Population Affected by Disabilities.

Rural and Migrant Health 

Read chapter 21 and 23 of the class textbook and review the attached PowerPoint presentations.  Once done, answer the following questions.

1. Mention and discuss the differentiation between the medical model and social construct definitions of disability.
2. Identify and discuss selected health care and social issues that influence the ability of people with disabilities to live and thrive in the community.
3. Mention and discuss the characteristics of rural community health nursing practice.
4. Mention and describe the features of the health care system and population characteristics common to rural aggregates.

As stated in the syllabus present your assignment in an APA format word document, Arial 12 font attached to the forum in the discussion tab of the blackboard titled “Week 6 discussion questions” and the SafeAssign exercise in the assignment tab of the blackboard.   If you don’t post your assignment in any of the required forums you will not get the points.  A minimum of 2 evidence-based references besides the class textbook no older than 5 years must be used (excluding the class textbook).  You must post two replies to any of your peers on different dates sustained with the proper references no older than 5 years as well and make sure the references are properly quoted in your assignment.  A minimum of 800 words is required.  Please make sure to follow the instructions as given and use either spell-check or Grammarly before you post your assignment.

Chapter 21

Populations Affected by Disabilities

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Most people whose lives do not end abruptly
will experience disability.
– Nies & McEwen (2015)
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Doing a Self-Assessment
What comes to mind when you think of someone with a disability?
Picture yourself as a person with a disability.
Imagine yourself as a nurse with a visible disability, or a client receiving care from a nurse with a disability.
Think about living in a family affected by disability.
What is the experience of living with disability within your community?
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Definitions for Disability
Disability is the interaction between individuals with a health condition and personal and environmental factors.
– World Health Organization, 2012
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WHO International Classification of Functioning, Disability, and Health
Disability is an umbrella term covering impairments, activity limitations, and participation restrictions (individual level).
An impairment is a problem in body function or structure—activity limitation or participation restriction (micro level).
A handicap is a disadvantage resulting from an impairment or disability that prevents fulfillment of an expected role (macro level).
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Table 21-1
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Characteristic Impairment Disability Handicap
Definition Physical deviation from normal structure, function, physical organization, or development
May be objective and measurable Not objective or measurable; is an experience related to the responses of others
Measurability Objective and measurable May be objective and measurable Not objective or measurable; is an experience related to the responses of others
Illustrations Spina bifida, spinal cord injury, amputation, and detached retina Cannot walk unassisted; uses crutches and/or a manual or power wheelchair; blindness
Reflects physical and psychological characteristics of the person, culture, and specific circumstances
Level of analysis Micro level
(e.g., body organ) Individual level
(e.g., person) Macro level
(e.g., societal)

6

National Agenda for Prevention of Disabilities (NAPD) Model
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Figure 21-1 Reprinted with permission from Pope AM, Tarlov AR, editors: Disability in America: toward a national agenda for prevention, Washington, DC, 1991, Institute of Medicine, National Academy Press. Copyright © 1991 by the National Academy of Sciences. Courtesy National Academy Press, Washington, DC.

Quality of Life Issues
Transportation to a needed service
Cost of care
Appointment challenges
Language barriers
Financial issues
Migrant/noninsured issues
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Models for Disability
Medical model—a defect in need of cure through medical intervention
Rehabilitation model—a defect to be treated by a rehabilitation professional
Moral model—connected with sin and shame
Disability model—socially constructed
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Disability: A Socially Constructed Issue
Disability is a complex, multifaceted, culturally rich concept that cannot be readily defined, explained, or measured (Mont, 2007).
Whether the inability to perform a certain function is seen as disabling depends on socio-environmental barriers (e.g., attitudinal, architectural, sensory, cognitive, and economic), inadequate support services, and other factors (Kaplan, 2009).
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“Medicalization” Issues
Nurse needs to differentiate …
A person who has an illness and becomes disabled secondary to the illness
versus …
A person who has a disability, but may not need treatment
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“Medicalization” Issues (Cont.)
Nurse’s interaction with PWD and families
Approach on an eye-to-eye level
Listen to understand
Collaborate with the person/family
Make plans and goals that meet the other’s needs and draw on strengths and improve weaknesses
Empower and affirm the worth and knowledge of the person/family with a disability
Promote self-determination and allow choices
Note: PWD = persons with disabilities
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Historical Perspectives
Long history of institutionalization/segregation
Often viewed as sick and helpless
In the 20th century, special interest groups emerged to advocate for PWD (e.g., ARC)
Tragedies include Hitler’s euthanasia program
Deinstitutionalization began in 1960s-1970s
Stereotypical images still common in literature and media; these images influence prevailing perceptions of disability
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Historical Context for Disability
Early attitudes toward PWD
Set apart from others
Viewed as different or unusual
Documented in carvings and writings
Infanticide or left to die (not in Jewish culture)
Viewed as unclean and/or sinful
Served as entertainers, circus performers, and sideshow exhibitions
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Historical Context
18th and 19th century attitudes
No scientific model for understanding and treating
Disability seen as an irreparable condition caused by supernatural agency
Viewed as sick and helpless
Expected to participate in whatever treatment was deemed necessary to cure or perform
Industrial Revolution stimulated a societal need for increased education
If not third-grade level = feeble-minded
Special schools established in early 1800s
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Historical Context (Cont.)
20th century attitudes
Special interest groups were formed
First federal vocational rehabilitation legislation passed in early 1920s
Involuntary sterilization of many with intellectual disabilities
ARC (Association for Retarded Children) began to advocate for children with intellectual disabilities—today is Association for Retarded Citizens
ARC is “world’s largest community-based organization of and for people with intellectual and developmental disabilities” (ARC, 2009)
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Historical Context (Cont.)
20th century attitudes
One of the most horrendous tragedies under Hitler’s euthanasia or “good death” program
Killed at least 5000 mentally and physically disabled children by starvation or lethal overdoses
Killed 70,274 adults with disabilities by 1941
Over 200,000 people exterminated because they were “unworthy of life”
Deinstitutionalization movement in 1960s and 1970s
Community-based Independent Living Centers established
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Historical Context (Cont.)
Contemporary conceptualization
Stereotypical images remain common in literature and media
Population portrayed as a burden to society or from pity/pathos or heroic “supercrip” perspectives
“just as the paralytic cannot clear his mind of his impairment, society will not let him forget it.” (Murphy, 1990, p. 106)
Societal stigma still exists
Teasing or bullying often occurs in schools
Rehabilitation Act of 1973 and American with Disabilities Act of 1990 prohibit “disability harassment”
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Characteristics of Disability
Americans with Disabilities Act (ADA) of 1990 and Rehabilitation Act of 1973 defined disability according to limitations in a person’s ability to carry out a major life activity.
Major life activities: ability to breathe, walk, see, hear, speak, work, care for oneself, perform manual tasks, and learn
U.S. Census Bureau (2006) defines disability as long-lasting physical, mental, or emotional condition that creates a limitation or inability to function according to certain criteria.
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Examples of Disabilities
Physical disabilities
Sensory disabilities
Intellectual disabilities
Serious emotional disturbances
Learning disabilities
Significant chemical and environmental sensitivities
Health problems
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Measurement of Disability
Survey of Income and Program Participation (SIPP)
Functional activities
Activities of daily living (ADLs)
Instrumental activities of daily living (IADLs)
American Community Survey (ACS)
Surveys for disability limitation in six areas that affect function or activity (sensory, physical, mental/emotional, self-care, ability to go outside the home, employment)
Other organizations also collect disability data
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Prevalence of Disability
In 2010, approximately 18.7% of civilian noninstitutional population aged 5 years and older had a long-lasting condition or disability.
Of those with a disability, 12.6% had a “severe” disability.
Prevalence varies by race, age, and gender.
It is important for health care policymakers and health care providers to recognize that the prevalence of disability is increasing.
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Prevalence of Disability in Children
Approximately 15.2% of households with children have at least one child with a special health care need (disabling condition).
– National Survey of Children with
Special Health Care Needs (2009/2010)
A disability is defined by a communication-related difficulty, mental or emotional condition, difficulty with regular schoolwork, difficulty getting along with other children, difficulty walking or running, use of some assistive device, and/or difficulty with ADLs
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Recommendation for the Nurse
Listen to parental concerns
“Something is not right”
Establishes an important bond with parents
Nurse can serve as an intermediary
Regularly assess for key developmental milestones
Compare with predicted values
Work with team of resource providers on IEP
Be cognizant of disability within the context of culture and aging
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Legislation Affecting People with Disabilities
Individuals with Disabilities Education Act (IDEA) (1975); reauthorized in 1997, 2004
Ensured a free appropriate public education (FAPE) in the least-restrictive setting to children with disabilities based on their needs
Parents, students, and professionals join together to develop an Individualized Education Program (IEP), including measurable special educational goals and related services for the child.
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Americans with Disabilities Act of 1990 and ADA Amendments Act of 2008
ADA: Landmark civil rights legislation that prohibits discrimination toward people with disabilities in everyday activities
Guarantees equal opportunities for people with disabilities related to employment, transportation, public accommodations, public services, and telecommunications
Provides protections to people with disabilities similar to those provided to any person on basis of race, color, sex, national origin, age, and religion
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ADA (Cont.)
Refers to a “qualified individual” with a disability as a person with a physical or mental impairment that substantially limits one or more major life activities or bodily functions, a person with a record of such an impairment, or a person who is regarded as having such an impairment.
Qualifying organizations must provide reasonable accommodations unless they can demonstrate that the accommodation will cause significant difficulty or expense, producing an undue hardship.
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Americans with Disabilities Act of 1990 and ADA Amendments Act of 2008 (Cont.)

Ticket to Work and Work Incentives Improvement Act (TWWIIA)
Increases access to vocational services; provides new methods for retaining health insurance after returning to work
Increases available choices when obtaining employment services, vocational rehabilitation services, and other support services needed to get or keep a job
Became law in 1999, amended in 2008
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Public Assistance Programs
Cash assistance
Supplemental Security Income—SSI
Social Security Disability Insurance—SSDI
Food stamps
Public/subsidized housing
Costs associated with disability
Gaps in employment, income, education, access to transportation, attendance at religious services
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Health Disparities in Quality and Access
Disparities are caused by …
Differences in access to care
Provider biases
Poor provider-patient communication
Poor health literacy
Persons with disabilities experience …
Higher rates of chronic illness
Increased risks for medical, physical, social, emotional, and/or spiritual secondary issues
People with intellectual disabilities are
Undervalued and disadvantaged
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Systems of Support for People With Disabilities
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Figure 21-2

The Experience of Disability
PWD may be largest minority group in the United States
Different experiences, depending on …
Temporary disability
Permanent disability from accident or disease
Disability from progressive decline of a chronic illness
Benchmark event is acceptance of the label of “disabled”
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Children With Disabilities (CWD)
Family and caregiver responses
Redefine image and expectations for child and self
Sibling response influenced by age, coping, peer relationships, parents, impact on family
Levels of parental adjustment
The ostrich phase
Special designation
Normalization
Self-actualization
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Family Research Outcomes
Established various benefits, amid challenges
Families with satisfying emotional support experience fewer potentially negative effects of unplanned or distressing events.
Parents may grieve the loss of idealized or expected child over time.
Supportive relationship is needed.
Empowerment and enabling decision making on behalf of CWD is important.
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Knowledgeable Client
A person who lives with a disability commonly becomes an expert at knowing what works best for his or her body.
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The nurse who has information about the disability and the available community and governmental resources.
Knowledgeable Nurse

Strategies for the CH Nurse
Do not assume anything.
Adopt the client’s perspective.
Listen to and learn from client. Gather data from the perspective of the client and family.
Care for the client and family, not for the disability.
Be well informed about community resources.
Become a powerful advocate.
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Dealing With Ethical Issues
Spiritual perspectives
Quality of life (QOL) and justice perspectives
Proper use of scientific advances
Self-determination, deinstitutionalization, and disability rights
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When the Nurse Has a Disability
Education programs and employers must provide reasonable accommodations for qualified students and nurses.
Technical aspects of nursing tend to discriminate; nursing should emphasize “humanistic” capacities.
Type of setting influences functionability.
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Nurses Can …
… become familiar with a variety of ethical frameworks for decision making.
… help the patient and family access needed information to make informed decisions.
… help educate the public on health care issues.
… participate in the development of institutional policies and procedures related to disability.
… take a position on an ethical issue.
… work to influence government policies and laws.
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Chapter 23

Rural and Migrant Health

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Rural Populations
The largest rural population in history of United States is now.
75% of counties are classified as rural; they contain only 20% of the U.S. population
Number/size of rural counties are highest …
in the South (35%)
in the Midwest and West (23%)
in the Northeast (19%)
Census data
20% of nation’s children under 18
15% of nation’s elderly
More than 50% of nation’s poor
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Rural Populations (Cont.)
Economic base is shifting
Agriculture is the “food and fiber system”
All aspects of agriculture (core materials to wholesale and retail and food service sectors) are included
Poverty in rural areas greater than in urban areas
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Rural Populations (Cont.)
Poverty continues to be greater in rural America than in urban areas.
Aging-in-place, out-migration of young adults, and immigration of older persons from metro areas.
Greater diversity among residents: a country of immigrants historically and today.
Health disparities exist—rural population more likely to be older, less educated, live in poverty, lack health insurance, and experience a lack of available health care providers and access to health care
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Health Disparities Among Rural Americans
Only 10% of U.S. physicians practice in rural areas
Ratio of physicians in rural population is 36:100,000 (nearly double in urban settings)
More often assess their health as fair or poor
More disability days resulting from acute conditions
More negative health behaviors (untreated mental illness, obesity, alcohol, tobacco, and drug use) that contribute to excess deaths and chronic disease and disability rates
Higher number of unintentional injuries
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Defining Rural Populations
Population size
Rural = towns with population of less than 2500 or in open country [farm/nonfarm]
Density
Rural = fewer than 45 persons per square mile
Frontier = less than 6 people per square mile
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Defining Rural Populations (Cont.)
The Rural-Urban Continuum uses population and adjacency to metropolitan areas
Core Based Statistical Areas (CBSAs)
Metropolitan areas = county with at least one urbanized area of 50,000 or more people
Micropolitan area = area contains a cluster of 10,000 to 50,000 persons
Outside CBSAs = noncare areas
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Describing Rural Health and Populations
Differ in complex geographical, social, and economic areas
Disparities include key indicators of health:
Employment
Income
Education
Health insurance
Mortality
Morbidity
Access to care
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Rural Health Disparities: Context and Composition
Context: characteristics of places of residence
Geography, environment, political, social, and economic institutions
Composition: collective health effects that result from a concentration of persons with certain characteristics
Age, education, income, ethnicity, and health behaviors
– Braveman (2010)
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Context: Health Disparities Related to Place
A downward spiral may exist:
people leave  services are lost  tax base becomes insufficient  fewer services are provided  long distances to get health care  jobs become scarce and more people leave  the cycle continues
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Context: Health Disparities Related to Place (Cont.)
Access to health care (#1 priority)
Fewer primary care physicians
General health services lacking
Health insurance coverage …
Varies according to race and ethnicity;
age and residence (rural or urban)
Influences health patterns
May create financial barriers to health care
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Composition: Health Disparities Related to Persons
Income and Poverty
One of the most important indicators of the health and well-being of all Americans, regardless of where they live.
Regional differences—highest in the South
Racial and ethnic minorities—rates among rural racial minorities two to three times higher than for rural whites
Family composition—female-headed families have highest rates
Children—among the poorest citizens in rural America
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Composition: Health Disparities Related to Persons (Cont.)
Health risk, injury, and death
Higher rates of obesity, smoking, sedentary lifestyles, alcohol use, firearms usage, suicide, vehicular accidents; lower rates of seat belt use
Risk factors
Age, education, gender, race, ethnicity, language, and culture
Education and employment
Occupational health risks
Perceptions of health (gender, race, ethnicity)
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Agricultural Workers
Accidents and injuries caused by:
Environmental conditions
Geographic isolation and working alone
Use of agricultural machinery
Delayed access to emergency or trauma care
Acute and chronic illnesses:
Musculoskeletal discomfort, acute and chronic respiratory conditions, hearing loss, hypertension
Chemical exposure (pesticides, herbicides, etc.)
Secondary conditions related to demanding farm work
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Migrant and Seasonal Farm Workers (MSFW)
Health Disparities
Poorest health and the least access
Low income and migratory status
Cultural, linguistic, economic, and mobility barriers
Minimal or no preventive care
Mobile clinic sites form a central link to health services
Migrant Health Program (MHP) bases services on enumeration of MSFW
Migrant and Seasonal Farm Worker Enumeration Profile Study (MSFWEPS) (2000)
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“Thinking Upstream”
Concepts applied to Rural Health
Attack community-based problems at their roots
Emphasize the “doing” aspects of health
Maximize the use of informal networks
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Rural Health Care Delivery System
Health care provider shortages
Rural shortages likely to become worse
Need to “grow their own”
Telemedicine
Cost-effective alternative to face-to-face care
Telehealth includes telephones, fax machines, email, and remote monitoring
Telemedicine permits two-way, real-time, interactive communication between patient and provider
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Rural Health Care Delivery System (Cont.)
Managed care in the rural environment
Possible benefits:
Potential to lower primary care costs
Improve the quality of care
Help stabilize the local rural health care system
Risks
Probable high start-up and administrative costs
Volatile effect of large, urban-based, for-profit managed care companies
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Community-Based Care
A myriad of services provided outside the walls of an institution
Home health and hospice care, occupation health programs, community mental health programs, ambulatory care services, school health programs, faith-based care, elder services (adult day care)
Community participation in decisions about health care services
Focus on all three levels of prevention
An understanding that the hospital is no longer the exclusive health care provider
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Home Care and Hospice
Nurse case management and development of local resources
Often hospital based in rural areas
Use county extension services as a bridge for outreach services
Improve home care for these patients and provide support for their families
A partnership between the public health nurse and county extension service could provide support, as well as information groups and caregiving classes, for the important informal provider network.
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Faith Communities and Parish Nursing
A strong sense of community, family life, and religious faith
Integrating nursing expertise and faith-based knowledge to provide holistic care to members of congregations
Involved in case management and coordination of services
Collaboration with other organizations to extend limited rural community health resources
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Informal Care Systems
Evolve from self-reliance and self-help traits of rural residents
Include people who have assumed the role of caregiver based on their individual qualities, life situations, or social roles
Provide direct help, advice, or information
Need to identify and combine informal services with formal systems
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Rural Public Health Departments
Public health nurses are often the core providers of public health services in rural areas.
Collaboration of services is key—need to develop partnerships with other heath provider agencies.
Environmental health, maternal and child health, and communicable disease control are the three highest-priority programs.
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Rural Mental Health Care
Lack of specialized mental health providers in rural areas.
Most services provided by primary care providers without adequate preparation or support.
Perceived stigma prevents individuals from seeking mental health services.
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Emergency Services
Getting patients from the place of injury to the trauma center within the “golden hour” is frequently not possible because of distance, terrain, climatic conditions, and communication methods.
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Emergency Services (Cont.)
Challenges faced by rural EMS systems
Shortage of volunteers and lower levels of training
Training curricula that often do not reflect rural hazards (e.g., farm equipment trauma)
Lack of guidance from physicians
Lack of physician training and orientation to EMS
Also contributing to difficult public access for emergency care:
Low population density
Large, isolated, or inaccessible areas
Sever weather
Poor roads
Lower density of telephone/communication methods
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Emergency Preparedness in Rural Communities
Challenges in rural areas:
Resource limitation
Human, financial, and social capital
Separation and remoteness
Longer response times
Low population density
Impacts funding
Communication
Warning systems often absent or neglected in remote areas; burden on individuals
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Legislation and Programs Affecting Rural Public Health
Programs that augment health care facilities and services
Community Health Centers (CHC) program
Migrant Health Clinic (MHC) program and the Migrant Health Program (MHP)
Medicare’s Rural Hospital Flexibility (RHF) grant program
Primary care cooperative agreements
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Rural Community Health Nursing
“CH nursing along the rural continuum”
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Nonmetropolitan Areas
Metropolitan Areas

Rural Nursing …
… is the practice of professional nursing within the physical and sociocultural context of sparsely populated communities. It involves the continual interaction of the rural environment, the nurse, and his or her practice. Rural nursing is the diagnosis and treatment of a diversified population of people of all ages and a variety of human responses to actual (or potential) occupational hazards or actual or potential health problems existent in maternity, pediatric, medical/surgical and emergency nursing in a given rural area.
–– Bigbee (1993), Lee & Winters (2004),
Rosentahl (2005), Williams et al. (2012)
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Characteristics of Rural Nursing
Should rural nursing practice be designated as a specialty or subspecialty area because of factors such as isolation, scarce resources, and the need for a wide range of practice skills that must be adapted to social and economic structures?
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Characteristics of Rural Nursing (Cont.)
Positive aspects
Ability to provide holistic care
Know everyone well
Develop close relationships with the community and with coworkers
Enjoy rural lifestyle
Autonomy and professional status
Being valued by the agency and community
Negative aspects
Professional isolation
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The newcomer practices nursing in a rural setting, unlike the more experienced nurse, who practices rural nursing. Somewhere between these extremes lies the transitional period of events and conditions through which each nurse passes at her or his own pace. It is within this time zone that nurses experience rural reality and move toward becoming professionals who understand that having gone rural, they are not less than they were, but rather, they are more than they expected to be. Some may be conscious of the transition, and others may not, but in the end, a few will say, “I am a rural nurse.”
– Scharff (1998, p. 38)
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Rural Health Research
Research agendas must address:
The capacity of rural public health to manage improvements in health
Information technology capacity in rural communities
Developing and monitoring performance standards in rural public health
Developing leadership and public health workforce capacity within rural public health
Interaction and integration of community health systems, managed care, and public health in rural America
– Berkowitz, Ivory, & Morris (2002)
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Capacity of Rural Public Health to Manage Improvements in Health
Healthy People 2020 objectives and intervention strategies
Information Technology in Rural Communities
EHR and reimbursement
Preparedness strengthens infrastructure
Continuing education and advanced education
Telehealth impact on public health
Skills via distance learning?
Costs and infrastructure of IT?
Gaps in epidemiology and surveillance capacity?
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Performance Standards in Rural Public Health
National Public Health Performance Standards Program (NPHPSP) describe an optimal level of performance by public health systems regardless of location.
Used to improve collaborations among key public health partners, educate participants about public health, strengthen the network of public health partners, identify strengths and weaknesses, and provide benchmarks for public health practice improvements
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Leadership and Workforce Capacity for Rural Public Health
IOM report (2003)—preparing public health workforce for 21st century
CDC Public Health Improvement Initiative (2012)—accreditation support
Medicaid impact on interaction and integration of community health systems, managed care, and public health
New models of health care delivery for rural and frontier areas being tested
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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