Caring Rural Client

Definitions and Demographics

Source Nomenclature Definitions
U.S Bureau Rural Communities with less than 25.000 residents
SEnsus & population density below 1,000/square mile

U.S Non Metropolitan Counties without cities of 50, resident

Management
and Budget

U.S.Rural Completely Rural Completely Rural or Less than 2.500 Urban

Urban Population no to metro area
Continum
code
U.S Author Frontier Rural Less than six people /square mile

Indonesia Pedesaan ? Daerah jauh jangkauan pelayanan,

terpencil, penduduk sedikit, Dirjen pedasan
 Population Characteristic
• Age and Gender; More Older ? More
Women?
• Race and Ethnicity; Less Racial diversity
some more racial diversity
• Level of education; Lower education?
• Income and occupation;
– Poor? Wealthy?
– Farmer? Mining? Forestry? business?
 Rural Population at Risk
• Homeless Families?
• Perinatal Clients?
• The Elderly?
• The mentally Ill
• Farm worker
• Other?
 Rural Health Issue
• Self-management of health care problems
– Barrier ; cost, travel, weather distance
– Rural client are resourceful & supportive network
– Traditional healing, etc
Ethnography study;
- Circle of continuity of care; support all
together; Doctor, nurse, pharmacy, etc
- Circle of family & community support;
Meals, transportation, household task
,personal care, shopping, & other service
 Continue..
• Major Health problem; In developing
country--- Communicable diseases?
– Cardiovascular. HIV/AIDS
• Access to Health Care
– Barriers to Access; Physical distance ,
Transportation, Weather, Limited choice of
health provider, ----- Client Frustrates! Or
Pasrah!
 New Approach to improve Access
The Healthy People 2010 objective---Clients
in Rural areas should receive quality of
care
• Mobile clinic
• School based Clinic
• Telehealth
– What success a new approach In Indonesia
to reach rural areas?
 Rural Community Health Nursing
• They have close community ties
• They are expected to be all things to all people
• Confidently is concern of blurring of social &
professional role
• Autonomy is Important in retaining and satisfying
rural nurse
• Rural staff are generally cohesive
• Rural nurse are seen as positive assets to their
community
 Working as a Community
Health nurse in Rural Community
• Approach the community without preconceived
• Observe/describe the people, places and
activities
• Use all your senses
• Talk With key informants
• Review available demographic, morbidity and
mortality data
• Determine potential community strengths and
problems
• Verify your Impressions
• Enjoy your learning
 Challenges and Opportunity
“UU Kesehatan”
• Autonomy in daily practice; Independent &
interdependent decision making roles
• “Always a Nurse”
• Funding Your education
• ISOLATION;
• “Rupiah/Dolarss and Sense” High Salary or low
salary ?
• Many possibilities
• Innovations
 Studi Casus
• Assume You are in the community health
nurse in rural community. Describe your
approach to solve the problems of overuse
of the emergency room for minor or major
child illness by community residents
Caring Urban Client
 Urban health
Urban health has at least two distinct
meanings:
• the health of the urban settlement in
terms of how well it functions as a
community and as an ecosystem, and
• the health of the human population
that lives within the urban ecosystem
– It also sometimes refers to urban health
care
 Healthy cities
• Intended to take health promotion
“out to the streets”, into every day
life
• Health promotion is “the process of
enabling people to increase control
over and improve their health”
Ottawa Charter, 1986
• So healthy cities is about the
process (= “governance”)
 Key components of
the urban ecosystem
• The built environment
• Social, economic, cultural and
political environments
• Bio-regions and the biosphere
• Human beings
• Other biota
 Dimensions of urban
ecosystem health
• Human population health status
• Urban community social well-being
• Quality of the built environment
• Quality of urban environmental
media
• Health of the biotic community
• Urban ecological footprint
Hancock, 2000
 1. Human population
health status
• The health status of the urban
human population in terms of
their physical and mental
wellbeing, including the
distribution of health and
wellbeing across the different
segments of the community
(health equity);
 2. Urban community
social well-being
• The health of the urban community -
its social well-being - including
social, economic and cultural
conditions, and the distribution of
these and other determinants of
health (social equity);
 3. Quality of the
built environment
• The quality of the built
environment including aspects of
housing quality, transportation,
sewage and water supply, roads
and public transport systems,
parks and recreation facilities and
other civic amenities
4. Quality of the urban
environmental media
• The quality of the urban
environmental media in terms
of air, water, soil and noise
pollution. This is a measure
of environmental quality;
 5. Health of the
biotic community
• The health of the biotic
community, including aspects
of habitat quality and
genetic and species
diversity;
 6. Urban ecological
footprint
• The impact of the urban
ecosystem on the wider natural
ecosystems of which it is a part
(the urban ecological footprint).
This is a measure of
environmental sustainability.
 Measuring urban health/
the health of the city
There are six aspects of "health" that need
to be measured:
• - the bio-psychological health of individuals and
populations
• - the social health of the community as a whole,
• - the quality of the built environment
• - the quality of key environmental media
• - the health and diversity of the biotic community
• - the ecological impact or footprint of the city.
2. Urban population
health
 City health and
citizen health
The ‘health’ of a city is determined by the broad
socio-ecological influences.
The health of its citizens is determined by the
‘health’ of the city and by other factors
• human biology and heredity
• personal behaviour
• income
• health and other services
 1. Human population
health status
• The health status of the urban
human population in terms of
their physical and mental
wellbeing, including the
distribution of health and
wellbeing across the different
segments of the community
(health equity);
 Urban health care?
• Not the same as “urban health”
• The provision of health care to urban
populations
• Challenges (in Canadian cities) include
– Ethno-racial diversity
– Homeless population
– Mobility (home v work, etc)
3. Healthy cities
and healthy
urban governance
 Healthy cities
• Intended to take health promotion
“out to the streets”, into every day
life
• Health promotion is “the process of
enabling people to increase control
over and improve their health”
Ottawa Charter, 1986
• So healthy cities is about the
process (= “governance”)
 Apply the
Ottawa Charter
• Build healthy public policy
• Create environments supportive of
health
• Strengthen community action
• Develop personal skills
• Re-orient health care services
 Governance

• “management of the course of

events in a social system”
(Burris, Drahos and Shearing, 2005)
• “the sum of the many ways
individuals and institutions, public
and private, plan and manage the
common affairs of the city”
(UN Habitat, 2002)
 Implications for
governance
1. Governance is more than
government
– it involves all the stakeholders in the
city
2. ‘Private policy’ matters
– the policies of the private sector that
have public effect, e.g.
• Lending policies and urban form
• Portion size and obesity
3. Governance requires involving both
community organisations and
individual citizens.
4. The governance of cities is
concerned with the “common
affairs of the city”.
– Common concerns/issues
– Common vision
– Common approaches/solutions
 The purpose
of governance
• The central purpose of
governance – and government –
is (or should be) sustainable
and equitable human
development
– Improving the health of the urban
population is one part of that
broader agenda
 New forms of
governance
Focusing on sustainable and
equitable human development
requires new forms of governance
for
• corporations
• societies
• cities
 New corporate
governance
• The Natural Step
• ISO 14001
• Sustainable business
– Corporate social responsibility
– World Economic Forum
– Dow Jones Sustainability Index
• Ethical investment
• Workplace democracy
 Healthy Private
Policy
Policy of the private sector
that has public effect, e.g.,
– fatty foods and portion size
– urban development
– housing design
– working conditions
– car design
 New societal
governance
• Integrated planning
– link the three sectors
• Human development impact analysis
• Intersectoral governance
– public, private and NGO sectors work together
– Steering, not rowing
• Democratic reform
– e.g. BC referendum
 New city governance
As for society, but also
• Participatory democracy
– e.g. budget process in Porto Alegre,
Brasil
• Empowering services
• Community development
– working from the bottom up
• Bioregional government?
 How we usually
operate
Human
Social capital Natural
capital capital

Economic
capital
 How we ought
to operate
Social Natural
capital capital
Human
capital

Economic
capital
 3a. Intersectoral
action for health
Originally one of the key elements of “Health for All”
(1978)
• Three aspects
– Inter-department/inter-ministry/inter-agency
• Across different departments within government (“whole of
government”)
• or within Universities, business corporations, large NGOs
– Cross or intersectoral action
• Across different sectors (public, private, NGO/community,
academic etc)
– Vertical integration
• From local to regional to state to national to
international/global
Intersectoral Action for Local Development
Inter-department/Inter-ministry/
Inter-agency
Government NGO and Academics Private
Community sector

Local

Regional

State

National

International

“Whole of Government”
Intersectoral Action for Local Development
Cross or Intersectoral Action

Government NGO and Academics Private sector

Community

Local

Regional

State

National

International
Intersectoral Action for Local Development
Vertical integration

Government NGO and Academics Private

Community sector

Local

Regional

State

National

International
 Partnerships are key
Which means finding common cause
is key
– What is in it for ‘them’?
– Why would they help you?
– How can you help them?
 Local government
partners
Interested in
• Planning department • designing better communities
• protecting humans and the
• Engineering dept environment
• Police • creating safer communities
• Education • improving human potential
• Transportation • moving people and goods
efficiently and safely
• Others?
 Private sector
partners
• Lots of capacity – people, money, skills
and competencies, facilities etc
• But - caveat partner!
– Who makes money out of creating illness,
or profits from illness?
• Whose ‘bottom line’ improves when
population health improves?
• Who are the ‘producers of health’,
who could help?
 Caveat partner!
Don’t partner with those who
• make money from selling ill
health
– the tobacco industry and others
• lose or don’t make money if the
health of the population
improves
– the ‘medical-industrial complex’?
• profit in ways that harm health
 Whose bottom
line improves?
So whose bottom line improves when
the public’s health improves?
• health and life insurance companies
• tourism and recreation industries
• sport and fitness industries
• others?
And all businesses when the health and
productivity of their employees improves
 How is health
produced?
The main determinants of health are
• peace • a stable
• food ecosystem
• shelter • sustainable
resources
• education
• social justice
• income
and equity

Ottawa Charter for Health WHO, 1986

 So who are the
producers of health?
Those who
• Build peaceful relations, locally and
globally
• Grow our food
• Build our homes and communities
• Educate children and adults
• Create safe communities
• Protect our environment and resources
• Create good jobs and generate income
Poverty
 Which are VP?
1. Keluarga miskin (Poor and homeless persons)
a. Pengertian:
Miskin: sedikit atau tidak ada barang yang dimiliki atau
tidak adekuatnya jangkauan terhadap sumber-sumber
keluarga dan komunitas (Allender & Spradley, 2005)
Atau…
poverty is a lack of basic human needs, such as
adequate and nutritious food, clothing, housing, clean
water, and health services (Corbett,
http://encarta.msn.com)
 Lanjutan:
— Miskin/ kemiskinan merupakan kondisi serba
kekurangan dalam memenuhi kebutuhan hidup
sehari-hari agar dapat bertahan untuk hidup.
Kebutuhan mencakup pangan, sandang dan
papan dan pelayanan kesehatan dasar yang tidak
dapat dipenuhi secara mandiri oleh individu atau
keluarga.
— Ciri-ciri keluarga miskin:
a. Pendapatan yang sangat rendah, tidak ada
simpanan aset, tidak memiliki jaringan kekuasaan,
status pendidikan dan pekerjaan sangat rendah
dan beresiko (Allender & Spradley, 2005)
 Ciri-ciri keluarga miskin:

b. Luas lantai hunian kurang dari 8 m2 per

anggota keluarga; jenis lantai sebagian besar
tanah; tidak memiliki fas air bersih, tidak ada
jamban;konsumsi lauk pauk tdk bervariasi;
tidak mampu membeli pakaian baru minimal
1 thn sekali; dinding rumah terbuat dari
papan atau triplek (BPS, 2004, diadop dari
Konsep Keluarga Sejahtera)
c. Rumah tangga yang memiliki penghasilan
kurang dari 2 dollar per hari (Bappenas,
2007)
2. Dampak Kemiskinan terhadap kesehatan

Allender & Spradley, 2005:

1. Meningkatnya angka kesakitan dan
kematian
……

2. Menurunnya jangkauan pelayanan

kesehatan
……….
 Poverty may be categorized as the following:
1. Acute poverty (occurs suddenly after a crisis such
as job or illness)
2. Chronic poverty (persists over many years)
3. Absolute poverty (indicates a lack of food, shelter,
clothing)
4. Relative poverty (indicates less than averages
resources)
5. Administrative poverty (refers to having met a
govermentally determined standard for poverty, the
federal poverty level)
6. Subjective poverty (individual has inadequate
income for basic necessities within a particular area
(Erickson, 1996)
Homeless
Why do people become homeless?

61
Why do people become homeless?

• Individual Risk Factors / Vulnerabilities

– Substance abuse
– Mental illness
– Childhood family environment
– Lack of job skills

62
Why do people become homeless?

• Social Problems
– Lack of affordable housing
– Lack of jobs
– Inadequate levels of welfare &
disability payments
– Ethnic & racial discrimination
– Economic downturn

63
Why do people become homeless?
Why is this Why is water
part of the so salty,
iceberg causing the
above the iceberg float
water? so high in the
water?
This is the
clinical This is the
perspective – population
focus on health
individual risk perspective –
factors focus on
social forces
64
 Are we focusing on the right group?
Approach B: Shift population
Frequency in Population

norm slightly upwards

Approach A: Focus on
improving conditions
for extreme groups

Homeless Poor Fair Moderate Good Excellent

Housing Quality 65
 Housing Transitions

Shelters Streets, Parks,

Vehicles, etc.
Pan
Handling

HOMELESS
VULNERABLY HOUSED

Staying with Stable Hospitals/ Prisons/

Friends/Family Housing Drug Jails
Treatment
Adapted from S. Kertesz

66
 Injuries and Assault

• Drug overdoses common

• 35% assaulted in last year
• 20% of women raped in last year
• 52% have had traumatic brain
injuries in their lifetime

67
 Chronic Medical Conditions

• Poorly controlled hypertension

• Poorly controlled diabetes
• Chronic pain
• Emphysema / bronchitis
• Seizures

68
 Infectious Diseases

• Pneumonia
• Infestations (body lice, scabies,
bed bugs)
• Tuberculosis
• Hepatitis C
• HIV / AIDS
• Sexually Transmitted Infections

69
 Homelessness and
the Health Care System
• Many barriers to obtaining care, but
high levels of disease
• High rate of Emergency Dept. visits
• High hospitalization rates
• Expensive hospital stays

70
Leading Causes of Mortality among
Homeless People

• Injuries
• Drug Overdose
• Suicide
• HIV/AIDS
• Cancer
• Heart Disease

71
Principles of Clinical Care for
Patients who are Homeless
• Patient-centered care
– Trust & listening
– The patient’s top concern, not yours
• Acute vs. Chronic (unmanaged) vs.
Chronic (managed) conditions
• Collateral history from clinicians and
pharmacists
• Promote continuity of care
• Understand the person’s life situation
72