Canadian Aboriginal Community Assessment and Diagnosis - Essay Example

 Community Assessment and Diagnosis Assessment of the health status is an essential pre-requisite for devising suitable healthcare programmes. In this connection there are certain terms which need explanation. According to Stamler and Yiu (2012), an aggregate community is “a group of people with common interests, culture, beliefs, or goals” and the core of the community is people “characterized by their age, sex, socioeconomic status, education level, occupation, ethnicity and religion” (pg. 214). Therefore, community health care providers and health nurses, when examining a community or aggregate for current health status, must determine the characteristics of the core of the aggregate community. While assessing an aggregate, the World Health Organization’s (2012) definition of health should be followed because different communities may have difference in perception of health. According to WHO, health is defined as being “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. One may have a chronic or even terminal disease and still have a state of well-being. WHO (2012) also describes how “the health status of indigenous peoples varies significantly from that of non-indigenous population groups in countries all over the world” indicating Aboriginal communities may have different requirements to achieve a state of health and well-being as compared to the general population around them. They may be therefore considered as specific aggregates. However, in Canada, Aboriginal populations are both widespread and unique. They are found in the Pacific coast to the Atlantic, with no two communities, even within one Treaty, necessarily comprising of culturally or genetically similar peoples. Each community faces specific challenges and barriers to health promotion such as economic burden, lack of local health services, difference in cultural beliefs, and levels of education. They even face different provincial-specific governmental regulations. Therefore, an example of a community with specialized needs would be Canadian Aboriginal (or First Nations) individuals suffering from diabetes. Aboriginal diabetics are a large population to investigate, and data is collected and compiled province-wide by Alberta Health Services as opposed to geographical or Treaty-specific statistics. Therefore, the most appropriate aggregate for assessment would be diabetic Aboriginals in Alberta, in and around the Calgary area. Diabetic Aboriginals in Calgary (Alberta) as an Identified Aggregate: Statistically, Aboriginal or First Nations peoples regardless of their location face similar pre-dispositions for certain diseases, such as type II diabetes. Diabetes mellitus (DM) is a chronic disorder of carbohydrate, protein, and fat metabolism caused by a discrepancy between the amount of insulin required by the body and the amount of insulin available (Sommers, 2011). The disease leads to inappropriate glucose utilization within the body which causes a variety of related diseases, thus modifying the mortality rates. Type II DM is often called ‘adult onset’ diabetes and is related to obesity, poor diet and other factors. Diabetes is a life-long disease that can be treated with diet, exercise, supportive medications and close management of blood glucose levels, and also treated for its effects on other body organs and systems. Aboriginal communities in Canada commonly believe that diabetes prevention is ineffective in Aboriginal populations because it fails to offer diabetes prevention strategies specific to their needs (Ghosh & Gomes, 2011, pg. 246). The Alberta Diabetes Surveillance System (ADSS) has reported that in status Aboriginals the diabetes incidence and prevalence rates are twice the incidence rates compared to the general population. Accordingly, the use of hospital and emergency department services is 2 to 3 times higher for the Status Aboriginal population as compared to the general population (Alberta Diabetes Atlas, 2009, pg. 191). According to statistical estimates by Health Canada (2011), the Type 2 diabetes is about 3 to 5 times higher among First Nations people. These numbers clearly indicate that the incidence of diabetes in our Aboriginal populations is a matter of serious concern for health care providers, and also for the Aboriginal communities. Using data from Alberta Health and Wellness databases, Oster et al. (2011) have stated that Alberta alone has “161 268 people with prevalent diabetes, 7055 of whom were status Aboriginal individuals” (pg. 3). This data may represent individuals living on reservations or in urban areas. “In 2005, the estimated diabetes prevalence rate among First Nations residents in Alberta was 12%. This could be an underestimate owing to the high rates of undiagnosed diabetes” (Oster, Virani, Strong, Shade & Toth, 2009, pg. 388). Diabetes is a chronic condition, which can possibly lead to multiple disease condition. Therefore, it is important that Aboriginal Albertans are provided a strong system of community care to enhance their well-being. Assessment Using ‘Community-as-Partner’ Model: The Community-as-Partner Model for community assessment incorporates the nursing process and two main attributes to organize assessments. The community assessment wheel is comprised of nine defined but interacting subsections including: physical environment, socioeconomic environments, health and social services, culture and religion, communication, transportation, government and politics, law and safety, education and healthy child development (Stampler and Yiu, 2012). These subsections surround the people, the biological endowment, and they promote flow through the nursing process including five phases: assessment, analysis, planning, intervention and evaluation. In the assessment phase, the focus is on what determines the health of the community. The analysis identifies community strengths and needs, and formulates nursing diagnoses. Planning phase addresses specific health promotion challenges with emphasis on reducing inequities, enhancing coping ability, and increasing preventative measures. Interventions may be at the primary, secondary or tertiary level involving accessibility of care, inter-sectorial and public collaborations, supportive environments and technology appropriation. The evaluation phase gathers evidence to assist with monitoring results and influence continuous modifications (Stamler & Yiu, 2012). “The phenomena of interest are the community system and its related environment. The environment can be internal, external, or created” (Vollman, Anderson & McFarlane, 2012, pg. 224). The nursing attribute follows Neuman’s stress adaptation model which relates to an aggregate’s response to stressors, reflected in the community-as-partner model’s solid and broken lines surrounding the community. The solid line surrounding the community “represents its normal line of defence (NLD) or the level of health… the community/population has reached over time” (Vollman et al., 2012, pg. 215). The broken lines represent flexible lines of defence, which are the community/aggregate’s temporary responses to stressors. General lines of resistance within the community are strengths that defend against stressors, and they work together for various subsections as asset to the community. Diabetes running rampant through this aggregate has disrupted normal and flexible lines of defence, resulting in the community having an impaired ability to respond to those stressors. This results in overall decreased in health for these individuals, thus increasing mortality and morbidity rates as well as increasing diabetic complications, increasing cost and energy required of the community to support these people’s health needs. Possibly, this situation also puts younger diabetics at the risk of poor health management. When initiating assessment of a community, the first section to be evaluated is the people themselves. “Understanding this core is essential in community planning, and changes in the community demographics must be identified and considered over time as development and change are facilitated by working with a community” (Vollman et al., 2012, pg. 225). Epidemiological data applicable to the aggregate was mentioned earlier in general discussion of First Nation’s members in Alberta and this now leads to an assessment of the three chosen segments in the Community-as-Partner model: environment, transportation, health and social services. Environment Assessment begins with an environmental scan to observe conditions of people living on the Tsuu T’ina Reservation near Calgary, Alberta and to discuss with any possible informants of “what the community perceives as the gap between its current situation and desired situation” (Stamler & Yiu, 2012, pg. 218). These discussions should be pertaining to needs of diabetic individuals specifically applicable to the three spheres of environment, transportation and health/social services, results of which are available in Appendix A. When preparing for an environmental scan, which in this case was both a walking and windshield survey, Vollman et al. (2012) recommend utilizing a table to record observations and data for each aspect being assessed on the visual survey (pg. 235-236) that includes assessments of the core (demographics, ethnicity, values and beliefs), subsystems (all should be considered, not just the three being assessed at this time) and perceptions (community of themselves, them vs. outside world, the surveyor’s perceptions). Any community members interviewed either during the survey or as an intentional interview should be aware their responses are being recorded in order to comply with ethical data collection guidelines. Personal interviews and/or focus groups are a beneficial source of information for this aggregate as it allows for specific examples from individuals as to what they would consider beneficial for their overall well-being as well as what are considered to be obstacles of obtaining care. Interviewing individuals afflicted with diabetes or diabetic family members should also be completed, if possible, as they may have a varying perspective of available care. While analyzing the data collected and synthesizing it into usable information, it is important to evaluate both the community’s weaknesses and strengths in allowing stressors to affect them. Perceived weaknesses of this aggregate include: lack of aboriginal health care providers, lack of transportation or local clinics to support their diabetes management and lack of culturally sensitive education. The community’s strengths cover aspects like multi-generational families which allow for education and lifestyle changes to be encouraged for younger generations; large extended families in close ratio allow for family support as many members may have diabetes; and mutually-shared environmental factors may promote stronger community ties. Capacity building is also an important aspect of planning care with communities. It involves development in key areas such as organizational, human resources, “leadership, partnership, resource allocation and policy formation” (Stamler & Yiu, 2012). Capacity building in communities helps them to take charge of their well-being and become more capable of moving forward in designing health strategies that work for both themselves and future generations in that aggregate. Data gaps are evident in this assessment, as this was reservation-specific with minimal outside opinions available only from personal conversations with aboriginal health care providers. More concise data would be beneficial including assessment of individuals not associated with the Tsuu T’ina band, those that live in urban areas and possibly the thoughts of their health care providers as well. After discussion with diabetic individuals and their families, a community diagnosis was established as per outlines established by Vollman et al. (2008) that aboriginal Albertans with diabetes are at risk for altered health maintenance related to lack of transportation and lack of local diabetic health care management teams as manifested by increased rates of diabetes in the aboriginal population, increase of diabetes-associated diseases in this aggregate and higher than average hospitalizations relating to diabetic complications. According to Neufeld and Harrison (2000) “a deficit nursing diagnosis is defined as the statement of a client’s response that is actually or potentially unhealthy and that nursing intervention can help to change in the direction of health” with a wellness diagnosis representing the healthy response which nursing interventions strengthen. Diagnosis of risk for altered health maintenance is a deficit in that the lack of support and infrastructure allows for a deficit in care. This also qualifies as an at-risk diagnosis as several conditions quoted by Neufeld and Harrison were met: “First, a risk must be present. Second, only modifiable risk factors are included. Not all risk factors are a legitimate focus for community health nursing intervention” (pg. 374). Though internal issues such as a lack of transportation may not seem modifiable by nursing standards, there are solutions that could be assisted by the community health nurse to be developed such as car-pool programs or mobile clinics. Aspects of Neuman’s stress adaptation model are visible within this diagnosis and imply solutions within their relationship to the lines of defence within the aggregate and larger community. The subsystems of transportation and health services may be modified by establishing on-reserve and possible mobile diabetes management clinics or other programs within the environmental subsystem. Their normal lines of resistance, or normal health care routine, are supplemented by these programs which are considered to be a flexible line of defence as they are in response to poor resilience to the stressor of diabetes. Once a diagnosis is established that the community health nurse and associated team can act upon, Stamler and Yiu (2012) emphasize it is important to understand the larger economic-political factors affecting the aboriginal aggregate, such as how health care is a treaty right as supplied and supported by the Federal government. This is important to be aware of as it will affect how programs are implemented both legally and economically. “The majority of reserve residents are dependent on social services for their subsistence. Considerable economic development must be made to improve the economy of First Nations” (Stamler & Yiu, 2012) which in turn will allow the community higher self-efficacy in materializing culturally competent and help cover complex health care management. Macaulay (2009) cautions health care providers to practice cultural humility remembering “that health encompasses physical, emotional, intellectual, and spiritual well-being, as reflected in the 4 quadrants of the medicine wheel” (pg. 335) as well as being defined in the nine subsystems of the community-as-partner model. Local history and practices are important to incorporate when building capacity and efficacy of an aggregate, and therefore should be incorporated into program establishment. References Ghosh, H. & Gomes, J. (2011). Type 2 diabetes among aboriginal peoples in Canada: a focus on direct and associated risk factors. Pimatisiwin: A Journal of Aboriginal and Indigenous Community Health 9(2). Retrieved from http://www.pimatisiwin.com/online/ Health Canada. (2011). First Nations, Inuit and Aboriginal Health. Diseases and Conditions. Retrieved from http://www.hc-sc.gc.ca/fniah-spnia/diseases-maladies/index-eng.php Macaulay, A. C. (2009). Improving aboriginal health: how can health care professionals contribute? Canadian Family Physician (55) 4, 334-336. Retrieved from http://www.cfp.ca/content/55/4/334.short Neufeld, A., & Harrison, M. J. (2000). Nursing diagnosis for aggregates and groups. In M. J. Stewart (Ed.), Community nursing: Promoting Canadians' Health (pp. 370-385). Toronto: Saunders Oster, R., Hemmelgarn, B., Toth, E., King, M., Crowshoe, L., Ralph-Campbell, K. (2009). Diabetes and the Status Aboriginal Population in Alberta. Alberta Diabetes Atlas. Retrieved from: http://www.albertadiabetes.ca/pdf/atlas/09/Atlas-10(web).pdf Oster, R., Johnson, J., Hemmelgarn, B., King, M., Balko., S., Svenson, L., Crowshoe, L. & Toth, E. (2011). Recent epidemiologic trends of diabetes mellitus among status Aboriginal adults. Canadian Medical Association Journal, 7, retrieved from http://www.cmaj.ca/content/early/2011/07/25/cmaj.101882.full.pdf+html Oster, R., Virani, S., Strong, D., Shade, S. & Toth, E. (2009) Diabetes care and health status of First Nation individuals with type 2 diabetes in Alberta. Canadian Family Physician, 55, 386-393. Sommers, M. S. (2011). Diabetes Mellitus. Diseases and Disorders. Nursing Central, copyright Unbound Medicine, Inc., available at www.nursing.unboundmedicine.com Stamler, L. L., & Yiu. L. (Eds.). (2008). Community health nursing: A Canadian perspective (2nd ed.). Toronto: Pearson/Prentice Hall. Vollman, A. R., Anderson, E. T., & McFarlane, J. (2008). Canadian community as partner: Theory and multidisciplinary practice (2nd ed.). Philadelphia: Wolters Kluwer Health | Lippincott Williams & Wilkins. World Health Organization. (2012, January 20). Health of Indigenous Peoples. Retrieved from http://www.who.int/mediacentre/factsheets/fs326/en/ Appendix A - Environmental Scan with Personal Informant Information Environment: In normal days, with no rains or snow, the air quality near major roads is dusty and hazy. Scrub bushes and unkempt grass pervades the roads, breaking through the asphalt at the one and only gas station on the main road leading off the reservation. There appears to be no sprinkler systems or any indication of lawn maintenance until one reaches, the Chief Joseph Big Plume Building, which is the largest community structure. It is well kept, with a maintained parking lot, shovelled side-walks, beautiful paint and cultural decorations. There are minimal industrial/businesses, less than 10 visible from the main road, and that includes the Tsuu T’ina Police Station. Signboards and houses seen from the road appear withered with chipped paint. Some houses are well kept with gardens, decorations, shovelled driveways with relatively new vehicles and other houses are dilapidated, their fences lean onto the ground, rusted cars line causing a slush-covered drive. Transportation: The main road leading onto Tsuu T’ina land from south-western Calgary is paved leading to the Chief’s building, gas station, golf course and several kilometres into reservation land where it eventually fades into a dirt road. Some roads are newer construction with well-kept edges and distinct lines from the forest and shrubbery. One resident told a story to me of calling EMS for his father, but had to meet the ambulance right on the road to lead it to the right house. Other roads have grass and cracks encroaching, with sloping curbs leading into ditches. There are no bus stops or any indication of public transit. People are seen walking from the gas station down the main road, perhaps towards their homes, or to the few businesses visible, despite temperatures below zero. There is a winding, paved bike trail leading away from those main buildings towards the Glenmore Reservoir. Many cyclists, none appearing to be community residents were seen on bike trails. Health/social services: Between 2009 and 2011, Tsuu T’ina made federal proposals for funding for several programs including the Health Human Resource Capacity Building Proposal to increase nursing staff. There already exist three registered nurses, two for community health, as well as three RN’s, two licensed practical nurses and five personal care aids in home care to initiate an integrated comprehensive Mental Health plan. The only diabetes-focused health plan is related to the SLICK research initiative. One physician visits the reservation health centre on two days a week. There are no diabetic educators or designated nurses. Many residents cannot remember any health care support before the health centre opened within the last 10 years. The vaccination nurses come only once a year. The Tsuu T’ina band’s median-term goals are to expand the diabetes program including increasing the doctor’s availability and possibly open a full medical clinic. Read More