Rural and Remote Health

Question 1

Rural and Remote Nursing

Answer 1

• 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.
• Technical & social are both recommended ways to define rural

Question 2

Technical Approaches to Defining Rural

Answer 2

• 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

Question 3

Census “Rural” definition

Answer 3

Refers to an area with less than 1,000 inhabitants and a population density less than 400 people per square kilometre

Question 4

Social Approaches to Defining Rural

Answer 4

• 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

Question 5

First Nations and Inuit Health Branch (FNIHB): The degrees of rurality

Answer 5

• 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

Question 6

Rural Health System Model

Answer 6

• Many factors affect health status, health needs, system use and health system performance
• The model has four uses
• The model is divided into 3 parts
  o Geography
  o Population
  o Health System and Community Context

Question 7

The Resource Base

Answer 7

• 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
• Many risks such as occupational illness and diseases and various hazards (biological, chemical, ergonomic, physical)

Question 8

Rural Determinants of Health

Answer 8

• 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

Question 9

Diversity in Rural and Remote Areas

Answer 9

• 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

Question 10

Cultural Safety Protocol; 5 Principles

Answer 10

1. Protocols: respect for cultural forms of engagement
2. Personal knowledge: understanding one’s own cultural identity
3. Process: engaging in mutual learning
4. Positive purpose: ensuring the process yields the right outcome for the client
5. Partnership: Promoting collaborative practice

Question 11

Health Inequities in R&R Communities

Answer 11

• Faced with many challenges
• Access to technologies
• Poor water quality
• Food insecurity
• Fewer health care delivery options; people must travel longer distances for services
• Unreliable access to internet; increasing social isolation

Question 12

Health Informatics

Answer 12

• 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

Question 13

Other Telehealth Services in Rural Canada

Answer 13

• 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

Question 14

Water Quality; The CNA supports nurses to:

Answer 14

o Assess community hazards
o Advocate for change
o Engage in interdisciplinary collaboration to address hazards
o Decrease exposure
o Reduce harm to people and the environment

Question 15

Water Quality

Answer 15

• Access to potable water is everyone’s fundamental right as acknowledged by the United Nations
• Inadequate water resources also make us more vulnerable to infectious disease due to poor sanitation

Question 16

The Walkerton tragedy of May 2000

Answer 16

o 7 people died of e.coli from contaminated water
o 2300 people were ill
o Public health officials felt the issue was probably preventable

Question 17

Boil Water Advisories (BWA)

Answer 17

• 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

Question 18

During a BWA, water should not be used for…

Answer 18

o Drinking
o Making infant formula or juices
o Cooking
o Making ice
o Washing produce
o Brushing teeth
o Bathing depends on age but should avoid the face
o Giving to your pets

Question 19

How does water become contaminated?

Answer 19

o Fertilizers, pesticides, other chemicals applied to the land near water
o Concentrated feeding operations (industrial animal farms)
o Manufacturing operations
o Sewer over flows
o Storm water
o Wildlife
o Rocks and soil (natural sources of arsenic, radon, uranium)
o Cracks in water pipes or other problems in distribution systems

Question 20

Contaminated water/poor sanitation is linked to which diseases?

Answer 20

• Cholera
• Dysentery
• Hep A
• Typhoid
• Polio

Question 21

Contaminated water may include the following chemicals..

Answer 21

• Arsenic (decreases production of red + white blood cells)
• Copper
• Lead
• Nitrate (affects oxygen carrying capacity, infants 6months and under are high
  risk)
• Radon (second leading cause of lung cancer)

Question 22

Water Quality - Indigenous Communities

Answer 22

-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”
- 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

Question 23

Impetigo

Answer 23

• 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

Question 24

Cholera

Answer 24

• Since mid 2021, the world is facing it’s 7th cholera pandemic
• 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

Question 25

What is the deal with Cholera?

Answer 25

• 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

Question 26

Food Insecurity

Answer 26

• Food insecurity is defined as a situation that exists when people lack secure access to
  sufficient amounts of safe and nutritious food
• Poverty, financial hardship, underemployment or unemployment, low income and low educational attainment contribute to food insecurity
• Isolated communities face food insecurity due to exorbitant transportation costs to bring
  in fresh foods
• Many remote Indigenous communities, use hunting and fishing to increase self-sufficiency of access to food

Question 27

Consequences of food insecurity

Answer 27

• 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

Question 28

CHN’s in R&R Communities

Answer 28

• 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
• 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