Midterm 2 Flashcards
Violence and Health
Violence is an integral aspect of life for all whether experienced directly or not
- We are all impacted by war and related crimes
- Sexualized violence is endemic in Western cultures
- Mass rape of women and girls is a well-documented weapon of war.
- Violence is a complex social and public health problem that is strongly associated with the distribution of social + structural determinants of health
- related to historical and contemporary patterns of thought, perspective, attitudes and behaviours
- Deep roots in cultural, political, and economic contexts
What is Violance?
WHO defines violence as:
“The intentional use of physical force or power against yourself, another person, or a group or community”
- violence can be threatened or actual
- Can result in or is likely to result in injury, or death.
- The word power and phrase “use of physical force” are included to expand the conventional understanding psychological harm, maldevelopment, or deprivation
- Can include threats and intimidation
Role of CHN (Violence)
- Unique position
- Public policy
- Capacity building across disciplines and sectors
- Violence prevention
- Evidence-based strategies
Family Violence
- Any form of abuse or neglect that a child or adult experiences from a family member or someone with whom they have an intimate relationship
- Some of it is against the law
Many terms with similar meanings:
- Domestic Violence
- Intimate Partner Violence
-> Dating Violence
-> Violence Against Women
-> Gender-BasedViolence
- Child Abuse
-> Child Maltreatment or neglect
- Elder Abuse
-> Neglect
Who Is The Most At Risk of Violence?
- Women + Children
- First Nations, Inuit, and Metis people
- People with disabilities
- People who identify as 2SLGBTQIA+
- Family violence affects Canadians in all types of families and relationships - no matter how old they are, where they live, or how much money, education or type of job they have
- It can affect people of every race, religion, and sexual orientation
Who can be involved in violence?
Can happen between anyone in a family or close intimate relationship in opposite and same-sex relationships
Examples:
o Child abuse, neglect, and childhood exposure to intimate partner violence
o Elder abuse and neglect
o Early and forced marriage and “honour” related violence
o Female genital mutilation
Family Violence Based on police reports and population surveys in Canada
- Estimated over 323,000 Canadians were victims of violent crimes where the perpetrators were family members
- 2/3 of victims of intimate partner violence (IPV), and family-related homicide are women
- 1⁄3 Canadians report having experienced abuse before the age of 15
Statistics: Youth and Children According to Statistics Canada
In 2016, approx. 54900 children and youth lived with:
- family violence (age 17 and younger)
- Approx. 16200 (30%) were victims of family violence perpetrated by a parent, sibling, spouse or other family member
- Majority (59%) of children and youth were abused by their parents
- From 2011-2016 rates of family-related sexual assault against children remained 4-5 times higher among female victims
- Children with physical or mental disability were at an even greater threat of experiencing physical and psychological abuse + sexual abuse
Statistics: Older Adults According to Statistics Canada (2018)
- More than 10300 seniors (age65+) were victims of police-reported violence crime in Canada
- 58% were women which was 19% higher than older adult men
- Overall, older adult victims were likely to have been victimized by their child (32%), spouse (27%), or other family member (29%)
Micro aggression
Associated with ageism, genderism, heterosexism, sexism, and racism are also common forms of violence
- For example: LGBT youth experience verbal homophobic abuse that is often preceded by physical abuse
- For example: In Canada, the violence of genocide, including cultural genocide against First Nations, Inuit, and Metis people is a well-documented form of violence that impacts Indigenous people and the country
The Cost of Violence
- Lifelong ill health
- Early death
- Costs the health, criminal justice, social and welfare, and economic sectors billons of
dollars per year - ACE Pyramid
ACE Study
- Adverse Childhood Experience (ACE) study is one of the largest investigations of childhood abuse and neglect + household challenges and later-life health and well-being
- Conducted from 1995-1997 in two waves
- Over 17 000 people from southern California completed confidential surveys
- Data collection remains ongoing
- ACE events are categorized into three groups: abuse, neglect, household challenges
- Participant demographics are available by age, gender, race, and education
How to Use the ACE Study
- Anticipate and recognize current risk for ACEs in children and history of ACEs in adults
- Refer patients for effective support
- Link adults to family-centred treatment approaches that include substance abuse
treatments and parenting interventions - Employers can adopt and support family-friendly policies like paid family leave and flexible schedules
- Communities can improve access to childcare by expanding eligibility, activities offered, and family involvement
Root Cause of Societal Violence
- Approaching from a structural perspective enables us to think about the role of systemic processes and how they create violence.
- Violence is framed and organized by health care systems , legal systems, and other societal institutions
- We don’t see the root cause of violence because they are hidden below the surface in systemic structures
- Systemic oppressions include heterosexism, racism, and sexism are all examples of these structures
- Systemic oppression is a broad term describing systemic injustice that intersect and impede peoples aspirations, progression, and quality of life
Privilege happens in those with power
- Examples of privilege include: white privilege, settler privilege, heterosexual privilege, male privilege, and class privilege
- These are some of the underlying structures that create and sustain the many forms of violence
- Privilege gives people/groups access to unearned power more than others
- It is very difficult to see for some people
White privilege
- Finding children’s books that overwhelmingly present caucasian race
- Learning about caucasian race in school curriculum
- Media biased towards caucasian race (humanizing white killers while dehumanizing people of colour)
Heterosexual privilege
- Not being identified or labeled - politically, socially, economically, or otherwise by your sexual orientation
- No one questions the “normality” of your sexuality or believes it was “caused” by psychological trauma, sin, or abuse
- Not having fear that family/friends/coworkers will find out about your sexual orientation, and it will have negative consequences
- Can walk in public holding your partners hand/hug/kiss infant of others without disapproval, comments, laughter, harassment or threats of violence
- Can easily find a religious community that will welcome both you and your partner
Settler privilege
- Not being forcefully relocated to a different area
- Not being denied the right to vote on decisions affecting land owned by your ancestors for a millennia (FN people didn’t have the right to vote federally until 1960)
- Being able to access clean drinking water in your community
- Having your medical concerns listened to in hospital
- Knowing that if a member of your family went missing, an effort would be made to find them
Male privilege
- Being less likely to be interrupted when you’re speaking
- People automatically assume you know what you’re talking about
- Social norms allow you to take up more physical space
- You can buy clothes with functional pockets at better prices
- You’re less likely to experience IPV, stalked, or be a victim of revenge porn
Class privilege
- Buying what you want without worry
- Knowing people of similar class background by exclusively frequenting places people gather (school, clubs, workplace)
- Being in control of how you spend your time
- Can live where you choose, and move when/ where you choose + expect to be welcomed
- Believed to be innocent by the criminal justice system at least until proven guilty
Role of the CHN (Societal Violence)
- need to focus on tackling the root, or structural, systemic cause of violence and inequities
- It’s important to re-frame vulnerable people as people under threat
- The language of vulnerability implies that an individual/community is somehow more prone to experiencing health inequities. Similar to saying someone might be prone to catching a cold
- Pivotal role in violence prevention
- Screening and early detection of violence
- Prevention at all levels
- Expanded collaboration across sectors
- Work with community partners to intervene at all levels of health prevention and promotion
- Data to support strategies can be hard to find with respect to violence, due to the reliance on individual reports
People, Poverty, Power Model (3P)
- Provides an overarching way for CHN’s to understand and intervene
- Enables CHN’s to act for social change
- Addresses violence and its economic, psychological, spiritual, and physical health impacts
- This model demonstrates that violence involves more than individual behaviour
- The model is a result of direct interaction between oppressive societal structures and social conditions ie. poverty
- How people perceive power imbalances informs how they see their value and position in the world
- Central to this model is trauma, poverty, power, violence, and people
People, Poverty, Power Model - Trauma
- Results from people’s cumulative stressful experiences
- It is different from stress, trauma is long-term, and has greater physiological, psychological, and spiritual impact
- Makes people more sensitive to perceived risk
- Different kinds of trauma intersect and can compound
People, Poverty, Power Model - Poverty
- Central to experiences of community violence
- Related to factors and conditions usually found in poor neighbourhoods
- Directly + indirectly linked to structural oppression
- Power + poverty are supporting foundations of peoples trauma
- Can also experience social poverty as a result of inequities like lack of social support, connection, community support, access to culturally safe care
People, Poverty, Power Model - Violence
- Model allows us to pay attention to the way violence manifests not only on the person, but through the intersection of poverty and power
- Poverty, privilege, and oppression lead to violence + are acts of violence themselves
People, Poverty, Power Model - the Model
- Highlights the importance of empathy to both address and prevent violence
- Encourages us to ask “how” and “why”
- Promotes systemic empathy and self- empathy to prevent violence
Sexualized Violence
“any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts of traffic, or otherwise directed against a person’s sexuality, using coercion by any person regardless of their relationship to the victim in any setting”
- Includes sexual harassment and sexual assault
- Disproportionately impacts women
- Violence is rooted in gender inequity
- Rates of sexual assault are highest amongst: single women, FNIM individuals who rate their mental health as fair/poor, students, and individuals who identify as gay, lesbian, or bisexual, and women aged 15-24.
- The phrase #MeToo was coined in 2006 by Tarana Burke, a woman who had experienced sexual assault and wanted to prevent other incidents against African American women
- In the last decade, the #MeToo movement has become the slogan for the anti-sexual harassment movement
- The movement has sparked conversations and created pressure to influence Canadian Policy
- Through public pressure, more than 37,000 sexual assault cases have been reviewed and some agencies have pledged to revamp their approach to policing sexual violence
Family Violence
- Defined as violence, abuse, unhealthy conflict, or neglect by a family member towards another family member that has the potential to lead to ill health
- Common types of family violence include physical, sexual, emotional, and financial abuse, as well as neglect and exposure to intimate partner violence
- More common among women, children, older adults, FNMI people, people with disabilities, and 2SLGBTQIA+ community members
- FNMI people family violence has roots in the impacts of generational trauma related to residential schools + historical and political contexts that have contributed to generations of oppression
- Physical impacts of IPV + family violence are compounded by chronic stress and responses used to cope with chronic stress
- Women are more likely than men to experience health impacts of IPV
- Social impacts include diminished capacity to have healthy social relationships, poor academic performance in school, missing work or being less productive —> all of which can lead to unemployment and financial instability
Intimate Partner Violence
- Women are more likely to experience the most severe forms of spousal violence (sexual assault, being beaten or choked), have injuries, and suffer long-term psychological consequences including PTSD
- CHN’s have a role in caring for women experiencing IPV
- Universal screening is recommended for all girls + women > 12y/o (RNAO, 2012)
- We also need to identify men and boys who are under threat of violence as well such as trans men and 2SLGBTQIA+ men, and people regardless of gender who work in the sex trade
- There is no single cause, but there is a strong association between social determinants of health. Chronic stress of housing, food, and heat insecurity should be considered
Mandatory Reporting
- In Canada there is no mandatory obligations to report IPV unless the person experiencing violence decides this is what they want to do
- Age of consent to sexual activity is 16 years
- “Close-in-age” exceptions include people between 12-13y/o where the age differences between two people engaging in sexual activity is greater than 2 years, or the other person is in a position of trust/authority must be reported
- For those 14 - 15 y/o the nurse must report the age difference if it is greater than 5 years, or the position is in a position of trust/authority
- If IPV is happening in the home, and children are exposed emotionally, verbally or physically it must be reported to CAS
- Important to advise the person of this obligation
Interviewing for IPV
- It is important to interview people in a private location when they are alone
Examples of ways to ask about IPV according to RNAO
- “Because violence against women is so common in many people’s lives, I ask all my clients about it. May I ask you a couple of questions?”
- “Many of the women I see are dealing with abuse in their relationships. Some are afraid and uncomfortable to bring it up themselves, so I’ve started asking about it routinely. May I ask you a couple of questions?”
- “Have you ever been emotionally, physically, or sexually abused by your partner or someone important to you?”
The Power and Control Wheel
- The “Power and Control Wheel” is a key tool for CHNs to assess and intervene in violence
- The wheel describes ways interpersonal power can operate
- Designed to help you think about the many forms of violence and how they operate in every day life
- Coercion and threats, intimidation, emotional abuse, isolations, and minimizing, denying, and blaming are some of the well-known forms of violence that occur in interpersonal relationships
- Other forms include using children, male privilege, and economic abuse
Social-Ecological Model
- Four level social-ecological model to better understand violence and the effect of prevention strategies
- Considers the complex interplay between individual, relationship, community, and societal factors
- Allows us to understand the range of factors that put people at risk for violence, or protect them from experiencing or perpetuating violence
- There can be overlap, as evidenced by the rings in the model
- It is necessary to act across multiple levels of the model at the same time, this is more likely to sustain prevention efforts over time and achieve population-level impact
Social-Ecological Model: Individual
- Identifies biological and personal history factors that increase the likelihood of becoming a victim, or perpetrator of violence
- Includes: age, education, income, substance use, or history of abuse
- Prevention strategies: promote attitudes, beliefs, and behaviours that prevent violence
- Specific approaches: conflict resolution and life skills training, social-emotional learning, and safe sating and healthy relationship skills programs
Social-Ecological Model: Relationships
- Examines close relationships that may increase the risk of experiencing violence as a victim or perpetrator. A person’s closest social circle-peers, partners, and family members influence their behaviours and contribute to their experience.
- Prevention strategies: parenting or family focused prevention programs, mentoring and peer programs designed to strengthen parent-child communication, promote positive peer norms, problem solving skills, and promote healthy relationships
Social-Ecological Model: Community
- Explores the settings ie. schools, workplaces, neighbourhoods in which social
relationships occur and seeks to identify the characteristics of these settings that are associated with becoming a victim or perpetrator of violence. - Prevention strategies: improving physical and social environments ie. by creating safe places where people live, learn, work, and play. Also by addressing other conditions that give rise to violence ie neighbourhood poverty, residential segregation, instability, and high density of alcohol outlets
Social-Ecological Model:
Looks at broad societal factors that help create a climate in which violence is encouraged or inhibited.
These factors include:
- social and cultural norms that support violence as an acceptable way to resolve conflict.
- health, economic, educational, and social policies that help maintain economic or social inequalities between groups in society.
Prevention strategies: efforts to promote societal norms that protect against violence as well as efforts to strengthen household financial security, education, and employment opportunities, and other policies that affect the structural determinants of health
Trauma and Violence Informed Care
- One treatment approach that aligns well with the diverse and interdependent needs of residents is trauma-informed care (TIC)
- TIC is an evidence-based environment of care approach initiated by the Substance Abuse and Mental Health Services Administration (SAMHSA)
- TIC emerged as an approach to deliver mental health treatment
- TIC should be included in every facet of care delivery, as it establishes an environment of trust, safety, and stabilization
- To be trauma informed is to possess a thorough understanding of the development, symptoms, and impact of trauma through a culturally sensitive lens
- TIC is a way of responding, interacting, and approaching clients that recognizes complex experiences of trauma to avoid re-traumatization
- TIC challenges pathologizing, deficit-based language, treatment, and environments
- Instead it promotes growth, hope, understanding, empowerment, safety and healing
- For an organization to be trauma informed, every staff from kitchen to the CEO need to possess a basic understanding of the complexities of trauma
- In a TIC environment, colleagues hold one another accountable to the use of trauma- informed language, conceptualization, and treatment
- TIC should be represented in the physical environment. Buildings and therapy rooms support clients through artwork placed on the walls, and chairs that are comfortable and accommodate individuals of all abilities and needs
6 Principles of a TIC framework
- Safety
- Trustworthiness and Transparency
- Peer Support
- Collaboration and Mutuality
- Empowerment, voice, and choice
- Cultural, historical, and Gender issues
Principles of a TIC framework: 1. Safety
- Trauma experiences often include exposure to abusive systems and power differentials.
- TIC setting should provide physical and emotional safety for clients + staff. It exceeds standard safety requirements and places emphasis on environmental factors that may re- traumatize individuals
Principles of a TIC framework: 2. Trustworthiness and Transparency
- Many people have experienced boundary violations and chronic feelings of helplessness.
- Healthcare centres may inadvertently perpetuate feelings of helplessness if intake procedures are unclear and not welcoming to persons with limited literacy skills
Principles of a TIC framework: 3. Peer Support
- Clients can benefit from receiving empathy, support, and guidance from someone who has successfully navigated their own recovery in addition to medical supports
- Peer services are evidence-based and have been shown to promote positive health outcomes and control the cost of health care.They should be offered by trained individuals with lived experience and recovery.
Principles of a TIC framework: 4. Collaboration and Mutuality
- Traditional models of treatment often involve a clinician or case manager who provide referrals to resources with minimal follow up or collaboration. This results in the client navigating the process alone.
- TIC provides one-stop shopping where the client could potentially see multiple providers in the same setting.
- These providers ideally have access to the same records to develop treatment plans
Principles of a TIC framework: 5. Empowerment, voice and Choice
- Health care environments that enhance a clients capacity to make decisions about healthcare can avoid re-traumatizing them
- TIC clinicians and organizations routinely seek to empower clients by being transparent in their communications, providing choices, and listening to the client
- Mutual respect and collaboration create a client experience with a sense of control
and autonomy in the mental health recovery process
Principles of a TIC framework:
6. Cultural, Historical, and Gender issues
- Trauma is best understood within the context in which it took place. Meaning, symptoms associated with trauma may vary across culture, gender, race, ethnicity, historical context, and sociopolitical context.
- A TIC clinician attempts to treat trauma through a socioecological lens, considering individual factors (gender, socioeconomic status etc), relationships, community factors, social policies, cultural and developmental factors
- A TIC competent provider will honour and respect beliefs, languages, interpersonal styles, and behaviours
TIC In Primary Health for First Nations Women - Experiencing Violence - Building trust through understanding the intersecting drivers of trauma and violence
- Clients must be able to establish trusting relationships with service providers over time
- Trust is facilitated when clients felt providers had an understanding of historical and contextual drivers of violence
- Providers must be responsive of historical lack of trust in mainstream organizations and fear of being judged by non- Indigenous service providers
- Raising awareness of multiple forms of violence was also seen as important in promoting disclosure and help seeking
TIC In Primary Health for First Nations Women Experiencing Violence - Reducing re-traumatization
- Happens by providing care that is informed by an understanding of the triggers for First Nations women who experience violence
- Varcoe et al. (2017) described an elder and nurse led “sharing circle” as an intervention component that promoted healing from trauma by providing emotional, spiritual, and social support to women
- Some women did find hearing stories of loss and trauma to be triggering, and resulted in leaving or tuning out from the circle
TIC In Primary Health for First Nations Women Experiencing Violence - Raising awareness and accessible health care
- In many studies there is limited awareness of health services that can support women who have experienced violence and trauma
- Posters and pamphlets were helpful in raising awareness, but materials must be culturally appropriate
- Prioritizing women’s physical, mental, emotional, and spiritual health ensures patients health is viewed holistically and in the broad context of their lives
TIC In Primary Health for First Nations Women Experiencing Violence - Culturally Safe Care - Engaging Elders
- Have been seen as a culturally safe strategy as they provided compassion without judgement and countered negative stereotypes with history, cultural practices, and tradition
- Consider using storytelling to counter stereotypes imposed on First Nations people
- Cultural practices must be used appropriately and may not resonate with all women
TIC In Primary Health for First Nations Women Experiencing Violence - Culturally Safe Care - Family-centred care
- Family has been seen as an important source of support which could provide practical assistance in the form of a safe place for the woman and her children
- The role of the perpetrator within the support and healing process may also be recognized, as women may still be living with the perpetrators - there is a clear need to include perpetrators and/or ensure that appropriate supports are available
TIC In Primary Health for First Nations Women Experiencing Violence - Culturally Safe Care - Culturally competent workforce
- Characteristics of staff, in particular the importance of having First Nations staff in mainstream and specialist organizations
- There is a perception that mainstream staff do not adequately understand or respond to contextual and historical factors that impact experiences. Not being culturally competent means not being able to establish rapport, trust, and long-term relationships
- Being able to speak local Indigenous languages is key in program success
- Ongoing cultural competence training for non-Indigenous staff to understand racism and acknowledge white privilege and power imbalance has been proven beneficial in improving cultural competency
TIC In Primary Health for First Nations Women Experiencing Violence - Culturally Safe Care - Confidentiality
- The issue of confidentiality can potentially impeded the delivery of culturally safe care
- Drawing of staff from small communities or specific neighbourhoods can discourage patients from disclosing when they may have close connections, or do not feel confident privacy will be maintained
- The physical consultation space should also ensure confidentiality through sufficient privacy
TIC In Primary Health for First Nations Women Experiencing Violence - Contextually Tailored Care - Responsive to the needs and priorities of the local community
- Understanding the needs and history of the local community was identified in multiple studies
- Centred on specific practices that appreciate the importance to community and belonging to a place
- Viewing the holistic nature of family and intimate partner violence through contextual dimensions of poverty, health, substance use, historical, and present trauma
TIC In Primary Health for First Nations Women Experiencing Violence - Contextually Tailored Care - Community ownership and partnerships
- Facilitated by community ownership and intersectional partnerships
- Means involving local community leaders along with an external advisory board in the oversight of service delivery, partnerships, reporting, and resourcing
- Developing productive relationships with mainstream services was identified as critical to ensuring the community is well supported
- Can be challenging due to inadequate resourcing for partnership building and short-term funding of services
Vicarious Trauma
- As CHN’s we bear witness to all forms of violence, and honour the complex pathways that lead people to become violent toward each other
- For example, CHNs observe the profound struggles of homeless people or the
intergenerational impacts of violence in the home - Nurses often experience vicarious trauma (VT) as a result of engagement in practice
- VT changes our cognition and worldview that result from empathetic response and repeat exposure to narratives of trauma
- Responses to VT involve the same experiences as post-traumatic stress including nightmares, fearful thoughts, and intrusive images. Practitioners may also become more cynical and distrustful. This may result in emotional numbing, nightmares, irritability, distancing, and withdrawal.
- It is SO IMPORTANT for nurses to openly discuss and debrief about their experiences of VT
Molly is a 15 year old high school student. She has come to the community clinic looking for the morning after pill.You explore with her what circumstances led to her requiring this, and she reveals that her 19 year old boyfriend raped her. She doesn’t want her parents or police to know. She doesn’t think this is sexual assault since they’ve had sex before. Which of the following statements if correct?
A. This must be reported to police as it is outside the close- in-age exception
B. She requires her parents permission to have emergency contraception
C. It is her choice whether or not to report, and her parents cannot be told
D. If they have had sex before, it is not considered sexual assault
C
Which of the following is not a main principle of trauma and violence- informed care?
A. Emphasis on safety and trustworthiness
B. Opportunity for choice, collaboration, and connection
C. Report all forms of violence and trauma to the RCMP
D. Trauma awareness
C
Violence has deep roots in all of the following expect for?
A. Cultural
B. Political
C. Economic
D. Social Media
D
T or F:
Family violence includes any form of abuse or neglect that a child or adult experiences from family/someone they are close with
True
Youth and child abuse trends in which direction after COVID?
A. Downwards
B. Unchanged
C. Upwards
C
In the ACE Pyramid, “ACE” stands for?
Adverse Childhood Experiences
ACE events are categorized into three groups, which of the following is not one of these?
A. Abuse
B. Violence
C. Neglect
D. Household Challenges
B
Structural violence is also called ______ violence
Systemic
T or F:
We can see the root cause of violence
False
Age of consent to sexual activity in Canada is?
A. 12
B. 16
C. 18
D. 14
16
T or F:
If someone who is 12 is engaging in sexual activity with someone who is 15, this is within the close-in-age exception and does not need to be reported
False
Someone who is 14 is engaging in sexual activity with someone who is 19, is this reportable?
A. Yes
B. No
C. Only if the person is in a position of power
C
Which of the following is included on the “individual” level of the social-ecological model?
A. Peers
B. Family
C. Cultural norms
D. Age
D
Rural & remote nursing
- Approximately 95% of Canada’s land mass can be considered rural and remote.
- Longstanding debate exists about the definition of geographic communities such as rural, remote, Northern and isolated.
- Little consensus exists amongst literature, so the choice of index is dependent on the focus of the researcher. Technical & social are both recommended ways to define rural
Technical Approaches To Defining Rural
Locators or geographic regions
- Example: location of hospitals, roads, or specific political areas (province or county)
Statistics Canada define rural by emphasizing
- Population size
- Population density
- Settlement or labour market contexts
The Canadian Institute for Health Information (CIHI) includes:
- Distance to + relationship with urban areas
Census Rural
Refers to an area with less than 1,000 inhabitants and a population density less than 400 people per square kilometre
Social Approaches To Defining Rural
- Refers to the nature of the rural community, and specific services that are normally associated with a larger population
-> Example: specific restaurants or stores - Includes healthcare delivery, including retention and recruitment of health professionals
-> Example: Registered Nurses - Statistics Canada identifies “rural and small town” as:
-> “individuals in towns or municipalities outside the commuting zone of larger urban centres”
-> Using this - 17% of Canadians lived in communities less than 10k people!
First Nations and Inuit Health Branch (FNIHB) - Define degrees of rurality:
Non-isolated community:
- Communities with road access of less than 90km to physician services
Semi-isolated community:
- Communities with road access greater than 90km to physician services Isolated community:
- Communities with good telephone service, scheduled air transportation flights, but no road access
- This model highlights the importance of access to services
Remote, isolated community:
- Communities with no scheduled air flights, minimal telephone or radio access, and no road access
- Considers transportation and communication limitations between what is and isn’t isolated
Rural Health System Model
- Many factors affect health status, health needs, system use and health system performance
- The model has four uses
- Quantitative data tells us a lot, but it’s not the whole story
- The model is divided into 3 parts
o Geography
o Population
o Health System and Community Context
Diversity of Rural and Remote Communities
- These communities in Canada are diverse
- Economies vary by specific geographic region/features
- Traditionally these economies have been dependent on natural resources of the landscape
- Examples: oil and gas extraction, forestry, fishing and agriculture
The Resource Base
- Influences the health status of those who live in the community
- In rural, remote and isolated communities where there is reliance on industries such as oil, gas, logging, mining, fishing, and agriculture
o Injuries and illnesses
o In 2015, there were 271 935 farm operators - operators on medium-size farms had the highest incidence of injury from working the longest hours without reliance on hired help compared to larger farms
Risks - Mining
- Since 2000, 10 people have died and 50 people have been critically injured in underground mines in Ontario
- Injuries may occur due to water accumulating in mines, remote control equipment, explosives, mobile equipment
- Occupational illness & disease:
-> Diesel emissions (carcinogenic) and silica are airborne hazards
Risks - Oil & Gas Industry
- From 2001-2020 349 people died on the job in Western Canada
- Transportation accidents accounted for 40% of fatalities followed by exposure to harmful substances or environments (22%), contact with objects/equipment (16%), falls (4%), and finally fires and explosions (4%)
- Occupational diseases include asbestosis and mesothelioma
- Strains, sprains and tears are typically the most commonly occurring nature of injury and affected a large number of peoples backs (including spine and spinal cord)
Risk - Agriculture
Biological hazards
- Respiratory disorders from inhaling moulds
- Exposure to zoonotic diseases ie. toxoplasmosis, rabies, histoplasmosis, Lyme disease, hantavirus
- Needlestick or sharps injuries
Chemical hazards
- Hazardous products (fuel, fertilizers, pesticides)
- Gases in manure pits/tanks – Can contain: Methane, hydrogen sulfide, carbon dioxide, ammania
- Gases in silos during grain storage
Ergonomic hazards
- Standing or sitting for long hours
- Awkward working postures, repetitive tasks, lifting
Physical hazards
- Excessive noise
- Extreme conditions ie heat
- UV radiation
- Safety hazards (heights, animals, machinery)
Workplace Safety and Insurance Board (WSIB)
- Provides wage-loss benefits, medical coverage and support to get people back to work after a work-related injury or illness
- Nurses and physicians assist patients in reporting workplace injuries and accessing the appropriate care
- Health Professionals are typically responsible for filling out a Form 8 on the initial visit
-> A copy is given to the employee to share with their employer
-> A copy is sent to WSIB
Diversity of Rural and Remote Communities
- Local health regions may be responsible for enforcing environmental and public health regulations for camps
-> Potential health issues: shift work, obesity, emotional distress, domestic issues, and interrelated substance abuse - Socioeconomic status of rural and remote communities is variable, and when resources are depleted -> communities will shift to alternate economic ventures
- Boom-and-bust cycles affect economic stability and availability of services
Diversity of Rural and Remote Communities - Employment opportunities
- Not all individuals have access to earn a reasonable living wage, purchase healthier food options, and care for family members
- Statistics Canada (2017) reported only 45.6% of rural and 44.6% of remote women were in the labour force
- Reserve-based First Nation women’s income was lower than non-Indigenous women working on reserves and Indigenous women living in rural or urban settings
Diversity of Rural and Remote Communities - Employment opportunities
- Not all individuals have access to earn a reasonable living wage, purchase healthier food options, and care for family members
- Statistics Canada (2017) reported only 45.6% of rural and 44.6% of remote women were in the labour force
- Reserve-based First Nation women’s income was lower than non-Indigenous women working on reserves and Indigenous women living in rural or urban settings
Being Rural and Remote
- It’s important to not generalize regarding people who live in rural or remote areas, it’s inaccurate!
- The definition of health has been found to vary between remote, rural, and urban dwellers
Example: Two western provinces found being healthy was defined as a holistic relationship between mental, social, physical, and spiritual aspects
Rural Determinants of Health
- Disease prevention and health promotion occurs through public health initiatives
- It is unclear whether conventional strategies developed in urban programs are effective
- CHN’s can apply three levels of prevention:
Primary (reducing risk for a potential problem)
-> Ex: : Providing health education for individuals in rural and remote communicates to maintain lower rates of cause-specific cancers
Secondary (providing screening and early detection and treatment)
-> Ex: Developing and implementing diabetes screening programs
Tertiary (maintaining health)
-> Ex: monitoring the effectiveness of treatment for circulatory and respiratory diseases
Diversity in Rural and Remote Areas of Canada
- In addition to unique geographic features, there is diversity of people who live in these areas
- Many groups face challenges like feeling excluded from community life, whereas others want to live apart where they can co-exist
-> Consider religious groups like Amish, Hutterites, Mennonites, and Conservative Dutch groups - CHN’s must assess the communities within which they work to determine diversity, strengths, and needs that arise from diversity
- Immigration also adds to diversity in rural community populations and challenges the delivery of culturally sensitive health care services
- CHN’s must conduct community assessments that acknowledge religious, socio-historical, and policy contexts within which individuals, families and groups are located
- Rather than focus on describing specific groups and practices, the principles of cultural safety and awareness, sensitivity, and competence should be followed
Cultural Safety Protocols
- CHN’s must encompass an understanding of the historical colonial context that informs the basis of our knowledge
- Colonialism is perpetuated in social and political contexts of the health care system
Cultural Safety Protocols - Five principles
- Protocols: respect for cultural forms of engagement
- Personal knowledge: understanding one’s own cultural identity
- Process: engaging in mutual learning
- Positive purpose: ensuring the process yields the right outcome for the client
- Partnership: Promoting collaborative practice
Health Inequities In Rural and Remote Communities
- Although these communities are known for strength, resilience, and cohesion
- Faced with many challenges
o Access to technologies
o Poor water quality
o Food insecurity
Health Care Access - Inequity
- Fewer health care delivery options
- People must travel longer distances for services
-> More challenging when experiencing poverty - In remote Indigenous communities, health and education programs are provided by primarily non-Indigenous people —> affects cultural sensitivity
- CHN’s need to advocate for the inclusion of Indigenous healers and local knowledge keepers in program design and delivery
Internet connectivity, health informatics, and Telehealth
- Unreliable access to internet
o Family communication is hindered
o Social isolation is increased
o Affects reserve-based Indigenous people as well as those in rural and remote communities
Health informatics
- Represents bringing together data, information, knowledge and technologies to support decision making by patients, consumers, physicians, nurses and stakeholders
- Telehealth allows for health education on prenatal teaching, or online support programs for those with chronic illness
Cost of providing health care in northern Canada is higher than the rest of Canada
- Telehealth can reduce spending
- Remote present robotic technology has been associated with a 60% reduction in medical transportation
- Video conferencing allows for visiting clinics
- Email enables the delivery of health services
- Video conference mental health assessments save money without compromising care
Other Telehealth Services In Rural Canada
- Preoperative assessments and postoperative care for surgery
- Management of fractures and dislocations
- Assistance with procedures and surgeries from more experienced colleagues
- Remote hemodialysis rounds
- Tele-oncology
- POC Ultrasound
- Speech pathology
- Dietary consult
- Physiotherapy consult
- Professional development + supervising learners
Water Quality
- The Canadian Nurses Association (CNA) updated their position regarding the role of nurses in addressing indoor and outdoor environments linked to determinants of health
- Access to potable water is everyone’s fundamental right as acknowledged by the United Nations
- In the absence of sufficient water quantity and quality, resources, livelihoods, and communities are negatively impacted
-> Cooking, bathing, farming - Inadequate water resources also make us more vulnerable to infectious disease due to poor sanitation
- Can create conflict between water users and reduce resilience of communities
- Water infrastructure must be monitored, maintained, and working properly in order to supply good quality drinking water
- Addressing aging and deteriorating water infrastructure has not been a priority in many areas since the 1970’s
