos
Care for children throughout country
Care for more than 1000 children in clinics each day
30-60 referrals each day outside San Jose
Antiquated (Consumer Product Safety Commission)
EBAIS
947 EBAIS across country. Each covers care for 3500-4000 patients across the lifespan.
1 physician, a nurse, medical records technician, and pharmacy technician
Indigenous Culture
Traditional medicine and practices
2% of population = 65,000 people
Nearly half are impoverished and live in mountains
Only 26% access to clean water
We learned about health care within the community context. We learned about how pre-Columbian cultures practiced and continue to use herbal medicine (traditional medicine) to protect and heal the body of illness. We also learned about access for those who still reside in the mountains.
Nearly half are Bribri and Guaymi, are impoverished, and have minimal access to healthcare because they live in secluded areas such as the mountains.
Social Security System
Working class support health care system
Uninsured include Nicaraguan population – 30% unemployed
Challenges with sustainability, growth, and equity
Covers medical, sick leave, maternity, and pension
Free Time
Allowed students to talk to locals
Describe activities and observations based on sensory experience. Describe your reactions such as feelings, desires, thoughts, and behaviors. Explain the insights you gained to develop cultural competence as a nurse practitioner.
Location
Students identified location as an issue related to access. While in Costa Rica, we travelled throughout the country. Students learned that people located in rural parts of the country didn’t have access to healthcare. The terrain is Costa Rica is beautiful and mountainous but makes it challenging for those who need care to access an EBAIS very easily. This was particularly noted about indigenous community members who reside in the mountains.
Availability
Each EBAIS has a physician, a nurse, a receptionist, pharmacist,
Insurance
Students learned about how health care costs are paid for in a universal health care system. Visiting a private and public hospital provided the opportunity to compare access to what students’ defined as quality of health care between the two. They talked about how socioeconomic status impacted residents’ access to quality of care, efficiency, and use of the most modern equipment.
For the students who enrolled in this course, studying abroad was unforgettable.
By being in our own element, become blinded to community health issues and social inequality. But when you step outside of your own environment, evaluate what is happening in other countries, and reflect upon what one’s own biases, we learn where we are and can then transform into what we want to be. My hope for these students is that they would be moved to advocate for patients both locally and globally after this experience.
It has been my pleasure to share this course with you.
Thank you.
