Community Health Factors and Health Disparities

Based on a community health approach, the THRIVE tool addresses the features of
communities which affect health and safety. These community factors represent key
opportunities to reduce disparities in health and improve community health and
wellbeing. According to the National Institutes of Health, health disparities are the
“differences in the incidence, prevalence, mortality and burden of diseases and other
adverse health conditions that exist among specific populations.” When a health
condition affects the general population, it affects low income and people of color at a
higher rate and more severely.

Trajectory of Health Disparities

What Leads to Health Disparities?

Prevention Institute has identified key elements leading to inequitable health outcomes
for low income people and people of color. As depicted in the diagram above, we have
arranged these elements into a course or trajectory First, people are born into a society
that treats them unequally on the basis of race, class, and gender. Therefore, the trajectory
starts with root factors of oppression, such as discrimination, poverty and racism. These
root factors shape the overall community environment, and affect where people live, what
they do, the education they receive, and their overall quality of life. It is important to note
that the “community environment” has implications beyond the quality of air and water
or the level of pollution in a community. It also refers to whole range of environmental
factors affecting quality of life in a community, including the kind of housing, jobs and
schools, and products available in a community. People who live in environments with
pollution, high rates of joblessness, inadequate access to healthy and affordable food, few
opportunities for physical activity, or that are targeted by corporations pushing unhealthy
products such as alcohol, cigarettes and fast food, tend to experience adverse health
outcomes. The environment influences the community it surrounds and shapes behaviors.
Behavioral factors, such as how and what people eat, their level of alcohol consumption,
their engagement in physical activity, or their propensity for violence, are all affected by
the environments around them. The combination of environmental and behavioral factors
contributes to an increased number of people getting sick and injured who then require
medical services. Inequities in access to and quality of medical services for people of
color and low income people are well-documented and contribute to even greater
disparities in health outcomes. For example, if there is no affordable healthy food and no
places to exercise in a neighborhood, a community is unable to easily eat healthy or
engage in physical activity, and most likely will experience higher rates of cardiovascular
disease and diabetes. These conditions, created by underlying factors in the community
environment, are exacerbated lack of access to quality medical care.

Reducing Disparities

When attempting to eliminate health disparities, most people look at increasing

communities’ access to and quality of medical care. However, even with adequate access
to quality medical services, inequities in health will not be significantly reduced. Health
care often comes after people are already sick, and some serious health conditions can be
treated, but not cured. Medical services also treat or screen one person at a time, and
don’t affect the community overall. Thus, when attempting to address disparities in
health, it is important to concentrate on those environmental and behavioral factors which
affect health outcomes. It is important to focus on how we can prevent people from
getting sick in the first place.

“Two Steps Back”: A Prevention-Oriented Approach

One way to think about a prevention-oriented model for reducing health disparities is to
think backwards from a given health problem or medical condition, such as diabetes,
injury, or cancer. The first step back is from the injury or illness to what researchers
McGinnis and Foege called “the actual causes of death.” For instance, if diabetes is the
medical problem, it is eating and activity patterns (as well as genetics) that underlie it. If
injury is the medical condition, car crashes, falls and violence are the actual causes. If
lung cancer in the medical condition, it can often be traced back to smoking. While it is
critical to focus on those behaviors that contribute to poor health outcomes, it is equally
important to remember that one’s behavior is shaped by one’s environment. As The
Institute of Medicine has stated, “It is unreasonable to expect that people will change
their behavior so easily when so many forces in the social, cultural, and physical
environment conspire against change.” This requires an additional step back from the
‘actual causes’ to the environmental factors that impact health throughout communities
and broadly influence behavior. In the case of lung cancer and smoking, we can step back
to factors such as availability of tobacco and cultural norms that reinforce smoking as
desirable.

The second step back, addressing the environmental factors depicted in the trajectory,
presents a key opportunity for prevention. Through extensive research, Prevention
Institute determined 13 environmental factors that either directly influence health
outcomes (e.g., air and water quality) or directly influence behaviors that in turn affect
health outcomes (e.g., the availability of healthy food affects nutrition). They are
organized into 3 interrelated clusters: equitable opportunity, people, and place, and are
the same community factors included in THRIVE.

McGinnis, J.M., Foege W.H. Actual causes of death in the United States. Journal of the
American Medical Association: 270:2207–2212, 1993.
Additional Prevention Institute Resources:

• Health Disparities and Community Health Glossary of Terms

• A Community Resilience Approach to Reducing Ethnic and Racial Disparities in
Health (PDF) (December 2005 ) The American Journal of Public Health
published this article by Rachel Davis, MSW, Danice Cook, BA and Larry Cohen,
MSW of Prevention Institute in its December 2005 issue (Vol 95, No. 12). The
article captures outcomes from piloting a modified version of the THRIVE tool;
including its demonstrated utility in urban, rural, and suburban settings.
• Health For All: California's Strategic Approach to Eliminating Racial and Ethnic
Health Disparities (PDF) - Executive Summary (PDF) (November 2003) The
California Strategic Approach delineates how the resources of diverse
governmental and private institutions can be marshaled to work with communities
to make significant progress towards eliminating health disparities in California.
It illuminates the critical pathways that affect health and the key points for
intervention to ensure health for all.
• Strengthening Communities: A Prevention Framework for Eliminating Health
Disparities (July 2003) This Prevention Institute paper sheds light on the
environmental conditions that hold the most promise for reducing health
disparities in low-income, communities of color.
• Eliminating Health Disparities: The Role of Primary Prevention (PDF) ( February
2002) A Prevention Institute paper describing how health disparities can be
reduced through systems-based prevention strategies that address the underlying
factors influencing health.
• The Imperative of Reducing Health Disparities through Prevention: Challenges,
Implications, and Opportunities (PDF) (August 2006).This paper was prepared for
the Institute for Alternative Futures by Prevention Institute.
• Good Health Counts: A 21 st Century Approach to Health and Community for
California (May 2006) This Prevention Institute paper was prepared for The
California Endowment [coming soon]
• Prevention Institute Community Health and Health Disparities Website at
http://www.preventioninstitute.org/healthdis.html

Notes

McGinnis JM & Foege WH. Actual causes of death in the United States . Journal of the
American Medical Association: 270:2207–2212, 1993.

B.D. Smedley & S.L. Syme (Eds.) Promoting Health: Intervention Strategies from Social
and Behavioral Research. Washington , D.C. : National Academy of Sciences Press. Pg.
4.

The Nursing Process

By Kathy Quan RN BSN PHN
© 2007-9 All Rights reserved

The nursing process is based on a nursing theory developed by Ida Jean Orlando. She
developed this theory in the late 1950's as she observed nurses in action. She saw "good"
nursing and "bad" nursing. From her observations she learned:

• The patient must be the central character

• Nursing care needs to be directed at improving outcomes for the patient; not about
nursing goals

• The nursing process is an essential part of the nursing care plan

Not As Complicated as it Seems

The nursing process is really not as complicated as it seems. It consists of basically five
steps. Originally, Ms. Orlando had four, but through practical application over the past 40
years, one step evolved into two and now there are five. All nursing personnel take part in
the nursing process. The RN has the primary responsibility however.

The Five Steps

• Assessment
• Diagnosis
• Planning
• Implementation
• Evaluation

Assessment
This is the data collection step. For RNs it also entails analyzing the data and possibly
making a more complex and in-depth assessment based on the findings. LPNs, CNAs and
all non-licensed nursing personnel are not trained in analyzing data. This gives rise to
statements that "LPNs cannot assess patients". In truth they do asses, they just don't
complete the second portion of that step; analysis. They may not make any independent
decisions about the patient's plan of care. It is important for LPNs as well as CNAs and
non-licensed nursing personnel to understand the nursing process, but to also understand
and adhere to their job description and/or scope of practice.

Assessment involves taking vital signs, performing a head to toe assessment, listening to
the patient's comments and questions about his health status, observing his reactions and
interactions with others. It involves asking pertinent questions about his signs and
symptoms, and listening carefully to the answers.

Once you have collected the data, the process moves on to analysis of the data to
determine the health status, the patient's coping mechanisms or lack thereof, his ability to
use these mechanisms and to identify his problems related to his health status.

Diagnosis
Nurses only make nursing diagnoses, except in the case of Nurse Practitioners who have
been trained and licensed to make medical diagnoses. Once you have identified the
patient's problems related to his health status, you formulate a nursing diagnosis for each
of them. You will also prioritize the problems in formulating your plan and goals.

The nursing diagnoses are categorized by a system commonly referred

to as NANDA. The North American Nursing Diagnosis Association
(NANDA) has now become an international group who works to
classify nursing diagnoses, and to review and accept new diagnoses as
needed.
Nursing Diagnosis
Handbook
In 2000, NANDA adopted the current classification system (known as
Betty J. Ackley, G... a taxonomy) as Taxonomy II. There are 13 domains which are
Best Price $30.92 subdivided into 106 classes and 155 nursing diagnoses.
or Buy New $40.80

The RN chooses a nursing diagnosis from the NANDA list which

most closely describes the patient's problem related to his health
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status. This might be a current problem or a potential problem which
needs to be addressed. It can even be a problem that relates to his
family rather then to him alone such as the family's inability to cope
with life style changes necessitated by the patient's illness.

In fact, most patients will have more than one problem to diagnose and address. The
severity of the problem and how it is effecting patient outcomes will determine the
priority for that problem. This priority can change, and the nurse has to adapt to these
changes. This is often difficult for students and new nurses to grasp. As they begin to
understand and utilize the nursing process, this will become more clear.

Planning
Setting goals to improve the outcomes for the patient is a primary focus of the nursing
process. Based on the nursing diagnoses, what are the expectations for this patient? This
not about nursing goals. They are patient goals. This is about improving the health status
and quality of life for your patient. This is about what your patient needs to do to improve
his health status and/or better cope with his illness.

Planning also involves making plans to carry out the necessary interventions to achieve
those goals. The use of formal care plans or care maps and protocols is highly advised.

For example: "after instruction insulin therapy, the patient will successfully return
demonstrate the ability to accurately draw up the insulin by Monday and safely self inject
by Tuesday."

Implementation
Implementation is setting your plans in motion and delegating responsibilities for each
step. Communication is essential to the nursing process. All members of the health care
team should be informed of the patient's status and nursing diagnosis, the goals and the
plans. They are also responsible to report back to the RN all significant findings and to
document their observations and interventions as well as the patient's response and
outcomes.

Evaluation
The nursing process is an ongoing process. Evaluation involves not only analyzing the
success (or failure) of the current goals and interventions, but examining the need for
adjustments and changes as well. The evaluation process incorporates all input from the
entire health care team, including the patient. Evaluation leads back to Assessment and
the whole process begins again.

The Whole Patient

The nursing process involves looking at the whole patient at all times. It personalizes the
patient. He is Mr. Jones, not "the CVA in 214B." It also forces the health care team to
observe and interact with the patient, and not just become the task they are performing
such as a dressing change (the dressing change in 317A), or a bed bath. In so doing, the
process provides a roadmap that ensures good nursing care and improves patient
outcomes.

Most Misunderstood Theory

The nursing process is perhaps one of the most misunderstood nursing theories, and yet
one of the most effective as well as practical. Many students struggle with this theory. It
takes time for students and new nurses to get the hang of this process, and many fight it
every step of the way, until one day a light bulb begins to burn brightly. The nursing
process is used to help nurses make nursing care plans, carry them out and improve
patient outcomes.

Here are a few books that may help you to better understand and apply the nursing
process:

HOME

Nursing Theories

©2007 by Kathy Quan RN BSN PHN, all rights reserved. No portion of this document
may be used in any format without written permission. Email Me. Reprints may be
purchased in single or bulk quantities.