H&I: III- Pop Health: Community Empowerment (care of populations: refugees, migrant workers, Asylum seekers)

what are the principles of community health nursing

-systems thinking

-upstream thinking

-determinants of health

what is systems thinking

how an individual or unit interacts with other organizations/systems

-useful for examining cause and effect relationships

what is upstream thinking

focus on interventions that promote health or prevent illness, as opposed to med tx models that focus on care after illness occurs

what are determinants of health

client or environmental factors that influence (cause) health outcomes

what are theories for community health nursing

-health belief model

-milios framework for prevention

-pender's health promotion model

-transtheoretical stages of change model

what is the health belief model

purpose is to predict/explain behaviors, emphasizes change at the individual level

what is milio's framework for prevention

emphasizes change at community level and that change within a large number of ppl would lead to social change

what is pender's health promotion model

examines factors that affect individual action such as personal behavior or self-efficacy, competing demands

what is transtheoretical stages of change model

change occurs overtime in 6 distinct stages, emphasizes change at an individual level

what are the theoretical stages of change

1. precontemplation

2. contemplation

3. determination

4. action

5. maintenance

6. recurrence

what is stage 1 precontemplation in theoretical stages of change

not yet considering change or is unwilling/unable to change

what is the primary task of stage 1 precontemplation in theoretical stages of change

raising awareness

what is stage 2 contemplation in theoretical stages of change

sees the possibility of change but is ambivalent/uncertain

what is the primary task of stage 2 contemplation in theoretical stages of change

resolving ambivalence/helping to choose change

what is stage 3 determination in theoretical stages of change

committed to changing, still considering what to do

what is the primary task in stage 3 determination in theoretical stages of change

help identify appropriate change strategies

what is stage 4 action in theoretical stages of change

taking steps toward change but hasn't stabilized in the process

what is the primary task in stage 4 action in theoretical stages of change

help implement change strategies and learn to eliminate potential relapses

what is stage 5 maintenance in theoretical stages of change

has achieved the goals and is working to maintain change

what is the primary task in stage 5 maintenance in theoretical stages of change

develop new skills for maintaining recovery

what is stage 6 recurrence in theoretical stages of change

experienced a recurrence of the symptoms

what is the primary task in stage 6 recurrence in theoretical stages of change

cope with consequences and determine what to do next

what is the first distinct stage of change according to the transtheoretical stages of change model

precontemplation

what is community empowerment

-Enables communities to identify health problems and act to resolve them

• One of key strategies to address health disparities throughout the world

• One of five principles of primary health care promoted by W H O

what is empowerment

transferring power from those with power to those without

what is powerlessness

antithesis of empowerment

what does empowerment do

leads to increased community capacity and competence

what are the levels of empowerment

-individual community members

-organizations within the community

-community as a whole

what levels of empowerment are population health nurses involved in

all of them

what is horizontal empowerment

-internal to community

-reflected in communities ability to solve problems mobilizing its own resources

what is vertical empowerment

-involves efforts to change power structures outside the community

-leverages outside power and resources to address community concerns

what is of the following best describes horizontal community empowerment:

A. The community solves problems by mobilizing their own resources

B. Efforts are focused on changing the power structure of the national government

C. Outside resources are used to address community concerns

D. Empowerment comes from outside the community

the community solves problems by mobilizing their own resources

components of assessing community strengths and needs

-understands elements of strength

-understands dimensions of culture

-Population health nurses can engage members of the community conduct an assessment as a first step in community empowerment

example of understanding the elements of strength

shared values, willingness to communicate, trust, shared sense of belonging

example of understanding the dimensions of culture

language, infrastructures, money and financing, worldview

what are the principles of community empowerment

Holders of power must want the community to be more self-reliant and must be willing to cede power to community members.

• A trained facilitator is needed to guide the community in its efforts to be more self-reliant.

• Assistance should be offered in the form of a collaborative partnership rather than charity and should be designed to promote increased self-reliance and capacity in the

community.

• Empowerment starts where community members are and does not try to force change on the community

• Struggle and adversity strengthen social organizations and communities when they are

overcome through community activity.

• Hands-on participation in decision making and problem resolution increases problem-

solving capabilities. Decisions need to be made by community members, not for them by others, however well-intentioned.

• The community should supply a substantial portion of the resources needed for problem resolution or project implementation to promote long-term sustainability.

• Community empowerment activities should be designed from the beginning to achieve

the ultimate goal of community control of and responsibility for decision making and

actions taken

Which of the following would be important question(s) to

ask when selecting an issue that fosters community

empowerment?

A. Is the issue consistent with the long-range goals of the

community?

B. Is the issue providing greater visibility and credibility for the

community?

C. Is the issue simply and easily explained by the community

members?

D. Is the issue first identified and approved by the population

health nurse?

A. Is the issue consistent with the long-range goals of the community?

B. Is the issue providing greater visibility and credibility for the

community?

C. Is the issue simply and easily explained by the community members

strategies for promoting community empowerment

-Involve members of community in identification of the problem or issue to be addressed

-Development of objectives or expected outcomes to be achieved

-Development of strategic approaches to achieve those outcomes

-Management of everyday implementation of the campaign

-Evaluation of its effectiveness

-Building trusting relationships

-Building community members' confidence and skill

-Engaging in empowering educational strategies

-Connecting individuals and groups to broader social networks

what are the domains of community empowerment

-community evaluation

-community competence development

-program management skill development

-supportive environment development

what are the potential evaluation questions in the community activation domain

-To what extent have community members increased their participation in small

groups and organizations designed to take action on community problems?

• To what extent have new community participants been engaged in problem

resolution?

• To what extent have new community networks or or groups been established?

• To what extent is the community able to engage in critical assessment of causes of inequities and powerlessness

what are the potential evaluation questions in the community competence development domain

-To what extent is the community able to identify community problems and

possible solutions?

• How effective is the community in disseminating information to improve community members' understanding of issues and potential solutions?

what are the potential evaluation questions in the program management skill development domain

-To what extent has local community leadership been developed?

• To what extent are local leaders able to foster community participation, facilitate problem resolution, resolve conflict, and so on?

• To what extent are effective communication strategies used within the community?

• To what extent are community members able to identify and evaluate evidence-based solutions to problems

what are the potential evaluation questions in the supportive environment development domain

-To what extent has the community developed organizational structures that facilitate

participation in decision making, effectively mobilize and allocate resources, and so on?

• To what extent is the community able to mobilize both internal and external resources?

• To what extent are community members able to effectively lobby and advocate for political support or needed resources?

• To what extent are community assets and existing resources brought to bear to solve identified

problems?

• To what extent have internal links between individuals or organizations within the community

been developed or strengthened?

• To what extent have links to external organizations been created or strengthened?

• To what extent have power relationships with outside entities been equalized?

• To what extent has the community been able to exercise control of decisions and resource allocations affecting the welfare of its members

what are migrants

An umbrella term, not defined under international law, reflecting the common lay

understanding of a person who moves away from his or her place of usual residence, whether within a country or across an international border, temporarily or permanently, and for a variety of reasons.

what does the term migrants include

a number of well-defined legal categories of people, such as migrant

workers; persons whose particular types of movements are legally-defined, such as smuggled migrants; as well as those whose status or means of movement are not specifically defined under international law, such as international students

note about the term migrants

At the international level, no universally accepted definition for "migrant" exists.

The present definition was developed by IOM for its own purposes, and it is not meant to imply or create any new legal category.

what is a migrant worker

a person who is to be engaged, is engaged or has been engaged in a salaried/paid activity in a state of which he or she is not a national

what is the average life expectancy of a migrant worker

51 years of age, which is aging for this population

components of migrant employment

-Seasonal and migrant workers often employed in farming and agriculture

• May have temporary home during employment, also paying for family to live in different/permanent home

• Agricultural workers are not covered under common labor laws

• Minors 12 y/o and older are not covered under Child Labor Act and can work with family members under hazardous conditions

components of work related injuries, illness, and fatalities in migrant/seasonal farmworkers

-Greater mortality and morbidity compared to general population due to poverty

• Limited access to health care, hazardous working conditions, lack of regulations

components of documentation in migrant/seasonal farmworkers

-Many migrant farmworkers have permanent residence

• Annually, 50,000-100,000 additional workers are given temporary foreign certification

through H2A

• Others attempt unauthorized crossing of US-Mexico border

components of healthcare access for migrant/seasonal farmworkers

-Not required to be provided by employer

• Those lawfully present can purchase coverage under ACA, or qualify for Medicaid

• Application process often complicated

• HRSA funded health centers provide care to over 1 million workers and families

what is a refugee

-a person who, owning a well-founded fear of persecution for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of their nationality and is unable or, owing to such fear, is unwilling to avail themself of the protection of that country; or who, not having a nationality and being outside the country of his former habitual residence as a result of such events, is unable or, owing to such fear, is unwilling to return to it

what is an asylum seeker

-An individual who is seeking international protection.

• In countries with individualized procedures, an asylum seeker is someone

whose claim has not yet been finally decided on by the country in which he or

she has submitted it.

-Not every asylum seeker will ultimately be recognized as a refugee, but every recognized refugee is initially an asylum seeker

how is a refugee different from an asylum seeker

upon entering US has been granted refugee status prior to entering

how is an asylum seeker different from a refugee

has applied for refugee status but has not been granted as of yet, may apply after entering US or at US port of entry

Applicants for refugee status→

outside the US

Applicants seeking asylum→

in the US or arrived at a US port of entry

asylum-seeker/refugee ratio

1 in every 11 3 people on earth is a n

asylum-seeker, internally displaced or a refugee

US refugee eligibility requirements

(1) be of special humanitarian concern to the United States

(2) meet the refugee definition as set forth in section 101(a)(42) of the INA

(3) be admissible under the INA (or be granted a waiver of inadmissibility)

AND

(4) not be firmly resettled in any foreign country

what is the US refugee admissions program (USRAP)

establishes processing priorities that

identify individuals and groups who are of special humanitarian concern to the US and therefore eligible for refugee resettlement consideration

what is the USRAP priority category 1

individuals referred by the United Nations High Commission on

Refugees (UNHCR), a U.S. Embassy, or certain non-governmental organizations (NGO)

what is the USRAP priority category 2

groups of special humanitarian concern

what is the USRAP priority category 3

family reunification cases

what must happen once applications are referred or granted access to USRAP under any of the priority categories

must still meet all other eligibility criteria

what has to be completed before a request for refugee status is approved

multiple security checks and a medical exam

how does a refugee come to the US

UNHCR/embassy --> RSC conducts prescreening interview --> DHS interview --> approved applicants go through multiple security checks --> approved applicants receive a med screening --> cultural orientation --> the case is allocated to a national volag by the RPC --> the national volag completes verification of placement with local field office --> the national volag assures the care --> approved applicants who successfully complete all screenings are schedule for departure to US

what are the volunteer agencies in WI

-Resettlement Agency (affiliate) in WI & Parent VOLAG (national organization)

-International Institute of Wisconsin

-U.S. Committee for Refugees and Immigrants

-Lutheran Social Services of Wisconsin and Upper Michigan

-Lutheran Immigration and Refugee Services

-World Relief Fox Valley

-World Relief

-Jewish Social Services

-Hebrew Immigrant Aid Society

-Multicultural Community Center

-Ethiopian Community Development Council (ECDC)

-Catholic Charities of Green Bay

-United States Conference of Catholic Bishops (USCCB)

what is the refugee act

2 distinct processes for refugees seeking US entry

what is refugee resettlement (process 1)

-18-24 months of vetting while living in refugee camps or

urban settings abroad

-Refugee admissions →maximum number set each year by the President -Recently cut by nearly 50% to 45,000, the lowest level in decades

what is asylum (process 2)

-Any person currently in the US or arrives at the US border can apply for asylum. An asylum seeker may initially enter with legal documents(tourist visa) or after being caught inside the USA by immigration authorities, and may have to pursue their

asylum claims while in detention

-To be granted asylum, an individual must meet the refugee definition and that none of the various bars to asylum apply (e.g., "serious" criminal conduct, persecution of others, or terrorist ties)

standard for being granted asylum

To meet the refugee definition and therefore qualify for asylum→ show suffering from past

persecution and/or have reasonable grounds to fear future persecution, based on one of five

protected grounds: political opinion, race, religion, nationality, or membership in a particular social group

-cannot just be discrimination or harrassment

what does persecution be based on (standard for being granted asylum)

-sexual orientation/gender identity

-gender based harms such as DV or female genital mutilation

-targeted gang violence (sometimes)

what is persecution only technically granted with cases of

torture, rape, repeated physical abuse, prolonged imprisonment, severe mental or emotional abuse, imminent and menacing death threats, and extreme economic punishments

best practices in caring for asylum seekers

Qualifications and expectations: NPs, mental health professionals, and other clinicians already have many of the basic skills necessary to conduct asylum evaluations,

including (hopefully) empathic medical interviewing skills, the physical and psychological assessment of trauma sequelae, and medical

documentation

• General competencies

At a minimum, clinicians who perform asylum evaluations should be able to demonstrate the following competencies:

1. Familiarity with asylum law and the role of clinicians in evaluating asylum seekers

2. Knowledge of medical and mental health consequences of torture and ill treatment

3. An objective and professional approach that includes respect for privacy and confidentiality, informed consent, appropriate language

interpretation services, and attention to trauma-informed care

4. Relevant history-taking and interview techniques and physical examination skills

5. Familiarity with standardized language for describing the diagnostic probability or consistency of medical and mental health findings

(Istanbul Protocol)

6. Medicolegal documentation as it pertains to the clinical assessment of asylum seekers

7. Effective and responsive interpersonal and communication skills that extend to legal professionals and referring agencies

8. Ongoing personal & professional development, including continuing ed & attention to the potential for vicarious trauma

how does the UN convention against torture (CAT) define torture

Any act by which severe pain or suffering, whether physical or mental, is intentionally

inflicted on a person for purposes of punishment, coercion, obtaining information, or discrimination

what are the two types of torture

physical or psychological

% of asylum seekers who received forensic evaluations were granted asylum

89% of asylum seekers who received forensic evaluations were granted asylum, compared to

the national average of 37.5% of US asylum seekers who did not

what is the istanbul protocol

-(1999) First document→ international guidelines for documentation of torture

• 3 years of analysis, research, and creation undertaken →75+ forensic doctors,

nurses, psychologists, human rights monitors, and lawyers from 40 organizations and institutions from 15 countries

components of LGBTQ asylum seekers

• Over a third (38.60%) of survey participants→ no access mental healthcare since arriving in the United

States or Canada because of cost

• Conclusion→ LGBTQ asylum seekers in North America have a high burden of mental distress

• Previous research LGBTQ asylum seekers avoid associating with members of their own ethnic group due to experienced/expected homophobia consistent with the infrequent endorsement of

family and immigrant communities as a primary source of social support

• Religious organizations→ the least popular forms of support in this sample

• Other LGBTQ people→ most common source of primary support

-Our findings point to a need for recognition of sexual orientation and gender identity as important pre- and

post-migration social determinants of immigrant health in cross-national frameworks and for the elucidation

of modifiable post-migration factors that the influence mental health of LGBTQ asylum seekers

refugee minor components

-In 2018, 38.5 million children displaced from place of origin

• 20-52.7% → Post-traumatic stress disorder (PTSD)

• Related to pre-migration disturbances such as witnessing death or torture of relatives, assaults and separation from family.

• Intra-migration difficulties relate to the hazardous journey, length of detention, type of facility and failed asylum application.

• 38.3%→depression

• 69%→ anxiety

• Post-migration difficulties highlighted are insecure asylum status, housing worries, multiple relocations and poor acculturation

technique and are more related to depression and anxiety

• Majority of children report good functionality in their host countries in the long-term

• Health and social care providers must understand the complex interplay between the damaging effects of

displacement, and the innate protective factors that persecuted children possess

stressors from displacing children chart