To Pauperize or Empower

Abstract From its inception, public health nursing has provided health care and teaching to all people including those who are disadvantaged and impoverished. Based on the work and beliefs of Florence Nightingale and Lillian Wald, public health nurses developed positive relationships with people which resulted in healthier environments and lifestyles among diverse families and communities. And, despite societal concern that nursing care for the poor would pauperize them, it did not. It empowered them. A review of concepts of poverty and comparisons of issues and circumstances at the turn of the 20th and 21st centuries underscores the values inherent in these early initiatives and their continuing relevance to public health nursing practice that can empower, rather than pauperize, those who are disadvantaged or living in poverty.     

Determinants of health-service use by low-income people.

Poverty influences health status, life expectancy, health behaviours, and use of health services. This study examined factors influencing the use of health-related services by people living in poverty. In the first phase, 199 impoverished users of health-related services in 2 large Canadian cities were interviewed by their peers. In the second phase, group interviews with people living in poverty (n = 52) were conducted. Data were analyzed using thematic content analysis. Diverse health-related services were used to meet basic and health needs, to maintain human contact, and to cope with life's challenges. Use of services depended on proximity, affordability, convenience, information, and providers' attitudes and behaviours. Use was impeded by inequities based on income status. To promote the health of people living in poverty, nurses and other health professionals can enhance the accessibility and quality of services, improve their interactions with people living in poverty, provide information about available programs, offer coordinated community-based services, collaborate with other sectors, and advocate for more equitable services and policies.     

Nurses' role in the prevention of infant mortality in 1884-1925: health disparities then and now

Nursing has a strong historical precedence in the treatment of health disparities. This article evaluates the public health nurses' (PHNs') role with infant mortality during 1884-1920, specifically how nursing care impacted on conditions of poverty, poor nutrition, poor living conditions, lack of education, and lack of governmental policies that contributed to the poor health of infants a century ago. The historical significance of the early PHNs' role can improve our understanding of nursing practice with childhood health issues today. Suggestions are made for nursing to focus on health disparities in childhood obesity, in areas of environmental and policy changes, and the development of social programs and education for families to support healthier living.     

Development of the role of public health nurses in addressing child and family poverty: a framework for action

Title. Development of the role of public health nurses in addressing child and family poverty: a framework for action Aim. The purpose of this paper is to invite dialogue about how public health nurses could best address child and family poverty. Their current role is reviewed and a framework for expanding this role is presented. Background. The negative health consequences of poverty for children are well‐documented worldwide. The high levels of children living in poverty in wealthy industrialized countries such as Canada should be of concern to the health sector. What role(s) can public health nurses play in addressing child and family poverty? Method. A review of scholarly literature from Canada, the United States of America and the United Kingdom was conducted to ascertain support for public health nurses’ roles in reducing poverty and its effects. We then reviewed professional standards and competencies for nursing practice in Canada. The data were collected between 2005 and 2006. Findings. Numerous nursing scholars have called for public health nurses to address the causes and consequences of poverty through policy advocacy. However, this role was less likely to be identified in professional standards and competencies, and we found little empirical evidence documenting Canadian public health nurses’ efforts to engage in this role. Public health nurses’ roles in relation to poverty focus primarily on assisting families living in poverty to access appropriate services rather than directing efforts at the policy level. Factors associated with this limited involvement are identified. We suggest that the conceptual framework developed by Blackburn in the United Kingdom offers direction for a more fully developed public health nursing role. Prerequisites to engaging in the strategies articulated in the framework are discussed. Conclusion. Given more organizational support and enhanced knowledge and skills, public health nurses could be playing a greater role in working with others to make child and family poverty history.     

Exploring the challenges of implementing Participatory Action Research in the context of HIV and poverty

HIV/AIDS is having a devastating impact on South Africa and particularly on poor communities. Empowerment of communities has been identified as an important step towards mitigating the consequences and helping communities to overcome the challenges presented. Participatory Action Research (PAR) has been identified as a useful methodology for the purpose of facilitating empowerment. This study explores the challenges involved in implementing PAR in the context of HIV/AIDS and poverty. In this article, the author describes a PAR project that took place in 2003/ 2004 with a group of five Xhosa speaking people living with HIV/AIDS in Masiphumelele, Cape Town. The aims of the study were to: 1. Create an opportunity for the participants to engage in a participatory process aimed at self-awareness and empowerment. 2. To record and analyse this process with the intention of producing insight into the use of PAR in the context of poverty and HIV/AIDS and to identify the challenges involved. The findings of this study highlight some important insights into the process of engaging people in the PAR process and the experiences of HIV positive people living in the context of poverty. The study explores the challenges involved in the process of empowerment and examines the process of "transferring" power and control from the researcher to the participants. Challenges were uncovered both from the point of view of the researcher who had to "let go of control" and participants who had to take on control. Participants struggled with issues of low self-efficacy and learned helplessness. Fluctuations in health also contributed towards alternating periods of hope and despair and these problems had an impact on their motivation to participate in the study. Lack of motivation to participate is a challenge highlighted in the literature and explored in this study. Participation is necessary for a study of this nature to be of benefit to the community, but unfortunately those most in need were found to be least likely to participate. The study also critically examines the research process that was conducted and highlights the positive and negative contribution of the process towards empowerment. Certain aspects of the research process, including the contracting process, were identified as being problematic as they emphasize the power and control of the researcher rather than the participants. Recommendations for future research include: Promoting participation among the disempowered; the Contracting process and Power relations in PAR.     

Baccalaureate nursing students' attitudes toward poverty: implications for nursing curricula

Given the link between poverty and health, nurses, in their work in hospitals and in the community, often come into contact with people who are poor. To be effective care providers, nurses must have an adequate understanding of poverty and a positive attitude toward people who are poor. This study examined attitudes toward poverty among baccalaureate nursing students (N = 740) at three Canadian universities. Students' attitudes were neutral to slightly positive. Personal experiences appeared to have an important influence on the development of favorable attitudes. The findings point to several considerations for nursing curricula. Students should not only be provided with classroom opportunities for critical exploration of poverty and its negative effects on individuals and society, but also have clinical learning experiences that bring them face-to-face with people who are poor, their health concerns, and the realities of their circumstances. Thoughtful critique of poverty-related issues and interpersonal contact may be effective strategies to foster attitude change.     

Down and out in New York City: a participant-observation study of the poor and marginalized

Poor and marginalized individuals have greater difficulty accessing health care compared to more privileged members of society. Classic theories on poverty help to explain the relationship between poverty and health. In an attempt to understand the experiences and perceived needs of the poor as well as their interactions with health care providers, a participant-observation study was conducted. The investigator spent time on the streets of New York City among the poor and homeless and attempted to access various health care services specifically set up for this population. The purpose of this article is to describe what it was like to be "down and out" and in need of basic health care.     

Assertive community treatment of the long-term mentally ill

For several reasons including the failures of deinstitutionalization, the inadequacy of community resources, and poor coordination among service agencies, the needs of people with long-term mental illness living in the community have not been adequately met. Yet recent changes in the mental health care treatment system have sustained the shift in the locus of mental health care from inpatient settings to the community. This article discusses the characteristics and needs of people with long-term mental illness living in the community. Gaps in service are identified, and an innovative assertive community treatment approach to close some of those gaps is described. Suggestions are proposed for differentiating the role of the psychiatric nurse from other clinicians in assertive community treatment teams.     

Enhancing oral health for better mental health: Exploring the views of mental health professionals

The association between oral health, self‐esteem and quality of life is well established yet there is limited research on the impact of addressing the poor oral health of people living with mental health disorders. Greater consideration is warranted on how enhancing oral health in the course of mental healthcare might reduce the burden of a person's ill health. The role of mental health professionals is important in this regard yet uncertainty persists about the role these providers can and should play in promoting oral health care for people with mental health disorders. This qualitative study explored the issue of oral health and mental health with community based mental health professionals in Perth, Western Australia. It examined their views on the oral health status and experiences of their clients, and the different and alternative ways to improve access to care, knowledge and preventative regimens. Findings indicated participants’ ambivalence, reluctance and lack of training in raising oral health issues, despite its acknowledged importance, indicating a siloed approach to care. Findings offer an opportunity to reflect on whether a more integrated approach to oral health care for people with mental health disorders would improve health outcomes.     

Falls prevention in practice: guidance and case study

Falls are a major health issue for older people. Each year 1.57 million older people fall more than three times and 70,000 fracture their hips, and injury which frequently leads to disability and even death. The National Service framework for Older People identified falls prevention as a major health priority. This article explains how a community based falls service led by a nurse and physiotherapist identified falls risk factors affecting a housebound 97-year-old lady. Factors identified and treated were poor balance and strength, osteoarthritis of the knees and thumbs, inadequate pain control, uncorrected poor vision, oedema of the legs and feet, unsuitable footwear and an unsuitable walking aid. As a result of the interventions falls risk was reduced and quality of life improved.     

How home care agencies in Germany view the AIDS challenge: results of an exploratory study.

The purpose of this article is to examine the current state of home care services for people living with HIV/AIDS and other seriously ill patients in Germany. It is based on a research project promoted by the Federal Ministry for Labor that aimed to investigate the possibilities and problems related to home care of the critically ill and thus establish basic scientific principles that could be used to close a health care gap that has long been of concern. The article will initially offer a brief explanation of the causes underlying the current problems in the field of home care for seriously ill patients. The authors then present the implications for nursing qualification that will have to be addressed to develop a patient-oriented, priority-level home nursing care program for people with HIV/AIDS in Germany.     

Nursing students' beliefs about poverty and health

PURPOSE: This paper examines baccalaureate nursing students' beliefs about the relationship between poverty and health, and the factors that influence these beliefs. BACKGROUND: The relationship between poverty and health is well established, and poverty remains a persistent problem in many industrialized nations. Nurses' understanding of how poverty influences health will affect how they interact with individual clients as well as the strategies they employ to address poverty-related issues. No studies have examined nursing students' understandings of how poverty influences health and the factors that influence that understanding. METHODS: A cross-sectional survey of a random sample (n = 740) of basic baccalaureate nursing students was conducted in three Canadian universities in 2000. Students completed a 59-item questionnaire eliciting data on demographic variables, personal and educational exposure to poverty, beliefs about the relationship between poverty and health (myth, drift, behavioural, structural), and attitudes to poverty. RESULTS: Students were most likely to adhere to a structural explanation of the relationship between poverty and health. Very little of the variance in myth and drift explanations was accounted for by course or personal exposure, programme level, age, and attitudes toward poverty. Greater course exposure and more positive attitudes toward the poor predicted support for the structural explanation. Support for the behavioural explanation was influenced by attitudes toward the poor and, to a lesser extent, by course exposure, age, and programme level. CONCLUSION: Students would benefit from greater exposure to poverty through coursework that emphasizes the structural factors contributing to poverty and its negative health consequences. Classroom experience should be complemented with clinical placements that provide students with opportunities to interact with families living in poverty and to work collaboratively with others to address the causes and consequences of poverty at community and policy levels.     

'The very pests of society': the Irish and 150 years of public health in England

In the context of efforts to reduce health inequalities, the health status of the Irish in England should be a major subject for concern. As England's longest standing and most numerous ethnic minority, the Irish have at times been regarded as a public health threat and have repeatedly been stereotyped in literature and image. There has also been a failure to recognise and celebrate the contributions to the improvement of public health made by members of the irish community such as Kitty Wilkinson. In recent years alarming evidence has emerged that the mortality of Irish people living in England appears to have worsened in successive generations. Comparison of available data on some of the key determinants of ill health shows that the Irish in England have a worse profile than the Irish living in Ireland. A concerted programme of action is needed to investigate why the Irish should have such poor health status and to develop a programme to address it.     

The physical health of the seriously mentally ill: an overview of the literature

Despite the wealth of literature which attests to the relationship between serious mental illness (SMI) and physical ill health, the provision of optimum physical health care for mental health service users remains a challenge. In England the Department of Health has identified the evident health inequalities for people with SMI as a priority area for health improvement, publishing numerous policy directives aimed at addressing these inequalities. However, this is a highly complex process and little is known about why the rhetoric of holistic health care has proved unattainable thus far. In this paper we present an informed commentary of the contemporary literature with the aim of offering a more comprehensive understanding of the health inequalities faced by people with SMI. We searched relevant databases for publications related to: the causes of poor physical health among the mentally ill, strategies to address these health needs and the impact which professional education, culture and services structure has on this facet of service delivery. This enabled us to identify potential strategies that can be adopted by health care practitioners wishing to improve the health of this vulnerable group, and by educationalists to advance professionals' knowledge of this important and ostensibly neglected area.     

Perspectives of health workers regarding primary health care delivery to the rural population in the Bothaville district

This article reports on the views of public health workers regarding recent changes in the delivery of primary health care to people living and working in the Bothaville rural area. These changes in mobile health care form part of the Initiative for Sub-District Support's programme to provide sustained, concerted support to sub-districts to bring about improvements in health care management and health care delivery. Main shortcomings of the recent changes were identified as inadequate transportation facilities in rural areas, insufficient information dissemination to rural dwellers and lack of farmers' participation in rural health matters. Furthermore, poor communication and co-operation between different public health services prevailed and the need for an integration of these services was emphasised.     

Health improvement through dietary management of type 2 diabetes

Diabetes is found to be one of the fastest growing chronic diseases with a high incidence among older people, and in residential care homes the prevalence of diabetes can be as high as 25% percent. A range of complications can develop following the onset of the disease. The prevention of these complications is in line with the emphasis that is being placed on health promotion and the prevention of ill health in current health strategies. This article will discuss a district nurse's approach to health improvement through dietary management of diabetes for elderly residents with type 2 diabetes living in a care home. The PRECEDE-PROCEED health promotion model chosen to assess the learning needs of the residents and to structure the implementation and evaluation of the health promotion project was good guidance and will form the structure for this article.     

A multidisciplinary team approach to public health working

For several years the government's health agenda has provided a strong directive for primary care professionals to work in a more public, health focused way. There remains, however, the constant challenge to incorporate a public health focus into existing clinical practice and caseload commitments in an achievable and manageable way, while at the same time impacting on ill health. This article explores a pragmatic public health approach to addressing some of the common health needs of people, as identified collectively in the national service frameworks for mental health, coronary heart disease, diabetes, older people and cancer. A practical example of facilitating collaborative working between disciplines and agencies is offered using the author's successful experiences form a review and modernization project of health visiting services in East Somerset (Dion, 2003).     

Exploring the experience of people with schizophrenia who live in boarding houses or private homes: a grounded theory study

Housing has been identified as a crucial component of successful community living for people with schizophrenia. Unfortunately, many mental health services only focus on acute care and drug solutions for their clients. This grounded theory study aimed to develop a theoretical understanding of the impact of housing on the mental health of people with schizophrenia. Data were collected from thirteen people with schizophrenia who were living in boarding houses (considered the least suitable housing) or living in their own home (considered the most suitable housing). Semi-structured, in-depth interviews were conducted to explore the participants' experiences and views of the impact of their housing on their mental health. Findings indicated that participants living in their own homes have access to more opportunities and resources for staying well than people with schizophrenia living in boarding houses. Findings also indicated a strong desire amongst all participants to live in their own home. When they do have this opportunity they make choices that enhance their ability to stay well.     

Retirement in France: from the past to the future

Mortality and fertility declines will shape the features of the elderly population in the future. Families with four generations will be frequent. The future elderly will have a higher life expectancy, the time they will live in good health will be even more longer, but they will have likely to devote a part of this time to caring about their own old parents. The proportion of widows among the future elderly will decrease, however, as celibacy and divorce have been frequent during the adulthood of these generations, the proportion of people living alone may increase. The trend will not prevent them to enter at a later age into the nursing homes since they will be probably more educated, wealthier and in better shape, as compared to the elderly of today.     

WEAVING A NEW SAFETY NET OF MENTAL HEALTH CARE IN RURAL AMERICA: A MODEL OF INTEGRATED PRACTICE

Life in rural America is often idealized, yet rural Americans suffer from mental illness in rates comparable to urban America and require similar types of support and services. However, millions of individuals living in rural areas go without needed mental health services. The dominant care model allows the treatment of mental illness to be delivered by non-mental health professionals with little or no education or training in psychiatric care and who have little desire to provide this type of care, resulting most often in ineffective or inappropriate treatment. Lacking access to appropriate and effective care, rural mentally ill individuals are more often symptomatic than their urban counterparts and may never find relief from the disabling symptoms of treatable mental illnesses. This article will focus on the current state of psychiatric-mental health care in the context of these realities and discuss the impact of the current trend of mental illness being treated by non-mental health professionals. The article will conclude by proposing a model of advanced practice nursing that the authors believe will increase both access and efficacy of treatment for the mentally ill living in rural America. This Integrated Model views the current system of care that completely separates location for traditional physical and mental health care as antithetical to integration and to holism and presents a new model for understanding and provided integrated health care to meet the needs of rural mentally ill individuals and families.