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
Water Quality - The CNA supports nurses to:
- Assess community hazards
- Advocate for change
- Engage in interdisciplinary collaboration to address hazards
- Decrease exposure
- Reduce harm to people and the environment
The Walkerton tragedy of May 2000
- 7 people died of e.coli from contaminated water
- 2300 people were ill
- Public health officials felt the issue was probably preventable
BWA are of particular concern in First Nation communities
- According to Water Canada, 87% of Boil Water Advisories (BWA) issued in Canada in 2019 were due to problems with the equipment and processes used to treat, store, and distribute potable water
- Long term BWA continue to exist
- As of Oct. 2021 Newfoundland and Labrador reported
- 161 BWA’s that had been in place for over one year in over 124 communities
BWA Water shouldn’t be used for:
- Drinking
- Making infant formula or juices
- Cooking
- Making ice
- Washing produce
- Brushing teeth
- Bathing depends on age but should avoid the face
- Giving to your pets
How does water become contaminated?
- Fertilizers, pesticides, other chemicals applied to the land near water
- Concentrated feeding operations (industrial animal farms)
- Manufacturing operations
- Sewer overflows
- Storm water
- Wildlife
- Rocks and soil (natural sources of arsenic, radon, uranium)
- Cracks in water pipes or other problems in distribution systems
Contaminated water and poor sanitation are linked to the following disease transmissions:
- Cholera
- Dysentery
- Hepatitis A
- Typhoid
- Polio
Contaminated water may include the following chemicals:
- Arsenic (decreases production of red + white blood cells)
- Copper
- Lead
- Nitrate (affects oxygen carrying capacity, infants 6 months and under are high risk)
- Radon (second leading cause of lung cancer)
Some people are more likely to get sick from germs and chemicals:
- Infants
- Young Children
- Pregnant people
- Older Adults
- Immunocompromised (HIV, chemo, transplant recipients)
Water Quality - Impacts
- Water may be unsafe for bathing, or even laundry, not just drinking: “do not use” advisory
- Communities must spend a large amount of water on bottled water
- Then have to deal with plastic waste that accumulates
- Households often have to ration water
- Water that is deemed unsafe to drink, but safe enough to use for bathing may cause skin infections or worsen conditions like eczema
Water Quality - Indigenous Communities
In 1876 the federal government introduced the Indian Act
- Government was responsible for building and upkeep of infrastructure on First Nation reserves including drinking water treatment plants, and pipes delivering water to homes and buildings
- Limit which people it has financial and legal responsibilities to for clean drinking water
- Pledges to end BWA only cover long-term drinking water advisories for systems serving 5+ homes on serves aka “public systems”
- Not fixing piping into homes or on homes without piping that rely on large collection tanks, or supporting wastewater treatment systems
- Since then, the federal government has chronically underfunded First Nation reserves
- Forced relocation of Indigenous peoples onto reserves is also a factor -> moved people away from traditional territories
- Government inaction on pollution and industrial accidents caused corporations to harm water sources
- In 2015 the government committed ending boil water advisories by 2021, this deadline has passed
Impetigo
- Bacterial infection of the skin
-> Group A Streptococcus* and Staphylococcus aureus - Most common in young children 2-5 y/o
- Very contagious
- Spread through direct contact with sores or fluids from the sores
- Usually takes 10 days for symptom onset
- Typically mild
- Common around nose/mouth or on the arms/legs
- Symptoms: red, itchy sores that break open and leak serous or purulent fluid for several days. Will become “crusty honey-coloured scabs prior to healing
- Management: topical or oral antibiotics, hand hygiene, excellent personal hygiene, washing clothes, linens and towels daily when infected
- Complications: Kidney problems, rheumatic fever
Cholera
- Since mid 2021, the world is facing it’s 7th cholera pandemic
- In 2021, 23 countries reported cholera outbreaks (mainly Africa and Eastern Mediterranean regions)
- In 2022, 30 countries reported outbreaks 14 of them had not reported cholera in 2021or the last 3 years
- Acute diarrheal infection
- Caused by the ingestion of food or water contaminated with Vibrio cholerae
- Short incubation period 12 hours - 5 days
- Most people experience mild-moderate symptoms
-> 20% of ill persons will develop severe dehydration and are at risk of death
What’s the Deal?
- Mortality has been increasing
- Compounded in countries facing complex humanitarian crisis with fragile health systems
- Aggravated by climate change
- Response is strained
- Limited resources
- Lack of oral cholera vaccine
- Overstretched public health + medical personnel
Food Insecurity
- Rural communities experience a higher cost of food the further are from urban centres
- Costs can include transportation to the community
- Isolated communities face food insecurity due to exorbitant transportation costs to bring in fresh foods
- Many remote Indigenous communities, hunting and fishing increase self-sufficiency of access to food
- Regulatory policies for food, packaging, and inspection make innovation and economic development hard for communities
- Food insecurity is defined as a situation that exists when people lack secure access to sufficient amounts of safe and nutritious food
- In 2017-2018 12.7% of Canadian households were food insecure (4.4 million individuals)
o This is worse in the North where household rates reach 16.9% - Yukon, 21.6% - NWT, and 57% in Nunavut - Poverty, financial hardship, underemployment or unemployment, low income and low educational attainment contribute to food insecurity
- In Canada, First Nations, Inuit and Metis people generally have a lower socio-economic status than non-Indigenous Canadians (National Collaborating Centre for Aboriginal People, 2009).
Consequences of food insecurity:
- Malnutrition
- Infections
- Chronic diseases
- Obesity
- Distress, social exclusion, depression, suicidal ideation and attempts
- Negatively impacts children’s ability to learn
- Threat to overall social and cultural stability in Inuit
- communities
- Food insecurity has been identified as the largest contributor to psychological distress and suicidal behaviour among low-income Indigenous people
Food Insecurity - Current Initiatives:
- Nutrition North Canada program (NNC), provides retail subsidies to improve access to perishable, nutritious and traditional food in certain communities
o Reducing food insecurity is not a part of their mandate - targets the high cost of perishable and nutritious food in the north - Food Policy for Canada
o “All people in Canada are able to access a sufficient amount of safe, nutritious, and culturally diverse food”
o Identifies 4 short term and medium term actions
-> One is the need to support food security in northern and Indigenous communities
CHN’s In Rural and Remote Communities
- Primary health care is the focus, and CHN’s provide services based on the needs of the community, as well as the complexity of their surrounding area
- Practice is shaped by limited transportation, communication and other resources
- Rural nurses must be multifaceted care that can be complex with considerable decision-making and little backup
- Must recognize collaboration between rural and remote stakeholders to support the spread of innovation
- May practice in acute, chronic, tertiary, mental health or occupational health care
- Blends knowledge for performing activities related to public health, home care, emergency care, palliative care, and management of episodic and chronic conditions
- In the first national study of rural and remote nursing practices in Canada
-> Almost all nurses identified issues r/t leadership- Working through conflicting priorities
- Coping with leaders being at a distance
- Creating support networks
- Leadership was more effective when leaders set up possibilities for quality practice
In 2010, there were 28 799 RNs working in rural and remote Canada
- 22.9% worked in community settings
- Nurse: population ratios vary by region but on average there were half as many nurses per 100 000 people in rural/remote Canada compared to urban
- Rural and remote nurses were found to have lower levels of education at entry to practice
- Limited access to continuing nursing education
Key Issues to address
- Federal and provincial nursing associations need to ensure the profession is meeting responsibilities and acknowledging our colonial history, and work to address the Truth and Reconciliation Commission’s call to actions
- Ongoing research supports for rural remote nursing research chairs in Canada that continue to address the unique situations experienced by residents, particularly regarding access to care
- CHN’s need to be encouraged to embrace the strength of their political voice - as few are educationally prepared for work in policy
- Relevant information about the nature of rural, remote, and Indigenous communities including the number and location of residents and their health issues
- This isn’t readily available to inform health policy!
T or F:
Reporting to WSIB is mandatory?
False
Substance Use: The role of the CHN
Assists with:
- Prevention and minimization of harm associated with problematic substance use
CHN’s must:
- Develop and engage in health-promoting practice
- Must understand dynamics, social and health effects, and root causes of substance use
- Advocate for nursing practice that creates and embraces social justice
- Practice intentionally, aiming at achieving social justice goals and outcomes that improve health experiences and conditions of individuals, their communities, and society.
What is PRAXIS?
- By definition: it is the process of using a theory or something you’ve learned in a practical way
- Think of it as “putting your money where your mouth is”
- It is the process by which a theory/lesson/concept/skill is enacted/performed/realized
- It is deliberate and is used to create a more just world
- In nursing, we use praxis to apply knowledge in nursing situations to advance goals in society and in the world, and to eliminate any injustice and discrimination in care
What you say Matters
- Language is a powerful tool
- How we discuss and understand substances in regards to use, what is problematic, and addiction is evidence of this
- Please refrain from using the term “substance abuse” due to negative judgments, instead use language from the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) which uses “substance use disorder”
- Other activities like gambling, shopping, or sex are characterized as process addictions or behavioural addictions
Substance use disorder
- Defined as mild, moderate, or severe
Determined by the number of diagnostic criteria met by the individual - Occurs when the recurrent use of alcohol or drugs causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at home, work, or school.
DSM 5: Substance Use Disorder
- No longer uses the terms substance abuse and substance dependence -> “substance use disorder”
- Focuses less on withdrawal and more on symptoms that characterize severity
- Defined as mild, moderate, or severe and determined by the number of diagnostic criteria met by an individual
- Occurs when the recurrent use of alcohol and/or drugs causes clinically and functionally significant health problems, disability, and failure to meet responsibilities in the home, at work, or at school
11 criteria under four basic categories:
impaired control, physical dependence, social problems, and risky use
- 1 criteria could indicate an individual at risk
- 2-3 criteria point to a mild substance use disorder
- 4-5 criteria show someone has a moderate substance use disorder
- 6 + criteria indicate a severe substance use disorder which signals an addiction to that substance
Substance Use Criteria
- Using more of a substance than intended or using it for longer than you’re meant to
- Trying to cut down or stop using the substance but being unable to
- Experiencing intense cravings or uses to use the substance
- Needing more of the substance to get the desired effect (tolerance)
- Neglecting responsibilities at home, work, or school because of substance use
- Developing withdrawal symptoms when not using the substance
- Spending more time getting and using drugs and recovering from substance use
- Continuing to use even when it causes relationship problems
- Giving up important social/ recreational activities due to substance use
- Using substances in risky settings that put you in danger
- Continuing to use despite the substance causing problems to your physical or mental health
Dependence
- Progressive in nature, and affects the physiological, cognitive, behavioural, and psychological dimensions of a person’s health.
- It is manifested by continuous use despite the presence of problems
- Results in tolerance, withdrawal, and compulsive substance taking behaviour
Physical Dependence
Occurs when an individual body reacts to the absence of a drug with withdrawal symptoms
Psychological Dependence
Occurs when drug use becomes central to a person’s thoughts and emotions
Problematic Substance Use
- Complex issue that spans the life cycle
- Can have severe and permanent consequences for individuals, families, and communities
- Leads to adverse physical, psychological, legal, social, or interpersonal consequences, which may or may not involve dependence.
- Can be episodic with periods of control and increased use
According to the CHMA, a simple way of describing “addiction” is to use the “4 C’s”
- Craving
- Loss of control of amount or frequency of use
- Compulsion to use
- Continued substance use
Spectrum of Substance Use
Casual / Nonproblamatic Use:
- Recreational, casual, other use that has negligible health or social effects.
Chronic Dependence:
- Use that has become habitual and compulsive despite negative health and social effects.
Addict
- Terms like substance use, substance abuse, substance use disorder, addiction, and dependence are sometimes used interchangeably
- The term addict carries the greatest stigma of all
It is often equated with physical dependence, but it also is used to define non-substance related behavioural addictions - The term “addiction” has been removed from medical diagnoses, as it is both hard to define + carries strong negative connotations
- Consider the impact of labelling someone “an addict”, consider the stigma attached both in healthcare and in society
- Try to “check yourself” in conversations with peers, ie joking about being a “coffee addict”
o The term “addict” reduces someones identity to their struggle with substance use
o The term “addict” implies a permanency to the condition, leaving no room for change
o We should always refrain from using language that denies someone of dignity and humanity
True or False
Upon experimenting or using an addictive substance, the individual will immediately experience dependency or be “hooked”?
False
Violence, Trauma, Mental Health and Substance Use
- An estimated 50% of women and 33% of men (Canadian of course) have experienced at least one incidence of sexual or physical violence over their lifetime
- Intimate partner violence, child abuse, and sexual assault have all been associated with negative health effects including problematic substance use and mental health challenges
- These effects must be understood in the context of a cumulative lifetime rather than one event
- Reflect back on your learning -> research tells use that there is a strong relationship between adverse childhood experiences (ACE’s) and problematic substance use, persistent pain, and behavioural problems
- The extent of violence and trauma in the Canadian population and its strong association with negative health effects:
o Means the CHN must understand that violence is a possibility in the lives of any person - Women who experienced violence have significantly higher rates of substance use and mental health concerns compared to women who have not
- A concurrent disorder refers to one or more co-occuring mental health challenges simultaneously with problematic substance use within the same person
- The CHN should look at the root causes of substance use such as: trauma, violence, social isolation, homelessness, and poverty and not overlap with root causes of mental health challenges
Chronic Pain
- Chronic pain is complex, contextual, and subjective
- Every patient will respond to treatment differently, as pain is produced and processed within the brain
- Trauma and violence actually have a marked impact on structures and processes of the brain that mediate pain responses
- It is not uncommon for those experiencing problematic substance use to encounter resistance in health care for their requests for pain management
- Clinicians become overly suspicious of “drug-seeking” behaviour when considering opioids for pain management - especially when working with vulnerable populations
- Someone’s housing status is not a reason to not address chronic pain management
- Opioids should not be used as first line treatment for chronic pain, and neither should they be a last attempt
- Stress of living in shelters, poor sleeping conditions, financial barriers to accessing over the counter medications all negatively impact the experiences of those with chronic pain who are homeless
- CHN pain management education should be:
o Respectful of underlying beliefs
o Must be evidence-based
o In line with the lens of cultural safety
Problematic Substance Use
- The overall cost of substance use, including alcohol, tobacco, and illicit drugs to Canadians, is an estimated $46 billion with tobacco, and alcohol accounting for almost 63% of the total
o That’s $1258/person
o Lost productivity accounted for $20 billion (44% total cost) Healthcare costs associated with substance use were $13.1 billion (28%), criminal justice $9.2 billion (20%), and “other direct costs” were $3.6 billion (8%) - Alcohol and tobacco contributed to 66 000 preventable deaths in 2017
Alcohol and tobacco use contributed to 89% of 277,060 hospital admissions in 2017 - Statistics obtained from “Substance Use Costs” (July 7, 2020) by the Canadian Centre on Substance Use and Addiction
Multi-factorial - Substance Use
- Familial, genetic, psychological, socioeconomic, and historical factors are all determinants of the problem
- Gender, education, income and employment may also be factors
- CHN’s need to use a socio-ecological perspective for developing comprehensive community health interventions that acknowledge the link between person, substance, and environment
Lets apply the Socio-ecological Model for Opioid Use
- Age
- Intimate partner violence
- Policy
Unpleasant emotion - Withdrawal symptoms
- Quality care
Current recession - Gender Race
- Perceived neighbourhood violence
- Unemployment
- Family history of substance use
- Drug disposal facilities
- Nearest treatment facility >200km away
- Mental health history
- Social and cultural norms
- Common use of opioids in public
- Stress and trauma
- Opioid access via friends and family
- Law enforcement
Social-ecological Framework & Opioid crisis
- Individual: age, race, gender, socio-demographic factors, stress and trauma exposure, physical and mental health, pain, withdrawal symptoms, self-stigma, self-determination, biological and genetic susceptibility
- Relationships (or interpersonal): influence of family, friends, coworkers, opioid access via family, friends, coworkers, family history of substance use
- Community: quality care, treatment availability + access, drug disposal facilities, community norms, workplace + school, geographic variations, access to legal and illegal opioids, over- prescription, types of rx opioids,
- Society: law enforcement & policing, educational campaigns, insurance coverage, government regulation & policies, economic conditions & employment rate, opioid supply and price, legal & illegal advertising, discrimination & prejudice, social stigma, media & social networks
Tobacco Use
- In 2020, approx 3.2 million Canadians (10% of the population) smoked tobacco
o This includes a higher percentage of men (12% or 1.9 million) versus women (9% or 1.4 million)
o 8% of Canadians smoke daily (2.5 million) and 2% (741 000) smoked occasionally.
o Youth smoking (ages 15-19 years) decreased to 3% (63 000) from 5% in 2019
o Only 2% of the population reported smoking cigars, 1% reported water-pipe smoking, and 1% reported using chewing tobacco - 17% (5.2 million) of Canadians aged 15 years + had ever vaped, majority having used a vaping liquid containing nicotine
o 45% reported using a fruit flavour, 17% a mint or menthol, and 10% a tobacco flavour
o Most people purchased their vape from a vape shop, convenience or gas store, supermarket/grocery store, and online sales
Health Effects of Tobacco Use
- Smoking leads to disease and disability and harms nearly every organ of the body
o Cancer (Mouth and throat, esophagus, lungs, bronchus, trachea, larynx, liver, stomach, pancreas, colon and rectum, kidney and pelvis, bladder, cervix, and acute myeloid leukaemia)
o Heart disease (Coronary artery disease, raise triglycerides, damages blood vessels and cause thickening/narrowing of vessel walls, increases stroke risk)
o COPD
o Fertility (affects men’s sperm)
o Bone health
o Cataracts (increases risk)
o Type 2 Diabetes Mellitus (increases risk and can make it harder to control) - Its important to remember smoking causes adverse effects on the body like inflammation and decreasing immune function.
Alcohol Use
- In 2020:
o 64% (20 million) Canadians aged 15 + reported using alcohol in the last 30 days
o Heavy alcohol use (4+ drinks/occasion): 47% (14.8 million) Canadians reported heavy use in the last 12 months
o Heavy alcohol use was higher among men (52% or 8.0 million) compared to women (43% or 6.8 million)
Health Effects of Alcohol Use - SHORT TERM
o Injuries (MVC, falls, drownings, burns)
o Violence (homicide, suicide, sexual assault, intimate partner violence)
o Alcohol poisoning
o Risk sexual behaviours (unprotected sex, or sex with multiple partners which could result in unintended pregnancy or sexually transmitted diseases)
o Miscarriage and stillbirth, or fetal alcohol spectrum disorders among pregnant women
Health Effects of Alcohol Use - LONG TERM
o High blood pressure, heart disease, stroke Liver disease, digestive problems, pancreatitis
o Cancer of the breast, mouth, throat, esophagus, larynx, liver, colon, and rectum
o Weakened immune system
o Learning and memory problems
o Mental health problems including depression + anxiety Social problems including family and job related problems Alcohol use disorders or alcohol dependence
Low risk Drinking Guildines
- Reduce your long-term health risks by drinking no more than:
o 10 drinks/week for women, with no more than 2 drinks a day “most days”
o 15 drinks/week for men, with no more than 3 drinks a day “most days”
o Plan non-drinking days every week to avoid developing a habit - Special Occasions
o Reduce your risk of injury/harm by drinking no more than 3 drinks (women) and 4 drinks (men) on any single occasion - Drinking Tips:
o Drink slowly, have no more than 2 drinks in 3 hours
o For every drink of alcohol, have one non-alcoholic drink
o Eat before and while you’re drinking
Cannabis Use
- In 2020:
o 40% (12.6 million) Canadians aged 15+ reported ever smoking cannabis
o Smoking in the last 30 days was reported by 10% (3.2 million) Canadians aged 15+
o 11% (3.5 million) Canadians aged 15+ reported vaping cannabis, and use within the last 30 days was reported by 4% (1.1 million) Canadians age 15+
Health Effects of Cannabis Use - SHORT TERM
o Decreased blood pressure, which can increase risk of falls and syncope
o Increased heart rate (concerning for some cardiac conditions)
o Psychotic episodes (paranoia, delusions, hallucinations)
o Confusion
o Impaired ability to remember, concentrate, pay attention
Health Effects of Cannabis Use - LONG TERM
o Increased risk of dependency
o Lung health (bronchitis, lung infections, chronic cough, increase mucous production)
o Effects on the brain (memory, concentration, decision making)
o Increased risk of developing mental illnesses like psychosis or schizophrenia, in addition to an increased risk of suicide, depression, and anxiety disorders
o Cannabis hyperemesis syndrome (CHS) resulting in reoccurring nausea, vomiting, dehydration and abdominal pain
Health Effects of Cannabis Use - PREGNANCY
o Lower birth weight of baby
o Has also been associated with long-term development effects in children (decrease in memory, ability to pay attention, reasoning and problem-solving, hyperactive behaviour, and increased risk for future substance use)
Opioid Reliance
- Has increased over time, as has opioid-related morbidity and deaths
- In 2018, 12.7% of Canadians reported having used opioid pain relief medications within the last year
o Among these 9.6% had engaged in problematic use that could cause harm to their health
Opioid Crisis
Is a result of multiple factors:
o Misunderstanding of the additive risk of prescription opioids
o Psychological, social, and biological risk factors (genetics, mental health, early life experiences, trauma, poverty, lack of secure housing, and other social determinants)
o Stigma towards substance use disorders
o Frequent opioid prescribing and high amounts being prescribed for pain relief
o Lack of awareness or access to alternative treatments for pain
o Use of prescription opioids to whom they are not prescribed
o Lack of access to prescription opioids leading to illicit opioid use
o Illegal drugs that are laced with fentanyl and its analogues
o A lack of comprehensive care to respond to physical and mental health needs of an individual
Opioid Overdose – Government of Canada
- There were a total of 30, 843 apparent opioid toxicity deaths between January 2016 and March 2022
- In 2022, there have been approximately 21 deaths/day
- 94% of opioid overdose deaths happen by accident
- Young Canadians aged 15-24 are the fastest-growing population requiring hospital care from opioid overdoses
- Males accounted for the majority of accidental apparent opioid deaths (76%) so far in 2022 The majority of accidental apparent opioid toxicity deaths were among ages 20-59
- Majority of deaths occurred in British Columbia, Alberta, and Ontario (90% of ask deaths in these areas alone)
- Elevated rates were also seen in the Yukon
Construction Workers and Opioid Use
- In Ontario, a 2021 report found that one third of those who died from opioid toxicity were employed at the time of death/ worked in the construction industry
- The pattern has also been reported in BC where one fifth of deaths occurred among those in the construction industry 98.4% of construction workers who died of an opioid toxicity were male
- In only 17.5% of cases there was an individual present who could have intervened (80% of incidents occurred in a private residence, not the job site)
o In deaths with someone present, Naloxone was only administered 50% of the time
Opioid Overdose
- Canada’s street drugs have become tainted with other powerful opioids like Fentanyl
o Fake pills are produced with unknown amounts of fentanyl
o Some drugs contain fentanyl accidentally when made on the same surfaces
o You can’t see, taste, or smell fentanyl - Fentanyl is approximately 100 times stronger than morphine
- Just under half (44%) of accidental apparent opioid related deaths in 2022 also involved a stimulant - reflecting a poly substance nature of the crisis
- In a report released by the DEA, 42% of pills tested for fentanyl contained at least 2mg of fentanyl
o They also reported that drug trafficking organizations typically distribute fentanyl by the kilogram, and one kilogram of fentanyl is enough to kill approximately 500 000 people - Because of the potency, dealers only need to traffic smaller quantities to maintain the drug effects consumers expect. They can also add bulking agents like flour or baking soda to increase supply without adding costs
o It is much more profitable to cut a kg of fentanyl compared to a kg of heroin
Standard Medical Fentanyl Dosing
- Fentanyl is a synthetic opioid analgesic
- Indications: Pain management pre-operatively, general anesthesia, and analgesia
- Routes: Typically IM or IV in hospital, also available as transdermal patches, can also be administered intranasally for pediatrics
- Standard Medical Dosing (ADULT):
o IV: bolus 1-2 mcg/kg or 25-100mcg/dose PRN
Continus IV infusion: 25-200mcg/hr
o IM: 50-100mcg/dose IM q1-2hr PRN
Naloxone
- NARCAN
- Temporarily reverses the effects of opioid overdoses within 2-5 minutes
o Only remains active in the body for 20-90 minutes - Works by unbinding opioids from receptors in the brain
- Only works on opioids ie: fentanyl, heroin, morphine, codeine
- Available in IM and intranasal formats
PHO: Interactive Opioid Tool
- Opioid related morbidity and mortality in Ontario
- Looks at ER visits, hospitalizations and deaths
- Can be viewed by public health unit, health integration network, age, sex, and in some cases drug type
Harm Reduction
- Refers to policies, programs, and practices that aim to reduce the negative health, social and economic consequences that may ensue from the use of legal and illegal psychoactive drugs without reducing necessarily reducing drug use
- It is a cornerstone of public health, human rights and social justice. It benefits people who use drugs, families and communities.
- Represents a continuum of services that embody a philosophical, pragmatic, and compassionate approach to providing care while minimizing the negative harms associated with substance use
- Understands that not all people have the same ability to change, the same level of substance use, or even experience the same harms
- We may view harm reduction and abstinence in regards to substance use as a continuum with one on each end.
o Example: in terms of alcohol intake, harm reduction would focus on safe alcohol consumption regardless of the level of consumption versus abstinence where the focus would be on complete cessation (Alcoholics Anonymous promotes an abstinence based model)
Harm reduction – The basics
- Umbrella term used to describe programs, policies, and practices that aim to reduce the negative consequences associated with behaviours that are typically considered high risk
- It is:
o Goal-oriented
o Humanistic
o Non judgemental and accepting of people with problematic substance use
o Uses a person-centred approach
o Healthcare providers “meet people where they’re at” and work collaboratively
o Underpinned by a commitment to change policy or is integrated in to new policy
Housing First
- A mental health strategy that focuses on housing people regardless of current patterns of substance use
- Provides clients with assistance in finding and obtaining safe, secure, and permanent housing as quickly as possible
- Individuals and families are not required to demonstrate that they are “ready” for housing
- Housing is not conditional on sobriety or abstinence
- Is an evidence-based practice intended to serve chronically homeless individuals with co-occuring mental illness and substance use disorders
- There are typically 5 core principles of Housing First approaches
o Immediate access to housing with no readiness requirements
o Consumer choice and self-determination (client choice in location, type)
o Recovery orientation (access to a range of supports)
o Individualized and client-driven supports
o Social and community integration
Supervised Consumption Sites
- They provide a safe, clean space for people to bring their own drugs to use in the presence of trained staff
- Prevent accidental overdose
- Reduce the spread of infectious diseases such as HIV
- In Ontario, supervised consumption sites are called “Consumptions and
- Treatment Services” (CTS)
- Closest site to North Bay is in Sudbury
- Find the closest site to your home town here
Needle Exchange Programs (NEP)
- Reduce transmission of HIV, Hep B, Hep C, and other blood borne pathogens
- Reduce usage drug use and sexual behaviours associated with the transmission of blood borne pathogens
- Reduce the number of needles discarded in the community
- NEP is often the only contact some people have with health or social service providers
- Basic services:
o Needle distribution and disposal
o Condom distribution
o Education and information
o Referrals and counselling - Services:
o Testing for HIV and STI’s, Hep B and Hep C, and pregnancy
o Offer immunizations, food and clothing banks, job referrals
o Methadone maintenance clinics and medical care - Offer suppliers including: alcohol swabs, sterile filters, sterile cookers, sterile water, tourniquets, straight stems, bowl pipes, foil, paper straws
o To see BPG and patient teaching for these items check out this link
Methadone
- Is an opioid medication used to create severe pain and opioid addiction
- Is the most commonly used opioid agonist therapy and can be used in pregnancy
- When being used for opioid treatment, it usually comes in the form of a fruit-flavoured drink
- Long-acting opioid drug used to replace shorter acting opioids that someone may rely on (heroin, oxycodone, fentanyl, hydromorphone)
- Effects typically last for 24-36 hours
- Long-term treatment
- When the correct dose is taken, it prevents withdrawal symptoms and reduces cravings If a dose is missed, the client will experience withdrawals
- It lowers the risk for harm/misuse and gives people a chance to stabilize their lives
- *It’s not a cure for opioid addiction, but helps provide the opportunity to “break the habit” and is very effective when combined with counselling and support groups
Buprenorphine
- Buprenorphine/naloxone combined medication, common brand name is Suboxone and is administered sublingually (SL)
- Opioid partial agonist, and is a long-acting opioid drug used to replace shorter-acting opioids and lasts for 24-36 hours
- Used to treat pain and opioid addiction
- Helps diminish the effects of physical dependency to opioids such as withdrawal symptoms and cravings
- Increases safety in cases of overdose Lowers the potential for misuse
Nurses can provide education regarding the basics of safe injections
o IV injections
o How to safely choose a site
o Veins VS arteries
o Excersises for improving vein visibility
o Cleaning your site
o Inserting your needle
o Missed shots & aftercare
Injecting Cocaine - Education
- Has a numbing effect on the vein + causes constriction so be extra careful you’re in the right spot before injecting
- IV cocaine only lasts for a short period of time, so if you are injecting multiple times it can be traumatic for the tissues
Injecting Crack - Education
It comes in a solid form, so it has to be dissolved first. The safest way to do this is with powdered citric or ascorbic acid - avoid lemon juice or vinegar as they can lead to infection
To dissolve Opioid - Education
Put the crack in the citric/ascorbic acid in the cooker, add water and mash +mix well. Only use what you need because it’s hard on the veins
Complications of IV Drug Use
- It is estimated that street drugs are contaminated with at least one pathogen, often bacteria and fungi.
- Contaminants in the substance, combined with general non-sterile equipment, poor hygiene and technique increase the risk for infection
- Potential complications of IV drug use (to name a few):
o Abscess/skin infections
o Scarring
o Endocarditis
o HIV/AIDS
Cellulitis
- Type of infection that affects the skin and tissue underneath
- Causes pain and redness to the affected area
- Group A streptococcal bacteria is a very common cause
- Can progress to life-threatening necrotizing fasciitis and severe sepsis
- Symptoms: Redness, swelling, warmth at the site, possible fevers
- Management: Assess the site, trace borders, ultrasound for abscesses requiring surgical intervention, blood cultures, culture swabs when indicated, antibiotic therapy
Inefective Endocarditis
- Injected material causes endothelial damage and is followed by infection from high bacterial loads
- Staphylococcus aureus is the most common cause
- Symptoms: Fever, chills, tachycardia, fatigue, persistent cough, aching joints, shortness of breath, pallor, swelling in the feet/legs/abdo
- Diagnosis: Blood cultures, echocardiogram, ECG, CXR/CT
- Complications: Severe sepsis, septic emboli that can involve the lungs, kidney and brain, vegetation can grow on heart valves causing damage and failure
- Management: Antibiotic therapy up to 6 weeks or longer Heart valve replacement
True or False
Invasive group A strep is a reportable communicable disease in Ontario?
True
Naloxone Programs
- Naloxone (Narcan) is a drug that can temporarily reverse an opioid overdose
- Only works if the person has opioids in their system
- Intranasal and intramuscular kits are available to the public for free over the counter
- Available through 3 programs:
o Ontario Naloxone Program (ONP): Needle syringe/exchange program, Hep C programs, and participating community agencies
o Ontario Naloxone Program for Pharmacies (ONPP): Participating pharmacies distribute kits
o Ministry of Community Safety and Correction Services - Take Home Naloxone Program: Individuals in provincial correctional facilities who are at risk of an opioid overdose and would like a kit are trained and given kits when released from custody
Safer Supply of Opioids
- Provides prescribed medications as a safer alternative to toxic illegal supplies that are of higher risk of overdose
- Overseen by a health care practitioner with the goal of preventing overdoses and saving lives
- Focuses on “meeting people where they are at” and does not focus on stopping drug use, rather reducing risk of overdose
- May provide: opioids, stimulants, or benzodiazepines
- Additional services: connecting people with other health care services like general medicine, mental health counselling, employment and housing supports
- In 2020 a pilot program of 10 safer supply sites occurred in three provinces. Participants reported improve health, wellbeing and quality of life, in addition to decrease stress, more energy and feeling more active, as well as being able to address other health issues
CHNs and Harm reduction
- Need to be prepared for controversy and debates that harm reduction may elicit
- Strong community stakeholder endorsement is essential, and there may be public resistance to the “appropriateness” of harm reduction programs
- Be aware that this can polarize the conversation, but also open up the conversation for a shift in knowledge, attitudes, and values!
Substance Use - Primordial Prevention
- Nurses supporting public policy making that reduces structural inequities
- Example: poverty is structural in that its related to economic policies, employment policies, discriminatory histories and systems, access to social services, and related factors
- Reducing poverty could including implementing guaranteed annual income, employment supports geared to refugees, or an increase in child benefits
Substance Use - Primary Prevention:
- Involves preventing problematic substance use before it occurs with more focus on the individual or community rather than broader system
- Includes activities geared towards preventing regular substance use from becoming problematic ie: the initiative that created Canada’s Low-Risk Alcohol Drinking Guidelines
- Intervene with families around issues that lead to trauma, which might involve programs that support men who have been violent in changing their violent behaviours, parenting programs that provide alternative discipline options to corporal punishment, anti-racism problems in schools, or education for health and social service providers in how to be 2SLGBTQIA + allies
- Programs that prevent “ism’s” (racism, classism, sexism, ageism, ableism, colonialism) are protective against life experiences that put individuals, families, and communities at risk for problematic substance use
- Also consider tobacco by-laws, limits on private sale of alcohol, or narcotic prescription databases intended to reduce the risks around substances that may become problematic
Substance Use - Secondary Prevention:
- Involve early identification of what substance use becomes problematic and rapid support to assist the individual in addressing root causes to reduce or end substance use
- Example: screening, tools, or conversations that allow for the detection of signs and symptoms of problematic use ie the 11 criteria of substance use disorders
- Can occur on an inpatient or outpatient basis, be supported privately or publicly and involve a wide variety of tools
- May involve individual or group counselling with a focus on moving the individual from problematic use to recovery
Substance Use - Tertiary Prevention:
- Reducing harms of problematic use both for individuals and their families + communities Treatment can be included as a form of tertiary prevention as well as secondary
- Other examples: clean needles, pop-up supervised consumption sites, managed alcohol programs, naloxone distribution programs
- Might include services for families such as Al-Anon, child welfare system (is intended to be used as this, but we understand this isn’t necessarily reflective of the current system and the systemic racism by the overrepresentation of First Nation, Metis, and Inuit children in the system)
Substance Use -
- Addressing stigma around substances within the health care system among professionals, and ensuring CHN’s are following the lead of individuals, families and communities in determining if substance use is problematic
- Consider education on appropriate language and stigmatizing terms!
Blood Born Infections (BBIS)
- Includes HIV, Hepatitis B, and Hepatitis C
- Need special consideration as they are not solely transmitted by sexual activity
- Transmission can also occur by reusing drug, tattooing, or piercing equipment that has residual traces of infected blood
o Hep B + C can be transmitted through sharing razors or toothbrushes - Can be transmitted from mother to neonate during pregnancy or birth
o HIV can be transmitted through breast milk
Human Immunodeficiency Virus (HIV)
- Virus that attacks the body’s immune system
- HIV is a manageable chronic condition
- If left untreated, it causes a weakened immune system or acquired immune deficiency syndrome (AIDS)
- In 2018 there was an estimated 62,050 people living with HIV in Canada - 85% being diagnosed and on treatment
- An estimated 2,242 new HIV infections occurred in Canada in 2018
- Can only be transmitted through 5 body fluids: blood, semen (including pre-cum), rectal fluid, vaginal fluid, and breast milk
- HIV is not transmitted through:
o Kissing, hugging, toilet seats, sharing foods, shaking hands, coughing/sneezing, or mosquito bites
HIV Symptoms
- Some people may not develop symptoms after contracting HIV, and could remain undiagnosed until symptoms of AIDS appear (this can be up to 10 years later)
- Symptoms may last from a few days to weeks
- Misdiagnosis of early HIV is common.
- 50% or more of people living with HIV may develop the following within 2-4 weeks:
o Chills
o Fever
o Fatigue
o Joint Pain
o Headache
o Sore throat
o Muscle aches
o Swollen lymph nodes
HIV Testing
- Blood serum testing
- Some are not able to detect the virus during the first 2-4 weeks of HIV infection, however the individual is still infectious
- May repeat testing if it’s negative and there’s a possibility of having HIV
o Anonymous testing (available in some but not all provinces)
o Rapid HIV testing (point of care)
o Online testing - Canadian AIDS Treatment Information Exchange (CATIE) bridges research and practice, and is Canada’s official knowledge broker for HIV and Hep C. Use their website to obtain reliable practice information link
HIV Testing Window period
o Refers to the time between HIV exposure and when a test can detect HIV in your body
o Depends on the type of HIV test used
HIV Types of Testing
Nucleic Acid Test (NAT): usually detect HIV 10-33 days after exposure and is done using venipuncture. Also tells us viral load
Antigen/Antibody Lab test: usually detects HIV 18-45 days after exposure and is done using venipuncture
Rapid Antigen/Antibody test: usually detects HIV 18-90 days after exposure and is done from a finger stick sample (30 minutes for results)
Antibody test: usually detects HIV 23-90 days after exposure and are available as self-tests (20 minutes for results)
Treating HIV
- Treatment is highly effective, and can prevent HIV transmission
- Client’s can be treated with antiretroviral medications as part of antiretroviral therapy (ART)
o Lower the level of HIV in the body (suppresses the viral load)
o Slows the spread of the virus in your body
o Helps the immune system fight off other infections - In Canada, if you have HIV you have a legal duty to tell your sexual partners before having sex
Undetectable = Untransmittable
- Clinical evidence has firmly established U=U as a scientifically sound concept in regards to HIV
- People with HIV who achieve and maintain undetectable viral loads by taking antiretroviral therapy (ART) daily as prescribed, cannot sexually transmit the virus to others
- It can take up to 6 months to achieve an undetectable viral load on ART
- Viral load is a key determinant of HIV transmission
o Higher viral loads correlate with higher rates of both sexual and perinatal transmission of HIV
Prep Medication - Pre-exposure prophylaxis (PrEP)
o Highly effective HIV prevention strategy that HIV negative people can use to lower risk
o Involves taking antiretroviral (anti-HIV) drugs and having regular medical appointments, monitoring, and supporting
o When taken as prescribed, the risk of transmission is extremely low
o Generally safe and well tolerated
o Available by prescription
o Two PrEP pills approved by Health Canada, both contain emtricitabine + either tenofovir disoproxil or tenofovir alafenamide
o Only covered under OHIP for those 24 years or younger, otherwise costs $250-280/month in Ontario
Prep Medication - Post-Exposure Prophylaxis (PEP)
o Can be taken after HIV exposure to help prevent infection
o Should be started as soon as possible, up to a maximum of 72 hours afterwards
o Very effective but will not prevent 100% of HIV transmissions from occurring
o Must have high adherence to the full course of PEP drugs (4 weeks) and should have no further exposures to HIV while taking PEP
PEP is a combination of three medications
Tenofovir disoproxil fumarate, emtricitbine, raltegravir (or dolutegravir)
Attitudes about HIV
- Stigma remains one of the greatest barriers for Canadians in accessing HIV prevention, testing, treatment and support
- When someone is diagnosed with HIV, other people may have negative attitudes or beliefs about the person’s behaviour, lifestyle, or circumstances in life
- Stigma decreases quality life as it includes:
o Judging
o Labelling
o Isolation
o Prejudice
o Stereotyping
o Discrimination
Reducing Stigma
- Reduce stigma by being respectful, compassionate and non- judgemental
- Model this behaviour for others when you witness stigmatizing behaviours
- When talking about HIV, be thoughtful of the words you use Learn more about the facts of HIV:
o Treatment lowers the viral load, making it too low to be measured in blood tests and therefore undetectable
o People on HIV treatment who maintain an undetectable viral load have effectively no risk of transmitting HIV to their sexual partners
Sex, Drugs & HIV
- Elizabeth Pisani: Sex, drugs and HIV - let’s get rational (2010)
- American epidemiologist, public health consultant and academic researcher
- We do need to acknowledge the transition in acceptable language related to substance use now in 2022.
Hepatitis B
- Is a liver disease spread by contact with infected body fluids, including blood, semen and vaginal fluid
- It is more infectious than HIV
Following infection, 50% of people are asymptomatic - 50% will develop symptoms of fatigue, nausea, vomiting, jaundice, decreased appetite, and arthralgia
- Approximately 95% of healthy people will clear the virus, the remaining will become chronic carriers
- Those Hepatitis B may eventually develop liver cancer, liver failure, or cirrhosis
- Diagnosis is confirmed by blood tests and can be treated using antiviral drugs
Four Hepatitis B-Containing Vaccines Available for Use in Canada
- Engerix-B + Engerix-B Pediatric
- Infanrix hexa, also contained diphtheria, tetanus toxoids, acellular pertussis, hep B, inactivated poliomyelitis, and conjugated Haemophilus influenza type B
- Recombivax HB, Recombinvax HB - Pediatric, Recombivax-HB Adult dialysis
- Twinrix + Twinrix Junior, combined Hepatitis A and B
o 3 vaccine series over 6 months
o Not covered under OHIP
Hepatitis C
- Is a liver disease caused by the hepatitis C virus (HCV)
- Most commonly spread by percutaneous exposure with infected blood and less commonly by sexual activity or perinatal exposure
- Hepatitis C can progress to cause liver injury and eventually end- stage disease
- Following infection, most people are asymptomatic
o 30% of people may experience fatigue, jaundice, or arthralgia
o Approximately 45% of healthy people will spontaneously clear HCV
o 55-85% of people will develop chronic infection - In 2019, there were 11,141 hepatitis C cases reported in Canada
- 61.1% of cases were among males, and 38.3% were among females
- Rates are highest among 25-29 year olds
- Routine surveillance data does not include risk factor data which would help improve the understanding of acute hepatitis C trends
o People who inject drugs are estimated to make up between 60-85% of new Hepatitis C infections - Harm reduction efforts in Canada have increased, and there is significant evidence that harm reduction strategies (needle and syringe programs, opioid antagonist therapy, supervised consumption sites) have been fundamental in reducing risk of transmission
Hepatitis C Treatment
- Diagnosis is made through serum blood testing
- Medications used are called “direct-acting antivirals” (DAAs), which block the ability of the HCV to replicate
- Being cured of hepatitis C, or a sustained virological response (SVR) is achieved after a negative/undetectable HCV RNA test 12 weeks after the end of their treatment
- Treatment is based on amount of liver injury, drug interactions, genotype/ strain of the HCV, length of treatment, and previous treatment experience
- Treatment is highly effective and cures of 95% of people with Hep C
o Typically includes taking pills for 8-12 weeks
o Most people don’t pay out of pocket
Sex Workers
- Increased risk for contracting and spreading STBBIs due to stigma and discrimination, high numbers of sexual partners, limited access to social, health and legal services, lifestyle risks such as substance use, and limited economic resources
- CHN’s can promote risk-reduction strategies like the proper use of male and female condoms, ensuring free access to condoms, peer education, vaccination clinics, and making access to testing and treatment available (ie through mobile van, at a hotel, or at a community centre)
Street Involved Youth
- Addressing basic necessities of life is of greater priority than preventing or addressing potential health risks
- Stigma is an intersecting factor
- Research shows street involved youth do not always take effective action in preventing STBBI’s, for example:inconsistent use of condoms
- Use of alcohol and drugs impact ability to make decisions, and use of drugs is reportedly higher amongst street youth compared to mainstream youth
People in Correctional Facilities
- Disproportionally high rates of STBBIs including HIV, Hep C and Hep B
- May participate in high-risk actives ie injection drug use, substance use, and unprotected sex, prevalence of non-consensual or consensual sexual contact, sharing tattooing or piercing equipment
- There are many barriers to accessing health care which results in negative health consequences, disrupted treatment regimes, and poor physical and mental health
- Upon admission, Correctional Services Canada offers voluntary infectious disease testing, pre and post test counselling, treatment, and access to medical specialists
- STBBI prevention programs offer education, voluntary testing, and counselling, drug-dependence treatment, and harm reduction strategies
Implications of STBBIS
- All STBBIs are underreported as many don’t go for testing or don’t know they’re infected
- Rates of reportable STBBIs provide CHN’s with some understanding of the scope of the problem
- STBBIs can negatively impact a person’s relationships, self-esteem, mental health, coping abilities, and work productivity
- There are also economic implications of medical costs (treatment, time off for appointments)
Prevention & Harm Reduction - Primordial Prevention
- Preventing STBBIs and risk factors from existing
- Creation of programs and policies that keep youth off the streets, or advocating for access to comprehensive sexual health education
Prevention & Harm Reduction - Primary Prevention
- Refers to preventing the start of disease with the goal of decreasing incidence
- Involves activities prior to any sign of disease, injury, or transmission of STBBIs
- Includes the use of penile or male condoms + vaginal or female condom
- *Remember condoms are not 100% effective in protecting against herpes or HPV
- Vaccination is very valuable
Prevention & Harm Reduction - Secondary Prevention
- Refers to early detection
- Involves regular testing and screening for STBBIs, including blood testing, urine samples, genital examination, and sometimes swabs
Prevention & Harm Reduction - Tertiary Prevention
- Measures aimed at decreasing the progress of a disease and controlling long-term negative consequences
- Involves using medications to treat an infection
- Manage symptoms
Prevention & Harm Reduction - Quaternary Prevention
- Methods to avoid results of unnecessary or excessive intervention
- As new medications are developed for STBBIs, is it important to ensure patients are not placed in any harm - ensuring consent is obtained in trials, and having the ability to withdraw at any time
STBBI’S AND PUBLIC HEALTH
- Are a significant health issue in Canada
- STBBI’s are infections that are spread through insertive and receptive sexual practices (vaginal, anal, or oral) with someone who is carrying the infection
- Some viral STBBI’s like genital herpes, and HPV can be transmitted by intimate skin-to- skin contact
- STBBIs like HIV and Hep B are carried and transmitted through the blood
- People affected often encounter stigma and discrimination which may elicit reactions such as anxiety, fear and shame
Some STBBI’s are “reportable” aka notifiable diseases
- The Public Health Agency of Canada (PHAC) stipulates which are reportable nationally
- Each province/territory can add diseases in their own jurisdiction
- Partner notification, contact tracing, testing, and treatment differ among jurisdiction
STBBI’s History - Labelling
- “Venereal disease” (VD) was defined as a disease that was only transmitted by sexual intercourse
- Term was used for centuries
- In the 1970’s the term “VD” was viewed as inaccurate and replaced by sexually transmitted disease (STD)
- The term “Venereal” refers to “of or relating to sexual pleasure or interpose”
STBBI’s History - STD
- Defined as a disease that could be transmitted from person to person through sexual intercourse
- OR intimate contact with genitals, mouth, or rectum
- The term sexually transmitted infection (STI) became preferred in 2006 in Canada
-> Encompassing term that includes infections that may be asymptomatic
STBBI’s History - Blood Born Infections (BBI)
- Used when referring to infections that could be carried and transmitted through the blood
- Sexually transmitted and blood-borne infections (STBBI)
- Used when referring to both STIs and BBIs
Public policy is frequently updated and reviewed based on current research
- Prior to discovering antibiotics, bacterial STBBI’s weren’t treatable
- At one point public policy was implemented to test men and women for syphilis prior to marriage
- An anti-VD campaign emerged in the 1920’s that targeted both education and treatment
- Social stigma influenced both doctors and patients to the extent that infections were rarely reported
- To help, municipalities sent their PH nurses to Toronto to train
with the city’s VD division for 3 months
HEALTHY PUBLIC POLICY - HISTORICALLY
- During the mid 1920’s, interest was lost in “the crusade against STDs”
- Resulted in politicians questioning funding and cutting back on funds
- First World War STD rates: 222 per 1000 people
- Second World War - STD rates 92 per 1000 people
- A significant catalyst for change in the 1980’s was the appearance of AIDS
- Lead to the rethinking and redevelopment of PH efforts
CURRENT HEALTHY PUBLIC POLICY
- Screening for HIV, syphilis, chlamydia, gonorrhoea, and hepatitis B at the first prenatal visit
- BBI screening with blood products (blood safety)
- Immunization Partnership Fund
- Public Health Surveillance (HIV & AIDS, Gonorrhoea, Hep B + C, Syphilis)
Blood Safety Contribution Program
Blood Safety Contribution Program (BSCP)
- Supports the development and enhancement of provincial and territorial systems to monitor errors and adverse events associated with blood/blood product transfusions
- Also includes transplantation of cells, tissues, and organs
Canadian Blood Services
- Mandated to provide Canada with safe, secure, and affordable blood and blood components systems
- Has been managing Canada’s blood system since 1998, and there has not been any recorded instances of blood-borne infections like Hep C or HIV
STBBI’S
- Categorized as bacterial, viral or ectoparasitic infections
- A person who has one STBBI is at risk for others
- All insertive and receptive sexual practices (oral, vaginal, anal) put people at risk for STBBIs
BACTERIAL STI’S
Most commonly reported are chlamydia, gonorrhea, and syphilis
- Chlamydia & gonorrhea are primarily transmitted through unprotected vaginal and anal sex
- Less often through unprotected oral intercourse
- Infection can also pass from mother to newborn baby during delivery
- Very common for people to be asymptomatic
- Unprotected = without a condom/dental dam
CHLAMYDIA
- Cause by Chlamydia trachomatis (C.trachomatis)
- Symptoms typically appear within 1-3 weeks after
having unprotected sex - Transmitted through vaginal, anal, and oral sex
- Can be transmitted from mother to child during childbirth
- Women may contract chlamydia in the cervix, rectum, and throat
- Men may contract chlamydia in the urethra, rectum, and throat
CHLAMYDIA + WOMEN
Can lead to:
- Pelvic inflammatory disease (PID)
- Tubal factor infertility
- Ectopic pregnancy
- Chronic pelvic pain
In pregnancy:
- Premature birth
- Eye infection + pneumonia for baby
Symptoms:
- Cervicitis: mucopurulent endocervical discharge, easily induced endocervical bleeding
- Urethritis: pyuria, dysuria, urinary frequency
70% of infected women have no symptoms and are unaware of their condition.
PID effects include: abdo pain, fever, internal abscesses, long term pelvic pain + scarring of the fallopian tubes
CHLAMYDIA + MEN
Can lead to:
- Lymphogranuloma venereum (LGV) which is caused by C.trachomatis
- LGV can cause proctitis (inflammation of the lining of the rectum)
- LGV has been the recent cause of proctitis outbreaks among gay, bisexual, and other men who have sex with men worldwide.
Symptoms:
- Urethritis: Discharge from the penis, typically mucoid or watery
- Burning sensation when urinating (dysuria)
- Burning or itching at the opening of the penis
- Epididymitis: unilateral testicular pain, tenderness, and swelling
50% of infected men have no symptoms and are unaware of their condition
RECTAL CHLAMYDIA
Affects both men and women
Rectal Symptoms:
- Rectal pain
- Bleeding
- Discharge
- Mucous with stools
- Painful bowel movements
OCULAR CHLAMYDIA
- Affects both men and women
- Occurs through contact with infected genital secretions
Eye Symptoms:
- Appear after 2-6 weeks
- Chlamydial conjunctivitis (pink/red eye)
- Mucous discharge
- Crusting of the lashes
- Tearing
- Photophobia
- Foreign body sensation
- Decreased vision
RECOMMENDED TREATMENT: CHLAMYDIA
Non-LGV Strains = 1 gram PO Azithromycin single dose
-> Or Doxycycline 100mg PO BID x 7 days
LGV Strains
-> Doxycycline 100mg PO BID x 21 days
Order: Azithromycin 1gram PO x1 now
Available: Azithromycin 250mg tabs
How many tabs will you administer?
4
Order: Doxycycline 100mg PO BID x 7days
Available: Doxycycline 100mg capsules
How many tabs will the client receive from the pharmacy when they fill this script?
14
GONORRHEA
- Caused by the bacteria Neisseria gonorrhoea Often referred to as “the clap” or “the drip”
- Can cause infection in the penis, vagina, cervix, anus, urethra, throat and eyes
- Bacteria is carried in the semen and vaginal fluids
- Spread by having vaginal, anal, or oral sex with someone who has gonorrhea
- A pregnant person with gonorrhea can give the infection the baby during childbirth
- Symptoms usually develop within 2 weeks of infection
- Best way of preventing is condom and dental dam use every time you have sex
GONORRHEA + WOMEN
- Unusual vaginal discharge that may be thin, watery and green, or yellow in colour
- Dysuria
- Pain or tenderness in the lower abdominal area
- Bleeding between periods, heavier periods, and bleeding after sex
GONORRHEA + MEN
- Unusual discharge from the tip of the penis, which may be white, yellow or green
- Dysuria
- Inflammation of the foreskin
- Pain or tenderness in the testicles
GONORRHEA IN THE RECTUM, THROAT OR EYES
- Both men and women may develop an infection by having unprotected anal or oral sex
- If infected semen or vaginal fluid come into contact with the eyes, you can also develop conjunctivitis
-> If the eyes are infected, one may experience pain, photophobia, and purulent drainages from one or both eyes - Infection in the rectum can cause:
-> Discomfort, pain, itching, discharge, spots of bright red blood on toilet tissue - Infection in the throat can cause:
-> Sore throat and swollen lymph nodes in the neck
Gonococcal arthritis may result from the bacteraemic spread of the bacteria
- Symptoms: warm, red, swollen, and painful joints
MANAGEMENT OF GONORRHOEA
Recommended regime:
Ceftriaxone 250mg IM x1 + Azithromycin 1gram PO x1
OR Doxycycline 100mg PO BID x 7 days
SYPHILIS
- Caused by the bacterium Treponema pallidum
- Has been nationally notifiable since 1924
- Average onset of first symptoms is 21 days, however can range from 10-90 days
- If untreated, it progresses through primary, secondary, and early latent stages
SYPHILIS STAGING
Primary (Patient is most infectious)
- Chancre sore or proctitis
- Single sore or multiple are common
- Sores appear where the syphilis entered the body, are usually firm, round small and painless
- Chancres last 3-6 weeks and will heal without treatment
Secondary (Patient is infectious)
- Begins with skin rash and mucous membrane lesions
- Rash is rough, red or reddish brown spots on palms of hands, soles of feet, and/or torso extremities, not usually itchy
- Can also include fever, swollen lymph glands, sore throat, patchy hair loss, muscle aches, fatigue, flu-like symptoms
- During incubation (10-90 days from exposure to clinical onset)
- There are no symptoms of syphilis, and the individual is not infectious
- During incubation, serologic testing will be non-reactive but those that have been exposed within the past 90 days should be preventatively treated
SYPHILIS STAGING
Early non-primary, non-secondary (Patient is infectious)
- No primary or secondary symptoms identified at the time of medical visit
- May occur between primary or secondary stages, and after the secondary stage
- Infection has been identified to have occurred within the last 12 months
Late Stage (Patient is not infectious)
- No symptoms identified at the time of medical visit
- Infection has been identified to have occurred after the last 12 months (ie, no evidence of any of the above stages in the past year)
SYPHILIS SIGNS AND SYMPTOMS
Primary Stage
- Chancre sores - are usually firm, round and painless. On occasion are open and wet
- Chancres can show up on your vulva, vagina, anus, penis, scrotum, lips or mouth
- They can be easy to mistake for an ingrown hair
Secondary Stage
- Rashes on the palms of your hands, soles of your feet or other body parts
- Not usually itchy
- May develop mild flu-like symptoms (slight fever, tired, sore throat, swollen glands, headache, muscle aches)
- Can also have sores in your mouth, vagina, or anus
- May note hair or weight loss
Late stages
- Tumors
- Blindness
- Paralysis
- Damage the nervous system, brain and other organs
- May result in death
MANAGEMENT OF SYPHILIS
Recommended regime:
- Primary or Secondary syphilis: Penicillin G benzathine 2.4 million units IM x1
- Neurosyphilis: 2.4 million units IM qWeek x3
- Doxycycline, tetracycline, and possibly ceftriaxone can be used in patients with PCN allergy
- Pregnant women should only be treated with penicillin
VIRAL STI’S
- Genital herpes simples virus (HSV)
- Human papilloma virus (HPV)
- Both are non-reportable
- Genital HSV and HPV are transmitted through intimate skin-skin sexual contact, can also be spread from mother to baby through childbirth (resulting in serious complications such as abnormal development or death)
- Untreated HSV 1 or 2 in the second half of pregnancy, carries a 30-50% risk of vertical transmission
- Neonatal herpes can cause serious morbidity (including long-term neurological damage ie cognitive dysfunction and learning disabilities) and high mortality
HERPES SIMPLEX VIRUS (HSV) - Type 1 & 2
2 is most common
- Either can cause genital infections, however HSV-2 rarely causes oral herpes
- Often appear as one or a group of painful, itchy, fluid filled blisters in or around the genitals, buttocks, and/or thighs
- You can get genital HSV-1 by receiving oral sex from someone who has a cold sore
- May experiences burning while voiding, fever and flu-like symptoms, and swollen glands
- Some people experience only one outbreak, others may experience recurrent outbreaks
- Transmission occurs when both symptomatic and asymptomatic
- A first outbreak of genital herpes may take 2-3 weeks to heal without treatment
- The first outbreak doesn’t mean you’ve been recently infected
- Symptoms can occur days, weeks months, even years after being infected
- Genital herpes is common, it is estimated 14% of people between 14-59 y/o in Canada have HSV-2
HERPES SIMPLEX VIRUS (HSV)
Diagnostics:
- Viral identification “Nucleic Acid Amplification Test” (NAAT) or viral culture
- HSV serology may be useful if testing isn’t available
Treatment:
- Oral acyclovir, famciclovir, valacyclovir within the first 3-4 days of symptom onset for maximum benefit
- Caesarean delivery is strongly recommended if a first episode of genital herpes occurs in the third trimester
- Suppressive therapy is recommended for those with frequent (>6/year) or highly symptomatic recurrences
Partner Notification:
- Not required as a public health measure
- People are encouraged to inform their partners so that partners are aware of risk of infection
HUMAN PAPILLOMA VIRUS (HPV)
- HPV is one of the most common STI’s in Canada + worldwide
- There are many types of HPV, some lead to cancer and others to skin lesions
- It is estimated that as many as 75% of sexually active people will have at least one HPV infection in their lifetime
-> Most peoples immune systems will eventually clear the infection
-> Only a small proportion of people will go on to develop cancer - There is no cure for HPV infections but many symptoms are treatable
- Practicing safer sex reduces your change of getting an HPV infection
- Routine Papanicolaou (Pap) exams are important screening tools for cervical cancer
-> There is no equivalent of the Pap testing in males, penile cancer is rare and occurs in less than <1% of male cancers - warts are more frequent - 3 vaccines are available to help prevent some types of HPV, including strains that cause 7-% of anal and genital cancers + 90% of anogenital warts
- HPV causes almost all cervical cancers, and is also linked to cancer of the throat, oral cavity, penis, anus, vagina or vulva
HUMAN PAPILLOMA VIRUS (HPV) - Symptoms
- Many people are asymptomatic
- Anogenital warts (also known as Condylomata) are one sign, they look like small cauliflower or may be flat
- In women, warts may appear on the vulva, thigh, any, rectum, or in the vagina or urethra with the cervix being a common HPV site
- During pregnancy the number and size of warts can increase
- With an inactive infection, cells of the cervix paper normal under the microscope during a Pap
-> Active infection will demonstrate a change in cells and will either become normal again or the cells slowly progress to cervical cancer - HPV DNA testing is available in Canada, but is not a part of women’s regular check-ups or Pap tests.
- It isn’t covered by provincial/territorial health programs
HPV VACCINES
Health Canada has authorized 3 vaccines
- Gardasil, Gardasil 9 (for females and males), and Cervarix (for females only)
- Studies have found the vaccines to be safe
- Vaccines cannot cause disease as they contain no live biologicals or DNA
- Vaccines do not contain any preservatives, thimerosal, or mercury
- If you are infected with one type of HPV, you can still benefit from the vaccine
- None of the vaccines have an impact on existing infection
GARDASIL + GARDASIL 9
- Protects against two high risk types of HPV (16 and 18) which cause approximately 70% of anal and genital cancers
- Also covers two low risk types of HPV (6 + 11) which cause 90% of anogenital warts
- Gardasil 9 prevents up to an additional 14% of anogenital cancers cause by HPV types 31, 33, 45, 52, 58
- Vaccines are approved for females age 9-45 and in males 9-26
- Involves one dose initially followed by one dose two months later, and another dose given 6 months after the first dose
- Not recommended for pregnant or lactating women
SCREENING FOR STI’S
- In 2018, 60% of Canadians reported never having been screened for STI’s
- STI screening provides an opportunity to discuss transmission, signs and symptoms, risk reduction, and preventative measures
- More frequent STI screening may be appropriate for individuals:
-> Who have had a previous STI diagnosis
-> New sexual partner
-> Multiple or anonymous sexual partners
-> Sexual partner(s) having a STI
-> Condomless sex
-> Sex while under the influence of alcohol or drugs
