APPLICATION OF COMMUNITY EMPOWERMENT TO PRACTICENR.110.500 Philosophical, Theoretical, and Ethical Basis forNursingSara Cawrse, Jamie Hatcher, Sandeep Lehil, & Jessica Vargas
INTRODUCTIONApply the CommunityEmpowerment theoryto socio-economicallydisadvantaged, urbanAfrican Americans withuncontrolled type 2diabetes
PROBLEM & SIGNIFICANCE According to ADA, African Americans (AA) are at high risk for diabetes due to: Genetics High rates of obesity Low levels of physical activity In 2005, more than 18 million adults had diabetes in the United States AA accounted for a disproportionate amount (Green, McClellan, Gardner, & Larson, 2006). AA are 1.6 times more likely to develop diabetes than non-Latino Whites
PROBLEM & SIGNIFICANCE AA have higher rates of diabetes than their white counterparts, and tend to have poorer outcomes. Social, economic, and environmental factors contribute to health disparities (Green, McClellan, Gardner, & Larson, 2006). Differences in glucose control persist between AA and Whites even after adjusting for socioeconomic status, access to health care, and severity of disease (Marshall, 2005).
PROBLEM & SIGNIFICANCE AA increased rates of diabetic sequelae including retinopathy, microalbuminuria, end stage renal disease, lower extremity amputation mortality(Green, McClellan, Gardner, & Larson, 2006; Marshall, 2005).
PROBLEM & SIGNIFICANCE AA less likely to attain glucose control Possible reasons: Poor compliance with self-monitoring Poor adherence to treatment Cost of test strips and drugs Literacy rates Lack of diabetic education Sociocultural components Physician related factors
PROBLEM & SIGNIFICANCE Patients who are able to control their diabetes, (Green, McClellan, Gardner, & Larson, 2006; Austin & Claiborne, 2011): Often have friends or family with diabetes Seek out information about the disease Evidence-based self-management strategies Accurate perceptions of their own diabetes control Experience “turning point” events
PROBLEM & SIGNIFICANCE Further focus needed on: Preventing and controlling diabetes in this population Alternative interventions to traditional primary care Peer support and education Community Empowerment Theory
N U R S I N G T H E O RY: C O M M U N I T Y EMPOWERMENT Developed by Eugenie Hildebrandt and Cynthia Armstrong Persily (Persily & Hildebrandt, 2008) Middle range nursing theory Built off both empowerment and the community development theories Creates a community involvement approach Members of the community take responsibility for increasing their knowledge and decision-making abilities.
N U R S I N G T H E O RY: C O M M U N I T Y EMPOWERMENT Three main concepts: Involvement Lay Workers Reciprocal Health Involvement: People in the community create support groups or coalitions to identify their mutual needs, resources, and barriers to ultimately respond to a problem the community is facing. Done through planning, implementing, and intervening as a group (Persily & Hildebrandt, 2008)
N U R S I N G T H E O RY: C O M M U N I T Y EMPOWERMENT Lay Workers (Persily & Hildebrandt, 2008): Trained persons indigenous to the community to which they live in and work in. Reach out to families in the community Know community cultural values firsthand Encourage preventative services, healthy behaviors, and assist with access to social services
N U R S I N G T H E O RY: C O M M U N I T Y EMPOWERMENT Reciprocal Health (Persily & Hildebrandt, 2008): Actualization of inherent and acquired human potential. Occurs when professionals and community residents work together, respecting, and sharing what each other has to offer. Desired outcome of community empowerment as community members participate proactively in ways to attain their highest potential.
N U R S I N G T H E O RY: C O M M U N I T Y EMPOWERMENT (Smith & Lierhr, 2008)
E VA L U AT I O N : S I G N I F I C A N C E Clearly addresses the metaparadigm concepts of the person, the environment, health, and nursing goals/processes. Person: members of the community (these are the individuals who will receive the care/intervention) Environment: community itself as well as the communitys social constructs, the neighborhood, and the economy of the community Health: issues identified by the community as important to address Nursing goals/processes: empowerment of members of the community (lay persons and other community members) in order to promote changes that will address the needs and issues identified by the community
E VA L U AT I O N : S I G N I F I C A N C E The metaparadigm propositions addressed include: life processes patterns of human-environment interaction processes that affect health interaction between health and environment Philosophical basis: the foundation of this theory is that through empowerment change is possible.
E VA L U AT I O N : S I G N I F I C A N C E Derived from a merging of the empowerment theory and the community development theory. Posits that individuals and groups "grow through community participant interaction and achievement of identified goals." Guided by models that advocate for supporting individuals and communities to develop while working together on commonly identified problems. Empowerment involves developing problem-solving capacity and competence that allows individuals and communities to gain mastery over their lives. Critical in primary health care Part of the nurse-individual dyad Vital for linking health care providers and communities. When community development and empowerment are considered together, they demonstrate the "potential for empowerment of community people through the involvement of lay workers in promoting reciprocal health” (Persily & Hildebrant, 2008). It does not appear that the theory acknowledges use of adjunct or antecedent theories.
E VA L U AT I O N : CONSISTENCY & CLARITY Congruency between context and content Context: includes both change through empowerment and that change must come from within (oneself or the community). Content: includes identification of problems by the community and education of lay persons (members of the community) who will then educate others in the community, thus empowering them to change. The content is semantically clear and consistent.
E VA L U AT I O N : A D E Q U A C Y The theory assertions appear to be fairly well supported by empirical evidence. The theory itself was developed based on the experiences and observations of the two theorists and has been applied by them in their research.
E VA L U AT I O N : F E A S I B I L I T Y Pragmatic adequacy: Special training and skills may be required Implementing the theory primarily be limited by the motivation of the community Cost may or may not be a factor Legally, the nurse will likely be practicing within her scope of practice when providing health education to the lay persons and measuring its effectiveness within the community. Education and empowerment and key components of nursing practice, The theory is organized in such a way that, should one want to, Comparisons could be made between a community in which this theory was applied and a community in which the theory was not used Outcomes to be measured would depend upon the problems identified by the community Measurement of such outcomes should accurately indicate the effectiveness of the theory.
RATIONALE FOR THEORY SELECTION Significant disparities exist between AA and whites with regards to diabetes management and the rates of associated morbidity and mortality, AA face several barriers: including poor access to care, limited resources for physical activity due to residential barriers, and interference of care due to other life events or stressors (Samuel-Hodge, et al., 2000). Can address barriers by: Bringing the care to the patient through lay-educators, Altering the care so that it is appropriate and reasonable for the patient’s lifestyle and culture. For diabetes management to be effective, it must be approached with an understanding of the population’s social, cultural, and familial influence (Chesla, et al., 2004; Samuel- Hodge, et al., 2000; Two Feathers, et al., 2005)
POSSIBLE SOLUTION Community health worker (CHW) programs have shown promise in improving health behaviors and health outcomes Particularly for racial and ethnic minority communities and for those who have disparate access to health care (Spencer, Rosland, Kieffer, Sinco, Valero, Palmisano, & Anderson, 2011). CHWs can provide comprehensive care regarding social and some medical needs at a less expensive cost (Gary, Bone, Hill, Levine, McGuire, Saudek, & Brancati, 2003).
POSSIBLE SOLUTION CHWs use their ethnic,cultural, or geographicbackgrounds to promotehealth within their owncommunities. They are a bridge for those with disparities to accessible healthcare Become part of the patient’s support system Can also provide resources, transportation, and coordinate case management.
EXAMPLE OF THEORY IN USE In Heisler, Spencer, Forman, et al. (2009), participants felt CHWs gave them “clear and specific strategies on managing diabetes care, nonjudgmental assistance to increase confidence in maintaining diabetic care, and social and peer support”. CHW programs that provide both one-on-one support and group self-management training sessions may be effective in promoting more effective diabetes care and patient–doctor relationships among African-American adults with diabetes than without CHW support (Heisler, Spencer, Forman, et al., 2009).
POTENTIAL PROBLEMS WITH IMPLEMENTING Most studies on community health workers have not used a randomized controlled trial design. Studies have small samples in a localized neighborhood and therefore have threats to external validity. Potential problems may arise with training and retaining community health workers when implementing programs (Hill-Briggs, Batts- Turner, Gary, Brancati, Hill, Levine, Bone, 2007).
REFERENCESAustin, S. A., Claiborne, N. (2011). Faith wellness collaboration: A community-based approach to address type II diabetes disparities in an African-American community. Social Work Health Care, 50(5), 360-375.Chesla, C. A., Fisher, L., Mullan, J. T., Skaff, M. M., Gardiner, P., Chun, K., & Kanter, R. (2004). Family and disease management in African-American patients with type 2 diabetes. Diabetes Care, 27: 2850-2855.Fawcett, J. (2005). Criteria for evaluation of theory. Nursing Science Quarterly, 18(2), 131-135.Gary, T. L., Bone, L. R., Hill, M. N., Levine, D. M., McGuire, M. Saudek, C., and Brancati, F. L. (2003). Randomized controlled trial of the effects of nurse case manager and community health worker interventions on risk factors for diabetes related complications in urban African Americans., 37 (1), 23–32.Greene, C., McClellan, L., Gardner, T., & Larson, C. O. (2006). Diabetes management among low- income African Americans: A description of a pilot strategy for empowerment. Journal of Ambulatory Care Management, 29(2), 162-166.Heisler, M., Spencer, M., Forman, J., Robinson, C., Shultz, G., Graddy Dansby, G., Kieffer, E. (2009). Participants assessments of the effects of a community health worker Intervention on their diabetes self-management and interactions with healthcare providers. American Journal of Preventive Medicine, 37(6, 1), S270-S279.Hill-Briggs, F. Batts-Turner, M., Gary, T. L., Brancati, F. L., Hill, M. N., Levine, D. M., Bone, L. R. (2007). Training community health workers as diabetes educators for urban African Americans: Value added using participatory methods. Progress in Community Health Partnerships: Research, Education, and Action, 1(2), 185-194.
REFERENCESMadden, M. H., Tomsik, P., Tercheck, J., Navracruz, L., Reichsman, A., Clarck, T. C., & Werner, J. J. (2011). Keys to successful diabetes self-management for uninsured patients: Social support, observational learning, and turning points. Journal of the National Medical Association, 103(3), 257-264.Marshall, M. C. (2005). Diabetes in African Americans. Postgraduate Medical Journal, 81(962), 734-740.Persily, C. A. & Hildebrant, E. (2008). Theory of community empowerment. In Smith, M. J. & Lierhr, P. R. Middle Range Theories for Nursing (2nd Eds.). New York, NY: Springer Publishing Company.Samuel-Hodge, C. D., Headen, S. W., Skelly, A. H., Ingram, A. F., Keyserling, T. C., Jackson, E. J., & Elasy, T. A. (2000). Influences on day-to-day self-management of type 2 diabetes among African American women. Diabetes Care, 23: 928-933.Shacter, H. E., Shea, J. A., Achabue, E., Sablani, N., & Long, J. A. (2009). A qualitative evaluation of racial disparities in glucose control. Ethnic Disparities, 19(2), 121-127.Spencer, M. S., Rosland, A. Kieffer, E. C., Sinco, B. R., Valero, M., & Palmisano, G., Anderson, M., Guzman, R., & Heisler, M. (2011). Effectiveness of a community health worker intervention among African American and Latino adults with type 2 diabetes: A randomized controlled trial. American Journal of Public Health, e1-e8.Two Feathers, J., Kieffer, E.C., Palmisano, G., Anderson, M., Sinco, B., Janz, N., & James, S. A. (2005). Racial and ethnic approaches to community health (REACH) Detroit partnership: Improving diabetes-related outcomes among African American and Latino adults. The American Journal of Public Health, 95(9): 1552-1560.