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544 public health Exam 1


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What is a community?
1)A group of people
2)who share some type of bond
3)who engage in interaction with each other
4)and who function collectively re: common concerns.
What is a community-based nurse?
A nurse who is not baccalaureate prepared who works outside of a hospital or nursing home.
What is a community/public health nurse?
A nurse who has received formal public health nurse preparation (often baccalaureate prepared), who is population-focused.
What is an aggregate?
A group of people with some characteristics in common. Characteristics may be either environmental or personal.
What are major classes of aggregates?
age/developmental stage
health needs/problems
level of wellness
risk factor clusters

**aggregates may or may not be a community
What is community oriented nursing?
-philosphy of nursing care delivery
-involves generalist & specialist public health and community health nurses
-provides health care and health surveillance
What does "health care" mean in terms of community oriented nursing?
-assessment of health and environmental problems resulting in community diagnosis
What does "health surveillance" mean in terms of community oriented nursing?
- monitoring and evaluation of the community and population health status to:
prevent disability and disease
and promote, protect, and maintain health
What is community health nursing (CHN)?
Synthesis of nursing theory and public health practice, focusing on total population, with the goal of:
health promotion (wellness)
health protection (preserve)
disease prevention (levels of prevention)
What are the components of CHN?
prevent health problems
treatment of disorders
Who is the client in community health nursing?
families, groups, aggregates
Community Based nursing as a practice model is characterized by:
individual and family centered orientation, in whatever setting (home, work, school).
-a partnership with clients to manage acute and chronic conditions
-focuses on secondary and tertiary levels of prevention
Community Based Nursing
-emphasis on acute or chronic conditions
-focus on individual/family
-autonomy for individual and family
-across lifespan
-culturally appropriate
-direct service
-service-local community
Community Health Nursing
-preserve, protect health and self-care
-focus on community
-community autonomy
-across lifespan emphasis on high risk aggregates
-collaborates with diverse groups & communities
-service: local, state, federal, international
What are the public health sciences?
assessment r/t behavioral, cultural, and economic factors
program planning
policy development

*public health nursing synthesizes the body of knowledge from each.
Components of public health nursing
-public health sciences
-professional nursing theories
-GOAL - improve health of community
-ID subgroups (aggregates)at risk within the community
-primary prevention and health promotion
-works with groups, families, individuals
What are the core functions of public health?
policy development
Health Services Pyramid
tertiary - $$$, rehab back to health or maintain state, limit progression of disease
secondary - $$, screenings
primary - $, disease prevention and health promotion
clinical preventive services
population based health care services

*the lower the level, the more effective use of resources
Essential Public Health Services
1.monitor population health status, ID problems
2.diag. & investigate health problems and hazards
3.inform, educate, empower people re: health
4.bring together partnerships to ID and solve health problems
5.develop policies to support health efforts
6.enforce laws for health & safety people to resources, follow-up
8.adequate and competent health care workforce
9.evaluate effectiveness, accessibility, and quality of both personal and population-focused health services
10.conduct research to develop new and creative solutions to health problems
public health: population focused practice
focuses on health of general public in their environment using a scientific, systematic approach
The current US welfare system...
is based upon the Elizabethan Poor Laws
What are the 4 concepts of the nursing metaparadigm related to Community Health Nursing?
person=aggregates of the population
health=health promotion/disease prevention
Describe and given an example of the Epidemiological Triangle.
<-->susceptible person or host<-->
<-->causative agent<--> <-->Environment<-->

At the center: RISK (the probability that a person will become ill)

this model is simpler than the web of causation

Ex: hepatatis A, students/staff of schools, school cafeteria strawberries
Things to consider: Host
A living species capable of being infected or affected by an agent.
demographic characteristics
level of health
history of prior disease
genetic predisposition
state of immunity
body defenses
human behavior/lifestyle

Ex: human being
Things to consider: Causative Agent
presence or absence of biologic, physical, chemical, nutritional, genetic, or psychological factors that have the ability to affect the host's health
Ex: virus, bacteria, lead, pesticides, cold, heat, radiation
Things to consider: Environment
anything external to the host or agent, including presence of other people or animals. Influences and is influenced by the host and/or agent.
Ex: climate, peers, socioeconomic, work environment
Levels of Prevention (p. 156 graphic)
primary - altering susceptibility/reducing exposure
secondary - early detection/prompt treatment
tertiary - limiting disability/rehabilitation
What is epidemiology?
The study or investigation of the distribution or the patterns of health events in populations and the determinants or the factors that influence those patterns.
*Descriptive: Who, What, Where, When
*Analytic: How, Why

Healthy People 2010 addresses...
the need for epidemiological services and the use of data - 28 areas of focus were identified for data collection.
Who was the father of epidemiology?
John Snow - developed a mapping of the cholera epidemic and pinpointed contaminated water source.
Epidemiology has become a basis for nursing practice...
nurses use data from genetics, emerging infections, environmental toxins, behavioral and social factors to look at health and disease causation for treatment/prevention interventions.
Sources of epidemiological data
(sources of health/disease indicators)
secondary: vital statistics, surveillance data (reportable diseases), medical records, insurance records, census data

interviews, focus groups, surveys

(help to determine risk)
the measure of frequency of health events in a defined population during a specified period of time, taking into account the size of the population
Ex: Rate per 1000
500 cases/15,000 people

500/15000 = x/1000

= 33/1000
Measures of Morbidity:
Prevalence Rate
total number of new cases and old cases of a disease or health conditon
Measures of Morbidity:
Incidence Rate
total number of new cases of a disease or health condition over time
Measures of Morbidity:
Attack Rate
The proprtion of people who are exposed to an agency and the number of people who acquire the disease.
Mortality Rates
Death Rate
reported as per 1000, per 10,000 or per 100,000
cause specific
Rates and ratios:
statistics used to describe births, deaths and incidencses and prevalences of disease and disability in populations.
includes personal characteristics observed in populations
race, gender, age, education level, socoeconomic.
Disparities in mortality rates related to these factors. Age is #1.
do mortality and morbidity rates vary based on the geography, population density, location of vectors, healthcare accessibility, social patterns, cultural health beliefs.
an increase or decrease in the frequency of disease over time.
Secular Trends
long-term patterns

Ex: seatbelt and infant mortality
Point Epidemic
time and space related pattern; important in investigate of infectious disease
Cyclical Time Patterns
Seasonal influence based upon weather, calendar events (holidays), recreational activity
Event Related Cluster
patterns where time is not measure from a fixed date but the point of exposure.
Ex: immunization adverse sign reports
Analytic Epidemiology:
Cross-sectional studies
discover determinants of outcomes, using a snapshot or cross section of the population.
Analytic Epidemiology:
ecological studies
discover determinants of outcomes,
Analytic Epidemiology:
cohort studies
discover determinants of outcomes, a group of people who are born about the same time or sharing some common characteristic
prospective: longitudinal
Analytic Epidemiology:
case-control studies
discover determinants of outcomes, study enrolls those with a condition and those without (control)

Result is an Odds Ratio
Odds Ratio
abuse 68/suicideattempt 32
no history36/no attempt 164

cross multiply=9.68

which represents that those with a history of abuse have 10X greater risk of suicide attempt
Interventionl studies
measures the effectiveness of a treatment or intervention to reduce risk

Ex: clinical trials
The secondary level of prevention
Screening: reliability
consistency of measurement
Ex: trait, observer, tool
Screening: validity
sensitivity and specificity
Ex: false positive/false negative

preference for retesting a false positive rather than sending someone away with a false negative
Screening: Ethical Consideration
Disclosure of what the test fully means?
A screen IS NOT a diagnostic test.
statistical association b/w the disease and the risk
*Bias - sampling, data collection, confounding factors
Criteria for causality
1. strength of association
2. consistency of findings
3. biological plausibility
4. demonstration of correct temporal sequence
5. dose-response relationship
6. specificity of the association
7. experimental evidence
Health promotion
the process of helping people enhance their well being and maximize their human potential.
Focus is on people and populations as a whole and changing behaviors to promote rather than simply avoid illness.
Goal is to enable people to exercise control over their well being and ultimately improve their health.
Combines education, organization involvement, economics, and political influences to bring changes.

Ex: make people move away from New Orleans
Disease prevention
Reducing disease causing factors such as:
demographic trends, nutrition, fitness, stress, toxic agent control, major causes of disease and risks to health.

Ex: fix the levee and clean up the flood
Core functions of Public Health: Assessment
windshield survey (subj.)
participant observation (subj.)
key informant interviews (obj.)
community forums/focus groups (obj.)

seondary analysis of existing data
Community or population, BCFs
family system structure
educational level
Community Universal Requisites
Air, Water, Food Quality & Supply
Community Developmental Requisites
family support systems
economic and social welfare
educational system
religious expression
political participation
Community Health Deviation Requisites
communicable diseases
Relate nursing process to community assessment:
assess: assess community
plan: organize partners/prioritise problems/pland interventions
implement: implement plan
evaluate: evaluate
Format for community diagnosis:
Risk of ____
among _____
related to ____
(Demonstrated by _____)

Ex: Eisk for abuse among dependent community dwelling elderly in Aging county r/t lack of support systems for caregivers, lace of available, certified home health aides demonstrated by 12% increase in rate of abuse reports filled with adult protective services.
Policy Development
planning and implementing health care based on a community assessment
evaluating and making sure policies are being carried out.
Goals of Health People 2010
1. increase quality and years of health life

2. eliminate health disparities
Leading Causes of Death:
Today vs. 1900
pneumonia, TB, GI, heart disease, ill-defined senility

heart disease, malignant neoplasms, cerebrovascular, COPD, accidents
Why use the web of causation instead of Epi triangle
It recognizes the complexity of some health conditions.

** Models are helpful when developing interventions.
Epidemiological Investigations:
What are methods of analytic studies?
Answer questions about cause-and-effect relationships b/w potential risk factors and a specific health phenomenon or disease condition.

Hypotheses are tested through retrospective studies, cross-sectional studies, or prospective studies.
Community competence
A Framework (theory)

Community processes that contribute to inclusion and particiaption of members.

Based on 8 variables:
self & other awareness
clarity of situation definitions
conflict containment & accommodation
management of relations w/larger society
machinery for facilitating interaction & decisionmaking
population or aggregate "do not"s
do not interact
do not share a bond
do not have group orientation
Indicators of physical health status
1. race/ethnicity specific infant mortality
2. death rates for MVA, occupational, suicide, lung cancer, breast cancer, CV disease, homicide,
3. incidence reports for AIDS, measles, TB syphillis
4. risk incidence fo low birth weight, teen births, prenatal care, child poverty, EPA standards
Indicators of emotional and social indices
consumer satisfaction and mental health
crime rates
Upstream thinking (upstream intervention)
"the earlier the causal process (or more upstream) intervention occurs, the greater the likelihood of imrpoved health for the community."
Comparison of assessment factors
NSG: person, environment, health, nursing
OREM: community: BCF, UR, UR/DR/HDR, nursing systems
the organized approach to meet the assessed needs of the individuals, families, groups or communities by reducing or eliminating one or more health problems.
program model
diagram showing links b/w program components, objectives, and goals
systematic development of a program
essential for process, outcome, and impact evaluation
uses limited resources and yields greatest rewards
Four steps of the program model
1.Describe the problem
2.Identify goals and objective
3.Define program components
4.Develop the model
Needs assessment tools
community forum
key informant
indicators approach
survey of existing agencies
Needs assessment tools, benefits and limitations: community forum
cost-efficient and effective way to obtain opinion data
wide variety of community members supply input on wide range of topics, may find an otherwise unidentified need

may be too difficult to keep the forum from becoming a gripe session
Needs assessment tools, benefits and limitations: key informant
interviews with people in the community

inexpensive-valuable subjective data that may be too difficult to obtain on written survery

biased view
Needs assessment tools, benefits and limitations: indicators approach
readily available data, shows trends over time

may not include data for specific community being assessed by nurse
Needs assessment tools, benefits and limitations: survey of existing agencies

low return rate, costly
Needs assessment tools, benefits and limitations: census
readily available, trends over time

collected once every 10 years
Program Objective
more immediate pathways to program goals
more numerous than goals
measured in the short-term

EX: To achieve the GOAL of "increasing abstinence rates in 9th graders", an objective will be to significantly enhance teen's refusal skills
A clear program objective requires:
specific, relevant, appropriate, acceptable, realistic, and measureable

link each objective to a goal

EX: short-term objective - improve teen's contraception knowledge

long-term objective - by end of program, 75% of teens will name 2 forms of contraception
A clear program goal requires:
specific, relevant, appropriate, acceptable, realistic, and measureable


Ex: short-term goal: decrease incidence of teen pregnancy

long-term goal: decrease teen preg. to 2% of 9th graders by yr. 2009
Needs Assessment
who is the client
what is the need to be met
how large is the population to be served
where is the population located
are other programs addressing the same need
why is the need not met
Aspects of Program Evaluation: formative evaluation
Ongoing evaluation of process
Aspects of Program Evaluation: summative evaluation
evaluation of outcome - is it solving the problem - are the benefits worth the costs?
Aspects of Program Evaluation
Sources for evaluating program data
surveys, client satisfaction tools
program records: number of participants, clinical changes
community health indexes - mortality, morbidity rates, birth/death certificates

(pre & post tests)
State Clear Objectives (and Goals)
a specific behavior
the accomplishments
success criteria
strong action oriented verbs
a single purpose
a single result
time frame

Ex: to decrease by 50% the incidence of early childhood disease in Lucas county by providing immunization clinics in all schools between Aug and Dec 2006.
What are the advantages of a systematic program planning process?
helps client, nurse, & agency
ids resources/activities required
anticipatory benefits
enhances quality decisions and control over results
clarifies who is responsible for what
clearly delineates the environment
enables the provider to adapt to the environment

essential to evaluation process
Four Steps to the Program Model
1.Describe the problem
2.ID goals and objective
3.Define program components
4.Develop the model

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